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In patients with significant valvular heart disease (VHD) undergoing non-cardiac surgery (NCS), perioperative adverse cardiac events are a relevant issue. Although postoperative outcomes can be adversely affected by valve-related haemodynamic instability, recommended perioperative risk scores prioritise the risk of the surgical procedure and the presence of cardiovascular risk factors, neglecting the presence or extent of VHD. Perioperative management and anaesthetic approach should focus on the underlying type and severity of VHD, the compensatory mechanisms deployed by left ventricle and right ventricle and the type and risk of NCS. Due to the lack of randomised trials investigating different therapeutic approaches of valvular intervention prior to NCS, recommendations mainly rely on consensus opinion and inference based on large observational registries. As a general rule, valvular intervention is recommended prior to NCS in symptomatic patients or in those who meet standard criteria for cardiac intervention. In the absence of such conditions, it is reasonable to perform NCS with tailored anaesthetic management and close invasive perioperative haemodynamic monitoring. However, patient-specific management strategies should be discussed with the heart team preoperatively. Symptomatic patients with severe VHD or those undergoing high-risk NCS should ideally be treated at a high-volume medical centre that is equipped to manage haemodynamically complex patients during the perioperative period.

This study compared myocardial injury after non-cardiac surgery (MINS) and mortalities between patients under and over the age of 45 years.Methods and Results:From January 2010 and June 2019, patients with cardiac troponin measurement within 30 days after non-cardiac surgery were enrolled and divided into groups according to age:45 (≥45 years) and45 (45 years). Further analyses were conducted only in patients who were diagnosed with MINS. The outcomes were MINS and 30-day mortality. Of the 35,223 patients, 31,161 (88.5%) patients were in the45-year group and 4,062 (11.5%) were in the45-year group. After adjustment with inverse probability of weighting, the45-years group showed a lower incidence of MINS and cardiovascular mortality (16.6% vs. 11.7%; odds ratio, 0.77; 95% confidence interval [CI], 0.69-0.84; P0.001 and 0.4% vs. 0.2%; hazard ratio [HR], 0.41; 95% CI, 0.19-0.88; P=0.02, respectively). In a comparison of only the45-years group, MINS was associated with increased 30-day mortality (0.7% vs. 10.3%; HR, 10.48; 95% CI, 6.18-17.78; P0.001), but the mortalities of patients with MINS did not differ according to age.MINS has a comparable prognostic impact in patients aged under and over 45 years; therefore, future studies need to also consider patients aged45 years regarding risk factors of MINS and screening of perioperative troponin elevation.

В статье представлена периоперационная оценка пациента, у которого сердечная патология может стать причиной осложнений во время проведения некардиальных оперативных вмешательств. Проанализированы последние рекомендации, опубликованные Европейским обществом кардиологов совместно с Европейским обществом анестезиологов (2014), Американским колледжем кардиологов и Американской ассоциацией сердца (2014) и Канадским сердечно-сосудистым обществом (2017). Возникновение осложнений со стороны сердца в некардиальной хирургии зависит от факторов риска как со стороны пациента, так и от оперативного вмешательства. Предоперационная оценка должна охватывать как клинические факторы риска, так и результаты дополнительных обследований и возможные последствия предполагаемого стресса оперативного вмешательства. Индивидуализированная оценка сердечного риска дает возможность начать соответствующую медикаментозную терапию, принять решение о целесообразности коронарной интервенции, определиться со спецификой хирургической и анестезиологической тактики. Состояние пациента, его готовность к оперативному вмешательству оцениваются согласно алгоритму «шаг за шагом»: выявляется патология сердечно-сосудистой системы, кардиальные факторы риска, а также определяется его функциональный статус. Проводится оценка риска хирургической процедуры по индексу Ли (Lee score) и NSQIP MICA, что позволяет предсказать вероятность развития в послеоперационном периоде острого инфаркта миокарда, отека легких, фибрилляции желудочков, остановки сердца, полной атриовентрикулярной блокады. Для индивидуализированного периоперационного ведения сложного пациента рекомендовано привлекать мультидисциплинарную команду специалистов. В статье освещены особенности периоперационной фармакотерапии кардиальной патологии, акцентировано на целесооб­разности продолжения употребления бета-блокаторов в день оперативного вмешательства. Описана тактика ведения пациента, нуждающегося в антитромбоцитарной или антикоагулянтной терапии. Для примера приведены клинические случаи пошаговой предоперационной оценки пациента согласно современным рекомендациям.

