Peri-operative silent myocardial ischaemia and long-term adverse outcomes in non-cardiac surgical patients*

Two hundred and seventy-five non-cardiac surgical patients were recruited to determine risk factors associated with the development of postoperative cardiovascular complications during the first year after surgery. Patients underwent ambulatory electrocardiography pre- and postoperatively. There were 34 adverse events over the whole study period. Twenty-four occurred within 6 months and the remaining 10 occurred between 6 and 12 months postoperatively. Silent myocardial ischaemia was associated with adverse outcome over both the first 6 months [OR 4.44 (95% CI 1.77-11.13)] and the whole study period [OR 2.81 (1.26-6.07)]. Other risk factors were: vascular surgery [OR 17.09 (2.67-351.44)], history of angina [OR 6.29 (2.21-17.62)], concurrent treatment with calcium entry blockers [OR 2.68 (1.03-6.93)] and smoking [OR 4.93 (2.00-12.02)]. None of these was a useful predictor of long-term outcome (between 6 and 12 months postsurgery). These results are at variance with other published data, but we conclude that monitoring for peri-operative silent myocardial ischaemia does not aid the prediction of long-term cardiovascular complications.     

Anaesthetic management and postoperative care of cardiac surgical patients in a general recovery ward

The postoperative care of 143 cardiac surgical patients has been successfully conducted in a general surgical recovery ward. Admission was limited to overnight stay only and all but two patients were returned to the general ward the following day. There were no deaths. The intra-operative anaesthetic management was considered to have played an important part in the success of this technique.     

A survey of peri-operative use of magnesium sulphate in adult cardiac surgery in the UK

We conducted a postal survey of cardiac anaesthetists in the UK, to determine the extent of magnesium sulphate (MgSO4) use and the main indications for its administration. Questionnaires were sent to anaesthetists at 35 UK hospitals undertaking adult cardiac surgery. Responses were received from 24 hospitals (69%) totalling 124 individual responses. Twenty-five (20%) of the anaesthetists responding to the questionnaire routinely gave magnesium other than in cardioplegia. The most common indications for administration were arrhythmia prophylaxis and treatment, myocardial protection, and the treatment of hypomagnesaemia.     

Prevention of cardiac complications following non-cardiac surgery

It is the challenging task of the anaesthesiologist as primary peri-operative care provider to identify patients with unstable or high-risk conditions and ensure adequate care prior to, during and following surgery. Approximately 5% of the population undergoing non-cardiac surgery suffer from some form of peri-operative cardiac morbidity. The yearly costs associated with peri-operative cardiac complications can be as high as 2% of the total national health care budget. Active measures to prevent myocardial ischaemia will save more lives than monitoring and waiting until cardiac complications occur. There are no randomized controlled trials showing that prophylactic coronary revascularization reduces the cardiac risk of non-cardiac surgery. The anaesthesiologist has many means to influence the cardiac outcome of non-cardiac surgery. Peri-operative optimization of cardiac medication reduces the incidence of cardiac complications. Pre-operative optimization of high-risk surgical patients in the intensive care unit and prophylactic treatment with β-blockers will reduce the cardiac morbidity and mortality significantly. The use of local or regional anaesthesia techniques may influence the cardiac outcome following non-cardiac surgery. Maintaining the haemoglobin level between 9 and 10 g/ dl (haematocrit 0.28–0.33) and the temperature above 36°C in the peri-operative period will reduce cardiac morbidity and mortality. Future therapies probably consist of drugs that influence the inflammatory process in the atherosclerotic vascular wall, the opioid receptors, the clotting system and the potassium-dependent ATP channel. Ischaemic preconditioning as an intervention to improve cardiac outcome of non-cardiac surgery is a subject for future research.     

