Medicine › Cardiology and Cardiovascular Medicine

Cardiac, Anesthesia and Surgical Outcomes

Works Count: 227604

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Description

This cluster of papers focuses on the assessment and management of cardiac risk in patients undergoing noncardiac surgery. It covers topics such as perioperative mortality, troponin levels, beta-blocker therapy, cardiovascular evaluation, surgical risk calculators, and postoperative complications. The papers also discuss various guidelines for pre-operative cardiac risk assessment and perioperative cardiac management.

Keywords

Perioperative; Cardiac Risk; Noncardiac Surgery; Mortality; Troponin Levels; Beta-Blocker Therapy; Cardiovascular Evaluation; Surgical Risk Calculator; Postoperative Complications; Guidelines

Physiology of the Gastrointestinal Tract.

1987-07-01

Graeme Duthie , Angie Gardner

The Role of The Nurse Practitioner in Clinical Physiology. Iindications for Gastrointestinal Physiological Assessment. Pathophysical correlations in Upper Gastrointestinal Physiology. Manometry and pH of The upper Gastrointestinal Tract. Breath Testing … The Role of The Nurse Practitioner in Clinical Physiology. Iindications for Gastrointestinal Physiological Assessment. Pathophysical correlations in Upper Gastrointestinal Physiology. Manometry and pH of The upper Gastrointestinal Tract. Breath Testing and its Interpretation. Pathophysiological Correlations in Anorectal Conditions. Anorectal Physiology. Functional Radiology of The Gastrointestinal Tract. Anorectal Ultrasonography. Biofeedback and Anorectal Disease. Developing Methods in Physiological assessment.

ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary

2002-02-01

Kim A. Eagle , Peter B. Berger , Hugh Calkins +7 more

EuroSCORE II

2012-02-29

Samer A.M. Nashef , F. Roques , Linda Sharples +4 more

To update the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk model. A dedicated website collected prospective risk and outcome data on 22 381 consecutive patients undergoing major cardiac … To update the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk model. A dedicated website collected prospective risk and outcome data on 22 381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May–July 2010). Completeness and accuracy were validated during data collection using mandatory field entry, error and range checks and after data collection using summary feedback confirmation by responsible officers and multiple logic checks. Information was obtained on existing EuroSCORE risk factors and additional factors proven to influence risk from research conducted since the original model. The primary outcome was mortality at the base hospital. Secondary outcomes were mortality at 30 and 90 days. The data set was divided into a developmental subset for logistic regression modelling and a validation subset for model testing. A logistic risk model (EuroSCORE II) was then constructed and tested. Compared with the original 1995 EuroSCORE database (in brackets), the mean age was up at 64.7 (62.5) with 31% females (28%). More patients had New York Heart Association class IV, extracardiac arteriopathy, renal and pulmonary dysfunction. Overall mortality was 3.9% (4.6%). When applied to the current data, the old risk models overpredicted mortality (actual: 3.9%; additive predicted: 5.8%; logistic predicted: 7.57%). EuroSCORE II was well calibrated on testing in the validation data subset of 5553 patients (actual mortality: 4.18%; predicted: 3.95%). Very good discrimination was maintained with an area under the receiver operating characteristic curve of 0.8095. Cardiac surgical mortality has significantly reduced in the last 15 years despite older and sicker patients. EuroSCORE II is better calibrated than the original model yet preserves powerful discrimination. It is proposed for the future assessment of cardiac surgical risk.

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GRADING OF PATIENTS FOR SURGICAL PROCEDURES

1941-05-01

Meyer Saklad

2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension

2007-08-06

Giuseppe Mancia , Guy De Backer , Anna F. Dominiczak +7 more

Mancia, Giuseppe; De Backer, Guy; Dominiczak, Anna; Cifkova, Renata; Fagard, Robert; Germano, Giuseppe; Grassi, Guido; Heagerty, Anthony M; Kjeldsen, Sverre E; Laurent, Stephane; Narkiewicz, Krzysztof; Ruilope, Luis; Rynkiewicz, Andrzej; Schmieder, … Mancia, Giuseppe; De Backer, Guy; Dominiczak, Anna; Cifkova, Renata; Fagard, Robert; Germano, Giuseppe; Grassi, Guido; Heagerty, Anthony M; Kjeldsen, Sverre E; Laurent, Stephane; Narkiewicz, Krzysztof; Ruilope, Luis; Rynkiewicz, Andrzej; Schmieder, Roland E; Boudier, Harry AJ Struijker; Zanchetti, Alberto Authors/Task Force Members: Co-Chairperson (Italy) Co-Chairperson (Belgium) (UK) (Czech Republic) (Belgium) (Italy) (Italy) (UK) (Norway) (France) (Poland) (Spain) (Poland) (Germany) (Netherlands) (Italy) Author Information

No surgical innovation without evaluation: the IDEAL recommendations

2009-09-01

Peter McCulloch , Douglas G. Altman , Marion Campbell +4 more

Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens

2003-10-24

Birgitte Brandstrup , Hanne Tønnesen , Randi Beier‐Holgersen +7 more

In Brief Objective: To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. Summary Background Data: Current fluid administration in major … In Brief Objective: To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. Summary Background Data: Current fluid administration in major surgery causes a weight increase of 3–6 kg. Complications after colorectal surgery are reported in up to 68% of patients. Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown. Methods: We did a randomized observer-blinded multicenter trial. After informed consent was obtained, 172 patients were allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects. Results: The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, P = 0.013) and per-protocol (30% versus 56%, P = 0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, P = 0.007) and tissue-healing complications (16% versus 31%, P = 0.04) were significantly reduced. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P = 0.12). No harmful adverse effects were observed. Conclusion: The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection. A restricted intraoperative and postoperative intravenous fluid regimen was tested against a standard regimen representing current practice. The restricted regimen significantly reduced postoperative complications, with the most distinct effect on cardiopulmonary complications.

What is subjective global assessment of nutritional status?

1987-01-01

AS Detsky , McLaughlin , JP Baker +4 more

Presented and described in detail is a clinical technique called subjective global assessment (SGA), which assesses nutritional status based on features of the history and physical examination. Illustrative cases are … Presented and described in detail is a clinical technique called subjective global assessment (SGA), which assesses nutritional status based on features of the history and physical examination. Illustrative cases are presented. To clarify further the nature of the SGA, the method was applied before gastrointestinal surgery to 202 hospitalized patients. The primary aim of the study was to determine the extent to which our clinician's SGA ratings were influenced by the individual clinical variables on which the clinicians were taught to base their assessments. Virtually all of these variables were significantly related to SGA class. Multivariate analysis showed that ratings were most affected by loss of subcutaneous tissue, muscle wasting, and weight loss. A high degree of interobserver agreement was found (kappa = 0.78, 95% confidence interval 0.624 to 0.944, p less than 0.001). We conclude that SGA can easily be taught to a variety of clinicians (residents, nurses), and that this technique is reproducible.

Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature

2002-09-17

Ethan A. Halm , Clara Lee , Mark R. Chassin

Purpose: To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. Data Sources: The authors … Purpose: To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. Data Sources: The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Study Selection: Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions. Data Extraction: Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results. Data Synthesis: The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume–outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume–outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data. Conclusions: High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

Hospital Volume and Surgical Mortality in the United States

2002-04-11

John D. Birkmeyer , Andrea E. Siewers , Emily Finlayson +5 more

Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is … Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed.

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Development and Evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A Decision Aid and Informed Consent Tool for Patients and Surgeons

2013-09-18

Karl Y. Bilimoria , Yaoming Liu , Jennifer L. Paruch +4 more

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ASA Physical Status Classifications

1978-10-01

William D. Owens , James A. Felts , Edward L. Spitznagel

The American Society of Anesthesiologists' (ASA) Physical Status Classification was tested for consistency of use by a questionnaire sent to 304 anesthesiologists. They were requested to classify ten hypothetical patients. … The American Society of Anesthesiologists' (ASA) Physical Status Classification was tested for consistency of use by a questionnaire sent to 304 anesthesiologists. They were requested to classify ten hypothetical patients. Two hundred fifty-five (77.3 percent) responded to two mailings. The mean number of patients rated consistently was 5.9. Four patients elicited wide ranges of responses. Age, obesity, previous myocardial infarction, and anemia provoked controversy. There was no significant difference in responses from different regions of the country. Academic anesthesiologists rated a greater number identical than did those in private practice (P less than 0.01). There was no difference in ratings between those who used the classification for billing purposes and those who did not. The ASA Physical Status Classification is useful but suffers from a lack of scientific precision.

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Adverse Cerebral Outcomes after Coronary Bypass Surgery

1996-12-19

Gary W. Roach , Marc S. Kanchuger , Christina Mora Mangano +7 more

Acute changes in cerebral function after elective coronary bypass surgery are a difficult clinical problem. We carried out a multicenter study to determine the incidence and predictors of — and … Acute changes in cerebral function after elective coronary bypass surgery are a difficult clinical problem. We carried out a multicenter study to determine the incidence and predictors of — and the use of resources associated with — perioperative adverse neurologic events, including cerebral injury.

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Impact of Hospital Volume on Operative Mortality for Major Cancer Surgery

1998-11-25

Colin B. Begg

Context.-Hospitals that treat a relatively high volume of patients for selected surgical oncology procedures report lower surgical in-hospital mortality rates than hospitals with a low volume of the procedures, but … Context.-Hospitals that treat a relatively high volume of patients for selected surgical oncology procedures report lower surgical in-hospital mortality rates than hospitals with a low volume of the procedures, but the reports do not take into account length of stay or adjust for case mix.Objective.-Todetermine whether hospital volume was inversely associated with 30-day operative mortality, after adjusting for case mix.Design and Setting.-Retrospectivecohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in which the hypothesis was prospectively specified.Surgeons determined in advance the surgical oncology procedures for which the experience of treating a larger volume of patients was most likely to lead to the knowledge or technical expertise that might offset surgical fatalities.Patients.-All5013 patients in the SEER registry aged 65 years or older at cancer diagnosis who underwent pancreatectomy, esophagectomy, pneumonectomy, liver resection, or pelvic exenteration, using incident cancers of the pancreas, esophagus, lung, colon, and rectum, and various genitourinary cancers diagnosed between 1984 and 1993.Main Outcome Measure.-Thirty-daymortality in relation to procedure volume, adjusted for comorbidity, patient age, and cancer stage.Results.-Higher volume was linked with lower mortality for pancreatectomy (P = .004),esophagectomy (PϽ.001), liver resection (P = .04),and pelvic exenteration (P = .04),but not for pneumonectomy (P = .32).The most striking results were for esophagectomy, for which the operative mortality rose to 17.3% in low-volume hospitals, compared with 3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding rates were 12.9% vs 5.8%.Adjustments for case mix and other patient factors did not change the finding that low volume was strongly associated with excess mortality.Conclusions.-Thesedata support the hypothesis that when complex surgical oncologic procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower.

Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery

2008-08-01

Henrik Kehlet , Douglas W. Wilmore

In Brief Background: Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. Objective: To assess, synthesize, and discuss implementation of … In Brief Background: Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. Objective: To assess, synthesize, and discuss implementation of “fast-track” recovery programs. Data Sources: Medline MBASE (January 1966–May 2007) and the Cochrane library (January 1966–May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. Data Synthesis: Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the “fast-track methodology” has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered “surgery-specific” morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. Conclusion: Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia. The integration of unimodality evidence-based perioperative care principles into a multimodal “fast-track” rehabilitation program is now well documented to accelerate postoperative recovery and decrease hospital stay. Therefore, this multidisciplinary effort should be more widely adopted.

POSSUM: A scoring system for surgical audit

1991-03-01

G P Copeland , Daryl Jones , James Walters

POSSUM, a Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, is described. This system has been devised from both a retrospective and prospective analysis and the … POSSUM, a Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, is described. This system has been devised from both a retrospective and prospective analysis and the present paper attempts to validate it prospectively. Logistic regression analysis yielded statistically significant equations for both mortality and morbidity (P less than 0.001). When displayed graphically zones of increasing morbidity and mortality rates could be defined which could be of value in surgical audit. The scoring system produced assessments for morbidity and mortality rates which did not significantly differ from observed rates.

GRADE guidelines 6. Rating the quality of evidence—imprecision

2011-08-15

Gordon Guyatt , Andrew D Oxman , Regina Kunz +7 more

Classification of Surgical Complications

2004-07-22

Daniel Dindo , Nicolas Demartines , Pierre-Alain Clavien

In Brief Objective: Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data … In Brief Objective: Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. Patients and Methods: A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. Results: The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. Conclusions: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world. The lack of a uniform way of reporting complications hampers interpretation of surgical outcome data and quality assessment. The authors revisited a previously reported classification of complications and propose a new grading system. The new classification was tested in a cohort of 6336 patients undergoing general surgery and through an international survey.