ObjectiveMyocardial injury after non-cardiac surgery (MINS) is strongly associated with mortality, but few studies assessed treatment strategies. This study aimed to identify whether evaluation by cardiologists could reduce mortality in MINS patients.MethodsFrom a single-centre retrospective cohort, we enrolled a total of 5633 adult patients diagnosed with MINS between January 2010 and June 2019. The patients were divided into two groups based on evaluation by cardiologist, which was defined as a cardiology consultation or transfer to the cardiology department. For the outcome, 30-day mortality was compared in crude and propensity-score matched populations.ResultsOf a total of 5633 patients, 2120 (37.6%) were evaluated by cardiologists and 3513 (62.4%) were not. Mortality during the first 30 days after surgery was significantly lower in MINS patients who were evaluated by cardiologists compared with those who were not (5.8% vs 8.3%; HR, 0.64; 95% CI 0.51 to 0.80; pConclusionsCardiologist evaluation was associated with lower mortality in patients diagnosed with MINS. Further studies are needed to identify effective treatment strategies for MINS.Trial registration numberKCT0004244.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare form of congenital heart diseases, present with or without associated anomalies. It is a complex congenital heart disease with both atrioventricular and ventriculoarterial discordance. Such patients tend to develop systemic ventricular dysfuction with the stress of surgery. Patients with CCTGA are usually diagnosed at early stages of life due to associated anomalies, but they may even remain asymptomatic till later decades of their life. Literature search revealed very few reported cases of anaesthetic management of such high risk cases for non cardiac surgery. These patients have the tendency to develop cardiac dysrhythmias and left ventricular failure during intraoperative and postoperative period.We report anaesthetic management of a case of a 24 years old male with the congenitally corrected transposition of great arteries(CCTGA) who was operated for fracture left distal radius and ulna and right sided galeazzi fracture. Keywords: Congenitally corrected transposition of great arteries, Fracture distal end radius, Non cardiac surgery, Supraclavicular block.

Background Remote ischemic preconditioning (RIPC) may mitigate physiological stress related to surgery. There is no clear consensus on conduct of RIPC studies, or whether it is effective. The aim of this study was to (i) assess delivery of RIPC, (ii) identify reported outcomes, (iii) measure effect on key clinical outcomes. Methods This review was registered on PROSPERO (CRD:42020180725). EMBASE and Medline databases were searched, and results screened by two reviewers. Full-texts were assessed for eligibility by two reviewers. Data extracted were methods of RIPC and outcomes reported. Meta-analysis of key clinical events was performed using a Mantel-Haenszel random effects model. The TIDieR framework was used to assess intervention reporting, and Cochrane risk of bias tool was used for all studies included. Results Searches identified 25 studies; 25 were included in the narrative analysis and 18 in the meta-analysis. RIPC was frequently performed by occluding arm circulation (15/25), at 200 mmHg (9/25), with three cycles of 5 min ischemia and 5 min of reperfusion (16/25). No study fulfilled all 12 TIDieR items (mean score 7.68). Meta-analysis showed no benefit of RIPC on MI (OR 0.71 95% CI 0.48-1.04, I2 = 0%), mortality (OR 0.56, 95% CI 0.31-1.01, I2 = 0%), or acute kidney injury (OR 0.72 95% CI 0.48-1.08). Conclusions RIPC could be standardized as 200 mmHg pressure in 3 × 5 min on and off cycles. The signal of benefit should be explored in a larger well-designed randomized trial.

