Intraoperative transesophageal echocardiography following mitral valve repair: a systematic review.

OBJECTIVE: We aimed to examine the recent evidence and search for novel assessments on intraoperative TEE following mitral valve repair that can impact short and long-term outcomes. METHODS: The Ovid MEDLINE, PubMed, and EMBASE databases were searched from January 1, 2008, until January 27, 2021, for studies on patients with severe Mitral Valve Regurgitation (MR) undergoing Mitral Valve (MV) repair surgery with intraoperative Transesophageal Echocardiography (TEE) performed after the repair. Additional searches were conducted using Google search engine, Web of Science, and Cochrane Library. RESULTS: After reviewing 302 records, 8 retrospective and 22 prospective studies were included (n = 30). Due to clinical and methodological diversity, these studies are noncomparable and data were not amenable to quantitative synthesis. CONCLUSION: Although technological advances allowed the objective assessment of geometric and dynamic alterations of the MV, the impact of the use of these technologies on short- or long-term outcomes was not studied. There is uncertainty and conflicting evidence on the ideal method and metrics to evaluate MV patency post-repair. Few isolated studies validated methods to assess coaptation surface and LV function post-repair.

Efficacy and Safety of Sugammadex versus Neostigmine in Reversing Neuromuscular Blockade in Morbidly Obese Adult Patients: A Systematic Review and Meta-Analysis.

CONTEXT: Sugammadex is known to reverse neuromuscular blockade (NMB) more rapidly and reliably than neostigmine. However, data remain limited in bariatric patients. In this review, we systematically evaluated the efficacy and safety of sugammadex versus neostigmine in reversing NMB in morbidly obese (MO) patients undergoing bariatric surgery. AIMS: Our primary objective was to determine the recovery time from drug administration to a train-of-four (TOF) ratio >0.9 from a moderate or deep NMB. SETTINGS AND DESIGN: This systematic review and meta-analysis (SR and MA) was conducted in accordance with the Preferred Items for SRs and MAs guidelines. SUBJECTS AND METHODS: A systematic search was conducted within multiple databases for studies that compared sugammadex and neostigmine in MO patients. STATISTICAL ANALYSIS USED: We reported data as mean difference (MD) or odds ratios (OR) and corresponding 95% confidence interval (CI) using random-effects models. A two-sided P < 0.05 was considered statistically significant. RESULTS: Seven studies with 386 participants met the inclusion criteria. Sugammadex significantly reduced the time of reversal of moderate NMB-to-TOF ratio >0.9 compared to neostigmine, with a mean time of 2.5 min (standard deviation [SD] 1.25) versus 18.2 min (SD 17.6), respectively (MD: -14.52; 95% CI: -20.08, -8.96; P < 0.00001; I 2 = 96%). The number of patients who had composite adverse events was significantly lower with sugammadex (21.2% of patients) compared to neostigmine (52.5% of patients) (OR: 0.15; 95% CI: 0.07-0.32; P < 0.00001; I 2 = 0%). CONCLUSIONS: Sugammadex reverses NMB more rapidly with fewer adverse events than neostigmine in MO patients undergoing bariatric surgery.

Incidence, Risk Factors, and Outcomes of Perioperative Atrial Fibrillation following Noncardiothoracic Surgery: A Systematic Review and Meta-Regression Analysis of Observational Studies.

