RESUMO
BACKGROUND: Cardiac risk evaluation prior to noncardiac surgery is fundamental to tailor peri-operative management to patient's estimated risk. Data on the degree of adherence to guidelines in patients at cardiovascular risk in Europe and factors influencing adherence are underexplored. OBJECTIVES: The aim of this analysis was to describe the degree of adherence to [2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines] recommendations on rest echocardiography [transthoracic echocardiography (TTE)] and to stress imaging prior to noncardiac surgery in a large European sample and to assess factors potentially affecting adherence. DESIGN: Secondary analysis of a multicentre, international, prospective cohort study (MET-REPAIR). SETTING: Twenty-five European centres of all levels of care that enrolled patients between 2017 and 2020. PATIENTS: With elevated cardiovascular risk undergoing in-hospital elective, noncardiac surgery. MAIN OUTCOME MEASURES: (Non)adherence to each pre-operative TTE and stress imaging recommendations classified as guideline-adherent, overuse and underuse. We performed descriptive analysis. To explore the impact of patients' sex, age, geographical region, and hospital teaching status, we conducted multivariate multinominal regression analysis. RESULTS: Out of 15â983 patients, 15â529 were analysed (61% men, mean age 72â±â8âyears). Overuse (conduction in spite of class III) and underuse (nonconduction in spite of class I recommendation) for pre-operative TTE amounted to 16.6% (2542/15â344) and 6.6% (1015/15â344), respectively. Stress imaging overuse and underuse amounted to 1.7% (241/14â202) and 0.4% (52/14â202) respectively. Male sex, some age categories and some geographical regions were significantly associated with TTE overuse. Male sex and some regions were also associated with TTE underuse. Age and regions were associated with overuse of stress imaging. Male sex, age, and some regions were associated with stress imaging underuse. CONCLUSION: Adherence to pre-operative stress imaging recommendation was high. In contrast, adherence to TTE recommendations was moderate. Both patients' and geographical factors affected adherence to joint ESC/ESA guidelines. TRIAL REGISTRATION: NCT03016936.
Assuntos
Fidelidade a Diretrizes , Cuidados Pré-Operatórios , Humanos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Estudos Prospectivos , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Estudos de Coortes , Europa (Continente) , Ecocardiografia sob Estresse , Ecocardiografia/normas , Guias de Prática Clínica como Assunto , Medição de Risco/métodos , Doenças Cardiovasculares/diagnóstico , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. METHODS: This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. RESULTS: In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. CONCLUSIONS: The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.
Assuntos
Cardiologia , Humanos , Feminino , Idoso , Masculino , Estudos Prospectivos , Ecocardiografia , Peptídeo Natriurético Encefálico , Fragmentos de Peptídeos , Isquemia , BiomarcadoresRESUMO
PURPOSE OF REVIEW: Published clinical practice guidelines frequently have difficulties for implementation of the recommendations and adherence in daily clinical practice. The present review summarizes the current knowledge on the barriers encountered when implementing clinical practice guideline and the strategies proposed to address these barriers. RECENT FINDINGS: Studies on strategies for implementation of clinical guidelines are scarce. Evidence indicates that a multidisciplinary policy is necessary in order to address the barriers at various levels. Continuous education and motivation of the stakeholders, together with structural adaptations are key elements in the process. SUMMARY: The barriers for implementation of guidelines involve different levels, including the healthcare system, organizational, societal and cultural specificities, and individual attitudes. All of these should be addressed with policy-driven strategies. Such strategies could include optimization of resources allocations, and establishing well coordinated multidisciplinary networks, finally, future studies should also evaluate the effectiveness of the potential strategies.
Assuntos
Atenção à Saúde , Fidelidade a Diretrizes , HumanosRESUMO
Dynamic preload parameters are used to guide perioperative fluid management. However, reported cut-off values vary and the presence of a gray zone complicates clinical decision making. Measurement error, intrinsic to the calculation of pulse pressure variation (PPV) has not been studied but could contribute to this level of uncertainty. The purpose of this study was to quantify and compare measurement errors associated with PPV calculations. Hemodynamic data of patients undergoing liver transplantation were extracted from the open-access VitalDatabase. Three algorithms were applied to calculate PPV based on 1 min observation periods. For each method, different durations of sampling periods were assessed. Best Linear Unbiased Prediction was determined as the reference PPV-value for each observation period. A Bayesian model was used to determine bias and precision of each method and to simulate the uncertainty of measured PPV-values. All methods were associated with measurement error. The range of differential and proportional bias were [- 0.04%, 1.64%] and [0.92%, 1.17%] respectively. Heteroscedasticity influenced by sampling period was detected in all methods. This resulted in a predicted range of reference PPV-values for a measured PPV of 12% of [10.2%, 13.9%] and [10.3%, 15.1%] for two selected methods. The predicted range in reference PPV-value changes for a measured absolute change of 1% was [- 1.3%, 3.3%] and [- 1.9%, 4%] for these two methods. We showed that all methods that calculate PPV come with varying degrees of uncertainty. Accounting for bias and precision may have important implications for the interpretation of measured PPV-values or PPV-changes.
