Association between perioperative hypotension and postoperative delirium and atrial fibrillation after cardiac surgery: A post-hoc analysis of the DECADE trial

Study objectiveTo test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days.DesignSub-analysis of the DECADE multi-center randomized trial.SettingPatients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic.InterventionsIn the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo.MeasurementsIntraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1–5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration.Main resultsThere was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation.ConclusionsIn patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.     

The effectiveness of positive airway pressure therapy in reducing postoperative adverse outcomes in surgical patients with obstructive sleep apnea: A systematic review and meta-analysis

ImportanceObstructive sleep apnea (OSA) is prevalent in surgical patients and is associated with an increased risk of adverse perioperative events.Study objectiveTo determine the effectiveness of positive airway pressure (PAP) therapy in reducing the risk of postoperative complications in patients with OSA undergoing surgery.DesignSystematic review and meta-analysis searching Medline and other databases from inception to October 17, 2021. The search terms included: “positive airway pressure,” “surgery,” “post-operative,” and “obstructive sleep apnea.” The inclusion criteria were: 1) adult patients with OSA undergoing surgery; (2) patients using preoperative and/or postoperative PAP; (3) at least one postoperative outcome reported; (4) control group (patients with OSA undergoing surgery without preoperative and/or postoperative PAP therapy); and (5) English language articles.PatientsTwenty-seven studies included 30,514 OSA patients undergoing non-cardiac surgery and 837 OSA patients undergoing cardiac surgery.InterventionPAP therapyMain resultsIn patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a decreased risk of postoperative respiratory complications (2.3% vs 3.6%; RR: 0.72, 95% CI: 0.51–1.00, asymptotic P = 0.05) and unplanned ICU admission (0.12% vs 4.1%; RR: 0.44, 95% CI: 0.19–0.99, asymptotic P = 0.05). No significant differences were found for all-cause complications (11.6% vs 14.4%; RR: 0.89, 95% CI: 0.74–1.06, P = 0.18), postoperative cardiac and neurological complications, in-hospital length of stay, and in-hospital mortality between the two groups. In patients with OSA undergoing cardiac surgery, PAP therapy was associated with decreased postoperative cardiac complications (33.7% vs 50%; RR: 0.63, 95% CI: 0.51–0.77, P < 0.0001), and postoperative atrial fibrillation (40.1% vs 66.7%; RR: 0.59, 95% CI 0.45–0.77, P < 0.0001).ConclusionIn patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a 28% reduction in the risk of postoperative respiratory complications and 56% reduction in unplanned ICU admission. In patients with OSA undergoing cardiac surgery, PAP therapy decreased the risk of postoperative cardiac complications and atrial fibrillation by 37% and 41%, respectively.     

The effect of delirium preventive measures on the occurrence of postoperative cognitive dysfunction in older adults undergoing cardiovascular surgery. The DelPOCD randomised controlled trial

Study objectiveThis trial examines the effect of delirium preventive measures on the incidence of postoperative cognitive dysfunction in older adults.DesignIn a randomised approach, a delirium prevention and a standard care group were compared regarding manifestation of postoperative cognitive dysfunction at seven days, three and twelve months postoperatively (primary outcome). To correct for practice effects and age-depended cognitive decline, a control group of age-matched healthy subjects was included.SettingThe trial was conducted at the University Medical Centre Hamburg between 2014 and 2018, data assessment took place in the Anaesthesia Outpatient Clinic and on the surgical ward.PatientsA total of 609 patients ≥60 years scheduled for cardiovascular surgery were enrolled, allocated treatment was received by 284 patients in the delirium prevention and 274 patients in the standard care group.InterventionThe intervention consisted of a delirium prevention bundle including reorientation measures, sleeping aids and early mobilisation. Measurements: Cognitive functions were assessed via neuropsychological testing of attention, executive functions including word fluency, and verbal memory utilizing a computerised test of attentional performance, the trail making test, the digit span subtest from the Wechsler Adult Intelligence Scale-IV, the verbal learning and memory test, and the Regensburg Word Fluency Test. Assessments were performed preoperatively and at three time points postoperatively (one week, three months and 12 months).Main resultsPostoperative cognitive dysfunction was defined as a clinically meaningful decline in at least two out of nine chosen test parameters compared to the preoperative level (reliable change index ≤ − 1.96). The rates of postoperative cognitive dysfunction were 25.9% (delirium prevention group, n = 284) vs. 28.1% (standard care group, n = 274) [X²(1,n = 433) = 0.245;p = 0.621] at postoperative day seven and declined to 7.8% vs. 6.8% [X²(1,n = 219) = 0.081;p = 0.775] and 1.3% vs. 5.6% (p = 0.215, Fisher's exact test) at three and 12 months following surgery, respectively. The postoperative delirium rates did not differ between the two groups (delirium prevention group: 13.4% vs. standard care group: 17.3%). Attentional performance was impaired shortly after surgery, whereas verbal delayed recall was most frequently affected over the whole postoperative period.ConclusionThese findings suggest that an intervention combining specific measures extracted from established postoperative delirium prevention programs did not reduce the rate of postoperative cognitive dysfunction in older adults.     

