Perioperative Medicine

MIAMI BEACH — Using physiologic insulin replacement strategies, physicians can manage glycemia throughout the perioperative period and optimize patient outcomes.

“We have a number of options to improve glycemic control … and a number of strategies for transitioning the patient after surgery,” Dr. Luigi F. Meneghini said during a meeting on perioperative medicine sponsored by the University of Miami. He explained how to use basal insulin, supplemental scale boluses, and/or prandial insulin during the preoperative, intraoperative, and postoperative periods.

Even surgical patients not diagnosed with diabetes can experience hyperglycemia and associated perioperative and postoperative risks, said Dr. Meneghini, director of clinical operations, division of endocrinology, diabetes and metabolism at the University of Miami.

Why is the perioperative period such a risky time for people with diabetes? Surgery and anesthesia can increase levels of stress hormones, epinephrine, cortisol, growth hormones, and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Also, general anesthesia, bypass surgery, sepsis, parenteral nutrition, and use of steroids can alter insulin resistance, decrease insulin secretion, and cause lipolysis and protein catabolism. “This all makes perioperative management of diabetes so much more difficult,” he said.

Perioperative glycemic control can be achieved through implementation of the following strategies before, during, or after surgery:

▸ Preoperatively. The goal is to stabilize glycemia, in many cases with subcutaneous insulin. However, if the patient has type 1 diabetes, continue basal insulin, “no questions asked,” Dr. Meneghini said.

Discontinue all oral agents prior to surgery, perform a finger-stick glucose test every 4-6 hours, and use a supplemental scale for additional insulin if blood glucose levels exceed target values.

“You will need some basal insulin replacement. Insulin needs are still there when you are fasting; you can give [basal insulin] to anyone whether they are NPO [nothing by mouth] or not,” Dr. Meneghini said.

The American Diabetes Association recommends a glycemic target of about 110 mg/dL to less than 140 mg/dL for critically ill patients. For patients who are not critically ill, fasting blood glucose levels of less than 126 mg/dL or random blood glucose levels less than 180-200 mg/dL are recommended (Diabetes Care 2008;31[suppl. 1]:S12-54).

Several preoperative factors should be checked, but at least do an ECG, basic metabolic panel (BMP), and hemoglobin A1c assay, Dr. Meneghini said. “The [Hb]A1c before surgery may be useful for assessing risk and to determine if preoperative glycemic control is adequate.”

▸ Intraoperatively. Intraoperative management depends on the length of the procedure, Dr. Meneghini said. “For a 1- to 2-hour surgery, you can probably continue preoperative glucose management orders.” However, for a longer or more complex surgery, switch to intravenous drip insulin, ideally before surgery in order to stabilize glucose. Physicians can use the Modified Markovitz Protocol (Endocr. Pract. 2002;8:10-8) to calculate glycemic control intraoperatively.

Intravenous regular insulin has a half-life of 7 minutes, and by half an hour there is no more on board, “which can be very handy,” Dr. Meneghini said. “This is why we usually go to [intravenous] regular insulin for the perioperative period or critical care.”

▸ Postoperatively. After surgery, transition patients from intravenous to subcutaneous insulin management, Dr. Meneghini advised. “And that is a tricky passage in many cases. … We need to deal with inconsistent PO intake, stress, infection, and increased insulin resistance.”

Ensure adequate basal insulin levels during the transition to subcutaneous insulin, especially in type 1 diabetes patients. Basal insulin replacement can start at any time, Dr. Meneghini said. “I recommend you start 24 hours prior to discontinuation of the [intravenous] insulin drip. This ensures adequate basal coverage during the transition.”

Replace insulin according to physiologic needs. Match the basal replacement to hepatic glucose output, for example. Also match the prandial glucose to carbohydrate intake, and correct hyperglycemia as needed using a supplemental scale.

Postoperative nutrition should be taken into account. For example, if a patient is receiving total parenteral nutrition, start 1 U of regular insulin subcutaneously per 10-15 g of dextrose in the bag, Dr. Meneghini said. If the patient is on continuous enteral feeding, administer regular insulin every 6 hours or a rapid-acting insulin analog every 4 hours. Also, start 1 U of subcutaneous insulin to cover every 10-15 g of carbohydrates. If the enteral feed is a bolus, start 1 U of insulin subcutaneous per 10-15 g of carbohydrates and inject 15-20 minutes prior to the bolus.

If the patient is eating, use regular insulin or an insulin analog (preferred to minimize stacking) to cover meals, Dr. Meneghini said. Start 1 U of insulin subcutaneously to cover 10-15 g of carbohydrates and use what he calls the “Miami 4/12 Rule,” whereby the basal insulin replacement dose is calculated by taking the patient's weight in kilograms and dividing it by 4 and the prandial coverage is calculated by dividing the patient's weight in kilograms by 12.

MIAMI BEACH — Using physiologic insulin replacement strategies, physicians can manage glycemia throughout the perioperative period and optimize patient outcomes.

“We have a number of options to improve glycemic control … and a number of strategies for transitioning the patient after surgery,” Dr. Luigi F. Meneghini said during a meeting on perioperative medicine sponsored by the University of Miami. He explained how to use basal insulin, supplemental scale boluses, and/or prandial insulin during the preoperative, intraoperative, and postoperative periods.

Even surgical patients not diagnosed with diabetes can experience hyperglycemia and associated perioperative and postoperative risks, said Dr. Meneghini, director of clinical operations, division of endocrinology, diabetes and metabolism at the University of Miami.

Why is the perioperative period such a risky time for people with diabetes? Surgery and anesthesia can increase levels of stress hormones, epinephrine, cortisol, growth hormones, and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Also, general anesthesia, bypass surgery, sepsis, parenteral nutrition, and use of steroids can alter insulin resistance, decrease insulin secretion, and cause lipolysis and protein catabolism. “This all makes perioperative management of diabetes so much more difficult,” he said.

Perioperative glycemic control can be achieved through implementation of the following strategies before, during, or after surgery:

▸ Preoperatively. The goal is to stabilize glycemia, in many cases with subcutaneous insulin. However, if the patient has type 1 diabetes, continue basal insulin, “no questions asked,” Dr. Meneghini said.

Discontinue all oral agents prior to surgery, perform a finger-stick glucose test every 4-6 hours, and use a supplemental scale for additional insulin if blood glucose levels exceed target values.

“You will need some basal insulin replacement. Insulin needs are still there when you are fasting; you can give [basal insulin] to anyone whether they are NPO [nothing by mouth] or not,” Dr. Meneghini said.

The American Diabetes Association recommends a glycemic target of about 110 mg/dL to less than 140 mg/dL for critically ill patients. For patients who are not critically ill, fasting blood glucose levels of less than 126 mg/dL or random blood glucose levels less than 180-200 mg/dL are recommended (Diabetes Care 2008;31[suppl. 1]:S12-54).

Several preoperative factors should be checked, but at least do an ECG, basic metabolic panel (BMP), and hemoglobin A1c assay, Dr. Meneghini said. “The [Hb]A1c before surgery may be useful for assessing risk and to determine if preoperative glycemic control is adequate.”

▸ Intraoperatively. Intraoperative management depends on the length of the procedure, Dr. Meneghini said. “For a 1- to 2-hour surgery, you can probably continue preoperative glucose management orders.” However, for a longer or more complex surgery, switch to intravenous drip insulin, ideally before surgery in order to stabilize glucose. Physicians can use the Modified Markovitz Protocol (Endocr. Pract. 2002;8:10-8) to calculate glycemic control intraoperatively.

Intravenous regular insulin has a half-life of 7 minutes, and by half an hour there is no more on board, “which can be very handy,” Dr. Meneghini said. “This is why we usually go to [intravenous] regular insulin for the perioperative period or critical care.”

▸ Postoperatively. After surgery, transition patients from intravenous to subcutaneous insulin management, Dr. Meneghini advised. “And that is a tricky passage in many cases. … We need to deal with inconsistent PO intake, stress, infection, and increased insulin resistance.”

Ensure adequate basal insulin levels during the transition to subcutaneous insulin, especially in type 1 diabetes patients. Basal insulin replacement can start at any time, Dr. Meneghini said. “I recommend you start 24 hours prior to discontinuation of the [intravenous] insulin drip. This ensures adequate basal coverage during the transition.”

Replace insulin according to physiologic needs. Match the basal replacement to hepatic glucose output, for example. Also match the prandial glucose to carbohydrate intake, and correct hyperglycemia as needed using a supplemental scale.

Postoperative nutrition should be taken into account. For example, if a patient is receiving total parenteral nutrition, start 1 U of regular insulin subcutaneously per 10-15 g of dextrose in the bag, Dr. Meneghini said. If the patient is on continuous enteral feeding, administer regular insulin every 6 hours or a rapid-acting insulin analog every 4 hours. Also, start 1 U of subcutaneous insulin to cover every 10-15 g of carbohydrates. If the enteral feed is a bolus, start 1 U of insulin subcutaneous per 10-15 g of carbohydrates and inject 15-20 minutes prior to the bolus.

If the patient is eating, use regular insulin or an insulin analog (preferred to minimize stacking) to cover meals, Dr. Meneghini said. Start 1 U of insulin subcutaneously to cover 10-15 g of carbohydrates and use what he calls the “Miami 4/12 Rule,” whereby the basal insulin replacement dose is calculated by taking the patient's weight in kilograms and dividing it by 4 and the prandial coverage is calculated by dividing the patient's weight in kilograms by 12.

MIAMI BEACH — Using physiologic insulin replacement strategies, physicians can manage glycemia throughout the perioperative period and optimize patient outcomes.

“We have a number of options to improve glycemic control … and a number of strategies for transitioning the patient after surgery,” Dr. Luigi F. Meneghini said during a meeting on perioperative medicine sponsored by the University of Miami. He explained how to use basal insulin, supplemental scale boluses, and/or prandial insulin during the preoperative, intraoperative, and postoperative periods.

Even surgical patients not diagnosed with diabetes can experience hyperglycemia and associated perioperative and postoperative risks, said Dr. Meneghini, director of clinical operations, division of endocrinology, diabetes and metabolism at the University of Miami.

Why is the perioperative period such a risky time for people with diabetes? Surgery and anesthesia can increase levels of stress hormones, epinephrine, cortisol, growth hormones, and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Also, general anesthesia, bypass surgery, sepsis, parenteral nutrition, and use of steroids can alter insulin resistance, decrease insulin secretion, and cause lipolysis and protein catabolism. “This all makes perioperative management of diabetes so much more difficult,” he said.

Perioperative glycemic control can be achieved through implementation of the following strategies before, during, or after surgery:

▸ Preoperatively. The goal is to stabilize glycemia, in many cases with subcutaneous insulin. However, if the patient has type 1 diabetes, continue basal insulin, “no questions asked,” Dr. Meneghini said.

Discontinue all oral agents prior to surgery, perform a finger-stick glucose test every 4-6 hours, and use a supplemental scale for additional insulin if blood glucose levels exceed target values.

“You will need some basal insulin replacement. Insulin needs are still there when you are fasting; you can give [basal insulin] to anyone whether they are NPO [nothing by mouth] or not,” Dr. Meneghini said.

The American Diabetes Association recommends a glycemic target of about 110 mg/dL to less than 140 mg/dL for critically ill patients. For patients who are not critically ill, fasting blood glucose levels of less than 126 mg/dL or random blood glucose levels less than 180-200 mg/dL are recommended (Diabetes Care 2008;31[suppl. 1]:S12-54).