BACKGROUND: Atrial fibrillation (AF) occurs in 16-30% of patients after cardiac and thoracic surgery and can lead to serious complications like hypoperfusion of vital organs, pulmonary edema, and myocardial infarction. The evidence on risk factors and complications associated with perioperative AF after noncardiothoracic surgery is limited. METHODS: The primary objective was to determine demographic and clinical risk factors for new-onset atrial fibrillation associated with noncardiothoracic surgery. A secondary aim was to identify the incidence and odds of perioperative complications associated with the new-onset atrial fibrillation. A systematic search within multiple databases was conducted for studies that explicitly reported on new-onset atrial fibrillation after noncardiothoracic surgery. We reported data on demographics, comorbidities, and perioperative complications as mean difference (MD) or odds ratios (OR) and corresponding 95% confidence interval (CI) using random effects models. A two-sided P value of less than 0.05 was considered significant. We performed meta-regression and sensitivity analysis of various subgroups to confirm the inference of our findings. RESULTS: Eleven studies reporting on 121,517 patients were included, of whom 2,944 developed perioperative AF (incidence rate: 3.7%; 95% CI: 2.3%--6.2%). Advanced age (AF group versus control group: 69.36 ± 10.5 versus 64.37 ± 9.53 years; MD: 4.06; 95% CI: 1.67--6.44; P=0.0009), male gender (52.85% versus 43.59%; OR: 1.08; 95% CI: 0.54 to 1.62; I 2: 84%; P < 0.0001), preoperative hypertension (60.42% versus 56.51%; OR: 1.15; 95% CI: 1.08 to 1.23; I 2: 0%; P < 0.00001), diabetes mellitus (22.6% versus 23.04%; OR: 0.97; 95% CI: 0.89 to 1.05; I 2: 0; P < 0.00001), and cardiac disease (30.64% versus 8.49%; OR: 2.3; 95% CI: 0.28 to 4.31; I 2: 93%; P=0.03) were found to be significant predictors for perioperative AF. The AF group was at increased odds of developing postoperative cardiac complications (34.1% versus 5%; OR: 5.44; 95% CI: 0.49 to 10.39; I 2: 82%; P=0.03), postoperative stroke (0.5% versus 0.1%; OR: 3; 95% CI: 0.65 to 5.35; I 2: 0%; P=0.01), and mortality (7.40% versus 1.92%; OR: 3.58; 95% CI: 0.14 to 7.02; I 2: 0%; P=0.04). Study quality assessment by meta-regression and sensitivity analysis of the various subgroups did not affect the final inference of the results. CONCLUSION: We identified advanced age, male gender, preoperative hypertension, diabetes mellitus, and cardiac disease as important risk factors for perioperative atrial fibrillation. The atrial fibrillation group was at increased odds for postoperative cardiac complications, stroke, and higher mortality, emphasizing the need for risk stratification and close monitoring.

Perioperative Satisfaction and Health Economic Questionnaires in Patients Undergoing an Elective Hip and Knee Arthroplasty: A Prospective Observational Cohort Study.

Background: Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated. Methods: We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care. Results: Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04). Conclusion: Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients' concerns.

Canadian recommendations for training and performance in basic perioperative point-of-care ultrasound: recommendations from a consensus of Canadian anesthesiology academic centres.

Point-of-care ultrasound (POCUS) uses ultrasound at the bedside to aid decision-making in acute clinical scenarios. The increased use of ultrasound for regional anesthesia and vascular cannulation, together with more anesthesiologists trained in transesophageal echocardiography have contributed to the widespread use of POCUS in perioperative care. Despite the support of international experts, the practice of POCUS in perioperative care is variable as Canadian guidelines for anesthesiologists do not currently exist. Using a Delphi process of online surveys and a face-to-face national Canadian meeting, we developed a consensus statement for basic POCUS (bPOCUS) performance and training with a group of national experts from all Canadian universities. The group of experts consisted of 55 anesthesiologists from 12 Canadian universities considered local leaders in the field. An initial exploratory online survey of 47 statements was conducted. These statements were derived from previous generic guidelines or consensus conferences, or were based on current literature. Fourteen statements reached full consensus, 19 had 90-100% agreement, and 14 had less than 90% agreement. Eight new statements were proposed during the national meeting, and all statements without full agreement were discussed. A second online survey included 42 modified or new statements. From this second survey, 16 statements obtained full consensus, 39 had very good agreement, and one had good agreement. The final document includes 56 statements that define the scope of practice and necessary training for perioperative bPOCUS. The statements include five bPOCUS domains: cardiac, lung, airway, gastric, and abdomen. The use of bPOCUS is evolving and will play a significant role in perioperative medicine. This consensus statement aims to define a Canadian national standard on which curricula may be based. It also provides a framework to allow further development of bPOCUS in the perioperative setting.

