Noncardiac Surgical Patients Research Articles

ANTICOAGULANT USE AND THE RISK OF THROMBOEMBOLISM AND BLEEDING IN PATIENTS WITH NEW ATRIAL FIBRILLATION FOLLOWING NON-CARDIAC SURGERY

While post-operative atrial fibrillation is associated with a high incidence of long-term thromboembolic events, a lack of data exists to support an anticoagulation strategy in non-cardiac surgical patients. We aim to determine if anticoagulation use is associated with a reduction in thromboembolic

Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery

BackgroundIntraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017. MethodsThe meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure. ResultsThree consensus statements on intraoperative blood pressure were established. 1) Intraoperative mean arterial pressures below 60–70 mm Hg are associated with myocardial injury, acute kidney injury, and death. Injury is a function of hypotension severity and duration. 2) For adult non-cardiac surgical patients, there is insufficient evidence to recommend a general upper limit of arterial pressure at which therapy should be initiated, although pressures above 160 mm Hg have been associated with myocardial injury and infarction. 3) During cardiac surgery, intraoperative systolic arterial pressure above 140 mm Hg is associated with increased 30 day mortality. Injury is a function of arterial pressure severity and duration. ConclusionsThere is increasing evidence that even brief durations of systolic arterial pressure <100 mm Hg and mean arterial pressure <60–70 mm Hg are harmful during non-cardiac surgery.

Pre-operative biomarkers and imaging tests as predictors of post-operative delirium in non-cardiac surgical patients: a systematic review

BackgroundPost-operative delirium (POD) is a common post-operative complication in elderly individuals and imposes a significant health and financial burden. Identifying predictive biomarkers may help understand the pathophysiology of POD. Our objective is to summarize the evidence of pre-operative biomarkers and imaging tests to predict POD in patients undergoing non-cardiac surgery.MethodsA systematic search of English language articles in MEDLINE, EMBASE, Cochrane Database, PsychINFO, PubMed and ClinicalTrials. Gov up to January 2018 was performed. Studies that used biomarkers or imaging tests to predict POD and a validated POD assessment tool were included. Animal studies, paediatric, cardiac and intracranial surgery were excluded. Risk of bias was assessed using the Quality In Prognosis Study tool.ResultsThirty-four prospective cohort studies involving 4424 patients were included. Nineteen studies described serum tests [Interleukin-6, Insulin-like Growth Factor 1, C-Reactive Protein (CRP), cholinesterases, apolipoprotein-E genotype, leptin, hypovitaminosis, hypoalbuminaemia, gamma-amino butyric acid], 10 described cerebral-spinal fluid tests (monoamine precursor, melatonin, acute phase proteins, S100B and neurofibrillary tangles), and 5 described imaging tests. Two studies had high risk of bias due to unclear outcome measurement and study participation. CRP was significantly associated with POD in 5 studies. Other biomarkers were either examined by only a single study or two or more studies with conflicting results.ConclusionCRP is the most promising biomarker associated with POD. However, we are still in the early stages in identifying biomarkers and imaging tests that may further understanding of the pathophysiology of POD.

Liberal transfusion strategy to prevent mortality and anaemia-associated, ischaemic events in elderly non-cardiac surgical patients \u2013 the study design of the LIBERAL-Trial

BackgroundPerioperative anaemia leads to impaired oxygen supply with a risk of vital organ ischaemia. In healthy and fit individuals, anaemia can be compensated by several mechanisms. Elderly patients, however, have less compensatory mechanisms because of multiple co-morbidities and age-related decline of functional reserves. The purpose of the study is to evaluate whether elderly surgical patients may benefit from a liberal red blood cell (RBC) transfusion strategy compared to a restrictive transfusion strategy.MethodsThe LIBERAL Trial is a prospective, randomized, multicentre, controlled clinical phase IV trial randomising 2470 elderly (≥ 70 years) patients undergoing intermediate- or high-risk non-cardiac surgery. Registered patients will be randomised only if Haemoglobin (Hb) reaches ≤9 g/dl during surgery or within 3 days after surgery either to the LIBERAL group (transfusion of a single RBC unit when Hb ≤ 9 g/dl with a target range for the post-transfusion Hb level of 9–10.5 g/dl) or the RESTRICTIVE group (transfusion of a single RBC unit when Hb ≤ 7.5 g/dl with a target range for the post-transfusion Hb level of 7.5–9 g/dl). The intervention per patient will be followed until hospital discharge or up to 30 days after surgery, whichever occurs first. The primary efficacy outcome is defined as a composite of all-cause mortality, acute myocardial infarction, acute ischaemic stroke, acute kidney injury (stage III), acute mesenteric ischaemia and acute peripheral vascular ischaemia within 90 days after surgery. Infections requiring iv antibiotics with re-hospitalisation are assessed as important secondary endpoint. The primary endpoint will be analysed by logistic regression adjusting for age, cancer surgery (y/n), type of surgery (intermediate- or high-risk), and incorporating centres as random effect.DiscussionThe LIBERAL-Trial will evaluate whether a liberal transfusion strategy reduces the occurrence of major adverse events after non-cardiac surgery in the geriatric population compared to a restrictive strategy within 90 days after surgery.Trial registrationClinicalTrials.gov (identifier: NCT03369210).