Several preoperative factors should be checked, but at least do an ECG, basic metabolic panel (BMP), and hemoglobin A1c assay, Dr. Meneghini said. “The [Hb]A1c before surgery may be useful for assessing risk and to determine if preoperative glycemic control is adequate.”

▸ Intraoperatively. Intraoperative management depends on the length of the procedure, Dr. Meneghini said. “For a 1- to 2-hour surgery, you can probably continue preoperative glucose management orders.” However, for a longer or more complex surgery, switch to intravenous drip insulin, ideally before surgery in order to stabilize glucose. Physicians can use the Modified Markovitz Protocol (Endocr. Pract. 2002;8:10-8) to calculate glycemic control intraoperatively.

Intravenous regular insulin has a half-life of 7 minutes, and by half an hour there is no more on board, “which can be very handy,” Dr. Meneghini said. “This is why we usually go to [intravenous] regular insulin for the perioperative period or critical care.”

▸ Postoperatively. After surgery, transition patients from intravenous to subcutaneous insulin management, Dr. Meneghini advised. “And that is a tricky passage in many cases. … We need to deal with inconsistent PO intake, stress, infection, and increased insulin resistance.”

Ensure adequate basal insulin levels during the transition to subcutaneous insulin, especially in type 1 diabetes patients. Basal insulin replacement can start at any time, Dr. Meneghini said. “I recommend you start 24 hours prior to discontinuation of the [intravenous] insulin drip. This ensures adequate basal coverage during the transition.”

Replace insulin according to physiologic needs. Match the basal replacement to hepatic glucose output, for example. Also match the prandial glucose to carbohydrate intake, and correct hyperglycemia as needed using a supplemental scale.

Postoperative nutrition should be taken into account. For example, if a patient is receiving total parenteral nutrition, start 1 U of regular insulin subcutaneously per 10-15 g of dextrose in the bag, Dr. Meneghini said. If the patient is on continuous enteral feeding, administer regular insulin every 6 hours or a rapid-acting insulin analog every 4 hours. Also, start 1 U of subcutaneous insulin to cover every 10-15 g of carbohydrates. If the enteral feed is a bolus, start 1 U of insulin subcutaneous per 10-15 g of carbohydrates and inject 15-20 minutes prior to the bolus.

If the patient is eating, use regular insulin or an insulin analog (preferred to minimize stacking) to cover meals, Dr. Meneghini said. Start 1 U of insulin subcutaneously to cover 10-15 g of carbohydrates and use what he calls the “Miami 4/12 Rule,” whereby the basal insulin replacement dose is calculated by taking the patient's weight in kilograms and dividing it by 4 and the prandial coverage is calculated by dividing the patient's weight in kilograms by 12.

MIAMI BEACH — Preoperative percent body fat is an independent predictor of surgical site infection risk and is a more accurate way to define obesity than is body mass index, according to preliminary results of a prospective, ongoing trial.

Surgical site infections (SSIs) develop in an estimated 290,000 of the 27 million procedures performed annually in the United States, data from the Centers for Disease Control and Prevention indicate. Previous research has linked obesity—as well as type of procedure, patient comorbidity, immunosuppression, and cigarette smoking—to an increased risk of such infections (Dis. Colon Rectum 2007;50:2223-37; J. Cardiovasc. Surg. 2007;48:641-6).

In the initial cohort of 194 patients in this study, Harvard medical student Emily Waisbren and her associates in the departments of anesthesiology and surgery at Brigham and Women's Hospital in Boston measured percent body fat using bioelectrical impedance analysis and body mass index (BMI) using the standard height and weight formula.

Patients ranged in age from 18 years to 64 years (mean age, 49), and 66% were women. The mean BMI was 29.5 kg/m

A total of 130 patients (67%) were obese according to the body fat criterion, compared with 74 (38%) using the BMI definition.

Participants were assessed before, during, and 30 days after elective surgery (primarily general, orthopedic, and obstetric procedures) on the basis of medical records, questionnaires, and follow-up telephone interviews. A total of 31% of the patients were taking antihypertensive medication, and 18% were current smokers. Most patients had an American Society of Anesthesiologists (ASA) score of 2, “so they were relatively healthy,” Ms. Waisbren said.

SSIs developed in 27 patients (14%). According to the percent body fat cutoffs, infections occurred in 4.7% of nonobese patients and in 18.5% of obese patients. In contrast, when the BMI cutoff was used, 14.2% of the nonobese and 13.5% of obese patients developed SSIs.

As percent body fat increased, there was a statistically significant increase in SSIs. For example, patients with percent body fat greater than 37% were two times more likely to develop an SSI, Ms. Waisbren said. “An association with increased SSI risk was seen with BMI also, but it was not statistically significant.”

Although there were no deaths related to these infections, Ms. Waisbren said that patients with an SSI experienced more adverse outcomes, including wound dehiscence, seroma, and hematoma, than did those without infections.

A meeting attendee asked if patients were possibly overlabeled as obese because two-thirds met the percent body fat definition. “There have been very little data to define the cutoff point,” Ms. Waisbren said. “But you raise the point of how appropriate the American Council on Exercise definition is.”

When a meeting attendee asked why the hip-to-waist ratio was not assessed, Ms. Waisbren said the investigators believed BMI was more accurate than hip-to-waist ratio.

However, she said, “BMI misses an important difference in body composition.” For example, a male body builder and an overweight woman with the same height and weight would have the same BMI, but very different body fat percentages.

Percent body fat was an independent predictor of SSI, according to a univariate analysis. Pedal edema, recent surgery, higher National Nosocomial Infection Surveillance score, and class 2 (clean-contaminated) or higher wound ratings were other predictors.

A multivariate assessment is planned as part of the ongoing study, Ms. Waisbren said.

This study was awarded the best research abstract at the meeting. Data collected for a total of 436 patients in this ongoing study concur with the initial cohort findings, Ms. Waisbren said.

She added that the plan is to enroll 600 elective surgery patients in the final assessment.

MIAMI BEACH — Preoperative percent body fat is an independent predictor of surgical site infection risk and is a more accurate way to define obesity than is body mass index, according to preliminary results of a prospective, ongoing trial.

Surgical site infections (SSIs) develop in an estimated 290,000 of the 27 million procedures performed annually in the United States, data from the Centers for Disease Control and Prevention indicate. Previous research has linked obesity—as well as type of procedure, patient comorbidity, immunosuppression, and cigarette smoking—to an increased risk of such infections (Dis. Colon Rectum 2007;50:2223-37; J. Cardiovasc. Surg. 2007;48:641-6).

In the initial cohort of 194 patients in this study, Harvard medical student Emily Waisbren and her associates in the departments of anesthesiology and surgery at Brigham and Women's Hospital in Boston measured percent body fat using bioelectrical impedance analysis and body mass index (BMI) using the standard height and weight formula.

Patients ranged in age from 18 years to 64 years (mean age, 49), and 66% were women. The mean BMI was 29.5 kg/m

A total of 130 patients (67%) were obese according to the body fat criterion, compared with 74 (38%) using the BMI definition.

Participants were assessed before, during, and 30 days after elective surgery (primarily general, orthopedic, and obstetric procedures) on the basis of medical records, questionnaires, and follow-up telephone interviews. A total of 31% of the patients were taking antihypertensive medication, and 18% were current smokers. Most patients had an American Society of Anesthesiologists (ASA) score of 2, “so they were relatively healthy,” Ms. Waisbren said.

SSIs developed in 27 patients (14%). According to the percent body fat cutoffs, infections occurred in 4.7% of nonobese patients and in 18.5% of obese patients. In contrast, when the BMI cutoff was used, 14.2% of the nonobese and 13.5% of obese patients developed SSIs.

As percent body fat increased, there was a statistically significant increase in SSIs. For example, patients with percent body fat greater than 37% were two times more likely to develop an SSI, Ms. Waisbren said. “An association with increased SSI risk was seen with BMI also, but it was not statistically significant.”

Although there were no deaths related to these infections, Ms. Waisbren said that patients with an SSI experienced more adverse outcomes, including wound dehiscence, seroma, and hematoma, than did those without infections.

A meeting attendee asked if patients were possibly overlabeled as obese because two-thirds met the percent body fat definition. “There have been very little data to define the cutoff point,” Ms. Waisbren said. “But you raise the point of how appropriate the American Council on Exercise definition is.”

When a meeting attendee asked why the hip-to-waist ratio was not assessed, Ms. Waisbren said the investigators believed BMI was more accurate than hip-to-waist ratio.

However, she said, “BMI misses an important difference in body composition.” For example, a male body builder and an overweight woman with the same height and weight would have the same BMI, but very different body fat percentages.

Percent body fat was an independent predictor of SSI, according to a univariate analysis. Pedal edema, recent surgery, higher National Nosocomial Infection Surveillance score, and class 2 (clean-contaminated) or higher wound ratings were other predictors.

A multivariate assessment is planned as part of the ongoing study, Ms. Waisbren said.

This study was awarded the best research abstract at the meeting. Data collected for a total of 436 patients in this ongoing study concur with the initial cohort findings, Ms. Waisbren said.

She added that the plan is to enroll 600 elective surgery patients in the final assessment.

MIAMI BEACH — Preoperative percent body fat is an independent predictor of surgical site infection risk and is a more accurate way to define obesity than is body mass index, according to preliminary results of a prospective, ongoing trial.

Surgical site infections (SSIs) develop in an estimated 290,000 of the 27 million procedures performed annually in the United States, data from the Centers for Disease Control and Prevention indicate. Previous research has linked obesity—as well as type of procedure, patient comorbidity, immunosuppression, and cigarette smoking—to an increased risk of such infections (Dis. Colon Rectum 2007;50:2223-37; J. Cardiovasc. Surg. 2007;48:641-6).

In the initial cohort of 194 patients in this study, Harvard medical student Emily Waisbren and her associates in the departments of anesthesiology and surgery at Brigham and Women's Hospital in Boston measured percent body fat using bioelectrical impedance analysis and body mass index (BMI) using the standard height and weight formula.

Patients ranged in age from 18 years to 64 years (mean age, 49), and 66% were women. The mean BMI was 29.5 kg/m

A total of 130 patients (67%) were obese according to the body fat criterion, compared with 74 (38%) using the BMI definition.

Participants were assessed before, during, and 30 days after elective surgery (primarily general, orthopedic, and obstetric procedures) on the basis of medical records, questionnaires, and follow-up telephone interviews. A total of 31% of the patients were taking antihypertensive medication, and 18% were current smokers. Most patients had an American Society of Anesthesiologists (ASA) score of 2, “so they were relatively healthy,” Ms. Waisbren said.

SSIs developed in 27 patients (14%). According to the percent body fat cutoffs, infections occurred in 4.7% of nonobese patients and in 18.5% of obese patients. In contrast, when the BMI cutoff was used, 14.2% of the nonobese and 13.5% of obese patients developed SSIs.

As percent body fat increased, there was a statistically significant increase in SSIs. For example, patients with percent body fat greater than 37% were two times more likely to develop an SSI, Ms. Waisbren said. “An association with increased SSI risk was seen with BMI also, but it was not statistically significant.”

Although there were no deaths related to these infections, Ms. Waisbren said that patients with an SSI experienced more adverse outcomes, including wound dehiscence, seroma, and hematoma, than did those without infections.

A meeting attendee asked if patients were possibly overlabeled as obese because two-thirds met the percent body fat definition. “There have been very little data to define the cutoff point,” Ms. Waisbren said. “But you raise the point of how appropriate the American Council on Exercise definition is.”

