Cardiac

Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant

Many differing regimes have been recommended by different organizations as well as those using different direct oral anticoagulants (DOACs) based on their half life and renal function.

A simple regime was employed, largely amounting to interruption of DOACs 1 day before low bleeding procedures or 2 days before high bleeding risk procedures, with an adjustment for moderate renal dysfunction for Dabigatran. Resumption occurred in 1 day with low bleeding risk and 2 – 3 days with higher bleeding risk.

Conclusion: “A simple standardized perioperative management strategy without heparin bridging or measurement of coagulation function was associated with low rates of major bleeding and arterial thromboembolism.“

How this meshes with regional or neuraxial anesthesia guidelines as in ASRA is open to further discussion.

link

Association between complications and death within 30 days after noncardiac surgery

It is rare to die in the Operating Room.

This prospective study looked at the rate and cause of death after non-cardiac surgery.

“Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality”

link

Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

link

New Index for Preoperative Cardiovascular Evaluation

Another attempt to update or simplify prediction of cardiovascular morbidity and mortality in non-cardiac surgery.

Outcomes were: incidence of 30-day postoperative all-cause mortality, myocardial infarction (MI), or stroke.

This study identified six predictors of primary outcome: age ≥75 years, any history of heart disease, symptoms of angina or dyspnea with regular activities, hemoglobin <12 mg/dl, planned vascular surgery, and emergency surgery.

It is dubbed the Cardiovascular Risk Index (CVRI)

link

Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

link

Prolonged Perioperative Use of Pregabalin and Ketamine & Chronic Pain

This was a randomized study in cardiac surgery. Patients were randomly assigned to receive either usual care, pregabalin (150 mg preoperatively and twice daily for 14 postoperative days) alone, or pregabalin in combination with a 48-h postoperative infusion of intravenous ketamine at 0.1 mg · kg−1 · h−1.

Conclusions: Preoperative administration of 150 mg of pregabalin and postoperative continuation twice daily for 14 days significantly lowered the prevalence of persistent pain after cardiac surgery.

link

Trans-Nasal Evaporative Intra-arrest Cooling

Much of the earlier enthusiasm for therapeutic hypothermia has been tempered with disappointing trial results. This study examined cooling of the brain initiated during cardiopulmonary resuscitation and its impact on survival with good neurologic outcome in patients with out-of-hospital cardiac arrest.

Trans-nasal evaporative intra-arrest cooling did not result in a statistically significant improvement in survival with good neurologic outcome.

link

Off or On Pump CABG

Much hope for improvement in outcomes and cognitive impairment was held out for off pump CABG. This study shows no difference.

“The present study’s data did not show differences in key long-term outcomes between patients who underwent revascularization with or without cardiopulmonary bypass, supporting the idea that both methods achieve similar late results regarding overall survival, need for reintervention, and postoperative myocardial infarction.”

link

Incentive Spirometry after CABG

The ubiquitous incentive spirometer for breathing exercise after surgery has often been questioned as lacking evidence. Many prehabilitation programs use structured deep breathing as well as inspiratory muscle strength training, along with aerobic and resistance training. Australian choosing wisely physiotherapy guidelines recommended against incentive spirometry ( link ).

This was a single center randomized trial in coronary artery bypass surgery which aimed to improve adherence by incorporating hourly reminder bells. The results were quite impressive in improved Incentive Spirometer use adherence, atelectasis severity, early postoperative fevers, noninvasive positive pressure ventilation use, intensive care unit length of stay by a day, and 6-month mortality rates.

“Incentive spirometers can be clinically effective, but perhaps only when adherence is high”. Further studies are recommended on incentive spirometry without reminders. As a relatively small trial, further larger studies with balanced patient populations are essential.

link