High-risk Noncardiac Surgery Research Articles

Relationship between sST2 and NT-proBNP levels and postoperative atrial fibrillation in patients having non-cardiac surgery.

We explored the link between sST2 and NT-proBNP levels and postoperative atrial fibrillation (POAF) incidence in non-cardiac surgery patients in this study. The research involved 302 participants over 40 years old who underwent medium and/or high-risk non-cardiac surgeries. These patients were divided into two groups: those who developed POAF and those who did not. The study cohort consisted of a total of 302 patients, with 14 (4.6%) experiencing POAF. POAF was more common in patients with previous heart failure, a high Left Atrial Volume Index (LAVI), and elevated ASA and RCRI scores (all P<0.05). LAVI, sST2, NT-proBNP, and RCRI scores were found to be independent predictors of POAF in patients undergoing non-cardiac surgeries (all P<0.05). The area under the curve (AUC) for sST2 and NT-proBNP in predicting POAF was 0.707 (95% CI 0.544-0.869; P=0.009) and 0.727 (95% CI 0.598-0.857; P=0.004), respectively. Combined elevation of sST2 and NT-proBNP increased the likelihood of developing POAF by approximately 8.5 times (OR: 8.65, CI 95% 1.06-35.3, P=0.044). sST2 and NT-proBNP are valuable predictors of POAF in patients undergoing non-cardiac surgery. Identifying these predictors can help in recognizing high-risk patient groups for POAF.

Incidence, characteristics, and outcome of noncardiac surgery following transcatheter aortic valve implantation.

Planning noncardiac surgery after transcatheter aortic valve implantation (TAVI) is challenging. We evaluated the incidence, characteristics, and outcome of noncardiac surgeries in patients who underwent TAVI. We retrieved data from the Prospective Segeberg TAVI registry of all patients who received TAVI between 2007 and 2020. Type, timing, urgency, and risk of noncardiac surgery were assessed. We evaluated the patients' clinical outcomes within 30days following noncardiac surgery that included death, myocardial infarction, bleeding, stroke, and acute heart failure. A composite outcome of all adverse events was proposed to independently predict 30day adverse events. Among 1602 patients, 104 patients (mean age, 79.9 ± 7.14 years; 61 (58.7%) females) underwent 148 noncardiac surgeries after TAVI. More than half of the noncardiac surgeries were considered elective (n = 84, 56.7%). Procedures were categorized into low-risk (n = 27, 18.2%), intermediate-risk (n = 102, 68.9%), and high-risk (n = 19, 12.8%) surgery. The composite outcome of adverse events occurred after 57 noncardiac surgeries (38.5% of all procedures) and after more than half of the surgeries in the high-risk group (n = 11, 57.9%). Major or life-threatening bleeding occurred in 24 noncardiac surgeries (19.1%) and was more frequent in high-risk surgeries than in low- and intermediate-risk surgeries (36.8%, p < 0.047). High-risk category of surgery was independently associated with increased risk of the composite outcome (adjusted OR, 3.99; 95% CI 1.12-14.23; p = 0.033). Noncardiac surgery after TAVI was performed in 6.5% patient of our study cohort. High-risk noncardiac surgeries were associated with increased risk of adverse events.

Cerebral oximetry in high-risk surgical patients: where are we?

This review aims to summarize the latest evidence on the role of near-infrared spectroscopy (NIRS) in monitoring cerebral oxygenation in high-risk surgical patients, including both cardiac and noncardiac surgeries, and to present a new algorithm for its application. NIRS effectively measures brain oxygen saturation noninvasively, proving valuable in cardiac surgeries to reduce neurological complications, though its impact on nonneurological outcomes is less clear. In noncardiac surgeries, NIRS can help prevent complications like postoperative cognitive dysfunction, particularly in high-risk and major surgeries. Studies highlight the variability of cerebral oxygenation impacts based on surgical positions, with mixed results in positions like the beach chair and sitting positions. A structured algorithm for managing cerebral desaturation has been proposed to optimize outcomes by addressing multiple factors contributing to blood oxygen content and delivery. Despite its limitations, including spatial resolution and interindividual variability, NIRS is a useful tool for intraoperative cerebral monitoring. Further studies are needed to confirm its broader applicability in noncardiac surgeries, but current evidence supports its role in reducing postoperative complications especially in cardiac surgeries.

