BACKGROUND Atrial fibrillation(AF)represents a common arrhythmia with significant implications and may occur pre-,intra-,or postoperatively(POAF).After cardiac surgery POAF occurs in approximately 30% of patients,whil...BACKGROUND Atrial fibrillation(AF)represents a common arrhythmia with significant implications and may occur pre-,intra-,or postoperatively(POAF).After cardiac surgery POAF occurs in approximately 30% of patients,while non-cardiac/nonthoracic surgery has a reported incidence between 0.4% to 15%,with new onset POAF occurring at a rate of 0.4% to 3%.While AF has been extensively studied,it has not been well described in emergent non-cardiac surgery associated with increased surgical stress in an intensive care unit setting(ICU).AIM To investigate the incidence/predictors of POAF in emergent non-cardiac surgery and its associations with postoperative outcomes in the ICU.METHODS This retrospective study included patients≥18 years who underwent exploratory laparotomy or lower extremity amputation between October 2012 and September 2023 and were admitted in the ICU.Data of interest included occurrence of POAF,demographic characteristics,comorbidities,laboratory values,administered fluids,medications,and postoperative outcomes.Statistical analyses consisted of identifying predic-tors of POAF and associations of POAF with outcomes of interest.RESULTS A total of 347 ICU patients were included,16.4% had a history of AF,13.0% developed POAF,and 7.9%developed new-onset POAF.Patients with new-onset POAF were older(79.6±9.1 vs 68.1±14.8 years,<0.001),of white race(47.8%vs 28.8,P<0.001),hypertensive(87.0%vs 71.2%,P=0.011),had longer ICU length of stay(ICU-LOS)(13.4 vs 6.7 days,P=0.042),higher mortality(43.5%vs 17.6%,P=0.016)and higher rate of cardiac arrest(34.8%vs 14.6%,P=0.005)compared to patients without new-onset POAF.Multivariable analysis revealed increased POAF risk with advanced age(OR=1.06;95%CI:1.02-1.10,P=0.005),white race(OR=2.85;95%CI:1.26-6.76,P=0.014),high intraoperative fluid(OR>1;95%CI:1.00-1.00,P=0.018),and longer ICU-LOS(OR=1.04;95%CI:1.00-1.08,P=0.023).After adjusting for demographics,new onset POAF significantly predicted mortality(OR=3.07;95%CI:1.14-8.01,P=0.022).CONCLUSION POAF was associated with prolonged ICU-LOS,white race,and high intraoperative fluid.New-onset POAF was associated with increased risk of cardiac arrest and death in critically ill patients.展开更多
Background High body mass index （BMI） is a risk factor for chronic cardiac disease. However, mounting evidence supports that high BMI is associated with less risk of cardiac morbidity and mortality compared with nor...Background High body mass index （BMI） is a risk factor for chronic cardiac disease. However, mounting evidence supports that high BMI is associated with less risk of cardiac morbidity and mortality compared with normal BMI, also known as the obesity paradox. There- fore, we sought to determine the existence of the obesity paradox in regard to perioperative 30-day cardiac events among elderly Chinese patients with known coronary artery disease undergoing non-cardiac surgery. Methods A post-hoc analysis of a prospective, multi-institutional cohort study was performed. Patients aged 〉 60 years with a history of coronary artery disease and undergoing non-cardiac surgery were grouped according to BMI： underweight （〈 18.5 kg/m2）, normal weight （18.5-24.9 kg/m2）, overweight （25-29.9 kg/m2） and obese （≥ 30 kg/m2）. Demographic information, perioperative clinical variables and incidence of 30-day postoperative cardiac adverse event were retrieved from a research database. Results We identified 1202 eligible patients （BMI： 24.3 ± 3.8 kg/m2）. Across BMI groups, a U-shaped distribution pattern of incidence of 30-day postoperative major cardiac events was observed, with the lowest risk in the overweight group. When using the normal-weight group as a reference, no difference was found in either the obesity or overweight groups in terms of a major cardiac adverse event （MACE）. However, risk of a 30-day postoperative MACE was significantly higher in the underweight group （odds ratio [OR] 2.916, 95% confidence interval [CI]： 1.072-7.931, P = 0.036）. Conclusion Although not statistically significant, the U-shaped relation between BMI and cardiac complications indicates the obesity paradox possibly exists.展开更多