When a meeting attendee asked why the hip-to-waist ratio was not assessed, Ms. Waisbren said the investigators believed BMI was more accurate than hip-to-waist ratio.

However, she said, “BMI misses an important difference in body composition.” For example, a male body builder and an overweight woman with the same height and weight would have the same BMI, but very different body fat percentages.

Percent body fat was an independent predictor of SSI, according to a univariate analysis. Pedal edema, recent surgery, higher National Nosocomial Infection Surveillance score, and class 2 (clean-contaminated) or higher wound ratings were other predictors.

A multivariate assessment is planned as part of the ongoing study, Ms. Waisbren said.

This study was awarded the best research abstract at the meeting. Data collected for a total of 436 patients in this ongoing study concur with the initial cohort findings, Ms. Waisbren said.

She added that the plan is to enroll 600 elective surgery patients in the final assessment.

MIAMI BEACH — Patients taking most antihypertensive medications the morning of surgery are not at higher risk for hypotension or more vasopressor use during the perioperative period, according to a retrospective study.

However, significantly more patients taking an angiotensin-converting enzyme inhibitor experienced these events, and there was a higher incidence among those taking an angiotensin-receptor blocker as well.

“We think they should withhold ACE inhibitors and angiotensin-receptor blockers [ARBs]” on the morning of surgery, Dr. Matthieu Touchette said in an interview.

Dr. Touchette and his colleagues compared 371 patients with a diagnosis of hypertension evaluated in the preoperative clinic within the department of medicine at the University of Sherbrooke Central Hospital in Quebec.

All patients had elective surgery and a hospital length of stay longer than 1 day between November 2005 and November 2006. The researchers compared 91 patients who did not take their antihypertensive medication on the morning of surgery with 280 patients who did.

Their aim was to compare hypotensive episodes and use of vasopressors during the perioperative period between these groups. Results were presented in a poster at a meeting on perioperative medicine sponsored by the University of Miami.

Although the guidelines from the American College of Cardiology and the American Heart Association on antihypertensive medications suggest withholding ACE inhibitors and ARBs on the morning of surgery (Circulation 2007;116:e418-99), “we wanted to check if all hypertensive medications make a difference—do they really change” the perioperative course? said Dr. Touchette, an internist at the University of Sherbrooke Central Hospital.

The mean age of the patients was 67 years in the medicine group (43% men) and 69 years in the no-medicine group (54% men). There was more hypertension during preoperative evaluation in the medicine group (91%) than in the no-medicine group (81%). A lower proportion of patients in the medicine group had cardiovascular disease (24% vs. 46%), dyslipidemia (51% vs. 71%), and atrial fibrillation/flutter (7% vs. 21%).

The type of medication that patients were taking at the time of the preoperative clinical evaluation, not surprisingly, corresponded with these diagnoses. For example, more patients in the medicine group were taking diuretics (56% vs. 43%). In contrast, a higher proportion of patients who did not take hypertensives before surgery were on beta-blockers (54% vs. 23%), calcium channel blockers (48% vs. 25%), and nitroglycerin (9% vs. 2%).

“We found, and it's very interesting, that whether we give pills or not, many people have hypotension during surgery,” Dr. Touchette said.

Hypotension, defined as systolic blood pressure less than 90 mm Hg, occurred in 58% of the medicine group and 46% of the no-medicine group. “We were surprised how many of our patients have hypotensive episodes during surgery. I am an internist—so I am not usually in the OR.”

Despite a high incidence of perioperative hypotension, Dr. Touchette and his colleagues found no significant difference between groups. “There was no overall difference if we look at all the medications as one big bag,” he said.

They also found no significant difference in perioperative use of vasopressors between those who took their antihypertensive the morning of surgery (71%) and those who did not (79%).

However, “when we looked at individual drugs, the ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period,” Dr. Touchette said. Among the patients taking medication on the morning of surgery, there was a statistically significant increased association between perioperative hypotension or vasopressor use if they took an ACE inhibitor (adjusted odds ratio, 2.36), compared with those who did not take this type of medication.

Similarly, patients taking an ARB just before surgery had an increased risk for these two factors, although it was not statistically different (adjusted OR, 2.38).

In contrast, there was a lower risk among patients taking a calcium channel blocker on the morning of surgery (adjusted OR, 0.73), a diuretic (OR, 0.83), or a beta-blocker (OR, 0.89).

Dr. Touchette said that in the future they “would like to try to reproduce the study in a prospective manner.”

'ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period.' DR. TOUCHETTE

MIAMI BEACH — Patients taking most antihypertensive medications the morning of surgery are not at higher risk for hypotension or more vasopressor use during the perioperative period, according to a retrospective study.

However, significantly more patients taking an angiotensin-converting enzyme inhibitor experienced these events, and there was a higher incidence among those taking an angiotensin-receptor blocker as well.

“We think they should withhold ACE inhibitors and angiotensin-receptor blockers [ARBs]” on the morning of surgery, Dr. Matthieu Touchette said in an interview.

Dr. Touchette and his colleagues compared 371 patients with a diagnosis of hypertension evaluated in the preoperative clinic within the department of medicine at the University of Sherbrooke Central Hospital in Quebec.

All patients had elective surgery and a hospital length of stay longer than 1 day between November 2005 and November 2006. The researchers compared 91 patients who did not take their antihypertensive medication on the morning of surgery with 280 patients who did.

Their aim was to compare hypotensive episodes and use of vasopressors during the perioperative period between these groups. Results were presented in a poster at a meeting on perioperative medicine sponsored by the University of Miami.

Although the guidelines from the American College of Cardiology and the American Heart Association on antihypertensive medications suggest withholding ACE inhibitors and ARBs on the morning of surgery (Circulation 2007;116:e418-99), “we wanted to check if all hypertensive medications make a difference—do they really change” the perioperative course? said Dr. Touchette, an internist at the University of Sherbrooke Central Hospital.

The mean age of the patients was 67 years in the medicine group (43% men) and 69 years in the no-medicine group (54% men). There was more hypertension during preoperative evaluation in the medicine group (91%) than in the no-medicine group (81%). A lower proportion of patients in the medicine group had cardiovascular disease (24% vs. 46%), dyslipidemia (51% vs. 71%), and atrial fibrillation/flutter (7% vs. 21%).

The type of medication that patients were taking at the time of the preoperative clinical evaluation, not surprisingly, corresponded with these diagnoses. For example, more patients in the medicine group were taking diuretics (56% vs. 43%). In contrast, a higher proportion of patients who did not take hypertensives before surgery were on beta-blockers (54% vs. 23%), calcium channel blockers (48% vs. 25%), and nitroglycerin (9% vs. 2%).

“We found, and it's very interesting, that whether we give pills or not, many people have hypotension during surgery,” Dr. Touchette said.

Hypotension, defined as systolic blood pressure less than 90 mm Hg, occurred in 58% of the medicine group and 46% of the no-medicine group. “We were surprised how many of our patients have hypotensive episodes during surgery. I am an internist—so I am not usually in the OR.”

Despite a high incidence of perioperative hypotension, Dr. Touchette and his colleagues found no significant difference between groups. “There was no overall difference if we look at all the medications as one big bag,” he said.

They also found no significant difference in perioperative use of vasopressors between those who took their antihypertensive the morning of surgery (71%) and those who did not (79%).

However, “when we looked at individual drugs, the ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period,” Dr. Touchette said. Among the patients taking medication on the morning of surgery, there was a statistically significant increased association between perioperative hypotension or vasopressor use if they took an ACE inhibitor (adjusted odds ratio, 2.36), compared with those who did not take this type of medication.

Similarly, patients taking an ARB just before surgery had an increased risk for these two factors, although it was not statistically different (adjusted OR, 2.38).

In contrast, there was a lower risk among patients taking a calcium channel blocker on the morning of surgery (adjusted OR, 0.73), a diuretic (OR, 0.83), or a beta-blocker (OR, 0.89).

Dr. Touchette said that in the future they “would like to try to reproduce the study in a prospective manner.”

'ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period.' DR. TOUCHETTE

MIAMI BEACH — Patients taking most antihypertensive medications the morning of surgery are not at higher risk for hypotension or more vasopressor use during the perioperative period, according to a retrospective study.

However, significantly more patients taking an angiotensin-converting enzyme inhibitor experienced these events, and there was a higher incidence among those taking an angiotensin-receptor blocker as well.

“We think they should withhold ACE inhibitors and angiotensin-receptor blockers [ARBs]” on the morning of surgery, Dr. Matthieu Touchette said in an interview.

Dr. Touchette and his colleagues compared 371 patients with a diagnosis of hypertension evaluated in the preoperative clinic within the department of medicine at the University of Sherbrooke Central Hospital in Quebec.

All patients had elective surgery and a hospital length of stay longer than 1 day between November 2005 and November 2006. The researchers compared 91 patients who did not take their antihypertensive medication on the morning of surgery with 280 patients who did.

Their aim was to compare hypotensive episodes and use of vasopressors during the perioperative period between these groups. Results were presented in a poster at a meeting on perioperative medicine sponsored by the University of Miami.

Although the guidelines from the American College of Cardiology and the American Heart Association on antihypertensive medications suggest withholding ACE inhibitors and ARBs on the morning of surgery (Circulation 2007;116:e418-99), “we wanted to check if all hypertensive medications make a difference—do they really change” the perioperative course? said Dr. Touchette, an internist at the University of Sherbrooke Central Hospital.

The mean age of the patients was 67 years in the medicine group (43% men) and 69 years in the no-medicine group (54% men). There was more hypertension during preoperative evaluation in the medicine group (91%) than in the no-medicine group (81%). A lower proportion of patients in the medicine group had cardiovascular disease (24% vs. 46%), dyslipidemia (51% vs. 71%), and atrial fibrillation/flutter (7% vs. 21%).

The type of medication that patients were taking at the time of the preoperative clinical evaluation, not surprisingly, corresponded with these diagnoses. For example, more patients in the medicine group were taking diuretics (56% vs. 43%). In contrast, a higher proportion of patients who did not take hypertensives before surgery were on beta-blockers (54% vs. 23%), calcium channel blockers (48% vs. 25%), and nitroglycerin (9% vs. 2%).

“We found, and it's very interesting, that whether we give pills or not, many people have hypotension during surgery,” Dr. Touchette said.

Hypotension, defined as systolic blood pressure less than 90 mm Hg, occurred in 58% of the medicine group and 46% of the no-medicine group. “We were surprised how many of our patients have hypotensive episodes during surgery. I am an internist—so I am not usually in the OR.”

Despite a high incidence of perioperative hypotension, Dr. Touchette and his colleagues found no significant difference between groups. “There was no overall difference if we look at all the medications as one big bag,” he said.

They also found no significant difference in perioperative use of vasopressors between those who took their antihypertensive the morning of surgery (71%) and those who did not (79%).

However, “when we looked at individual drugs, the ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period,” Dr. Touchette said. Among the patients taking medication on the morning of surgery, there was a statistically significant increased association between perioperative hypotension or vasopressor use if they took an ACE inhibitor (adjusted odds ratio, 2.36), compared with those who did not take this type of medication.

Similarly, patients taking an ARB just before surgery had an increased risk for these two factors, although it was not statistically different (adjusted OR, 2.38).

In contrast, there was a lower risk among patients taking a calcium channel blocker on the morning of surgery (adjusted OR, 0.73), a diuretic (OR, 0.83), or a beta-blocker (OR, 0.89).

Dr. Touchette said that in the future they “would like to try to reproduce the study in a prospective manner.”

