The right time and “Pl ACE ”: Optimal management of perioperative angiotensin‐converting enzyme inhibitors

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106879/1/jhm2203.pd

Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity Meta-Analysis of Randomized and Observational Studies

ObjectivesThe purpose of this study was to assess the effects of off-pump coronary bypass surgery (OPCAB) on mortality and morbidity.BackgroundDespite its potential for reducing morbidity and mortality, OPCAB’s role in clinical practice remains controversial.MethodsA meta-analysis of 37 randomized controlled trials (RCTs) (n=3,449) and 22 risk-adjusted (logistic regression or propensity-score) observational studies (n=293,617) was performed. Two reviewers performed literature searches (MEDLINE, EMBASE, PubMed, reference lists), quality assessment, and data extraction. Treatment effects were calculated as odds ratios (ORs) with 95% confidence intervals (CIs).ResultsIn RCTs, OPCAB was associated with reduced atrial fibrillation (OR 0.59; 95% CI 0.46 to 0.77) and trends toward reduced 30-day mortality (OR 0.91 95% CI 0.45 to 1.83), stroke (OR 0.52; 95% CI 0.25 to 1.05), and myocardial infarction (OR 0.79; 95% CI 0.50 to 1.25). Observational studies showed OPCAB to be associated with reduced 30-day mortality (OR 0.72; 95% CI 0.66 to 0.78), stroke (OR 0.62; 95% CI 0.55 to 0.69), infarction (OR 0.66; 95% CI 0.50 to 0.88), and atrial fibrillation (OR 0.78; 95% CI 0.74 to 0.82). At one to two years, OPCAB was associated with trends toward reduced mortality, but also increased repeat revascularization (RCT: OR 1.75, 95% CI 0.78 to 3.94; Observational: OR 1.35, 95% CI 0.76 to 2.39).ConclusionsRandomized controlled trials did not find, aside from atrial fibrillation, the statistically significant reductions in short-term mortality and morbidity demonstrated by observational studies. These discrepancies might be due to differing patient-selection and study methodology. Future studies must focus on improving research methodology, recruiting high-risk patients, and collecting long-term data

Association between angiotensin converting enzyme inhibitor or angiotensin receptor blocker use prior to major elective surgery and the risk of acute dialysis

Background: Some studies but not others suggest angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use prior to major surgery associates with a higher risk of postoperative acute kidney injury (AKI) and death. Methods: We conducted a large population-based retrospective cohort study of patients aged 66 years or older who received major elective surgery in 118 hospitals in Ontario, Canada from 1995 to 2010 (n = 237,208). We grouped the cohort into ACEi/ARB users (n = 101,494) and non-users (n = 135,714) according to whether the patient filled at least one prescription for an ACEi or ARB (or not) in the 120 days prior to surgery. Our study outcomes were acute kidney injury treated with dialysis (AKI-D) within 14 days of surgery and all-cause mortality within 90 days of surgery. Results: After adjusting for potential confounders, preoperative ACEi/ARB use versus non-use was associated with 17% lower risk of post-operative AKI-D (adjusted relative risk (RR): 0.83; 95% confidence interval (CI): 0.71 to 0.98) and 9% lower risk of all-cause mortality (adjusted RR: 0.91; 95% CI: 0.87 to 0.95). Propensity score matched analyses provided similar results. The association between ACEi/ARB and AKI-D was significantly modified by the presence of preoperative chronic kidney disease (CKD) (P value for interaction < 0.001) with the observed association evident only in patients with CKD (CKD - adjusted RR: 0.62; 95% CI: 0.50 to 0.78 versus No CKD: adjusted RR: 1.00; 95% CI: 0.81 to 1.24). Conclusions: In this cohort study, preoperative ACEi/ARB use versus non-use was associated with a lower risk of AKI-D, and the association was primarily evident in patients with CKD. Large, multi-centre randomized trials are needed to inform optimal ACEi/ARB use in the peri-operative setting

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Self-reported fitness as a measure of perioperative cardiovascular risk: tension between subjective and objective assessments persists

Despite recent high-quality international studies, the optimal sum and sequence of subjective and objective assessments that build the complex picture of fitness for surgery remains to be defined. Physicians' subjective assessment of patient fitness after a typical unstructured interview has poor prognostic accuracy in predicting the risk of major cardiovascular events after noncardiac surgery. How does self-reported fitness assessed by structured questionnaire compare as an indicator of perioperative cardiovascular risk? Here we discuss the latest evidence in this evolving and fundamental aspect of perioperative care

Use of Gabapentin for Perioperative Pain Control – a Meta-Analysis

BACKGROUND: Gabapentin, an anticonvulsant, has recently been suggested as an effective postoperative ‘analgesic’ agent. The objective of the present study was to examine the analgesic effectiveness, opioid-sparing effects and side effects associated with the use of gabapentin in a perioperative setting.METHODS: Following the Quality of Reporting of Meta-analyses recommendations, nine electronic databases until February 2006 were searched, without language restriction, for randomized controlled trials comparing gabapentin with control for postoperative pain control. Outcome measures, namely, 24 h cumulative opioid consumption, visual analogue scale pain scores and adverse effects, were expressed as odds ratios, ratio of means or weighted mean differences (as appropriate), which were aggregated under the fixed or random effects models.RESULTS: Gabapentin caused a 35% reduction in total opioid consumption over the first 24 h following surgery (ratio of means 0.65, 95% CI 0.59 to 0.72), a significant reduction in postoperative pain at rest (in the first 24 h) and with movement (at 2 h, 4 h and 12 h), regardless of whether treatment effects were expressed as ratios of means or weighted mean differences, and a reduction of vomiting (relative risk [RR] 0.73, 95% CI 0.56 to 0.95) and pruritus (RR 0.30, 95% CI 0.13 to 0.70). It was associated with a significant increase in dizziness (RR 1.40, 95% CI 1.06 to 1.84) and an increase in sedation of borderline significance (RR 1.65, 95% CI 1.00 to 2.74).CONCLUSION: Gabapentin improves the analgesic efficacy of opioids both at rest and with movement, reduces analgesic consumption and opioid-related adverse effects, but is associated with an increased incidence of sedation and dizziness.Peer Reviewe

Use of gabapentin for perioperative pain control – A meta-analysis

BACKGROUND: Gabapentin, an anticonvulsant, has recently been suggested as an effective postoperative ‘analgesic’ agent. The objective of the present study was to examine the analgesic effectiveness, opioid-sparing effects and side effects associated with the use of gabapentin in a perioperative setting