Efeito do bloqueio do gânglio estrelado direito guiado por ultrassom na fibrilação atrial perioperatória em pacientes submetidos a lobectomia pulmonar: estudo controlado randomizado

ObjectiveTo observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy.MethodsTwo hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4 mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24 hours after surgery.ResultsThe respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p = 0.045); other atrial arrhythmias were 20% and 38% (p = 0.005); and ventricular arrhythmia were 28% and 39% (p = 0.09).ConclusionsThe results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.     

Ablation of atrial fibrillation during coronary artery bypass grafting: Late outcomes in a Medicare population

BackgroundThis study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a nationally representative Medicare cohort.ObjectivesThis study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization.MethodsIn the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years.ResultsLong-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group.ConclusionsConcomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years.     

Incidence of preoperative instrumental activities of daily living (IADL) dependence and adverse outcomes in older surgical patients: A systematic review and meta-analysis

Study objectiveInstrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population.DesignSystematic review and meta-analysis.SettingMEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022.PatientsPatients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale.InterventionsPreoperative assessment.MeasurementThe primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition.Main resultsTwenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I²: 0%; P = 0.0005).ConclusionsThere is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes.     

Should concomitant surgical ablation for atrial fibrillation be performed in elderly patients?

ObjectiveThe incidence of atrial fibrillation increases with age, and therefore many elderly patients presenting for cardiac surgery have atrial fibrillation. In recent publications, increasing age has been recognized as a predictor for ablation failure. Furthermore, many surgeons are reluctant to perform a surgical ablation in elderly patients. We investigated the safety and efficacy of concomitant surgical atrial fibrillation ablation in elderly patients.MethodsBetween 2003 and 2013, 556 patients underwent concomitant surgical atrial fibrillation ablation at the University Heart Center Hamburg and served as our primary study cohort. During follow-up, rhythm monitoring was established by 24-hour Holter electrocardiogram (70.5%) or an implantable loop recorder (29.5%) at 3, 6, and 12 months postoperatively. The primary end point of the study was freedom from atrial fibrillation at 12 months follow-up and the detection of deviations from a linear association between age and risk of atrial fibrillation recurrence. A multiple logistic regression model including age as a linear term was used to identify predictors for rhythm outcome.ResultsMean patients’ age was 68.4 ± 9.07 years, and 67.3% of the patients were male. Mean duration of atrial fibrillation was 3.5 ± 3.3 years, and mean left atrium diameters were enlarged with 50.5 ± 8.8 mm. There were no major ablation-related complications. The 30-day and 1-year survivals were 97.7% and 95.8%, respectively. The overall rate of freedom from atrial fibrillation ranged from 62% to 72% and was independent of age. The age-dependent risk of atrial fibrillation at 12 months was significantly increased in elderly patients undergoing a concomitant coronary artery bypass grafting surgery. Multiple logistic regression model revealed double valve procedures (odds ratio, 3.48; P = .020), preoperative persistent atrial fibrillation (odds ratio, 2.43; P = .001), and coronary artery bypass grafting surgery in elderly patients (odds ratio, 2.03; P = .009) as risk factors for recurrence of atrial fibrillation. Sinus rhythm at discharge (odds ratio, 0.39; P < .001) and bipolar ablation (odds ratio, 0.32; P < .001) were significant predictors for successful ablation.ConclusionsSurgical atrial fibrillation ablation was safe and effective independently of age. Sinus rhythm at discharge and bipolar ablation were significant predictors for successful ablation, whereas double valve procedures, preoperative persistent atrial fibrillation, and coronary artery bypass grafting surgery in elderly patients were risk factors for recurrence of atrial fibrillation.     