'ACE inhibitors and ARBs were associated with more hypotensive episodes in the perioperative period.' DR. TOUCHETTE

FORT MYERS, FLA. — The difference between successful and unsuccessful treatment of patients for postsurgical complications may help account for the wide variability in mortality rates following major surgery at hospitals nationwide, according to a retrospective study of data for more than 12,000 patients.

“High-mortality hospitals have mortality rates similar to those of low-mortality hospitals but markedly higher failure-to-rescue rates,” Dr. Amir A. Ghaferi said at the annual Academic Surgical Congress.

The failure-to-rescue rate (i.e., mortality following the development of a postsurgical complication) for high-mortality hospitals was more than twice that for low-mortality hospitals—26% versus 11%, respectively. “When we evaluated individual complications, this trend persisted,” said Dr. Ghaferi, a surgical resident at the University of Michigan, Ann Arbor.

Wide variability in mortality rates following major surgery has been noted previously. Dr. Ghaferi and his coinvestigators hypothesized that hospitals with higher mortality rates are less effective than low-mortality hospitals in rescuing patients, once they develop complications, and that this could account for some of the variability.

To test their hypothesis, they analyzed data from the American College of Surgeons' National Surgical Quality Improvement Program for all patients undergoing colectomy in 2005-2006. Data were available for 12,688 patients. Primary outcomes included 30-day mortality, the development of one of nine major postoperative complications (pneumonia, unplanned intubation, pulmonary embolism, myocardial infarction, acute renal failure, postoperative bleeding, deep wound infection, organ-space infection, and fascial dehiscence), and the mortality rates following each of these complications.

In all, 123 hospitals were grouped into quintiles by their risk-adjusted mortality rates. The investigators controlled 27 variables in the risk-adjustment model, including age, sex, race, and American Society of Anesthesiologists physical status classification. Risk-adjusted mortality rates ranged from 1.5% to 7.4% across the groups. Next, they compared complication rates for the nine common postoperative complications across the groups, as well as failure-to-rescue rates (i.e., rates of death caused by any of the nine postoperative complications).

A total of 51% of patients were female, and most (81%) were white, with a mean body mass index of 27 kg/m

High-mortality hospitals had a 1.5-fold greater risk of postsurgical complications: 16.2% in the high-mortality group, compared with 12.7% in the low-mortality group. “This cannot explain the nearly threefold mortality rate difference across our hospitals. However, when we looked at the failure-to-rescue rate, there's an astonishing difference,” he said.

“Many existing policies, which are aimed at reducing the incidence of complications, may not be able to reduce this observed variation in mortality. Rather, we may need to focus on the timely recognition and management of complications once they occur. The next step will be to develop a better understanding of the hospital resources and processes of care that lead to rescue from postsurgical complications.”

Dr. Ghaferi reported that he has no relevant financial relationships.

FORT MYERS, FLA. — The difference between successful and unsuccessful treatment of patients for postsurgical complications may help account for the wide variability in mortality rates following major surgery at hospitals nationwide, according to a retrospective study of data for more than 12,000 patients.

“High-mortality hospitals have mortality rates similar to those of low-mortality hospitals but markedly higher failure-to-rescue rates,” Dr. Amir A. Ghaferi said at the annual Academic Surgical Congress.

The failure-to-rescue rate (i.e., mortality following the development of a postsurgical complication) for high-mortality hospitals was more than twice that for low-mortality hospitals—26% versus 11%, respectively. “When we evaluated individual complications, this trend persisted,” said Dr. Ghaferi, a surgical resident at the University of Michigan, Ann Arbor.

Wide variability in mortality rates following major surgery has been noted previously. Dr. Ghaferi and his coinvestigators hypothesized that hospitals with higher mortality rates are less effective than low-mortality hospitals in rescuing patients, once they develop complications, and that this could account for some of the variability.

To test their hypothesis, they analyzed data from the American College of Surgeons' National Surgical Quality Improvement Program for all patients undergoing colectomy in 2005-2006. Data were available for 12,688 patients. Primary outcomes included 30-day mortality, the development of one of nine major postoperative complications (pneumonia, unplanned intubation, pulmonary embolism, myocardial infarction, acute renal failure, postoperative bleeding, deep wound infection, organ-space infection, and fascial dehiscence), and the mortality rates following each of these complications.

In all, 123 hospitals were grouped into quintiles by their risk-adjusted mortality rates. The investigators controlled 27 variables in the risk-adjustment model, including age, sex, race, and American Society of Anesthesiologists physical status classification. Risk-adjusted mortality rates ranged from 1.5% to 7.4% across the groups. Next, they compared complication rates for the nine common postoperative complications across the groups, as well as failure-to-rescue rates (i.e., rates of death caused by any of the nine postoperative complications).

A total of 51% of patients were female, and most (81%) were white, with a mean body mass index of 27 kg/m

High-mortality hospitals had a 1.5-fold greater risk of postsurgical complications: 16.2% in the high-mortality group, compared with 12.7% in the low-mortality group. “This cannot explain the nearly threefold mortality rate difference across our hospitals. However, when we looked at the failure-to-rescue rate, there's an astonishing difference,” he said.

“Many existing policies, which are aimed at reducing the incidence of complications, may not be able to reduce this observed variation in mortality. Rather, we may need to focus on the timely recognition and management of complications once they occur. The next step will be to develop a better understanding of the hospital resources and processes of care that lead to rescue from postsurgical complications.”

Dr. Ghaferi reported that he has no relevant financial relationships.

FORT MYERS, FLA. — The difference between successful and unsuccessful treatment of patients for postsurgical complications may help account for the wide variability in mortality rates following major surgery at hospitals nationwide, according to a retrospective study of data for more than 12,000 patients.

“High-mortality hospitals have mortality rates similar to those of low-mortality hospitals but markedly higher failure-to-rescue rates,” Dr. Amir A. Ghaferi said at the annual Academic Surgical Congress.

The failure-to-rescue rate (i.e., mortality following the development of a postsurgical complication) for high-mortality hospitals was more than twice that for low-mortality hospitals—26% versus 11%, respectively. “When we evaluated individual complications, this trend persisted,” said Dr. Ghaferi, a surgical resident at the University of Michigan, Ann Arbor.

Wide variability in mortality rates following major surgery has been noted previously. Dr. Ghaferi and his coinvestigators hypothesized that hospitals with higher mortality rates are less effective than low-mortality hospitals in rescuing patients, once they develop complications, and that this could account for some of the variability.

To test their hypothesis, they analyzed data from the American College of Surgeons' National Surgical Quality Improvement Program for all patients undergoing colectomy in 2005-2006. Data were available for 12,688 patients. Primary outcomes included 30-day mortality, the development of one of nine major postoperative complications (pneumonia, unplanned intubation, pulmonary embolism, myocardial infarction, acute renal failure, postoperative bleeding, deep wound infection, organ-space infection, and fascial dehiscence), and the mortality rates following each of these complications.

In all, 123 hospitals were grouped into quintiles by their risk-adjusted mortality rates. The investigators controlled 27 variables in the risk-adjustment model, including age, sex, race, and American Society of Anesthesiologists physical status classification. Risk-adjusted mortality rates ranged from 1.5% to 7.4% across the groups. Next, they compared complication rates for the nine common postoperative complications across the groups, as well as failure-to-rescue rates (i.e., rates of death caused by any of the nine postoperative complications).

A total of 51% of patients were female, and most (81%) were white, with a mean body mass index of 27 kg/m

High-mortality hospitals had a 1.5-fold greater risk of postsurgical complications: 16.2% in the high-mortality group, compared with 12.7% in the low-mortality group. “This cannot explain the nearly threefold mortality rate difference across our hospitals. However, when we looked at the failure-to-rescue rate, there's an astonishing difference,” he said.

“Many existing policies, which are aimed at reducing the incidence of complications, may not be able to reduce this observed variation in mortality. Rather, we may need to focus on the timely recognition and management of complications once they occur. The next step will be to develop a better understanding of the hospital resources and processes of care that lead to rescue from postsurgical complications.”

Dr. Ghaferi reported that he has no relevant financial relationships.

The use of a simple safety checklist dramatically reduced mortality and morbidity in a study of more than 7,600 consecutive surgery patients in diverse clinical settings around the world.

The 19-item checklist, which was based on the 2008 World Health Organization guidelines for improving the safety of surgical patients, cut the rate of postoperative complications by 36% on average, “and death rates fell by a similar amount,” said Dr. Alex B. Haynes of the Harvard School of Public Health, Boston, and his associates in the Safe Surgery Saves Lives study.

The overall complication rate decreased from 11% at baseline to 7% after introduction of the checklist, and in-hospital mortality decreased from 1.5% to 0.8%. Overall rates of surgical site infection and unplanned reoperation also markedly declined.

“Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications,” the investigators noted.

The medical literature suggests that at least half of all surgical complications are avoidable. The investigators designed the checklist and assessed its use in a prospective study at eight hospitals in North America, Europe, Asia, the Middle East, and Africa.

Each hospital identified one to four operating rooms to serve as study rooms. Consecutive inpatients undergoing noncardiac surgery in those rooms were enrolled. The 3,733 patients who underwent surgery during a baseline period served as a comparison group for the 3,955 patients who underwent surgery after implementation of the checklist.

“The checklist consists of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery,” and is used before anesthesia is administered, immediately before incision, and before the patient is removed from the operating room, according to the investigators.

They evaluated adherence to a subgroup of six key safety measures as a gauge of overall adherence: objective assessment of the patient's airway status; use of pulse oximetry at initiation of anesthesia; presence of at least two peripheral IV lines or a central venous line before incision in cases where blood loss was expected to be 500 mL or more; administration of prophylactic antibiotics within 1 hour before incision; oral confirmation of the patient's identity, the operative site, and the procedure to be performed, before commencing; and completion of a sponge count at the end of the operation.

After the intervention was implemented, it was still commonplace for some of the 19 individual steps in the checklist to be omitted. However, adherence to the key safety indicators increased by two-thirds. Appropriate use of prophylactic antibiotics, for example, rose from 56% to 83%, a single change that could reduce the rate of surgical site infection by as much as 88%, Dr. Haynes and his associates noted.

These “substantial and robust” improvements were seen at every study site, at high-income as well as low-income locations, the investigators said (doi:10.1056/NEJMsa0810119).

Implementation of the checklist should be very feasible, since it was “neither costly nor lengthy. All sites were able to introduce the checklist over a period of 1 week to 1 month.” Moreover, only two items on the checklist were potentially expensive: the use of pulse oximetry and the use of prophylactic antibiotics. Both of these were available at all the study sites before the intervention but had not been used consistently, Dr. Haynes and his colleagues said.

The use of a simple safety checklist dramatically reduced mortality and morbidity in a study of more than 7,600 consecutive surgery patients in diverse clinical settings around the world.

The 19-item checklist, which was based on the 2008 World Health Organization guidelines for improving the safety of surgical patients, cut the rate of postoperative complications by 36% on average, “and death rates fell by a similar amount,” said Dr. Alex B. Haynes of the Harvard School of Public Health, Boston, and his associates in the Safe Surgery Saves Lives study.

The overall complication rate decreased from 11% at baseline to 7% after introduction of the checklist, and in-hospital mortality decreased from 1.5% to 0.8%. Overall rates of surgical site infection and unplanned reoperation also markedly declined.

“Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications,” the investigators noted.

The medical literature suggests that at least half of all surgical complications are avoidable. The investigators designed the checklist and assessed its use in a prospective study at eight hospitals in North America, Europe, Asia, the Middle East, and Africa.