Evaluation of self-reported failures in cognitive function after cardiac and noncardiac surgery

Long-term cognitive deficits after cardiac surgical procedures involving cardiopulmonary bypass have been well documented. The occurrence of prolonged cognitive changes after noncardiac surgery has not, however, been clearly established. Using the Cognitive Failures Questionnaire, which permits self-assessment of cognitive impairment, we studied 50 patients before and 2 months after coronary bypass surgery and major vascular surgical procedures. Pre-operative test scores did not differ between groups. Postoperatively, 24 cardiac surgical patients and 22 vascular surgical patients completed the questionnaire. Both groups reported significantly more cognitive failures occurring after surgery than in the pre-operative period. This suggests that there are factors other than the exposure to cardiopulmonary bypass during cardiac surgery that affect self-assessed, long-term postoperative cognitive sequelae.     

术中静脉输注美托洛尔对心脏病患者非心脏手术后心脏并发症的影响

目的 评价术中静脉输注美托洛尔对心脏病患者非心脏手术后心脏并发症的影响.方法 拟行胸部手术或腹部手术的心脏病患者87例,年龄55～78岁,随机分为对照组(n=42)和试验组(n=45).试验组切皮前5 min静脉注射美托洛尔20 μg/kg负荷量,随后以0.1～1.0 μg·kg-1·min-1速率静脉输注至术毕,控制HR较术前降低15%～20%,但维持HR≥50次/min、平均动脉压≥60 mm Hg.分别于术前24 h内(术前)及术后24 h内(术后)持续监测心电图,记录平均HR、早搏次数、异位心律失常及心肌缺血的发生情况;记录术后7 d内心脏事件的发生情况.结果 与术前比较,术后对照组平均HR增快(P<0.05),而试验组差异无统计学意义(P<0.05);与对照组比较,术后试验组早搏次数、异位心律失常发生率和心肌缺血发生率降低(P<0.05),术后心脏事件发生率差异无统计学意义(P<0.05).结论 术中静脉输注美托洛尔(静脉注射负荷量20 μg/kg后以0.1～1.0 μg·kg-1·min-1的速率静脉输注)可降低心脏病患者非心脏手术后心脏并发症的发生.     

Effect of chronic beta-blockade on peri-operative outcome in patients undergoing non-cardiac surgery: an analysis of observational and case control studies

Little is known about the effect of chronic beta-adrenoceptor antagonist therapy during the peri-operative period in patients undergoing non-cardiac surgery. We conducted a literature review to identify studies examining the relationship between chronic therapy and adverse peri-operative outcome. Eighteen studies were identified in which it was possible to ascertain the incidence of adverse cardiac outcomes in those patients who were and were not receiving chronic beta-blocker therapy. None of the studies demonstrated a protective effect of chronic beta-blockade. The results of these studies were then combined and a cumulative odds ratio calculated for the likelihood of myocardial infarction, cardiac death and major cardiac complications. Patients receiving chronic beta-blocker therapy were more likely to suffer a myocardial infarction (p < 0.05). These findings differ from the published effects of acute beta-blockade. Reasons for this discrepancy are considered.     

Predictors of postoperative myocardial ischaemia The role of intercurrent arterial hypertension and other cardiovascular risk factors

One hundred and eighty-three patients were studied to examine the role of a number of risk factors in the development of silent ischaemia after general anaesthesia for general and vascular surgery. We collected evidence of cardiovascular risk factors using a binary questionnaire. The patients were monitored pre- and postoperatively using a Holter ECG monitor. Usable data were collected on 140 patients. Pre-operative silent myocardial ischaemia was found to be strongly associated with postoperative silent myocardial ischaemia (odds ratio: 10.8, 95% confidence intervals: 3.8–30.7). A history of hypertension, indicated by treatment with antihypertensive drugs, was associated with increased risk (odds ratio: 2.58, 95% confidence intervals: 1.12–5.96). A linear trend was found for risk associated with increasing admission systolic blood pressure (odds ratio: 1.20 for each 10-mmHg increase in systolic pressure, 95% confidence intervals: 1.01–1.42). An association between vascular surgery and postoperative silent myocardial ischaemia was also confirmed (odds ratio: 2.36, 95% confidence intervals: 1.1–5.1).     