Methylene blue reduces incidence of early postoperative cognitive disorders in elderly patients undergoing major non-cardiac surgery: An open–label randomized controlled clinical trial

Study objectiveThe purpose of the present study was to investigate whether methylene blue (MB) could reduce the incidences of postoperative delirium (POD) and early postoperative cognitive dysfunction (POCD) in elderly patients undergoing major non-cardiac surgery.DesignProspective, randomized, open–label clinical trial.SettingUniversity-affiliated hospital.PatientsTwo hundred and forty-eight elderly patients scheduled for non-cardiac surgery.InterventionsElderly patients undergoing non-cardiac major surgery were randomly assigned to MB group (n = 124), who receiving intravenous infusion of 2 mg/kg MB within 60 min immediately after anesthetic induction, or control group (n = 124), who receiving equal volume saline in the same way.MeasurementsAll patients were evaluated with delirium and neuropsychological batteries before and after surgery, as well as perioperative adverse events. Two plasma biomarkers superoxide dismutase (SOD) and homocysteine (HCY) were measured pre- and post-operatively.Main resultsThere were total 39 cases(15.7%)experienced POD. The incidence of POD in MB group was significantly less than that in control group (7.3% vs. 24.2%, OR = 0.24, 95%CI: 0.11–0.53, p < 0.001). The incidence of early POCD at postoperative 7th day in MB group was also less than that in control group (16.1% vs. 40.2%, OR = 0.30, 95% CI: 0.16–0.57, p < 0.001). The adverse events were comparable in both groups. In addition, there was no significant correlation between POD/POCD and levels of SOD or HCY.ConclusionWe conclude that intraoperative intravenous 2 mg/kg MB could significantly reduce the incidences of POD and early POCD in elderly surgical patients, while not remarkably increase incidence of perioperative adverse events, suggesting MB may be clinically effective and safe for prevention of early postoperative neurocognitive disorders.     

Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes

BackgroundPostoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures.MethodsAmong 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses.ResultsA Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02).ConclusionPostoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.     

Does ablation of atrial fibrillation at the time of septal myectomy improve survival of patients with obstructive hypertrophic cardiomyopathy?

ObjectiveTo evaluate the outcomes after septal myectomy in patients with obstructive hypertrophic cardiomyopathy according to atrial fibrillation and surgical ablation of atrial fibrillation.MethodsWe reviewed patients with obstructive hypertrophic cardiomyopathy who underwent septal myectomy at the Mayo Clinic from 2001 to 2016. History of atrial fibrillation was obtained from patient histories and electrocardiograms. All-cause mortality was the primary end point.ResultsA total of 2023 patients underwent septal myectomy, of whom 394 (19.5%) had at least 1 episode of atrial fibrillation preoperatively. Among patients with atrial fibrillation, 76 (19.3%) had only 1 known episode, 278 (70.6%) had recurrent paroxysmal atrial fibrillation, and 40 (10.2%) had persistent atrial fibrillation. Surgical ablation was performed in 190 patients at the time of septal myectomy, including 148 with pulmonary vein isolation and 42 with the classic maze procedure. Among all patients, operative mortality was 0.4%, and there were no early deaths in patients undergoing surgical ablation. Over a median follow-up of 5.6 years, patients with preoperative atrial fibrillation had increased mortality (hazard ratio, 1.36; 95% confidence interval, 0.97-1.91; P = .070) after multivariable adjustment for comorbidities. When considering the impact of atrial fibrillation with or without surgical treatment, the adjusted hazard ratio for mortality in patients undergoing ablation compared with no ablation was 0.93 (95% confidence interval, 0.52-1.69; P = .824).ConclusionsAtrial fibrillation is present preoperatively in one-fifth of patients with obstructive hypertrophic cardiomyopathy undergoing myectomy and showed a trend toward higher all-cause mortality. Survival of patients undergoing septal myectomy with preoperative atrial fibrillation was similar between those who did and did not receive concomitant surgical ablation.     

Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study

Purpose

Obstructive sleep apnea (OSA) is presumed to be a risk factor for postoperative morbidity and mortality, but the current evidence is incomplete. This retrospective matched cohort study tested the hypothesis that OSA is a risk factor for the development of postoperative complications.

Methods

Hospital ethics approval was obtained for the conduct of this study. The patients who were selected for the study were >18 yr of age, diagnosed preoperatively with OSA, and scheduled to undergo elective surgery. A cohort of surgical patients without OSA was used as a comparator group based on a one-to-one match. Matching criteria included gender, age difference <5 yr, type of surgery, and a <5 yr difference between two surgery dates. Summary data are presented and conditional logistic regression was used to identify risk factors for postoperative complications.

Results

The 240 pairs of study subjects aged 57 ± 13 yr included 184 (77%) males and 56 (23%) females. The OSA patients had a higher mean body mass index relative to their non-OSA counterparts (35 ± 9 vs 28 ± 6 kg · m^?2, respectively) and a higher frequency of co-morbidities, including hypertension (48% vs 36%, respectively) and obesity (61% vs 23%, respectively). Also, the incidence of postoperative complications in the OSA patients was significantly greater (44% OSA group vs 28% non-OSA group; P < 0.05). The most commonly observed between-group difference was oxygen desaturation < 90% (17% OSA group vs 8% non-OSA group). The OSA patients who did not use home continuous positive airway pressure (CPAP) devices prior to surgery but required the use of a CPAP device after surgery had the highest rate of complications. Conditional logistic regression was used to diagnose OSA and pre-existing stroke as significant risk factors for developing postoperative complications. The hazard ratio for OSA was 2.0 (1.25–3.19).

Conclusion

Patients with diagnosed OSA have an increased incidence of postoperative complications, the most frequent being oxygen desaturation.     

Association between intraoperative body temperature and postoperative delirium: A retrospective observational study

Study objectiveThe effect of perioperative body temperature derangement on postoperative delirium remains unclear. This study aimed to evaluate the association between intraoperative body temperature and postoperative delirium in patients having noncardiac surgery.DesignSingle-center retrospective observational study.SettingTertiary university hospital.PatientAdult patients who had major noncardiac surgery under general anesthesia for at least two hours between 2019 and 2021.InterventionsPatients were classified into three groups according to their intraoperative time-weighted average body temperature: severe hypothermia (<35.0 °C), mild hypothermia (35.0 °C–36.0 °C), and normothermia (≥36.0 °C) groups.MeasurementsThe primary outcome was the risk of delirium occurring within seven days after surgery, which was compared using logistic regression analysis. A multivariable procedure was performed adjusting for potential confounders including demographics, history of hypertension, diabetes, atrial fibrillation or flutter, myocardial infarction, congestive heart failure, and stroke or transient ischemic attack, preoperative use of antidepressants and statins, preoperative sodium imbalance, high-risk surgery, emergency surgery, duration of surgery, and red blood cell transfusion. Cox regression analysis was also performed using the same covariates.Main resultsAmong 27,674 patients analyzed, 5.5% experienced postoperative delirium. The incidence rates of delirium were 6.2% (63/388) in the severe hypothermia group, 6.4% (756/11779) in the mild hypothermia group, and 4.6% (712/15507) in the normothermia group. Compared with the normothermia group, the risk of delirium was significantly higher in the severe hypothermia (adjusted odds ratio, 1.43; 95% confidence interval, 1.04–1.97) and mild hypothermia (1.15; 1.02–1.28) groups. The mild hypothermia group also had a significantly increased risk of cumulative development of delirium than the normothermia group (adjusted hazard ratio 1.14; 95% confidence interval, 1.03–1.26).ConclusionsIntraoperative hypothermia (even mild hypothermia) was significantly associated with an increased risk of postoperative delirium.     