Each hospital identified one to four operating rooms to serve as study rooms. Consecutive inpatients undergoing noncardiac surgery in those rooms were enrolled. The 3,733 patients who underwent surgery during a baseline period served as a comparison group for the 3,955 patients who underwent surgery after implementation of the checklist.

“The checklist consists of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery,” and is used before anesthesia is administered, immediately before incision, and before the patient is removed from the operating room, according to the investigators.

They evaluated adherence to a subgroup of six key safety measures as a gauge of overall adherence: objective assessment of the patient's airway status; use of pulse oximetry at initiation of anesthesia; presence of at least two peripheral IV lines or a central venous line before incision in cases where blood loss was expected to be 500 mL or more; administration of prophylactic antibiotics within 1 hour before incision; oral confirmation of the patient's identity, the operative site, and the procedure to be performed, before commencing; and completion of a sponge count at the end of the operation.

After the intervention was implemented, it was still commonplace for some of the 19 individual steps in the checklist to be omitted. However, adherence to the key safety indicators increased by two-thirds. Appropriate use of prophylactic antibiotics, for example, rose from 56% to 83%, a single change that could reduce the rate of surgical site infection by as much as 88%, Dr. Haynes and his associates noted.

These “substantial and robust” improvements were seen at every study site, at high-income as well as low-income locations, the investigators said (doi:10.1056/NEJMsa0810119).

Implementation of the checklist should be very feasible, since it was “neither costly nor lengthy. All sites were able to introduce the checklist over a period of 1 week to 1 month.” Moreover, only two items on the checklist were potentially expensive: the use of pulse oximetry and the use of prophylactic antibiotics. Both of these were available at all the study sites before the intervention but had not been used consistently, Dr. Haynes and his colleagues said.

The use of a simple safety checklist dramatically reduced mortality and morbidity in a study of more than 7,600 consecutive surgery patients in diverse clinical settings around the world.

The 19-item checklist, which was based on the 2008 World Health Organization guidelines for improving the safety of surgical patients, cut the rate of postoperative complications by 36% on average, “and death rates fell by a similar amount,” said Dr. Alex B. Haynes of the Harvard School of Public Health, Boston, and his associates in the Safe Surgery Saves Lives study.

The overall complication rate decreased from 11% at baseline to 7% after introduction of the checklist, and in-hospital mortality decreased from 1.5% to 0.8%. Overall rates of surgical site infection and unplanned reoperation also markedly declined.

“Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications,” the investigators noted.

The medical literature suggests that at least half of all surgical complications are avoidable. The investigators designed the checklist and assessed its use in a prospective study at eight hospitals in North America, Europe, Asia, the Middle East, and Africa.

Each hospital identified one to four operating rooms to serve as study rooms. Consecutive inpatients undergoing noncardiac surgery in those rooms were enrolled. The 3,733 patients who underwent surgery during a baseline period served as a comparison group for the 3,955 patients who underwent surgery after implementation of the checklist.

“The checklist consists of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery,” and is used before anesthesia is administered, immediately before incision, and before the patient is removed from the operating room, according to the investigators.

They evaluated adherence to a subgroup of six key safety measures as a gauge of overall adherence: objective assessment of the patient's airway status; use of pulse oximetry at initiation of anesthesia; presence of at least two peripheral IV lines or a central venous line before incision in cases where blood loss was expected to be 500 mL or more; administration of prophylactic antibiotics within 1 hour before incision; oral confirmation of the patient's identity, the operative site, and the procedure to be performed, before commencing; and completion of a sponge count at the end of the operation.

After the intervention was implemented, it was still commonplace for some of the 19 individual steps in the checklist to be omitted. However, adherence to the key safety indicators increased by two-thirds. Appropriate use of prophylactic antibiotics, for example, rose from 56% to 83%, a single change that could reduce the rate of surgical site infection by as much as 88%, Dr. Haynes and his associates noted.

These “substantial and robust” improvements were seen at every study site, at high-income as well as low-income locations, the investigators said (doi:10.1056/NEJMsa0810119).

Implementation of the checklist should be very feasible, since it was “neither costly nor lengthy. All sites were able to introduce the checklist over a period of 1 week to 1 month.” Moreover, only two items on the checklist were potentially expensive: the use of pulse oximetry and the use of prophylactic antibiotics. Both of these were available at all the study sites before the intervention but had not been used consistently, Dr. Haynes and his colleagues said.

PALM BEACH, FLA. — Helical multidetector computed tomography increases the detection of smaller segmental and subsegmental—but not central—pulmonary emboli following cancer surgery, according to the results of a database review.

In the study of almost 300 cancer surgery patients at a single center, MDCT increased the detection of PEs fourfold because of the ability to diagnose subsegmental PEs. MDCT did not increase the detection of central PEs.

“Diagnosis of pulmonary embolism in most major hospitals has changed, mostly because of the MDCT scan,” said Dr. Yuman Fong, chair of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York, where the study was conducted. “There is increased sensitivity and the ability to get these scans much faster—in a single breath hold.”

MDCT has replaced ventilation/perfusion lung scans as the test of choice for detecting PE in most institutions, he noted at the annual meeting of the Southern Surgical Association.

Dr. Fong and his associates reviewed a prospective database of 47,601 patients who had abdominal, pelvic, thoracic, or soft-tissue major surgery at the cancer center. A total of 1,441 patients had a CT angiogram to rule out PE from January 2000 to December 2005. During this time, use of the contrast-enhanced, high-resolution MDCT scans of the chest within 30 days of surgery increased at the center from 5 per 1,000 patients in 2000 to 45 per 1,000 in 2005. The researchers sought to determine if patient outcomes changed as a result, said Dr. Fong, who is also vice chair of the technology department at the center.

They identified 311 patients who had a PE within 30 days of surgery. In all, 17 of the patients had a PE but no malignancy, and were excluded from the analysis; the remaining 294 cancer patients were assessed further.

The overall incidence of PE among cancer surgery patients increased from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 in 2005, a significant difference. This higher rate resulted from significantly greater diagnosis of subsegmental PEs, which increased from 0.1 per 1,000 patients in 2000 to 3 per 1,000 in 2005. At the same time, MDCT did not increase detection of central PEs, diagnosed in 0.7 per 1,000 patients in 2000 versus 0.6 per 1,000 in 2005.

Increased detection of subsegmental PEs with MDCT “makes sense because it's more sensitive,” Dr. Fong said. “Subsegmentals are harder to find with VQ [ventilation/perfusion] scan or single-detector CT.”

The researchers also looked at mortality. The annual incidence rate of fatal PE did not change during the study, remaining at 0.4 per 1,000. Not surprisingly, the 30-day mortality rate for patients with the more serious central PE was higher, at 44%, compared with 6% for patients with subsegmental PE. Those with central PE “were more likely to go to the ICU, have cardiopulmonary arrest, and die in the hospital,” Dr. Fong said.

More than half of the central PE group was symptomatic, whereas “only a few of the peripheral PEs were severely symptomatic,” Dr. Fong said. Shortness of breath, hypoxia, and an elevated heart rate (more than 100 beats per minute) were more common among central PE patients.

All 294 cancer patients with PE were treated with anticoagulants. Of these, 40 patients (14%) developed complications from the treatment. “Given a 14% complication rate with anticoagulation, are we putting some patients at increased risk?” asked Dr. Robert C.G. Martin, a surgical oncologist at the University of Louisville (Ky.).

“At Memorial Sloan-Kettering, when we discover a PE, whether or not it's central, we anticoagulate them,” Dr. Fong replied. “Surgeons put the patients on [anticoagulants,] and then the oncologists are generally afraid to take folks off anticoagulants, so they remain on semipermanent anticoagulation.” There is a balance to strike between a higher risk of complications and the lower likelihood of metastasizing cancer cells circulating in the blood “being able to stick,” he added.

PALM BEACH, FLA. — Helical multidetector computed tomography increases the detection of smaller segmental and subsegmental—but not central—pulmonary emboli following cancer surgery, according to the results of a database review.

In the study of almost 300 cancer surgery patients at a single center, MDCT increased the detection of PEs fourfold because of the ability to diagnose subsegmental PEs. MDCT did not increase the detection of central PEs.

“Diagnosis of pulmonary embolism in most major hospitals has changed, mostly because of the MDCT scan,” said Dr. Yuman Fong, chair of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York, where the study was conducted. “There is increased sensitivity and the ability to get these scans much faster—in a single breath hold.”

MDCT has replaced ventilation/perfusion lung scans as the test of choice for detecting PE in most institutions, he noted at the annual meeting of the Southern Surgical Association.

Dr. Fong and his associates reviewed a prospective database of 47,601 patients who had abdominal, pelvic, thoracic, or soft-tissue major surgery at the cancer center. A total of 1,441 patients had a CT angiogram to rule out PE from January 2000 to December 2005. During this time, use of the contrast-enhanced, high-resolution MDCT scans of the chest within 30 days of surgery increased at the center from 5 per 1,000 patients in 2000 to 45 per 1,000 in 2005. The researchers sought to determine if patient outcomes changed as a result, said Dr. Fong, who is also vice chair of the technology department at the center.

They identified 311 patients who had a PE within 30 days of surgery. In all, 17 of the patients had a PE but no malignancy, and were excluded from the analysis; the remaining 294 cancer patients were assessed further.

The overall incidence of PE among cancer surgery patients increased from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 in 2005, a significant difference. This higher rate resulted from significantly greater diagnosis of subsegmental PEs, which increased from 0.1 per 1,000 patients in 2000 to 3 per 1,000 in 2005. At the same time, MDCT did not increase detection of central PEs, diagnosed in 0.7 per 1,000 patients in 2000 versus 0.6 per 1,000 in 2005.

Increased detection of subsegmental PEs with MDCT “makes sense because it's more sensitive,” Dr. Fong said. “Subsegmentals are harder to find with VQ [ventilation/perfusion] scan or single-detector CT.”

The researchers also looked at mortality. The annual incidence rate of fatal PE did not change during the study, remaining at 0.4 per 1,000. Not surprisingly, the 30-day mortality rate for patients with the more serious central PE was higher, at 44%, compared with 6% for patients with subsegmental PE. Those with central PE “were more likely to go to the ICU, have cardiopulmonary arrest, and die in the hospital,” Dr. Fong said.

More than half of the central PE group was symptomatic, whereas “only a few of the peripheral PEs were severely symptomatic,” Dr. Fong said. Shortness of breath, hypoxia, and an elevated heart rate (more than 100 beats per minute) were more common among central PE patients.

All 294 cancer patients with PE were treated with anticoagulants. Of these, 40 patients (14%) developed complications from the treatment. “Given a 14% complication rate with anticoagulation, are we putting some patients at increased risk?” asked Dr. Robert C.G. Martin, a surgical oncologist at the University of Louisville (Ky.).

“At Memorial Sloan-Kettering, when we discover a PE, whether or not it's central, we anticoagulate them,” Dr. Fong replied. “Surgeons put the patients on [anticoagulants,] and then the oncologists are generally afraid to take folks off anticoagulants, so they remain on semipermanent anticoagulation.” There is a balance to strike between a higher risk of complications and the lower likelihood of metastasizing cancer cells circulating in the blood “being able to stick,” he added.

PALM BEACH, FLA. — Helical multidetector computed tomography increases the detection of smaller segmental and subsegmental—but not central—pulmonary emboli following cancer surgery, according to the results of a database review.

In the study of almost 300 cancer surgery patients at a single center, MDCT increased the detection of PEs fourfold because of the ability to diagnose subsegmental PEs. MDCT did not increase the detection of central PEs.