Frailty as a Predictor of Surgical Outcomes in Older Patients

2010-04-29

Martin A. Makary , Dorry L. Segev , Peter J. Pronovost +7 more

Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery

1999-09-07

Thomas H. Lee , Edward R. Marcantonio , Carol M. Mangione +7 more

Background —Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications. … Background —Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications. Methods and Results —We studied 4315 patients aged ≥50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital. The main outcome measures were major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL. Rates of major cardiac complication with 0, 1, 2, or ≥3 of these factors were 0.5%, 1.3%, 4%, and 9%, respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and 11%, respectively, among 1422 patients in the validation cohort. Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes. Conclusions —In stable patients undergoing nonurgent major noncardiac surgery, this index can identify patients at higher risk for complications. This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies, as well as low-risk patients in whom additional evaluation is unlikely to be helpful.

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2014 ESC/EACTS Guidelines on myocardial revascularization

2014-08-31

Philippe Kolh , Stephan Windecker , Fernándo Alfonso +7 more

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A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

2009-01-14

Alex B. Haynes , Thomas G. Weiser , William R. Berry +7 more

Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program … Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

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Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial

2008-05-01

Miriam de Nadal , Homer Yang , Salim Yusuf +7 more

An estimation of the global volume of surgery: a modelling strategy based on available data

2008-06-25

Thomas G. Weiser , Scott E. Regenbogen , Katherine D. Thompson +4 more

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

2014-08-02

Lee A. Fleisher , Kirsten E. Fleischmann , Andrew D. Auerbach +7 more

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Surgeon Volume and Operative Mortality in the United States

2003-11-26

John D. Birkmeyer , Thérèse A. Stukel , Andrea E. Siewers +3 more

Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.Using information from the … Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers.Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure--from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced.For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.

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The Clavien-Dindo Classification of Surgical Complications

2009-07-31

Pierre A. Clavien , Jeffrey Barkun , Michelle Oliveira +7 more

The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was … The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception.Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication.We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test).This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.

Multimodal strategies to improve surgical outcome

2002-06-01

Henrik Kehlet , Douglas W. Wilmore

Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)

2010-08-29

William Wijns , Philippe Kolh , N Danchin +7 more

Guidelines and Expert Consensus Documents summarize and evaluate all available evidence with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a … Guidelines and Expert Consensus Documents summarize and evaluate all available evidence with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome and the risk–benefit ratio of diagnostic or therapeutic means. Guidelines are no substitutes for textbooks and their legal implications have been discussed previously. Guidelines and recommendations should help physicians to make decisions in their daily practice. However, the ultimate judgement regarding the care of an individual patient must be made by his/her responsible physician(s). The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules). Members of this Task Force were selected by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) to represent all physicians involved with the medical and surgical care of patients with coronary artery disease (CAD). A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for society are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The members of the Task Force have provided disclosure statements of all relationships that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at European Heart House, headquarters of the ESC. Any changes in conflict of interest that arose during the writing period were notified to the ESC. The Task Force report received its entire financial support from the ESC and EACTS, without any involvement of the pharmaceutical, device, or surgical industry. ESC …

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Validation of a combined comorbidity index

1994-11-01

Mary E. Charlson , Ted P. Szatrowski , Janey C. Peterson +1 more

European system for cardiac operative risk evaluation (EuroSCORE)

1999-07-01

Samer A.M. Nashef , F. Roques , Philippe Michel +3 more

To construct a scoring system for the prediction of early mortality in cardiac surgical patients in Europe on the basis of objective risk factors.The EuroSCORE database was divided into developmental … To construct a scoring system for the prediction of early mortality in cardiac surgical patients in Europe on the basis of objective risk factors.The EuroSCORE database was divided into developmental and validation subsets. In the former, risk factors deemed to be objective, credible, obtainable and difficult to falsify were weighted on the basis of regression analysis. An additive score of predicted mortality was constructed. Its calibration and discrimination characteristics were assessed in the validation dataset. Thresholds were defined to distinguish low, moderate and high risk groups.The developmental dataset had 13,302 patients, calibration by Hosmer Lemeshow Chi square was (8) = 8.26 (P < 0.40) and discrimination by area under ROC curve was 0.79. The validation dataset had 1479 patients, calibration Chi square (10) = 7.5, P < 0.68 and the area under the ROC curve was 0.76. The scoring system identified three groups of risk factors with their weights (additive % predicted mortality) in brackets. Patient-related factors were age over 60 (one per 5 years or part thereof), female (1), chronic pulmonary disease (1), extracardiac arteriopathy (2), neurological dysfunction (2), previous cardiac surgery (3), serum creatinine >200 micromol/l (2), active endocarditis (3) and critical preoperative state (3). Cardiac factors were unstable angina on intravenous nitrates (2), reduced left ventricular ejection fraction (30-50%: 1, <30%: 3), recent (<90 days) myocardial infarction (2) and pulmonary systolic pressure >60 mmHg (2). Operation-related factors were emergency (2), other than isolated coronary surgery (2), thoracic aorta surgery (3) and surgery for postinfarct septal rupture (4). The scoring system was then applied to three risk groups. The low risk group (EuroSCORE 1-2) had 4529 patients with 36 deaths (0.8%), 95% confidence limits for observed mortality (0.56-1.10) and for expected mortality (1.27-1.29). The medium risk group (EuroSCORE 3-5) had 5977 patients with 182 deaths (3%), observed mortality (2.62-3.51), predicted (2.90-2.94). The high risk group (EuroSCORE 6 plus) had 4293 patients with 480 deaths (11.2%) observed mortality (10.25-12.16), predicted (10.93-11.54). Overall, there were 698 deaths in 14,799 patients (4.7%), observed mortality (4.37-5.06), predicted (4.72-4.95).EuroSCORE is a simple, objective and up-to-date system for assessing heart surgery, soundly based on one of the largest, most complete and accurate databases in European cardiac surgical history. We recommend its widespread use.

The stress response to trauma and surgery

2000-07-01

J.P. DESBOROUGH

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Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study

1998-03-01

J. T. Møller , Pjm Pierre Cluitmans , LS Rasmussen +7 more

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Surgical Risk as Related to Time of Intervention in the Repair of Intracranial Aneurysms

1968-01-01

William E. Hunt , R Hess

Multimodal approach to control postoperative pathophysiology and rehabilitation

1997-05-01

Henrik Kehlet

2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

2014-08-01

Authors Task Force Members , Steen Dalby Kristensen , Juhani Knuuti +7 more

AAA : abdominal aortic aneurysm ACEI : angiotensin converting enzyme inhibitor ACS : acute coronary syndromes AF : atrial fibrillation AKI : acute kidney injury AKIN : Acute Kidney Injury … AAA : abdominal aortic aneurysm ACEI : angiotensin converting enzyme inhibitor ACS : acute coronary syndromes AF : atrial fibrillation AKI : acute kidney injury AKIN : Acute Kidney Injury Network ARB : angiotensin receptor blocker ASA : American Society of Anesthesiologists b.i.d. : bis in diem (twice daily) BBSA : Beta-Blocker in Spinal Anesthesia BMS : bare-metal stent BNP : B-type natriuretic peptide bpm : beats per minute CABG : coronary artery bypass graft CAD : coronary artery disease CARP : Coronary Artery Revascularization Prophylaxis CAS : carotid artery stenting CASS : Coronary Artery Surgery Study CEA : carotid endarterectomy CHA2DS2-VASc : cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74 and sex category (female) CI : confidence interval CI-AKI : contrast-induced acute kidney injury CKD : chronic kidney disease CKD-EPI : Chronic Kidney Disease Epidemiology Collaboration Cmax : maximum concentration CMR : cardiovascular magnetic resonance COPD : chronic obstructive pulmonary disease CPG : Committee for Practice Guidelines CPX/CPET : cardiopulmonary exercise test CRP : C-reactive protein CRT : cardiac resynchronization therapy CRT-D : cardiac resynchronization therapy defibrillator CT : computed tomography cTnI : cardiac troponin I cTnT : cardiac troponin T CVD : cardiovascular disease CYP3a4 : cytochrome P3a4 enzyme DAPT : dual anti-platelet therapy DECREASE : Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography DES : drug-eluting stent DIPOM : DIabetic Post-Operative Mortality and Morbidity DSE : dobutamine stress echocardiography ECG : electrocardiography/electrocardiographically/electrocardiogram eGFR : estimated glomerular filtration rate ESA : European Society of Anaesthesiology ESC : European Society of Cardiology EVAR : endovascular abdominal aortic aneurysm repair FEV1 : Forced expiratory volume in 1 second HbA1c : glycosylated haemoglobin HF-PEF : heart failure with preserved left ventricular ejection fraction HF-REF : heart failure with reduced left ventricular ejection fraction ICD : implantable cardioverter defibrillator ICU : intensive care unit IHD : ischaemic heart disease INR : international normalized ratio IOCM : iso-osmolar contrast medium KDIGO : Kidney Disease: Improving Global Outcomes LMWH : low molecular weight heparin LOCM : low-osmolar contrast medium LV : left ventricular LVEF : left ventricular ejection fraction MaVS : Metoprolol after Vascular Surgery MDRD : Modification of Diet in Renal Disease MET : metabolic equivalent MRI : magnetic resonance imaging NHS : National Health Service NOAC : non-vitamin K oral anticoagulant NSQIP : National Surgical Quality Improvement Program NSTE-ACS : non-ST-elevation acute coronary syndromes NT-proBNP : N-terminal pro-BNP O2 : oxygen OHS : obesity hypoventilation syndrome OR : odds ratio P gp : platelet glycoprotein PAC : pulmonary artery catheter PAD : peripheral artery disease PAH : pulmonary artery hypertension PCC : prothrombin complex concentrate PCI : percutaneous coronary intervention POBBLE : Peri-Operative Beta-BLockadE POISE : Peri-Operative ISchemic Evaluation POISE-2 : Peri-Operative ISchemic Evaluation 2 q.d. : quaque die (once daily) RIFLE : Risk, Injury, Failure, Loss, End-stage renal disease SPECT : single photon emission computed tomography SVT : supraventricular tachycardia SYNTAX : Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery TAVI : transcatheter aortic valve implantation TdP : torsades de pointes TIA : transient ischaemic attack TOE : transoesophageal echocardiography TOD : transoesophageal doppler TTE : transthoracic echocardiography UFH : unfractionated heparin VATS : video-assisted thoracic surgery VHD : valvular heart disease VISION : Vascular Events In Noncardiac Surgery Patients Cohort Evaluation VKA : vitamin K antagonist VPB : ventricular premature beat VT : ventricular tachycardia Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic …

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The Effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High-Risk Patients Undergoing Vascular Surgery

1999-12-09

Don Poldermans , Eric Boersma , Jeroen J. Bax +7 more

Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery.We performed a randomized, multicenter trial to assess the effect of perioperative blockade … Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery.We performed a randomized, multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events. High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography. Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol.A total of 1351 patients were screened, and 846 were found to have one or more cardiac risk factors. Of these 846 patients, 173 had positive results on dobutamine echocardiography. Fifty-nine patients were randomly assigned to receive bisoprolol, and 53 to receive standard care. Fifty-three patients were excluded from randomization because they were already taking a beta-blocker, and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing. Two patients in the bisoprolol group died of cardiac causes (3.4 percent), as compared with nine patients in the standard-care group (17 percent, P=0.02). Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (P<0.001). Thus, the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (3.4 percent) and 18 patients in the standard-care group (34 percent, P<0.001).Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery.

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Longitudinal Assessment of Neurocognitive Function after Coronary-Artery Bypass Surgery

2001-02-08

Mark F. Newman , Jerry Kirchner , Yi‐Ju Li +6 more

Cognitive decline complicates early recovery after coronary-artery bypass grafting (CABG) and may be evident in as many as three quarters of patients at the time of discharge from the hospital … Cognitive decline complicates early recovery after coronary-artery bypass grafting (CABG) and may be evident in as many as three quarters of patients at the time of discharge from the hospital and a third of patients after six months. We sought to determine the course of cognitive change during the five years after CABG and the effect of perioperative decline on long-term cognitive function.In 261 patients who underwent CABG, neurocognitive tests were performed preoperatively (at base line), before discharge, and six weeks, six months, and five years after CABG surgery. Decline in postoperative function was defined as a drop of 1 SD or more in the scores on tests of any one of four domains of cognitive function. (A reduction of 1 SD represents a decline in function of approximately 20 percent.) Overall neurocognitive status was assessed with a composite cognitive index score representing the sum of the scores for the individual domains. Factors predicting long-term cognitive decline were determined by multivariable logistic and linear regression.Among the patients studied, the incidence of cognitive decline was 53 percent at discharge, 36 percent at six weeks, 24 percent at six months, and 42 percent at five years. We investigated predictors of cognitive decline at five years and found that cognitive function at discharge was a significant predictor of long-term function (P<0.001).These results confirm the relatively high prevalence and persistence of cognitive decline after CABG and suggest a pattern of early improvement followed by a later decline that is predicted by the presence of early postoperative cognitive decline. Interventions to prevent or reduce short- and long-term cognitive decline after cardiac surgery are warranted.