Postoperative Acute Kidney Injury After Intraoperative Hypotension in Major Risk Procedures.

Background Reportedly prevalent, intraoperative hypotension (IOH) is linked to kidney injury and increased risk of mortality. In this study, we aimed to assess IOH incidence in high-risk non-cardiac surgery and its correlation with postoperative acute kidney injury (PO-AKI) and 30-day postoperative mortality. Methodology This retrospective cohort study included adult inpatients who underwent elective, non-cardiac, high-risk European Society of Anaesthesiology/European Society of Cardiology surgery from October to November of 2020, 2021, and 2022, excluding cardiac, intracranial, or emergency surgery. IOH was primarily defined by the 2022 Anesthesia Quality Institute. PO-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours, the need for dialysis in dialysis-naïve patients, or the documentation of AKI in clinical records. For univariate analysis, the Mann-Whitney U test and chi-square or Fisher's exact tests were performed, as appropriate. Logistic regression was used to test risk factors for IOH in univariate analysis (p < 0.1). The significance level considered in multivariate analysis was 5%. Results Of the 197 patients included, 111 (56.3%) experienced IOH. After adjustment, surgical time >120 minutes remained associated with higher odds of IOH (odds ratio (OR) = 9.62, 95% confidence interval (CI) = 2.49-37.13), as well as combined general + locoregional (vs. general OR = 3.41, 95 CI% = 1.38-8.43, p = 0.008; vs. locoregional OR = 6.37, 95% CI = 1.48-27.47). No association was found between IOH and 30-day postoperative mortality (p = 0.565) or PO-AKI (p = 0.09). The incidence of PO-AKI was 14.9% (27 patients), being significantly associated with higher 30-day postoperative mortality (p = 0.018). Conclusions Our study highlights the high prevalence of IOH in high-risk non-cardiac surgical procedures. Its impact on PO-AKI and 30-day postoperative mortality appears less pronounced compared to the significant implications of PO-AKI, emphasizing the need for PO-AKI screening and renal protection strategies.

Predicting perioperative myocardial injury/infarction after noncardiac surgery in patients under surgical and medical co-management: a prospective cohort study

BackgroundPerioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model.MethodsA prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated.Results613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34–14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67–0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81–0.93).ConclusionsThe incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery.

Hypotension Prediction Index Is Equally Effective in Predicting Intraoperative Hypotension during Noncardiac Surgery Compared to a Mean Arterial Pressure Threshold: A Prospective Observational Study.

The Hypotension Prediction Index is designed to predict intraoperative hypotension in a timely manner and is based on arterial waveform analysis using machine learning. It has recently been suggested that this algorithm is highly correlated with the mean arterial pressure itself. Therefore, the aim of this study was to compare the index with mean arterial pressure-based prediction methods, and it is hypothesized that their ability to predict hypotension is comparable. In this observational study, the Hypotension Prediction Index was used in addition to routine intraoperative monitoring during moderate- to high-risk elective noncardiac surgery. The agreement in time between the default Hypotension Prediction Index alarm (greater than 85) and different concurrent mean arterial pressure thresholds was evaluated. Additionally, the predictive performance of the index and different mean arterial pressure-based methods were assessed within 5, 10, and 15 min before hypotension occurred. A total of 100 patients were included. A mean arterial pressure threshold of 73 mmHg agreed 97% of the time with the default index alarm, whereas a mean arterial pressure threshold of 72 mmHg had the most comparable predictive performance. The areas under the receiver operating characteristic curve of the Hypotension Prediction Index (0.89 [0.88 to 0.89]) and concurrent mean arterial pressure (0.88 [0.88 to 0.89]) were almost identical for predicting hypotension within 5 min, outperforming both linearly extrapolated mean arterial pressure (0.85 [0.84 to 0.85]) and delta mean arterial pressure (0.66 [0.65 to 0.67]). The positive predictive value was 31.9 (31.3 to 32.6)% for the default index alarm and 32.9 (32.2 to 33.6)% for a mean arterial pressure threshold of 72 mmHg. In clinical practice, the Hypotension Prediction Index alarms are highly similar to those derived from mean arterial pressure, which implies that the machine learning algorithm could be substituted by an alarm based on a mean arterial pressure threshold set at 72 or 73 mmHg. Further research on intraoperative hypotension prediction should therefore include comparison with mean arterial pressure-based alarms and related effects on patient outcome.