The management of patients with ischaemic heart disease undergoing non-cardiac elective surgery: a survey of Australian and New Zealand clinical practice

Improvements in patient risk stratification and peri-operative beta-blockade have been suggested as methods which can reduce cardiovascular risk in patients with known cardiac risk factors. A postal questionnaire was sent to all Australian and New Zealand teaching hospitals to identify patterns of pre-operative cardiac risk evaluation and methods of peri-operative beta-blocker use. In all, 67 replies were evaluated (64% response rate). Specialist anaesthetists are present in the majority of pre-admission clinics (78%), with a designated peri-operative physician in 9%. Further cardiological referral was possible in almost all institutions (96%), and specific peri-operative physician referral in 54%. Waiting times for specialist consultation were < 7 days in the majority of cases. Whilst 79% of institutions used peri-operative beta-blockade, specific protocols were available in only 10%. In 60% of institutions, beta-blockers were administered to high-risk patients, and in 25% they were given to intermediate risk group patients. There was a wide range in the duration of pre- and postoperative beta-blocker administration. Whilst peri-operative risk assessment appears to be consistent, the pattern of beta-blockade, a known beneficial intervention, is variable. Reasons need to be identified, protocols developed and consistent administration targeted for further improvements to be made.     

The effect of an infusion of esmolol on the incidence of myocardial ischaemia during tracheal extubation following coronary artery surgery

The aim of this randomised controlled study was to determine whether an esmolol infusion affected the incidence of ST segment changes during weaning from intermittent positive pressure ventilation and tracheal extubation after coronary artery surgery. Thirty-one patients received an infusion of esmolol 0-300 microg x kg(-1) x min(-1) and 37 patients comprised the control group. ST segment changes were monitored using a continuous ambulatory surveillance system. The electrocardiogram, direct arterial pressure and pulse oximetry were monitored continuously. The period of analysis was from 120 min before until 180 min after tracheal extubation. Three patients in the esmolol group developed myocardial ischaemia during the study period compared with 12 in the control group (p = 0.05). Heart rate increased with time during the study period (p = 0.002) in the control group but was unchanged in the esmolol group. Mean heart rate was significantly higher in the control group than in the esmolol group from 40 min before until 180 min after tracheal extubation. Seven patients in the esmolol group suffered adverse events related to the esmolol infusion. Although the use of esmolol reduced the incidence of myocardial ischaemia, the incidence of adverse effects makes it unsuitable prophylaxis for patients after coronary artery surgery.     

Social consequences and ethical considerations of postoperative complications of surgery

A certain percent of patients undergoing operative treatment would always run into complications following surgery. With millions of surgeries being performed every day, world over, the number of such patients is indeed quite high and their predicament needs to be appreciated by the surgical fraternity. One of the natural consequences of occurrence of a complication is prolongation of hospital stay in most circumstances. This also means increased financial burden for the family. There are many other implications involving these patients and these also affect the society as well. In our country no support systems exist for helping such patients either financially or socially, inspite of the fact that they are in difficulty. The hardship they are made to face remains unrecognized and even unappreciated most of the times by all concerned. Invariably they are left to suffer on their own. The present communication makes an effort to highlight this aspect of surgical complications, and the adverse effects, occurrence of such complications have on the individual, his/ her family and the society as a whole. An attempt has also been made to draw the attention of surgical fraternity to these happenings with a suggestion that one needs to react to a situation which is largely a creation of our own. As a surgeon, one ought to take this as a challenge to one’s professional capabilities and expertise, and make active efforts to perform routine as well as difficult surgery with no or minimum possible complication rates. And if an unfortunate patient does run into difficulty, the surgeon must play a positive role to minimize sufferings and to rehabilitate him/her back into the society.     