BACKGROUND High-sensitivity cardiac troponin(hs-cTn)levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events.However,most studies on the role of elevated hs-cTn ...BACKGROUND High-sensitivity cardiac troponin(hs-cTn)levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events.However,most studies on the role of elevated hs-cTn in elderly populations have investigated the prognostic value of hs-cTn in patients with a specific diagnosis or have assessed the relationship between hs-cTn and comorbidities.AIM To investigate the in-hospital prognosis of consecutive elderly patients admitted to the Internal Medicine Department with acute non-cardiac events and increased hs-cTnI levels.METHODS In this retrospective study,we selected patients who were aged≥65 years and admitted to the Internal Medicine Department of our hospital between January 2019 and December 2019 for non-cardiac reasons.Eligible patients were those who had hs-cTnI concentrations≥100 ng/L.We investigated the independent predictors of in-hospital mortality by multivariable logistic regression analysis.RESULTS One hundred and forty-six patients(59%female)were selected with an age range from 65 to 100(mean±SD:85.4±7.61)years.The median hs-cTnI value was 284.2 ng/L.For 72(49%)patients the diagnosis of hospitalization was an infectious disease.The overall in-hospital mortality was 32%(47 patients).Individuals who died did not have higher hs-cTnI levels compared with those who were discharged alive(median:314.8 vs 282.5 ng/L;P=0.565).There was no difference in mortality in patients with infectious vs non-infectious disease(29%vs 35%).Multivariable analysis showed that age(OR 1.062 per 1 year increase,95%CI:1.000-1.127;P=0.048)and creatinine levels(OR 2.065 per 1 mg/dL increase,95%CI:1.383-3.085;P<0.001)were the only independent predictors of death.Mortality was 49%in patients with eGFR<30 mL/min/1.73 m2.CONCLUSION Myocardial injury is a malignant condition in elderly patients admitted to the hospital for non-cardiac reasons.The presence of severe renal impairment is a marker of extremely high in-hospital mortality.展开更多
The appropriate preparation of the patient with asymptomatic congenital complete heart block (CCHB) and a narrow QRS complex for elective non-cardiac surgery is controversial. Prophylactic temporary pacemaker insertio...The appropriate preparation of the patient with asymptomatic congenital complete heart block (CCHB) and a narrow QRS complex for elective non-cardiac surgery is controversial. Prophylactic temporary pacemaker insertion is associated with well-defined risks, and less invasive techniques exist to treat transient, hemodynamically significant intraoperative brady-arrhythmias. The present case report details the performance of general anesthesia for arthroscopic knee surgery in an adult patient with this condition without a pacemaker. Documentation of preoperative chronotropic competence with isoproterenol may be of value in deciding whether to proceed without temporary pacing capability in this setting.展开更多
Objectives To measure circulating B-type natriuretic peptide （BNP） levels in patients with heart disease undergoing elective major non-cardiac surgery and to explore the relationship between the changes in BNP level...Objectives To measure circulating B-type natriuretic peptide （BNP） levels in patients with heart disease undergoing elective major non-cardiac surgery and to explore the relationship between the changes in BNP level and cardiac events after surgical intervention. Methods Subjects comprised 232 patients with heart disease undergoing elective major non- cardiac surgery. Patients were classified into two groups based on BNP concentrations before surgery： those with BNP plasma levels ≤ 100 pg/mL （ Group A, n = 170） ; and those with BNP plasma levels 〉 100 pg/mL （ Group B, n = 62 ）. Preoperative BNP sampling was undertaken 24h before surgery, and postoperative 2 h after surgery. Screening for cardiac events was performed using clinical criteria, cardiac tropnin I analysis and serial electrocardiography. Results There was no significant difference in BNP concentrations between before surgery （73.5 ± 20. 6） pg/mL and after non- cardiac surgery （69.3 ± 27.5 ） pg/mL in group A （P 〉 0. 05 ）, while there was a significant difference in BNP concentrations between before surgery （ 149.3 ± 73.5 ） pg/mL and after non-cardiac surgery （ 341.5 ± 162. 4 ） pg/mL in group B （P 〈 0. 001 ）. Patients with postoperative cardiac events had significantly higher BNP levels （207.3 ± 99. 1 ） pg/mL before and （416. 9 ± 202. 8） pg/mL after non-cardiac surgery than those in patients with no cardiac events in group B. There was a significant difference in cardiac events between group A, in which no patient had cardiac events, and group B, in which 15 patients had cardiac events （ P 〈 0. 001 ）. Conclusions The changes in BNP levels after non- cardiac surgery were influenced by the preoperative levels of BNP, and relative to cardiac events.展开更多