RéSUMé: L'échographie ciblée (POCUS) utilise l'échographie au chevet des patients pour faciliter la prise de décisions dans les situations cliniques urgentes. L'utilisation accrue de l'échographie pour l'anesthésie régionale et la cannulation vasculaire, ainsi que l'augmentation du nombre d'anesthésologistes formés à l'échocardiographie transesophagienne, ont contribué à l'utilisation généralisée de l'échographie ciblée dans les soins périopératoires. Malgré son endossement par des experts internationaux, la pratique de l'échographie ciblée en soins périopératoires est variable, car il n'existe pas, à l'heure actuelle, de lignes directrices canadiennes destinées aux anesthésiologistes. À l'aide d'un processus Delphi de sondages en ligne et d'une réunion nationale canadienne en personne, un groupe d'experts nationaux provenant de toutes les universités canadiennes a élaboré une déclaration consensuelle pour la formation de base en et l'exécution de l'échographie ciblée (bPOCUS). Le groupe d'experts était composé de 55 anesthésiologistes issus de 12 universités canadiennes considérés comme des chefs de file locaux dans le domaine. Un premier sondage exploratoire en ligne comportant 47 énoncés a été réalisé. Ces énoncés étaient dérivés de lignes directrices antérieures ou de conférences consensuelles, ou étaient fondés sur la littérature actuelle. Quatorze énoncés ont obtenu un consensus complet, 19 ont atteint un taux de 90 à 100 %, et 14 ont obtenu moins de 90 % d'accord. Huit nouveaux énoncés ont été proposés au cours de la réunion nationale, et tous les énoncés n'ayant pas obtenu d'accord complet ont été discutés. Un deuxième sondage en ligne comprenait 42 énoncés modifiés ou nouveaux. Dans ce deuxième sondage, 16 énoncés ont obtenu un consensus total, 39 un très bon accord et un énoncé un bon accord. Le document final comporte 56 énoncés qui définissent le champ de pratique et la formation nécessaire pour l'échographie ciblée périopératoire de base. Les énoncés portent sur cinq domaines de l'échographie ciblée de base : échographie cardiaque, pulmonaire, des voies respiratoires, gastrique et abdominale. L'utilisation de l'échographie ciblée de base évolue et jouera un rôle important en médecine périopératoire. Cette déclaration consensuelle vise à définir une norme nationale canadienne sur laquelle les programmes d'études pourront s'appuyer. Elle fournit également un cadre pour encourager le développement ultérieur de l'échographie ciblée de base dans un contexte périopératoire.

The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker-Description of the Technique.

The need for temporary cardiac pacing may occur in emergency and elective situations and may require transvenous right ventricular lead placement. The treatment of bradyarrhythmias presents the most common perioperative emergency indication. Intraoperatively, temporary rapid right ventricular pacing is accepted as a safe, titratable, and highly reliable method to achieve deliberate hypotension, and it has become a routine practice in the anesthetic management of cardiovascular interventions. The navigation of the lead into the right ventricle often requires fluoroscopy to guide placement and to confirm position. Ultrasound guidance has been accepted widely by perioperative physicians as a safe technique for central venous access. Basic ultrasound and transthoracic echocardiographic skills rapidly are becoming integral to anesthesiologists' practice. When used to guide transvenous pacemaker wire insertion, subcostal echocardiographic imaging offers attractive advantages over blind or fluoroscopic placement, including rapid deployment, avoidance of radiation, real-time visualization of the lead in relation to the cardiac structures, and early detection of potential complications, such as tamponade. Although several articles on echocardiographic guidance for transvenous pacing have been published in other acute care specialty fields in the last decade, this is the first description of the technique and of the recommended echocardiographic views in a perioperative context. In addition, a review of the current literature is presented, and the specific advantages and disadvantages of the approach are discussed in this article.