麻醉科医师术前受邀会诊与老年患者髋部手术后早期并发症的相关性

目的 探讨麻醉科医师术前受邀会诊与老年患者髋部手术后早期并发症的相关性。
方法 采用倾向性评分匹配（PSM）法回顾性分析2019年1—12月行髋部手术患者100例,男36例,女64例,年龄≥65岁,ASA Ⅲ或Ⅳ级。根据术前是否接受由外科医师提交会诊申请并由麻醉科高年资主治医师执行的正式会诊,将患者分为两组：受邀会诊组（会诊组）和非受邀会诊组（对照组）,每组50例。收集性别、年龄、BMI、ASA分级、年龄校正的Charlson合并症指数（aCCI）、麻醉方法、手术时间、麻醉时间、手术出血量、术前等待时间、术前住院时间、术后住院时间、总住院时间、术后1个月并发症等数据。比较两组一般情况、术中情况、住院时间和术后并发症等。
结果 两组性别、年龄、BMI、ASA分级和aCCI差异无统计学意义。会诊组椎管内麻醉比例明显高于对照组,术前等待时间、术前住院时间明显长于对照组,术后住院时间明显短于对照组（P<0.05）。两组手术时间、麻醉时间、出血量和总住院时间差异无统计学意义。会诊组术后并发症发生率明显低于对照组（P<0.05）。
结论 麻醉科医师术前受邀会诊与缩短老年患者髋部手术后住院时间及减少术后早期并发症相关。     

Vasoactive-inotropic score and the prediction of morbidity and mortality after cardiac surgery

Background

The vasoactive-inotropic score (VIS) predicts mortality and morbidity after paediatric cardiac surgery. Here we examined whether VIS also predicted outcome in adults after cardiac surgery, and compared predictive capability between VIS and three widely used scoring systems.

Effects of aspirin on cardiovascular outcomes in patients with chronic kidney disease

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Trends in early postoperative major adverse cardiovascular and cerebrovascular events associated with bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BackgroundThe population undergoing bariatric surgery (BaS) has many cardiovascular risk factors that can lead to significant perioperative cardiovascular morbidity.ObjectivesWe aimed to examine trends in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) after BaS.SettingAcademic Hospital, United StatesMethodsWe performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Data on demographics, co-morbidities, and type of procedure were collected. MACCE was defined as a composite variable including perioperative acute myocardial infarction (AMI), cardiac arrest requiring cardiopulmonary resuscitation, acute stroke, and all-cause mortality. We utilized the Cochrane-Armitage and Jonckheere-Terpstra tests to assess for significant trend changes throughout the years.ResultsA total of 752,722 patients were included in our analysis (LSG = 73.2%, LRYGB = 26.8%). Postoperative MACCE occurred in 1058 patients (.14%), and was more frequent in patients undergoing LRYGB (.20%). The frequency of MACCE declined from .17% to .14% (P = .053), driven by a decline in the frequency of AMI (.04% to .02%, P = .002), cardiac arrest (.05% to .04%, P = .897), and all-cause death (.11% to .08%, P = .040), but with an increase in perioperative stroke (.01% to .02%, P = .057).ConclusionThe overall risk of MACCE after BaS is .14% and has been declining in the last 5 years. This trend is likely multifactorial and further analysis is necessary to provide a detailed explanation.     

Haemodynamic changes during thoracoscopic surgery the effects of one-lung ventilation compared with carbon dioxide insufflation

We investigated the haemodynamic and respiratory effects of one-lung ventilation and carbon dioxide insufflation in 13 adult patients undergoing video-assisted thoracoscopy. Cardiorespiratory variables were determined during carbon dioxide insufflation at intrahemithoracic pressures of 5, 10 and 15 mmHg, and after 5 and 15 min of one-lung ventilation. Carbon dioxide insufflation was associated with a clear deterioration in circulatory function. The cardiac index decreased subsequent to increasing intrathoracic pressures. The mean cardiac index (SD) at pressures of 10 and 15 mmHg was 1.86 (0.39) and 1.52 (0.46), respectively, and may be compared with the reduced venous return consistent with tension pneumothorax. One-lung ventilation did not affect haemodynamic variables but reduced arterial oxygenation indices (PaO2/FIO2) from 424.29 (160.79) after induction of anaesthesia, to 207.72 (125.50) after 5 min and 172.04 (72.03) after 15 min of one-lung ventilation, respectively. The oxygenation index was not influenced by intrahemithoracic carbon dioxide insufflation. One-lung ventilation via a double-lumen endobronchial tube is safe and convenient for video-assisted thoracoscopic surgery. It has no further consequences on haemodynamic variables, whereas the compression of the lung by carbon dioxide insufflation may cause circulatory dysfunction.     