“Diagnosis of pulmonary embolism in most major hospitals has changed, mostly because of the MDCT scan,” said Dr. Yuman Fong, chair of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York, where the study was conducted. “There is increased sensitivity and the ability to get these scans much faster—in a single breath hold.”

MDCT has replaced ventilation/perfusion lung scans as the test of choice for detecting PE in most institutions, he noted at the annual meeting of the Southern Surgical Association.

Dr. Fong and his associates reviewed a prospective database of 47,601 patients who had abdominal, pelvic, thoracic, or soft-tissue major surgery at the cancer center. A total of 1,441 patients had a CT angiogram to rule out PE from January 2000 to December 2005. During this time, use of the contrast-enhanced, high-resolution MDCT scans of the chest within 30 days of surgery increased at the center from 5 per 1,000 patients in 2000 to 45 per 1,000 in 2005. The researchers sought to determine if patient outcomes changed as a result, said Dr. Fong, who is also vice chair of the technology department at the center.

They identified 311 patients who had a PE within 30 days of surgery. In all, 17 of the patients had a PE but no malignancy, and were excluded from the analysis; the remaining 294 cancer patients were assessed further.

The overall incidence of PE among cancer surgery patients increased from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 in 2005, a significant difference. This higher rate resulted from significantly greater diagnosis of subsegmental PEs, which increased from 0.1 per 1,000 patients in 2000 to 3 per 1,000 in 2005. At the same time, MDCT did not increase detection of central PEs, diagnosed in 0.7 per 1,000 patients in 2000 versus 0.6 per 1,000 in 2005.

Increased detection of subsegmental PEs with MDCT “makes sense because it's more sensitive,” Dr. Fong said. “Subsegmentals are harder to find with VQ [ventilation/perfusion] scan or single-detector CT.”

The researchers also looked at mortality. The annual incidence rate of fatal PE did not change during the study, remaining at 0.4 per 1,000. Not surprisingly, the 30-day mortality rate for patients with the more serious central PE was higher, at 44%, compared with 6% for patients with subsegmental PE. Those with central PE “were more likely to go to the ICU, have cardiopulmonary arrest, and die in the hospital,” Dr. Fong said.

More than half of the central PE group was symptomatic, whereas “only a few of the peripheral PEs were severely symptomatic,” Dr. Fong said. Shortness of breath, hypoxia, and an elevated heart rate (more than 100 beats per minute) were more common among central PE patients.

All 294 cancer patients with PE were treated with anticoagulants. Of these, 40 patients (14%) developed complications from the treatment. “Given a 14% complication rate with anticoagulation, are we putting some patients at increased risk?” asked Dr. Robert C.G. Martin, a surgical oncologist at the University of Louisville (Ky.).

“At Memorial Sloan-Kettering, when we discover a PE, whether or not it's central, we anticoagulate them,” Dr. Fong replied. “Surgeons put the patients on [anticoagulants,] and then the oncologists are generally afraid to take folks off anticoagulants, so they remain on semipermanent anticoagulation.” There is a balance to strike between a higher risk of complications and the lower likelihood of metastasizing cancer cells circulating in the blood “being able to stick,” he added.

ORLANDO — Patients on proton pump inhibitor therapy before abdominal cancer surgery were four times more likely to have postoperative infections than were those not taking such medication, according to a prospective, observational study.

Patients taking preoperative proton pump inhibitors (PPIs) also had significantly elevated serum levels of tumor necrosis factor (TNF)-α before and immediately after hemihepatectomy, as well as the day after surgery. Pneumonia and wound infections made up the majority of postoperative infections in the PPI group.

“There is evidence that PPIs have an effect on the immune system, especially TNF-α,” Dr. Felix Kork said in an interview. Other researchers have shown that TNF-α impairs the immune system (J. Gastrointest. Surg. 2007;11:1506–14), yet the exact mechanism of interaction between PPI use and this cytokine remains unknown. Inflammation could play a role, particularly with postoperative pneumonia, he added.

These findings from patients at Charité Medical University of Berlin need to be confirmed before physicians consider preoperative suspension of PPIs, said Dr. Kork, an anesthesiology and intensive-care medicine resident. “We should investigate this further—whether or not it helps to stop PPIs,” he said in a poster presented at the annual meeting of the American Society of Anesthesiologists.

Previously, researchers demonstrated that PPIs alter the expression of cytokines in antrum cells (Inflamm. Res. 2006;55:476–80). Also, polymorphisms of TNF-α have been shown to reduce eradication of Helicobacter pylori (Scand. J. Immunol. 2008;67:57–62).

Among the 166 patients who completed the current study, Dr. Kork and his colleagues found that 13 of 44 (30%) in the preoperative PPI group developed a postoperative infection, versus only 10 of 122 (8%) of the non-PPI patients. This difference was significant (odds ratio, 4.13).

“Those patients preoperatively taking PPIs also have an elevated total length of stay,” Dr. Kork said. This difference was statistically significant, compared with patients not taking PPIs before surgery, he said, although he did not present the number of days associated with length of stay.

Length of ICU stay did not differ significantly between groups, he added.

'We should investigate this further—whether or not it helps to stop PPIs.' DR. KORK

ORLANDO — Patients on proton pump inhibitor therapy before abdominal cancer surgery were four times more likely to have postoperative infections than were those not taking such medication, according to a prospective, observational study.

Patients taking preoperative proton pump inhibitors (PPIs) also had significantly elevated serum levels of tumor necrosis factor (TNF)-α before and immediately after hemihepatectomy, as well as the day after surgery. Pneumonia and wound infections made up the majority of postoperative infections in the PPI group.

“There is evidence that PPIs have an effect on the immune system, especially TNF-α,” Dr. Felix Kork said in an interview. Other researchers have shown that TNF-α impairs the immune system (J. Gastrointest. Surg. 2007;11:1506–14), yet the exact mechanism of interaction between PPI use and this cytokine remains unknown. Inflammation could play a role, particularly with postoperative pneumonia, he added.

These findings from patients at Charité Medical University of Berlin need to be confirmed before physicians consider preoperative suspension of PPIs, said Dr. Kork, an anesthesiology and intensive-care medicine resident. “We should investigate this further—whether or not it helps to stop PPIs,” he said in a poster presented at the annual meeting of the American Society of Anesthesiologists.

Previously, researchers demonstrated that PPIs alter the expression of cytokines in antrum cells (Inflamm. Res. 2006;55:476–80). Also, polymorphisms of TNF-α have been shown to reduce eradication of Helicobacter pylori (Scand. J. Immunol. 2008;67:57–62).

Among the 166 patients who completed the current study, Dr. Kork and his colleagues found that 13 of 44 (30%) in the preoperative PPI group developed a postoperative infection, versus only 10 of 122 (8%) of the non-PPI patients. This difference was significant (odds ratio, 4.13).

“Those patients preoperatively taking PPIs also have an elevated total length of stay,” Dr. Kork said. This difference was statistically significant, compared with patients not taking PPIs before surgery, he said, although he did not present the number of days associated with length of stay.

Length of ICU stay did not differ significantly between groups, he added.

'We should investigate this further—whether or not it helps to stop PPIs.' DR. KORK

ORLANDO — Patients on proton pump inhibitor therapy before abdominal cancer surgery were four times more likely to have postoperative infections than were those not taking such medication, according to a prospective, observational study.

Patients taking preoperative proton pump inhibitors (PPIs) also had significantly elevated serum levels of tumor necrosis factor (TNF)-α before and immediately after hemihepatectomy, as well as the day after surgery. Pneumonia and wound infections made up the majority of postoperative infections in the PPI group.

“There is evidence that PPIs have an effect on the immune system, especially TNF-α,” Dr. Felix Kork said in an interview. Other researchers have shown that TNF-α impairs the immune system (J. Gastrointest. Surg. 2007;11:1506–14), yet the exact mechanism of interaction between PPI use and this cytokine remains unknown. Inflammation could play a role, particularly with postoperative pneumonia, he added.

These findings from patients at Charité Medical University of Berlin need to be confirmed before physicians consider preoperative suspension of PPIs, said Dr. Kork, an anesthesiology and intensive-care medicine resident. “We should investigate this further—whether or not it helps to stop PPIs,” he said in a poster presented at the annual meeting of the American Society of Anesthesiologists.

Previously, researchers demonstrated that PPIs alter the expression of cytokines in antrum cells (Inflamm. Res. 2006;55:476–80). Also, polymorphisms of TNF-α have been shown to reduce eradication of Helicobacter pylori (Scand. J. Immunol. 2008;67:57–62).

Among the 166 patients who completed the current study, Dr. Kork and his colleagues found that 13 of 44 (30%) in the preoperative PPI group developed a postoperative infection, versus only 10 of 122 (8%) of the non-PPI patients. This difference was significant (odds ratio, 4.13).

“Those patients preoperatively taking PPIs also have an elevated total length of stay,” Dr. Kork said. This difference was statistically significant, compared with patients not taking PPIs before surgery, he said, although he did not present the number of days associated with length of stay.

Length of ICU stay did not differ significantly between groups, he added.

'We should investigate this further—whether or not it helps to stop PPIs.' DR. KORK

NEW YORK — A patient's preoperative cardiovascular assessment should do more than determine whether a patient is cleared for surgery.

Ideally, it also should take measures to reduce a patient's surgical risk. A major focus is to resolve cardiovascular disease and cut the patient's risk for a perioperative or postoperative myocardial infarction, Dr. Howard Weinstein said at a symposium on cardiovascular disease in cancer patients sponsored by the University of Texas M.D. Anderson Cancer Center.

Most postoperative MIs occur within the first 48 hours after surgery; these events generally do not involve plaque rupture but occur when myocardial oxygen demand outstrips coronary supply, said Dr. Weinstein, a cardiologist at Memorial Sloan-Kettering Cancer Center in New York. Demand ischemia occurs when one or more coronary vessels have greater than 70% stenosis and the patient has prolonged, stress-induced ischemia.

Prolonged operations that involve large fluid shifts or blood loss carry a high cardiac risk, and such surgeries are common for cancer. Surgery with an intermediate risk for cardiac events includes intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery, all of which are also common in cancer patients. Endoscopic, superficial, and breast surgery all produce low increased risks for cardiac events, he said.

Guidelines for gauging presurgical risk for cardiac events, published in 2007 by the American College of Cardiology and the American Heart Association, focus on comorbidities. Coexisting disorders that increase surgical risk include histories of ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency, arrhythmia, and severe valvular disease.

The key cause of postoperative MIs seems to be postoperative stress, including emergence from anesthesia, leading to cardiac ischemia, infarction, and myocardial death. Only about 1 in 13,000 patients dies directly because of anesthesia, Dr. Weinstein said at the meeting, also sponsored by the American College of Cardiology and the Society for Geriatric Cardiology.

Poor functional status just before surgery is another key risk factor. In a study reported last year by Dr. Weinstein and his associates, 2 of 53 (4%) patients with an exercise capacity of more than seven METs (metabolic equivalents) had a postsurgical hospital stay of 10 or more days, while 26 of 138 (19%) patients with an exercise capacity of seven METs or less had a prolonged postsurgical hospitalization.

If nonsurgical treatment is not an option, another approach is to do the least-extensive procedure possible that will accomplish the goal. A third option is to defer surgery. Operations for prostate, renal, and benign tumors can generally be delayed for several months. Surgery for lung, colon, and head or neck tumors can be postponed for a few weeks. Aggressive cancers with rapid growth or the immediate threat of lost function, as well as leukemias and lymphomas, are the only tumors that require surgery within days.