Hiperlactatemia en la ablación quirúrgica de la fibrilación auricular y cirugía cardiaca. ¿Es un factor predictivo de morbimortalidad posoperatoria?

IntroductionIncreased serum lactate in postoperative cardiac surgery is very common and its pathogenesis is due to multiple factors. The elevation of serum lactate is associated with tissue hypoxia (hyperlactatemia type A) and non-hypoxic (hyperlactatemia type B) metabolic disorders. The aim of the study was to assess the evolution of postoperative lactate in surgical atrial fibrillation ablation during cardiac surgery, and to determine whether lactate levels could be predictors of morbimortality.Material and methodsA case-control study was conducted on 32 patients undergoing surgical atrial fibrillation ablation and cardiac surgery (Maze group) and 32 matched patients (Control group), operated on between 2011 and 2012. An analysis was made of the levels of postoperative lactate, perioperative morbimortality and hospital length of stay. A univariate and multivariate study was performed for a composite endpoint of morbimortality, and prolonged length of stay.ResultsLactate levels were significantly higher at 6, 12 and 24 h in the Maze group. The univariate analysis showed that being in the Maze group (OR 3.88; 95% CI 1.3-11.1; P = .01) and an elevated lactate at 12 h (OR 1.33; 95% CI 1.01-1.7; P = .04) were significant predictors of major complications, mortality, and longer hospital stays. In the multivariate analysis, surgical atrial fibrillation ablation (Maze group) was an independent predictor of major complications (OR 4.13; 95% CI 1.312.9; P = .015) for the morbimortality composite endpoint (OR 3.9; 95% CI 1.3-11.6; P = .01), and prolonged length of stay in the Intensive Care Unit (OR 5.7; 95% CI 2.01-15.7; P = .01).ConclusionsThe atrial fibrillation surgical ablation may be a not-yet-described cause of type B hyperlactatemia, with serum peak values being reached between 4-24 h after cardiac surgery. The predictive value of this elevation, its correlation with morbimortality, its sensitivity and specificity to discriminate the significant thresholds needs to be defined.     

Incidência de delírio ao despertar e fatores de risco após o uso de sevoflurano em pacientes pediátricos para cirurgia ambulatorial,Kingston, Jamaica

Background and objectivesEmergence delirium is a distressing complication of the use of sevoflurane for general anesthesia. This study sought to determine the incidence of emergence delirium and risk factors in patients at a specialist pediatric hospital in Kingston, Jamaica.MethodsThis was a cross‐sectional, observational study including pediatric patients aged 3–10 years, ASA I and II, undergoing general anesthesia with sevoflurane for elective day‐case procedures. Data collected included patients’ level of anxiety pre‐operatively using the modified Yale Preoperative Anxiety Scale, surgery performed, anesthetic duration and analgesics administered. Postoperatively, patients were assessed for emergence delirium, defined as agitation with non‐purposeful movement, restlessness or thrashing; inconsolability and unresponsiveness to nursing and/or parental presence. The need for pharmacological treatment and post‐operative complications related to emergence delirium episodes were also noted.Results145 children were included, with emergence delirium occurring in 28 (19.3%). Emergence delirium episodes had a mean duration of 6.9 ± 7.8 min, required pharmacologic intervention in 19 (67.8%) children and were associated with a prolonged recovery time (49.4 ± 11.9 versus 29.7 ± 10.8 min for non‐agitated children; p < 0.001). Factors positively associated with emergence delirium included younger age (p = 0.01, OR 3.3, 95% CI 1.2–8.6) and moderate and severe anxiety prior to induction (p < 0.001, OR 5.6, 95% CI 2.3–13.0). Complications of emergence delirium included intravenous line removal (n = 1), and surgical site bleeding (n = 3).ConclusionChildren of younger age with greater preoperative anxiety are at increased risk of developing emergence delirium following general anesthesia with sevoflurane. The overall incidence of emergence delirium was 19%.     

