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BackgroundThe optimal timing of noncardiac surgery (NCS) following transcatheter aortic valve replacement (TAVR) for aortic stenosis has not been elucidated by current national guidelines.ObjectivesThe aim of this study was to evaluate the effect of the time interval between TAVR and NCS (Δt) on the perioperative risk of major adverse events (MAEs).MethodsAll adult admissions for isolated TAVR for aortic stenosis were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients who received NCS on subsequent admission were included for analysis and grouped by Δt as follows: ≤30, 31 to 60, 61 to 90, and >90 days. Multivariable regression models were constructed to examine the association of Δt with ensuing outcomes.ResultsOf 3,098 patients (median age = 79 years, 41.6% female), 19.1% underwent NCS at ≤30 days, 22.9% at 31 to 60 days, 16.7% at 61 to 90 days, and 41.3% at >90 days. After adjustment, the odds of MAEs were similar for operations performed at ≤30 days (adjusted OR [AOR]: 1.05; 95% confidence interval [CI]: 0.74-1.50), 31 to 60 days (AOR: 0.97; 95% CI: 0.71-1.31), and 61 to 90 days (AOR: 0.95; 95% CI: 0.67-1.34), with those at >90 days as reference. When examining the average marginal effect of the interval to surgery, risk-adjusted MAE rates were statistically similar across Δt groups for elective status and NCS risk category combinations.ConclusionsNCS within 30, 31 to 60, or 61 to 90 days after TAVR was not associated with increased odds of MAEs compared with operations after 90 days irrespective of NCS risk category or elective status. Our findings suggest that the interval between NCS and TAVR may not be an accurate predictor of MAE risk in this population.

The " 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed. [ABSTRACT FROM AUTHOR]

Background: There has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS. Methods: There were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed. Results: A total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08–1.66) in the T3 group and by 1.35 times (95% CI 1.08–1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21–2.12) in the T3 group and by 1.61 times (95% CI 1.21–2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008). Conclusion: In this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea (OSA) is common in surgical patients and associated with worse perioperative outcomes. Objectives: To investigate the effect of mini-dose dexmedetomidine supplemented analgesia on postoperative sleep quality pattern in patients at high risk of OSA. Design: A pilot randomized, double-blind, placebo-controlled trial. Setting: A tertiary university hospital in Beijing, China. Patients: One hundred and fifty-two adult patients who had a STOP-Bang score ≥3 and a serum bicarbonate level ≥28  mmol/L and were scheduled for major noncardiac surgery between 29 January 2021 and 20 September 2022. Intervention: After surgery, patients were provided with high-flow nasal cannula and randomized in a 1:1 ratio to receive self-controlled opioid analgesia supplemented with either mini-dose dexmedetomidine (median 0.02  μg/kg/h) or placebo. We monitored polysomnogram from 9:00  pm to 6:00  am during the first night. Main outcome measures: Our primary outcome was the percentage of stage 2 non-rapid eye movement (N2) sleep. Secondary and exploratory outcomes included other postoperative sleep structure parameters, sleep-respiratory parameters, and subjective sleep quality (Richards-Campbell Sleep Questionnaire; 0–100 score range, higher score better). Results: All 152 patients were included in intention-to-treat analysis; 123 patients were included in sleep structure analysis. Mini-dose dexmedetomidine supplemented analgesia increased the percentage of stage N2 sleep (median difference, 10%; 95% CI, 1 to 21%; p  =  0.029); it also decreased the percentage of stage N1 sleep (median difference, −10%; 95% CI, −20% to −1%; p  =  0.042). Other sleep structure and sleep-respiratory parameters did not differ significantly between the two groups. Subjective sleep quality was slightly improved with dexmedetomidine on the night of surgery, but not statistically significant (median difference, 6; 95% CI, 0 to 13; p  =  0.060). Adverse events were similar between groups. Conclusion: Among patients at high risk of OSA who underwent noncardiac surgery, mini-dose dexmedetomidine supplemented analgesia may improve sleep quality without increasing adverse events. [ABSTRACT FROM AUTHOR]

The aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA. Patients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into 4 groups based on the CCS guidelines. The study included 669 patients who had an average age of 67 years. There were 43 patients (6.4%), who experienced a rise in troponin levels ≥30 ng/L and developed myocardial injury after noncardiac surgery. Among these patients, 8 developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol. The implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality. [ABSTRACT FROM AUTHOR]

Background: There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. Case presentation: Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. Conclusion: Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery. [ABSTRACT FROM AUTHOR]

Numerous models have been developed to predict acute kidney injury (AKI) after noncardiac surgery, yet there is a lack of independent validation and comparison among them. We conducted a systematic literature search to review published risk prediction models for AKI after noncardiac surgery. An independent external validation was performed using a retrospective surgical cohort at a large Chinese hospital from January 2019 to October 2022. The cohort included patients undergoing a wide range of noncardiac surgeries with perioperative creatinine measurements. Postoperative AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria. Model performance was assessed in terms of discrimination (area under the receiver operating characteristic curve, AUROC), calibration (calibration plot), and clinical utility (net benefit), before and after model recalibration through intercept and slope updates. A sensitivity analysis was conducted by including patients without postoperative creatinine measurements in the validation cohort and categorising them as non-AKI cases. Nine prediction models were evaluated, each with varying clinical and methodological characteristics, including the types of surgical cohorts used for model development, AKI definitions, and predictors. In the validation cohort involving 13,186 patients, 650 (4.9%) developed AKI. Three models demonstrated fair discrimination (AUROC between 0.71 and 0.75); other models had poor or failed discrimination. All models exhibited some miscalibration; five of the nine models were well-calibrated after intercept and slope updates. Decision curve analysis indicated that the three models with fair discrimination consistently provided a positive net benefit after recalibration. The results were confirmed in the sensitivity analysis. We identified three models with fair discrimination and potential clinical utility after recalibration for assessing the risk of acute kidney injury after noncardiac surgery. [ABSTRACT FROM AUTHOR]

Abstract Background There has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS. Methods There were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed. Results A total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08–1.66) in the T3 group and by 1.35 times (95% CI 1.08–1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21–2.12) in the T3 group and by 1.61 times (95% CI 1.21–2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008). Conclusion In this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS.

