Type Of Noncardiac Surgery Research Articles

Association of preoperative neutrophil-lymphocyte ratio with acute kidney injury in patients with non-cardiac surgery: difference among surgical types.

To examine the relationship between Neutrophil-Lymphocyte Ratio (NLR) and Acute Kidney Injury (AKI) in patients undergoing noncardiac surgery, and subgroup analysis was performed for different types of non-cardiac surgery. The present retrospective cohort study included 10,159 adult patients who underwent major noncardiac surgery at Nanfang Hospital, Southern Medical University, between 2008 and 2018. Postoperative AKI was defined as an increase in serum creatinine level of at least 0.3mg/dl within 48h, or 1.5 times higher than baseline within 7days postoperatively according to the Kidney Disease Improving Global Outcome. The correlation between preoperative NLR and postoperative AKI was determined by stepwise multivariate logistic regression analysis, and the predictive value of NLR was evaluated by the receiver operating characteristics curve (ROC) analysis. Four hundred and eighty-five (4.77%) patients developed AKI postoperatively. Preoperative NLR was independently associated with postoperative AKI in all patients undergoing non-cardiac surgery (Odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06). The optimal cut-off value of NLR was 2.12 according ROC analysis. The OR and 95% CI of AKI for NLR > 2.12 was 1.48 (1.21-1.81) compared with NLR ≤ 2.12. In addition, the positive association was mainly shown in patients undergone digestive system surgery with a cut-off value of 2.12 but not in neurological and musculoskeletal system surgeries. The present study confirmed the association of preoperative NLR with postoperative AKI in digestive system surgical patients. A NLR value of 2.12 may be a useful cut-off to evaluate the risk of AKI.

Regional Anesthesia for Vascular Surgery and Pain Management

Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.

Risk of venous thromboembolism in pediatric hospitalized patients undergoing noncardiac surgery: A report from the Children's Hospital‐Acquired Thrombosis consortium

BackgroundSurgery is a known risk factor for hospital‐acquired venous thromboembolism (HA‐VTE) in children. ObjectivesTo assess whether the odds of HA‐VTE differs across six anatomic sites of noncardiac surgery and to identify risk factors for HA‐VTE in these children. Methodswas a multicenter, case–control study. Anatomic sites of surgery and risk factors for HA‐VTE were collected on hospitalized pediatric patients who had undergone a single noncardiac surgery and developed HA‐VTE (cases), and those who did not develop HA‐VTE (controls), via the Children's Hospital‐Acquired Thrombosis (CHAT) Registry. Logistic regression estimated the odds ratio (OR) and 95% confidence intervals (CIs) between six anatomic sites of surgery and 16 putative HA‐VTE risk factors. Variables with a p value of 0.10 or less in unadjusted analyses were included in adjusted models for further evaluation. The final model used backward selection, with a significance level of 0.05. ResultsFrom January 2012 to March 2020, 163 cases (median age, 5.7 years; interquartile range [IQR], 0.3–14.2) and 208 controls (median age of 7.5 years; IQR, 3.7–12.9) met our criteria. There was no statistically significant increased odds of VTE among the types of noncardiac surgery. In the final adjusted model, central venous catheter (CVC; OR, 14.69; 95% CI, 7.06–30.55), intensive care unit (ICU) stay (OR, 5.31; 95% CI, 2.53–11.16), and hospitalization in the month preceding surgery (OR, 2.75; 95% CI, 1.24–6.13) were each independently significant risk factors for HA‐VTE. ConclusionIn children undergoing noncardiac surgery, placement of CVCs, admission/transfer to the ICU, or hospitalization in the month prior to surgery were positively associated with HA‐VTE.

Cognitive changes in older women after urogynaecological surgery.

The need for pelvic floor surgery will increase with an aging population in the future. Aim of this prospective study was to evaluate the evolution of cognitive function in elderly women after urogynaecological surgery. Between 2010 and 2014, 51 female patients 70 years and older who underwent urogynaecological surgery participated in this study. Geriatric and urogynaecological assessment were performed before and six weeks after surgery, including the Mini-COG test, the clock-drawing test, a depression scale, an activities of daily living questionnaire, and the German pelvic floor questionnaire. Mean age was 77 years (range 70-91). Overall, 15 women were operated for incontinence, 31 for prolapse, and five for miscellaneous reasons. Only two (3.9%) of the 51 women developed postoperative delirium. Abnormal cognitive findings increased from preoperatively 15.7% to 39.2% six weeks after surgery (odds ratio 3.4, 95% confidence interval 1.3 to 8.7, p < 0.001). There were no statistically significant pre-post differences in activities of daily living and depression scores. Pelvic floor function indices improved significantly Conclusion: This study shows an overall decline of cognitive function in a vulnerable group of elderly women during the short-term postoperative period. Postoperative cognitive dysfunction (POCD) after surgery has been described for other types of non-cardiac surgery but has been understudied in urogynaecological surgery. These patients need interdisciplinary management to prevent or minimize adverse effects of surgery on cognitive function.