The incidence of cardiovascular complications in non-cardiac surgery is about 3 %. The review presents the data on the assessment of cardiovascular risk (CVR) in non-cardiac surgery. The algorithm of decisionmaking considers the functional state of the patient and the category of CVR of the upcoming surgery. Functional testing is not indicated for patients with low CVR. Stress tests should be considered in high-risk patients if the test results may change the perioperative drug therapy, the method of anesthesia, or the surgical approach. Routine coronary revascularization does not reduce perioperative risks and is used for special indications. Percutaneous coronary intervention and associated dual antiplatelet therapy may delay the timing of non-cardiac operations. Perioperative drug therapy (beta-blockers, aspirin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins) should be prescribed taking into account the individual risk of the patient.

Objective To evaluate the relationship between postoperative complications and long-term survival. Summary and background Postoperative complications remain a significant driver of healthcare costs and are associated with increased perioperative mortality, yet the extent to which they are associated with long-term survival is unclear. Methods National cohort study of Veterans who underwent non-cardiac surgery using data from the Veterans Affairs Surgical Quality Improvement Program (2011-2016). Patients were classified as having undergone outpatient, low-risk inpatient, or high-risk inpatient surgery. Patients were categorized based on number and type of complications. The association between the number of complications (or the specific type of complication) and risk of death was evaluated using multivariable Cox regression with robust standard errors using a 90-day survival landmark. Results Among 699,002 patients, complication rates were 3.0%, 6.1%, and 18.3% for outpatient, low-risk inpatient, and high-risk inpatient surgery, respectively. There was a dose-response relationship between an increasing number of complications and overall risk of death in all operative settings (outpatient surgery: no complications [ref]; one-Hazard Ratio [HR] 1.30 [1.23 - 1.38]; multiple-HR 1.61 [1.46 - 1.78]; low-risk inpatient surgery: one-HR 1.34 [1.26 - 1.41]; multiple-HR 1.69 [1.55 - 1.85]; high-risk inpatient surgery: one-HR 1.14 [1.10 - 1.18]; multiple-HR 1.42 [1.36 - 1.48]). All complication types were associated with risk of death in at least one operative setting, and pulmonary complications, sepsis, and C. Diff colitis were associated with higher risk of death across all settings. Conclusions Postoperative complications have an adverse impact on patients' long-term survival beyond the immediate postoperative period. Although most research and quality improvement initiatives primarily focus on the perioperative impact of complications, these data suggest they also have important longer-term implications that merit further investigation.

Background Current guidelines for the peri-operative assessment and management are not sufficient to allow effective risk assessment and management of the patient with pulmonary arterial hypertension associated with congenital heart disease. Well-established risk stratification tools are not validated in this group. Additional, disease-specific risks require individualised, specialist, multidisciplinary management. Case presentation We present an illustrative clinical case of patients with pulmonary arterial hypertension associated with congenital heart disease undergoing non-cardiac surgery. The case follows a 66-year-old male with pulmonary hypertension associated with an atrial septal defect underwent an elective hernia repair. Conclusions We discuss useful management strategies for minimising risk during the peri- and post-operative periods in this population.

Worldwide, more than 200 million non-cardiac surgeries are performed annually, and this number is constantly increasing; cardiac complications are the leading cause of death in such surgeries. So, in a multicenter study conducted in 27 countries, cardiovascular complications were present in 68% of cases of death in the postoperative period. Registers of recent years have shown that the number of such complications remains high, for example, with a dynamic assessment of troponins, perioperative myocardial damage was detected in 13-18% of cases. This review provides a critical analysis of the step-by-step algorithm for assessing cardiac risk of non-cardiac operations considering the emergence of new publications on this topic. The review discusses new data on risk assessment scales, functional state assessment, the use of non-invasive tests, biomarkers, the role of preventive myocardial revascularization in the preoperative period, and drug therapy. The issues of non-cardiac operations after percutaneous coronary intervention, perioperative myocardial damage are considered separately. The review emphasizes the difficulties in obtaining evidence, conducting randomized clinical trials in this section of medicine, which do not allow obtaining unambiguous conclusions in most cases and lead to inconsistencies and ambiguities in the recommendations of various expert groups. This review will help practitioners navigate this issue and help to use the optimal diagnostic and treatment strategy before performing non-cardiac surgery.

