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Open Access
2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
(Circulation) Thompson, Annemarie; Fleischmann, Kirsten E; Smilowitz, Nathaniel R; de Las Fuentes, Lisa; Mukherjee, Debabrata; Aggarwal, Niti R; Ahmad, Faraz S; Allen, Robert B; Altin, S Elissa; Auerbach, Andrew; Berger, Jeffrey S; Chow, Benjamin; Dakik, Habib A; Eisenstein, Eric L; Gerhard-Herman, Marie; Ghadimi, Kamrouz; Kachulis, Bessie; Leclerc, Jacinthe; Lee, Christopher S; Macaulay, Tracy E; Mates, Gail; Merli, Geno J; Parwani, Purvi; Poole, Jeanne E; Rich, Michael W; Ruetzler, Kurt; Stain, Steven C; Sweitzer, BobbieJean; Talbot, Amy W; Vallabhajosyula, Saraschandra; Whittle, John; Williams, Kim Allan
Aim: 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. Methods: 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. Structure: 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.
Open Access
2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
(Journal of the American College of Cardiology, 2024-09) Writing Committee Members; Thompson, Annemarie; Fleischmann, Kirsten E; Smilowitz, Nathaniel R; de Las Fuentes, Lisa; Mukherjee, Debabrata; Aggarwal, Niti R; Ahmad, Faraz S; Allen, Robert B; Altin, S Elissa; Auerbach, Andrew; Berger, Jeffrey S; Chow, Benjamin; Dakik, Habib A; Eisenstein, Eric L; Gerhard-Herman, Marie; Ghadimi, Kamrouz; Kachulis, Bessie; Leclerc, Jacinthe; Lee, Christopher S; Macaulay, Tracy E; Mates, Gail; Merli, Geno J; Parwani, Purvi; Poole, Jeanne E; Rich, Michael W; Ruetzler, Kurt; Stain, Steven C; Sweitzer, BobbieJean; Talbot, Amy W; Vallabhajosyula, Saraschandra; Whittle, John; Williams, Kim Allan
Aim
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.
Methods
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.
Structure
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.
Open Access
A genome-wide association study of variants associated with acquisition of Staphylococcus aureus bacteremia in a healthcare setting.
(BMC Infect Dis, 2014-02-13) Nelson, Charlotte L; Pelak, Kimberly; Podgoreanu, Mihai V; Ahn, Sun Hee; Scott, William K; Allen, Andrew S; Cowell, Lindsay G; Rude, Thomas H; Zhang, Yurong; Tong, Amy; Ruffin, Felicia; Sharma-Kuinkel, Batu K; Fowler, Vance G
BACKGROUND: Humans vary in their susceptibility to acquiring Staphylococcus aureus infection, and research suggests that there is a genetic basis for this variability. Several recent genome-wide association studies (GWAS) have identified variants that may affect susceptibility to infectious diseases, demonstrating the potential value of GWAS in this arena. METHODS: We conducted a GWAS to identify common variants associated with acquisition of S. aureus bacteremia (SAB) resulting from healthcare contact. We performed a logistic regression analysis to compare patients with healthcare contact who developed SAB (361 cases) to patients with healthcare contact in the same hospital who did not develop SAB (699 controls), testing 542,410 SNPs and adjusting for age (by decade), sex, and 6 significant principal components from our EIGENSTRAT analysis. Additionally, we evaluated the joint effect of the host and pathogen genomes in association with severity of SAB infection via logistic regression, including an interaction of host SNP with bacterial genotype, and adjusting for age (by decade), sex, the 6 significant principal components, and dialysis status. Bonferroni corrections were applied in both analyses to control for multiple comparisons. RESULTS: Ours is the first study that has attempted to evaluate the entire human genome for variants potentially involved in the acquisition or severity of SAB. Although this study identified no common variant of large effect size to have genome-wide significance for association with either the risk of acquiring SAB or severity of SAB, the variant (rs2043436) most significantly associated with severity of infection is located in a biologically plausible candidate gene (CDON, a member of the immunoglobulin family) and may warrant further study. CONCLUSIONS: The genetic architecture underlying SAB is likely to be complex. Future investigations using larger samples, narrowed phenotypes, and advances in both genotyping and analytical methodologies will be important tools for identifying causative variants for this common and serious cause of healthcare-associated infection.