AcumenTM hypotension prediction index guidance for prevention and treatment of hypotension in noncardiac surgery: a prospective, single-arm, multicenter trial

BackgroundIntraoperative hypotension is common during noncardiac surgery and is associated with postoperative myocardial infarction, acute kidney injury, stroke, and severe infection. The Hypotension Prediction Index software is an algorithm based on arterial waveform analysis that alerts clinicians of the patient’s likelihood of experiencing a future hypotensive event, defined as mean arterial pressure < 65 mmHg for at least 1 min.MethodsTwo analyses included (1) a prospective, single-arm trial, with continuous blood pressure measurements from study monitors, compared to a historical comparison cohort. (2) A post hoc analysis of a subset of trial participants versus a propensity score-weighted contemporaneous comparison group, using external data from the Multicenter Perioperative Outcomes Group (MPOG). The trial included 485 subjects in 11 sites; 406 were in the final effectiveness analysis. The post hoc analysis included 457 trial participants and 15,796 comparison patients. Patients were eligible if aged 18 years or older, American Society of Anesthesiologists (ASA) physical status 3 or 4, and scheduled for moderate- to high-risk noncardiac surgery expected to last at least 3 h. Measurements: minutes of mean arterial pressure (MAP) below 65 mmHg and area under MAP < 65 mmHg.ResultsAnalysis 1: Trial subjects (n = 406) experienced a mean of 9 ± 13 min of MAP below 65 mmHg, compared with the MPOG historical control mean of 25 ± 41 min, a 65% reduction (p < 0.001). Subjects with at least one episode of hypotension (n = 293) had a mean of 12 ± 14 min of MAP below 65 mmHg compared with the MPOG historical control mean of 28 ± 43 min, a 58% reduction (p< 0.001). Analysis 2: In the post hoc inverse probability treatment weighting model, patients in the trial demonstrated a 35% reduction in minutes of hypotension compared to a contemporaneous comparison group [exponentiated coefficient: − 0.35 (95%CI − 0.43, − 0.27); p < 0.001].ConclusionsThe use of prediction software for blood pressure management was associated with a clinically meaningful reduction in the duration of intraoperative hypotension. Further studies must investigate whether predictive algorithms to prevent hypotension can reduce adverse outcomes.Trial registrationClinical trial number: NCT03805217. Registry URL: https://clinicaltrials.gov/ct2/show/NCT03805217. Principal investigator: Xiaodong Bao, MD, PhD. Date of registration: January 15, 2019.

Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis.

A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated. This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions. In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions. The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.

Machine learning-based model for predicting major adverse cardiovascular and cerebrovascular events in patients aged 65 years and older undergoing noncardiac surgery