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Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery

1996-12-05

Dennis T. Mangano , Elizabeth L. Layug , Arthur W. Wallace +1 more

Perioperative myocardial ischemia is the single most important potentially reversible risk factor for mortality and cardiovascular complications after noncardiac surgery. Although more than 1 million patients have such complications annually, … Perioperative myocardial ischemia is the single most important potentially reversible risk factor for mortality and cardiovascular complications after noncardiac surgery. Although more than 1 million patients have such complications annually, there is no effective preventive therapy.

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Multifactorial Index of Cardiac Risk in Noncardiac Surgical Procedures

1977-10-20

Lee Goldman , D. L. CALDERA , Samuel R. Nussbaum +7 more

To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, … To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, we identified nine independent significant correlates of life-threatening and fatal cardiac complications: preoperative third heart sound or jugular venous distention; myocardial infarction in the preceding six months; more than five premature ventricular contractions per minute documented at any time before operation; rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram; age over 70 years; intraperitoneal, intrathoracic or aortic operation; emergency operation; important valvular aortic stenosis; and poor general medical condition. Patients could be separated into four classes of significantly different risk. Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk. If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.

Anesthesiology

1997-10-16

Richard A. Wiklund , Stanley H. Rosenbaum

A century and a half after the first administration of ether, at the Massachusetts General Hospital in Boston, and almost 30 years since the last review of anesthesiology in the … A century and a half after the first administration of ether, at the Massachusetts General Hospital in Boston, and almost 30 years since the last review of anesthesiology in the Journal, it is fitting to consider recent advances in the field.1 In the late 1960s, the National Institutes of Health decided to support training in clinical anesthesiology.2 Since that time, anesthesia-related deaths have decreased dramatically. In this review, we discuss the preparation of patients for surgery, recent developments in anesthetic agents and techniques, multimodal pain management, and postoperative complications related to anesthesia.Preoperative Assessment and PreparationApproximately 28 million patients . . .

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

2007-10-01

Lee A. Fleisher , Joshua A. Beckman , Kenneth A. Brown +7 more

ACC/AHA guidelines for coronary artery bypass graft surgery

1999-10-01

Kim A. Eagle , Robert A. Guyton , Ravin Davidoff +7 more

2018 ESC/EACTS Guidelines on myocardial revascularization

2018-08-25

Franz‐Josef Neumann , Miguel Sousa‐Uva , Anders Ahlsson +7 more

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2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

2014-08-29

Authors Task Force Members , Raimund Erbel , Victor Aboyans +7 more

The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their … The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating.The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of health care or therapeutic strategies.Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with that patient and, where appropriate and/or necessary, the patient's caregiver.Nor do the ESC Guidelines exempt health professionals from taking full and careful consideration of the relevant official updated recommendations or guidelines issued by the competent public health authorities in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations.It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

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The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

2020-11-09

Riaz Agha , Thomas Franchi , Catrin Sohrabi +7 more

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2014 ESC/EACTS Guidelines on myocardial revascularization

2014-08-29

Stephan Windecker , Philippe Kolh , Fernándo Alfonso +7 more

The ESC/EACTS Guidelines represent the views of the ESC and of the EACTS and were produced after careful consideration of the scientific and medical knowledge and the evidence available at … The ESC/EACTS Guidelines represent the views of the ESC and of the EACTS and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating.The ESC and EACTS are not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC/EACTS Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies.Health professionals are encouraged to take the ESC/ EACTS Guidelines fully into account when exercising their clinical judgment as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC/EACTS Guidelines do not in any way whatsoever override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and, where appropriate and/or necessary, in consultation with that patient and the patient's care provider.Nor do the ESC/EACTS Guidelines exempt health professionals from giving full and careful consideration to the relevant official, updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations.It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

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The Health Consequences of Smoking -- 50 Years of progress: A Report of the Surgeon General

2014-01-01

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Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists

2002-04-01

Developed by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists: Jeffrey B. Gross, M.D. (Chair), Farmington, CT; Peter L. Bailey, M.D., Rochester, NY; Richard T. … Developed by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists: Jeffrey B. Gross, M.D. (Chair), Farmington, CT; Peter L. Bailey, M.D., Rochester, NY; Richard T. Connis, Ph.D., Woodinville, WA; Charles J. Coté, M.D., Chicago, IL; Fred G. Davis, M.D., Burlington, MA; Burton S. Epstein, M.D., Washington, DC; Lesley Gilbertson, M.D., Boston, MA; David G. Nickinovich, Ph.D., Bellevue, WA; John M. Zerwas, M.D., Houston, TX; Gregory Zuccaro, Jr., M.D., Cleveland, OH.ANESTHESIOLOGISTS possess specific expertise in the pharmacology, physiology, and clinical management of patients receiving sedation and analgesia. For this reason, they are frequently called on to participate in the development of institutional policies and procedures for sedation and analgesia for diagnostic and therapeutic procedures. To assist in this process, the American Society of Anesthesiologists (ASA) has developed these “Guidelines for Sedation and Analgesia by Non-Anesthesiologists.”Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints. Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.This revision includes data published since the “Guidelines for Sedation and Analgesia by Non-Anesthesiologists” were adopted by the ASA in 1995; it also includes data and recommendations for a wider range of sedation levels than was previously addressed.“Sedation and analgesia” comprise a continuum of states ranging from minimal sedation (anxiolysis) through general anesthesia. Definitions of levels of sedation–analgesia, as developed and adopted by the ASA, are given in table 1. These Guidelines specifically apply to levels of sedation corresponding to moderate sedation (frequently called conscious sedation) and deep sedation, as defined in table 1.These Guidelines are designed to be applicable to procedures performed in a variety of settings (e.g. , hospitals, freestanding clinics, physician, dental, and other offices) by practitioners who are not specialists in anesthesiology. Because minimal sedation (anxiolysis) entails minimal risk, the Guidelines specifically exclude it. Examples of minimal sedation include peripheral nerve blocks, local or topical anesthesia, and either (1) less than 50% nitrous oxide (N2O) in oxygen with no other sedative or analgesic medications by any route, or (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of insomnia, anxiety, or pain. The Guidelines also exclude patients who are not undergoing a diagnostic or therapeutic procedure (e.g. , postoperative analgesia, sedation for treatment of insomnia). Finally, the Guidelines do not apply to patients receiving general or major conduction anesthesia (e.g. , spinal or epidural/caudal block), whose care should be provided, medically directed, or supervised by an anesthesiologist, the operating practitioner, or another licensed physician with specific training in sedation, anesthesia, and rescue techniques appropriate to the type of sedation or anesthesia being provided.The purpose of these Guidelines is to allow clinicians to provide their patients with the benefits of seda-tion/analgesia while minimizing the associated risks. Sedation/analgesia provides two general types of benefit: (1) sedation/analgesia allows patients to tolerate unpleasant procedures by relieving anxiety, discomfort, or pain; and (2) in children and uncooperative adults, sedation–analgesia may expedite the conduct of procedures that are not particularly uncomfortable but that require that the patient not move. At times, these sedation practices may result in cardiac or respiratory depression, which must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, car-diac arrest, or death. Conversely, inadequate sedation– analgesia may result in undue patient discomfort or patient injury because of lack of cooperation or adverse physiologic or psychological response to stress.These Guidelines are intended to be general in their application and broad in scope. The appropriate choice of agents and techniques for sedation/analgesia is dependent on the experience and preference of the individual practitioner, requirements or constraints imposed by the patient or procedure, and the likelihood of producing a deeper level of sedation than anticipated. Because it is not always possible to predict how a specific patient will respond to sedative and analgesic medications, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. For moderate sedation, this implies the ability to manage a compromised airway or hypoventilation in a patient who responds purposefully after repeated or painful stimulation, whereas for deep sedation, this implies the ability to manage respiratory or cardiovascular instability in a patient who does not respond purposefully to painful or repeated stimulation. Levels of sedation referred to in the recommendations relate to the level of sedation intended by the practitioner. Examples are provided to illustrate airway assessment, preoperative fasting, emergency equipment, and recovery procedures; however, clinicians and their institutions have ultimate responsibility for selecting patients, procedures, medications, and equipment.The ASA appointed a Task Force of 10 members to (1) review the published evidence; (2) obtain the opinion of a panel of consultants, including non-anesthesiologist physicians and dentists who routinely administer sedation–analgesia, as well as of anesthesiologists with a special interest in sedation–analgesia (see Appendix I); and (3) build consensus within the community of practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, a gastroenterologist, and methodologists from the ASA Committee on Practice Parameters.This Practice Guideline is an update and revision of the ASA “Guidelines for Sedation and Analgesia by Non-Anesthesiologists.”1The Task Force revised and updated the Guidelines by means of a five-step process. First, original published research studies relevant to the revision and update were reviewed and analyzed; only articles relevant to the administration of sedation by non-anesthesiologists were evaluated. Second, the panel of expert consultants was asked to (1) participate in a survey related to the effectiveness and safety of various methods and interventions that might be used during sedation–analgesia, and (2) review and comment on the initial draft report of the Task Force. Third, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing most of the specialties whose members typically administer sedation–analgesia were invited to send representatives. Fourth, the consultants were surveyed to assess their opinions on the feasibility and financial implications of implementing the revised and updated Guidelines. Finally, all of the available information was used by the Task Force to finalize the Guidelines.Evidence-based Guidelines are developed by a rigorous analytic process. To assist the reader, the Guidelines make use of several descriptive terms that are easier to understand than the technical terms and data that are used in the actual analyses. These descriptive terms are defined below.The following terms describe the strength of scientific data obtained from the scientific literature:The following terms describe the lack of available scientific evidence in the literature:The following terms describe survey responses from the consultants for any specified issue. Responses were solicited on a five-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being neutral.There is insufficient published evidence to evaluate the relationship between sedation–analgesia outcomes and the performance of a preprocedure patient evaluation. There is suggestive evidence that some preexisting medical conditions may be related to adverse outcomes in patients receiving either moderate or deep sedation/analgesia. The consultants strongly agree that appropriate preprocedure evaluation (history, physical examination) increases the likelihood of satisfactory sedation and decreases the likelihood of adverse outcomes for both moderate and deep sedation.Clinicians administering sedation/analgesia should be familiar with sedation-oriented aspects of the patient's medical history and how these might alter the patient's response to sedation/analgesia. These include: (1) abnormalities of the major organ systems; (2) previous adverse experience with sedation/analgesia as well as regional and general anesthesia; (3) drug allergies, current medications, and potential drug interactions; (4) time and nature of last oral intake; and (5) history of tobacco, alcohol, or substance use or abuse. Patients presenting for sedation/analgesia should undergo a focused physical examination, including vital signs, auscultation of the heart and lungs, and evaluation of the airway. (Example I). Preprocedure laboratory testing should be guided by the patient's underlying medical condition and the likelihood that the results will affect the management of sedation/analgesia. These evaluations should be confirmed immediately before sedation is initiated.The literature is insufficient regarding the benefits of providing the patient (or legal guardian, in the case of a child or impaired adult) with preprocedure information about sedation and analgesia. For moderate sedation the consultants agree, and for deep sedation the consultants strongly agree that appropriate preprocedure counseling of patients regarding risks, benefits, and alternatives to sedation and analgesia increases patient satisfaction.TABLESedatives and analgesics tend to impair airway reflexes in proportion to the degree of sedation–analgesia achieved. This dependence on level of sedation is reflected in the consultants opinion: They agree that preprocedure fasting decreases risks during moderate sedation, while strongly agreeing that it decreases risks during deep sedation. In emergency situations, when preprocedure fasting is not practical, the consultants agree that the target level of sedation should be modified (i.e. , less sedation should be administered) for moderate sedation, while strongly agreeing that it should be modified for deep sedation. The literature does not provide sufficient evidence to test the hypothesis that preprocedure fasting results in a decreased incidence of adverse outcomes in patients undergoing either moderate or deep sedation.Patients (or their legal guardians in the case of minors or legally incompetent adults) should be informed of and agree to the administration of sedation/analgesia, including its benefits, risks, and limitations associated with this therapy, as well as possible alternatives. Patients undergoing sedation/analgesia for elective procedures should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before their procedure, as recommended by the ASA “Guidelines for Preoperative Fasting”2(Example II). In urgent, emergent, or other situations in which gastric emptying is impaired, the potential for pulmonary aspiration of gastric contents must be considered in determining (1) the target level of sedation, (2) whether the procedure should be delayed,or (3) whether the trachea should be protected by intubation.TABLEThe response of patients to commands during procedures performed with sedation/analgesia serves as a guide to their level of consciousness. Spoken responses also provide an indication that the patients are breathing. Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated, approaching a state of general anesthesia, and should be treated accordingly. The literature is silent regarding whether monitoring patients’ level of consciousness improves patient outcomes or decreases risks. The consultants strongly agree that monitoring level of consciousness reduces risks for both moderate and deep sedation. The members of the Task Force believe that many of the complications associated with sedation and analgesia can be avoided if adverse drug responses are detected and treated in a timely manner (i.e. , before the development of cardiovascular decompensation or cerebral hypoxia). Patients given sedatives or analgesics in unmonitored settings in anticipation of a subsequent procedure may be at increased risk of these complications.It is the opinion of the Task Force that the primary causes of morbidity associated with sedation/analgesia are drug-induced respiratory depression and airway obstruction. For both moderate and deep sedation, the literature is insufficient to evaluate the benefit of monitoring ventilatory function by observation or auscultation. However, the consultants strongly agree that monitoring of ventilatory function by observation or auscultation reduces the risk of adverse outcomes associated with sedation/analgesia. The consultants were equivocal regarding the ability of capnography to decrease risks during moderate sedation, while agreeing that it may decrease risks during deep sedation. In circumstances in which patients are physically separated from the caregiver, the Task Force believes that automated apnea monitoring (by detection of exhaled carbon dioxide or other means) may decrease risks during both moderate and deep sedation, while cautioning practitioners that impedance plethysmography may fail to detect airway obstruction. The Task Force emphasizes that because ventilation and oxygenation are separate though related physiologic processes, monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory function.Published data suggest that oximetry effectively detects oxygen desaturation and hypoxemia in patients who are administered sedatives/analgesics. The consultants strongly agree that early detection of hypoxemia through the use of oximetry during seda-tion–analgesia decreases the likelihood of adverse outcomes such as cardiac arrest and death. The Task Force agrees that hypoxemia during sedation and analgesia is more likely to be detected by oximetry than by clinical assessment alone.Although there are insufficient published data to reach a conclusion, it is the opinion of the Task Force that sedative and analgesic agents may blunt the appropriate autonomic compensation for hypovolemia and procedure-related stresses. On the other hand, if sedation and analgesia are inadequate, patients may develop potentially harmful autonomic stress responses (e.g. , hypertension, tachycardia). Early detection of changes in patients’ heart rate and blood pressure may enable practitioners to detect problems and intervene in a timely fashion, reducing the risk of these complications. The consultants strongly agree that regular monitoring of vital signs reduces the likelihood of adverse outcomes during both moderate and deep sedation. For both moderate and deep sedation, a majority of the consultants indicated that vital signs should be monitored at 5-min intervals once a stable level of sedation is established. The consultants strongly agree that continuous electrocardiography reduces risks during deep sedation, while they were equivocal regarding its effect during moderate sedation. However, the Task Force believes that electrocardiographic monitoring of selected patients (e.g. , with significant cardiovascular disease or dysrhythmias) may decrease risks during moderate sedation.Monitoring of patient response to verbal commands should be routine during moderate sedation, except in patients who are unable to respond appropriately (e.g. , young children, mentally impaired or uncooperative patients), or during procedures where movement could be detrimental. During deep sedation, patient responsiveness to a more profound stimulus should be sought, unless contraindicated, to ensure that the patient has not drifted into a state of general anesthesia. During procedures where a verbal response is not possible (e.g. , oral surgery, upper endoscopy), the ability to give a “thumbs up” or other indication of consciousness in response to verbal or tactile (light tap) stimulation suggests that the patient will be able to control his airway and take deep breaths if necessary, corresponding to a state of moderate sedation. Note that a response limited to reflex withdrawal from a painful stimulus is not considered a purposeful response and thus represents a state of general anesthesia.All patients undergoing sedation/analgesia should be monitored by pulse oximetry with appropriate alarms. If available, the variable pitch “beep,” which gives a continuous audible indication of the oxygen saturation reading, may be helpful. In addition, ventilatory function should be continually monitored by observation or auscultation. Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation cannot be directly observed during moderate sedation. When possible, blood pressure should be determined before sedation/analgesia is initiated. Once sedation–analgesia is established, blood pressure should be measured at 5-min intervals during the procedure, unless such monitoring interferes with the procedure (e.g. , pediatric magnetic resonance imaging, where stimulation from the blood pressure cuff could arouse an appropriately sedated patient). Electrocardiographic monitoring should be used in all patients undergoing deep sedation. It should also be used during moderate sedation in patients with significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated.The literature is silent regarding the benefits of contemporaneous recording of patients’ level of consciousness, respiratory function, or hemodynamics. Consultant opinion agrees with the use of contemporaneous recording for moderate sedation and strongly agrees with its use for patients undergoing deep sedation. It is the consensus of the Task Force that, unless technically precluded (e.g. , uncooperative or combative patient), vital signs and respiratory variables should be recorded before initiating sedation/analgesia, after administration of sedative–analgesic medications, at regular intervals during the procedure, on initiation of recovery, and immediately before discharge. It is the opinion of the Task Force that contemporaneous recording (either automatic or manual) of patient data may disclose trends that could prove critical in determining the development or cause of adverse events. In addition, manual recording ensures that an individual caring for the patient is aware of changes in patient status in a timely fashion.For both moderate and deep sedation, patients’ level of consciousness, ventilatory and oxygenation status, and hemodynamic variables should be assessed and recorded at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient. At a minimum, this should be: (1) before the beginning of the procedure; (2) after administration of sedative–analgesic agents; (3) at regular intervals during the procedure, (4) during initial recovery; and (5) just before discharge. If recording is performed automatically, device alarms should be set to alert the care team to critical changes in patient status.Although the literature is silent on this issue, the Task Force recognizes that it may not be possible for the individual performing a procedure to be fully cognizant of the patient's condition during sedation/analgesia. For moderate sedation, the consultants agree that the availability of an individual other than the person performing the procedure to monitor the patient's status improves patient comfort and satisfaction and that risks are reduced. For deep sedation, the consultants strongly agree with these contentions. During moderate sedation, the consultants strongly agree that the individual monitoring the patient may assist the practitioner with interruptible ancillary tasks of short duration; during deep sedation, the consultants agree that this individual should have no other responsibilities.A designated individual, other than the practitioner performing the procedure, should be present to monitor the patient throughout procedures performed with sedation/analgesia. During deep sedation, this individual should have no other responsibilities. However, during moderate sedation, this individual may assist with minor, interruptible tasks once the patient's level of sedation–analgesia and vital signs have stabilized, provided that adequate monitoring for the patient's level of sedation is maintained.Although the literature is silent regarding the effectiveness of training on patient outcomes, the consultants strongly agree that education and training in the pharmacology of agents commonly used during sedation–analgesia improves the likelihood of satisfactory sedation and reduces the risk of adverse outcomes from either moderate or deep sedation. Specific concerns may include: (1) potentiation of sedative-induced respiratory depression by concomitantly administered opioids; (2) inadequate time intervals between doses of sedative or analgesic agents, resulting in a cumulative overdose; and (3) inadequate familiarity with the role of pharmacologic antagonists for sedative and analgesic agents.Because the primary complications of sedation/analgesia are related to respiratory or cardiovascular depression, it is the consensus of the Task Force that the individual responsible for monitoring the patient should be trained in the recognition of complications associated with sedation/analgesia. Because sedation/analgesia constitutes a continuum, practitioners administering moderate sedation should be able to rescue patients who enter a state of deep sedation, whereas those intending to administer deep sedation should be able to rescue patients who enter a state of general anesthesia. Therefore, the consultants strongly agree that at least one qualified individual trained in basic life support skills (cardiopulmonary resuscitation, bag-valve-mask ventilation) should be present in the procedure room during both moderate and deep sedation. In addition, the consultants strongly agree with the immediate availability (1–5 min away) of an individual with advanced life support skills (e.g. , tracheal intubation, defibrillation, use of resuscitation medications) for moderate sedation and in the procedure room itself for deep sedation.Individuals responsible for patients receiving sedation–analgesia should understand the pharmacology of the agents that are administered, as well as the role of pharmacologic antagonists for opioids and benzodiazepines. Individuals monitoring patients receiving sedation/analgesia should be able to recognize the associated complications. At least one individual capable of establishing a patent airway and positive pressure ventilation, as well as a means for summoning additional assistance, should be present whenever sedation–analgesia is administered. It is recommended that an individual with advanced life support skills be immediately available (within 5 min) for moderate sedation and within the procedure room for deep sedation.Although the literature is silent, the consultants strongly agree that the ready availability of appropriately sized emergency equipment reduces risks associated with both moderate and deep sedation. The literature is also silent regarding the need for cardiac defibrillators during sedation/analgesia. During moderate sedation, the consultants agree that a defibrillator should be immediately available for patients with both mild (e.g. , hypertension) and severe (e.g. , ischemia, congestive failure) cardiovascular disease. During deep sedation, the consultants agree that a defibrillator should be immediately available for all patients.Pharmacologic antagonists as well as appropriately sized equipment for establishing a patent airway and providing positive pressure ventilation with supplemental oxygen should be present whenever sedation–analgesiais administered. Suction, advanced airway equipment, and resuscitation medications should be immediately available and in good working order (Example III). A functional defibrillator should be immediately available whenever deep sedation is administered and when moderate sedation is administered to patients with mild or severe cardiovascular disease.TABLEThe literature supports the use of supplemental oxygen during moderate sedation and suggests that supplemental oxygen be used during deep sedation to reduce the frequency of hypoxemia. The consultants agree that supplemental oxygen decreases patient risk during moderate sedation, while strongly agreeing with this view for deep sedation.Equipment to administer supplemental oxygen should be present when sedation/analgesia is administered. Supplemental oxygen should be considered for moderate sedation and should be administered during deep sedation unless specifically contraindicated for a particular patient or procedure. If hypoxemia is anticipated or develops during sedation/analgesia, supplemental oxygen should be administered.The literature suggests that combining a sedative with an opioid provides effective moderate sedation; it is equivocal regarding whether the combination of a sedative and an opioid may be more effective than a sedative or an opioid alone in providing adequate moderate sedation. For deep sedation, the literature is insufficient to compare the efficacy of sedative–opioid combinations with that of a sedative alone. The consultants agree that combinations of sedatives and opioids provide satisfactory moderate and deep sedation. However, the published data also suggest that combinations of sedatives and opioids may increase the likelihood of adverse outcomes, including ventilatory depression and hypoxemia; the consultants were equivocal on this issue for both moderate and deep sedation. It is the consensus of the Task Force that fixed combinations of sedative and analgesic agents may not allow the individual components of sedation/analgesia to be appropriately titrated to meet the individual requirements of the patient and procedure while reducing the associated risks.Combinations of sedative and analgesic agents may be administered as appropriate for the procedure being performed and the condition of the patient. Ideally, each component should be administered individually to achieve the desired effect (e.g. , additional analgesic medication to relieve pain; additional sedative medication to decrease awareness or anxiety). The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component as well as the need to continually monitor respiratory function.The literature is insufficient to determine whether administration of small, incremental doses of intravenous sedative/analgesic drugs until the desired level of sedation or analgesia is achieved is preferable to a single dose based on patient size, weight, or age. The consultants strongly agree that incremental drug administration improves patient comfort and decreases risks for both moderate and deep sedation.Intravenous sedative/analgesic drugs should be given in small, incremental doses that are titrated to the desired end points of analgesia and sedation. Sufficient time must elapse between doses to allow the effect of each dose to be assessed before subsequent drug administration. When drugs are administered by nonintravenous routes (e.g. , oral, rectal, intramuscular, transmucosal), allowance should be made for the time required for drug absorption before supplementation is considered. Because absorption may be unpredictable, administration of repeat doses of oral medications to supplement sedation/analgesia is not recommended.The literature suggests that, when administered by non-anesthesiologists, propofol and ketamine can provide satisfactory moderate sedation, and suggests that methohexital can provide satisfactory deep sedation. The literature is insufficient to evaluate the efficacy of propofol or ketamine administered by non-anesthesiologists for deep sedation. There is insufficient literature to determine whether moderate or deep sedation with propofol is associated with a different incidence of adverse outcomes than similar levels of sedation with midazolam. The consultants are equivocal regarding whether use of these medications affects the likelihood of producing satisfactory moderate sedation, while agreeing that using them increases the likelihood of satisfactory deep sedation. However, the consultants agree that avoiding these medications decreases the likelihood of adverse outcomes during moderate sedation and are equivocal regarding their effect on adverse outcomes during deep sedation.The Task Force cautions practitioners that methohexit

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The Department of Veterans Affairs' NSQIP

1998-10-01

Shukri F. Khuri , Jennifer Daley , William G. Henderson +7 more

Objective To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the … Objective To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans. Summary Background Data Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive. Methods This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA). Results The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. Conclusions Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.