Open Access
A Multi-Center International Analysis of Lung Transplantation Outcomes in Patients With COVID-19.
(Clinical transplantation, 2024-09) Kashem, Mohammed Abul; Loor, Gabriel; Emtiazjoo, Amir; Hartwig, Matthew; Van Raemdonck, Dirk; Calvelli, Hannah; Leon Pena, Andres; Salan-Gomez, Marcelo; Zhao, Huaqing; Warnick, Michael; Villavicencio, Mauricio; Ius, Fabio; Ghadimi, Kamrouz; Salman, Jawad; Chandrashekaran, Satish; Machuca, Tiago; Sanchez, Pablo G; Subramaniam, Kathirvel; Neyrinck, Arne; Huddleston, Stephen; Ceulemans, Laurens; Osho, Asishana; D'Silva, Ethan; Ramamurthy, Uma; Shaffer, Andrew; Langer, Nathaniel; Toyoda, Yoshiya
Introduction
Lung transplantation has become increasingly utilized in patients with COVID-19. While several single-center and UNOS database studies have been published on lung transplants (LTs) for end-stage lung disease (ESLD) from Coronavirus disease 2019 (COVID-19), there is a lack of multi-center and international data.
Methods
This is a multicenter analysis from 11 high-volume lung transplant centers in the United States and Europe. Data were collected through the Multi-Institutional ECLS Registry and stratified by ESLD due to COVID-19 versus other etiologies. Demographics and clinical variables were compared using Chi-square test and Fisher's exact test. Survival was assessed by Kaplan-Meier curves and compared by log-rank test with propensity score matching.
Results
Of 1606 lung transplant recipients, 46 (2.9%) were transplanted for ESLD from COVID-19 compared to 1560 (97.1%) without a history of COVID-19. Among COVID-19 patients, 30 (65.2%) had COVID-19-associated ARDS and 16 (34.8%) had post-COVID-19 fibrosis. COVID-19 patients had higher lung allocation scores (78.0 vs. 44.4, p < 0.0001), had severely limited functional status (37.0% vs. 2.9%, p < 0.0001), had higher preoperative ECMO usage (65.2% vs. 5.4%, p < 0.0001), and spent less time on the waitlist (32 vs. 137 days, p < 0.0001). A 30-day survival was comparable between COVID-19 and non-COVID-19 patients before (100% vs. 98.7%, p = 0.39) and after propensity matching (p = 0.15).
Conclusions
Patients who received LTs due to COVID-19 had short-term survival comparable to that of patients without COVID-19. Our findings support the idea that lung transplantation should be considered for select patients with ESLD due to COVID-19.
Open Access
A Systematic Approach to Perioperative Smoking Cessation
(Techniques in Orthopaedics, 2020-01-01) Davis, JM; Thomas, LC; Dirkes, JEH; Aronson, S
© 2020 Wolters Kluwer Health, Inc. All rights reserved. Background:There is compelling evidence that smoking leads to poor postoperative outcomes including increased incidence of wound infection, respiratory infection, sepsis, cardiac arrest, and mortality. There is also compelling evidence that smoking cessation before surgery leads to improved outcomes. A recent meta-analysis found that brief smoking interventions may be insufficient to change postoperative outcomes. However, more intensive evidence-based smoking cessation interventions do improve postoperative outcomes and lead to long-term smoking abstinence. From a healthcare perspective, this raises a question of how to best provide effective perioperative smoking cessation treatment to a population.Methods:Duke University Health System recently developed a systematic approach to perioperative smoking cessation. In this report, we outline evidence-based principles for perioperative smoking cessation and describe initial results from a perioperative smoking cessation program.Results:In the first 100 days of the Duke Perioperative Smoking Cessation Program, we received 420 referrals. Participants had a mean pack-year history of 50.3 (packs/day×years smoking; SD 32.5), a mean Fagerström Test for Nicotine Dependence score of 4.5 (SD 2.5), and a mean expired breath carbon monoxide of 11.8 (SD 7.5) parts per million. Mean days from initial perioperative smoking cessation visit to surgery was 21.4 (SD 22.3).Discussion:This model of perioperative smoking cessation is in the early stages of development; however, evidence-based perioperative smoking cessation services can be effective across a health system.
Open Access
Abdominal Gunshot Causing Ventricular Septal Injury Without Perforation into the Pericardium.
