Factors affecting adherence to recommendations on pre-operative cardiac testing: A cohort study.

BACKGROUND: Cardiac risk evaluation prior to noncardiac surgery is fundamental to tailor peri-operative management to patient's estimated risk. Data on the degree of adherence to guidelines in patients at cardiovascular risk in Europe and factors influencing adherence are underexplored. OBJECTIVES: The aim of this analysis was to describe the degree of adherence to [2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines] recommendations on rest echocardiography [transthoracic echocardiography (TTE)] and to stress imaging prior to noncardiac surgery in a large European sample and to assess factors potentially affecting adherence. DESIGN: Secondary analysis of a multicentre, international, prospective cohort study (MET-REPAIR). SETTING: Twenty-five European centres of all levels of care that enrolled patients between 2017 and 2020. PATIENTS: With elevated cardiovascular risk undergoing in-hospital elective, noncardiac surgery. MAIN OUTCOME MEASURES: (Non)adherence to each pre-operative TTE and stress imaging recommendations classified as guideline-adherent, overuse and underuse. We performed descriptive analysis. To explore the impact of patients' sex, age, geographical region, and hospital teaching status, we conducted multivariate multinominal regression analysis. RESULTS: Out of 15 983 patients, 15 529 were analysed (61% men, mean age 72 ±â€Š8 years). Overuse (conduction in spite of class III) and underuse (nonconduction in spite of class I recommendation) for pre-operative TTE amounted to 16.6% (2542/15 344) and 6.6% (1015/15 344), respectively. Stress imaging overuse and underuse amounted to 1.7% (241/14 202) and 0.4% (52/14 202) respectively. Male sex, some age categories and some geographical regions were significantly associated with TTE overuse. Male sex and some regions were also associated with TTE underuse. Age and regions were associated with overuse of stress imaging. Male sex, age, and some regions were associated with stress imaging underuse. CONCLUSION: Adherence to pre-operative stress imaging recommendation was high. In contrast, adherence to TTE recommendations was moderate. Both patients' and geographical factors affected adherence to joint ESC/ESA guidelines. TRIAL REGISTRATION: NCT03016936.

Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study.

BACKGROUND: In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. METHODS: This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. RESULTS: In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. CONCLUSIONS: The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

Is Laryngeal Mask a Good Alternative in Children Undergoing Laparoscopic Inguinal Hernia Repair with Percutaneous Internal Ring Suturing Under and Over Two Years Old?

Objective: This study aimed to evaluate respiratory parameters during percutaneous internal ring suturing (PIRS) for inguinal hernia repair in two different-aged pediatric patients in whom the airway is provided with a laryngeal mask or endotracheal tube for general anaesthesia. Methods: After local ethics committee and parental consent, 180 ASAI-II children were randomly allocated to 4 groups; according to their age (0-24 months / 25-144 months) and airway device laryngeal mask (LMA) / endotracheal tube (ETT) used for general anaesthesia (45 children each) for laparoscopic inguinal hernia repair. Standard anaesthesia induction was done with lidocaine, propofol, and fentanyl, and 0.6 mg kg-1 rocuronium was added to the ETT groups. Sevoflurane is used for maintenance. Hemodynamic parameters, peak airway pressure, end-tidal carbon dioxide (EtCO2), and peripheric oxygen saturation (SpO2) values were recorded after induction, before, and during pneumoperitoneum. The duration of anaesthesia, surgery, recovery time, and surgical satisfaction was recorded. Airway complications (cough, laryngospasm, bronchospasm, desaturation, and aspiration) were recorded. Results: Hundred and eighty patients (45 in each group) were analyzed. Duration of surgery and surgical satisfaction were similar in all groups. Duration of anaesthesia and recovery times were significantly shorter in the LMA groups. Peak airway pressure and EtCO2 levels were significantly lower in the LMA groups. Rare airway complications were observed without significance. Conclusion: In laparoscopic inguinal hernia repair with the PIRS technique, LMA offered comparable operating conditions and surgical satisfaction.