Effect of Mannitol on Renal Function during Cardiac Surgery and Immediate Post-Operative in Selected Private Hospitals in Nablus City/ Palestine

2025-06-25

Belal Rahhal , Heba Salah , Leen Abu Abdoh +4 more | Jordan Journal of Pharmaceutical Sciences

Background: Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery, however, it is associated with acute kidney injury. The type of solution in the CPB circuit can potentially affect … Background: Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery, however, it is associated with acute kidney injury. The type of solution in the CPB circuit can potentially affect surgery outcome through affecting several organs and body homeostasis. The optimal prime solution for the CPB) circuit in adult cardiac surgery has not yet been defined. Mannitol is widely used in the priming solution for CPB even though there is no clear consensus on the role of mannitol in cardiac surgery. Purpose: The purpose of this study was to investigate the effect of mannitol in the CPB prime solution on renal function during cardiac surgery and post-operative in selected private hospitals in Nablus City Design and method: prospective cohort study design conducted at An-Najah National University Hospital and specialized Arab hospital. A sample of 120 patients was studied. The patients had cardiac surgery and they had preoperative normal renal function. Results: The use of mannitol in the CPB prime solution was associated with a decrease in creatinine and BUN readings levels in the postoperative period (postoperative period mean =0.7692 ± 0.26068, and 18.3917 ± 7.56629mg/dl, respectively; p-value<0.001) and an increase in GFR levels in the postoperative period (postoperative period mean = 112.27861 ± 1.43604, p-value<0.001) indicating and improvement in renal function following cardiac surgery.

Intensive Care

2025-06-25

Rachel Horton | Bristol University Press eBooks

Precision leak detection in the golden window: emerging biomarker strategies for anastomotic integrity monitoring after low anterior resection

2025-06-25

Z Xiong , Jie Liu , Lin Chen +2 more | International Journal of Surgery

Anastomotic leakage (AL) following low anterior resection (LAR) for rectal cancer is a devastating complication affecting 1–30% of patients, with profound clinical, oncological, and psychological implications. Early diagnosis of AL … Anastomotic leakage (AL) following low anterior resection (LAR) for rectal cancer is a devastating complication affecting 1–30% of patients, with profound clinical, oncological, and psychological implications. Early diagnosis of AL is crucial for timely intervention. We adopted a tiered evidence synthesis approach, prioritizing existing meta-analyses and systematic reviews while supplementing others with relevant primary studies, categorizing biomarkers by healing phase (inflammation, proliferation, remodeling). Our analysis reveals that CRP (cutoff: 140-159 mg/L on POD3-5) and PCT (cutoff: 0.7-1.3 ng/mL on POD3-5) offer high negative predictive value in blood, enabling early discharge within ERAS pathways. Drainage fluid biomarkers (e.g., IL-6, IL-10, MMP9, bile acids) demonstrate superior site-specificity, with MMP9 and IL-10 elevation on POD1 showing particular promise for incipient leak detection. Novel approaches include ischemia markers (lactate, I-FABP), collagenolytic microbiota profiling ( Enterococcus faecalis ), and excretion-derived biomarkers (urinary VOCs), though these require further validation. Critically, drainage fluid analysis capitalizes on existing clinical infrastructure, while combinatorial multi-marker surveillance appears essential to overcome the limitations of singular biomarkers. Future efforts must prioritize integrated diagnostic platforms embedding dynamic biomarker profiling, mechanistic drivers (ROS/FPR pathways, enteric dysbiosis, genetic polymorphisms), and real-time interventions to transition from reactive rescue to personalized AL prevention.

Major adverse cardiac events with haloperidol: A meta-analysis

2025-06-25

Michael Cristian Garcia , Mason Anderson , Michelle Li +7 more | PLoS ONE

Background Haloperidol is a commonly used antipsychotic drug and a frequent source of medication safety alerts because of its listing as a “known risk” QT interval-prolonging medication (QTPmed). We aimed … Background Haloperidol is a commonly used antipsychotic drug and a frequent source of medication safety alerts because of its listing as a “known risk” QT interval-prolonging medication (QTPmed). We aimed to summarize the high-quality literature on the frequency and nature of proarrhythmic major adverse cardiac events (MACE) associated with haloperidol. Methods We searched Medline, Embase, International Pharmaceutical Abstracts, and Cochrane Central for randomized controlled trials (RCTs) involving patients 18 years or older comparing haloperidol to placebo. The FDA-adapted MACE composite included death, non-fatal cardiac arrest, ventricular tachyarrhythmia including torsades de pointes, and seizure or syncope. Random-effects meta-analyses were performed with a treatment-arm continuity correction for single and double zero event studies. Results 84 RCTs (n = 12180, 46% female), 23.8% of trials reported mean or median ages of their participants to be older than 65 years with 37 (44.0%) involving participants with psychiatric diagnoses, and 50 (59.5%) including electrocardiograms. Median follow-up duration was 28.0 days (interquartile range [IQR]=51.0). There were 1144 events, of which 97.8% were deaths, with 22 ventricular arrhythmias and 3 seizures or syncope. There was no difference in MACE with exposure to haloperidol compared to placebo (risk ratio [RR] 0.93, 95% CI: 0.80–1.08; I 2 = 0%). IV haloperidol was not associated with increased risk of mortality (n = 5873, RR: 0.88, 95%CI:0.72–1.08). Conclusions We did not find that haloperidol was arrhythmogenic or increased mortality in these largely short-duration trials. Further research to clarify actual clinical outcomes related to QTPmeds is important to inform safe prescribing practices.

C-Type Natriuretic Peptide: Protecting the Aorta

2025-06-25

S. Jeson Sangaralingham , John C. Burnett | Arteriosclerosis Thrombosis and Vascular Biology

The BASIC Question of Disparities in Anesthesiology Assessment

2025-06-25

Daniel Saddawi‐Konefka , Maya Jalbout Hastie | Anesthesia & Analgesia

Multimodal Analgesia and Enhanced Recovery Outcomes in Cardiac Surgical Patients: An Observational Cohort Study

2025-06-25

Amanda M. Kleiman , Siny Tsang , Susan M. Walters +6 more | Anesthesia & Analgesia

BACKGROUND: Multimodal analgesia, the use of more than 1 pharmacologic agent targeting different receptors, is a cornerstone of enhanced recovery after cardiac surgery (ERACS), but there are limited studies to … BACKGROUND: Multimodal analgesia, the use of more than 1 pharmacologic agent targeting different receptors, is a cornerstone of enhanced recovery after cardiac surgery (ERACS), but there are limited studies to support its efficacy. We aimed to explore associations between multimodal analgesia and enhanced recovery outcomes after cardiac surgery. METHODS: We performed a retrospective cohort study using data from the Society of Thoracic Surgeons database from 2020 to 2023. Adults undergoing elective coronary artery bypass grafting (CABG), valve, or combined CABG-valve surgery were included. Our primary hypothesis was that multimodal analgesia would be associated with a lower maximum postoperative pain score on postoperative day 3 (POD3). Secondarily, we hypothesized that multimodal analgesia would be associated with reduced mechanical ventilation hours, intensive care unit stay, delirium, pneumonia, and reintubation. Linear mixed-effects regression models and generalized linear mixed-effects regression models were used to examine the extent the use of multimodal analgesia was associated with study outcomes after controlling for confounders. RESULTS: Over the 4-year study period, there were 17,371 eligible cardiac surgical cases and 15,515 patients (89.3%) received multimodal analgesia. There was no association between multimodal analgesia use and maximum postoperative pain score on POD3 ( b = −0.07, 95% confidence interval [CI], −0.32 to 0.18, P = .57), after adjusting for confounders. There was an association between multimodal analgesia use and initial mechanical ventilation hours ( b = 0.45 hours, 95% CI, 0.04–0.86, P = .03). Compared to patients who received multimodal analgesia, those who did not receive multimodal analgesia had approximately 30 minutes longer of initial mechanical ventilation time on average. Initial mechanical ventilation time decreased as the number of multimodal analgesic increased ( b = −0.33 hours, 95% CI, −76 to −0.10, P = .14) for 1 multimodal analgesic; Est = −1.98 hours, 95% CI, −3.79 to −0.18, P = .03 for 5 multimodal analgesics). Acetaminophen use was associated with a reduced likelihood of delirium (odds ratio [OR] = 0.75, 95% CI, 0.57–0.94, P = .02), while use of a regional nerve block was associated with increased likelihood of unplanned reintubation (OR = 1.59, 95% CI, 1.12–2.27, P = .01). CONCLUSIONS: In this retrospective study, multimodal analgesia was not associated with the primary outcome of reduction in maximum pain score but was associated with more rapid extubation. Larger prospective observational and randomized controlled trials of individual analgesic drugs are needed to optimize ERACS protocols.

Opioids in Critically Ill Acute Myocardial Infarction Patients: A Retrospective Analysis of the MIMIC-IV Database

2025-06-25

Siyuan Xie , Bryan Richard Sasmita | Journal of General Internal Medicine

Improving Pediatric Surgery Quality by Widely Adopting an Evidence-based Protocol

2025-06-25

J Joly , Mónica E. López , Erich J. Grethel +7 more | Annals of Surgery

Objective: This study aimed to demonstrate wide adoption of an evidence-based, short-course antibiotic protocol in pediatric complicated appendicitis, and assess impact of protocol adoption across multiple institutions. Summary Background Data: … Objective: This study aimed to demonstrate wide adoption of an evidence-based, short-course antibiotic protocol in pediatric complicated appendicitis, and assess impact of protocol adoption across multiple institutions. Summary Background Data: Short-course antibiotics for intraabdominal infection with source-control is an evidence-based practice not widely used in children. The Pediatric Surgery Quality Collaborative (PSQC), a partnership of National Surgical Quality Improvement Program-Pediatric (NSQIP-P) hospitals, proposed a short-course protocol for patients with complicated appendicitis post-appendectomy. Methods: This observational quality improvement study was conducted at 36 PSQC hospitals (7/1/2023-6/30/2024). A protocol recommending 4+/-1 antibiotic days (IV+PO) was proposed. Patients across hospitals were grouped by protocol versus usual care. Primary outcome was total antibiotic days. Secondary outcomes included 30-day surgical site infection (SSI). Multivariable regressions with propensity scoring and inverse-probability-of-treatment weighting were utilized. Results: The protocol was adopted by 21 hospitals; 15 continued usual care. Across hospitals, 1934 patients were analyzed: 1046 protocol, 888 usual care. The median age was 10 years (IQR:7.3-13.2), 59% were male. 30-day SSI rate was 13% (91% organ space). In multivariable regression, the protocol group had fewer antibiotic days (RR:0.69, 95%CI:0.62-0.78): mean of 5.8 days vs 8.4 for usual care, a difference of 2.6 fewer antibiotic days (95%CI:1.73-3.37). Multivariable regression showed no difference in 30-day SSI rates between groups (12.7% vs 13.6%) (OR:0.96, 95%CI:0.63-1.47). Conclusion: This PSQC effort demonstrates widespread standardization of care and quality improvement in pediatric surgery through multicenter adoption of an evidence-based, short-course antibiotic protocol. Protocol adoption was associated with fewer antibiotic days without increasing 30-day SSI.

Cardiac Intensive Care

2025-06-25

Sharon Jones | JAMA

Preoperative Cardiovascular Risk and Postoperative Outcomes by Renin-Angiotensin System Inhibitor Use

2025-06-25

Justine Tang , Romain Pirracchio , Bernard Cholley +7 more | JAMA Cardiology

Importance The STOP-or-NOT randomized clinical trial compared the outcomes of continuing vs discontinuing renin-angiotensin system inhibitors (RASi) prior to major noncardiac surgery and found no difference in the postoperative risk … Importance The STOP-or-NOT randomized clinical trial compared the outcomes of continuing vs discontinuing renin-angiotensin system inhibitors (RASi) prior to major noncardiac surgery and found no difference in the postoperative risk of death or major complications, but it remains unclear whether preoperative cardiovascular risk stratification influences the response to this intervention. This post hoc analysis explores whether preoperative cardiovascular risk stratification affects the outcomes in patients who continue vs discontinue RASi use before major surgery. Objective To evaluate whether preoperative cardiovascular risk stratification affects the strategy of RASi management before major noncardiac surgery. Design, Setting, and Participants This is a post hoc analysis of the multicenter STOP-or-NOT randomized clinical trial, conducted across 40 hospitals in France between January 2018 and April 2023, with follow-up for 28 days postoperatively. Data analysis was performed from September 2024 to January 2025. The participants were patients who had been treated with RASi for at least 3 months and were scheduled for major noncardiac surgery. Intervention Patients were randomized to either continue RASi until the day of surgery or to discontinue RASi 48 hours prior to surgery. Main Outcomes and Measures The primary outcome was a composite of all-cause mortality and major postoperative complications. Secondary outcomes were major adverse cardiovascular events and acute kidney injury. Cardiovascular risk stratification was assessed with the Revised Cardiac Risk Index (RCRI), American University of Beirut (AUB)–HAS2 Cardiovascular Risk Index, and systolic blood pressure prior to randomization. Results Among the 2222 patients (median [IQR] age, 68 [61-73] years; 771 [35%] female), 1107 were randomized to RASi continuation and 1115 were randomized to RASi discontinuation. Using the RCRI, 592 patients were categorized as low risk (0 points), 1095 as intermediate-low risk (1 point), 418 as intermediate-high risk (2 points), and 117 as high risk (≥3 points). Using the AUB-HAS2 Cardiac Risk Index, 1049 patients were categorized as low risk (0 points), 727 as intermediate-low risk (1 point), 333 as intermediate-high risk (2 points), and 113 as high risk (≥3 points). A total of 2132 patients were split into 4 quartiles of preoperative systolic blood pressure. The risk of postoperative complications and major adverse cardiovascular events varied with RCRI score. However, a strategy of RASi continuation vs discontinuation was not associated with a higher risk of postoperative complications. Conclusions This study found that preoperative cardiovascular risk did not affect patient outcomes with respect to the strategy of continuing vs discontinuing RASi before major noncardiac surgery, suggesting that the decision to continue or discontinue RASi should not be influenced by a patient’s preoperative cardiovascular risk assessment. Trial Registration ClinicalTrials.gov Identifier: NCT03374449

Association of ASA Score with Postoperative Complications in Uro-oncological Surgeries: A Retrospective Comparative Analysis of ASA 1-2 and ASA 3-4 Patients

2025-06-25

Adem Sancı , Hüseyin Mert Durak , Reyhan İşlek Özenç +5 more | Bulletin of Urooncology

Erratum zu: Zusammenfassung der EACTS/STS-Leitlinie zur Diagnose und Therapie akuter und chronischer Syndrome des Organs Aorta

2025-06-25

Murat Uzdenov , Maximilian Kreibich , Tim Berger +5 more | Zeitschrift für Herz- Thorax- und Gefäßchirurgie

[Artificial intelligence empowers functional preservation and safety guarantee in laparoscopic colorectal surgery].

