2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines.

Society for Vascular Medicine.
Circulation (Impact Factor: 14.95). 11/2009; 120(21):2123-51. DOI: 10.1161/CIRCULATIONAHA.109.192689
Source: PubMed
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    ABSTRACT: There is limited medical literature investigating the association between perioperative risk stratification methods and surgical intensive care unit (SICU) outcomes. Our hypothesis contends that routine assessments such as higher ASA physical status classification, surgical risk as defined by American College of Cardiology/American Heart Association guidelines, and simplified Revised Cardiac Index (SRCI) can reliably be associated with SICU outcomes. We performed a chart review of all patients 18 years or older admitted to the SICU between October 1, 2010, and March 1, 2011. We collected demographic and preoperative clinical data: age, sex, ASA physical status class, surgical risk, and SRCI. Outcome data included our primary end point, SICU length of stay, and secondary end points: mechanical ventilation and vasopressor treatment duration, number of acquired organ dysfunctions (NOD), readmission to the intensive care unit (ICU) within 7 days, SICU mortality, and 30-day mortality. Regression analysis and nonparametric tests were used, and P < 0.05 was considered significant. We screened 239 patients and included 220 patients in the study. The patients' mean age was 58 ± 16 years. There were 32% emergent surgery and 5% readmissions to the SICU within 7 days. The SICU mortality and the 30-day mortality were 3.2%. There was a significant difference between SICU length of stay (2.9 ± 2.1 vs 5.9 ± 7.4, P = 0.007), mechanical ventilation (0.9 ± 2.0 vs 3.4 ± 6.8, P = 0.01), and NOD (0 [0-2] vs 1 [0-5], P < 0.001) based on ASA physical status class (≤ 2 vs ≥ 3). Outcomes significantly associated with ASA physical status class after adjusting for confounders were: SICU length of stay (incidence rate ratio [IRR] = 1.79, 95% confidence interval [CI], 1.35-2.39, P < 0.001), mechanical ventilation (IRR = 2.57, 95% CI, 1.69-3.92, P < 0.001), vasopressor treatment (IRR = 3.57, 95% CI, 1.84-6. 94, P < 0.001), NOD (IRR = 1.71, 95% CI, 1.46-1.99, P < 0.001), and readmission to ICU (odds ratio = 3.39, 95% CI, 1.04-11.09, P = 0.04). We found significant association between surgery risk and NOD (IRR = 1.56, 95% CI, 1.29-1.89, P < 0.001, and adjusted IRR = 1.31, 95% CI, 1.05-1.64, P = 0.02). SRCI was not significantly associated with SICU outcomes. Our study revealed that ASA physical status class is associated with increased SICU length of stay, mechanical ventilation, vasopressor treatment duration, NOD, readmission to ICU, and surgery risk is associated with NOD.
    Anesthesia and analgesia 05/2014; 118(5):989-994. DOI:10.1213/ANE.0000000000000187 · 3.42 Impact Factor
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    ABSTRACT: Perioperative blood pressure management is a key factor of patient care for anesthetists, as perioperative hemodynamic instability is associated with cardiovascular complications. Hypertension is an independent predictive factor of cardiac adverse events in noncardiac surgery. Intraoperative hypotension is one of the most encountered factors associated with death related to anesthesia. In the preoperative setting, the majority of antihypertensive medications should be continued until surgery. Only renin-angiotensin system antagonists may be stopped. Hypertension, especially in the case of mild to moderate hypertension, is not a cause for delaying surgery. During the intraoperative period, anesthesia leads to hypotension. Hypotension episodes should be promptly treated by intravenous vasopressors, and according to their etiology. In the postoperative setting, hypertension predominates. Continuation of antihypertensive medications and postoperative care may be insufficient. In these cases, intravenous antihypertensive treatments are used to control blood pressure elevation.
    Integrated Blood Pressure Control 01/2014; 7:49-59. DOI:10.2147/IBPC.S45292
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    ABSTRACT: Postoperative cardiovascular complications are common, predictable, and typically treatable in geriatric patients who have sustained fractures. Although intervention-specific data are sparse, observational evidence from high-performing geriatric fracture centers coupled with an understanding of geriatric principles can serve as a basis for treatment guidelines. Many patients can be safely and effectively managed with close attention to intravascular volume status, heart rate control, and minimization of other physiologic stresses, including pain and delirium. Many chronic cardiovascular therapies may be harmful in the immediate postoperative period, and can usually be safely omitted or attenuated until hemodynamic stability and mobility have been restored.
    05/2014; 30(2):293-301. DOI:10.1016/j.cger.2014.01.008