Assuntos
Hidratação , Hemodinâmica , Humanos , Pressão Sanguínea , Teorema de Bayes , Hidratação/métodos , Algoritmos , Volume SistólicoRESUMO
In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
Assuntos
Humanos , Biomarcadores/análise , Avaliação de Risco e Mitigação , Medicina Perioperatória/normas , Fatores de Risco de Doenças Cardíacas , Peptídeo Natriurético EncefálicoRESUMO
Importance: Nearly 16 million surgical procedures are conducted in North America yearly, and postoperative cardiovascular events are frequent. Guidelines suggest functional capacity or B-type natriuretic peptides (BNP) to guide perioperative management. Data comparing the performance of these approaches are scarce. Objective: To compare the addition of either N-terminal pro-BNP (NT-proBNP) or self-reported functional capacity to clinical scores to estimate the risk of major adverse cardiac events (MACE). Design, Setting, and Participants: This cohort study included patients undergoing inpatient, elective, noncardiac surgery at 25 tertiary care hospitals in Europe between June 2017 and April 2020. Analysis was conducted in January 2023. Eligible patients were either aged 45 years or older with a Revised Cardiac Risk Index (RCRI) of 2 or higher or a National Surgical Quality Improvement Program, Risk Calculator for Myocardial Infarction and Cardiac (NSQIP MICA) above 1%, or they were aged 65 years or older and underwent intermediate or high-risk procedures. Exposures: Preoperative NT-proBNP and the following self-reported measures of functional capacity were the exposures: (1) questionnaire-estimated metabolic equivalents (METs), (2) ability to climb 1 floor, and (3) level of regular physical activity. Main Outcome and Measures: MACE was defined as a composite end point of in-hospital cardiovascular mortality, cardiac arrest, myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care. Results: A total of 3731 eligible patients undergoing noncardiac surgery were analyzed; 3597 patients had complete data (1258 women [35.0%]; 1463 (40.7%) aged 75 years or older; 86 [2.4%] experienced a MACE). Discrimination of NT-proBNP or functional capacity measures added to clinical scores did not significantly differ (Area under the receiver operating curve: RCRI, age, and 4MET, 0.704; 95% CI, 0.646-0.763; RCRI, age, and 4MET plus floor climbing, 0.702; 95% CI, 0.645-0.760; RCRI, age, and 4MET plus physical activity, 0.724; 95% CI, 0.672-0.775; RCRI, age, and 4MET plus NT-proBNP, 0.736; 95% CI, 0.682-0.790). Benefit analysis favored NT-proBNP at a threshold of 5% or below, ie, if true positives were valued 20 times or more compared with false positives. The findings were similar for NSQIP MICA as baseline clinical scores. Conclusions and relevance: In this cohort study of nearly 3600 patients with elevated cardiovascular risk undergoing noncardiac surgery, there was no conclusive evidence of a difference between a NT-proBNP-based and a self-reported functional capacity-based estimate of MACE risk. Trial Registration: ClinicalTrials.gov Identifier: NCT03016936.
Assuntos
Infarto do Miocárdio , Pré-Escolar , Feminino , Humanos , Biomarcadores , Estudos de Coortes , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Medição de Risco , AutorrelatoRESUMO
OBJECTIVES: To investigate the agreement between continuous noninvasive blood pressure measurement with the ClearSight system (cNIBP-CS) and standard intermittent noninvasive blood pressure measurement (iNIBP) in patients with peripheral arterial disease (PAD). Additionally, the influence of vasoactive medication on potential measurement differences was assessed. DESIGN: A secondary analysis of a randomized controlled trial. SETTING: At a university hospital. PARTICIPANTS: Thirty-four patients with PAD undergoing percutaneous transluminal angioplasty of the lower limbs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Continuous noninvasive blood pressures were measured with the "ClearSight" system and compared to standard iNIBPs. Bland-Altman analysis revealed a mean bias of 13 mmHg (±15) between cNIBP-CS and iNIBP, with 95% limits of agreement (LOA) ranging from -17 to 42 mmHg. When comparing both medication groups, a similar mean bias was found for phenylephrine and dobutamine (12 mmHg [±13] and 13 mmHg [±13], respectively). CONCLUSION: In this study, in patients with PAD, cNIBP-CS showed an underestimation of blood pressure compared to iNIBP in phenylephrine- and dobutamine-treated patients. Compared to previous studies, a larger bias and wider 95% LOA were found.