BackgroundFew evidence-based prediction models have been developed for predicting major adverse cardiovascular and cerebrovascular events (MACCE) in patients aged 65 years or older undergoing noncardiac surgery. In this study, we aimed to analyze the risk factors for perioperative MACCE in patients aged 65 years or older undergoing noncardiac surgery and construct a prediction model.MethodsIn this nested case–control study, a total of 342 Chinese patients who were aged ≥ 65 years and underwent medium- or high-risk noncardiac surgery in our hospital were included. There were 84 cases with MACCE (the MACCE group) and 258 without MACCE (the control group). Univariable logistic regression analysis was performed to identify the risk factors for MACCE. Least absolute shrinkage and selection operator (LASSO) regression was used to screen the variables. Nomogram was constructed using the selected variables. Machine learning methods, including Decision Tree, XGBoost, Support Vector Machine, K-nearest Neighbor, and Neural network, was used to establish, validate, and compare the performance of different prediction models.ResultsA prediction model based on nine variables, including age ≥ 85 years, history of ischemic chest pain, symptoms of decompensated heart failure, high-risk surgery, intraoperative minimum systolic blood pressure, postoperative systolic blood pressure, Cr levels over 2.0 mg/dL, left ventricular ejection fraction, and perioperative blood transfusion, was constructed. This LASSO logistic regression model showed good discriminatory ability to predict MACCE (area under the curve = 0.89; 95% confidence interval, 0.818 – 0.963) and fit to the test set (Hosmer–Lemeshow, χ2 = 7.4053, P = 0.4936). The decision curve analysis showed a positive net benefit of the new model. Compared with logistic regression model, the XGBoost model showed better prediction ability (area under the curve = 0.903). A preoperative prediction model based on five variables, including age ≥ 85 years, symptoms of decompensated heart failure, ischemic chest pain, high-risk type of surgery and Cr levels over 2.0 mg/dL was also constructed. This model showed good discriminatory ability to predict MACCE before surgery (area under the curve = 0.720 [95% CI, 0.591–0.848]. Both models compared with the modified RCRI score had improvement in reclassification.ConclusionBy analyzing Chinese patients aged ≥ 65 years undergoing medium- or high-risk noncardiac surgery, the risk factors for perioperative MACCE were identified. Then, simple prediction models were constructed and validated, which showed good prediction performance and may be used as a decision-making assistant tool for clinicians. These findings provide a basis for preventing and improving the perioperative management of MACCE.

Determinants of postoperative complications in high-risk noncardiac surgery patients optimized with hemodynamic treatment strategies: A post-hoc analysis of a randomized multicenter clinical trial

Study objectiveThis post-hoc analysis of a randomized controlled trial was undertaken to establish the determinants of postoperative complications and acute kidney injury in high-risk noncardiac surgery patients supported with hemodynamic treatment strategies. DesignWe conducted a post-hoc analysis of patients enrolled in the OPtimization Hemodynamic Individualized by the respiratory QUotiEnt (OPHIQUE) trial. SettingOperating rooms in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. PatientsWe enrolled 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia. InterventionsAll patients were treated according to hemodynamic treatment strategies which included cardiac output optimization by titration of fluid challenge and targeted systolic blood pressure to remain within ±10% of the reference value. MeasurementsWe assessed the association between pre-operative and intra-operative exposure of interest with a composite primary outcome of major complications or death within seven days following surgery using a multivariable logistic regression model. We also assessed the association between these exposures of interest and acute kidney injury. Main resultsThe data of 341 patients were analyzed. In multivariate analysis, the factors independently associated with the primary outcome were age (OR = 1.04 (1.01–1.06), P = 0.002), preoperative hemoglobin concentration (OR = 0.85 (0.75–0.96), P = 0.012), non-vascular surgery (OR = 0.30 (0.17–0.53), P < 0.0001), and intraoperative surgical complications (OR = 2.08 (1.02–4.24), P = 0.046). The factors independently associated with postoperative acute kidney injury were age (OR = 1.04 (1.01–1.08), P = 0.008), preoperative creatinine concentration (OR = 1.01 (1.00–1.01), P = 0.049), non-vascular surgery (OR = 0.36 (0.20–0.66), P = 0.001), and intraoperative surgical complications (OR = 3.36 (1.50–7.55), P = 0.031). ConclusionsSurgical complications, a lower preoperative hemoglobin concentration, age, and vascular surgery were associated with postoperative complications in a high-risk noncardiac surgery population supported with hemodynamic treatment strategies.