Abstract Background There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. Case presentation Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. Conclusion Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery.

Abstract Postoperative acute kidney injury (AKI) is a common complication that is associated with chronic kidney disease, early postsurgical mortality, and prolonged hospital stays. Preterm neonates who undergo surgery are at risk factors for AKI due to underdeveloped kidneys. To date, little is known about the incidence and perioperative risk factors for AKI in preterm neonates undergoing noncardiac surgery. Preterm neonates who underwent noncardiac surgery between January May 1, 2020, and February 28, 2023, were enrolled in the trial according to the inclusion criteria. Both multivariable and logistic regression analyses were used to analyze the associations between characteristic data and AKI. In total, 106 preterm neonates met the inclusion criteria, and 25 preterm neonates (23.6%) developed postoperative AKI. Multivariate analysis revealed that the factors associated with AKI were gestational age

Abstract Background Surgery in geriatric patients often poses risk of major postoperative complications. Acute kidney injury (AKI) is a common complication following noncardiac surgery and is associated with increased mortality. Early identification of geriatric patients at high risk of AKI could facilitate preventive measures and improve patient prognosis. This study used machine learning methods to identify important features and predict AKI following noncardiac surgery in geriatric patients. Methods The data for this study were obtained from a prospective cohort. Patients aged ≥ 65 years who received noncardiac surgery from June 2019 to December 2021 were enrolled. Data were split into training set (from June 2019 to March 2021) and internal validation set (from April 2021 to December 2021) by time. The least absolute shrinkage and selection operator (LASSO) regularization algorithm and the random forest recursive feature elimination algorithm (RF-RFE) were used to screen important predictors. Models were trained through extreme gradient boosting (XGBoost), random forest, and LASSO. The SHapley Additive exPlanations (SHAP) package was used to interpret the machine learning model. Results The training set included 6753 geriatric patients. Of these, 250 (3.70%) patients developed AKI. The XGBoost model with RF-RFE selected features outperformed other models with an area under the precision-recall curve (AUPRC) of 0.505 (95% confidence interval [CI]: 0.369–0.626) and an area under the receiver operating characteristic curve (AUROC) of 0.806 (95%CI: 0.733–0.875). The model incorporated ten predictors, including operation site and hypertension. The internal validation set included 3808 geriatric patients, and 96 (2.52%) patients developed AKI. The model maintained good predictive performance with an AUPRC of 0.431 (95%CI: 0.331–0.524) and an AUROC of 0.845 (95%CI: 0.796–0.888) in the internal validation. Conclusions This study developed a simple machine learning model and a web calculator for predicting AKI following noncardiac surgery in geriatric patients. This model may be a valuable tool for guiding preventive measures and improving patient prognosis. Trial registration The protocol of this study was approved by the Committee of Ethics from West China Hospital of Sichuan University (2019–473) with a waiver of informed consent and registered at www.chictr.org.cn (ChiCTR1900025160, 15/08/2019).

Abstract Background Perioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model. Methods A prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated. Results 613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34–14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67–0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81–0.93). Conclusions The incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery.