Background:Emergence delirium(ED)is a kind of delirium that occured in the immediate post-anesthesia period.Lower body temperature on post-anesthesia care unit(PACU)admission was an independent risk factor of ED.The p...Background:Emergence delirium(ED)is a kind of delirium that occured in the immediate post-anesthesia period.Lower body temperature on post-anesthesia care unit(PACU)admission was an independent risk factor of ED.The present study was designed to investigate the association between intraoperative body temperature and ED in elderly patients undergoing non-cardiac surgery.Methods:This study was a secondary analysis of a prospective observational study.Taking baseline body temperature as a reference,intraoperative absolute and relative temperature changes were calculated.The relative change was defined as the amplitude between intraoperative lowest/highest temperature and baseline reference.ED was assessed with the confusion assessment method for intensive care unit at 10 and 30 min after PACU admission and before PACU discharge.Results:A total of 874 patients were analyzed with a mean age of 71.8±5.3 years.The incidence of ED was 38.4%(336/874).When taking 36.0°C,35.5°C,and 35.0°C as thresholds,the incidences of absolute hypothermia were 76.7%(670/874),38.4%(336/874),and 17.5%(153/874),respectively.In multivariable logistic regression analysis,absolute hypothermia(lowest value<35.5°C)and its cumulative duration were respectively associated with an increased risk of ED after adjusting for confounders including age,education,preoperative mild cognitive impairment,American Society of Anesthesiologists grade,duration of surgery,site of surgery,and pain intensity.Relative hypothermia(decrement>1.0°C from baseline)and its cumulative duration were also associated with an increased risk of ED,respectively.When taking the relative increment>0.5°C as a threshold,the incidence of relative hyperthermia was 21.7%(190/874)and it was associated with a decreased risk of ED after adjusting above confounders.Conclusions:In the present study,we found that intraoperative hypothermia,defined as either absolute or relative hypothermia,was associated with an increased risk of ED in elderly patients after non-cardiac surgery.Relative hyperthermia,but not absolute hyperthermia,was associated with a decreased risk of ED.Registration:Chinese Clinical Trial Registry(No.ChiCTR-OOC-17012734).展开更多
Background:Despite the growing epidemic of heart failure(HF),there is limited data available to systematically compare noncardiac comorbidities in the young-old,old-old,and oldest-old patients hospitalized for HF.The ...Background:Despite the growing epidemic of heart failure(HF),there is limited data available to systematically compare noncardiac comorbidities in the young-old,old-old,and oldest-old patients hospitalized for HF.The precise differences will add valuable information for better management of HF in elderly patients.Methods:A total of 1053 patients aged 65 years or older hospitalized with HF were included in this study.Patients were compared among three age groups:(1)young-old:65 to 74 years,(2)old-old:75 to 84 years,and(3)oldest-old:≥85 years.Clinical details of presentation,comorbidities,and prescribed medications were recorded.Results:The mean age was 76.7 years and 12.7%were 85 years or older.Most elderly patients with HF(97.5%)had at least one of the non-cardiac comorbidities.The patterns of common non-cardiac comorbidities were different between the young-old and oldestold group.The three most common non-cardiac comorbidities were anemia(53.6%),hyperlipidemia(45.9%),and diabetes(42.4%)in the young-old group,while anemia(73.1%),infection(58.2%),and chronic kidney disease(44.0%)in the oldest-old group.Polypharmacy was observed in 93.0%elderly patients with HF.Additionally,29.2%patients were diagnosed with infection,and 67.0%patients were prescribed antibiotics.However,60.4%patients were diagnosed with anemia with only 8.9%of them receiving iron repletion.Conclusions:Non-cardiac comorbidities are nearly universal in three groups but obviously differ by age,and inappropriate medications are very common in elderly patients with HF.Further treatment strategies should be focused on providing optimal medications for age-specific non-cardiac conditions.展开更多
