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1.
Anaesthesia ; 75(1): 27-36, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31282570

RESUMO

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of 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. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17-1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS2 (c-index 0.62); CHA2 DS2 -VASc (c-index 0.63); and R2 CHADS2 (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.

3.
Anesthesiology ; 2019 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-31651439

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Low vitamin D is common in the general populationIn nonsurgical populations, low 25-hydroxyvitamin D is associated with hypertension, left ventricular hypertrophy, heart failure, and coronary artery diseaseIn nonsurgical populations, low vitamin D concentrations are also associated with increased risk of some infections and renal injury WHAT THIS ARTICLE TELLS US THAT IS NEW: Vitamin D deficiency was common in this surgical populationPreoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomesThere was an association between low vitamin D and a composite of infectious complications, and also evidence for an association with decreased kidney function BACKGROUND:: Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery. METHODS: We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications. RESULTS: A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml · min · 1.73 m per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004). CONCLUSIONS: Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.

4.
BMJ Open ; 9(9): e033150, 2019 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-31551393

RESUMO

INTRODUCTION: Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI. METHODS AND ANALYSIS: Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy. ETHICS AND DISSEMINATION: We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

5.
N Engl J Med ; 381(23): 2199-2208, 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31557429

RESUMO

BACKGROUND: Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty. METHODS: We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points. RESULTS: The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty. CONCLUSIONS: Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.).

6.
Am Heart J ; 216: 9-19, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31377568

RESUMO

BACKGROUND: There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy. OBJECTIVE: Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India. METHODS: We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs. RESULTS: We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ±â€¯21 to 128.3 ±â€¯15; intervention 130.3 ±â€¯21 to 127.6 ±â€¯15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001). CONCLUSION: A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31401207

RESUMO

OBJECTIVE: Steroids suppress the inflammatory response to cardiopulmonary bypass, but the impact on death at 30 days, myocardial infarction or injury, stroke, renal failure, respiratory failure, new atrial fibrillation, transfusion requirement, infection, and length of intensive care unit (ICU) and hospital stays are uncertain. DESIGN: Patient-level data meta-analysis of 2 randomized trials. SETTING: Eighty-eight cardiac surgical centers in 19 countries. PARTICIPANTS: A total of 11,989 participants, from the Steroids in Cardiac Surgery trial and the Dexamethasone in Cardiac Surgery study, undergoing cardiac surgery with the use of cardiopulmonary bypass. INTERVENTIONS: Participants were randomly assigned to steroid or placebo. MEASURES AND MAIN RESULTS: Outcomes assessed were mortality at 30 days, myocardial infarction or injury, stroke, renal failure, respiratory failure, new atrial fibrillation, transfusion requirement, infection, and length of ICU and hospital stays. There was no significant difference in death at 30 days between the steroid and placebo groups (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.72-1.07). Myocardial infarction did not differ significantly (OR, 1.17; 95% CI, 0.93-1.47); however, myocardial injury was higher in the steroid group (OR, 1.25; 95% CI, 1.12-1.40). There were no significant differences for the outcomes of stroke, renal failure, new atrial fibrillation, or transfusion. Steroids significantly reduced respiratory failure (OR, 0.83; 95% CI, 0.75-0.99), infection (OR, 0.80; 95% CI, 0.72-0.89), and length of ICU (p < 0.001) and hospital stays (p = 0.006). CONCLUSIONS: This patient-level meta-analysis does not support the routine use of steroids in cardiac surgery. Steroid administration did not decrease the risk of death, myocardial infarction, stroke, renal failure, new atrial fibrillation, or transfusion. Steroids increased the risk of myocardial injury in both the Steroids in Cardiac Surgery and Dexamethasone in Cardiac Surgery trials. Finally, steroids lowered the risk of respiratory failure and infection, and reduced length of ICU and hospital stay.

9.
Br J Anaesth ; 123(4): 421-429, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31256916

RESUMO

BACKGROUND: The National Surgical Quality Improvement Program Myocardial Infarction & Cardiac Arrest (NSQIP MICA) calculator and the Revised Cardiac Risk Index (RCRI) were derived using currently outdated methods of diagnosing perioperative myocardial infarctions. We tested the external validity of these tools in a setting of a systematic perioperative cardiac biomarker measurement. METHODS: Analysis of routinely collected data nested in the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study. A consecutive sample of patients ≥45 yr old undergoing in-hospital noncardiac surgery in a single tertiary care centre was enrolled. The predictive performance of the models was tested in terms of the occurrence of major cardiac complications defined as a composite of a nonfatal myocardial infarction, a nonfatal cardiac arrest, or a cardiac death within 30 days after surgery. The plasma concentration of high-sensitivity troponin T was measured before surgery, 6-12 h after operation, and on the first, second, and third days after surgery. Myocardial infarction was diagnosed according to the Third Universal Definition. RESULTS: The median age was 65 (59-72) yr, and 704/870 (80.9%) subjects were male. The primary outcome occurred in 76/870 (8.7%; 95% confidence interval [CI], 6.9-10.8%) patients. The c-statistic was 0.64 (95% CI, 0.57-0.70) for the NSQIP MICA and 0.60 (95% CI, 0.54-0.65) for the RCRI. Predicted risks were systematically underestimated in calibration belts (P<0.001). The RCRI and the NSQIP MICA showed no clinical utility before recalibration. CONCLUSIONS: The NSQIP and RCRI models had limited predictive performance in this at-risk population. The recently updated version of the RCRI was more reliable than the original index.