Postoperative acute kidney injury (AKI) is a common complication that is associated with chronic kidney disease, early postsurgical mortality, and prolonged hospital stays. Preterm neonates who undergo surgery are at risk factors for AKI due to underdeveloped kidneys. To date, little is known about the incidence and perioperative risk factors for AKI in preterm neonates undergoing noncardiac surgery. Preterm neonates who underwent noncardiac surgery between January May 1, 2020, and February 28, 2023, were enrolled in the trial according to the inclusion criteria. Both multivariable and logistic regression analyses were used to analyze the associations between characteristic data and AKI. In total, 106 preterm neonates met the inclusion criteria, and 25 preterm neonates (23.6%) developed postoperative AKI. Multivariate analysis revealed that the factors associated with AKI were gestational age < 32 weeks [OR: 4.88; 95% CI (1.23–19.42)], preoperative sepsis [OR: 3.98; 95% CI (1.29–12.28)], and intraoperative hypotension [OR: 3.75; 95% CI (1.26–11.15)]. Preterm neonates who developed AKI were more likely to have longer hospital length of stays (38 [18,69] days vs. 21[12,46]) and higher medical costs (93,181.6 [620450.0,173,219.0] ￥ vs. 58,134.6 [31015.1,97,224,1) ￥ than neonates who did not develop AKI. Preterm neonates who underwent noncardiac surgery had a high incidence of AKI. Independent risk factors for AKI in preterm neonates who underwent noncardiac surgery were low gestational age, preoperative sepsis, and intraoperative hypotension. Preterm neonates who developed AKI were more likely to have longer hospital stays and higher medical costs. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association between coronary heart disease (CHD) and the risk of perioperative ischemic stroke in patients undergoing noncardiac surgery. Methods: This retrospective study evaluated the incidence of ischemic stroke within 30 days after a noncardiac surgery. A cohort of 221,541 patients who underwent noncardiac surgery between January 2008 and August 2019 was segregated according to whether they were diagnosed with CHD. Primary, sensitivity, and subgroup logistic regression analyses were conducted to confirm that CHD is an independent risk factor for perioperative ischemic stroke. Propensity score matching analysis was used to account for the potential residual confounding effect of covariates. Results: Among the 221,541 included patients undergoing noncardiac surgery, 484 patients (0.22%) experienced perioperative ischemic stroke. The risk of perioperative ischemic stroke was higher in patients with CHD (0.7%) compared to patients without CHD (0.2%), and multivariate logistic regression analysis showed that CHD was associated with a significantly increased risk of perioperative ischemic stroke (odds ratio (OR), 3.7943; 95% confidence interval (CI) 2.865–4.934; p < 0.001). In a subset of patients selected by propensity score matching (PSM) in which all covariates between the two groups were well balanced, the association between CHD and increased risk of perioperative ischemic stroke remained significantly significant (OR 1.8150; 95% CI, 1.254–2.619; p = 0.001). In the subgroup analysis stratified by age, preoperative β‐blockers, and fibrinogen‐to‐albumin ratio (FAR), the association between CHD and perioperative ischemic stroke was stable (p for interaction >0.05). Subgroup analyses also showed that CHD was significantly increased the risk of perioperative ischemic stroke in the preoperative mean arterial pressure (MAP) ≥94.2 mmHg subgroups (p for interaction <0.001). Conclusion: CHD is significantly associated with an increased risk of perioperative ischemic stroke and is an independent risk factor for perioperative ischemic stroke after noncardiac surgery. Strict control of preoperative blood pressure may reduce the risk of perioperative ischemic stroke for patients with CHD undergoing noncardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Surgery in geriatric patients often poses risk of major postoperative complications. Acute kidney injury (AKI) is a common complication following noncardiac surgery and is associated with increased mortality. Early identification of geriatric patients at high risk of AKI could facilitate preventive measures and improve patient prognosis. This study used machine learning methods to identify important features and predict AKI following noncardiac surgery in geriatric patients. Methods: The data for this study were obtained from a prospective cohort. Patients aged ≥ 65 years who received noncardiac surgery from June 2019 to December 2021 were enrolled. Data were split into training set (from June 2019 to March 2021) and internal validation set (from April 2021 to December 2021) by time. The least absolute shrinkage and selection operator (LASSO) regularization algorithm and the random forest recursive feature elimination algorithm (RF-RFE) were used to screen important predictors. Models were trained through extreme gradient boosting (XGBoost), random forest, and LASSO. The SHapley Additive exPlanations (SHAP) package was used to interpret the machine learning model. Results: The training set included 6753 geriatric patients. Of these, 250 (3.70%) patients developed AKI. The XGBoost model with RF-RFE selected features outperformed other models with an area under the precision-recall curve (AUPRC) of 0.505 (95% confidence interval [CI]: 0.369–0.626) and an area under the receiver operating characteristic curve (AUROC) of 0.806 (95%CI: 0.733–0.875). The model incorporated ten predictors, including operation site and hypertension. The internal validation set included 3808 geriatric patients, and 96 (2.52%) patients developed AKI. The model maintained good predictive performance with an AUPRC of 0.431 (95%CI: 0.331–0.524) and an AUROC of 0.845 (95%CI: 0.796–0.888) in the internal validation. Conclusions: This study developed a simple machine learning model and a web calculator for predicting AKI following noncardiac surgery in geriatric patients. This model may be a valuable tool for guiding preventive measures and improving patient prognosis. Trial registration: The protocol of this study was approved by the Committee of Ethics from West China Hospital of Sichuan University (2019–473) with a waiver of informed consent and registered at www.chictr.org.cn (ChiCTR1900025160, 15/08/2019). [ABSTRACT FROM AUTHOR]

Background: Perioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model. Methods: A prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated. Results: 613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34–14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67–0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81–0.93). Conclusions: The incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery. [ABSTRACT FROM AUTHOR]

Limited knowledge exists regarding long-term renal outcomes after noncardiac surgery. This study investigated the incidence of, and risk factors for, developing advanced chronic kidney disease (CKD) and major adverse kidney events within 1 yr of surgery in a nationwide cohort. Adults without renal dysfunction before noncardiac surgery in Sweden were included between 2007 and 2013 in this observational multicentre cohort study. We analysed data from a national surgical database linked to several national and quality outcome registries. Associations of perioperative risk factors with advanced CKD (estimated glomerular filtration rate [eGFR] <30 ml min−1 1.73 m−2) and major adverse kidney events within 1 yr (MAKE365, comprising eGFR <30 ml min−1 1.73 m−2, chronic dialysis, death) were quantified. Of 237,124 patients, 1597 (0.67%) developed advanced CKD and 16,789 (7.1%) developed MAKE365. Risk factors for advanced CKD included higher ASA physical status, urological surgery, extended surgical duration, prolonged postoperative hospital stay, repeated surgery, and postoperative use of renin–angiotensin–aldosterone system blockers. Advanced acute kidney disease (AKD) (eGFR <30 ml min−1 1.73 m−2 within 90 postoperative days) occurred in 1661 (0.70%) patients and was associated with advanced CKD (subdistribution hazard ratio [SHR] 44.5, 95% confidence interval [CI] 38.7–51.1) and MAKE365 (hazard ratio [HR] 6.60, 95% CI 6.07–7.17). Among patients with advanced AKD after surgery 36% developed advanced CKD at 1 yr after surgery and 51% developed MAKE365. Advanced CKD within 1 yr after surgery is uncommon but clinically important in patients without preoperative renal dysfunction. Advanced AKD after surgery constitutes a major risk factor for advanced CKD and MAKE365. [ABSTRACT FROM AUTHOR]