Coronary revascularization before surgery requires careful assessment of the potential risks and benefits. Coronary artery bypass is generally not a good option because the recovery time is too long. Following coronary artery stenting, patients need treatment with aspirin indefinitely, and with clopidogrel for 1 month for bare-metal stents and ideally for at least a year with drug-eluting stents. Most surgeons stop clopidogrel treatment before an operation, but the trend now is to maintain patients on aspirin right up to the time of surgery and restart as soon as possible. The need for antiplatelet therapy following stent placement makes coronary revascularization by balloon angioplasty alone a reasonable alternative. Surgery is possible starting about 2 weeks after angioplasty, Dr. Weinstein said.

The value of presurgical revascularization was challenged by the Coronary Artery Revascularization Prophylaxis (CARP) study, which randomized 510 patients who were scheduled for elective vascular surgery and had coronary artery disease to revascularization or to presurgical medical management only (N. Engl. J. Med. 2004;351:2795–804). In the revascularization group, 41% underwent bypass surgery and 59% were stented. After the subsequent vascular surgery, the incidence of MIs was 12% in the revascularization group and 14% in the medical management group, a difference that was not statistically significant. After a mean follow-up of 2.7 years, the cumulative rate of death was essentially identical in the two groups, with rates of 22% and 23%.

The CARP study was not large enough to assess the benefit of presurgical revascularization in patients with high-risk coronary disease, Dr. Weinstein noted.

NEW YORK — A patient's preoperative cardiovascular assessment should do more than determine whether a patient is cleared for surgery.

Ideally, it also should take measures to reduce a patient's surgical risk. A major focus is to resolve cardiovascular disease and cut the patient's risk for a perioperative or postoperative myocardial infarction, Dr. Howard Weinstein said at a symposium on cardiovascular disease in cancer patients sponsored by the University of Texas M.D. Anderson Cancer Center.

Most postoperative MIs occur within the first 48 hours after surgery; these events generally do not involve plaque rupture but occur when myocardial oxygen demand outstrips coronary supply, said Dr. Weinstein, a cardiologist at Memorial Sloan-Kettering Cancer Center in New York. Demand ischemia occurs when one or more coronary vessels have greater than 70% stenosis and the patient has prolonged, stress-induced ischemia.

Prolonged operations that involve large fluid shifts or blood loss carry a high cardiac risk, and such surgeries are common for cancer. Surgery with an intermediate risk for cardiac events includes intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery, all of which are also common in cancer patients. Endoscopic, superficial, and breast surgery all produce low increased risks for cardiac events, he said.

Guidelines for gauging presurgical risk for cardiac events, published in 2007 by the American College of Cardiology and the American Heart Association, focus on comorbidities. Coexisting disorders that increase surgical risk include histories of ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency, arrhythmia, and severe valvular disease.

The key cause of postoperative MIs seems to be postoperative stress, including emergence from anesthesia, leading to cardiac ischemia, infarction, and myocardial death. Only about 1 in 13,000 patients dies directly because of anesthesia, Dr. Weinstein said at the meeting, also sponsored by the American College of Cardiology and the Society for Geriatric Cardiology.

Poor functional status just before surgery is another key risk factor. In a study reported last year by Dr. Weinstein and his associates, 2 of 53 (4%) patients with an exercise capacity of more than seven METs (metabolic equivalents) had a postsurgical hospital stay of 10 or more days, while 26 of 138 (19%) patients with an exercise capacity of seven METs or less had a prolonged postsurgical hospitalization.

If nonsurgical treatment is not an option, another approach is to do the least-extensive procedure possible that will accomplish the goal. A third option is to defer surgery. Operations for prostate, renal, and benign tumors can generally be delayed for several months. Surgery for lung, colon, and head or neck tumors can be postponed for a few weeks. Aggressive cancers with rapid growth or the immediate threat of lost function, as well as leukemias and lymphomas, are the only tumors that require surgery within days.

Coronary revascularization before surgery requires careful assessment of the potential risks and benefits. Coronary artery bypass is generally not a good option because the recovery time is too long. Following coronary artery stenting, patients need treatment with aspirin indefinitely, and with clopidogrel for 1 month for bare-metal stents and ideally for at least a year with drug-eluting stents. Most surgeons stop clopidogrel treatment before an operation, but the trend now is to maintain patients on aspirin right up to the time of surgery and restart as soon as possible. The need for antiplatelet therapy following stent placement makes coronary revascularization by balloon angioplasty alone a reasonable alternative. Surgery is possible starting about 2 weeks after angioplasty, Dr. Weinstein said.

The value of presurgical revascularization was challenged by the Coronary Artery Revascularization Prophylaxis (CARP) study, which randomized 510 patients who were scheduled for elective vascular surgery and had coronary artery disease to revascularization or to presurgical medical management only (N. Engl. J. Med. 2004;351:2795–804). In the revascularization group, 41% underwent bypass surgery and 59% were stented. After the subsequent vascular surgery, the incidence of MIs was 12% in the revascularization group and 14% in the medical management group, a difference that was not statistically significant. After a mean follow-up of 2.7 years, the cumulative rate of death was essentially identical in the two groups, with rates of 22% and 23%.

The CARP study was not large enough to assess the benefit of presurgical revascularization in patients with high-risk coronary disease, Dr. Weinstein noted.

NEW YORK — A patient's preoperative cardiovascular assessment should do more than determine whether a patient is cleared for surgery.

Ideally, it also should take measures to reduce a patient's surgical risk. A major focus is to resolve cardiovascular disease and cut the patient's risk for a perioperative or postoperative myocardial infarction, Dr. Howard Weinstein said at a symposium on cardiovascular disease in cancer patients sponsored by the University of Texas M.D. Anderson Cancer Center.

Most postoperative MIs occur within the first 48 hours after surgery; these events generally do not involve plaque rupture but occur when myocardial oxygen demand outstrips coronary supply, said Dr. Weinstein, a cardiologist at Memorial Sloan-Kettering Cancer Center in New York. Demand ischemia occurs when one or more coronary vessels have greater than 70% stenosis and the patient has prolonged, stress-induced ischemia.

Prolonged operations that involve large fluid shifts or blood loss carry a high cardiac risk, and such surgeries are common for cancer. Surgery with an intermediate risk for cardiac events includes intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery, all of which are also common in cancer patients. Endoscopic, superficial, and breast surgery all produce low increased risks for cardiac events, he said.

Guidelines for gauging presurgical risk for cardiac events, published in 2007 by the American College of Cardiology and the American Heart Association, focus on comorbidities. Coexisting disorders that increase surgical risk include histories of ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency, arrhythmia, and severe valvular disease.

The key cause of postoperative MIs seems to be postoperative stress, including emergence from anesthesia, leading to cardiac ischemia, infarction, and myocardial death. Only about 1 in 13,000 patients dies directly because of anesthesia, Dr. Weinstein said at the meeting, also sponsored by the American College of Cardiology and the Society for Geriatric Cardiology.

Poor functional status just before surgery is another key risk factor. In a study reported last year by Dr. Weinstein and his associates, 2 of 53 (4%) patients with an exercise capacity of more than seven METs (metabolic equivalents) had a postsurgical hospital stay of 10 or more days, while 26 of 138 (19%) patients with an exercise capacity of seven METs or less had a prolonged postsurgical hospitalization.

If nonsurgical treatment is not an option, another approach is to do the least-extensive procedure possible that will accomplish the goal. A third option is to defer surgery. Operations for prostate, renal, and benign tumors can generally be delayed for several months. Surgery for lung, colon, and head or neck tumors can be postponed for a few weeks. Aggressive cancers with rapid growth or the immediate threat of lost function, as well as leukemias and lymphomas, are the only tumors that require surgery within days.

Coronary revascularization before surgery requires careful assessment of the potential risks and benefits. Coronary artery bypass is generally not a good option because the recovery time is too long. Following coronary artery stenting, patients need treatment with aspirin indefinitely, and with clopidogrel for 1 month for bare-metal stents and ideally for at least a year with drug-eluting stents. Most surgeons stop clopidogrel treatment before an operation, but the trend now is to maintain patients on aspirin right up to the time of surgery and restart as soon as possible. The need for antiplatelet therapy following stent placement makes coronary revascularization by balloon angioplasty alone a reasonable alternative. Surgery is possible starting about 2 weeks after angioplasty, Dr. Weinstein said.

The value of presurgical revascularization was challenged by the Coronary Artery Revascularization Prophylaxis (CARP) study, which randomized 510 patients who were scheduled for elective vascular surgery and had coronary artery disease to revascularization or to presurgical medical management only (N. Engl. J. Med. 2004;351:2795–804). In the revascularization group, 41% underwent bypass surgery and 59% were stented. After the subsequent vascular surgery, the incidence of MIs was 12% in the revascularization group and 14% in the medical management group, a difference that was not statistically significant. After a mean follow-up of 2.7 years, the cumulative rate of death was essentially identical in the two groups, with rates of 22% and 23%.

The CARP study was not large enough to assess the benefit of presurgical revascularization in patients with high-risk coronary disease, Dr. Weinstein noted.

NEW YORK — Acute normovolemic hemodilution markedly reduced the need for blood products, compared with standard intraoperative management in a randomized trial of patients undergoing major hepatic resection.

In the 130-patient study, the red blood cell transfusion rate in patients managed with ANH was half that of patients who received standard management, Dr. William H. Jarnagin reported at the annual meeting of the American Surgical Association.

ANH “should be used routinely when moderate to high blood loss is anticipated,” concluded Dr. Jarnagin, vice chair of surgical services and chief of the hepatopancreatobiliary service at Memorial Sloan-Kettering Cancer Center, New York.

Hepatic resection often entails major blood loss. While transfusion of allogeneic blood products can often be lifesaving, it has many downsides, including increased risks of blood-borne infectious diseases, acute lung injury, transfusion reactions, immunomodulation, and other serious complications, as well as substantially higher direct and indirect costs of care.

ANH is a low-tech blood conservation technique that avoids exposing patients to the risks of allogeneic transfusion while preserving blood bank supplies for the situations where they are truly needed.

ANH involves intraoperative removal of whole blood by gravity collection prior to starting the resection. The lost volume is replaced with crystalloid and colloid. That way a smaller volume of the patient's red blood cell (RBC) mass is lost per volume of surgical blood lost. At the end of the operation, after hemostasis is attained, the patient's blood is transfused back.

“Compared with other blood conservation strategies, ANH has several advantages: It is technically and logistically simple, and there are minimal equipment requirements and no storage or administrative costs, no delay in procedure scheduling, and no waste of autologous units,” Dr. Jarnagin explained.

He presented a single-center prospective trial involving 130 patients undergoing resection of three or more hepatic segments who were randomized to ANH or standard intraoperative management. In the ANH group, blood was removed to a target hemoglobin of 8.0 g/dL. Patients had a median of 2,250 mL of blood removed; the hemodilution took 37 minutes on average to complete.

The RBC transfusion rate was 25% in controls and 13% with ANH, for a 50% reduction. Intraoperatively, a hemoglobin below 7.0 g/dL required transfusion; only 1.6% of patients managed with ANH required an intraoperative transfusion, versus 10% with standard management.

Historically, roughly 50% of patients at Sloan-Kettering undergoing major hepatic resection have required allogeneic transfusions. With contemporary techniques, the rate in the usual-care group in this study was just half that. “In fact, ANH wasn't necessary in many of our patients,” the surgeon noted.

