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Preoperative optimization of the vascular surgery patient.

ABSTRACT: It is well known that patients who suffer from peripheral (noncardiac) vascular disease often have coexisting atherosclerotic diseases of the heart. This may leave the patients susceptible to major adverse cardiac events, including death, myocardial infarction, unstable angina, and pulmonary edema, during the perioperative time period, in addition to the many other complications they may sustain as they undergo vascular surgery procedures, regardless of whether the procedure is performed as an open or endovascular modality. As these patients are at particularly high risk, up to 16% in published studies, for postoperative cardiac complications, many proposals and algorithms for perioperative optimization have been suggested and studied in the literature. Moreover, in patients with recent coronary stents, the risk of non-cardiac surgery on adverse cardiac events is incremental in the first 6 months following stent implantation. Just as postoperative management of patients is vital to the outcome of a patient, preoperative assessment and optimization may reduce, and possibly completely alleviate, the risks of major postoperative complications, as well as assist in the decision-making process regarding the appropriate surgical and anesthetic management. This review article addresses several tools and therapies that treating physicians may employ to medically optimize a patient before they undergo noncardiac vascular surgery.

SUBMITTER: Zhan HT

PROVIDER: S-EPMC4492637 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Preoperative optimization of the vascular surgery patient.

Zhan Henry T HT Purcell Seth T ST Bush Ruth L RL

Vascular health and risk management 20150701

It is well known that patients who suffer from peripheral (noncardiac) vascular disease often have coexisting atherosclerotic diseases of the heart. This may leave the patients susceptible to major adverse cardiac events, including death, myocardial infarction, unstable angina, and pulmonary edema, during the perioperative time period, in addition to the many other complications they may sustain as they undergo vascular surgery procedures, regardless of whether the procedure is performed as an o ...[more]

PMID: 26170688

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Project description:Placebo effects contribute substantially to outcome in most fields of medicine. While clinical trials typically try to control or minimize these effects, the potential of placebo mechanisms to improve outcome is rarely used. Patient expectations about treatment efficacy and outcome are major mechanisms that contribute to these placebo effects. We aimed to optimize these expectations to improve outcome in patients undergoing coronary artery bypass graft (CABG) surgery.In a prospective three-arm randomized clinical trial with a 6 month follow-up, 124 patients scheduled for CABG surgery were randomized to either a brief psychological pre-surgery intervention to optimize outcome expectations (EXPECT); or a psychological control intervention focusing on emotional support and general advice, but not on expectations (SUPPORT); or to standard medical care (SMC). Interventions were kept brief to be feasible with a heart surgery environment; "dose" of therapy was identical for both pre-surgery interventions. Primary outcome was disability 6 months after surgery. Secondary outcomes comprised further clinical and immunological variables.Patients in the EXPECT group showed significantly larger improvements in disability (-12.6; -17.6 to -7.5) than the SMC group (-1.9; -6.6 to +2.7); patients in the SUPPORT group (-6.7; -11.8 to 1.7) did not differ from the SMC group. Comparing follow-up scores and controlling for baseline scores of EXPECT versus SUPPORT on the variable disability only revealed a trend in favor of the EXPECT group (P?=?0.09). Specific advantages for EXPECT compared to SUPPORT were found for mental quality of life and fitness for work (hours per week). Both psychological pre-surgery interventions induced less pronounced increases in pro-inflammatory cytokine concentrations reflected by decreased interleukin-8 levels post-surgery compared to changes in SMC patients and lower interleukin-6 levels in patients of the EXPECT group at follow-up. Both pre-surgery interventions were characterized by great patient acceptability and no adverse effects were attributed to them. Considering the innovative nature of this approach, replication in larger, multicenter trials is needed.Optimizing patients' expectations pre-surgery helps to improve outcome 6 months after treatment. This implies that making use of placebo mechanisms has the potential to improve long-term outcome of highly invasive medical interventions. Further studies are warranted to generalize this approach to other fields of medicine.Ethical approval for the study was obtained from the IRB of the Medical School, University of Marburg, and the trial was registered at ( NCT01407055 ) on July 25, 2011.

Project description:IntroductionOsteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA.Materials/methodsThis retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ -2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ -2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD].ResultsThe study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.).Discussion/conclusionA simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.

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Preoperative optimization of the vascular surgery patient.

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Preoperative optimization of the vascular surgery patient.

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