Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery: association with adverse events.

BACKGROUND: Perioperative discontinuation of antiplatelet therapy (APT) in patients with coronary stents has been associated with major adverse cardiac events. Our aim was to analyse the perioperative management of APT in such patients and its relationship to the incidence of major adverse cardiac and cerebrovascular events (MACCE) and major bleeding events (MBE) in noncardiac surgery. METHODS: We completed a prospective multicentre observational study of patients with coronary stents undergoing noncardiac surgery in 11 hospitals in Spain. The main objectives were to record perioperative events and prospectively analyse the management of APT, and to assess whether the different preoperative APT regimens were associated with MACCE and MBE. RESULTS: Of 432 surgical procedures studied, 15% experienced a perioperative MACCE and 37% a MBE. Overall mortality was 3.0%. Presurgical APT was prescribed in 95% of procedures, and was preoperatively discontinued in 15%. Surgery was urgent or emergent in 22% of patients, 31% were ASA IV, and 38% had a Revised Cardiac Risk Index of IV. MACCE were related to recent myocardial infarction (P=0.038), chronic kidney disease (P<0.001), insulin-dependent diabetes (P=0.006) and no preoperative APT (P=0.018). MBE also increased MACCE risk (P<0.001). We found statin therapy (P=0.049) and obesity (P=0.016) to be protective factors for MACCE. CONCLUSIONS: Patients with coronary stents undergoing noncardiac surgery suffer a high incidence of perioperative adverse events, even with perioperative APT. Major adverse cardiac and cerebrovascular events are mainly related to previous medical conditions and perioperative major bleeingn events. Our findings should be treated with caution when applied to an elective surgery population. CLINICAL TRIAL REGISTRATION: NCT01171612.

Preoperative estimated glomerular filtration rate and the risk of major adverse cardiovascular and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Chronic kidney disease is an independent predictor of perioperative cardiovascular morbidity and mortality. We analysed the preoperative estimated glomerular filtration rate (eGFR) as a risk factor for perioperative major adverse cardiovascular and cerebrovascular events (MACCE) in non-cardiac surgery. METHODS: In a post hoc analysis of the ANESCARDIOCAT database, patients were classified into six stages of eGFR calculated with the abbreviated Modification of Diet in Renal Disease Study and the Chronic Kidney Disease Epidemiology Collaboration equations: >90 (1), 60-89.9 (2), 45-59.9 (3a), 30-44.9 (3b), 15-29.9 (4), and <15 (5) ml min(-1) 1.73 m(-2). We analysed differences in MACCE, length of hospital stay, and all-cause mortality between eGFR stages. RESULTS: The eGFR was available in 2323 patients. Perioperative MACCE occurred in 4.5% of patients and cardiac-related mortality was 0.5%. Five hundred and forty-three (23.4%) patients had an eGFR of <60 ml min(-1) 1.73 m(-2) and 127 (5.4%) had an eGFR below 45 ml min(-1) 1.73 m(-2). Logistic regression analysis showed that MACCE increased with eGFR impairment (P<0.001), with a marked increase from stage 3b onwards (odds ratio 1.8 vs 3.9 in 3a and 3b, respectively, P=0.047). All-cause mortality was not related to eGFR (P=0.071), but increased substantially between stages 3b and 4. The length of stay correlated with eGFR (P<0.001). CONCLUSIONS: Perioperative MACCE increase with declining eGFR, primarily when <45 ml min(-1) 1.73 m(-2). We recommend the use of preoperative eGFR for cardiovascular risk assessment.

Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Major adverse cardiac and cerebrovascular events (MACCE) represent the most common cause of serious perioperative morbidity and mortality. Our aim was to identify risk factors for MACCE in a broad surgical population with intermediate-to-high surgery-specific risk and to build and validate a model to predict the risk of MACCE. METHODS: A prospective, multicentre study of patients undergoing surgical procedures under general or regional anaesthesia in 23 hospitals. The main outcome was the occurrence of at least one perioperative MACCE, defined as any of the following complications from admittance to discharge: cardiac death, cerebrovascular death, non-fatal cardiac arrest, acute myocardial infarction, congestive heart failure, new cardiac arrhythmia, angina, or stroke. The MACCE predictive index was based on ß-coefficients and validated in an external data set. RESULTS: Of 3387 patients recruited, 146 (4.3%) developed at least one MACCE. The regression model identified seven independent risk factors for MACCE: history of coronary artery disease, history of chronic congestive heart failure, chronic kidney disease, history of cerebrovascular disease, preoperative abnormal ECG, intraoperative hypotension, and blood transfusion. The area under the receiver-operating characteristic curve was 75.9% (95% confidence interval, 71.2-80.6%). CONCLUSIONS: The risk score based on seven objective and easily assessed factors can accurately predict MACCE occurrence after non-cardiac surgery in a population at intermediate-to-high surgery-specific risk.