Cardiac complications after major noncardiac surgery are common and associated with high morbidity and mortality. How preoperative use of beta-blockers may impact perioperative cardiac complications remains unclear. In a multicentre prospective cohort study, preoperative beta-blocker use was ascertained in consecutive patients at elevated cardiovascular risk undergoing major noncardiac surgery. Cardiac complications were prospectively monitored and centrally adjudicated by two independent experts. The primary endpoint was perioperative myocardial infarction or injury attributable to a cardiac cause (cardiac PMI) within the first three postoperative days. The secondary endpoints were major adverse cardiac events (MACE), defined as a composite of myocardial infarction, acute heart failure, life-threatening arrhythmia, and cardiovascular death and all-cause death after 365 days. We used inverse probability of treatment weighting to account for differences between patients receiving beta-blockers and those who did not. A total of 3839/10 272 (37.4%) patients (mean age 74 yr; 44.8% female) received beta-blockers before surgery. Patients on beta-blockers were older, and more likely to be male with established cardiorespiratory and chronic kidney disease. Cardiac PMI occurred in 1077 patients, with a weighted odds ratio of 1.03 (95% confidence interval [CI] 0.94–1.12, P =0.55) for patients on beta-blockers. Within 365 days of surgery, 971/10 272 (9.5%) MACE had occurred, with a weighted hazard ratio of 0.99 (95% CI 0.83–1.18, P =0.90) for patients on beta-blockers. Preoperative use of beta-blockers was not associated with decreased cardiac complications including cardiac perioperative myocardial infarction or injury and major adverse cardiac event. Additionally, preoperative use of beta-blockers was not associated with increased all-cause death within 30 and 365 days. NCT02573532. [ABSTRACT FROM AUTHOR]

Postoperative respiratory failure is a serious complication that could benefit from early accurate identification of high-risk patients. We developed and validated a machine learning model to predict postoperative respiratory failure, defined as prolonged (>48 h) mechanical ventilation or reintubation after surgery. Easily extractable electronic health record (EHR) variables that do not require subjective assessment by clinicians were used. From EHR data of 307,333 noncardiac surgical cases, the model, trained with a gradient boosting algorithm, utilised a derivation cohort of 99,025 cases from Seoul National University Hospital (2013–9). External validation was performed using three separate cohorts A–C from different hospitals comprising 208,308 cases. Model performance was assessed by area under the receiver operating characteristic (AUROC) curve and area under the precision-recall curve (AUPRC), a measure of sensitivity and precision at different thresholds. The model included eight variables: serum albumin, age, duration of anaesthesia, serum glucose, prothrombin time, serum creatinine, white blood cell count, and body mass index. Internally, the model achieved an AUROC of 0.912 (95% confidence interval [CI], 0.908–0.915) and AUPRC of 0.113. In external validation cohorts A, B, and C, the model achieved AUROCs of 0.879 (95% CI, 0.876–0.882), 0.872 (95% CI, 0.870–0.874), and 0.931 (95% CI, 0.925–0.936), and AUPRCs of 0.029, 0.083, and 0.124, respectively. Utilising just eight easily extractable variables, this machine learning model demonstrated excellent discrimination in both internal and external validation for predicting postoperative respiratory failure. The model enables personalised risk stratification and facilitates data-driven clinical decision-making. [ABSTRACT FROM AUTHOR]

BackgroundThe number of patients living with left ventricular assist devices (LVADs) has gradually increased in the past decade. Non-cardiac surgery (NCS) in patients with LVAD poses a unique situation with its inherent challenges.AimWe conducted a comprehensive review to investigate the perioperative complications and mortality associated with emergent or elective NCS in patients with LVAD.MethodA comprehensive literature search for any papers referring to continuous LVAD patients with NCS. All publications with at least five durable LVAD patients who had NCS were eligible for inclusion.ResultTwenty articles matching our criteria were found and included in our study. This systematic review included 6,476 LVAD patients who underwent 6,824 NCS. There were 5–3,216 LVAD patients with NCS in each study. The median age was between 39 and 65 years, and most of the patients (78.8%) were male. Thirty-day postoperative mortality ranged from 0% to 60%. Eight studies reported no death within the 30 days of the operation. Common complications include gastrointestinal (GI) bleeding, intracranial bleeding, infection, acute kidney injury (AKI), urinary tract infection (UTI), stroke, sepsis, pneumonia, and VAD exchange. Emergent abdominal surgery had the highest (up to 60%) mortality rate, and vascular and neurological operations had the highest complication rates. Due to the diverse range of patients in each publication and the combination of outcomes presented in various publications, a meta-analysis was not conducted.ConclusionIn LVAD patients, noncardiac surgery may be performed effectively and safely. LVAD patients who undergo non-cardiac surgery may require more transfusions due to their complex coagulopathies. However, perioperative management of LVAD patients undergoing emergent NCS should be optimized to reduce mortality.Systematic Review Registrationhttps://osf.io/fetsb/.

Abstract Preoperative serum lactate dehydrogenase (LDH) has been reported to be associated with adverse outcomes following thoracic surgery. However, its association with outcomes in noncardiac surgery as a whole has not been investigated. We conducted a retrospective cohort study at West China Hospital, Sichuan University, from 2018 to 2020, including patients undergoing noncardiac surgery. Multivariable logistic regression and propensity score weighting were employed to assess the link between LDH levels and postoperative outcomes. Preoperative LDH was incorporated into four commonly used clinical models, and its discriminative ability, reclassification, and calibration were evaluated in comparison to models without LDH. Among 130,879 patients, higher preoperative LDH levels (cut-off: 220 U/L) were linked to increased in-hospital mortality (4.382% vs. 0.702%; OR 1.856, 95% CI 1.620–2.127, P

The now-routine clinical deployment of continuous glucose monitoring has demonstrated benefit in real-world settings. We make the case that continuous glucose monitoring can help re-examine, at scale, the role that (stress) hyperglycaemia plays in fuelling organ dysfunction after tissue trauma. Provided robust perioperative data do emerge, well-established continuous glucose monitoring technology could soon help transform the perioperative landscape. [ABSTRACT FROM AUTHOR]

Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml−1) experience more complications after noncardiac surgery. Individuals prescribed renin–angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L−1 or a ≥5 ng L−1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L−1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml −1) and stopping or continuing RAS inhibitors. Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml −1 (median 339 [160–833] pg ml−1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml−1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml −1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05–5.99); P <0.0001}. For subjects with preoperative NT-proBNP <100 pg ml−1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06–4.65]; P =0.03). For preoperative NT-proBNP >100 pg ml−1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44–2.22]). Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml −1) increased the likelihood of myocardial injury before noncardiac surgery. [ABSTRACT FROM AUTHOR]

Clinical presentation of postoperative myocardial infarction (POMI) is often silent. Several international guidelines recommend routine troponin surveillance in patients at risk. We compared how these different guidelines select patients for surveillance after noncardiac surgery with our established risk stratification model. We used outcome data from two prospective studies: Measurement of Exercise Tolerance before Surgery (METS) and Troponin Elevation After Major non-cardiac Surgery (TEAMS). We compared the major American, Canadian, and European guideline recommendations for troponin surveillance with our established risk stratification model. For each guideline and model, we quantified the number of patients requiring monitoring, % POMI detected, sensitivity, specificity, diagnostic odds ratio, and number needed to screen (NNS). METS and TEAMS contributed 2350 patients, of whom 319 (14%) had myocardial injury, 61 (2.5%) developed POMI, and 14 (0.6%) died. Our risk stratification model selected fewer patients for troponin monitoring (20%), compared with the Canadian (78%) and European (79%) guidelines. The sensitivity to detect POMI was highest with the Canadian and European guidelines (0.85; 95% confidence interval [CI] 0.74–0.92). Specificity was highest using the American guidelines (0.91; 95% CI 0.90–0.92). Our risk stratification model had the best diagnostic odds ratio (2.5; 95% CI 1.4–4.2) and a lower NNS (21 vs 35) compared with the guidelines. Most postoperative myocardial infarctions were detected by the Canadian and European guidelines but at the cost of low specificity and a higher number of patients undergoing screening. Patient selection based on our risk stratification model was optimal. [ABSTRACT FROM AUTHOR]

Background Temporal trends and risk factors of perioperative cardiac events (PCEs) in patients over 80 years old with coronary artery disease (CAD) undergoing noncardiac surgery are still unclear. Methods We retrospectively reviewed 1478 patients over 80 years old, with known CAD undergoing selective noncardiac surgery in a single center (2014–2022). Patients were divided into three equal time groups based on the discharge date (2014–2016, 2017–2019, and 2020–2022), with 367, 473, and 638 patients in Groups 1–3, respectively. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCEs intraoperatively or during hospitalization postoperatively, defined as any of the following events: myocardial infarction, heart failure, nonfatal cardiac arrest, and death. Results PCEs occurred in 180 (12.2%) patients. Eight independent risk factors were associated with PCEs, including four clinical factors (body mass index < 22 kg/m2, history of myocardial infarction, history of heart failure, and general anesthesia) and four preoperative laboratory results (hemoglobin < 110 g/L, albumin < 40 g/L, creatinine > 120 μmol/L, and potassium <3.6 mmol/L). Significant rising trends were seen over the 9-year study period in the incidence of PCEs and independent risk factors including history of myocardial infarction, history of heart failure, general anesthesia, preoperative hemoglobin < 110 g/L, preoperative albumin < 40 g/L, and preoperative creatinine > 120 μmol/L (P for trend <0.05). Conclusion The incidence and independent risk factors of PCEs in patients over 80 years old with CAD undergoing noncardiac surgery showed significant rising trends over the last 9-year period.   What is already known on this topic   1) Ever-increasing noncardiac surgeries are performed in patients over 80 years old with coronary artery disease (CAD). 2) This population have high risk of perioperative cardiac events (PCEs). What this study adds   1) The incidence of PCEs in patients over 80 years old with CAD undergoing noncardiac surgery showed significant rising trends over the last 9-year period. 2) Eight independent risk factors were associated with PCEs, including body mass index, history of myocardial infarction, history of heart failure, general anesthesia, and four preoperative laboratory results (hemoglobin, albumin, creatinine, and potassium). 3) Significant rising temporal trends were seen in the independent risk factors. How this study might affect research, practice, or policy   More comprehensive preoperative evaluation and regular perioperative monitoring would be necessary to reduce the occurrence of PCEs in this high-risk population. [ABSTRACT FROM AUTHOR]

Copyright of Gaceta Médica de Caracas is the property of Academia Nacional de Medicina and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Preoperative serum lactate dehydrogenase (LDH) has been reported to be associated with adverse outcomes following thoracic surgery. However, its association with outcomes in noncardiac surgery as a whole has not been investigated. We conducted a retrospective cohort study at West China Hospital, Sichuan University, from 2018 to 2020, including patients undergoing noncardiac surgery. Multivariable logistic regression and propensity score weighting were employed to assess the link between LDH levels and postoperative outcomes. Preoperative LDH was incorporated into four commonly used clinical models, and its discriminative ability, reclassification, and calibration were evaluated in comparison to models without LDH. Among 130,879 patients, higher preoperative LDH levels (cut-off: 220 U/L) were linked to increased in-hospital mortality (4.382% vs. 0.702%; OR 1.856, 95% CI 1.620–2.127, P < 0.001), myocardial injury after noncardiac surgery (MINS) (3.012% vs. 0.537%; OR 1.911, 95% CI 1.643–2.223, P < 0.001), and ICU admission (15.010% vs. 6.414%; OR 1.765, 95% CI 1.642–1.896, P < 0.001). The inverse probability of treatment-weighted estimation supported these results. Additionally, LDH contributed significantly to four surgical prognostic models, enhancing their predictive capability. Our study revealed a significant association between preoperative LDH and in-hospital mortality, MINS, and ICU admission following noncardiac surgery. Moreover, LDH provided supplementary predictive information, extending the utility of commonly used surgical prognostic scores. [ABSTRACT FROM AUTHOR]

