BACKGROUND:The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery, increasing numbers are taking either an angiotensin-converting ...enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB). The current recommendations of whether to continue or withhold ACE-I and ARB in the perioperative period are conflicting. Previous meta-analyses have linked preoperative ACE-I/ARB therapy to the increased incidence of postinduction hypotension; however, they have failed to correlate this with adverse patient outcomes. The aim of this meta-analysis was to determine whether continuation or withholding ACE-I or ARB therapy in the perioperative period is associated with mortality and major morbidity.
METHODS:This meta-analysis was prospectively registered on PROSPERO (CRD42017055291). A comprehensive search of MEDLINE (PubMed), CINAHL (EBSCO host), ProQuest, Cochrane database, Scopus, and Web of Science was conducted on December 6, 2016. We included adult patients >18 years of age on chronic ACE-I or ARB therapy who underwent noncardiac surgery in which ACE-I or ARB was either withheld or continued on the morning of surgery. Primary outcomes included all-cause mortality and major cardiac events (MACE). Secondary outcomes included the risk of congestive heart failure, acute kidney injury, stroke, intraoperative/postoperative hypotension, and the length of hospital stay.
RESULTS:After abstract review, the full text of 25 studies was retrieved, of which 9 fulfilled the inclusion criteria5 were randomized control trials, and 4 were cohort studies. These studies included a total of 6022 patients on chronic ACE-I/ARB therapy before noncardiac surgery. A total of 1816 patients withheld treatment the morning of surgery and 4206 continued their ACE-I/ARB. Preoperative demographics were similar between the 2 groups. Withholding ACE-I/ARB therapy was not associated with a difference in mortality (odds ratio OR, 0.97; 95% confidence interval CI, 0.62–1.52; I = 0%) or MACE (OR, 1.12; 95% CI, 0.82–1.52; I = 0%). However, withholding therapy was associated with significantly less intraoperative hypotension (OR, 0.63; 95% CI, 0.47–0.85; I = 71%). No effect estimate could be pooled concerning length of hospital stay and congestive heart failure.
CONCLUSIONS:This meta-analysis did not demonstrate an association between perioperative administration of ACE-I/ARB and mortality or MACE. It did, however, confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intraoperative hypotension. A large randomized control trial is necessary to determine the appropriate perioperative management of ACE-I and ARBs.
Objectives The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide BNP and N-terminal fragment of proBNP ...NT-proBNP) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured. Background Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done. Methods We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery. Results Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery. Conclusions Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.
Perioperative registries can be utilised to track outcomes, develop risk prediction models, and make evidence-based decisions and interventions. To better understand and support initiatives to ...establish clinical registries, this study aimed to assess the indications, challenges, and characteristics of successful perioperative registries in low-resource settings, where there is unmet surgical demand and patients have a mortality rate up to double that of high-income countries. We conducted a librarian-assisted literature search of international research databases of articles published between January 1969 and January 2021. Studies were filtered using predefined criteria and responses to two Mixed Method Appraisal Tool screening questions. A Direct Content Analysis Method was used to synthesis. e data for eligible studies based on predefined criteria. The search identified 2793 abstracts. After removing duplicates and excluding studies that did not meet eligibility criteria, twelve studies were included, conducted in South America (
n
= 4), Africa (
n
= 5), the Middle East (
n
= 2), and Asia (
n
= 1). The lack of context-specific data for determining and evaluating patient outcomes (
n
= 7) was the major indication for implementation. Organising local research teams and engaging stakeholders in the host country were associated with successful implementation. Inadequate funding for data collectors and monitoring data quality were identified as challenges (
n
= 4). The goal of a perioperative registry is to generate data to influence and support quality improvement, and national surgical policies. Efforts to establish perioperative registries in low- and middle-income countries should engage local teams and stakeholders and seek to overcome challenges in data collection and monitoring.
WHO defines universal health coverage (UHC) as “access to needed essential health services, without financial hardship”.1 UHC requires about US$100 per head for an essential package of 218 ...interventions, and approximately $50 per head for a basic package of 108 of the highest priority interventions.2 Yet, estimates in 2016 suggested that only nine of the 49 low-income and middle-income countries (LMICs) could afford the essential package, and that 16 countries could afford the 108 highest priority interventions of the basic package.2 At an average government spend on health in low-income countries of only $9 per head in 2018 (1·2% of Gross National Product), literally every cent counts.3 Surgical care is an indivisible component of UHC,4 yet the outcomes in low-income countries are poor.5,6 Provision of quality surgical care in these countries is difficult because resources and finances are limited. Surgical site infections (SSI) predominate perioperative complications,6 with a higher burden and more antibiotic resistance in low-income countries.9 The need for appropriate global guidelines for prevention of SSI is therefore important.10 However, some recommendations are based on little evidence, with a negative financial effect in low-income countries. Similar to FALCON, evidence is needed to challenge other controversial practice guidelines in low-income countries, such as the WHO recommendation for the use of liberal inspired oxygen concentrations of 80% during surgery to prevent SSI.11,12 The retraction of several trials has raised further concerns regarding the evidence base.13 The COVID-19 pandemic has highlighted the importance of oxygen as a scarce health-care resource, emphasising the need to establish the evidence for the recommendation for liberal inspired oxygen to prevent SSI.
Background Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary ...complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients. Methods A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves. Results In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds. Conclusions Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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