2025-06-25

Zhijian Sun , Yi Xiao | PubMed

Transabdominal and transanal endoscopic approaches have become mainstream in colorectal surgery. With the substantial improvement in survival outcomes for colorectal cancer patients, a growing number of colorectal surgeons are increasingly … Transabdominal and transanal endoscopic approaches have become mainstream in colorectal surgery. With the substantial improvement in survival outcomes for colorectal cancer patients, a growing number of colorectal surgeons are increasingly focusing on enhancing postoperative quality of life, prioritizing functional preservation, especially the intraoperative preservation of pelvic autonomic nerves. Recently, with the gradual deepening of artificial intelligence (AI) applications in the medical field, colorectal surgeons have begun exploring its implementation in colorectal surgery. Current achievements primarily involve the identification and protection of nerves and organs. However, most AI applications remain at preclinical exploration stages, limiting their clinical application. Furthermore, AI faces challenges in recognizing blood vessels with significant deformation and movement. Thus, the precise real-time navigation and protection of blood vessels during surgery have yet to be achieved. Therefore, future developments in this field should focus on resolving issues such as non-rigid registration, real-time calibration etc., thereby deepening the application of AI in functional preservation and surgical safety assurance during laparoscopic colorectal surgery.

Causalidad del deterioro cognitivo en cirugía cardiaca de pacientes atendidos en un hospital de tercer nivel de atención

2025-06-24

Álvaro J. Montiel‐Jarquín , Angélica Porras-Juárez , Arturo García-Galicia +4 more | Anales Médicos de la Asociación Médica del Centro Médico ABC

How can artificial intelligence (AI) transform ultrasonography for regional anesthesia and pain management?

2025-06-24

Qurba Kiran | Anaesthesia Pain & Intensive Care

Ultrasound is a well-recognized tool for regional anesthesia and tailored pain management. It offers real-time imaging of patient’s anatomy and provides guideline for needle insertion with precision. Though, its accuracy … Ultrasound is a well-recognized tool for regional anesthesia and tailored pain management. It offers real-time imaging of patient’s anatomy and provides guideline for needle insertion with precision. Though, its accuracy highly relies on operator’s skill and experience. The incorporation of Artificial Intelligence (AI) into ultrasound modality has transformed the field by upgrading the explication of images including tumor detection, segmentation and classification by inculcating the Convolution Neural Networks (CNNs) which is a type of deep learning.

Machine learning model for the prediction of postoperative acute kidney injury (AKI) in neonates undergoing digestive surgery

2025-06-24

Yu Cui , Diwei Zhang , Qinghua Huang +1 more | Pediatric Surgery International

Consensus on Key Attributes of Cardiac Surgeons’ Intraoperative Performance

2025-06-24

Roger D. Dias , Francis D. Pagani , Donald S. Likosky +4 more | Journal of surgical education

Post-Operative Ludwig's Angina in an 11-Year-Old: An Atypical Case of Unknown Aetiology

2025-06-24

ME Forrest , Shuchi S. Pandya , Hitesh Bansal | International Journal of Oral and Maxillofacial Surgery

False Positives in Doppler Monitoring in Flap Salvage Cases – A Previously Undescribed Pitfall

2025-06-24

R. Iqbal , Sadiq Mawji , Matthew Idle +3 more | International Journal of Oral and Maxillofacial Surgery

Surgical ICU Admission Criteria: A Scoping Review

2025-06-24

Kenneth L. Abbott , Philip Hong , Matthew M. Ruppert +6 more | Critical Care Explorations

The aims of this scoping review were to: 1) explore factors driving surgical ICU (SICU) admission decisions, 2) provide an environmental scan of SICU admission practices, and 3) identify underexamined … The aims of this scoping review were to: 1) explore factors driving surgical ICU (SICU) admission decisions, 2) provide an environmental scan of SICU admission practices, and 3) identify underexamined domains relevant for SICU triage, admission, and discharge inquiries. Embase, PubMed, and Medline were queried from inception to April 18, 2024, for English-language peer-reviewed studies related to adult SICU admission criteria and decision-making; neonatal ICU, PICU, veterinary ICU, and military ICU data and gray literature were excluded. Studies were not limited by design. Following duplicate removal, 363 of the initial 625 abstracts remained. After content screening, 54 abstracts remained topic aligned. Full-text review identified 44 articles appropriate for analysis. Abstracted data addressed SICU structure, function, findings, and potential future directions. Most included studies (n = 23, 52%) focused on identifying risk factors for SICU admission or risk factors for the need for SICU admission, including demographics, comorbidities, and procedural specifics. Admission protocol evaluation studies were less common (n = 5, 11%), but offered promise in reducing unnecessary admissions using preoperative or postoperative interventions. Future inquiry domains included admission and discharge protocol development (n = 17, 39%), risk factors for ICU admission or the need for ICU admission (n = 16, 36%), multicenter studies (n = 16, 36%), additional or specific patient populations (n = 15, 34%), prospective studies (n = 14, 32%), costs (n = 6, 14%), and implementation of embedded clinical decision-support aids to inform SICU triage decision-making (n = 2, 5%). No included studies presented results regarding SICU discharge decision-making or ICU stress adaptations relevant during surge episodes. Research on SICU triage decision-making primarily focuses at admission risk factor discovery, with less emphasis on protocol evaluation and implementation practices. Future research should focus on refining existing SICU triage approaches that include discharge and surge-based decision-making coupled with deployable clinical decision-support aids.

Mannitol and renal failure during cardiopulmonary bypass. Which of biomarkers should be use?

2025-06-24

Guillermo Lema | Perfusion

Midterm Outcomes of Transcatheter Closure of Anastomotic Leak after Ascending Aortic Surgery

2025-06-24

Chengwei Yang , Wei‐Guo Ma , Hao Liu +4 more | The Thoracic and Cardiovascular Surgeon

Objectives: To evaluate the safety and durability of transcatheter closure of anastomotic leak (AL) after ascending aortic (AAo) surgery. Methods: From 2016–2021, we performed transcatheter closure for 22 patients aged … Objectives: To evaluate the safety and durability of transcatheter closure of anastomotic leak (AL) after ascending aortic (AAo) surgery. Methods: From 2016–2021, we performed transcatheter closure for 22 patients aged 56.9±12 years (19 male, 86.4%) with AAoAL after AAo surgery. Access and device were selected according to the presence of patent Cabrol (perigraft-to-right atrium) shunt (n=16, 72.7%) and leak size. Results: Fifteen patients had tricuspid regurgitation (TR) (68.2%); 13 were symptomatic (59.1%), and 11 in NYHA functional class III/IV (50%). Mean AAoAL diameter was 3.3±1.5mm. Mean procedural time was 141±53min. Procedural success rate was 86.4% (19/22, 14 with Cabrol shunt). AAoAL was directly closed or coiled in 12 patients. Follow-up was complete in 100% at mean 4.9±1.1 years (range 3.6–8.1). All patients were alive and two underwent reoperation. Freedom from death and reoperation was 94.7% at 2 years and 89.5% through 7 years. AAoAL was obliterated in 11, while trace residual shunt was seen in 8 patients. The aorta at the leak shrank significantly in all (49.1 to 41.4mm, P=0.010). Patients with Cabrol shunt showed a significant shrinkage of right atrium (46.9±8.8 vs 39.1±8.2mm, P=0.030) and right ventricle (41.4±4.7 vs 30.4±6.2mm, P<0.001), with improved heart function (NHYA class III 4/12, IV 5/12 vs class III 4/12, IV 0/12, P=0.032) and alleviated TR (moderate 6/14 vs 2/14, severe 3/14 vs 1/14, P=0.081). Conclusions: Transcatheter closure may be a feasible, safe and effective approach to anastomotic leak after ascending aortic surgery in selected patients, which can achieve favorable short- to mid-term outcomes.

Integrating Functional Medicine With ERAS Protocol In Maxillofacial Surgery: Improving Patient Outcomes And Overall Well-being

2025-06-24

Bikram Dhara | International Journal of Oral and Maxillofacial Surgery

Non-Technical Skills in OMFS – Enhancing Surgical Performance

2025-06-24

C. Fowell | International Journal of Oral and Maxillofacial Surgery

In response to: Association of intraoperative end-tidal CO2 levels with postoperative outcomes – The importance of considering cardiac output in complication risk

2025-06-23

Prashant Nasa , Sabrine N.T. Hemmes , Marcus J. Schultz | Journal of Clinical Anesthesia

TÌNH HÌNH KIỂM SOÁT NỒNG ĐỘ NON HDL-C HUYẾT THANH Ở BỆNH NHÂN HỘI CHỨNG VÀNH CẤP KHI ĐƠN TRỊ ATORVASTATIN 40MG TẠI BỆNH VIỆN ĐA KHOA TỈNH BÌNH THUẬN NĂM 2024-2025

2025-06-23

Lượm Trần Thị , Khương Nguyễn Duy , D. Thanh | Tạp chí Y học Việt Nam

Đặt vấn đề: Nồng độ Non-HDL huyết thanh tăng cao có liên quan đến kết cục xấu ở bệnh nhân hội chứng vành cấp. Việc đơn trị atorvastatin liều 40mg … Đặt vấn đề: Nồng độ Non-HDL huyết thanh tăng cao có liên quan đến kết cục xấu ở bệnh nhân hội chứng vành cấp. Việc đơn trị atorvastatin liều 40mg nhằm kiểm soát non-HDL trong thời gian ngắn liệu có đạt kết quả tốt vẫn chưa được chứng minh rõ do dữ liệu hiện tại chưa có sự đồng nhất, đặc biệt tại Việt Nam. Mục tiêu: Xác định tỷ lệ đạt mục tiêu kiểm soát nồng độ non HDL-c huyết thanh ở bệnh nhân hội chứng vành cấp với đơn trị liệu atorvastatin 40mg. Đối tượng và phương pháp nghiên cứu: Nghiên cứu can thiệp không đối chứng trên 34 bệnh nhân hội chứng vành cấp được điều trị atorvastatin liều 40mg trong thời gian 4 tuần tại Bệnh viện Đa khoa tỉnh Bình Thuận từ tháng 09 năm 2024 đến tháng 03 năm 2025. Kết quả: Tỷ lệ nữ/nam ~ 1,27, độ tuổi trung bình là 73,18 ± 9,15, BMI trung bình là 24,41±2,37 kg/m2, tỷ lệ béo phì chiếm 55,9%. Về bệnh nền, có đến 55,9% bệnh nhân mắc kèm đái tháo đường. Đặc điểm về bilan lipid máu ghi nhận sau can thiệp: cholesterol toàn phần là 4,98±1,67 mmol/L, HDL-c là 1,14±0,32. Nồng độ non-HDL-c rất cao, trung bình là 3,84±1,64. Tỷ lệ bệnh nhân đạt mục tiêu non-HDLc với đơn trị liệu atorvastatin 40mg sau 04 tuần chỉ chiếm 26,5%. Kết luận: Nồng độ non HDL-c huyết thanh tăng cao trong hội chứng vành cấp. Việc kiểm soát bằng đơn trị liệu với atorvastatin 40mg không mang lại hiệu quả cao.