Aortic valve stenosis is a common condition that requires an anesthesiologist's in-depth knowledge of the pathophysiology, diagnostics and perioperative features of the disease. A newly diagnosed aortic valve stenosis is often initially identified from the anamnesis (dyspnea, syncope, angina pectoris) or a suspicious auscultation finding during the anesthesiologist's preoperative assessment. Interdisciplinary collaboration is essential to ensure the optimal management of these patients in the perioperative setting. An accurate anamnesis and examination during the preoperative assessment are crucial to select the most suitable anesthetic approach. Additionally, a precise understanding of the hemodynamic peculiarities associated with aortic valve stenosis is necessary. After a short summary of the overall pathophysiology of aortic valve stenosis, this review article focuses on the specific anesthetic considerations, risk factors for complications, and the perioperative management for noncardiac surgery in patients with aortic valve stenosis. [ABSTRACT FROM AUTHOR]

Since their initial approval by the Food and Drug Administration in 2016, leadless pacemakers have become increasingly prevalent. This growth has been driven by an improved adverse effect profile when compared to traditional pacemakers, including lower rates of infection, as well as eliminated risk of pocket hematoma and lead complications. More recently, technology enabling leadless synchronized atrioventricular pacing in patients with atrioventricular block has vastly expanded the indications for these devices. Anesthesiologists will increasingly be relied upon to safely care for patients with leadless pacemakers undergoing non-electrophysiology procedures and surgery. This article provides an overview of the technology, evidence base, current indications, and unique perioperative considerations for leadless pacemakers. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Background Beta-blocker (BB) therapy plays a central role in the treatment of cardiovascular diseases. An increasing number of patients with cardiovascular diseases undergoe noncardiac surgery, where opioids are an integral part of the anesthesiological management. There is evidence to suggest that short-term intravenous BB therapy may influence perioperative opioid requirements due to an assumed cross-talk between G-protein coupled beta-adrenergic and opioid receptors. Whether chronic BB therapy could also have an influence on perioperative opioid requirements is unclear. Methods A post hoc analysis of prospectively collected data from a multicenter observational (BioCog) study was performed. Inclusion criteria consisted of elderly patients (≥ 65 years) undergoing elective noncardiac surgery as well as total intravenous general anesthesia without the use of regional anesthesia and duration of anesthesia ≥ 60 min. Two groups were defined: patients with and without BB in their regular preopreative medication. The administered opioids were converted to their respective morphine equivalent doses. Multiple regression analysis was performed using the morphine-index to identify independent predictors. Results A total of 747 patients were included in the BioCog study in the study center Berlin. 106 patients fulfilled the inclusion criteria. Of these, 37 were on chronic BB. The latter were preoperatively significantly more likely to have arterial hypertension (94.6%), chronic renal failure (27%) and hyperlipoproteinemia (51.4%) compared to patients without BB. Both groups did not differ in terms of cumulative perioperative morphine equivalent dose (230.9 (BB group) vs. 214.8 mg (Non-BB group)). Predictive factors for increased morphine-index were older age, male sex, longer duration of anesthesia and surgery of the trunk. In a model with logarithmised morphine index, only gender (female) and duration of anesthesia remained predictive factors. Conclusions Chronic BB therapy was not associated with a reduced perioperative opioid consumption. Trial registration This study was registered at ClinicalTrials.gov ( NCT02265263 ) on the 15.10.2014 with the principal investigator being Univ.-Prof. Dr. med. Claudia Spies.

Background: Beta-blocker (BB) therapy plays a central role in the treatment of cardiovascular diseases. An increasing number of patients with cardiovascular diseases undergoe noncardiac surgery, where opioids are an integral part of the anesthesiological management. There is evidence to suggest that short-term intravenous BB therapy may influence perioperative opioid requirements due to an assumed cross-talk between G-protein coupled beta-adrenergic and opioid receptors. Whether chronic BB therapy could also have an influence on perioperative opioid requirements is unclear. Methods: A post hoc analysis of prospectively collected data from a multicenter observational (BioCog) study was performed. Inclusion criteria consisted of elderly patients (≥ 65 years) undergoing elective noncardiac surgery as well as total intravenous general anesthesia without the use of regional anesthesia and duration of anesthesia ≥ 60 min. Two groups were defined: patients with and without BB in their regular preopreative medication. The administered opioids were converted to their respective morphine equivalent doses. Multiple regression analysis was performed using the morphine-index to identify independent predictors. Results: A total of 747 patients were included in the BioCog study in the study center Berlin. 106 patients fulfilled the inclusion criteria. Of these, 37 were on chronic BB. The latter were preoperatively significantly more likely to have arterial hypertension (94.6%), chronic renal failure (27%) and hyperlipoproteinemia (51.4%) compared to patients without BB. Both groups did not differ in terms of cumulative perioperative morphine equivalent dose (230.9 (BB group) vs. 214.8 mg (Non-BB group)). Predictive factors for increased morphine-index were older age, male sex, longer duration of anesthesia and surgery of the trunk. In a model with logarithmised morphine index, only gender (female) and duration of anesthesia remained predictive factors. Conclusions: Chronic BB therapy was not associated with a reduced perioperative opioid consumption. Trial registration: This study was registered at ClinicalTrials.gov (NCT02265263) on the 15.10.2014 with the principal investigator being Univ.-Prof. Dr. med. Claudia Spies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The use of transesophageal echocardiography (TEE) by certified registered nurse anesthetists (CRNAs) during noncardiac surgery is relatively uncommon despite its unique potential to diagnose causes of hemodynamic instability. To address this problem, educational endeavors designed to provide practical TEE skills to CRNAs are needed. The aim of the current study was to evaluate the feasibility, acceptability, efficacy, and utility of a 2-day focused TEE workshop in nurse anesthesia education that employed a protocol involving a limited number of views and used goal-directed, qualitative assessments of critical physiologic parameters. METHODS: This was a prospective, observational study involving 14 second-year nurse anesthesia students. The cohort was evaluated following completion of this workshop by simulator-based testing involving hypothetical clinical scenarios, and this test data was analyzed according to the percent successful acquisition and interpretation of TEE views to determine immediate objective teaching efficacy. The acceptability, perceived efficacy, and perceived utility of the workshop were assessed by online survey, and survey responses were qualitative and quantitative in nature. RESULTS: Participants acquired appropriate TEE views associated with clinical scenarios 99% of the time and correctly interpreted the pathology in those views 93% of the time. Participants uniformly perceived significant educational value in this workshop and intend to incorporate TEE in their future clinical practice. CONCLUSIONS: A 2-day workshop to teach focused TEE to nurse anesthesia trainees directed by a streamlined protocol is feasible, acceptable, and perceived as useful by participants, and provides practical experience and entry-level competency in this point-of-care ultrasound modality. [ABSTRACT FROM AUTHOR]