A cost-consequence analysis of parecoxib and opioids vs opioids alone for postoperative pain: Chinese perspective.

PurposeThe use of parecoxib plus opioids for postoperative analgesia in noncardiac surgical patients seems to be cost-saving in Europe due to a reduction in opioid use and opioid-related adverse events. Given the lack of information on postoperative analgesic use in Asia, this study assessed the economic consequences of the addition of parecoxib to opioids vs opioids alone to treat postsurgical pain in China.MethodsA cost-consequence economic evaluation assessed direct medical costs related to opioid-related clinically meaningful events (CMEs) utilizing dosing information and reported frequency of events from a Phase III, randomized, double-blind, global clinical trial (PARA-0505-069) of parecoxib plus opioids vs opioids alone for 3 days following major orthopedic, abdominal, gynecologic, or noncardiac thoracic surgery requiring general or regional anesthesia. The cost of CMEs was calculated using information on resource utilization and unit costs provided by a panel of clinical experts in China. Sensitivity analyses were performed to test the robustness of the results.ResultsPatients treated with parecoxib plus opioids reported fewer CMEs (mean 0.62 vs 1.04 events per patient [P<0.0001]) compared with opioids alone for the 3-day postoperative period. This suggested a potential savings of 356 Chinese yuan (¥) per patient over the 3 days (total cost of ¥1,418 for parecoxib plus opioids vs ¥1,774 with opioid use alone).ConclusionFewer CMEs with parecoxib plus opioids suggest a reduction in medical resource utilization and reduced costs compared to opioids alone when modeling analgesic use in non-cardiac surgery patients in China.

Short- and long-term mortality in major non-cardiac surgical patients admitted to the intensive care unit.

The aim of this register-based cohort study was to characterize patients admitted to the intensive care unit (ICU) following non-cardiac surgery and identify risk factors associated with 30-days, 90-days and 1-year mortality after ICU admission. Patients aged 18+ years admitted to the intensive care unit within 30-days of non-cardiac surgery at four Capital Region hospitals in Denmark between January 2005 and December 2014 were included. Patients were identified through the Danish National Patient Register. The outcomes were 30-days, 90-days and 1-year mortality after ICU admission. Unadjusted and multivariate logistic regression analyses were performed to identify independent risk factors of mortality. The study included 3311 ICU patients. Gastrointestinal surgery accounted for 71.3%, orthopaedic surgery for 18.4% and urologic surgery for 10.2% of the population. For the total population, the median length of stay in hospital was 18days (9-36, 25th-75th percentile) and 2days (1-4, 25th-75th percentile) in the ICU. Thirty-days, 90-days and 1-year mortality were 37.8%, 44.5% and 51.2% respectively. Mortality within the ICU was 22.3% while the post-ICU in-hospital mortality was 19.4%. Higher age, comorbidity, delayed ICU admission, acute surgery, and gastrointestinal and orthopaedic surgery increased 30-days, 90-days and 1-year mortality. Short- and long-term mortality in non-cardiac surgical patients admitted to the ICU is very high, especially among the elderly comorbid patients undergoing acute surgery. Future research should focus on targeting clinically modifiable risk factors and performing tailored treatment for these high-risk patients.