Risk assessment for major adverse cardiovascular events after noncardiac surgery using self-reported functional capacity: international prospective cohort study.

BACKGROUND: Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery. METHODS: This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated. RESULTS: In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUCbaseline 0.74 [0.71-0.77], ROC AUCbaseline+4METs 0.74 [0.71-0.77], ROC AUCbaseline+floors climbed 0.75 [0.71-0.78], AUCbaseline+fitnessvspeers 0.74 [0.71-0.77], and AUCbaseline+physical activity 0.75 [0.72-0.78]). CONCLUSIONS: Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT03016936.

Outcomes of Antepartum and Postpartum Obstetric Admissions to the Intensive Care Unit of A Tertiary University Hospital: An 8-Year Review.

OBJECTIVE: Although their rates are decreasing, pregnancy-related mortality and morbidity are problems worldwide. In this study, we aimed to review the characteristics, diagnoses, required interventions and outcomes of obstetric patients admitted between 2006 and 2014 to the Intensive Care Unit (ICU) of a tertiary university hospital to provide an indicator for improving the management of critically ill obstetric patients. METHODS: A retrospective study of hospital records of obstetric admissions to the ICU was conducted. RESULTS: The pregnancy-related ICU admission rate was 0.21% among all deliveries during the study period. Nine antepartum (mean gestational age: 23 weeks) and 48 postpartum (mean gestational age: 34 weeks) obstetric ICU admissions were included. Most obstetric patients admitted antepartum were primiparous (88.8%), whereas those admitted postpartum were multiparous (64.6%). The mean ICU stay was 7 days among the patients admitted antepartum and 6 days among those admitted postpartum. Common medical reasons for ICU admission were respiratory failure and HELLP syndrome in both groups; DIC and eclampsia were also medical reasons causing ICU admission among the postpartum patients. Mechanical ventilation and blood derivative transfusion were the most common interventions required during the ICU stay of the obstetric patients. Maternal death was unique to the patients admitted postpartum (6 patients, 12.5%). CONCLUSION: We reviewed obstetric admissions to our institution over an 8-year period. We believe that a nationwide study in Turkey that provides an indicator of the frequency, reasons of ICU admission and outcome of obstetric patients is required to improve the quality of intensive care.

Can we gain an advantage by combining distal median, radial and ulnar nerve blocks with supraclavicular block? A randomized controlled study.

PURPOSE: The aim of this study was to compare the combined ultrasound-guided supraclavicular brachial plexus block (SCB) and distal median, radial, and ulnar nerve blocks, with the supraclavicular block alone. METHOD: Sixty-two patients undergoing upper extremity surgery were randomized to supraclavicular only (Group S, n = 31) or supraclavicular + distal (Group SD, n = 31) group. Patients in Group S received 32 mL of 1.5 % lidocaine + epinephrine 5 µg/mL, while those in Group SD received 20 mL of 1.5 % lidocaine + epinephrine 5 µg/mL followed by distal median, radial, and ulnar nerve blocks using equal volumes of 2 % lidocaine + 0.5 % levobupivacaine (4 mL/nerve). Sensory and motor blocks of the ulnar, median, radial and musculocutaneous nerves were assessed every 5 min starting at the 10th minute. The imaging, needling and performance times were recorded. Also, the onset and anesthesia-related times, need for analgesic and first analgesic times, were noted. RESULTS: In Group SD, the anesthesia onset [15 (10-25) vs. 20 (15-30) min, p < 0.001] and anesthesia related times [16.6 (10.7-28.2) vs. 22 (15.9-33.7) min, p < 0.001] were significantly shorter than those of Group S. Additionally, the analgesic requirement was lower in Group SD (56.7 vs. 88.5 %, p = 0.009), while among the patients who required analgesic, the first analgesic time was longer in Group SD in comparison to Group S [625 (347-1764) vs. 315 (233-746) min p < 0.001]. CONCLUSIONS: The addition of distal median, radial, and ulnar nerve blocks to SCB shortens anesthesia-related time and anesthesia onset time when compared with a SCB alone.