Perioperative care of cardiac patient's candidate for non-cardiac surgery: a critical appraisal of emergent evidence and international guidelines.

The perioperative management of a cardiac-patient candidate to non-cardiac surgery (NCS) remains a topic of considerable debate. In recent years, the overall tendency from professional societies has been to delineate how to identify and manage high-risk patients following the best evidence. However, significant concerns persist, especially in the care of intermediate-risk patients (also labeled at "acceptable" risk), who may not fit into the categories of "completely healthy" or "critically ill", but that might still encounter dramatic (and unexpected) perioperative events. The specific interest and main goal of this expert viewpoint pertains to the care of cardiac patients scheduled for NCS, addressing central questions of real-life clinical care that practicing anesthesiologists and cardiologists face daily, discussing recent American College of Cardiology/American Heart Association (ACC/AHA), European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA), and Canadian Cardiovascular Society (CCS) guidelines. The viewpoint aims to discuss few of the important topics pertaining perioperative assessment and management: type of NCS and perioperative cardiac events, risk prediction including testing, and perioperative management of cardiac therapy. The fact that cardiac adverse events have reduced in number mostly due to better preoperative management and prevention should not prompt a reduction in clinical evaluations. While debate remains pertaining the most appropriate way to evaluate patients for NCS within international societies, a comprehensive approach-evaluation best recognized to assess functional and heart status, should be maintained, keeping into consideration the surgical procedure and global health management.

Self-Reported, Structured Measures of Recovery to Detect Postoperative Morbidity.

Previous studies have focused on postoperative anaesthetic visit as a tool for measuring postoperative recovery or patient’s satisfaction. Whether it could also improve timely recognition of complications has not been studied yet. Aim of our study was to assess pathological findings in physical examination requiring further intervention during postoperative visit and to explore whether a self-administered version of the Quality of Recovery (QoR)-9 score, compared to a detailed medical history, can act as a screening tool for identification of patients who show a low risk to develop postoperative complications. This observational study included 918 patients recovering from various types of non-cardiac surgery and anaesthesia. The postoperative visit implied three steps: measuring the QoR-9 score, a structured medical history and a physical examination. QoR-9-score showed a comparable negative predictive value (0.93 vs. 0.92) and a higher sensitivity of finding at least one pathological examination than a detailed medical history (0.92 vs. 0.81 respectively). At least one postoperative pathological examination finding was observed in 23.7% of the patients. Our approach presents a strategy on screening postoperative patients in order to identify patients whose examination and consequent treatment should be intensified. In further studies the question could be addressed whether the postoperative visit may help to reduce complications and mortality after surgery.

Endothelial dysfunction after non-cardiac surgery: a systematic review.

More than 50% of patients with increased troponin levels after non-cardiac surgery have an impaired endothelial function pre-operatively. Non-invasive markers of endothelial function have been developed for the assessment of endothelial dysfunction. The aim of this paper was to systematically review the literature to evaluate the association between non-cardiac surgery and non-invasive markers of endothelial function. A systematic search was conducted in MEDLINE, EMBASE and Cochrane Library Database according to the PRISMA guidelines. Endothelial dysfunction was described only with non-invasive measurements done both pre- and post-operatively and published in English. All types of non-cardiac surgery and both men and women of all ages were included. We found 1722 eligible studies in our search, and of these, five studies fulfilled our inclusion and exclusion criteria. Endothelial function was disturbed in patients after non-cardiac surgery. Three studies found a significant decrease in the endothelial function immediately after surgery (2 and 24 h post-operatively). Two studies found that patients with previous endothelial dysfunction and scheduled for surgery (renal transplantation and vascular surgery respectively) had an improvement in endothelial dysfunction 1 month after surgery. Endothelial function changes in relation to surgery. Assessment of endothelial function by non-invasive measures has the potential to guide clinicians in the prevention or treatment of post-operative myocardial damage.