NGHIÊN CỨU HIỆU QUẢ GIẢM ĐAU THEO THANG ĐIỂM VAS SAU ĐIỀU TRỊ THOÁT VỊ ĐĨA ĐỆM CỘT SỐNG THẮT LƯNG BẰNG LIỆU PHÁP OZONE QUA DA DƯỚI HƯỚNG DẪN CỦA CẮT LỚP VI TÍNH

2025-06-23

Đinh Thị Thảo , Thành Đinh Trung , Nghĩa Nguyễn Văn | Tạp chí Y học Việt Nam

Mục tiêu: Đánh giá hiệu quả giảm đau theo thang điểm VAS của liệu pháp ozone qua da dưới hướng dẫn của chụp cắt lớp vi tính điều trị thoát … Mục tiêu: Đánh giá hiệu quả giảm đau theo thang điểm VAS của liệu pháp ozone qua da dưới hướng dẫn của chụp cắt lớp vi tính điều trị thoát vị đĩa đệm cột sống thắt lưng tại Bệnh viện Đa khoa Xanh Pôn. Phương pháp: Nghiên cứu can thiệp được tiến hành trên 147 bệnh nhân (nhóm can thiệp 100 bệnh nhân, nhóm chứng 47 bệnh nhân). Sử dụng liệu Ozon và Corticoid qua da dưới hướng dẫn của MRI. Kết quả: Đường can thiệp kim vào đĩa đệm chủ yếu theo hướng sau ngoài chếch 45 độ (81%), còn lại theo đường giữa qua mảnh sống (19%). Mức độ tập trung đĩa đệm tốt trong 74% trường hợp, trung bình 20% và kém 6%. Điểm VAS giảm có ý nghĩa thống kê, từ 8,1 xuống 2,8 sau 6 tháng. Hiệu quả điều trị ngắn hạn và trung hạn (1 tháng, 3 tháng) tương đương giữa hai nhóm, nhưng sau 6 tháng, nhóm nghiên cứu có mức độ đau và mất chức năng thấp hơn nhóm chứng. Kết luận: Liệu pháp ozone qua da dưới hướng dẫn của MRI là phương pháp can thiệp hiệu quả trong điều trị thoát vị đĩa đệm cột sống thắt lưng, giúp giảm đau rõ rệt và duy trì chức năng vận động tốt hơn trong theo dõi dài hạn.

Author's Reply: Risk Factors for Duodenal Stump Leakage in Gastric Cancer Surgery and the Preventive Effect of Duodenal Stump Reinforcement

2025-06-23

Masanori Terashima | World Journal of Surgery

The Effect of Hypotension on Cerebral Metabolism and Perfusion in Adults Undergoing Cardiopulmonary Bypass: A Prospective Cohort Study

2025-06-23

Marianne Suwalski , Daniel Milej , John Paul Mousseau +5 more | Anesthesia & Analgesia

Current blood pressure management strategies cannot accommodate large interindividual variations in cerebral autoregulation, which may result in inadvertent cerebral ischemia. A novel optical neuromonitoring device was developed to explore the … Current blood pressure management strategies cannot accommodate large interindividual variations in cerebral autoregulation, which may result in inadvertent cerebral ischemia. A novel optical neuromonitoring device was developed to explore the relationships between blood pressure and cerebral metabolism and hemodynamics during hypotension on cardiopulmonary bypass and the transition on bypass in cardiac surgery. Forty-five elective adult patients were monitored by a hybrid optical device incorporating broadband near-infrared spectroscopy for monitoring changes in tissue oxygen saturation and the oxidative state of cytochrome c oxidase (oxCCO) in the brain along with diffuse correlation spectroscopy for measuring a cerebral blood flow index. Changes in the optical variables were evaluated. Seventy-four hypotensive events were associated with significant decreases (mean ± standard deviation) in oxCCO (-0.55 ± 0.18 μM), cerebral blood flow index (-48% ± 20%), and tissue oxygen saturation (-9% ± 5%, P < .001) when mean arterial pressure fell below 50, 35, and 25 mm Hg, respectively. Decreases in oxCCO corresponding to literature-defined cerebral blood flow lesion and functional thresholds were -1.10 and -0.87 μM. During transition on bypass, mild reductions in blood pressure and body temperature (34.9 ± 0.6°C) occurred without significant cerebral blood flow changes. Multiple linear regression demonstrated reduction in oxCCO was significantly associated with temperature and blood pressure (R2 = 0.92, P < .001), while tissue oxygen saturation and cerebral blood flow index had weaker associations (R2 = 0.75, P < .001; R2 = 0.42, P = .002, respectively). No significant changes in scalp oxCCO and tissue oxygen saturation were found during hypotensive episodes or CPB transition. This study identifies oxCCO as an optical variable that is highly responsive to hypotension. The work also highlights the link between blood pressure and cerebral metabolism and hemodynamics, offering potential insights into optimizing current blood pressure management.

Increase in calcidiol level is associated with improved sternal bone healing after cardiac surgery with sternotomy—REINFORCE-D trial results

2025-06-23

Dalibor Černý , Michal Čečrle , Eva Sedláčková +5 more | Trials

Heart surgery is associated with a sternotomy in most patients. Low serum calcidiol level below 80 nmol/l carries the risk of bone loss as a risk factor in sternotomy healing. … Heart surgery is associated with a sternotomy in most patients. Low serum calcidiol level below 80 nmol/l carries the risk of bone loss as a risk factor in sternotomy healing. The primary objective was to compare postoperative complications of sternotomy healing in two groups of patients treated with cholecalciferol or placebo. Secondary objectives were focused on the degree of sternal healing, length of hospitalization, number of days spent in ICU and mechanical ventilation, and number of repeated hospitalizations for sternotomy complications. Monocentric, randomized, double-blind, placebo-controlled, prospective study was conducted from September 2016 to December 2020 at Na Homolce Hospital. Of the 216 originally recruited and randomized subjects, 141 completed the study. Seventy-two subjects were enrolled in the cholecalciferol arm, and sixty-nine subjects in the placebo arm. The detailed methodology has been published previously. The results are presented as a comparison between two groups: calcidiol above 80 nmol/l (saturated subjects) and the calcidiol lower or equal to 80 nmol/l (unsaturated subjects). Statistics include 141 subjects. After a 6-month follow-up, CT imaging and calcidiol levels were performed. postoperative complications in sternotomy were not among the population under or above 80 nmol/l statistical difference (p = 0.907). monitored parameters did not differ between individual arms. But the key was the state of saturation with calcidiol (> 80 nmol/l), which was associated with a significantly lower risk of complete non-healed sternotomy (p = 0.008). Optimal calcidiol level (> 80 nmol/l) indicates a positive trend towards greater sternal healing. Cholecalciferol oral administration can be considered as a safe method how to achieve the required calcidiol concentration. EU Clinical Trials Register, EUDRA CT No: 2016-002606-39.

Dynamic Updating Strategies to Assess Hospital Performance of Surgical Aortic Valve Replacement

2025-06-23

Jackie Pollack , Wei Yang , George J. Arnaoutakis +2 more | Circulation Cardiovascular Quality and Outcomes

BACKGROUND: Prediction models determining expected outcomes are infrequently updated (ie, static), which may reduce accuracy and misclassify hospital performance over time. Dynamic models incorporate changes over time and may improve … BACKGROUND: Prediction models determining expected outcomes are infrequently updated (ie, static), which may reduce accuracy and misclassify hospital performance over time. Dynamic models incorporate changes over time and may improve accuracy and fairness in hospital comparisons. This study evaluated whether dynamic updating, compared with a static model, altered hospital rankings and outlier detection among surgical aortic valve replacement patients. METHODS: This retrospective cohort study assessed performance across 53 hospitals using claims data from the Pennsylvania Health Care Cost Containment Council. A multivariable logistic regression model using clinical and demographic variables was developed on data from 1999 to 2006 to predict 30-day postoperative mortality, then applied to testing data from 2007 to 2018 to compare 4 strategies: (1) a static model with fixed parameters, (2) an annual correction factor based on The Society of Thoracic Surgeons methodology, (3) calibration regression for annual recalibration, and (4) dynamic logistic state space model to continuously update model coefficients. Performance was evaluated using observed-to-expected ratios and Z scores. Lower values indicate better-than-expected outcomes. RESULTS: The training sample included 14 070 patients (mean age 66.6; 43.1% female); the testing sample included 29 127 patients (mean age 67.4; 39.1% female). The static model had the widest Z score variability (range −6.97 to 1.38), compared with calibration regression (−3.04 to 2.85), correction factor (−2.87 to 3.24), and dynamic logistic state space model (−2.57 to 3.03). The static model labeled 15 hospitals as significantly better-than-expected; only 3 (20.0%) maintained this classification with the correction factor and dynamic logistic state space model, and 5 (33.3%) with calibration regression. No hospitals were classified as significantly worse-than-expected under the static model, whereas calibration regression identified 6, and both dynamic logistic state space model and the correction factor identified 7. CONCLUSIONS: Static models may misclassify hospital performance and rankings. Dynamic strategies influence outlier detection and change hospital rankings over time. Regular model updates may better reflect current performance, supporting fairer hospital comparisons.

Elevated drain fluid calprotectin as a predictor of early anastomotic leakage in colorectal surgery

2025-06-23

Limian Ling , Zhongchao Zuo , Ying Lv +6 more | World Journal of Surgical Oncology

Anastomotic leakage (AL) is a major cause of postoperative mortality following colorectal cancer surgery. This prospective investigation sought to establish the diagnostic utility of perioperative drain fluid calprotectin quantification in … Anastomotic leakage (AL) is a major cause of postoperative mortality following colorectal cancer surgery. This prospective investigation sought to establish the diagnostic utility of perioperative drain fluid calprotectin quantification in anticipating anastomotic complications following colorectal resections. A consecutive cohort of 306 subjects undergoing anterior resection for sigmoid colon or rectal cancer were prospectively enrolled and stratified based on postoperative clinical outcomes: 25 cases developing AL (Group A) versus 281 without AL (Group B). Calprotectin levels in drainage fluid, serum C-reactive protein (CRP), and interleukin-6 (IL-6) were compared between the groups. The diagnosis of AL was made between the 3rd and 11th postoperative day (POD), with a mean diagnosis time of 7 days. Group A showed significantly higher calprotectin levels starting from POD3 (207 vs. 96 ng/mL, p < 0.0001). POD3 calprotectin concentrations exceeding 110 ng/mL demonstrated superior discriminative capacity, achieving 92% diagnostic sensitivity with 82% specificity for preclinical AL detection. Early and persistent elevation of drain fluid calprotectin after colorectal surgery is a significant marker for AL, potentially offering an advantage over traditional inflammatory markers like CRP and IL-6 in the earlier prediction of AL. These findings provide valuable insights for improving postoperative management and patient outcomes.

External Validation of an Algorithm to Guide Opioid Administration at the End of Surgery—Protocol for an Observational Cohort Study of the <scp>OPIAID</scp> Algorithm

2025-06-23

Anders Peder Højer Karlsen , Pernille Bjersand Sunde , Ida Rasmussen +7 more | Acta Anaesthesiologica Scandinavica

Despite advances in pain management, inadequate pain relief and opioid-related adverse events remain common challenges in perioperative care, often contributing to prolonged recovery and reduced quality of life. The perioperative … Despite advances in pain management, inadequate pain relief and opioid-related adverse events remain common challenges in perioperative care, often contributing to prolonged recovery and reduced quality of life. The perioperative opioid algorithms for individualized dosing (OPIAID) project aims to develop machine-learning algorithms tailored to provide patient-specific opioid dosing across the different phases of perioperative care. For each phase, eight models are trained on granular data from 1.1 million surgical procedures, including demographic and surgical details, vital signs, administered analgesics, pain, and opioid-related adverse events. The two most accurate models will proceed to external validation. The best-performing model will subsequently be tested as a decision support against current standard of care. This protocol describes the design and external validation of the intraoperative OPIAID algorithm, which suggests the end-of-surgery opioid dose intended for postoperative analgesia by approximating clinical performance and evaluating reliability, agreement, and calibration. In this multicenter, TRIPOD+AI-adherent, prospective observational cohort study, we will collect data from a diverse surgical population of 656 adult patients undergoing elective or acute surgery under general anesthesia. All patients will require intraoperative opioid administration at the end of surgery for postoperative pain management and a subsequent stay in the post-anesthesia care unit. The cohort will be used to externally validate two machine-learning models through standardized measures of reliability, agreement, and calibration, and thereby designate the intraoperative OPIAID algorithm. Subsequently, the cohort will be used to approximate the clinical efficacy, safety and overall performance of the intraoperative OPIAID algorithm's recommended doses versus the clinician-administered doses. These comparisons will be based on each approach's proximity to a golden standard "optimal dose," which is calculated based on a predefined generic ruleset incorporating intraoperative opioid dosing, postoperative pain, opioid-related adverse events, and need for rescue opioid administrations. The intraoperative OPIAID algorithm is intended as a clinical decision aid for anesthesiologists and nurse anesthetists in providing adequate postoperative pain management.