Background:Post-operative acute kidney injury(AKI)is one of the most common and serious complications after major surgery and is significantly associated with increased risks of morbidity and mortality.This meta-analy...Background:Post-operative acute kidney injury(AKI)is one of the most common and serious complications after major surgery and is significantly associated with increased risks of morbidity and mortality.This meta-analysis was conducted to evaluate the effects of perioperative dexmedetomidine(Dex)administration on the occurrence of AKI and the outcomes of recovery after non-cardiac surgery.Methods:The PubMed,Embase,Web of Science,and Cochrane Library databases were systematically searched for studies comparing the effects of Dexvs.placebo on kidney function after non-cardiac surgery,and a pooled fixed-effect meta-analysis of the included studies was performed.The primary outcome was the occurence of post-operative AKI.The secondary outcomes included the occurence of intra-operative hypotension and bradycardia,intensive care unit(ICU)admission,duration of ICU stay,and hospital length of stay(LOS).Results:Six studies,including four randomized controlled trials(RCTs)and two observational studies,with a total of 2586 patients were selected.Compared with placebo,Dex administration could not reduce the odds of post-operative AKI(odds ratio[OR],0.44;95%confidence interval(CI),0.18-1.06;P=0.07;I^(2)=0.00%,P=0.72)in RCTs,but it showed a significant renoprotective effect(OR,0.67;95%CI,0.48-0.95;P=0.02;I^(2)=0.00%,P=0.36)in observational studies.Besides,Dex administration significantly increased the odds of intra-operative bradycardia and shortened the duration of ICU stay.However,there was no significant difference in the odds of intra-operative hypotension,ICU admission,and hospital LOS.Conclusions:This meta-analysis suggests that perioperative Dex administration does not reduce the risk of AKI after non-cardiac surgery.However,the quality of evidence for this result is low due to imprecision and inconsistent types of non-cardiac operations.Thus,large and high-quality RCTs are needed to verify the real effects of perioperative Dex administration on the occurrence of AKI and the outcomes of recovery after non-cardiac surgery.展开更多
Background:Acute kidney injury(AKI)is a common surgical complication and is associated with intraoperative hypotension.However,the total duration and magnitude of intraoperative hypotension associated with AKI remains...Background:Acute kidney injury(AKI)is a common surgical complication and is associated with intraoperative hypotension.However,the total duration and magnitude of intraoperative hypotension associated with AKI remains unknown.In this study,the causal relationship between the intraoperative arterial pressure and postoperative AKI was investigated among chronic hypertension patients undergoing non-cardiac surgery.Methods:A retrospective cohort study of 6552 hypertension patients undergoing non-cardiac surgery(2011 to 2019)was conducted.The primary outcome was AKI as diagnosed with the Kidney Disease-Improving Global Outcomes criteria and the primary exposure was intraoperative hypotension.Patients’baseline demographics,pre-and post-operative data were harvested and then analyzed with multivariable logistic regression to assess the exposure-outcome relationship.Results:Among 6552 hypertension patients,579(8.84%)had postoperative AKI after non-cardiac surgery.The proportions of patients admitted to ICU(3.97 vs.1.24%,p<0.001)and experiencing all-cause death(2.76 vs.0.80%,p<0.001)were higher in the patients with postoperative AKI.Moreover,the patients with postoperative AKI had longer hospital stays(13.50 vs.12.00 days,p<0.001).Intraoperative mean arterial pressure(MAP)<60 mmHg for>20 min was an independent risk factor of postoperative AKI.Furthermore,MAP<60 mmHg for>10 min was also an independent risk factor of postoperative AKI in patients whose MAP was measured invasively in the subgroup analysis.Conclusions:Our work suggested that MAP<60 mmHg for>10 min measured invasively or 20 min measured non-invasively during non-cardiac surgery may be the threshold of postoperative AKI development in hypertension patients.This work may serve as a perioperative management guide for chronic hypertension patients.展开更多
目的回顾性分析重症监护室(intensive care unit,ICU)非心脏手术患者发生围手术期心肌损伤(myocardial injury after non-cardiac surgery,MINS)的临床危险因素及预后情况。方法选取2020年1月至2023年12月复旦大学附属闵行医院重症医学...目的回顾性分析重症监护室(intensive care unit,ICU)非心脏手术患者发生围手术期心肌损伤(myocardial injury after non-cardiac surgery,MINS)的临床危险因素及预后情况。方法选取2020年1月至2023年12月复旦大学附属闵行医院重症医学科的手术后患者478例,按术后7天内是否发生心肌损伤分为MINS组(n=302)与正常组(n=176),比较两组患者临床资料特征的差异性,筛选出围手术期发生心肌损害的危险因素。以30天死亡为临床终点,分析MINS组患者死亡的危险因素。结果MINS组急性生理与慢性健康状况Ⅱ(acute physiology and chronic health evaluationⅡ,ApacheⅡ)评分、冠心病、慢性肾脏病患病率均较正常组高,差异有统计学意义(P<0.05)。MINS组急诊手术占比、合并感染、围手术期低血压与正常组相比差异有统计学意义(P<0.05)。多因素Logistic回归分析显示慢性肾脏病、急诊手术、合并感染、术中术后低血压是MINS的危险因素。预后分析显示围手术期低血压是MINS患者30天死亡的危险因素。结论MINS与患者的基础疾病、手术时机、围手术期低血压状态等密切相关,特别是围手术期低血压影响最终结局。展开更多