Ultrasound anatomy of the brachial plexus nerves in the neurovascular bundle at the axilla in patients undergoing upper-extremity block anesthesia.

PURPOSE: Familiarity with the localization of the nerves in the neurovascular bundle that constitutes the axillary segment of the brachial plexus (BP) is important when applying ultrasound (US)-guided block anesthesia. Therefore in this study we aimed to delineate the anatomy of the median, radial, and ulnar nerves of the BP at the axilla with US and electrical stimulation. MATERIALS AND METHODS: The study included 60 patients who were scheduled to undergo upper-arm surgery with axillary block anesthesia. Prior to anesthesia, ulnar, radial, and median nerves were localized with US using a 12-h quadrant identification system that placed the axillary artery (AA) in the middle. The nerves were then functionally tested using a neurostimulator. RESULTS: The radial nerve was mainly located in the 4-6 o'clock arc (posterior and posteromedial to AA) in 50 (83 %) of patients. Ulnar nerve was mainly at the 12-3 o'clock arc (anteromedial to AA) in 51 (85 %) of patients. Ulnar nerve showed a second peak at 9-10 o'clock quadrant (anterolateral to AA) in 11 % (7) of patients. Median nerve location was most common in the 12 and 9 o'clock arc (anterior and anterolateral to AA) in 53 (88 %) of the patients. CONCLUSIONS: Ultrasound is a useful tool for depicting BP anatomy in the axillary fossa prior to block anesthesia. Median, ulnar, and radial nerves form a highly consistent triangular pattern around the axillary artery that is easily recognizable with US.

Has the quality of abstracts for randomised controlled trials improved since the release of Consolidated Standards of Reporting Trial guideline for abstract reporting? A survey of four high-profile anaesthesia journals.

BACKGROUND AND OBJECTIVE: Randomised controlled trial (RCT) abstracts published in journal articles have traditionally been deficient of crucial information. To improve the quality of RCT abstracts, in January 2008, the Consolidated Standards of Reporting Trial (CONSORT) group published a checklist of essential information for inclusion. The current study assessed whether there has been an improvement in the quality of RCT abstracts published in main anaesthesia journals since this new guideline was introduced. METHODS: Articles involving human RCTs published in four high-profile anaesthesia journals (Anaesthesia, Anesthesia & Analgesia, Anesthesiology and the European Journal of Anaesthesiology) were reviewed, comparing those published from October 2005 to September 2006 (pre-CONSORT abstracts) with those published from October 2008 to September 2009 (post-CONSORT abstracts). Trials involving healthy volunteers or cadavers, cost-effectiveness studies, meta-analyses and letters were excluded. Abstracts from remaining RCTs were randomly assigned to four reviewers in a blinded fashion and reviewed for content using the new CONSORT checklist. RESULTS: In total, 527 RCT abstracts (pre-CONSORT RCTs, n = 275 and post-CONSORT RCTs, n = 252) were analysed. The majority of abstracts in both groups provided an appropriate description of study interventions (73.1 and 73.8%, pre-CONSORT abstracts versus post-CONSORT abstracts, respectively), objective (91.3 and 90.1%) and conclusions (72.4 and 66.3%). From pre-CONSORT to post-CONSORT guidelines for abstract reporting, there were significant improvements in correctly identifying blinding (18.2-29%) and harmful effects (31.6-42.1%). The improvement in reporting the nature of the trial in abstract titles (20.1-29%) and primary outcome measure in the methods section (22.9-30.6%) did not reach significance. There was no clear improvement in the already poor reporting of trial design, participants, randomisation, recruitment, outcomes, trial registration and funding sources. CONCLUSIONS: Despite some promising improvements and inter-journal differences, the overall quality of RCT abstracts and adherence to the CONSORT checklist for abstracts remains poor.