Assuntos
Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Cardiopatias/epidemiologia , Complicações Intraoperatórias/terapia , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/terapia , Complicações Pós-Operatórias/terapia , Medição de Risco/normas , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Estudos de Coortes , Morte Súbita Cardíaca/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Valor Preditivo dos Testes , Melhoria de Qualidade , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
10.
Can J Anaesth ; 66(11): 1338-1346, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31264194

RESUMO

PURPOSE: We performed a retrospective cohort study in patients who underwent endovascular aneurysm repair (EVAR) to determine the incidence and predictors of myocardial injury and acute kidney injury (AKI). METHODS: We included 267 consecutive patients who underwent EVAR at two tertiary centres in Canada and Poland. The primary outcome was myocardial injury during hospital stay after EVAR defined as a troponin elevation (ultra-sensitivity troponin I Vidas ≥ 19 ng·L-1, non-high-sensitivity troponin I Vidas ≥ 0.01 µg·L-1, high-sensitivity troponin T ≥ 20 ng·L-1, non-high-sensitivity troponin T ≥ 0.03 ng·mL-1). The secondary outcome was AKI defined using the stage 1 of the Acute Kidney Injury Network criteria. RESULTS: Myocardial injury occurred in 78/267 patients (29%; 95% confidence interval [CI], 24.1 to 34.9) and with AKI occurring in 25/267 (9.4%; 95% CI, 6.4 to 13.5). In a multivariable analysis, the following variables were associated with an increased risk of myocardial injury: age (adjusted odds ratio [aOR], 1.65 per ten-year increase; 95% CI, 1.09 to 2.49), Revised Cardiac Risk Index score ≥3 (aOR, 2.85; 95% CI, 1.26 to 6.41), The American Society of Anesthesiology physical status score 4 (aOR, 2.24; 95% CI, 1.12 to 4.47), duration of surgery (aOR, 1.27 per each hour; 95% CI, 1.00 to 1.61), and perioperative drop in hemoglobin (aOR, 3.35 per 10 g·dL-1 decrease; 95% CI, 1.00 to 11.3). Predictors of AKI were duration of surgery (aOR, 1.72 per hour; 95% CI, 1.36 to 2.17), a preoperative estimated glomerular filtration rate (eGFR) of 30-59 mL·min-1 (aOR, 3.82; 95% CI, 1.42 to 10.3), and an eGFR < 30 mL·min-1 (aOR, 37.0; 95% CI, 7.1 to 193.8). CONCLUSION: Myocardial injury and AKI are frequent during hospital stay after EVAR and warrant further investigation in prospective studies.

11.
Can J Anaesth ; 66(9): 1095-1105, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31290119

RESUMO

BACKGROUND: Collaborative ("shared-care") models of postoperative care improve outcomes in patients undergoing surgery for hip fracture. Despite being widely adopted, it is unclear if similar benefits of shared-care models exist for other at-risk surgical patient populations. Thus, we performed a systematic review to understand the impact of shared-care models. METHODS: EMBASE, MEDLINE, CINAHL, and Cochrane Central Register databases were searched for prospective studies examining an in-hospital shared-care approach to postoperative management of adult non-cardiac surgery patients. The primary outcome was a composite of in-hospital mortality and mortality of up to 30 days. Secondary outcomes were long-term mortality (> 90 days) and hospital length of stay. Tertiary outcomes included quality of life and health utility measures. Risk of bias was assessed using Cochrane Collaboration tools. RESULTS: Six thousand eight hundred and ninety-six citations were reviewed and four studies (n = 987 patients) met the inclusion criteria-two randomized-controlled trials (RCT, n = 729 patients) and two non-randomized-controlled trials (NRCT, n = 258 patients). All studies were conducted in the elective surgical setting. There was no association between shared-care and control groups for in-hospital mortality (Peto odds ratio, 1.76; 95% confidence interval [CI], 0.65 to 4.80), or hospital length of stay (mean difference, -1.41; 95% CI, -3.18 to 0.35). Reporting of other outcomes was limited. Both RCTs were judged to be at high risk of bias for blinding and both NRCTs were judged to be at moderate risk of bias for reported outcomes. CONCLUSION: Overall, there was limited high-quality evidence to evaluate the effect of postoperative shared-care. Well-designed interventional studies, perhaps targeting higher risk surgical populations, are needed. REGISTRATION: PROSPERO (CRD42018094943); registered 16 May, 2018.