(Journal of Cardiothoracic and Vascular Anesthesia, 2019-03-01) Sigurdsson, Martin I; Brockbank, Benjamin; Haney, John C; Andrews, Jon; MacLeod, David B; Vaslef, Steven N; Brooks, Kelli R; Manning, Erin L; Nicoara, Alina
Open Access
Activated Coagulation Time and Hepcon Protamine Titration Device to Manage Unfractionated Heparin During Cardiopulmonary Bypass in a Hemophilia A Patient on Emicizumab.
(Journal of cardiothoracic and vascular anesthesia, 2021-11) Isaacs, James; Welsby, Ian J; Schroder, Jacob N; Onwuemene, Oluwatoyosi A
In the perioperative management of patients with hemophilia A, emicizumab prevents the accurate measurement of common clotting assays, including the activated clotting time (ACT), which is essential for high-dose heparin monitoring during cardiopulmonary bypass surgery. The authors describe the successful perioperative management of a hemophilia A patient on maintenance emicizumab who, following a non-ST myocardial infarction, underwent cardiopulmonary bypass grafting surgery with heparin monitoring using both the ACT and heparin levels from the Hepcon protamine titration device. Postoperatively, the patient was transitioned to recombinant factor VIII replacement therapy. In hemophilia A patients on emicizumab who require heparin titration on cardiopulmonary bypass surgery, the ACT, combined with Hepcon heparin levels, may be used to complete the surgery successfully without excessive bleeding or morbidity.
Open Access
Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors.
(The New England journal of medicine, 2016-09) Connolly, Stuart J; Milling, Truman J; Eikelboom, John W; Gibson, C Michael; Curnutte, John T; Gold, Alex; Bronson, Michele D; Lu, Genmin; Conley, Pamela B; Verhamme, Peter; Schmidt, Jeannot; Middeldorp, Saskia; Cohen, Alexander T; Beyer-Westendorf, Jan; Albaladejo, Pierre; Lopez-Sendon, Jose; Goodman, Shelly; Leeds, Janet; Wiens, Brian L; Siegal, Deborah M; Zotova, Elena; Meeks, Brandi; Nakamya, Juliet; Lim, W Ting; Crowther, Mark; ANNEXA-4 Investigators
Background
Andexanet alfa (andexanet) is a recombinant modified human factor Xa decoy protein that has been shown to reverse the inhibition of factor Xa in healthy volunteers.
Methods
In this multicenter, prospective, open-label, single-group study, we evaluated 67 patients who had acute major bleeding within 18 hours after the administration of a factor Xa inhibitor. The patients all received a bolus of andexanet followed by a 2-hour infusion of the drug. Patients were evaluated for changes in measures of anti-factor Xa activity and were assessed for clinical hemostatic efficacy during a 12-hour period. All the patients were subsequently followed for 30 days. The efficacy population of 47 patients had a baseline value for anti-factor Xa activity of at least 75 ng per milliliter (or ≥0.5 IU per milliliter for those receiving enoxaparin) and had confirmed bleeding severity at adjudication.
Results
The mean age of the patients was 77 years; most of the patients had substantial cardiovascular disease. Bleeding was predominantly gastrointestinal or intracranial. The mean (±SD) time from emergency department presentation to the administration of the andexanet bolus was 4.8±1.8 hours. After the bolus administration, the median anti-factor Xa activity decreased by 89% (95% confidence interval [CI], 58 to 94) from baseline among patients receiving rivaroxaban and by 93% (95% CI, 87 to 94) among patients receiving apixaban. These levels remained similar during the 2-hour infusion. Four hours after the end of the infusion, there was a relative decrease from baseline of 39% in the measure of anti-factor Xa activity among patients receiving rivaroxaban and of 30% among those receiving apixaban. Twelve hours after the andexanet infusion, clinical hemostasis was adjudicated as excellent or good in 37 of 47 patients in the efficacy analysis (79%; 95% CI, 64 to 89). Thrombotic events occurred in 12 of 67 patients (18%) during the 30-day follow-up.
Conclusions
On the basis of a descriptive preliminary analysis, an initial bolus and subsequent 2-hour infusion of andexanet substantially reduced anti-factor Xa activity in patients with acute major bleeding associated with factor Xa inhibitors, with effective hemostasis occurring in 79%. (Funded by Portola Pharmaceuticals; ANNEXA-4 ClinicalTrials.gov number, NCT02329327 .).