Low ejection fraction in the elderly presenting for anaesthesia could be very challenging to the anaesthetist on account of the heightened risk of perioperative complications. The combined risk of low ejection fraction and poor cardiac reserve may predispose to increase perioperative mortality. Complications in the perioperative period includes acute exacerbation of heart failure which can arise from pump failure or cardiac dyskinesia, and these could be debilitating in the elderly. Therefore, maintaining good systolic function and cardiac rhythm will ensure cardiovascular stability. We present the management of an 89year old man who had hypertensive heart disease with ejection fraction of 40% that successfully had dynamic hip replacement under combined spinal epidural (CSE) anaesthesia. Keywords: neuraxial blockade, ejection fraction, elderly. French title: Prise en charge anesthésique des âgées à faible taux d'éjection subissant une chirurgie non cardiaqueUne faible fraction d'éjection chez les âgées se présentant pour une anesthésie pourrait être très difficile pour l'anesthésiste en raison du risque accru de complications péri opératoires. Le risque combiné de faible fraction d'éjection et de faible réserve cardiaque peut prédisposer à une augmentation de la mortalité péri opératoire. Les complications de la période péri opératoire comprennent une exacerbation aiguë de l'insuffisance cardiaque qui peut résulter d'une défaillance de la pompe ou d'une dyskinésie cardiaque, et celles-ci pourraient être débilitantes chez les personnes âgées. Par conséquent, le maintien d'une bonne fonction systolique et d'un bon rythme cardiaque assurera la stabilité cardiovasculaire. Nous présentons la prise en charge d'un homme de 89 ans qui avait une cardiopathie hypertensive avec une fraction d'éjection de 40% qui a eu avec succès une arthroplastie dynamique de la hanche sous anesthésie épidurale rachidienne combinée (AERC). Mots-clés : Blocage neuraxial, fraction d'éjection, personnes âgées

The review presents the main aspects of the cardioprotective properties of the xenon inhalation anesthetic. Based on the analysis of publications, the article discusses modern views on the mechanisms of the protective action of xenon, realized using pre- and post-conditioning mechanisms, shows major molecular targets and their effects. The article presents the results of experimental studies in vivo and in vitro, which showed the protective effect of xenon on the myocardium and the results of recent randomized clinical trials. The analysis of studies demonstrates the ability of xenon to increase myocardial resistance to ischemia and reperfusion and opens up good prospects for its use in clinical practice in patients with a high risk of cardiac complications.

Background & aim. The study aimed to identify preventable risk factors for the occurrence of intraoperative and 24-hour postoperative cardiac arrest in geriatric patients. Methods. This was a matched case-control study. Patients aged 65 and older who experienced intraoperative and 24-hour postoperative cardiac arrest between 2011 and 2018 were consecutively recruited into the case group. Cases were matched with controls by sex, age range, and in the same year of surgery in the ratio of 1:3. The outcome was the occurrence of intraoperative and 24-hour postoperative cardiac arrest. Univariate and multivariate logistic regression analyses were carried out to identify factor related outcomes. Results. From a total of 20,024 geriatric patients, 98 cases and 294 controls were recruited. The risk factors of intraoperative and 24-hour postoperative cardiac arrest were ASA classifications 3 (odds ratio [OR] 3.95, 95% confidence interval [CI] 1.24-12.62) and 4 (OR 8.46, 95% CI 2.15-33.36) compared to ASA classification 2, aortic surgery (OR 16.86, 95% CI 2.9-97.99) compared to trunk and perineal surgery, potassium imbalance (OR 2.71, 95% CI 1.02-7.22), and receiving preoperative benzodiazepine (OR 3.92, 95% CI 1.36-11.28). Regional anesthesia (OR 0.18, 95% CI 0.04-0.83) and propofol (OR 0.09, 95% CI 0.03-0.24) were found to be protective factors. Conclusions. The study found that potassium imbalance might be a preventable risk factor. If feasible, performing regional anesthesia while avoiding preoperative benzodiazepine is recommended.