Prevention of Postoperative Pneumonia in Noncardiac Surgical Patients: A Prospective Study Using the National Surgical Quality Improvement Program Database

Postoperative pneumonia increases morbidity, length of stay, and hospital readmission rates. Current data support the use of perioperative chlorhexidine gluconate in elective cardiac surgery patients to prevent postoperative pneumonia. The objectives of this study were to implement a resident-driven quality improvement project and determine the efficacy of an oral care bundle in preventing postoperative pneumonia among noncardiac surgical patients. A retrospective review of postoperative pneumonia occurrences at our hospital captured by the NSQIP database from 2014 to 2016 was conducted. A pre- and postoperative pulmonary care bundle was implemented in all surgical patients undergoing general anesthesia and outcomes were tracked by NSQIP for up to 90 days postoperatively for calendar year 2017. The NSQIP-reported incidence of postoperative pneumonia at our hospital was reduced from 0.8 to 0 per cent (P = 0). The risk-adjusted smoothed rate fell from 1.17 (95% confidence interval 0.77-1.66) in 2014 to 0.33 (95% confidence interval 0.03-0.98) in 2017. We encountered multiple systematic issues while conducting this study, which led to an imbalanced compliance to the preoperative (90%) and postoperative (31%) bundle; however, there was no significant difference between these two groups. Successful implementation of a resident-driven quality project resulted in a decreased rate of postoperative pneumonia.

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.

Incidence and Epidemiology of Perioperative Transfusion-Related Pulmonary Complications in Pediatric Noncardiac Surgical Patients: A Single-Center, 5-Year Experience.

Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion-related fatalities. While these transfusion-related pulmonary complications (TRPCs) have been well detailed in adults, their burden in pediatric subsets remains poorly defined. We sought to delineate the incidence and epidemiology of pediatric TRPCs after intraoperative blood product transfusion. In this retrospective cohort study, we evaluated all consecutive pediatric patients receiving intraoperative blood product transfusions during noncardiac surgeries between January 2010 and December 2014. Exclusion criteria were cyanotic heart disease, preoperative respiratory insufficiency, extracorporeal membrane oxygenation, and American Society of Anesthesiologists physical status VI. Medical records were electronically screened to identify those with evidence of hypoxemia, and in whom a chest x-ray was obtained within 24 hours of surgery. Records were then manually reviewed by 2 physicians to determine whether they met diagnostic criteria for TACO or TRALI. Disagreements were adjudicated by a third senior physician. Of 19,288 unique pediatric surgical patients, 411 were eligible for inclusion. The incidence of TRPCs was 3.6% (95% confidence interval [CI], 2.2-5.9). TACO occurred in 3.4% (95% CI, 2.0-5.6) of patients, TRALI was identified in 1.2% (95% CI, 0.5-2.8), and 1.0% (95% CI, 0.4-2.5) had evidence for both TRALI and TACO. Incidence was not different between males (3.4%) and females (3.8%; P = .815). Although a trend toward an increased incidence of TRPCs was observed in younger patients, this did not reach statistical significance (P = .109). Incidence was comparable across subsets of transfusion volume (P = .184) and surgical specialties (P = .088). Among the 15 patients experiencing TRPCs, red blood cells were administered to 13 subjects, plasma to 3, platelets to 3, cryoprecipitate to 2, and autologous blood to 3. Three patients with TRCPs were transfused mixed blood components. TRPCs occurred in 3.6% of transfused pediatric surgical patients, with the majority of cases attributable to TACO, congruent with adult literature. The frequency of TRPCs was comparable between genders and across surgical procedures and transfusion volumes. The observed trend toward increased TRPCs in younger children warrants further consideration in future investigations. Red blood cell administration was the associated component for the majority of TRPCs, although platelets demonstrated the highest risk per component transfused. Mitigation of perioperative risk associated with TRPCs in pediatric patients is reliant on further multiinstitutional studies powered to examine patterns and predictors of this highly morbid entity.