Higher versus lower mean arterial pressure target management in older patients having non-cardiothoracic surgery: A prospective randomized controlled trial

Study objectiveThis study aimed to evaluate the effects of low versus high mean arterial pressure (MAP) levels on the incidence of postoperative delirium during non-cardiothoracic surgery in older patients.DesignMulticenter, randomized, parallel-controlled, open-label, and assessor-blinded clinical trial.SettingUniversity hospital.PatientsThree hundred twenty-two patients aged ≥65 with an American Society of Anesthesiologists physical status of I-II who underwent non-cardiothoracic surgery with general anaesthesia.InterventionsParticipants were randomly assigned into a low-level MAP (60–70 mmHg) or high-level MAP (90–100 mmHg) group during general anaesthesia. The study was conducted from November 2016 to February 2020. Participants were older patients having non-cardiothoracic surgery. The follow-up period ranged from 1 to 7 days after surgery. The primary outcome was the incidence of postoperative delirium.Main resultsIn total, 322 patients were included and randomized; 298 completed in-hospital delirium assessments [median (interquartile range) age, 73 (68–77) years; 173 (58.1%) women]. Fifty-four (18.1%) patients total, including 36 (24.5%) and 18 (11.9%) in the low-level and high-level MAP groups [relative risk (RR) 0.48, 95% confidence interval (CI) 0.25 to 0.87, P = 0.02], respectively, experienced postoperative delirium. The adjusted RR was 0.34 (95% CI 0.16 to 0.70, P < 0.01) in the multiple regression analysis. High-level MAP was associated with a shorter delirium span and a higher intraoperative urine volume than low-level MAP.ConclusionsIn older patients during non-cardiothoracic surgery, high-level blood pressure management might help reduce the incidence of postoperative delirium.     

Post-operative outcomes and anesthesia type in total hip arthroplasty in patients with obstructive sleep apnea: A retrospective analysis of the State Inpatient Databases

Study objectivesTo investigate postoperative outcomes following total hip arthroplasty (THA) in patients with obstructive sleep apnea (OSA). To evaluate trends in the use of regional anesthesia (RA) versus general anesthesia (GA) following the publication of practical guidelines. To compare postoperative outcomes according to anesthesia type.DesignRetrospective analysis.SettingOperating room.Patients349,008 patients who underwent elective THA in Florida, New York, Maryland, and Kentucky between 2007 and 2014 were extracted from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, including 18,063 patients with OSA (5.2%).InterventionsNo intervention.MeasurementsThe effect of OSA on postoperative outcomes was investigated using bivariate analysis and multivariable logistic regression models. Outcomes studied included in-hospital mortality, postoperative complications, length of stay (LOS), and post-discharge readmissions. In a population from New York only, (n = 105,838 with 5306 patients with OSA [5.0%]), we investigated the outcomes in the OSA population according to the anesthesia type. Analysis was performed overall and for each individual year.Main resultsThe OSA prevalence increased from 1.7% in 2007 to 7.1% in 2014. In multivariable analysis, there was no effect of OSA on in-hospital mortality (aOR:0.57; 0.31–1.04). Postoperative complications, LOS, and readmission rates were all higher in patients with OSA. In patients with OSA receiving GA than those receiving RA, we found a higher rate of complications overall and pulmonary complications specifically in men and higher rate of 90-day readmission in women. Over the study period, the rate of GA use in patients with OSA increased.ConclusionsThe OSA prevalence in patients undergoing THA increased fourfold over the study period. OSA was associated with increased overall postoperative complications, LOS, and readmission, but not with in-hospital mortality. Despite the publication of guidelines favoring RA over GA, the use of GA increased over the study period.     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Intensive glucose control during the perioperative period for diabetic patients undergoing surgery: An updated systematic review and meta-analysis