Open Access
Andexanet alfa for the reversal of Factor Xa inhibitor related anticoagulation
(Expert review of hematology, 2016-01) Ghadimi, K; Welsby, IJ; Levy, JH; Dombrowski, KE
Andexanet alfa is a specific reversal agent for Factor Xa inhibitors. The molecule is a recombinant protein analog of factor Xa that binds to Factor Xa inhibitors and antithrombin:LMWH complex but does not trigger prothrombotic activity. In ex vivo, animal, and volunteer human studies, andexanet alfa (AnXa) was able to dose-dependently reverse Factor Xa inhibition and restore thrombin generation for the duration of drug administration. Further trials are underway to examine its safety and efficacy in the population of patients experiencing FXa inhibitor-related bleeding.
Open Access
Arterial and venous thrombosis complicating coronary artery bypass grafting after use of epoetin alfa-epbx.
(JTCVS techniques, 2020-08-04) Murillo-Berlioz, Alejandro; Guinn, Nicole R; Levy, Jerrold H; Milano, Carmelo A
Open Access
Assessment of Coronary Blood Flow by Transesophageal Echocardiography.
(J Cardiothorac Vasc Anesth, 2016-01) Maxwell, Cory; Cherry, Anne; Daneshmand, Mani; Swaminathan, Madhav; Nicoara, Alina
Open Access
Association between CK-MB Area Under the Curve and Tranexamic Acid Utilization in Patients Undergoing Coronary Artery Bypass Surgery.
(J Thromb Thrombolysis, 2017-02-14) van Diepen, Sean; Merrill, Peter D; Carrier, Michel; Tardif, Jean-Claude; Podgoreanu, Mihai; Alexander, John H; Lopes, Renato D
Myonecrosis after coronary artery bypass graft (CABG) surgery is associated with excess mortality. Tranexamic acid (TA), an anti-fibrinolytic agent, has been shown to reduce peri-operative blood loss without increasing the risk of myocardial infarction (MI); however, no large study has examined the association between TA treatment and post-CABG myonecrosis. In the MC-1 to Eliminate Necrosis and Damage in Coronary Artery Bypass Graft Surgery II trial, inverse probability weighting of the propensity to receive TA was used to test for differences among the 656 patients receiving and 770 patients not receiving TA. The primary outcome was creatine kinase MB (CK-MB) area under the curve (AUC) through 24 h. The secondary outcome was 30-day cardiovascular death or MI. Patients who received TA were more frequently female, had a previous MI, heart failure, low molecular weight heparin therapy, on-pump CABG, valvular surgery, and saphenous vein or radial grafts. The median 24-h CK-MB AUC was higher in TA-treated patients [301.9 (IQR 196.7-495.6) vs 253.5 (153.4-432.5) ng h/mL, p < 0.001]. No differences in the 30-day incidence of cardiovascular death or MI were observed (8.7 vs 8.3%, adjusted OR 0.99; 95% CI 0.67-1.45, p = 0.948). In patients undergoing CABG, TA use was associated with a higher risk of myonecrosis; however, no differences were observed in death or MI. Future larger studies should be directed at examining the pathophysiology of TA myonecrosis, and its association with subsequent clinical outcomes.
Open Access
Association of Brain Injury Biomarkers and Circulatory Shock Following Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study.
(Journal of neurosurgical anesthesiology, 2021-12) Toro, Camilo; Jain, Sonia; Sun, Shelly; Temkin, Nancy; Barber, Jason; Manley, Geoffrey; Komisarow, Jordan M; Ohnuma, Tetsu; Foreman, Brandon; Korley, Frederick; James, Michael L; Laskowitz, Daniel; Vavilala, Monica S; Hernandez, Adrian; Mathew, Joseph P; Markowitz, Amy J; Krishnamoorthy, Vijay; TRACK-TBI Investigators
Introduction
Early circulatory shock following traumatic brain injury (TBI) is a multifactorial process; however, the impact of brain injury biomarkers on the risk of shock has not been evaluated. We examined the association between neuronal injury biomarker levels and the development of circulatory shock following moderate-severe TBI.