Comparative Effectiveness and Harms of Intraoperative Transesophageal Echocardiography in Noncardiac Surgery: A Systematic Review.

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.

Postoperative Home Monitoring After Joint Replacement: Feasibility Study.

BACKGROUND: We conducted a prospective observational study of patients undergoing elective primary hip or knee replacements to examine the feasibility of a postoperative home monitoring system as transitional care to support patients following their surgery in real time. OBJECTIVE: The primary outcome was the mean percentage of successful wireless transmissions from home of blood pressure levels, heart rate, oxygen saturation levels, and pain scores until postoperative day 4 with a feasibility target of ≥90%. METHODS: Patients with an expected length of stay ≤1 day, age 18-80 years, Revised Cardiac Risk Index ≤ class 2, and caretakers willing to assist at home were eligible. Patient satisfaction, as a secondary outcome, was also evaluated. Wireless monitoring equipment (remote patient monitoring, Telus Canada) was obtained and a multidisciplinary care team was formed. RESULTS: We conducted the study after obtaining Research Ethics Board approval; 54 patients completed the study: 21 males, 33 females. In total, we evaluated 9 hips, 4 hip resurfacing, 26 total knees, and 15 hemi-knees. The mean transmission rate was 96.4% (SD 5.9%; 95% CI 94.8-98.0). The median response to "I would recommend the Remote Monitoring System program to future patients" was 4.5 (interquartile range 4-5), with 1 being "strongly disagree" and 5 "strongly agree." At 30 days postop, there was no mortality or readmission. CONCLUSIONS: This is an evolving new paradigm for postoperative care and the first feasibility study on monitoring biometrics after primary hip or knee replacement. Postoperative home monitoring combines current technology with real-time support by a multidisciplinary transitional care team after discharge, facilitating postsurgical care with successful wireless transmission of vitals. The postoperative home monitoring implementation is, therefore, generalizable to other surgical discharges from hospitals. TRIAL REGISTRATION: ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/71ugAhhIk).

Postoperative Home Monitoring After Joint Replacement: Retrospective Outcome Study Comparing Cases With Matched Historical Controls.

BACKGROUND: A retrospective cohort study was conducted in patients undergoing postoperative home monitoring (POHM) following elective primary hip or knee replacements. OBJECTIVE: The objectives of our study were to compare the cost per patient, readmissions rate, emergency room visits, and mortality within 30 days to the historical standard of care using descriptive analysis. METHODS: After Research Ethics Board approval, patients who were enrolled and had completed a POHM study were individually matched to historical controls by age, American Society of Anesthesiology class, and procedure at a ratio 1:2. RESULTS: A total of 54 patients in the study group and 107 in the control group were eligible for the analysis. Compared with the historical standard of care, the average cost per case was Can $5826.32 (SD 1418.89) in the POHM group and Can $9198.58 (SD 1513.59) for controls. After 30 days, there were 2 emergency room visits (3.7%) and 0 readmissions in the POHM group, whereas there were 8 emergency room visits (7.5%) and 2 readmissions (1.9%) in the control group. No mortalities occurred in either group. CONCLUSIONS: The POHM study offers an early hospital discharge pathway for elective hip and knee procedures at a 38% reduction of the standard of care cost. The multidisciplinary transitional POHM team may provide a reliable forum to minimize readmissions, and emergency room visits within 30 days postoperatively. TRIAL REGISTRATION: ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/73WQ9QR6P).

Perioperative transesophageal echocardiography for non-cardiac surgery.

PURPOSE: The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination. PRINCIPAL FINDINGS: Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, "rescue TEE" can be used to help identify the underlying cause. CONCLUSIONS: Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.

Postoperative real-time electrocardiography monitoring detects myocardial ischemia: a case report.