目的:总结危重症患者无创心输出量监测管理的证据,为加强临床医护人员无创心输出量监测操作规范性和测量准确性提供循证依据。方法:检索UpToDate、英国医学杂志最佳临床实践数据库(BMJ Best Practice)、英国国家临床医学研究所指南库、P...目的:总结危重症患者无创心输出量监测管理的证据,为加强临床医护人员无创心输出量监测操作规范性和测量准确性提供循证依据。方法:检索UpToDate、英国医学杂志最佳临床实践数据库(BMJ Best Practice)、英国国家临床医学研究所指南库、PubMed、Embase、美国重症医学会网站、美国重症护理协会网站、万方数据库、中国知网、中国生物医学文献数据库等数据库中无创心输出量监测管理相关研究,包括临床决策、指南、专家共识、证据总结、最佳实践、系统评价、Meta分析、随机对照试验,检索时限为自建库起至2023年8月。循证团队人员对文献进行筛选、质量评价后,提取符合标准的相关证据。结果:共纳入11篇文献,包括系统评价7篇、专家共识4篇。形成20条关于危重症患者无创心输出量监测管理的证据,证据包括无创心输出量监测所适宜的患者、与有创心输出量监测的相关性、监测过程中的误差来源等,内容涉及监测人群、临床应用、干扰因素、注意事项、人员培训5方面。结论:应加强临床医护人员关于无创心输出量监测技术的培训,结合具体临床情境选择合适的实践证据,以提高无创心输出量监测的操作规范性与测量准确度。展开更多
文摘BACKGROUND Atrial fibrillation(AF)represents a common arrhythmia with significant implications and may occur pre-,intra-,or postoperatively(POAF).After cardiac surgery POAF occurs in approximately 30% of patients,while non-cardiac/nonthoracic surgery has a reported incidence between 0.4% to 15%,with new onset POAF occurring at a rate of 0.4% to 3%.While AF has been extensively studied,it has not been well described in emergent non-cardiac surgery associated with increased surgical stress in an intensive care unit setting(ICU).AIM To investigate the incidence/predictors of POAF in emergent non-cardiac surgery and its associations with postoperative outcomes in the ICU.METHODS This retrospective study included patients≥18 years who underwent exploratory laparotomy or lower extremity amputation between October 2012 and September 2023 and were admitted in the ICU.Data of interest included occurrence of POAF,demographic characteristics,comorbidities,laboratory values,administered fluids,medications,and postoperative outcomes.Statistical analyses consisted of identifying predic-tors of POAF and associations of POAF with outcomes of interest.RESULTS A total of 347 ICU patients were included,16.4% had a history of AF,13.0% developed POAF,and 7.9%developed new-onset POAF.Patients with new-onset POAF were older(79.6±9.1 vs 68.1±14.8 years,<0.001),of white race(47.8%vs 28.8,P<0.001),hypertensive(87.0%vs 71.2%,P=0.011),had longer ICU length of stay(ICU-LOS)(13.4 vs 6.7 days,P=0.042),higher mortality(43.5%vs 17.6%,P=0.016)and higher rate of cardiac arrest(34.8%vs 14.6%,P=0.005)compared to patients without new-onset POAF.Multivariable analysis revealed increased POAF risk with advanced age(OR=1.06;95%CI:1.02-1.10,P=0.005),white race(OR=2.85;95%CI:1.26-6.76,P=0.014),high intraoperative fluid(OR>1;95%CI:1.00-1.00,P=0.018),and longer ICU-LOS(OR=1.04;95%CI:1.00-1.08,P=0.023).After adjusting for demographics,new onset POAF significantly predicted mortality(OR=3.07;95%CI:1.14-8.01,P=0.022).CONCLUSION POAF was associated with prolonged ICU-LOS,white race,and high intraoperative fluid.New-onset POAF was associated with increased risk of cardiac arrest and death in critically ill patients.
文摘Background High body mass index （BMI） is a risk factor for chronic cardiac disease. However, mounting evidence supports that high BMI is associated with less risk of cardiac morbidity and mortality compared with normal BMI, also known as the obesity paradox. There- fore, we sought to determine the existence of the obesity paradox in regard to perioperative 30-day cardiac events among elderly Chinese patients with known coronary artery disease undergoing non-cardiac surgery. Methods A post-hoc analysis of a prospective, multi-institutional cohort study was performed. Patients aged 〉 60 years with a history of coronary artery disease and undergoing non-cardiac surgery were grouped according to BMI： underweight （〈 18.5 kg/m2）, normal weight （18.5-24.9 kg/m2）, overweight （25-29.9 kg/m2） and obese （≥ 30 kg/m2）. Demographic information, perioperative clinical variables and incidence of 30-day postoperative cardiac adverse event were retrieved from a research database. Results We identified 1202 eligible patients （BMI： 24.3 ± 3.8 kg/m2）. Across BMI groups, a U-shaped distribution pattern of incidence of 30-day postoperative major cardiac events was observed, with the lowest risk in the overweight group. When using the normal-weight group as a reference, no difference was found in either the obesity or overweight groups in terms of a major cardiac adverse event （MACE）. However, risk of a 30-day postoperative MACE was significantly higher in the underweight group （odds ratio [OR] 2.916, 95% confidence interval [CI]： 1.072-7.931, P = 0.036）. Conclusion Although not statistically significant, the U-shaped relation between BMI and cardiac complications indicates the obesity paradox possibly exists.