Heart rate and pulse pressure at rest are major prognostic markers of early postoperative complications after coronary bypass surgery

OBJECTIVE: There is substantial evidence to consider both heart rate (HR) at rest and pulse pressure (PP) as significant markers of cardiovascular prognosis in the general population. Despite this, neither of these two parameters has been taken into consideration in the design of modern coronary artery bypass risk prediction scores, and little data on their early postoperative prognostic value are currently available. We aimed to assess the predictive value of preoperative HR and PP in the 30-day postoperative period. METHODS: We prospectively enrolled all patients referred to our institution for non-urgent coronary artery bypass grafting. We measured HR on ECG at admittance. Preoperative pulse pressure was obtained by the difference of the mean of three consecutive systolic and diastolic blood pressures. The primary outcome combined the 30-day postoperative mortality, myocardial infarction (new Q-waves on ECG or Troponin-I >20 microg/l) and stroke or transient ischemic attack. The secondary outcome corresponded to clinical events only (stroke or death). Statistical analysis was performed by usual methods. RESULTS: We enrolled 1022 patients (age 66.9+/-9.2 years). Those meeting the primary outcome (n=146) had a significantly higher HR (69.9+/-14.3 bpm vs 64.9+/-13.2 bpm, p<0.0001) and a higher proportion presented a PP >70 mmHg (17.1% vs 10.2%, p<0.03). After adjustments for age, gender, systolic blood pressure, preoperative beta-blocker therapy, left ventricular ejection fraction <0.40, unstable cardiac status, redo surgery, peripheral arterial disease, renal failure, and combined vascular surgery, both HR (OR=1.17 per 10 bpm, p<0.03) and PP >70 mmHg (OR=1.99, p=0.03) remained significant risk predictors. Similar results were found when considering only clinical events. CONCLUSION: This prospective study highlights the usefulness of HR and PP as preoperative risk markers in CABG candidates.     

Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery

Background

We evaluated coronary angiography use among patients with coronary stents suffering postoperative myocardial infarction (MI) and the association with mortality.

Methods

Patients with prior coronary stenting who underwent inpatient noncardiac surgery in Veterans Affairs hospitals between 2000 and 2012 and experienced postoperative MI were identified. Predictors of 30-day post-MI mortality were evaluated.

Results

Following 12,096 operations, 353 (2.9%) patients had postoperative MI and 58 (16.4%) died. Post-MI coronary angiography was performed in 103 (29.2%) patients. Coronary angiography was not associated with 30-day mortality (odds ratio [OR]: .70, 95% CI: .35–1.42). Instead, 30-day mortality was predicted by revised cardiac risk index ≥3 (OR 1.91, 95% CI: 1.04–3.50) and prior bare metal stent (OR 2.12, 95% CI: 1.04–4.33).

Conclusions

Less than one-third of patients with coronary stents suffering postoperative MI underwent coronary angiography. Significant predictors of mortality were higher revised cardiac risk index and prior bare metal stent. These findings highlight the importance of comorbidities in predicting mortality following postoperative MI.     

Peri-operative beta-blockade and haemodynamic optimisation in patients with coronary artery disease and decreasing exercise capacity presenting for major noncardiac surgery

Patients with coronary artery disease presenting for major noncardiac surgery may have indications for both peri-operative beta-blockade and haemodynamic optimisation. The combination of peri-operative cardiorespiratory failure and myocardial ischaemia has a grave prognosis. Recent investigations have shown that in patients with coronary artery disease, beta-blockade does not depress cardiac output as much as originally thought. There may, therefore, be a place for both peri-operative beta-blockade and haemodynamic optimisation. The indications for peri-operative beta-blockade and haemodynamic optimisation, the effect of acute beta-blockade on cardiac output in patients with coronary artery disease, and the interaction of peri-operative beta-blockade and haemodynamic optimisation are discussed.