PURPOSE: This case report outlines the utility and challenges of remote continuous postoperative electrocardiography ECG) monitoring, which is routed through a secure smartphone to provide real-time detection and management of myocardial ischemia. CLINICAL FEATURES: A 42-yr-old male with previous myocardial infarction and angioplasty underwent a radical prostatectomy. At three hours and 45 min postoperatively, remote real-time ECG monitoring was initiated upon the patient's arrival on a regular surgical ward. Monitor alerts were routed to a study clinician's smartphone. About six hours postoperatively, alarms were received and horizontal ST segment depressions were observed. A 12-lead ECG validated the ST segment changes, prompting initiation of a metoprolol iv and a red blood cell transfusion. Approximately seven hours and 30 min postoperatively, the ST segments normalized. The patient was discharged on postoperative day 3 and followed for four years without any sequelae. CONCLUSION: This case report illustrates the use of remote ECG monitoring and clinician response in real time with the use of a smartphone. With each alert, a small ECG strip is transmitted to the smartphone for viewing. In our view, this technology and management system provides a possible means to interrupt myocardial ischemic cascades in real time and prevent postoperative myocardial infarction.

Perioperative Diastolic Dysfunction in Patients Undergoing Noncardiac Surgery Is an Independent Risk Factor for Cardiovascular Events: A Systematic Review and Meta-analysis.

BACKGROUND: The prognostic value of perioperative diastolic dysfunction (PDD) in patients undergoing noncardiac surgery remains uncertain, and the current guidelines do not recognize PDD as a perioperative risk factor. This systematic review aimed to investigate whether existing evidence supports PDD as an independent predictor of adverse events after noncardiac surgery. METHODS: Ovid MEDLINE, PubMed, EMBASE, the Cochrane Library, and Google search engine were searched for English-language citations in April 2015 investigating PDD as a risk factor for perioperative adverse events in adult patients undergoing noncardiac surgery. Two reviewers independently assessed the study risk of bias. Extracted data were verified. Random-effects model was used for meta-analysis, and reviewers' certainty was graded. RESULTS: Seventeen studies met eligibility criteria; however, 13 contributed to evidence synthesis. The entire body of evidence addressing the research question was based on a total of 3,876 patients. PDD was significantly associated with pulmonary edema/congestive heart failure (odds ratio [OR], 3.90; 95% CI, 2.23 to 6.83; 3 studies; 996 patients), myocardial infarction (OR, 1.74; 95% CI, 1.14 to 2.67; 3 studies; 717 patients), and the composite outcome of major adverse cardiovascular events (OR, 2.03; 95% CI, 1.24 to 3.32; 4 studies; 1,814 patients). Evidence addressing other outcomes had low statistical power, but higher long-term cardiovascular mortality was observed in patients undergoing open vascular repair (OR, 3.00; 95% CI, 1.50 to 6.00). Reviewers' overall certainty of the evidence was moderate. CONCLUSION: Evidence of moderate certainty indicates that PDD is an independent risk factor for adverse cardiovascular outcomes after noncardiac surgery.

Cerebral Oximetry Monitoring to Maintain Normal Cerebral Oxygen Saturation during High-risk Cardiac Surgery: A Randomized Controlled Feasibility Trial.

BACKGROUND: Cerebral oxygen desaturation during cardiac surgery has been associated with adverse perioperative outcomes. Before a large multicenter randomized controlled trial (RCT) on the impact of preventing desaturations on perioperative outcomes, the authors undertook a randomized prospective, parallel-arm, multicenter feasibility RCT to determine whether an intervention algorithm could prevent desaturations. METHODS: Eight Canadian sites randomized 201 patients between April 2012 and October 2013. The primary outcome was the success rate of reversing cerebral desaturations below 10% relative to baseline in the intervention group. Anesthesiologists were blinded to the cerebral saturation values in the control group. Intensive care unit personnel were blinded to cerebral saturation values for both groups. Secondary outcomes included the area under the curve of cerebral desaturation load, enrolment rates, and a 30-day follow-up for adverse events. RESULTS: Cerebral desaturations occurred in 71 (70%) of the 102 intervention group patients and 56 (57%) of the 99 control group patients (P = 0.04). Reversal was successful in 69 (97%) of the intervention group patients. The mean cerebral desaturation load (SD) in the operating room was smaller for intervention group patients compared with control group patients (104 [217] %.min vs. 398 [869] %.min, mean difference, -294; 95% CI, -562 to -26; P = 0.03). This was also true in the intensive care unit (P = 0.02). There were no differences in adverse events between the groups. CONCLUSIONS: Study sites were successful in reversal of desaturation, patient recruitment, randomization, and follow-up in cardiac surgery, supporting the feasibility of conducting a large multicenter RCT.

Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis.

OBJECTIVE: Although ultrasound guidance for subclavian vein catheterization has been well described, evidence for its use has not been comprehensively appraised. Thus, we conducted a systematic review and meta-analysis to determine whether ultrasound guidance of subclavian vein catheterization reduces catheterization failures and adverse events compared to the traditional "blind" landmark method. All forms of ultrasound were included (dynamic 2D ultrasound, static 2D ultrasound, and Doppler). DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL (from inception to September 2014). STUDY SELECTION: Randomized controlled trials of ultrasound compared to landmark technique for subclavian catheterization in adult populations were considered. Outcomes of interest included safety and failure of catheterization. DATA EXTRACTION: Adverse event data were analyzed according to Peto's method and expressed as odd ratios and 95% CIs. Failure of catheterization was analyzed with inverse variance random effects modeling and expressed as risk ratios and 95% CI. DATA SYNTHESIS: Six hundred and one studies were reviewed and 10 met inclusion criteria (n = 2,168 participants). Six used dynamic 2D ultrasound (n = 719), one used static 2D ultrasound (n = 821), and three used Doppler-guided insertion techniques (n = 628). Overall complication rates were reduced with ultrasound use compared to the landmark group (odd ratio, 0.53; 95% CI, 0.41-0.69). Subgroup analysis demonstrated that dynamic 2D ultrasound reduced inadvertent arterial puncture, pneumothorax, and hematoma formation. No difference in failure of catheterization was noted between the ultrasound group and the landmark method (risk ratio, 0.85; 95% CI, 0.48-1.51). Subgroup analysis of dynamic 2D ultrasound demonstrated a significant decrease in failed catheterization (risk ratio, 0.24; 95% CI, 0.06-0.92). CONCLUSIONS: Ultrasound-guided subclavian catheterization reduced the frequency of adverse events compared with the landmark technique. Our findings support the use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse events and failed catheterization.

Perioperative myocardial ischemia and isolated systolic hypertension in non-cardiac surgery.

PURPOSE: To determine whether patients with isolated systolic hypertension (ISH) undergoing non-cardiac surgery have a higher incidence of perioperative myocardial ischemia than normotensive patients and hence a greater risk for perioperative adverse events. METHODS: After obtaining Research Ethics Board approval, patients were recruited to either an ISH group (systolic blood pressure [SBP] > 140 mmHg with diastolic blood pressure [DBP] < 90 mmHg) or a normotensive group (SBP < 140 mmHg and DBP < 90 mmHg), according to their resting preoperative blood pressure. The primary outcome was the overall incidence of perioperative myocardial ischemia (PMI) as determined by 48-hr ambulatory Holter monitoring. P values ≤ 0.05 were considered to be statistically significant. RESULTS: A total of 312 (150 ISH and 162 normotensive) patients completed the study. Orthopedic surgery was the most frequent surgical procedure in both groups. The overall incidence of PMI was 19.7% in the ISH group compared with 18.8% in the normotensive group (difference 0.9%; 95% confidence interval [CI], -7.9% to 9.8%). The overall incidence of adverse events was 4.0% in the ISH group compared with 1.9% in the normotensive group (difference 2.2%; 95% CI, -1.6% to 5.9%). CONCLUSION: In this study, we chose to examine ISH as potential cardiac risk factor for patients undergoing non-cardiac surgery. The incidence of myocardial ischemia, a surrogate outcome, was similar in the two groups. The relatively high incidence of myocardial ischemia (19.2%) was of particular interest in this relatively low cardiac risk surgical population. (ClinicalTrials.gov number, NCT01237652).