Cardiopulmonary Exercise Testing Predicts Postoperative Outcome in Patients Undergoing Gastric Bypass Surgery

Hennis, P. J.*; Meale, P. M.†; Hurst, R. A.‡; O’Doherty, A. F.§; Otto, J.§; Kuper, M.∥; Harper, N.∥; Sufi, P. A.¶; Heath, D.#; Montgomery, H. E.†; Grocott, M. P. W.**††‡‡ Author Information

Abstract TMP9: The Neurovision Pilot Study: Non-cardiac Surgery Carries A Significant Risk Of Acute Covert Stroke

Introduction: 200 million patients worldwide undergo noncardiac surgery every year. Overt stroke is a serious complication of noncardiac surgery with significant impact on duration and quality of life. In the non-surgical population, covert stroke is 10 times more common then overt stroke and is associated with an increased risk of dementia and cognitive decline. The epidemiology of covert stroke after noncardiac surgery is not well characterized. Study Objectives: We undertook a pilot study to determine the incidence of covert stroke after noncardiac surgery. Methods: This was a prospective, international cohort study. Eligible patients were 65 years or older, and were admitted to hospital for at least one night after noncardiac surgery. A sampling strategy was employed to ensure a representative surgical population. Study personnel recorded clinical characteristics and the incidence of perioperative adverse events. We also assessed neurocognitive function, physical function and quality of life before surgery and 30 days after surgery. Patients underwent a brain magnetic resonance imaging (MRI) study between postoperative days 3 and 10. Fluid attenuated inversion recovery, gradient echo, T2 and diffusion-weighted imaging MRI sequences were obtained. Results: A total of 70 patients from three centres were enrolled in this study. The incidence of covert stroke was 11.4% (8/70 patients, 95% CI 5.9% to 21.0%). The single overt stroke was diagnosed after the research MRI study demonstrated findings of an acute stroke. All three centres experienced a similar prevalence of covert stroke (range 8.0% to 15.0%), and covert stroke was found in patients undergoing general (4/16), orthopedic (3/36), and urological/gynecological surgery (2/8). Conclusions: There is a significant risk of covert stroke after all types of noncardiac surgery. Given that globally 200 million adults undergoing major noncardiac surgery every year, postoperative covert stroke may be responsible for a significant proportion of small vessel cerebral ischemic disease in the overall population. A large study is needed to characterize the impact of postoperative covert stroke on clinically meaningful outcomes.

Cardiopulmonary exercise testing predicts postoperative outcome in patients undergoing gastric bypass surgery

For several types of non-cardiac surgery, the cardiopulmonary exercise testing (CPET)-derived variables anaerobic threshold (AT), peak oxygen consumption (VO2 peak), and ventilatory equivalent for CO(2) (VE/VCO2 ) are predictive of increased postoperative risk: less physically fit patients having a greater risk of adverse outcome. We investigated this relationship in patients undergoing gastric bypass surgery. All patients (<190 kg) who were referred for CPET and underwent elective gastric bypass surgery at the Whittington Hospital NHS Trust between September 1, 2009, and February 25, 2011, were included in the study (n=121). Fifteen patients did not complete CPET. CPET variables (VO2 peak, AT, and VE/VCO2 ) were derived for 106 patients. The primary outcome variables were day 5 morbidity and hospital length of stay (LOS). The independent t-test and Fisher's exact test were used to test for differences between surgical outcome groups. The predictive capacity of CPET markers was determined using receiver operating characteristic (ROC) curves. The AT was lower in patients with postoperative complications than in those without [9.9 (1.5) vs 11.1 (1.7) ml kg(-1) min(-1), P=0.049] and in patients with a LOS>3 days compared with LOS ≤ 3 days [10.4 (1.4) vs 11.3 (1.8) ml kg(-1) min(-1), P=0.023]. ROC curve analysis identified AT as a significant predictor of LOS>3 days (AUC 0.640, P=0.030). The VO2 peak and VE/VCO2 were not associated with postoperative outcome. AT, determined using CPET, predicts LOS after gastric bypass surgery.