TRACE (Routine posTsuRgical Anesthesia visit to improve patient outComE): a prospective, multicenter, stepped-wedge, cluster-randomized interventional study

BackgroundPerioperative complications occur in 30–40% of non-cardiac surgical patients and are the leading cause of early postoperative morbidity and mortality. Regular visits by trained health professionals may decrease the incidence of complications and mortality through earlier detection and adequate treatment of complications. Until now, no studies have been performed on the impact of routine postsurgical anesthesia visits on the incidence of postoperative complications and mortality.MethodsTRACE is a prospective, multicenter, stepped-wedge cluster randomized interventional study in academic and peripheral hospitals in the Netherlands. All hospitals start simultaneously with a control phase in which standard care is provided. Sequentially, in a randomized order, hospitals cross over to the intervention phase in which patients at risk are routinely followed up by an anesthesia professional at postoperative days 1 and 3, aiming to detect and prevent or treat postoperative complications. We aim to include 5600 adult patients who are at high risk of developing complications. The primary outcome variable is 30-day postoperative mortality. Secondary outcomes include incidence of postoperative complications and postoperative quality of life up to one year following surgery.Statistical analyses will be performed to compare the control and intervention cohorts with multilevel linear and logistic regression models, adjusted for temporal trends and for clusters (hospitals). The time horizon of the economic (cost-effectiveness) evaluation will be 30 days and one year following surgery.DiscussionTRACE is the first to study the effects of a routine postoperative visit by an anesthesia healthcare professional on mortality and cost-effectiveness of surgical patients. If the intervention proves to be beneficial for the patient and cost-effective, the stepped-wedge design ensures direct implementation in the participating hospitals.Trial registrationNederlands Trial Register/Netherlands Trial Registration, NTR5506. Registered on 02 December 2015.

EFFICACY OF IBUTILIDE IN THE RAPID CONVERSION OF ACUTE ATRIAL FIBRILLATION IN TRAUMA AND NONCARDIAC SURGICAL PATIENTS

SESSION TITLE: Critical Care 1 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: New onset atrial fibrillation/flutter (AF) is a known complication of trauma and non-cardiac post-surgical patients. Ibutilide is a class-III antiarrhythmic that has been extensively studied in both medical and post-cardiac surgical patients for rapid conversion of acute AF. To date, there has been no study that examines the use of this drug in trauma and non-cardiac surgical populations. The goal of the study is to examine the efficacy and safety of this agent in the above-described patient population. METHODS: A retrospective chart review was conducted in the pharmacy database to identify patients who received ibutilide between May 2002 to Jan 2017; a total of 158 patients met inclusion criteria. Data included demographics, independent risk factors for AF, pretreatment with magnesium sulfate, conversion success, and complications. A standard intravenously dose of ibutilide was administered, repeated once if immediate conversion failed, with cardioversion considered successful if occurring within 24 hours. Patients were monitored per protocol in ICU for QT prolongation, Torsades de pointes, and hypotension. Chi-square analysis and T-test was conducted to identify factors associated with successful conversion. RESULTS: Among the 158 patients who received ibutilide, more than half were males (63.9%, n=101), and the average age was 62.4 (SD=17.2)years. Patients were evenly distributed between surgical (33.5%, n=53), trauma (31.0%, n=49), and medical (35.4%, n=56) groups. The average number of risk factors per patient was 1.2, with HTN being the most common risk factor. COPD, HTN, and DM had higher conversion rates when compared to CAD and CHF. The overall successful conversion rate was 72.2% (n=114) and the overall mortality was 27.7% (n=36; no mortality was drug-related). There was a higher conversion rate in the trauma subgroup. One person experienced Torsades de pointes and had to be electrically cardioverted. Magnesium sulfate was associated with increased successful conversion rate (75% vs 65.4%, p=0.0049) and also protection against Torsades. CONCLUSIONS: These results are comparable to previously published data on cardiac surgical and medical patients. This study demonstrates that ibutilide is a safe and effective medication for conversion of new-onset atrial fibrillation in trauma, surgical and nonsurgical patients. CLINICAL IMPLICATIONS: Ibutilide is a safe and effective drug for the rapid conversion of acute AF in trauma and non-cardiac surgical patients, with CHF and CAD predicting lower conversion rates. DISCLOSURES: No relevant relationships by Esther Bae, source=Web Response No relevant relationships by Nguyen Dao, source=Web Response No relevant relationships by Fanglong Dong, source=Web Response No relevant relationships by Yamuna GnanaDev, source=Web Response No relevant relationships by Daniel Jo, source=Web Response No relevant relationships by David Turay, source=Web Response No relevant relationships by David Wong, source=Web Response

A multicentre, cross-sectional study investigating the prevalence of hypertensive disease in patients presenting for elective surgery in the Western Cape Province, South Africa.