Study objectiveTo evaluate the impact of intensive glucose control on diabetic patients undergoing surgery.DesignA systematic review and meta-analysis of randomized controlled trials. PubMed, CENTRAL, EMBASE, ISI Web of Science, and CINAHL databases were searched from inception to 13 December 2020.SettingOperating room, postoperative recovery area and ward, up to 30 days after surgery.PatientsDiabetic patients undergoing surgery.InterventionsWe used Review Manager 5.4 to pool the data with a random-effects model. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system.MeasurementsThe primary outcomes were infectious complications, postoperative mortality, and hypoglycaemia. The secondary outcomes included atrial fibrillation, myocardial infarction, stroke, delirium, renal failure, postoperative mechanical ventilation time, length of intensive care unit (ICU) stay, and hospital stay.Main resultsThirteen studies involving 1582 participants were included. Compared with conventional glucose control, intensive glucose control was associated with a lower risk of infectious complications (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.19–0.63; low-quality evidence), atrial fibrillation (RR, 0.55; 95% CI, 0.42–0.71; high-quality evidence), and renal failure (RR, 0.38; 95% CI, 0.15–0.95; moderate-quality evidence), as well as a shorter length of stay in the ICU (mean difference (MD), −0.55 day; 95% CI, −1.05 to −0.05 days; very-low-quality evidence) and hospital (MD, −1.61 days; 95% CI, −2.78 to −0.44 days; very-low-quality evidence). However, intensive glucose control was associated with a higher risk of hypoglycaemia (RR, 3.00; 95% CI, 1.97–4.55; high-quality evidence). There were no significant differences in postoperative mortality, myocardial infarction, stroke, delirium, or postoperative mechanical ventilation time.ConclusionsIntensive glucose control in diabetic patients is associated with a reduction in some adverse postoperative outcomes including infectious complications, but also appears to increase the risk of hypoglycaemia. Further well-designed studies may be needed to determine appropriate regimens to reduce hypoglycaemia incidence.PROSPERO registration numberCRD42021226138.     

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study

BackgroundThere is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE.MethodsMulti-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3?6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4 h/day) were compared with those with not adherent or those who had not been prescribed CPAP.ResultsValid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96?2.7; p = 0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07?15.1; p = 0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2?11.6; p = 0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05?1.02; p = 0.053).ConclusionsIn patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events.     

Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis

Study objectiveTo evaluate the efficacy of perioperative dexmedetomidine (DEX) administration for preventing delirium in adults after non-cardiac surgery.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).InterventionsPerioperative administration of DEX to prevent delirium in adults following non-cardiac surgery.MeasurementsThe incidence of postoperative delirium (POD).MethodsThe databases of PubMed, Embase and Cochrane Central Register were searched from inception to Mar 4, 2021 for all available RCTs that assessed DEX for POD in adults after non-cardiac surgery. Risk ratio (RR) with a 95% confidence interval (CI) was calculated for dichotomous data. Standardized mean difference (SMD) was calculated for continuous data. Risk of bias was assessed using the second version of the Cochrane risk-of-bias tool for RCTs (RoB 2.0), and the level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.Main resultsThirteen studies, including the meta-analysis with a total of 4015 patients (DEX group: 2050 patients; placebo group: 1965 patients), showed that DEX significantly reduced the incidence of POD in adults after non-cardiac surgery compared with control group (RR: 0.60; 95%CI: 0.46 to 0.77, P = 0.0001, I² = 55%, GRADE = moderate). Meanwhile, there was a statistical difference by the subgroup analysis between the mean age ≥ 65 years group and the mean age<65 years group. There were no statistical differences in length of hospital stay following surgery (SMD: -0.36; 95%CI: −0.80 to 0.07, P = 0.1, I² = 97%, GRADE = low) and all-cause mortality rate (RR:0.57; 95%CI: 0.25 to 1.28, P < 0.17, I² = 0%, GRADE = moderate) compared with placebo group. However, Meta-analysis showed that DEX administration significantly resulted in intraoperative bradycardia when compared with placebo group (RR: 1.39; 95%CI: 1.14 to 1.69, P = 0.0009, I² = 0%, GRADE = high), and as well as intraoperative hypotension (RR: 1.25; 95%CI: 1.11 to 1.42, P = 0.0004, I² = 0%, GRADE = high).ConclusionThis systematic review and meta-analysis suggests that perioperative administration of DEX could significantly reduce the incidence of POD in patients elder than 65 years following non-cardiac surgery. However, there was no definite evidence that perioperative DEX could reduce the incidence of POD in patients younger than 65 years of age after non-cardiac surgery. In addition, perioperative DEX administration was associated with an elevated risk of bradycardia and hypotension.