A few randomized controlled trials (RCTs) have compared crystalloid-based goal-directed fluid therapy (GDFT) with starch-based GDFT in patients undergoing major surgical procedures with conflicting results. In this meta-analysis, colloid-based GDFT was compared with crystalloid-based GDFT. In this meta-analysis, RCTs comparing colloid- and crystalloid-based GDFT in patients undergoing non-cardiac surgery were included. Binary outcomes were reported as risk ratio (RR) and continuous outcomes were reported as mean difference (MD) with 95% confidence interval (95% CI). PubMed, PubMed central, The Cochrane Library database and EMBASE were searched for potentially eligible trials from inception to 28 February 2020. Data of 2392 patients from nine RCTs were included in this meta-analysis. Mortality at the longest available follow-up [RR (95% CI) 1.44 (0.88, 2.34); p = 0.15], postoperative kidney dysfunction [RR (95% CI) 1.07 (0.72, 1.60); p = 0.73], postoperative length of hospital stay [MD (95% CI) – 0.29 ( – 1.25, 0.66) d; p = 0.55], cardiovascular complications [RR (95% CI) 1.20 (0.50, 2.88); p = 0.68], wound complications [RR (95% CI) 1.08 (0.76, 1.54); p = 0.66], pulmonary complications [RR (95% CI) 0.90 (0.71, 1.140); p = 0.40] and bleeding [RR (95% CI) 1.24 (0.77, 1.99); p = 0.37] were similar in both the groups. Postoperative major complications were also similar between patients who received colloid and crystalloid [RR (95% CI) 0.79 (0.48, 1.29); p = 0.34]. Colloids in goal-directed fluid therapy protocol does not offer any benefit over crystalloid-based goal-directed fluid therapy protocol in patients undergoing major non-cardiac surgical procedure.

Objectives • To outline the key components of a pre-operative cardiac risk assessment. • To review the major guidelines utilized to assess patients' surgical risks. • To discuss the perioperative management of surgical patients to prevent cardiac and pulmonary complications. • To review the utility of biomarkers in the pre- and post-operative period.

Myocardial injury after non-cardiac surgery is common and defined as myocardial ischaemia within 30 days after non-cardiac surgery. Diagnosis of myocardial injury after non-cardiac surgery is challenging as this could be clinically asymptomatic during the postoperative period due to many other factors. Role of high-sensitive cardiac troponin in diagnosing myocardial injury after non-cardiac surgery had been evaluated in several studies. Due to the fact that high-sensitive cardiac troponin remains positive for about two weeks in the body and is highly specific in diagnosing clinically silent myocardial injuries, it is recognised as the most useful biomarker in detecting myocardial injury after non-cardiac surgery. However, high-sensitive cardiac troponin is not well incorporated as a biomarker in current major perioperative guidelines or in clinical practice. The aim of this review is to discuss evidence and guidelines in this area in view of the use of high-sensitive cardiac troponin in early identification of myocardial injury after non-cardiac surgery.

Background Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. Design An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. Methods Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. Results A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5–2.0; P Conclusions Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.

Background and Aims: Postoperative pulmonary complications (PPCs) lead to increased morbidity, mortality, length of hospital stay, and cost to the patient. This study was conducted to determine the risk factors and assess the incidence of PPC after non-cardiac surgery. Material and Methods: This prospective, observational study was conducted on 1,170 patients undergoing non-cardiac surgery. Details of patient, surgical, and anesthetic factors were collected and patients were followed up for the entire duration of hospital stay for the occurrence of PPC. Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score and the length of hospital stay was noted for all the patients. Regression analysis was used to find the risk factors associated with development of respiratory complications. Results: The incidence of PPC was found to be 59 in 1,170 patients (5%) in our hospital. Multivariate analysis revealed that patients with intermediate and high risk ARISCAT scoring had higher odds of developing PPC. Higher age (>50 years), positive cough test, presence of nasogastric tube, and intraoperative pulmonary complications were identified as independent risk factors associated with the occurrence of PPC. Conclusion: We found 5% incidence of PPC in our study. Recognition of the delineated risk factors and routine use of ARISCAT score for preoperative assessment may help identify patients at a higher risk of developing postoperative pulmonary complications.