Clinical Impact of Incidental Findings on Surgical Planning in Coronary Artery Bypass Surgery

2025-06-23

Ufuk Türkmen , Görkem Yiğit , Ayla Ece Çelikten +1 more | Hitit Medical Journal

Objective: To determine the frequency of incidental findings detected by preoperative non-contrast thoracoabdominal computed tomography (CT) in patients undergoing elective isolated coronary artery bypass grafting (CABG) and to assess their … Objective: To determine the frequency of incidental findings detected by preoperative non-contrast thoracoabdominal computed tomography (CT) in patients undergoing elective isolated coronary artery bypass grafting (CABG) and to assess their impact on surgical planning. Material and Method: This retrospective study included 534 patients who underwent elective CABG between January 2021 and December 2024. As part of the routine preoperative assessment protocol, all patients received a non-contrast thoracoabdominal CT scan. Incidental findings were classified by clinical significance. Patients were grouped based on whether surgical planning was altered (Group 1), unchanged with incidental findings (Group 2), or unchanged without findings (Group 3). Demographic, intraoperative, and postoperative data were compared across groups. Results: At least one incidentaloma was detected in 70.8% of patients. Of these, 12% led to changes in surgical strategy, most commonly off-pump surgery or graft modification. Surgery was canceled in six patients due to high-risk findings. Group 1 patients were older and had lower left ventricular function. Thirty-day mortality did not differ significantly between groups. Conclusion: Preoperative non-contrast thoracoabdominal CT in elective CABG candidates contributes significantly to both surgical planning and systemic evaluation, enhancing patient safety. Given its accessibility and cost-effectiveness, this method represents a valuable tool in routine preoperative assessment.

Improving surgical efficiency with the dynamic grasper: a cost-effective and innovative solution for optimizing exposure in minimally invasive surgery

2025-06-23

Treerat Tangpulphon , Chucheep Sahakitrungruang | Annals of Coloproctology

Association of ACGME Milestones With Other Performance Measures in General Surgery: A Meta-Analytic Study

2025-06-23

Ting Sun , Binbin Zheng-Lin , Kenji Yamazaki +2 more | Academic Medicine

The Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings in general surgery have the potential to be used as formative feedback to enhance trainee performance. This assumption rests on … The Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings in general surgery have the potential to be used as formative feedback to enhance trainee performance. This assumption rests on validity evidence, such as correlations with learning outcomes and early-career outcomes. This meta-analysis aims to estimate the effect size of the association between Milestone ratings and other performance measures in general surgery. The authors conducted electronic database (search dates: August 9, 2023, March 25, 2024, and February 20, 2025) and forward and backward reference searching. A 3-level meta-analysis was performed to account for clustering and dependency of effect sizes. Overall effect size and heterogeneity statistics were estimated. Moderated analyses were conducted to examine whether any observed heterogeneity could be accounted for by training level, Milestones competency category, outcomes, and Milestones version. The authors extracted 445 effect sizes from 16 studies. Milestone ratings were statistically significantly correlated with Entrustable Professional Activities (r = 0.59, P < .001) and American Board of Surgery In-Training Examination (r = 0.39, P < .001) but not with United States Medical Licensing Examination (r = 0.11, P = .20), social-emotional outcomes (r = 0.14, P = .25), patient outcomes (r = -0.08, P = .41), and residency application factors (r = 0.07, P = .42). Training level, Milestones competency category, and Milestones version did not moderate effect size estimates. The ACGME Milestone ratings in general surgery correlate strongly with some indicators of performance, including Entrustable Professional Activity assessments and the American Board of Surgery In-Training Examination, but not for other outcomes, such as United States Medical Licensing Examination, social-emotional outcomes, residency application factors, or patient outcomes.

Correction to: 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

2025-06-23

Sunil V. Rao , Michelle L. O’Donoghue , Marc Ruel +7 more | Circulation

Machine learning-based hybrid risk estimation system (ERES) in cardiac surgery: Supplementary insights from the ASA score analysis

2025-06-23

Ayşe Banu Birlik , Hakan Tozan , Banu Kose | PLOS Digital Health

Accurate prediction of postoperative mortality risk after cardiac surgery is essential to improve patient outcomes. Traditional models, such as EuroSCORE I, often struggle to capture the complex interactions among clinical … Accurate prediction of postoperative mortality risk after cardiac surgery is essential to improve patient outcomes. Traditional models, such as EuroSCORE I, often struggle to capture the complex interactions among clinical variables, leading to suboptimal performance in specific populations. In this study, we developed and validated the Ensemble-Based Risk Estimation System (ERES), a machine learning model designed to enhance mortality prediction in patients undergoing coronary artery bypass grafting and/or valve surgery. A retrospective analysis of 543 patients was performed using six machine learning algorithms applied to preoperative clinical data to assess predictive accuracy and clinical outcomes. Feature selection techniques, including Gini importance, Recursive Feature Elimination, and Adaptive Synthetic Sampling, were employed to improve accuracy and address class imbalance. ERES, which utilizes 15 key features, demonstrated superior predictive performance compared to EuroSCORE I. Calibration plots indicated more accurate probability estimates, whereas SHAP analysis identified creatinine, age, and left ventricular ejection fraction as the most significant predictors. The decision curve analysis further confirmed the superior clinical utility of ERES across a range of decision thresholds. Additionally, although the American Society of Anesthesiologists (ASA PS) score had limited predictive power independently, its combination with EuroSCORE I enhanced the predictive performance. Integrating machine learning models like ERES into clinical practice can improve decision making and patient outcomes although external validation is warranted for broader implementation.

A national perioperative platform trial to improve outcomes for surgical patients (PROTECT)

2025-06-23

Priyanthi Dias , Tom Abbott | http://isrctn.com/

Prognosis of Nonagenarian ICU Patients A Bayesian analysis of prospective European studies

2025-06-23

Daniel Dankl , Raphael Romano Bruno , Michael Beil +7 more | Annals of Intensive Care

Effectiveness of WALANT Technique in Various Orthopedic Surgeries: A Prospective Observational Study

2025-06-23

Ravi Bharatbhai Bhingaradiya , Shiv Acharya | International Journal of Science and Research (IJSR)

Optimized post-discharge care in patients with frailty after colon cancer surgery (project ERAS® 3.0): A protocol for a randomized controlled trial

2025-06-23

Elna A. Dalsgaard , Troels Gammeltoft Dolin , Cecilia Margareta Lund +4 more | Journal of Geriatric Oncology

The incidence of colon cancer increases with age, and the primary treatment is surgical resection. Patients with frailty have a reduced ability to handle stressors and face a higher risk … The incidence of colon cancer increases with age, and the primary treatment is surgical resection. Patients with frailty have a reduced ability to handle stressors and face a higher risk of complications and poor recovery after surgery. While Enhanced Recovery After Surgery (ERAS®) pathways improve in-hospital recovery, readmission rates remain high, and no structured post-discharge interventions exist for this population. Home-based post-discharge support may further enhance recovery in patients with frailty. This study evaluates the effect of an ERAS® 3.0 programme incorporating home-based geriatric, nutritional, and exercise interventions after discharge. This randomized controlled trial includes patients with colon cancer undergoing elective colonic resection within the ERAS® pathway during hospitalization. Patients with frailty (Clinical Frailty Scale score 4-7) and at nutritional risk (Nutritional Risk Screening 2002 ≥ 3) will be randomized 1:1 to either the intervention group (home-based geriatric, nutritional, and exercise interventions after discharge, n = 30) or standard post-discharge care (n = 30). The ERAS® 3.0 intervention includes protein-enriched foods and drinks at discharge, home-based comprehensive geriatric assessment, dietary counselling and exercise instructions, and outpatient follow-up with dietary counselling. The primary outcome is change in the Quality of Recovery-15 score from baseline to 12 ± 2 days after surgery. Secondary outcomes include quality of life, activities of daily living, energy and protein intake, appetite, 30-s chair-stand-test, muscle mass, total length of hospital stay, readmission rate, postoperative complications occurring after discharge, mortality, and costs. This study extends the ERAS® principles beyond hospitalization, addressing the post-discharge needs of patients with frailty at nutritional risk following colon cancer surgery. While ERAS® protocols significantly improve in-hospital recovery, readmission rates remain high and structured post-discharge interventions are lacking. By incorporating home-based geriatric, nutritional, and exercise interventions, this study aims to reduce complications, improve functional recovery, and quality of life. A key strength is the use of patient-reported outcome measures, providing an assessment of recovery beyond traditional clinical metrics. If effective, the ERAS® 3.0 intervention could offer a strategy for optimizing post-discharge care for surgical patients with frailty.

Efektivitas Penggunaan Blanket Warmer untuk Pencegahan Hipotermi pada Pasien Post-Operative dengan Pengaruh Anastesi Spinal

2025-06-22

Annisa Ranti Nur Azizah , Fahni Haris , Rahmawanto | TRIAGE Jurnal Ilmu Keperawatan

Latar Belakang: Hipotermia pascaoperasi merupakan komplikasi umum yang sering terjadi pada pasien yang menjalani anestesi spinal. Kondisi ini dapat memperlambat pemulihan, meningkatkan risiko infeksi luka, dan memperpanjang lama rawat inap. … Latar Belakang: Hipotermia pascaoperasi merupakan komplikasi umum yang sering terjadi pada pasien yang menjalani anestesi spinal. Kondisi ini dapat memperlambat pemulihan, meningkatkan risiko infeksi luka, dan memperpanjang lama rawat inap. Salah satu metode yang digunakan untuk menjaga suhu tubuh pasien adalah penggunaan blanket warmer. Tujuan: Mengetahui efektivitas penggunaan blanket warmer dalam mencegah terjadinya hipotermia pada pasien pascaoperasi yang menjalani anestesi spinal. Metode: Penelitian ini menggunakan desain case study dengan pendekatan pretest-posttest dan kelompok tanpa kontrol. Sampel terdiri dari 12 pasien post operasi di Ruang Pemulihan RSUD dr. Tjitrowardojo Purworejo yang menjalani prosedur pembedahan dengan anestesi spinal. Kelompok intervensi diberikan blanket warmer selama 10 menit dalam fase pemulihan pascaoperasi. Pengukuran suhu tubuh dilakukan sebelum dan sesudah intervensi menggunakan termometer aksila selama 1 menit. Hasil: Penggunaan blanket warmer menunjukkan peningkatan signifikan pada suhu tubuh pasien sebelum dan sesudah diberikan blanket warmer (p value 0,001<0,05). Mayoritas pasien pada kelompok intervensi berhasil mempertahankan suhu tubuh dengan rerata (mean) 36,32°C. Kesimpulan: Blanket warmer efektif dalam mencegah hipotermia pada pasien pascaoperasi dengan anestesi spinal. Penggunaan alat ini direkomendasikan sebagai bagian dari standar perawatan pascaoperasi untuk meningkatkan kenyamanan dan keamanan pasien.

Intensive Care

2025-06-22

| Bristol University Press eBooks

Altered Mental Status and Quadriparesis in Ambulatory Surgical Care: A Case Report

2025-06-22

Gonçalo Torrinha , Rui Vieira , Cecília Pacheco +2 more | Cureus

Adverse Event : Myocardial Injury after Non-Cardiac Surgery (MINS) Post Craniectomy in Critical Care

2025-06-21

Doni Fajri , Novita Anggraeni , Nopian Hidayat +1 more | Jurnal Neuroanestesi Indonesia

Intracerebral hemorrhage (ICH) describes the non-traumatic parenchymal hemorrhage caused by the rupture of cerebral vessels, accounting for 20–30% of all strokes. ICH will cause compression on the surrounding brain tissues, … Intracerebral hemorrhage (ICH) describes the non-traumatic parenchymal hemorrhage caused by the rupture of cerebral vessels, accounting for 20–30% of all strokes. ICH will cause compression on the surrounding brain tissues, eventually giving rise to increased intracranial pressure. Decompressive craniectomy (DC) effectively reduce intracranial pressure. Myocardial injury is defined as an elevation of cardiac troponin levels with or without associated ischemic symptoms. Case a male, 66 years old patient was admitted to the ICU after undergoing Emergency Craniectomy Hematoma Evacuation due to Spontaneous ICH. After 52 hours of treatment, the patient was found to have ventricular tachycardia (VT) on the monitor and restlessness. The patient was also found to have comorbid hypertension. On a 12-Lead ECG we found NSTEMI, and Troponin I level was measured at 453.0 ng/L (positive). This patient was treated with anticoagulants, antiplatelet and statin, with monitoring of the ECG daily. On The 6th day patient was moved to High Care Unit (HCU). Myocardial Injury after Noncardiac Surgery is defined by elevated postoperative cardiac troponin concentrations, with or without accompanying symptoms or signs. It typically occurs within 30 days after surgery. The management of MINS involves the use of anticoagulants and antiplatelet therapy. Anticoagulant therapy should be considered between benefit and risk of re-bleeding post operative. MINS is a rare condition but is associated with an increased risk of 30-day mortality. A multidisciplinary treatment approach and a coordinated team effort are essential for improving the outcomes of patients with this condition