Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process.

OBJECTIVE: Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. DESIGN AND SETTING: A web-based international consensus conference. PARTICIPANTS: The study comprised 500 clinicians from 61 countries. INTERVENTIONS: A systematic literature search was performed to identify published literature about nonsurgical interventions, supported by randomized evidence, showing a statistically significant impact on mortality. A consensus conference of experts discussed eligible papers. The interventions identified by the conference then were submitted to colleagues worldwide through a web-based survey. MEASUREMENTS AND MAIN RESULTS: The authors identified 11 interventions contributing to increased survival (perioperative hemodynamic optimization, neuraxial anesthesia, noninvasive ventilation, tranexamic acid, selective decontamination of the gastrointestinal tract, insulin for tight glycemic control, preoperative intra-aortic balloon pump, leuko-depleted red blood cells transfusion, levosimendan, volatile agents, and remote ischemic preconditioning) and 2 interventions showing increased mortality (beta-blocker therapy and aprotinin). Interventions then were voted on by participating clinicians. Percentages of agreement among clinicians in different countries differed significantly for 6 interventions, and a variable gap between evidence and clinical practice was noted. CONCLUSIONS: The authors identified 13 nonsurgical interventions that may decrease or increase perioperative mortality, with variable agreement by clinicians. Such interventions may be optimal candidates for investigation in high-quality trials and discussion in international guidelines to reduce perioperative mortality.

Operative morbidity and mortality in octogenarians after carotid endarterectomy: a propensity score matching study.

BACKGROUND: Carotid endarterectomy remains the most effective surgical treatment for reducing the risk of stroke in patients with significant carotid stenosis. In fact, endovascular approach is associated with a higher incidence of perioperative and long-term minor stroke when compared to carotid endarterectomy although long-term functional outcome and risk of major stroke are similar. However, advanced age resulted to be associated with an increased risk of complications after carotid endarterectomy. Therefore, we decided to evaluate the outcome of carotid endarterectomy in octogenarians in our high-volume center. METHODS: Data of all patients who underwent CEA between June 2009 and December 2014 were retrospectively recorded. Patients were categorized as aged <80 or ≥80 years. Propensity score matching based on baseline clinical variables was performed to correct for any bias. Primary outcome was the difference in combined stroke and death. Secondary outcomes included incidence of myocardial infarction, surgical reintervention, unplanned intensive care unit admission and length of hospital stay. RESULTS: A total of 2463 carotid endarterectomies were performed, including 439 patients aged ≥80 years. After propensity score adjustment all octogenarians were matched one-to-one to younger patients. No differences in combined stroke and death were found (1.10% in octogenarians vs. 0.46% in younger patients; P=0.45). Octogenarians had an increased length of hospital stay when compared to younger patients (3.1±0.7 vs. 3.4±1.3 days; P=0.0001). No differences in other secondary outcomes were found. CONCLUSIONS: Age ≥80 years does not entail an increased perioperative risk after carotid endarterectomy. Hence, surgical carotid revascularization in octogenarians can be regarded as a safe and viable alternative to best medical therapy alone when performed in high-volume centers.

Enhanced recovery after surgery program in elective infrarenal abdominal aortic aneurysm repair.

BACKGROUND: The aim of this paper was to investigate the differences in length of hospital stay (LOS) between patients receiving an enhanced recovery after surgery (ERAS) approach and patients receiving conventional perioperative care in elective infrarenal abdominal aortic aneurysm (AAA) repair. Secondary endpoints were the difference in postoperative pulmonary, renal, cardiovascular and gastrointestinal complications, unplanned intensive care unit admission, surgical reintervention and in-hospital mortality between groups. METHODS: In this retrospective observational study, data of all patients undergoing open infrarenal AAA repair between June 2009 and December 2014 were recorded. After excluding the first month, we propensity matched 2:1 patients operated on before and after the introduction of an ERAS program (started in September 2012). RESULTS: A total of 1034 elective open infrarenal AAA repairs were performed during the study period. Six-hundred and sixty-three patients who underwent surgery between June 2009-September 2012 received standard perioperative care and were propensity matched with 371 patients who underwent surgery between October 2012-December 2014 after implementing ERAS approach in September 2012 in 13 patients. A statistically significant reduction in LOS (6.0 [5.5-6.5] vs. 5.5 [5.4-6.5] days; P=0.021) and pulmonary complications (9.6% vs. 4.7%; P=0.014) in the ERAS group were recorded. Other postoperative complications, need for unplanned intensive care unit admission, need for surgical reintervention and in-hospital mortality were similar between groups. CONCLUSIONS: An ERAS program is effective in reducing LOS and pulmonary complications after elective infrarenal AAA repair.

Kounis Syndrome: An analysis of spontaneous reports from international pharmacovigilance database.

INTRODUCTION: The coincidental occurrence of a cardiac symptomatology (e.g. an acute coronary syndrome or a myocardial infarction), during an anaphylactic or anaphylactoid episode is known as Kounis Syndrome. A variety of drugs, substances, food and environmental exposures are associated with this reaction. There is an exponential increase in the number of published scientific articles reports on this syndrome, but since it is rare, the largest case series published so far included only 10 and 6 patients. METHODS: We searched the global World Health Organization database called VigiBase™ to detect all cases of Kounis Syndrome ever reported (last update December 31st 2014). RESULTS: We identified 51 cases of Kounis Syndrome reported to International Pharmacovigilance Agency (VigiBase™). All these cases were reported in the period 2010-2014 and almost half cases (22 reports) belonged to the year 2014. Most cases occurred in the USA and non-steroidal anti-inflammatory drugs were the most frequent trigger drugs. DISCUSSION: We collected pharmacovigilance international data representing the largest case series ever published on the recently identified Kounis Syndrome.