Postoperative myocardial injury (PMI) comprises a spectrum of mechanisms resulting in troponin release. The impact of different PMI phenotypes on postoperative disability remains unknown. This was a multicentre prospective cohort study including patients aged ≥50 yr undergoing elective major noncardiac surgery. Patients were stratified in five groups based on the occurrence of PMI and clinical information on postoperative adverse events: PMI classified as myocardial infarction (MI; according to fourth definition), PMI plus adverse event other than MI, clinically silent PMI (PMI without adverse events), adverse events without PMI, and neither PMI nor an adverse event (reference). The primary endpoint was 6-month self-reported disability (assessed by WHO Disability Assessment Schedule 2.0 [WHODAS]). Disability-free survival was defined as WHODAS ≤16%. We included 888 patients of mean age 69 (range 53–91) yr, of which 356 (40%) were women; 151 (17%) patients experienced PMI, and 625 (71%) experienced 6-month disability-free survival. Patients with PMI, regardless of its phenotype, had higher preoperative disability scores than patients without PMI (difference in WHODAS; β: 3.3, 95% confidence interval [CI]: 0.5–6.2), but scores remained stable after surgery (β: 1.2, 95% CI: –3.2–5.6). Before surgery, patients with MI (n =36, 4%) were more disabled compared with patients without PMI and no adverse events (β: 5.5, 95% CI: 0.3–10.8). At 6 months, patients with MI and patients without PMI but with adverse events worsened in disability score (β: 11.2, 95% CI: 2.3–20.2; β: 8.1, 95% CI: 3.0–13.2, respectively). Patients with clinically silent PMI did not change in disability score at 6 months (β: 1.39, 95% CI: –4.50–7.29, P =0.642). Although patients with postoperative myocardial injury had higher preoperative self-reported disability, disability scores did not change at 6 months after surgery. However, patients experiencing myocardial infarction worsened in disability score after surgery. [ABSTRACT FROM AUTHOR]

Background: Bispectral index (BIS) is a processed electroencephalography monitoring tool and is widely used in anesthetic depth monitoring. Deep anesthesia exposure may be associated with multiple adverse outcomes. However, the relationship between anesthetic depth and postoperative acute kidney injury (AKI) remains unclear. We sought to determine the effect of BIS-based deep anesthesia duration on postoperative AKI following noncardiac surgery. Methods: This retrospective study used data from the Vital Signs DataBase, including patients undergoing noncardiac surgeries with BIS monitoring. The BIS values were collected every second during anesthesia. Restricted cubic splines and logistic regression were used to assess the association between the cumulative duration of deep anesthesia and postoperative AKI. Results: 4774 patients were eligible, and 129 (2.7%) experienced postoperative AKI. Restricted cubic splines showed that a cumulative duration of BIS < 45 was nonlinearly associated with postoperative AKI (P-overall = 0.033 and P-non-linear = 0.023). Using the group with the duration of BIS < 45 less than 15 min as the reference, ORs of postoperative AKI were 2.59 (95% confidence interval [CI]:0.60 to 11.09, p = 0.200) in the 15-100 min group, and 4.04 (95%CI:0.92 to 17.76, p = 0.064) in the = 100 min group after adjusting for preoperative and intraoperative covariates in multivariable logistic regression. Conclusions: The cumulative duration of BIS < 45 was independently and nonlinearly associated with the risk of postoperative AKI in patients undergoing noncardiac surgery. [ABSTRACT FROM AUTHOR]

Background Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. Methods and Results Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. Conclusions There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.

Abstract Background This study compared the effects of remimazolam and sevoflurane on intraoperative hemodynamics including intraoperative hypotension (IOH). Results This study involved adult patients undergoing noncardiac surgery using remimazolam (Group R) or sevoflurane (Group S) for maintenance anesthesia, and invasive arterial pressure measurements, from September 2020 to March 2023 at our hospital. IOH was defined as a mean blood pressure

Abstract Background The current study aimed to investigate the incidence and risk factors for postoperative acute ischemic stroke (PAIS) in advanced-aged patients (≥ 75 years) with previous ischemic stroke undergoing noncardiac surgery. Methods In this single-center retrospective cohort study, all advanced-aged patients underwent noncardiac surgery from 1 January, 2019, to 30 April, 2022. Data were extracted from hospital electronic medical records. Multivariable logistic regression analysis was performed to determine predictors of PAIS. Multivariable linear or logistic regression analysis was performed to determine predictors of outcomes due to PAIS. Results Twenty-four patients (6.0%) of the 400 patients developed PAIS. Carotid endarterectomy (CEA), length of surgery and preoperative Modified Rankin scale (mRS) ≥ 3 were significant predictors of PAIS. CEA was associated with increased risk of PAIS (OR 4.14; 95%CI, 1.43–11.99). Each additional minute in length of surgery had slightly increased the risk of PAIS (OR, 1.01; 95%CI, 1.00-1.01). Compared with reference (mRS