ANH proved most useful for patients with an operative blood loss of at least 800 mL, which was actually the median blood loss in the study. Among that population, 42% of controls required allogeneic RBC transfusion, compared with 18% in the ANH group. Moreover, 21% of patients in the ANH group required fresh frozen plasma, compared with 48% on standard intraoperative management.

Sixty-day major morbidity rates were similar at about 30% in the two study arms.

Discussant Dr. William C. Chapman said the well-designed study provides convincing evidence that ANH is safe and effective. He predicted that as a result ANH will be instituted at many centers in selected high-risk patients.

“I don't think there's any doubt that this strategy works,” said Dr. Chapman, professor of surgery and chief of the section of transplantation at Washington University, St. Louis.

The red blood cell transfusion rate was 25% in controls and 13% with ANH, about a 50% reduction. DR. JARNAGIN

NEW YORK — Acute normovolemic hemodilution markedly reduced the need for blood products, compared with standard intraoperative management in a randomized trial of patients undergoing major hepatic resection.

In the 130-patient study, the red blood cell transfusion rate in patients managed with ANH was half that of patients who received standard management, Dr. William H. Jarnagin reported at the annual meeting of the American Surgical Association.

ANH “should be used routinely when moderate to high blood loss is anticipated,” concluded Dr. Jarnagin, vice chair of surgical services and chief of the hepatopancreatobiliary service at Memorial Sloan-Kettering Cancer Center, New York.

Hepatic resection often entails major blood loss. While transfusion of allogeneic blood products can often be lifesaving, it has many downsides, including increased risks of blood-borne infectious diseases, acute lung injury, transfusion reactions, immunomodulation, and other serious complications, as well as substantially higher direct and indirect costs of care.

ANH is a low-tech blood conservation technique that avoids exposing patients to the risks of allogeneic transfusion while preserving blood bank supplies for the situations where they are truly needed.

ANH involves intraoperative removal of whole blood by gravity collection prior to starting the resection. The lost volume is replaced with crystalloid and colloid. That way a smaller volume of the patient's red blood cell (RBC) mass is lost per volume of surgical blood lost. At the end of the operation, after hemostasis is attained, the patient's blood is transfused back.

“Compared with other blood conservation strategies, ANH has several advantages: It is technically and logistically simple, and there are minimal equipment requirements and no storage or administrative costs, no delay in procedure scheduling, and no waste of autologous units,” Dr. Jarnagin explained.

He presented a single-center prospective trial involving 130 patients undergoing resection of three or more hepatic segments who were randomized to ANH or standard intraoperative management. In the ANH group, blood was removed to a target hemoglobin of 8.0 g/dL. Patients had a median of 2,250 mL of blood removed; the hemodilution took 37 minutes on average to complete.

The RBC transfusion rate was 25% in controls and 13% with ANH, for a 50% reduction. Intraoperatively, a hemoglobin below 7.0 g/dL required transfusion; only 1.6% of patients managed with ANH required an intraoperative transfusion, versus 10% with standard management.

Historically, roughly 50% of patients at Sloan-Kettering undergoing major hepatic resection have required allogeneic transfusions. With contemporary techniques, the rate in the usual-care group in this study was just half that. “In fact, ANH wasn't necessary in many of our patients,” the surgeon noted.

ANH proved most useful for patients with an operative blood loss of at least 800 mL, which was actually the median blood loss in the study. Among that population, 42% of controls required allogeneic RBC transfusion, compared with 18% in the ANH group. Moreover, 21% of patients in the ANH group required fresh frozen plasma, compared with 48% on standard intraoperative management.

Sixty-day major morbidity rates were similar at about 30% in the two study arms.

Discussant Dr. William C. Chapman said the well-designed study provides convincing evidence that ANH is safe and effective. He predicted that as a result ANH will be instituted at many centers in selected high-risk patients.

“I don't think there's any doubt that this strategy works,” said Dr. Chapman, professor of surgery and chief of the section of transplantation at Washington University, St. Louis.

The red blood cell transfusion rate was 25% in controls and 13% with ANH, about a 50% reduction. DR. JARNAGIN

NEW YORK — Acute normovolemic hemodilution markedly reduced the need for blood products, compared with standard intraoperative management in a randomized trial of patients undergoing major hepatic resection.

In the 130-patient study, the red blood cell transfusion rate in patients managed with ANH was half that of patients who received standard management, Dr. William H. Jarnagin reported at the annual meeting of the American Surgical Association.

ANH “should be used routinely when moderate to high blood loss is anticipated,” concluded Dr. Jarnagin, vice chair of surgical services and chief of the hepatopancreatobiliary service at Memorial Sloan-Kettering Cancer Center, New York.

Hepatic resection often entails major blood loss. While transfusion of allogeneic blood products can often be lifesaving, it has many downsides, including increased risks of blood-borne infectious diseases, acute lung injury, transfusion reactions, immunomodulation, and other serious complications, as well as substantially higher direct and indirect costs of care.

ANH is a low-tech blood conservation technique that avoids exposing patients to the risks of allogeneic transfusion while preserving blood bank supplies for the situations where they are truly needed.

ANH involves intraoperative removal of whole blood by gravity collection prior to starting the resection. The lost volume is replaced with crystalloid and colloid. That way a smaller volume of the patient's red blood cell (RBC) mass is lost per volume of surgical blood lost. At the end of the operation, after hemostasis is attained, the patient's blood is transfused back.

“Compared with other blood conservation strategies, ANH has several advantages: It is technically and logistically simple, and there are minimal equipment requirements and no storage or administrative costs, no delay in procedure scheduling, and no waste of autologous units,” Dr. Jarnagin explained.

He presented a single-center prospective trial involving 130 patients undergoing resection of three or more hepatic segments who were randomized to ANH or standard intraoperative management. In the ANH group, blood was removed to a target hemoglobin of 8.0 g/dL. Patients had a median of 2,250 mL of blood removed; the hemodilution took 37 minutes on average to complete.

The RBC transfusion rate was 25% in controls and 13% with ANH, for a 50% reduction. Intraoperatively, a hemoglobin below 7.0 g/dL required transfusion; only 1.6% of patients managed with ANH required an intraoperative transfusion, versus 10% with standard management.

Historically, roughly 50% of patients at Sloan-Kettering undergoing major hepatic resection have required allogeneic transfusions. With contemporary techniques, the rate in the usual-care group in this study was just half that. “In fact, ANH wasn't necessary in many of our patients,” the surgeon noted.

ANH proved most useful for patients with an operative blood loss of at least 800 mL, which was actually the median blood loss in the study. Among that population, 42% of controls required allogeneic RBC transfusion, compared with 18% in the ANH group. Moreover, 21% of patients in the ANH group required fresh frozen plasma, compared with 48% on standard intraoperative management.

Sixty-day major morbidity rates were similar at about 30% in the two study arms.

Discussant Dr. William C. Chapman said the well-designed study provides convincing evidence that ANH is safe and effective. He predicted that as a result ANH will be instituted at many centers in selected high-risk patients.

“I don't think there's any doubt that this strategy works,” said Dr. Chapman, professor of surgery and chief of the section of transplantation at Washington University, St. Louis.

The red blood cell transfusion rate was 25% in controls and 13% with ANH, about a 50% reduction. DR. JARNAGIN

CHICAGO — Octogenarians undergoing thyroid surgery experience a markedly increased rate of serious perioperative complications, compared with younger patients, according to Dr. Michal Mekel.

Dr. Mekel of Massachusetts General Hospital, Boston, presented a review of 90 consecutive patients over age 80 years and 242 randomly selected 18- to 79-year-olds, all of whom underwent thyroid surgery at the hospital during the same recent period. Eighty percent of the octogenarians were women, Dr. Mekel reported at the annual meeting of the American Thyroid Association.

The overall 30-day complication rate was 23% in octogenarians and 9% in controls. Moreover, most affected octogenarians had multiple complications. However, no deaths occurred in either group. Mean length of stay was 1.7 days in patients over age 80 years, compared with 1.2 days in the younger group. The most frequent complications in patients over age 80 years were cardiovascular, with 6.7% of them being affected. Pulmonary complications, occurring in 3.3%, were next most common.

Complications experienced only by the octogenarians included atrial fibrillation, other arrhythmias, heart failure, pneumonia, ischemic colitis, and tracheostomy.

In an analysis, comorbid respiratory conditions proved to be an independent risk factor for perioperative complications in patients over age 80 years, conferring a 10-fold increased risk. Elderly women had an over threefold increased risk of perioperative complications.

Interestingly, advanced age was not an independent risk factor for serious complications. This finding underscores the point that while careful selection of elderly candidates for thyroid surgery is warranted, advanced age is not a contraindication to surgery, Dr. Mekel emphasized.

CHICAGO — Octogenarians undergoing thyroid surgery experience a markedly increased rate of serious perioperative complications, compared with younger patients, according to Dr. Michal Mekel.

Dr. Mekel of Massachusetts General Hospital, Boston, presented a review of 90 consecutive patients over age 80 years and 242 randomly selected 18- to 79-year-olds, all of whom underwent thyroid surgery at the hospital during the same recent period. Eighty percent of the octogenarians were women, Dr. Mekel reported at the annual meeting of the American Thyroid Association.

The overall 30-day complication rate was 23% in octogenarians and 9% in controls. Moreover, most affected octogenarians had multiple complications. However, no deaths occurred in either group. Mean length of stay was 1.7 days in patients over age 80 years, compared with 1.2 days in the younger group. The most frequent complications in patients over age 80 years were cardiovascular, with 6.7% of them being affected. Pulmonary complications, occurring in 3.3%, were next most common.

Complications experienced only by the octogenarians included atrial fibrillation, other arrhythmias, heart failure, pneumonia, ischemic colitis, and tracheostomy.

In an analysis, comorbid respiratory conditions proved to be an independent risk factor for perioperative complications in patients over age 80 years, conferring a 10-fold increased risk. Elderly women had an over threefold increased risk of perioperative complications.

Interestingly, advanced age was not an independent risk factor for serious complications. This finding underscores the point that while careful selection of elderly candidates for thyroid surgery is warranted, advanced age is not a contraindication to surgery, Dr. Mekel emphasized.

CHICAGO — Octogenarians undergoing thyroid surgery experience a markedly increased rate of serious perioperative complications, compared with younger patients, according to Dr. Michal Mekel.

Dr. Mekel of Massachusetts General Hospital, Boston, presented a review of 90 consecutive patients over age 80 years and 242 randomly selected 18- to 79-year-olds, all of whom underwent thyroid surgery at the hospital during the same recent period. Eighty percent of the octogenarians were women, Dr. Mekel reported at the annual meeting of the American Thyroid Association.

The overall 30-day complication rate was 23% in octogenarians and 9% in controls. Moreover, most affected octogenarians had multiple complications. However, no deaths occurred in either group. Mean length of stay was 1.7 days in patients over age 80 years, compared with 1.2 days in the younger group. The most frequent complications in patients over age 80 years were cardiovascular, with 6.7% of them being affected. Pulmonary complications, occurring in 3.3%, were next most common.

Complications experienced only by the octogenarians included atrial fibrillation, other arrhythmias, heart failure, pneumonia, ischemic colitis, and tracheostomy.

In an analysis, comorbid respiratory conditions proved to be an independent risk factor for perioperative complications in patients over age 80 years, conferring a 10-fold increased risk. Elderly women had an over threefold increased risk of perioperative complications.

Interestingly, advanced age was not an independent risk factor for serious complications. This finding underscores the point that while careful selection of elderly candidates for thyroid surgery is warranted, advanced age is not a contraindication to surgery, Dr. Mekel emphasized.