Methods
In this retrospective cohort study, we examined adults with moderate-severe TBI (Glasgow Coma Scale score <13) enrolled in the TRACK-TBI study, an 18-center prospective TBI cohort study. The exposures were day-1 levels of neuronal injury biomarkers (glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1 [UCH-L1], S100 calcium-binding protein B [S100B], neuron-specific enolase), and of an inflammatory biomarker (high-sensitivity C-reactive protein). The primary outcome was the development of circulatory shock, defined as cardiovascular Sequential Organ Failure Assessment Score ≥2 within 72 hours of admission. Association between day-1 biomarker levels and the development of circulatory shock was assessed with regression analysis.
Results
The study included 392 subjects, with a mean age of 40 years; 314 (80%) were male and 165 (42%) developed circulatory shock. Median (interquartile range) day-1 levels of UCH-L1 (994.8 [518.7 to 1988.2] pg/mL vs. 548.1 [280.2 to 1151.9] pg/mL; P<0.0001) and S100B (0.47 μg/mL [0.25 to 0.88] vs. 0.27 [0.16 to 0.46] μg/mL; P<0.0001) were elevated in those who developed early circulatory shock compared with those who did not. In multivariable regression, there were associations between levels of both UCH-L1 (odds ratio, 1.63 [95% confidence interval, 1.25-2.12]; P<0.0005) and S100B (odds ratio, 1.73 [95% confidence interval 1.27-2.36]; P<0.0005) with the development of circulatory shock.
Conclusion
Neuronal injury biomarkers may provide the improved mechanistic understanding and possibly early identification of patients at risk for early circulatory shock following moderate-severe TBI.
Open Access
Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study.
(Critical care explorations, 2023-09) Kelly-Hedrick, Margot; Liu, Sunny Yang; Temkin, Nancy; Barber, Jason; Komisarow, Jordan; Manley, Geoffrey; Ohnuma, Tetsu; Colton, Katharine; Treggiari, Miriam M; Monson, Eric E; Vavilala, Monica S; Grandhi, Ramesh; Laskowitz, Daniel T; Mathew, Joseph P; Hernandez, Adrian; James, Michael L; Raghunathan, Karthik; Goldstein, Ben; Markowitz, Amy J; Krishnamoorthy, Vijay
Objectives
We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury.
Design
Retrospective cohort study.
Setting
ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.
Patients
Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI.
Interventions
None.
Measurements
Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction.
Main results
Of the 450 eligible participants, 57 (13%) received early beta blockers (BB⁺ group). The BB⁺ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB⁺ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB⁺ group and BB^- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes.
Conclusions
About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.
Unknown
Baseline Pulse Pressure, Acute Kidney Injury, and Mortality After Noncardiac Surgery.
(Anesth Analg, 2016-12) Oprea, Adriana D; Lombard, Frederick W; Liu, Wen-Wei; White, William D; Karhausen, Jörn A; Li, Yi-Ju; Miller, Timothy E; Aronson, Solomon; Gan, Tong J; Fontes, Manuel L; Kertai, Miklos D
BACKGROUND: Increased pulse pressure (PP) is an important independent predictor of cardiovascular outcome and acute kidney injury (AKI) after cardiac surgery. The objective of this study was to determine whether elevated baseline PP is associated with postoperative AKI and 30-day mortality after noncardiac surgery. METHODS: We evaluated 9125 adult patients who underwent noncardiac surgery at Duke University Medical Center between January 2006 and December 2009. Baseline arterial blood pressure was defined as the mean of the first 5 measurements recorded by the automated record keeping system before inducing anesthesia. Multivariable logistic regression analysis was performed to determine whether baseline PP adjusted for other perioperative risk factors was independently associated with postoperative AKI and 30-day mortality. RESULTS: Of the 9125 patients, the baseline PP was <40 mm Hg in 1426 (15.6%), 40-80 mm Hg in 6926 (75.9%), and >80 mm Hg in 773 (8.5%) patients. The incidence of AKI was 19.8%, which included 8.4% (151 patients) and 4.2% (76 patients) who experienced stage II and III AKI, respectively. In the risk-adjusted model for postoperative AKI, elevated baseline PP was associated with higher odds for postoperative AKI (adjusted odds ratio [OR] for every 20 mm Hg increase in PP, 1.17; 95% confidence interval [CI], 1.10-1.25; P < .0001). Also elevated baseline preoperative PP was significantly associated with mild (stage I; OR, 1.19; 95% CI, 1.11-1.27; P < .0001), but not with more advanced stages of postoperative AKI or with an incremental risk for 30-day mortality. CONCLUSIONS: We found a significant association between elevated baseline PP and postoperative AKI in patients who underwent noncardiac surgery. However, elevated PP was not significantly associated with more advanced stages of postoperative AKI or 30-day mortality in these patients.