Hypertension is common, affecting over one billion people worldwide. In sub-Saharan Africa, hypertensive disease not only affects the older population but is becoming increasingly prevalent in younger individuals. In South Africa (SA), &gt;30% of the adult population has hypertension, making it the single most common cardiovascular risk factor and the predominant contributor to cardiovascular disease and mortality. Elevated blood pressure is the most common perioperative comorbidity encountered in non-cardiac surgical patients, with an overall prevalence of 20 - 25%, and it remains poorly controlled in low- and middle-income countries. Hypertension in the perioperative setting may adversely affect patient outcome. It therefore not only flags possible perioperative challenges to anaesthesiologists, but also identifies patients at risk of long-term morbidity and mortality. To determine the prevalence and severity of hypertension in elective adult surgical patients in the Western Cape Province, SA. The study population included all elective surgical patients from seven hospitals in the Western Cape during a 1-week period. Hypertension, defined as having had a previous diagnosis of hypertension or meeting the blood pressure criteria of &gt;140/90 mmHg, was identified in 51.8% of patients during preoperative assessment. Significantly, newly diagnosed hypertension was present in 9.9% of all patients presenting for elective surgery. Although 98.1% of the known hypertensive patients were on antihypertensive therapy, 36.9% were inadequately controlled. There are numerous reasons for this, but notably 32.1% of patients admitted to forgetting to take their medication, making patient factors the most common reason for treatment non-compliance. The perioperative period may be an important opportunity to identify undiagnosed hypertensive patients. The perioperative encounter may have a significant public health implication in facilitating appropriate referral and treatment of patients with hypertension to decrease long-term cardiovascular complications in SA.

Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults.

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) may complicate a patient's postoperative recovery in several ways. Monitoring of processed electroencephalogram (EEG) or evoked potential (EP) indices may prevent or minimize POD and POCD, probably through optimization of anaesthetic doses. To assess whether the use of processed EEG or auditory evoked potential (AEP) indices (bispectral index (BIS), narcotrend index, cerebral state index, state entropy and response entropy, patient state index, index of consciousness, A-line autoregressive index, and auditory evoked potentials (AEP index)) as guides to anaesthetic delivery can reduce the risk of POD and POCD in non-cardiac surgical or non-neurosurgical adult patients undergoing general anaesthesia compared with standard practice where only clinical signs are used. We searched CENTRAL, MEDLINE, Embase and clinical trial registry databases up to 28 March 2017. We updated this search in February 2018, but these results have not been incorporated in the review. We included randomized or quasi-randomized controlled trials comparing any method of processed EEG or evoked potential techniques (entropy, BIS, AEP etc.) against a control group where clinical signs were used to guide doses of anaesthetics in adults aged 18 years or over undergoing general anaesthesia for non-cardiac or non-neurosurgical elective operations. We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: occurrence of POD; and occurrence of POCD. Secondary outcomes included: all-cause mortality; any postoperative complications; and postoperative length of stay. We used GRADE to assess the quality of evidence for each outcome. We included six randomized controlled trials (RCTs) with 2929 participants comparing processed EEG or EP indices-guided anaesthesia with clinical signs-guided anaesthesia. There are five ongoing studies and one study awaiting classification.Anaesthesia administration guided by the indices from a processed EEG (bispectral index) probably reduces the risk of POD within seven days after surgery with risk ratio (RR) of 0.71 (95% CI 0.59 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) of 17, 95% CI 11 to 34; 2197 participants; 3 RCTs; moderate quality of evidence). Three trials also showed the lower rate of POCD at 12 weeks after surgery (RR 0.71, 95% CI 0.53 to 0.96; NNTB 38, 95% CI 21 to 289; 2051 participants; moderate-quality evidence), but it is uncertain whether processed EEG indices reduce POCD at one week (RR 0.84, 95% CI 0.69 to 1.02; 3 trials; 1989 participants; moderate-quality evidence), and at 52 weeks (RR 0.30, 95% CI 0.05 to 1.80; 1 trial; 59 participants; very low quality of evidence). There may be little or no effect on all-cause mortality (RR 1.01, 95% CI 0.62 to 1.64; 1 trial; 1155 participants; low-quality evidence). One trial suggested a lower risk of any postoperative complications with processed EEG (RR 0.51, 95% CI 0.37 to 0.71; 902 participants, moderate-quality evidence). There may be little or no effect on reduced postoperative length of stay (mean difference -0.2 days, 95% CI -2.02 to 1.62; 1155 participants; low-quality evidence). There is moderate-quality evidence that optimized anaesthesia guided by processed EEG indices could reduce the risk of postoperative delirium in patients aged 60 years or over undergoing non-cardiac surgical and non-neurosurgical procedures. We found moderate-quality evidence that postoperative cognitive dysfunction at three months could be reduced in these patients. The effect on POCD at one week and over one year after surgery is uncertain. There are no data available for patients under 60 years. Further blinded randomized controlled trials are needed to elucidate strategies for the amelioration of postoperative delirium and postoperative cognitive dysfunction, and their consequences such as dementia (including Alzheimer's disease (AD)) in both non-elderly (below 60 years) and elderly (60 years or over) adult patients. The one study awaiting classification and five ongoing studies may alter the conclusions of the review once assessed.