[Specialized training in anesthesiology: the opinions of supervising tutors]. / La formación especializada en Anestesiología desde la perspectiva de los tutores.

OBJECTIVE: To evaluate the common curriculum for teaching theoretical knowledge in anesthesiology in Catalonia, Spain; to assess differences between hospital teaching programs, evaluation systems, and the situation for tutors. MATERIAL AND METHODS: A 35-item questionnaire was sent to 49 accredited tutors during the 2005-2006 academic year. The questionnaire covered 1) the curriculum and training rotations, 2) teaching and research, and 3) assessment and tutorial interventions. An additional question asked the respondent's view on how to improve instruction. RESULTS: Eighty-five percent of the tutors responded. Seventy-eight percent of the residents (168/216) follow some form of external rotation, most often in pediatric anesthesia (79%). The common courses are considered useful by 96% of the tutors. Ninety-two percent are satisfied with the current annual examination and 79% would extend the residency training period to 5 years. Eighty-two percent of the teaching centers have weekly instructional sessions. Eighty-one percent of the tutors consider the resident's logbook, filled in by 77% of residents, to be useful for assessment. Eighty-five percent take teacher training courses, 65% feel that their work is being recognized, and 92% do not allot a specific period of time for teaching. CONCLUSIONS: The survey has helped shed light on the current training situation in Catalonia. The common courses are of great help. The number of external rotations is high, overloading certain areas. Improvements could be made by unifying external rotations, updating the curriculum and extending the training period to 5 years, recognizing the role of the tutor, and establishing a specific time for teaching activity.

[Extreme leucocytosis can lead to an erroneous diagnosis of severe hypoxaemia. Description of a case]. / La leucocitosis extrema puede inducir a un diagnóstico erróneo de hipoxemia severa. Descripción de un caso.

The diagnosis and treatment of respiratory failure is a part of the anaesthesist's daily practice, as well as the hypoxaemia that is one of its physiological and analytical consequences. Patients with an extreme leucocytosis secondary to leukaemia can suffer an incorrect diagnosis of hypoxemia, called "pseudohypoxaemia". This is basically due to the rapid in vitro oxygen consumption, and is characterized by a low partial pressure of oxygen in arterial blood (PaO2) despite a normal oxygen saturation (SpO2) measured by pulse oximetry. Pseudohypoxaemia appears in patients with thrombocytosis or hyper-leucocytosis occurring during blastic crisis of a leukaemia. It must be suspected in patients with a discrepancy between the SpO2 measured by oximetry and the PaO2. In this context, pulse oximetry is the most accurate way to establish the diagnosis and to avoid unnecessary actions. We report the case of a patient with chronic myeloid leukaemia and extreme leucocytosis requiring emergency surgery, and diagnosed with pseudohypoxaemia during the perioperative period that led to a delay in the extubation of the patient.

Simple method to determine the size of the laryngeal mask airway in children.

BACKGROUND AND OBJECTIVE: The size of the laryngeal mask airway in children is determined by the patient's weight. However, in some instances an alternative method may be wanted. The aim was to search for a new method that would be easy to perform at the bedside. METHODS: The size of the laryngeal mask airway was determined in 183 children by choosing the laryngeal mask that best matched the combined widths of the patient's index, middle and ring fingers. The results were compared with the standard method recommended by the manufacturer's weight-related guidelines. The patients were classified in different groups depending on the laryngeal mask airway sizes determined by both methods. A kappa coefficient evaluated the agreement between both techniques. RESULTS: The kappa coefficient was 0.81, showing an 'excellent agreement' between both methods. The size was the same for both methods in 142 children (78%). The disagreement between both techniques was only of one size in the remaining 41 patients (22%). In such patients, the weight was a borderline value that would indicate a change in the size of the laryngeal mask airway using the classic method. CONCLUSIONS: This new approach is of valid and practical use in children, particularly as an alternative in those situations where the patient's weight is unknown, such as in emergency situations or in those borderline instances where an alternative measurement would be useful.

Injury to the abdominal aorta during laparoscopic surgery: an unusual presentation.

IMPLICATIONS: Laparoscopic cholecystectomy is a very common surgical procedure, and vascular injuries account for one third of major complications during this surgery. We describe an unusual presentation of an abdominal aorta injury.