12.
Ann Intern Med ; 171(5): 368-369, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31357214
13.
Clin Trials ; 16(5): 552-554, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31347396
14.
Artigo em Inglês | MEDLINE | ID: mdl-31180497

RESUMO

OBJECTIVES: Using data from the CORONARY trial (n = 4752), we evaluated the incidence and prognostic significance of myocardial infarction (MI) applying different definitions based on peak postoperative creatine kinase-MB isoenzyme and cardiac troponin levels. We then aimed to identify the peak cardiac troponin during the first 3 postoperative days that was independently associated with a 2-fold increase in 30-day mortality. METHODS: To combine different assays, we analysed cardiac troponins in multiples of their respective upper limit of normal (ULN). We identified the lowest threshold with a hazard ratio (HR) >2 for 30-day mortality independent of EuroSCORE and on- versus off-pump surgery. RESULTS: Depending on the definition used based on creatine kinase-MB, the incidence of MI after coronary artery bypass grafting (CABG) ranged from 0.6% to 19% and the associated HRs for 30-day mortality ranged from 2.7 to 6.9. Using cardiac troponin (1528 patients), the incidence of MI ranged from 1.7% to 13% depending on the definition used with HRs for 30-day mortality ranging from 5.1 to 7.2. The first cardiac troponin threshold we evaluated, 180xULN, was associated with an adjusted HR for 30-day mortality of 7.6 [95% confidence interval (CI) 3.4-17.1] when compared to <130xULN. The next independent threshold was 130xULN with an adjusted HR for 30-day mortality of 7.8 (95% CI 2.3-26.1). The next cardiac troponin tested threshold (70xULN) did not meet criteria for significance. CONCLUSIONS: Our results illustrate that the incidence and prognosis of a post-CABG MI varies based on the definition used. Validated post-CABG MI diagnostic criteria formulated from their independent association with important clinical outcomes are needed.

16.
Eur Heart J ; 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31237939

RESUMO

AIMS: To determine the 1-year risk of stroke and other adverse outcomes in patients with a new diagnosis of perioperative atrial fibrillation (POAF) after non-cardiac surgery. METHODS AND RESULTS: The PeriOperative ISchemic Evaluation (POISE)-1 trial evaluated the effects of metoprolol vs. placebo in 8351 patients, and POISE-2 compared the effect of aspirin vs. placebo, and clonidine vs. placebo in 10 010 patients. These trials included patients with, or at risk of, cardiovascular disease who were undergoing non-cardiac surgery. For the purpose of this study, we combined the POISE datasets, excluding 244 patients who were in atrial fibrillation (AF) at the time of randomization. Perioperative atrial fibrillation was defined as new AF that occurred within 30 days after surgery. Our primary outcome was the incidence of stroke at 1 year of follow-up; secondary outcomes were mortality and myocardial infarction (MI). We compared outcomes among patients with and without POAF using multivariable adjusted Cox proportional hazards models. Among 18 117 patients (mean age 69 years, 57.4% male), 404 had POAF (2.2%). The stroke incidence 1 year after surgery was 5.58 vs. 1.54 per 100 patient-years in patients with and without POAF, adjusted hazard ratio (aHR) 3.43, 95% confidence interval (CI) 2.00-5.90; P < 0.001. Patients with POAF also had an increased risk of death (incidence 31.37 vs. 9.34; aHR 2.51, 95% CI 2.01-3.14; P < 0.001) and MI (incidence 26.20 vs. 8.23; aHR 5.10, 95% CI 3.91-6.64; P < 0.001). CONCLUSION: Patients with POAF have a significantly increased risk of stroke, MI, and death at 1 year. Intervention studies are needed to evaluate risk reduction strategies in this high-risk population.