Impact and treatment success of new-onset atrial fibrillation with rapid ventricular rate development in the surgical intensive care unit

BackgroundAtrial fibrillation (AF) with rapid ventricular rate (RVR; heart rate >100) in noncardiac postoperative surgical patients is associated with poor outcomes. The objective of this study was to evaluate the practice patterns of AF management in a surgical intensive care unit to determine practices associated with rate and rhythm control and additional outcomes. Materials and methodsAdult patients (≥18 y) admitted to the surgical intensive care unit (SICU) from June 2014 to June 2015 were retrospectively screened for the development of new-onset AF with RVR. Demographics, hospital course, evaluation and treatment of AF with RVR, and outcome were evaluated and analyzed. ResultsThousand seventy patients were admitted to the SICU during the study period; 33 met inclusion criteria (3.1%). Twenty-six patients (79%) had rate and rhythm control within 48 h of AF with RVR onset. β-Blockers were the most commonly used initial medication (67%) but were successful at rate and rhythm control in only 27% of patients (6/22). Amiodarone had the highest rate of success if used initially (5/6, 83%) and secondarily (11/13, 85%). Failure to control rate and rhythm was associated with a greater likelihood of comorbidities (100% versus 57%; P = 0.06). ConclusionsNew-onset AF with RVR in the noncardiac postoperative patient is associated with a high mortality (21%). Amiodarone is the most effective treatment for rate and rhythm control. Failure to establish rate and rhythm control was associated with cardiac comorbidities. These results will help to form future algorithms for the treatment of AF with RVR in the SICU.

The effect of a multifaceted postoperative nausea and vomiting reduction strategy on prophylaxis administration amongst higher-risk adult surgical patients.

Postoperative nausea and vomiting (PONV) is a common and distressing problem for patients and increases the burden of care in post-anaesthesia care units (PACU). As such it has been a recent focus for quality improvement. Evidence-based guidelines have demonstrated the benefit of PONV risk stratification and prophylaxis, but may be underutilised in clinical practice. This prospective pre-/post-intervention study was conducted at an adult tertiary hospital in non-cardiac adult surgical patients at higher-risk of PONV. The intervention included promotion of an evidence-based PONV guideline, and provision of individualised prescribing and patient outcome data to anaesthetists. Six hundred and twenty-eight patients with ≥2 risk factors for PONV following general anaesthesia for non-cardiac surgery were included (333 pre-intervention and 295 post-intervention). Prior to the intervention, 9.0% (30/333) of moderate- and high-risk patients received antiemetic prophylaxis consistent with our guideline. Post-intervention, the rate of guideline adherence was 19.3% (57/295). In the high-risk PONV group, the time in PACU was significantly reduced post-intervention, 66 minutes versus 83 minutes (<i>P</i>=0.032). This institution-specific PONV reduction strategy had a modest but significant effect on improving prophylaxis administration. However, our findings indicate that further efforts would be required to ensure fuller compliance with the current extensive evidence base for PONV management in higher-risk patients.

Introductory Experience in Transesophageal Echocardiography for Anesthesiology Residents.