The perioperative period induces unpredictable and significant alterations in coronary plaque characteristics which may culminate as adverse cardiovascular events in background of a compromised myocardial oxygen supply and demand balance. This “ischemic-imbalance” provides a substrate for perioperative cardiac adversities which incur a considerable morbidity and mortality. The propensity of myocardial injury is dictated by the conglomeration of various factors like pre-existing medical condition, high-risk surgical interventions, intraoperative hemodynamic management, and the postoperative care. Perioperative myocardial infarction (PMI) differs from myocardial infarction (MI) in a non-operative setting. PMI can often be notoriously “silent” demonstrating a conspicuous absence of the classic clinical symptoms. Moreover, myocardial injury following non-cardiac surgery (MINS) characterized by an elevation of the cardiac insult biomarkers has demonstrated an independent prognostic significance in the perioperative scenario despite the lack of a formal categorization as PMI. This has evoked interest in the meticulous characterization of MINS as a discrete clinical entity. Multifactorial etiology, varying symptomatology, close differential diagnosis, and a debatable management regime makes perioperative myocardial injury-infarction, a subject of detailed discussion.

Introduction: Ebstein anomaly, a congenital heart defect characterized by a morphological and functional abnormality of the tricuspid valvula while moving the mouth of the tricuspid valvula towards the apex of the right chamber. Case report: A patient aged 39 years on the Department of Surgery was admitted under the image of an acute abdomen and the need for emergency surgical treatment. Routine preoperative preparation, laboratory treatment, examination of internist and examination of anesthesiologist on the part of the part was carried out. He has a history of occasional breathing problems during respiratory infection, a smoker. Clinical status, other than primary problems, is orderly. Operational treatment passed neatly, on the fourth postoperative day the patient complained of suffocation, lack of air and chest pain, translated into intensive care monitored (spo2 87% f about 110/min TA 90/60), blood gas analysis done and laboratory treatment (fibrinogen, D dimer) due to suspected pulmonary thromboembolia consulted cardiologist, dilation of the right atrium seen by ultrasound. Discussion: Non-cardiac surgeries in patients with pre-existing congenital heart defects are high-risk surgeries with increased mobility and mortality in the perioperative period. In accordance with the accompanying pathoanatomical and pathophysiological changes that define the congenital heart defect, a detailed plan must be made - anesthesiological management for each patient separately. Hemodynamic and respiratory stability with avoidance of hypoxia and paradoxical arrhythmias are the basic postulates in patients with Ebstein's anomaly.

Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn’t.

The Authors’ reply: In response to valuable comments by Muller et al ,1 we are pleased to share results of additional analysis on our recent study ‘Association between cardiologist evaluation and mortality in myocardial injury after non-cardiac surgery’.2 We hope the additional information would be helpful for readers. First, we agree with the concern and conducted analysis on 2322 myocardial injury after non-cardiac surgery patients who had preoperative cardiac troponin (cTn) measurements. Within these patients, 945 patients were evaluated by cardiologists, and the incidence of 30-day morality …