Unknown
Bipolar tissue sealant device decreases hemoglobin loss in multilevel spine surgery.
(Transfusion, 2012-12) Hill, Steven E; Broomer, Bob; Stover, John; White, William; Richardson, William
Background
Traditional techniques for obtaining hemostasis during orthopedic surgery, such as conventional electrocautery and sealants, have limited clinical effectiveness in reducing hemoglobin (Hb) loss and requirement for transfusion. The bipolar tissue sealant device studied in this trial combines radiofrequency energy with saline irrigation to hemostatically seal both cut bone and soft tissue, potentially aiding hemostasis.
Study design and methods
Sixty patients undergoing multilevel posterior lumbar instrumentation and fusion were randomly assigned to unipolar cautery alone (control group) or unipolar cautery plus use of the bipolar tissue sealant device (treatment group). Hb loss from the surgical field was measured (rather than estimated) and compared between the two groups. The primary hypothesis was that the treatment group would lose significantly less Hb than the control group.
Results
The control group experienced a mean Hb loss of 102.4 g while the treatment group showed a significantly lower mean Hb loss of 66.2 g (p = 0.0004). No significant difference was found between groups with respect to secondary endpoints including length of surgery, number of red blood cell units transfused, number of total blood component units transfused, transfusion avoidance, length of stay, or serious adverse events.
Conclusion
Use of a bipolar tissue sealant device in addition to unipolar cautery significantly decreased Hb loss during multilevel, posterior lumbar spinal instrumentation and fusion when compared with unipolar cautery alone.
Unknown
Bleeding and the new anticoagulants: Strategies and concerns
(Anesthesiology, 2015-01-01) Samama, Charles Marc; Levy, Jerrold H
Unknown
Cardiac arrest and resuscitation activates the hypothalamic-pituitary-adrenal axis and results in severe immunosuppression.
(Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism, 2021-05) Zhao, Qiang; Shen, Yuntian; Li, Ran; Wu, Jiangbo; Lyu, Jingjun; Jiang, Maorong; Lu, Liping; Zhu, Minghua; Wang, Wei; Wang, Zhuoran; Liu, Qiang; Hoffmann, Ulrike; Karhausen, Jörn; Sheng, Huaxin; Zhang, Weiguo; Yang, Wei
In patients who are successfully resuscitated after initial cardiac arrest (CA), mortality and morbidity rates are high, due to ischemia/reperfusion injury to the whole body including the nervous and immune systems. How the interactions between these two critical systems contribute to post-CA outcome remains largely unknown. Using a mouse model of CA and cardiopulmonary resuscitation (CA/CPR), we demonstrate that CA/CPR induced neuroinflammation in the brain, in particular, a marked increase in pro-inflammatory cytokines, which subsequently activated the hypothalamic-pituitary-adrenal (HPA) axis. Importantly, this activation was associated with a severe immunosuppression phenotype after CA. The phenotype was characterized by a striking reduction in size of lymphoid organs accompanied by a massive loss of immune cells and reduced immune function of splenic lymphocytes. The mechanistic link between post-CA immunosuppression and the HPA axis was substantiated, as we discovered that glucocorticoid treatment, which mimics effects of the activated HPA axis, exacerbated post-CA immunosuppression, while RU486 treatment, which suppresses its effects, significantly mitigated lymphopenia and lymphoid organ atrophy and improved CA outcome. Taken together, targeting the HPA axis could be a viable immunomodulatory therapeutic to preserve immune homeostasis after CA/CPR and thus improve prognosis of post-resuscitation CA patients.
Open Access
Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins.
(J Cardiothorac Vasc Anesth, 2018-01-10) Yalamuri, Suraj; Heath, Michele; McCartney, Sharon; Cushman, Tera; Maxwell, Cory
Open Access
CASE 7---2015: Perioperative Considerations for a Cardiac Paraganglioma...Not Just Another Cardiac Mass.
(J Cardiothorac Vasc Anesth, 2015-08) Gerlach, Rebecca M; Barrus, Adam B; Ramzy, Danny; Hernandez Conte, Antonio; Khoche, Swapnil; McCartney, Sharon L; Swaminathan, Madhav