Benefits and risks associated with β-blocker prophylaxis in noncardiac surgery

The benefits and risks associated with use of beta-blocker prophylaxis in noncardiac surgery (NCS) are described. Perioperative beta-blockade is recommended by the American College of Cardiology and the American Heart Association for use in patients already on beta-blockers or in high-risk patients undergoing NCS to reduce myocardial ischemia and myocardial infarction (MI); however, the recommendations are not as clear for patients undergoing intermediate- or low-risk NCS. Numerous trials have evaluated the effect of perioperative beta-blockers on MI, stroke, bradycardia, hypotension, overall mortality, and cardiovascular mortality in patients undergoing NCS. Several trials suggest that dosing, patient population, type of NCS, genetic polymorphisms, and type of anesthesia may be important in determining the benefits and risks of perioperative beta-blockade in these patients. In the meta-analyses evaluating beta-blockers in NCS, the balance of benefits to harms associated with aggressive perioperative beta-blocker therapy was not favorable. However, the largest, most recent trial drove the meta-analyses results and has some methodological caveats and limitations that must be considered. Recent meta-analyses have found that the use of beta-blockers reduces the rate of MI but increases the frequency of stroke, and these MIs and strokes can occur with differing severities. Perioperative use of beta-blockers in NCS can protect against postoperative MI but increases the risk of stroke, severe hypotension, and severe bradycardia. Although less common, the strokes are severe, and the troubling trend toward increasing cardiovascular and total mortality precludes the recommendation for their use in patients not previously treated with beta-blockers.

A meta-analysis of safety and effectiveness of perioperative beta-blocker use for the prevention of cardiac events in different types of noncardiac surgery

Perioperative beta-blocker therapy has been proposed to improve outcome. Most of the trials conducted, however, lacked statistical power to evaluate the incidence of hard cardiac events and the relationship to the type of surgery. Therefore, we conducted a meta-analysis of all randomized controlled trials in which beta-blocker therapy was evaluated. An electronic search of published reports on Medline was undertaken to identify studies published between January 1980 and November 2004 in English language journals. All studies reported on at least one of three endpoints: perioperative myocardial ischemia, perioperative nonfatal myocardial infarction, and cardiac mortality. Type of surgery, defined as low, intermediate, and high risk according to the American College of Cardiology/American Heart Association guidelines, was noted. In total, 15 studies were identified, which enrolled 1,077 patient. No significant differences were observed in baseline clinical characteristics between patients randomized to beta-blocker therapy and control/placebo. Beta-blocker therapy was associated with a 65% reduction in perioperative myocardial ischemia (11.0% vs. 25.6%; odds ratio 0.35, 95% confidence interval 0.23-0.54; P<0.001). Furthermore, a 56% reduction in myocardial infarction (0.5% vs. 3.9%, odds ratio 0.44, 95% confidence interval 0.20-0.97; P=0.04) and a 67% reduction (1.1% vs. 6.1%, odds ratio 0.33, 95% confidence interval 0.17-0.67; P=0.002) in the composite endpoint of cardiac death and nonfatal myocardial infarction were observed. No statistical evidence was observed for heterogeneity in the treatment effect in subgroups according to type of surgery (P for heterogeneity 0.2). This meta-analysis shows that beta-blocker use in noncardiac surgical procedures is associated with a significant reduction of perioperative cardiac adverse events.

Perioperative myocardial injury: individual and population implications

It is generally understood that patients who have cardiovascular disease are at risk of cardiac complications after surgery. In patients undergoing major or vascular surgery, the risk of such complications can be signi®cant. Eagle and colleagues studied patients enrolled on the CASS (Coronary Artery Surgery Study) registry who subsequently underwent non-cardiac surgery. They reported a perioperative myocardial infarction rate of 8.5% in patients with medically managed coronary artery disease who underwent vascular surgery. The authors de®ned high-risk surgery as surgery associated with a risk of perioperative death or myocardial infarction of greater than 4%. Abdominal surgery, thoracic surgery, and head and neck surgery fell into this category. For patients undergoing these types of surgery who had medically treated coronary artery disease, the overall perioperative myocardial infarction rate was 2.7% and the overall death rate 3.3%. This compared with rates of 0.8 and 1% respectively in patients undergoing similar surgery who did not have coronary artery disease. Data such as these are often considered with information on the prevalence of coronary artery disease to obtain some indication of the population burden of disease. For example, in 1990 Mangano stated that 25 million patients undergo major surgery in the USA each year and suggested that perhaps 6±7 million of these people are at risk of perioperative cardiac complications. Such estimates suggest that perioperative cardiac complications are both a major issue in the care of individual surgical patients and a major public health issue. This review will examine in more detail the population impact of perioperative cardiac morbidity and the implications of this for the individual patient.