Background This study was conducted to investigate the relationship between the Neutrophil-Lymphocyte Ratio (NLR) and the incidence of surgery-related acute kidney injury (AKI) in non-cardiac surgery patients under general anaesthesia. Methods In this retrospective study, 5057 patients from Third Xiangya hospital from January 2012 to December 2016 and 1686 patients from Second Xiangya hospital from January 2016 to December 2016 for non-cardiac surgery under general anesthesia were included. According to receiver operating characteristic (ROC) curve constructed by NLR for postoperative AKI, the cut-off point was obtained as the basis for grouping low or high NLR. The baseline characteristics of two sets were compared with each other. A multi-factor model was constructed by Least absolute shrinkage and selection operator (LASSO) method with the training set, and verified by outside validation set. Results 243 patients (3.604%) developed postoperative AKI. The ROC curve showed that the AUC of the NLR for predicting postoperative AKI in non-cardiac surgery was 0.743 (95% CI, 0.717–0.769), and the cut-off value was 3.555 (sensitivity, 86.4%; specificity 51.9%). There was no significant difference in the baseline characteristics of training set and validation set. The AUC in the training set was 0.817 (95% CI, 0.784–0.850), and the AUC in the validation set was 0.804 (95% CI, 0.749–0.858), the AUC deviation was 0.012 (P > 0.05) from validation set, and the likelihood ratio test showed P < 0.05. Conclusion This study showed that preoperative high NLR (NLR≥3.555) was an independent risk factor associated with postoperative AKI (OR, 2.410; 95% CI, 1.371–4.335) in patients for non-cardiac surgery under general anesthesia.

Background: Hyperglycemia in surgical candidates is associated with increased mortality and morbidity. We aimed to evaluate the effect of intraoperative blood glucose level on the incidence of myocardial injury after non-cardiac surgery (MINS) in diabetic patients. Methods: Diabetic patients with available intraoperative blood glucose measurement during non-cardiac surgery were enrolled in this study. Based on the highest intraoperative blood glucose level, patients were stratified into two groups: the blood sugar glucose (BST) &lt, 180 group (intraoperative peak glucose &lt, 180 mg/dL) and BST ≥ 180 group (intraoperative peak glucose ≥ 180 mg/dL). The primary outcome was the incidence of MINS, and secondary outcomes were in-hospital and 30-day mortalities. Results: Of the 11,302 diabetic patients, 8337 were in the BST &lt, 180 group (73.8%) and 2965 in the BST ≥ 180 group (26.2%). After adjustment with inverse probability weighting, MINS was significantly higher in the BST ≥ 180 group (24.0% vs. 17.2%, odds ratio (OR), 1.26, 95% confidence interval (CI), 1.14–1.40, p &lt, 0.001). In addition, in-hospital and 30-day mortalities were also higher in the BST ≥ 180 group compared to the BST &lt, 180 group (4.2% vs. 2.3%, hazard ratio (HR), 1.39, 95% CI, 1.07–1.81, p = 0.001, and 3.1% vs. 1.8%, HR, 1.76, 95% CI, 1.31–2.36, 0.001, respectively). Receiver-operating characteristic plots showed that the threshold of glucose level associated with MINS was 149 mg/dL. Conclusion: Intraoperative hyperglycemia was associated with an increased MINS incidence and postoperative mortality in diabetic patients. Close monitoring of intraoperative blood glucose level may be helpful in detection and management of MINS.

Background: Intraoperative hypotension is associated with increased postoperative morbidity and mortality. We tested whether the clinical application of an early warning system (EWS) in combination with an algorithm for hemodynamic management reduces the occurrence of intraoperative hypotension as well as decrease the degree of organ injury and oxidative stress. Methods: We randomly assigned patients undergoing major general surgery EWS and hemodynamic algorithm (intervention group, n=20) or standard care (n=20). The primary outcome was the difference in hypotension (defined as mean arterial pressureResults: The median number of hypotensive episodes was lower in the intervention group [-5.0 (95%CI:-9.0,-0.5);P Conclusions: The use of an EWS coupled with an hemodynamic algorithm resulted in reduced intraoperative hypotension. This finding was coupled with a reduction of biomarkers of brain injury and oxidative stress.Trial Registration number and date: “Correlation Between Circulating Biomarkers of Organ Damage and Intraoperative Hypotension Management”, NCT03527758, registered on May 17, 2018.https://www.clinicaltrials.gov/ct2/show/NCT03527758?term=NCT03527758&draw=2&rank=1

