Perioperative cardiovascular evaluation and treatment of elderly patients undergoing noncardiac surgery
Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich in Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
There are a few studies that report long-term cardiac outcomes after noncardiac surgery among patients with abnormal preoperative DSE. In one study, patients were followed for up to 2 years after major vascular surgery (44). There were two cardiac events (3%) among patients with negative DSE. Among patients with positive DSE, 68% subsequently underwent coronary revascularization before the noncardiac surgery was performed. There were no perioperative events in the group of patients with positive DSE who underwent coronary revascularization before noncardiac surgery. By contrast, 40% of those with positive DSE who did not undergo coronary revascularization had perioperative adverse cardiac outcomes. In this study, DSE predicted perioperative and long-term outcome among patients undergoing major vascular surgery, with a high negative predictive value. In a second study, patients undergoing major vascular surgery were evaluated by clinical parameters and results of DSE and followed for an average of 19 months postoperatively. The presence of extensive dobutamine-induced WMAs and a previous history of MI independently predicted late cardiac events, increasing risk up to sixfold (45).
Assessment of Cardiac and Noncardiac Risk Factors
Stephen M. Cohn, Matthew O. Dolich in Complications in Surgery and Trauma, 2014
The evaluation of cardiac risk always involves a thorough history and directed physical exam. The primary goal of any cardiac risk assessment is to evaluate for active cardiac conditions. The initial history, physical examination, and electrocardiogram (EKG) assessment should focus on the identification of these conditions. The active conditions that should delay elective surgery until they are addressed include unstable coronary syndromes, acute heart failure, and significant arrhythmias or valvular disease. Through appropriate questioning about chest pain, palpitations, orthostasis, or dyspnea along with adequate heart and lung auscultation for murmurs, rhythm irregularities, and respiratory rales, these conditions should be identified. A resting EKG can also help detect abnormalities specifically related to arrhythmias, ischemia, and conduction abnormalities. An EKG is indicated in certain groups of patients: (a) patients undergoing major vascular surgery; (b) patients with known CAD, peripheral artery disease, or cerebrovascular disease, undergoing intermediate-risk surgery; and (c) patients with clinical risk factors for CAD that will be undergoing intermediate or high-risk surgery. The identification of active cardiac conditions should prompt the surgical team to delay nonemergent surgery and obtain medical consultation to evaluate and medically optimize the patient prior to surgery.
Selected topics
Henry J. Woodford in Essential Geriatrics, 2022
Large vessel ischaemia is associated with signs of arterial insufficiency, i.e. pallor, reduced temperature, prolonged capillary refill time and absent pulses. These signs may be absent if small vessel disease is the cause of the ulceration. There may be hair loss in the surrounding skin. Arterial ulcers are usually painful. The most common location is on the distal toes. Assessment should include identifying vascular risk factors. An APBI should be performed; it is usually below 0.5 in cases of arterial insufficiency. Vascular surgery may be indicated to restore adequate blood flow. Secondary vascular prevention medication should be considered (e.g. antiplatelets and statins). Smoking-cessation and diabetic control may also be appropriate.
A rare case of an infected aortoiliac graft complicated with Eggerthella lenta bacteremia and septic shock
Published in Journal of Community Hospital Internal Medicine Perspectives, 2020
Harith A. Alataby, Lloyd G. Muzangwa, Muhamed K. Atere, Joseph Bibawy, Keith T. Diaz, Jay M. Nfonoyim
Vascular surgery extensively evaluated the patient for graft replacement surgery. However, given the unstable condition of the patient, vascular interventions were deferred. Due to the patient’s frail condition, we chose a less invasive and conservative strategy. Seven days’ course of IV antibiotics vancomycin (1 g daily) and Meropenem (1 g twice a day) were administered; however, the patient continued to have a spiking of fever and was unable to be weaned from mechanical ventilation. Repeat blood culture drawn during the same period grew the same bacteria (Eggerthella lenta, Escherichia coli Extended-spectrum beta-lactamase (ESBL), and Enterococcus Faecalis). The antibiotic regimen was changed to Tigecycline (50 mg twice a day), which was administered for 14 days. Two days after conducting Tigecycline, repeat blood cultures were negative. After completion of the course of antibiotics and stabilization of other comorbidities, the patient was discharged home with long term antibiotic therapy under close control of inflammation markers.
Rise and fall of preoperative coronary revascularization
Published in Expert Review of Cardiovascular Therapy, 2020
Deepa Raghunathan, Nicolas L. Palaskas, Syed Wamique Yusuf, Kim A. Eagle
The incidence of major adverse cardiac events (MACE) such as cardiac arrest, cardiac death and myocardial infarction (MI) in the perioperative period after noncardiac surgery (NCS) is 3.9% by pooled analysis [1]. The incidence of postoperative MI, as defined by elevated cardiac biomarkers and electrocardiogram (ECG) findings consistent with ischemia, is about 5%, of which 65% are asymptomatic [2]. The 30-day mortality is higher in patients who have perioperative MI compared to those who do not have cardiac events (11.6% and 2.2%, respectively, p < 0.001) [2]. The type of surgery also affects the likelihood for perioperative MI, with vascular surgery incurring the highest risk [3]. As a majority of NCS occur electively, cardiac risk assessment prior to surgery is performed to potentially reduce postoperative cardiac events.
Performance Evaluation of a New Point of Care Viscoelastic Coagulation Monitoring System in Major Abdominal, Orthopaedic and Vascular Surgery
Published in Platelets, 2020
Chris Brearton, Andrew Rushton, Jane Parker, Hannah Martin, Jake Hodgson
Two native blood samples of up to 10ml were taken from each participant, one immediately before surgery and the other during surgery, with the intention of obtaining both normal blood and blood with a disruption of hemostasis. The intra-operative sample from patients in the abdominal and major orthopedic surgery groups was taken at the end of the procedure unless the patient required blood products. If therapeutic blood products were required, the sample was taken immediately before the products were administered. The time of the intra-operative sample collection from the vascular surgery group was optimized during the study. Typically, samples were collected at least 90 minutes after heparinisation in order to allow the full heparin effect to wear off.
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