文摘BACKGROUND High-sensitivity cardiac troponin(hs-cTn)levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events.However,most studies on the role of elevated hs-cTn in elderly populations have investigated the prognostic value of hs-cTn in patients with a specific diagnosis or have assessed the relationship between hs-cTn and comorbidities.AIM To investigate the in-hospital prognosis of consecutive elderly patients admitted to the Internal Medicine Department with acute non-cardiac events and increased hs-cTnI levels.METHODS In this retrospective study,we selected patients who were aged≥65 years and admitted to the Internal Medicine Department of our hospital between January 2019 and December 2019 for non-cardiac reasons.Eligible patients were those who had hs-cTnI concentrations≥100 ng/L.We investigated the independent predictors of in-hospital mortality by multivariable logistic regression analysis.RESULTS One hundred and forty-six patients(59%female)were selected with an age range from 65 to 100(mean±SD:85.4±7.61)years.The median hs-cTnI value was 284.2 ng/L.For 72(49%)patients the diagnosis of hospitalization was an infectious disease.The overall in-hospital mortality was 32%(47 patients).Individuals who died did not have higher hs-cTnI levels compared with those who were discharged alive(median:314.8 vs 282.5 ng/L;P=0.565).There was no difference in mortality in patients with infectious vs non-infectious disease(29%vs 35%).Multivariable analysis showed that age(OR 1.062 per 1 year increase,95%CI:1.000-1.127;P=0.048)and creatinine levels(OR 2.065 per 1 mg/dL increase,95%CI:1.383-3.085;P<0.001)were the only independent predictors of death.Mortality was 49%in patients with eGFR<30 mL/min/1.73 m2.CONCLUSION Myocardial injury is a malignant condition in elderly patients admitted to the hospital for non-cardiac reasons.The presence of severe renal impairment is a marker of extremely high in-hospital mortality.
文摘The appropriate preparation of the patient with asymptomatic congenital complete heart block (CCHB) and a narrow QRS complex for elective non-cardiac surgery is controversial. Prophylactic temporary pacemaker insertion is associated with well-defined risks, and less invasive techniques exist to treat transient, hemodynamically significant intraoperative brady-arrhythmias. The present case report details the performance of general anesthesia for arthroscopic knee surgery in an adult patient with this condition without a pacemaker. Documentation of preoperative chronotropic competence with isoproterenol may be of value in deciding whether to proceed without temporary pacing capability in this setting.
基金supported by Research Foundation of the Second Affiliated Hospital of Chinese PLA General Hospital
文摘Objectives To measure circulating B-type natriuretic peptide （BNP） levels in patients with heart disease undergoing elective major non-cardiac surgery and to explore the relationship between the changes in BNP level and cardiac events after surgical intervention. Methods Subjects comprised 232 patients with heart disease undergoing elective major non- cardiac surgery. Patients were classified into two groups based on BNP concentrations before surgery： those with BNP plasma levels ≤ 100 pg/mL （ Group A, n = 170） ; and those with BNP plasma levels 〉 100 pg/mL （ Group B, n = 62 ）. Preoperative BNP sampling was undertaken 24h before surgery, and postoperative 2 h after surgery. Screening for cardiac events was performed using clinical criteria, cardiac tropnin I analysis and serial electrocardiography. Results There was no significant difference in BNP concentrations between before surgery （73.5 ± 20. 6） pg/mL and after non- cardiac surgery （69.3 ± 27.5 ） pg/mL in group A （P 〉 0. 05 ）, while there was a significant difference in BNP concentrations between before surgery （ 149.3 ± 73.5 ） pg/mL and after non-cardiac surgery （ 341.5 ± 162. 4 ） pg/mL in group B （P 〈 0. 001 ）. Patients with postoperative cardiac events had significantly higher BNP levels （207.3 ± 99. 1 ） pg/mL before and （416. 9 ± 202. 8） pg/mL after non-cardiac surgery than those in patients with no cardiac events in group B. There was a significant difference in cardiac events between group A, in which no patient had cardiac events, and group B, in which 15 patients had cardiac events （ P 〈 0. 001 ）. Conclusions The changes in BNP levels after non- cardiac surgery were influenced by the preoperative levels of BNP, and relative to cardiac events.