NT-proBNP level as a substitute for myocardial perfusion scan in preoperative cardiovascular risk assessment in noncardiac surgery

BackgroundPreoperative cardiovascular risk assessment is one of the main principles before noncardiac surgeries. Cardiac stress imaging, such as myocardial perfusion scan (MPS), is a proposed cardiovascular risk evaluation method according to the latest guidelines. Yet, its efficacy, along with the cost-effectiveness of the method, has been questioned in previous studies. Our study aims to evaluate the utility of N-terminal pro-b-type natriuretic peptide (NT-proBNP) level measurement in predicting postoperative cardiovascular complications in candidates who have undergone an MPS before surgery and compare the results.MethodsA cohort of 80 patients with a revised cardiac risk index score of one or more who were scheduled for moderate to high-risk noncardiac surgeries and met the criteria to undergo an MPS for risk assessment were included in the study. All of them underwent an MPS one week before surgery. Their preoperative NT-proBNP, troponin levels, and electrocardiograms were obtained one day before surgery and again on day three postoperative. The predictive efficacy of NT-proBNP levels and MPS were compared.ResultsSeventy-eight patients underwent surgery, three of which exhibited a rise in troponin level, six showed changes on electrocardiogram, and pulmonary edema was detected in one, three days after surgery. There was no mortality in our patients. The sensitivity and specificity of the MPS for predicting postoperative cardiovascular complications were 100% and 66%, respectively. MPS also had a positive predictive value of 20% and a negative predictive value of 100% in our study. A 332.5 pg/ml cut-off value for NT-proBNP level yielded a sensitivity of 100%, specificity of 79.2%, positive predictive value of 40%, and negative predictive value of 100%.ConclusionsOur study reveals the incremental specificity and positive predictive value of NT-proBNP level measurement in preoperative cardiovascular risk evaluation compared to MPS. Given the low feasibility, high costs, and disappointing predictive value of MPS, preoperative NT-proBNP level assessment can be substituted. This method can assist anesthesiologists and surgeons with precisely detecting at-risk patients resulting in taking proper measures to reduce the morbidity and mortality of the proposed patients before and during surgeries.

Predictors of unplanned hospital readmission after non-cardiac surgery in Singapore: a 2-year retrospective review

IntroductionUnplanned hospital readmissions after surgery contribute significantly to healthcare costs and potential complications. Identifying predictors of readmission is inherently complex and involves an intricate interplay between medical factors, healthcare system factors and sociocultural factors. Therefore, the aim of this study was to elucidate the predictors of readmissions in an Asian surgical patient population.MethodsA two-year single-institution retrospective cohort study of 2744 patients was performed in a university-affiliated tertiary hospital in Singapore, including patients aged 45 and above undergoing intermediate or high-risk non-cardiac surgery. Unadjusted analysis was first performed, followed by multivariable logistic regression.ResultsTwo hundred forty-nine patients (9.1%) had unplanned 30-day readmissions. Significant predictors identified from multivariable analysis include: American Society of Anaesthesiologists (ASA) Classification grades 3 to 5 (adjusted OR 1.51, 95% CI 1.10–2.08, p = 0.01), obesity (adjusted OR 1.66, 95% CI 1.18–2.34, p = 0.04), asthma (OR 1.70, 95% CI 1.03–2.81, p = 0.04), renal disease (OR 2.03, 95% CI 1.41–2.92, p < 0.001), malignancy (OR 1.68, 95% CI 1.29–2.37, p < 0.001), chronic obstructive pulmonary disease (OR 2.46, 95% CI 1.19–5.11, p = 0.02), cerebrovascular disease (OR 1.73, 95% CI 1.17–2.58, p < 0.001) and anaemia (OR 1.45, 95% CI 1.07–1.96, p = 0.02).ConclusionSeveral significant predictors of unplanned readmissions identified in this Asian surgical population corroborate well with findings from Western studies. Further research will require future prospective studies and development of predictive risk modelling to further address and mitigate this phenomenon.

Effectiveness of intraoperative nicorandil in patients with a history of ischemic heart disease undergoing high-risk noncardiac surgery: a retrospective cohort study.