Abstract Background Preoperative cardiovascular risk assessment is one of the main principles before noncardiac surgeries. Cardiac stress imaging, such as myocardial perfusion scan (MPS), is a proposed cardiovascular risk evaluation method according to the latest guidelines. Yet, its efficacy, along with the cost-effectiveness of the method, has been questioned in previous studies. Our study aims to evaluate the utility of N-terminal pro-b-type natriuretic peptide (NT-proBNP) level measurement in predicting postoperative cardiovascular complications in candidates who have undergone an MPS before surgery and compare the results. Methods A cohort of 80 patients with a revised cardiac risk index score of one or more who were scheduled for moderate to high-risk noncardiac surgeries and met the criteria to undergo an MPS for risk assessment were included in the study. All of them underwent an MPS one week before surgery. Their preoperative NT-proBNP, troponin levels, and electrocardiograms were obtained one day before surgery and again on day three postoperative. The predictive efficacy of NT-proBNP levels and MPS were compared. Results Seventy-eight patients underwent surgery, three of which exhibited a rise in troponin level, six showed changes on electrocardiogram, and pulmonary edema was detected in one, three days after surgery. There was no mortality in our patients. The sensitivity and specificity of the MPS for predicting postoperative cardiovascular complications were 100% and 66%, respectively. MPS also had a positive predictive value of 20% and a negative predictive value of 100% in our study. A 332.5 pg/ml cut-off value for NT-proBNP level yielded a sensitivity of 100%, specificity of 79.2%, positive predictive value of 40%, and negative predictive value of 100%. Conclusions Our study reveals the incremental specificity and positive predictive value of NT-proBNP level measurement in preoperative cardiovascular risk evaluation compared to MPS. Given the low feasibility, high costs, and disappointing predictive value of MPS, preoperative NT-proBNP level assessment can be substituted. This method can assist anesthesiologists and surgeons with precisely detecting at-risk patients resulting in taking proper measures to reduce the morbidity and mortality of the proposed patients before and during surgeries.

Perioperative myocardial injury is a relatively common complication after noncardiac surgery associated with significant morbidity and mortality. It is frequently driven by physiologic factors such as hypotension, tachycardia, and anemia. Diagnosis of perioperative myocardial injury after noncardiac surgery is based on elevated cardiac troponin levels, greater than the 99th percentile of the assay's upper reference limit within 30 days of surgery. Perioperative myocardial injury is further classified into non-ischemic and ischemic based on the underlying pathophysiology. Ischemic injury, also called myocardial injury after non-cardiac surgery (MINS), is further classified into perioperative myocardial infarction or myocardial injury without infarction. Classifying perioperative myocardial injury further is particularly important for clinical management and prognosis. MINS—with or without infarction—is independently and strongly associated with short- and long-term mortality. Compared to nonoperative myocardial infarction, perioperative myocardial infarction carries an increased risk of adverse outcomes including all-cause mortality. Preventative measures include a thorough preoperative risk assessment, risk factor optimization, and avoidance of intraoperative mismatch of myocardial oxygen supply and demand. Surveillance of patients at higher risk of cardiovascular complications is warranted and can lead to early recognition, closer monitoring, and appropriate management. This review will provide a framework for understanding perioperative myocardial injury and highlight the contemporary literature addressing its diagnosis and management.

Background: This study compared the effects of remimazolam and sevoflurane on intraoperative hemodynamics including intraoperative hypotension (IOH). Results: This study involved adult patients undergoing noncardiac surgery using remimazolam (Group R) or sevoflurane (Group S) for maintenance anesthesia, and invasive arterial pressure measurements, from September 2020 to March 2023 at our hospital. IOH was defined as a mean blood pressure < 65 mmHg occurring for a cumulative duration of at least 10 min. A 1:1 propensity score-matching method was used. The primary endpoint was the occurrence of IOH, and the secondary endpoints were the cumulative hypotensive time, incidence of vasopressor use, and dose of vasopressor used (ephedrine, phenylephrine, dopamine, and noradrenaline). Group R comprised 169 patients, Group S comprised 393 patients, and a matched cohort of 141 patients was created by propensity score matching. There was no significant difference in the incidence of IOH between the two groups (85.1% in Group R vs. 91.5% in Group S, p = 0.138). Patients in Group R had a significantly lower cumulative hypotension duration (55 [18–119] vs. 83 [39–144] min, p = 0.005), vasopressor use (81.6% vs. 91.5%, p = 0.023), and dose of ephedrine (4 [0–8] vs. 12 [4–20] mg, p < 0.001) than those in Group S. There were no significant differences in the doses of other vasopressors between groups. Conclusions: Compared with sevoflurane, the maintenance of anesthesia with remimazolam was not associated with a decreased incidence of IOH; however, it reduced the cumulative hypotension time, incidence of vasopressor use, and dose of ephedrine. [ABSTRACT FROM AUTHOR]

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

Dilated cardiomyopathy (DCM), a primary myocardial disease, is characterized by dilation of the left or both ventricles and systolic dysfunction with or without congestive heart failure. DCM per se is a well-recognized risk factor for sudden cardiac death and poor surgical outcomes following noncardiac surgery. Surgical trauma/stress represents unique challenges for DCM patient management. Unfortunately, there is a big knowledge gap in managing DCM patients undergoing non-cardiac surgery. Therefore, the aim of our review is to provide basic facts and current advances in DCM, as well as a practical guideline to perioperative care providers, for the management of surgical patients with DCM, who are quite rare compared with the general surgical population. This review summarizes recent advances in the medical management of DCM as well as perioperative assessment and management strategies for DCM patients undergoing noncardiac surgery. Optimal surgical outcomes depend on multiple-disciplinary care to minimize perioperative cardiovascular disturbances. [ABSTRACT FROM AUTHOR]