基金supported by a grant from the National Key Research and Development Program of China(No.2018YFC2001800)
文摘Background:Emergence delirium(ED)is a kind of delirium that occured in the immediate post-anesthesia period.Lower body temperature on post-anesthesia care unit(PACU)admission was an independent risk factor of ED.The present study was designed to investigate the association between intraoperative body temperature and ED in elderly patients undergoing non-cardiac surgery.Methods:This study was a secondary analysis of a prospective observational study.Taking baseline body temperature as a reference,intraoperative absolute and relative temperature changes were calculated.The relative change was defined as the amplitude between intraoperative lowest/highest temperature and baseline reference.ED was assessed with the confusion assessment method for intensive care unit at 10 and 30 min after PACU admission and before PACU discharge.Results:A total of 874 patients were analyzed with a mean age of 71.8±5.3 years.The incidence of ED was 38.4%(336/874).When taking 36.0°C,35.5°C,and 35.0°C as thresholds,the incidences of absolute hypothermia were 76.7%(670/874),38.4%(336/874),and 17.5%(153/874),respectively.In multivariable logistic regression analysis,absolute hypothermia(lowest value<35.5°C)and its cumulative duration were respectively associated with an increased risk of ED after adjusting for confounders including age,education,preoperative mild cognitive impairment,American Society of Anesthesiologists grade,duration of surgery,site of surgery,and pain intensity.Relative hypothermia(decrement>1.0°C from baseline)and its cumulative duration were also associated with an increased risk of ED,respectively.When taking the relative increment>0.5°C as a threshold,the incidence of relative hyperthermia was 21.7%(190/874)and it was associated with a decreased risk of ED after adjusting above confounders.Conclusions:In the present study,we found that intraoperative hypothermia,defined as either absolute or relative hypothermia,was associated with an increased risk of ED in elderly patients after non-cardiac surgery.Relative hyperthermia,but not absolute hyperthermia,was associated with a decreased risk of ED.Registration:Chinese Clinical Trial Registry(No.ChiCTR-OOC-17012734).
基金This work was supported by the National Natural Science Foundation of China(81770359 and 81270276)Central Health Research Project of China(W2017BJ30)+1 种基金State Key Laboratory of Molecular Developmental Biology of China(2017-MDB-KF-13)to Jingyi RenChina-Japan Friendship Hospital Scientific Research Funds(2017-1-QN-10)to Mengxi Yang.
文摘Background:Despite the growing epidemic of heart failure(HF),there is limited data available to systematically compare noncardiac comorbidities in the young-old,old-old,and oldest-old patients hospitalized for HF.The precise differences will add valuable information for better management of HF in elderly patients.Methods:A total of 1053 patients aged 65 years or older hospitalized with HF were included in this study.Patients were compared among three age groups:(1)young-old:65 to 74 years,(2)old-old:75 to 84 years,and(3)oldest-old:≥85 years.Clinical details of presentation,comorbidities,and prescribed medications were recorded.Results:The mean age was 76.7 years and 12.7%were 85 years or older.Most elderly patients with HF(97.5%)had at least one of the non-cardiac comorbidities.The patterns of common non-cardiac comorbidities were different between the young-old and oldestold group.The three most common non-cardiac comorbidities were anemia(53.6%),hyperlipidemia(45.9%),and diabetes(42.4%)in the young-old group,while anemia(73.1%),infection(58.2%),and chronic kidney disease(44.0%)in the oldest-old group.Polypharmacy was observed in 93.0%elderly patients with HF.Additionally,29.2%patients were diagnosed with infection,and 67.0%patients were prescribed antibiotics.However,60.4%patients were diagnosed with anemia with only 8.9%of them receiving iron repletion.Conclusions:Non-cardiac comorbidities are nearly universal in three groups but obviously differ by age,and inappropriate medications are very common in elderly patients with HF.Further treatment strategies should be focused on providing optimal medications for age-specific non-cardiac conditions.
基金National Natural Science Foundation of China(No.81470019)。
文摘Background:Post-operative acute kidney injury(AKI)is one of the most common and serious complications after major surgery and is significantly associated with increased risks of morbidity and mortality.This meta-analysis was conducted to evaluate the effects of perioperative dexmedetomidine(Dex)administration on the occurrence of AKI and the outcomes of recovery after non-cardiac surgery.Methods:The PubMed,Embase,Web of Science,and Cochrane Library databases were systematically searched for studies comparing the effects of Dexvs.placebo on kidney function after non-cardiac surgery,and a pooled fixed-effect meta-analysis of the included studies was performed.The primary outcome was the occurence of post-operative AKI.The secondary outcomes included the occurence of intra-operative hypotension and bradycardia,intensive care unit(ICU)admission,duration of ICU stay,and hospital length of stay(LOS).Results:Six studies,including four randomized controlled trials(RCTs)and two observational studies,with a total of 2586 patients were selected.Compared with placebo,Dex administration could not reduce the odds of post-operative AKI(odds ratio[OR],0.44;95%confidence interval(CI),0.18-1.06;P=0.07;I^(2)=0.00%,P=0.72)in RCTs,but it showed a significant renoprotective effect(OR,0.67;95%CI,0.48-0.95;P=0.02;I^(2)=0.00%,P=0.36)in observational studies.Besides,Dex administration significantly increased the odds of intra-operative bradycardia and shortened the duration of ICU stay.However,there was no significant difference in the odds of intra-operative hypotension,ICU admission,and hospital LOS.Conclusions:This meta-analysis suggests that perioperative Dex administration does not reduce the risk of AKI after non-cardiac surgery.However,the quality of evidence for this result is low due to imprecision and inconsistent types of non-cardiac operations.Thus,large and high-quality RCTs are needed to verify the real effects of perioperative Dex administration on the occurrence of AKI and the outcomes of recovery after non-cardiac surgery.