Nicorandil is occasionally administered to prevent myocardial ischemia during the perioperative period in patients with ischemic heart disease (IHD); however, its effectiveness has not been clarified. In this study, we examined the effectiveness of intraoperative nicorandil administration in noncardiac surgery. We identified patients with a history of IHD who had undergone high-risk noncardiac surgery between April 2015 and March 2020 from a nationwide in-patient database in Japan. The patients were divided into those who received nicorandil (nicorandil group) and those who did not (control group). The primary outcome was the 30-day in-hospital mortality. The secondary outcome was major adverse cardiovascular events (MACE), defined as the composite outcome of the 30-day in-hospital mortality, acute myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting. One-to-one propensity score matching was performed. The outcomes were analyzed using a Cox proportional hazards model. Of 8037 patients, 2886 received nicorandil during surgery. After propensity score matching, 2554 pairs were analyzed. There was no significant difference in the 30-day in-hospital mortality (26 [1.02%] vs. 36 [1.41%]; hazard ratio [HR] 1.36; 95% confidence interval [CI] 0.82-2.26; P = 0.229) or incidence of MACE (42 [1.64%] vs. 55 [2.15%]; HR 1.24; 95% CI 0.86-1.93; P = 0.216) between the control and nicorandil groups. The findings of this study suggest that intraoperative nicorandil administration is not associated with the 30-day in-hospital mortality in high-risk noncardiac surgery.

Intraoperative hypotension in noncardiac surgery patients with chronic beta-blocker therapy: A matched cohort analysis

Study objectiveTo explore the incidence of intraoperative hypotension in patients with chronic beta-blocker therapy, expressed as time spent, area and time-weighted average under predefined mean arterial pressure thresholds. DesignRetrospective analysis of a prospective observational cohort registry. SettingPatients ≥60 years undergoing intermediate- to high-risk noncardiac surgery with routine postoperative troponin measurements on the first three days after surgery. Patients1468 matched sets of patients (1:1 ratio with replacement) with and without chronic beta-blocker treatment. InterventionsNone. MeasurementsThe primary outcome was the exposure to intraoperative hypotension in beta-blocker users vs. non-users. Time spent, area and time-weighted average under predefined mean arterial pressure thresholds (55–75 mmHg) were calculated to express the duration and severity of exposure. Secondary outcomes included incidence of postoperative myocardial injury and thirty-day mortality, myocardial infarction (MI) and stroke. Furthermore, analyses for patient subgroup and beta-blocker subtype were conducted. Main resultsIn patients with chronic beta-blocker therapy, no increased exposure to intraoperative hypotension was observed for all characteristics and thresholds calculated (all P > .05). Beta-blocker users had lower heart rate before, during and after surgery (70 vs. 74, 61 vs. 65 and 68 vs. 74 bpm, all P < .001, respectively). Postoperative myocardial injury (13.6% vs. 11.6%, P = .269) and thirty-day mortality (2.5% vs. 1.4%, P = .055), MI (1.4% vs. 1.5%, P = .944) and stroke (1.0% vs 0.7%, P = .474) rates were comparable. The results were consistent in subtype and subgroup analyses. ConclusionsIn this matched cohort analysis, chronic beta-blocker therapy was not associated with increased exposure to intraoperative hypotension in patients undergoing intermediate- to high-risk noncardiac surgery. Furthermore, differences in patient subgroups and postoperative adverse cardiovascular events as a function of treatment regimen could not be demonstrated.

Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model.

The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance. Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed. Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%. Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.

Perioperative Decision-Making in Pulmonary Hypertension.

Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.

Cohort profile of PLUTO: a perioperative biobank focusing on prediction and early diagnosis of postoperative complications

PurposeAlthough elective surgery is generally safe, some procedures remain associated with an increased risk of complications. Improved preoperative risk stratification and earlier recognition of these complications may ameliorate postoperative recovery...