Assuntos
Pressão Arterial , Doença Arterial Periférica , Humanos , Pressão Sanguínea , Pressão Arterial/fisiologia , Dobutamina , Fenilefrina , Estudos Prospectivos , Determinação da Pressão Arterial , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/terapiaRESUMO
It is timely and necessary to consider what Postgraduate Medical Training Programme outcomes are, how they are defined and revised over time, and how they can be used to align health professional performance with the healthcare needs of society. This article which addresses those issues, with specific reference to training in anaesthesiology, was prepared using a modified nominal group (or expert panel) approach.
Assuntos
Anestesiologia , Internato e Residência , Humanos , Anestesiologia/educação , Currículo , ConsensoRESUMO
BACKGROUND: In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS: The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS: The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS: In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION: The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
Assuntos
Disparidades nos Níveis de Saúde , Peptídeo Natriurético Encefálico , Adulto , Humanos , Biomarcadores , Período Pós-Operatório , TroponinaRESUMO
Preserving haemodynamics is expected to positively affect tissue oxygen saturation. We hypothesized that maintaining mean arterial blood pressure (MAP) (using phenylephrine (PE) or dobutamine (Dobu)) would equally affect regional cerebral and paravertebral tissue saturation (rScO2 and rSpvO2, respectively). Thirty-four patients were randomly assigned to receive either PE or Dobu, in order to keep MAP within 20% of the preoperative value. Their effect on haemodynamics, rScO2 and rSpvO2 at thoracic level T3-T4, T9-T10 and lumbar level L1-L2 was calculated at different doses. Drug-induced haemodynamic effects differed between groups (∆MAP: -2%±21 and - 19%±17, ∆CI: -14.6%±14.6 and 24.1%±49.9, ∆HR: -21%±21 and 0%±16 for PE and Dobu, respectively). Both groups exhibited a significant decrease in rScO2, with a more pronounced decline in the PE group (-14.1%±16.1) compared to the Dobu group (-5.9%±10.6). There were no significant changes at the paravertebral level in either group, but a slight but statistically significant difference was detected between the two groups at T3-T4 and L1-L2. Current guidelines advocate maintaining adequate systemic blood pressures to prevent spinal cord ischaemia in specific procedures. However, it is still unknown which circulatory supportive drug is more beneficial for maintaining spinal cord perfusion. Our data indicates that, when used for maintenance of blood pressure within a 20% range of preoperative values, neither phenylephrine nor dobutamine affect paravertebral tissue saturation.
Assuntos
Dobutamina , Espectroscopia de Luz Próxima ao Infravermelho , Humanos , Fenilefrina/farmacologia , Pressão Sanguínea/fisiologia , Dobutamina/farmacologia , Saturação de Oxigênio , OxigênioRESUMO
BACKGROUND: There is a growing awareness of the effects of fatigue on trainee wellbeing and health. Trainees in anaesthesiology and intensive care work long hours, switching work schedules frequently with insufficient rest. This may have unwanted long-term effects on mental and physical health and emotional well being, resulting in burnout and affecting patient safety. OBJECTIVE: The study aimed to evaluate the prevalence, severity, causes and effects of work-related fatigue in trainees in anaesthesiology and intensive care. DESIGN: Online survey of trainees in anaesthesiology and intensive care. SETTINGS: A total of 31 countries within Europe were included in the survey. PARTICIPANTS: European anaesthesiology and intensive care trainees who responded to an invitation to take part by electronic mail or through social media. MAIN OUTCOME MEASURES: Responses from a 29-item online survey to assess the realities within European countries with regards to work-related fatigue. RESULTS: One thousand and two hundred trainees from 31 European countries answered the survey demonstrating that an alarming number of trainees were fatigued by their working patterns and night shifts. Trainees reported effects on personal well being, safe commuting and potential for clinical errors. Respondents described a lack of support from hospitals and management for recovery during and after night shifts. CONCLUSION: Fatigue among trainees in anaesthesiology and intensive care has a significant impact on their well being and potentially, on the incidence of clinical errors. Current measures from authorities and hospital management are not sufficient to prevent serious fatigue, and therefore a fatigue risk management system should be considered. Failure to address this issue might lead to a further decline in trainees' wellbeing, their capacity to work in the speciality in the future, and potentially increase patient care errors.