Transesophageal echocardiography (TEE) has become an important imaging modality for anesthesiologists to monitor and identify major cardiothoracic pathology in both noncardiac and cardiac surgical patients during the perioperative period. Knowledge in basic TEE sonoanatomy and the ability to obtain 11 basic views is a necessary foundation for junior residents so they may focus on using TEE as a monitor and tool to identify major cardiothoracic pathology later in their training. The purpose of the rotation is to introduce TEE image acquisition to clinical anesthesia Year 1 (CA-1) and CA-2 residents. In this module, the anesthesiology resident is assigned to a specific TEE-week rotation in the cardiovascular center. There are three main components to our TEE curriculum: (1) web-based and simulator-based exposure to image acquisition and sonoanatomy, (2) intraoperative exposure to image acquisition and sonoanatomy, and (3) the 11 standard basic TEE views worksheet and assessment tool. Using the 11 standard basic TEE views assessment tool, 100% of the residents who went through the curriculum were able to obtain at least nine of the 11 views without prompting. Forty-five percent (n = 5) of CA-1 were able to obtain all 11 views without prompting, while 58% of the CA-2s were able to obtain all 11 views without prompting. The preliminary results from our TEE curriculum are promising. We hope that this early exposure will lead to better learning on the residents' cardiac rotations in the CA-2 and CA-3 years by allowing them to start recognizing major pathology on TEE early on.

Postoperative Atrial Fibrillation and Cardiac Complications After Liver Transplantation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and is associated with significant morbidity and mortality. Postoperative AF has been increasingly identified in non-cardiac surgical patients. Liver transplantation (LT) outcomes have improved in the last two decades, but cardiovascular complications remain the leading cause of death. This is primarily due to the complexity of operations and haemodynamic shifts, which occur intraoperatively. Therefore, LT candidates undergo extensive transplant cardiac workup. The impact of postoperative AF in LT patients is largely unknown.

The Effect of Elevated A1C on Immediate Postoperative Complications: A Prospective Observational Study.

IN BRIEF This study examined whether elevated A1C in patients with diabetes is associated with a higher incidence of postoperative infections and other complications. Researchers followed 50 noncardiac surgical patients for 7 postoperative days. Half of the patients had an A1C <7% and the other half had an A1C ≥7%. The two groups were otherwise comparable except that the higher-A1C group had significantly higher pre-induction and postoperative blood glucose levels, with wider variability in the first 24 hours after surgery. During the first postoperative week, 11 patients developed complications, of whom 10 were in the higher-A1C group. Elevated A1C, unlike a single preoperative blood glucose value, may predict difficult postoperative glucose control and postsurgical complications.

A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study

BACKGROUND:The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).METHODS:Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.RESULTS:After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05–1.70]; P = .02), and mortality (OR, 2.65 [2.06–3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05–1.39]; P = .01) and mortality (OR, 1.81 [1.39–2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98–1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59–0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58–0.97]; P = .03), and mortality (OR, 0.58 [0.41–0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03–1.40]; P = .02).CONCLUSIONS:Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.

Perioperative ultrasound applied to diagnosis and decision making in anesthesia.

Ultrasound is a portable and safe technology that is increasingly used to assist anesthetic procedures and has been integrated into the routine practice of a wide range of invasive procedures. As a complementary diagnostic tool, publications related to perioperative support other than vascular access and nerve blocks are currently lacking. Given the growing interest of anesthesiologists in acquisition of knowledge and skills of ultrasound, we propose a systematic review of the diagnosis, decision making or change in perioperative management of non-cardiac surgical patients derived from ultrasound practice. Of 1112 references found in electronic databases, 62 studies resulted from the screening process. A complete critical reading of 19 full-text publications was carried out with quantitative analysis of 1825 ultrasound examinations including echocardiography, neck and laryngeal ultrasound, pulmonary ultrasound and abdominal ultrasound, all of them performed by anesthesiologists. Diagnosis applied ultrasound and decision making during perioperative period resulted in change in the management of 31% with 95% CI of 21.06 to 42.04 and odds ratio of 2.68 (1.77 to 4.06) related to hemodynamic, airway and respiratory perioperative management. Since most of the articles included in this review are observational studies with inherent design concerns, there is an urgent requirement for randomized controlled trials in this area. As anesthesiologists become more comfortable and knowledgeable in ultrasound applied to the perioperative support, emergence of protocols with multidisciplinary ultrasound exploration is expected to allow an improvement in perioperative safety.