Respiratory Exchange Ratio guided management in high-risk noncardiac surgery: The OPHIQUE multicentre randomised controlled trial

BackgroundThere is a need to develop non-invasive markers to identify the occurrence of anaerobic metabolism in high-risk surgery. Our objective was to demonstrate that a goal-directed therapy algorithm incorporating the respiratory exchange ratio (ratio between CO2 production and O2 consumption) can reduce postoperative complications. MethodsWe conducted a randomized, multicenter, controlled clinical trial in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia were enrolled. The control group was treated according to current hemodynamic guidelines. The interventional group was treated according to an algorithm based on the measurement of the respiratory exchange ratio. The primary outcome was a composite of major complications or death within seven days of surgery. The secondary outcomes were the length of hospital stay, 30-day mortality, and the total intraoperative volume of fluids administered. ResultsThe primary outcome occurred for 78 patients (45.6%) in the interventional group and 83 patients (48.8%) in the control group (relative risk: 0.93, 95% confidence interval [CI]: 0.75–1.17; p = 0.55). There were no clinically relevant differences between the two groups for secondary outcomes. ConclusionsIn high-risk surgery, a goal-directed therapy algorithm integrating the measurement of the respiratory-exchange ratio did not reduce a composite outcome of major postoperative complications or death within seven days after surgery compared to routine care. Trial RegistrationClinicalTrials.gov, NCT03852147.

Effect of Supplemental Oxygen on von Willebrand Factor Activity and Ristocetin Cofactor Activity in Patients at Risk for Cardiovascular Complications Undergoing Moderate-to High-Risk Major Noncardiac Surgery-A Secondary Analysis of a Randomized Trial.

Increased von Willebrand Factor (vWF) activity mediates platelet adhesion and might be a contributor to the development of thrombotic complications after surgery. Although in vitro studies have shown that hyperoxia induces endovascular damage, the effect of perioperative supplemental oxygen as a possible trigger for increased vWF activity has not been investigated yet. We tested our primary hypothesis that the perioperative administration of 80% oxygen concentration increases postoperative vWF activity as compared to 30% oxygen concentration in patients at risk of cardiovascular complications undergoing major noncardiac surgery. A total of 260 patients were randomly assigned to receive 80% versus 30% oxygen throughout surgery and for two hours postoperatively. We assessed vWF activity and Ristocetin cofactor activity in all patients shortly before the induction of anesthesia, within two hours after surgery and on the first and third postoperative day. Patient characteristics were similar in both groups. We found no significant difference in vWF activity in the overall perioperative time course between both randomization groups. We observed significantly increased vWF activity in the overall study population throughout the postoperative time course. Perioperative supplemental oxygen showed no significant effect on postoperative vWF and Ristocetin cofactor activity in cardiac risk patients undergoing major noncardiac surgery. In conclusion, we found no significant influence of supplemental oxygen in patients undergoing major non-cardiac surgery on postoperative vWF activity and Ristocetin cofactor activity.

Preoperative cerebral oxygenation in high-risk noncardiac surgical patients: an observational study on postoperative mortality and complications

Near Infrared Spectroscopy (NIRS) has become widely accepted to evaluate regional cerebral oxygen saturation (rScO2), potentially acting as a surrogate parameter of reduced cerebral oxygen delivery or increased consumption. Low preoperative rScO2 is associated with increased postoperative complications after cardiac surgery. However, its universal potential in pre-anesthesia risk assessment remains unclear. Therefore, we investigated whether low preoperative rScO2 is indicative of postoperative complications and associated with poor outcomes in noncardiac surgical patients. We prospectively enrolled 130 patients undergoing high-risk noncardiac surgery. During pre-anesthesia evaluation, baseline rScO2 was recorded with and without oxygen supplementation. The primary endpoint was 30-day mortality, while secondary endpoints were postoperative myocardial injury, respiratory complications, and renal failure. We further evaluated the impact of body position and preoperative hemoglobin (Hb) concentration on rScO2. Of the initially enrolled 130 patients, 126 remained for final analysis. Six (4.76%) patients died within 30 postoperative days. 95 (75.4%) patients were admitted to the ICU. 32 (25.4%) patients suffered from major postoperative complications. There was no significant association between rScO2 and 30-day mortality or secondary endpoints. Oxygen supplementation induced a significant increase of rScO2. Furthermore, Hb concentration correlated with rScO2 values and body position affected rScO2. No significant association between rScO2 values and NYHA, LVEF, or MET classes were observed. Preoperative rScO2 is not associated with postoperative complications in patients undergoing high-risk noncardiac surgery. We speculate that the discriminatory power of NIRS is insufficient due to individual variability of rScO2 values and confounding factors.