Assuntos
Anestesiologia , Humanos , Europa (Continente)/epidemiologia , Fadiga/diagnóstico , Fadiga/epidemiologia , Cuidados Críticos , Assistência ao Paciente , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery. METHODS: This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated. RESULTS: In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUCbaseline 0.74 [0.71-0.77], ROC AUCbaseline+4METs 0.74 [0.71-0.77], ROC AUCbaseline+floors climbed 0.75 [0.71-0.78], AUCbaseline+fitnessvspeers 0.74 [0.71-0.77], and AUCbaseline+physical activity 0.75 [0.72-0.78]). CONCLUSIONS: Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT03016936.
Assuntos
Infarto do Miocárdio , Complicações Pós-Operatórias , Humanos , Estudos Prospectivos , Autorrelato , Complicações Pós-Operatórias/etiologia , Infarto do Miocárdio/etiologia , Medição de Risco , Fatores de RiscoRESUMO
PURPOSE OF REVIEW: In this review, we want to collect all the adaptations that anaesthesiology training has faced because of the health crisis and social distancing measures resulting from coronavirus 2019 disease (COVID-19). We reviewed new teaching tools launched during the COVID-19 outbreak worldwide and particularly those implemented by the European Society of Anaesthesiology and Intensive Care (ESAIC) and the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC). RECENT FINDINGS: Globally, COVID-19 has interrupted health services and all aspects of training programmes. These unprecedented changes have led to teaching and trainee support innovation tools, focusing on online learning and simulation programmes. Airway management, critical care and regional anaesthesia, have been enhanced during the pandemic, while there were major obstacles in paediatrics, obstetrics and pain medicine. SUMMARY: The COVID-19 pandemic has altered profoundly the functioning of health systems worldwide. Anaesthesiologists and trainees have fought on the front lines of the battle against COVID-19. As a result, training in anaesthesiology during the last 2 years has focused on managing patients in intensive care. New training programmes have been designed to continue teaching residents of this speciality, focusing on e-learning and advanced simulation. It is necessary to present a review describing the impact that this turbulent period has had on the different subsections of anaesthesiology and to review the innovative measures that have been implemented to address these possible deficits in education and training.
Assuntos
Anestesia , Anestesiologia , COVID-19 , Humanos , Criança , Anestesiologia/educação , Pandemias/prevenção & controle , Cuidados CríticosRESUMO
BACKGROUND: Oxygen is one of the most commonly used drugs by anesthesiologists. The World Health Organization (WHO) gave recommendations regarding perioperative oxygen administration, but the practice of oxygen use in anesthesia, critical emergency, and intensive care medicine remains unclear. METHODS: We conducted an online survey among members of the European Society of Anaesthesiology and Intensive Care (ESAIC). The questionnaire consisted of 46 queries appraising the perioperative period, emergency medicine and in the intensive care, knowledge about current recommendations by the WHO, oxygen toxicity, and devices for supplemental oxygen therapy. RESULTS: Seven hundred ninety-eight ESAIC members (2.1% of all ESAIC members) completed the survey. Most respondents were board-certified and worked in hospitals with > 500 beds. The majority affirmed that they do not use specific protocols for oxygen administration. WHO recommendations are unknown to 42% of respondents, known but not followed by 14%, and known and followed by 24% of them. Respondents prefer inspiratory oxygen fraction (FiO2) ≥80% during induction and emergence from anesthesia, but intraoperatively < 60% for maintenance, and higher FiO2 in patients with diseased than non-diseased lungs. Postoperative oxygen therapy is prescribed more commonly according to peripheral oxygen saturation (SpO2), but shortage of devices still limits monitoring. When monitoring is used, SpO2 ≤ 95% is often targeted. In critical emergency medicine, oxygen is used frequently in patients aged ≥80 years, or presenting with respiratory distress, chronic obstructive pulmonary disease, myocardial infarction, and stroke. In the intensive care unit, oxygen is mostly targeted at 96%, especially in patients with pulmonary diseases. CONCLUSIONS: The current practice of perioperative oxygen therapy among respondents does not follow WHO recommendations or current evidence, and access to postoperative monitoring devices impairs the individualization of oxygen therapy. Further research and additional teaching about use of oxygen are necessary.