Background Myocardial injury that occurs after non-cardiac surgery (MINS) increases mortality in 30 days. However, few studies have assessed the impact of MINS occurrence on long-term mortality. Methods Retrospective study including all non-cardiac surgery patients admitted to an postoperative care unit who stayed at least one night in this unit, and had at least one measurement of high-sensitive cardiac troponin. Patients undergoing coronary angiography and patients with an underlying disease with a poor prognosis were excluded. The study period was from January/2011 to December/2019, ensuring a minimum follow-up of 2 years. Clinical characteristics and the occurrence of MINS were assessed between deaths and survivors using the chi-square test and Student's t-test. Variables with p Results 2532 patients were included, with a mean follow-up of 8.62±2.72 years, mean age = 63.23±16.5 years and 53.6% women. The prevalence of MINS was 12.5% (317 patients). There were 620 deaths (24.5%). In the univariate analysis, the following variables were associated with death: MINS (OR 2.65; p Conclusion In patients undergoing non-cardiac surgery, the increase in high-sensitive troponin increased the risk of death from all causes in the long term. Funding Acknowledgement Type of funding sources: None. Survival curve

Myocardial injury after non-cardiac surgery (MINS) is a well-known and relevant indicator of early postoperative mortality, but factors related to increased mortality in MINS patients are as yet unknown. The Charlson Comorbidity Index (CCI) is widely used to classify various comorbid conditions and underlying diseases. Our study aimed to determine the prognostic value of CCI with regard to mortality of patients with MINS. This study comprises 5633 patients who had MINS as diagnosed by a rise of postoperative cardiac troponin I above the normal range (≥ 0.04 ng/mL) from January 2010 to June 2019. Patients were divided into two groups according to median weighted CCI score: low CCI (≤ 2) and high CCI (> 2) groups. The primary outcome was 30-day mortality after surgery, and secondary outcomes were 1-year and overall mortalities. Of the 5633 patients, 3428 (60.9%) were in the low CCI group (1.21 ± 0.84) and 2205 (39.1%) were in the high CCI group (4.17 ± 1.82). After propensity score matching, mortality during the first 30 days after surgery was significantly greater in the high CCI group than the low CCI group (9.4% vs. 6.0%, respectively; hazard ratio 1.56, 95% confidence interval 1.23–1.98, p

ObjectiveThe association of non-steroidal anti-inflammatory drugs with postoperative acute kidney injury (AKI) is controversial. However, there are few studies focusing on the association between parecoxib and postoperative AKI. Our study aimed at the possible correlation between the intraoperative administration of cyclooxygenase-2 inhibitors parecoxib and perioperative AKI.DesignA retrospective cohort study.SettingThird Xiangya Hospital of Central South University in Hunan Province, China.ParticipantsThe electronic medical records and laboratory results were obtained from 9246 adult patients (18–60 years) undergoing non-cardiac surgery performed between 1 January 2012 and 31 August 2017. Study groups were treated with or without parecoxib.InterventionsUnivariable analysis identified demographic, preoperative laboratory and intraoperative factors associated with AKI. Logistic stepwise regression was used to calculate the adjusted OR of parecoxib and AKI association.ResultsThe incidence of AKI was lower in the parecoxib-administered group (4%) than that in the group without parecoxib (6.3%, p=0.005). In the multivariable regression analysis, postoperative AKI risk reduced by 39% (OR 0.61; 95% CI 0.43 to 0.87) in the parecoxib-administered group after adjusting for interference factors. Sensitivity analysis showed that postoperative AKI risk reduced in four subgroups: eGRF 2 (OR 0.49; 95% CI 0.29 to 0.82), non-smoker (OR 0.55; 95% CI 0.37 to 0.83), blood loss ConclusionsThus, parecoxib is associated with a modest reduction of postoperative AKI risk among adult patients undergoing non-cardiac surgery.