17.
J Cardiothorac Surg ; 14(1): 85, 2019 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-31046806

RESUMO

BACKGROUND: Single centre studies support No Touch (NT) saphenous vein graft (SVG) harvesting technique. The primary objective of the SUPERIOR SVG study was to determine whether NT versus conventional (CON) SVG harvesting was associated with improved SVG patency 1 year after coronary artery bypass grafting surgery (CABG). METHODS: Adults undergoing isolated CABG with at least 1 SVG were eligible. CT angiography was performed 1-year post CABG. Leg adverse events were assessed with a questionnaire. A systematic review was performed for published NT graft patency studies and results aggregated including the SUPERIOR study results. RESULTS: Two hundred and-fifty patients were randomized across 12-centres (NT 127 versus CON 123 patients). The primary outcome (study SVG occlusion or cardiovascular (CV) death) was not significantly different in NT versus CON (NT: 7/127 (5.5%), CON 13/123 (10.6%), p = 0.15). Similarly, the proportion of study SVGs with significant stenosis or total occlusion was not significantly different between groups (NT: 8/102 (7.8%), CON: 16/107 (15.0%), p = 0.11). Vein harvest site infection was more common in the NT patients 1 month postoperatively (23.3% vs 9.5%, p < 0.01). Including this study's results, in a meta-analysis, NT was associated with a significant reduction in SVG occlusion, Odds Ratio 0.49, 95% Confidence Interval 0.29-0.82, p = 0.007 in 3 randomized and 1 observational study at 1 year postoperatively. CONCLUSIONS: The NT technique was not associated with improved patency of SVGs at 1-year following CABG while early vein harvest infection was increased. The aggregated data is supportive of an important reduction of SVG occlusion at 1 year with NT harvesting. TRIAL REGISTRATION: NCT01047449 .


Assuntos
Ponte de Artéria Coronária/métodos , Veia Safena/transplante , Coleta de Tecidos e Órgãos/métodos , Adulto , Feminino , Humanos , Masculino , Grau de Desobstrução Vascular
18.
Eur Heart J ; 2019 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-31095334

RESUMO

Myocardial injury after non-cardiac surgery (MINS) is due to myocardial ischaemia (i.e. supply-demand mismatch or thrombus) and is associated with an increased risk of mortality and major vascular complications at 30 days and up to 2 years after non-cardiac surgery. The diagnostic criteria for MINS includes an elevated post-operative troponin measurement judged as resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), during or within 30 days after non-cardiac surgery, and without the requirement of an ischaemic feature (e.g. ischaemic symptom, ischaemic electrocardiography finding). For patients with MINS who are not at high risk of bleeding, physicians should consider initiating dabigatran 110 mg twice daily and low-dose aspirin. Physicians should also consider initiating statin therapy in patients with MINS. Most MINS patients should only be referred to cardiac catheterization if they demonstrate recurrent instability (e.g. cardiac ischaemia, heart failure). Patients ≥65 years of age or with known atherosclerotic disease should have troponin measurements on days 1, 2, and 3 after surgery while the patient is in hospital to avoid missing >90% of MINS and the opportunity to initiate secondary prophylactic measures and follow-up.

19.
BMJ Open ; 9(4): e028537, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31048449

RESUMO

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

20.
Br J Anaesth ; 122(6): e107-e113, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31027915

RESUMO

BACKGROUND: Opioids remain the mainstay therapy for post-surgical pain. Although both morphine and hydromorphone are potent analgesics, it has been suggested that hydromorphone is clinically better. Our primary objective was to compare morphine with hydromorphone for achieving satisfactory analgesia with minimal emesis (SAME). METHODS: We performed a multicentre RCT in 402 patients having ambulatory surgery. A random computer-generated allocation, stratified by site, was developed by our pharmacy. Concealment was achieved by allocating patients to study groups by nurses using sequentially coded study medication syringes having equi-analgesic doses, made available in the postoperative recovery room. Patients, health providers, and research personnel were blinded. The operating-room protocol allowed for routine anaesthetic management, excluding the use of study medications. Study medications were administered by recovery nurses as per an algorithm. Analyses utilised the intention-to-treat principle, and regression analyses were used for outcomes as appropriate and using multiple imputation. RESULTS: Of 751 patients, 402 were randomised between morphine (n=199) and hydromorphone (n=203). Baseline and intraoperative variables were comparable across the groups. The odds of achieving SAME were similar between the groups (odds ratio: 1.01; 95% confidence interval: 0.57-1.80). There were no differences in the side-effects of severe itching, respiratory depression, or sedation. Patient satisfaction, discharge times, and post-discharge outcomes, including pain and nausea/vomiting over 24 h, were also comparable. CONCLUSIONS: There was no difference between morphine and hydromorphone regarding analgesia and common side-effects. The appearance of dose-limiting side-effects is idiosyncratic; the clinical decision must be based on individual responses. CLINICAL TRIAL REGISTRATION: NCT02223377.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides/uso terapêutico , Hidromorfona/uso terapêutico , Morfina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/induzido quimicamente , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Hidromorfona/efeitos adversos , Masculino , Pessoa de Meia-Idade , Morfina/efeitos adversos , Manejo da Dor/métodos , Medição da Dor/métodos , Dor Pós-Operatória/etiologia , Cuidados Pós-Operatórios/métodos , Resultado do Tratamento
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