基金supported by the Xiangya Bigdata foundation(to YZT),the Health Commission of Hunan Province Project D202303017033(to YSM)the Natural Science Foundation of Hunan Province 2021JJ31028(to JX).
文摘Background:Acute kidney injury(AKI)is a common surgical complication and is associated with intraoperative hypotension.However,the total duration and magnitude of intraoperative hypotension associated with AKI remains unknown.In this study,the causal relationship between the intraoperative arterial pressure and postoperative AKI was investigated among chronic hypertension patients undergoing non-cardiac surgery.Methods:A retrospective cohort study of 6552 hypertension patients undergoing non-cardiac surgery(2011 to 2019)was conducted.The primary outcome was AKI as diagnosed with the Kidney Disease-Improving Global Outcomes criteria and the primary exposure was intraoperative hypotension.Patients’baseline demographics,pre-and post-operative data were harvested and then analyzed with multivariable logistic regression to assess the exposure-outcome relationship.Results:Among 6552 hypertension patients,579(8.84%)had postoperative AKI after non-cardiac surgery.The proportions of patients admitted to ICU(3.97 vs.1.24%,p<0.001)and experiencing all-cause death(2.76 vs.0.80%,p<0.001)were higher in the patients with postoperative AKI.Moreover,the patients with postoperative AKI had longer hospital stays(13.50 vs.12.00 days,p<0.001).Intraoperative mean arterial pressure(MAP)<60 mmHg for>20 min was an independent risk factor of postoperative AKI.Furthermore,MAP<60 mmHg for>10 min was also an independent risk factor of postoperative AKI in patients whose MAP was measured invasively in the subgroup analysis.Conclusions:Our work suggested that MAP<60 mmHg for>10 min measured invasively or 20 min measured non-invasively during non-cardiac surgery may be the threshold of postoperative AKI development in hypertension patients.This work may serve as a perioperative management guide for chronic hypertension patients.
文摘目的回顾性分析重症监护室(intensive care unit,ICU)非心脏手术患者发生围手术期心肌损伤(myocardial injury after non-cardiac surgery,MINS)的临床危险因素及预后情况。方法选取2020年1月至2023年12月复旦大学附属闵行医院重症医学科的手术后患者478例,按术后7天内是否发生心肌损伤分为MINS组(n=302)与正常组(n=176),比较两组患者临床资料特征的差异性,筛选出围手术期发生心肌损害的危险因素。以30天死亡为临床终点,分析MINS组患者死亡的危险因素。结果MINS组急性生理与慢性健康状况Ⅱ(acute physiology and chronic health evaluationⅡ,ApacheⅡ)评分、冠心病、慢性肾脏病患病率均较正常组高,差异有统计学意义(P<0.05)。MINS组急诊手术占比、合并感染、围手术期低血压与正常组相比差异有统计学意义(P<0.05)。多因素Logistic回归分析显示慢性肾脏病、急诊手术、合并感染、术中术后低血压是MINS的危险因素。预后分析显示围手术期低血压是MINS患者30天死亡的危险因素。结论MINS与患者的基础疾病、手术时机、围手术期低血压状态等密切相关,特别是围手术期低血压影响最终结局。
文摘目的:总结危重症患者无创心输出量监测管理的证据,为加强临床医护人员无创心输出量监测操作规范性和测量准确性提供循证依据。方法:检索UpToDate、英国医学杂志最佳临床实践数据库(BMJ Best Practice)、英国国家临床医学研究所指南库、PubMed、Embase、美国重症医学会网站、美国重症护理协会网站、万方数据库、中国知网、中国生物医学文献数据库等数据库中无创心输出量监测管理相关研究,包括临床决策、指南、专家共识、证据总结、最佳实践、系统评价、Meta分析、随机对照试验,检索时限为自建库起至2023年8月。循证团队人员对文献进行筛选、质量评价后,提取符合标准的相关证据。结果:共纳入11篇文献,包括系统评价7篇、专家共识4篇。形成20条关于危重症患者无创心输出量监测管理的证据,证据包括无创心输出量监测所适宜的患者、与有创心输出量监测的相关性、监测过程中的误差来源等,内容涉及监测人群、临床应用、干扰因素、注意事项、人员培训5方面。结论:应加强临床医护人员关于无创心输出量监测技术的培训,结合具体临床情境选择合适的实践证据,以提高无创心输出量监测的操作规范性与测量准确度。
