Faculty: R Makaryus, U Landman
Drs. Andraous, Moses, Floyd and Makaryus
|Better Beta Blockade
Dr. Andreous gave a good review of the Decrease and Poise studies. Dr. Moses presented a concise review of meta-analysis.
A meta-analysis should contain certain elements. 1. A focus question -- perioperative Beta blockade, in this case. 2. A position of interest -- patients undergoing noncardiac surgery. 3. A comparison of two interventions -- beta blockers vs other treatment. 4. There should be an outcome for success or failure of the interventions -- MI, CVA, bradycardia or hypotension.
Some potential problems with meta-analyses were also reviewed: heterogeneity, selection/ publication bias and other performance biases such as detection bias. One area of dissimilarity we noted was the different dosing regiments used in the individual studies. With regards to publication bias, the conclusions of a meta-analysis will depend on whether or not unpublished studies are included. Investigator misconduct was also discussed. Here, many patients were administered beta blockers even though they may not have needed them. This puts patients unnecessarily at risk from side effects and adds unnecessary drug expense. These articles increased awareness of the topic and made for a lively discussion.
* Fleischmann KE et al. 2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation. 2009 Nov 24;120(21):2123-51. [Abstract]
* Bangalore S et al. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet. 2008 Dec 6;372(9654):1962-76. [Abstract]
* Bouri S, et al. Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Heart. 2013 Jul 31. [Abstract]
* Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002 Jun 15;21(11):1539-58. [Abstract]
* London MJ et al. Association of perioperative β-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013 Apr 24;309(16):1704-13. [Abstract]
* Mashour GA et al. Perioperative Metoprolol and Risk of Stroke after Noncardiac Surgery. Anesthesiology. 2013 Apr 22. [Epub ahead of print] [Abstract]
Drs. Chiu, Evans, Seidman, Moller and Makaryus
HSC Galleria 5:30 pm
|CVP Monitoring: Pressure to Change?
Dr. Chiu gave a very good presentation on the Strickler et al article. We discussed the ethical problems associated with pediatric research studies, specifically studies on babies. Craniosynostosis repair was reviewed; it is an isolated anomaly but needs to be repaired by a certain age. Craniosynostosis repair involves opening one or more sutures that are permanently fused. If the repair is not done, there can be limited brain function, increased ICP, and it can also affect eating. The repair surgery has an incidence of VAE. Because there can be a large blood loss, the Kearney assessment of blood loss was also discussed. It may provide a more accurate measurement of blood loss than other techniques. Other methods to asses volume status were discussed. Some were: pulse pressure variation from an A-line or from pulse oximeter variability and SVV which is based on an algorithm. In addition, in pediatric patients SV is fixed and heart rate is the variable that changes. Under age six, there is a fixed stroke volume. Overall the routine use of CVP monitoring was found to be of questionable use as a means to decrease hypotension.
Dr. Evans gave a nice review of the Dunki-Jacobs et al article. Some limitations of SVV are that you need measurement on mechanical ventilation and a tidal volume of >8cc/kg as well as a fixed respiratory rate. Another limitation of SVV is that it cannot be used on IABP patients or pediatric patients (minimum wt is 40 kg). SVV does require placement of an A-line which also has risks. This study had limitations 1. Both laparoscopic and open case were included. 2. The patient’s cardiac status and EF were unknown. 3. The TV was set at the beginning of the case and then was never adjusted for CO2 during the surgery. We also discussed some of the noninvasive monitors which are in use today: COQ, Flotrac Vigileo system. Right now we are not using any of these devices at SBUMC.
* Stricker PA, et al. Evaluation of central venous pressure monitoring in children undergoing craniofacial reconstruction surgery. Anesth Analg. 2013 Feb;116(2):411-9. [Abstract]
* Dunki-Jacobs EM, et al. Stroke Volume Variation in Hepatic Resection: A Replacement for Standard Central Venous Pressure Monitoring. Ann Surg Oncol. 2013 Oct 23. Lancet. 2008 Dec 6;372(9654):1962-76. [Abstract]
Drs. Eisenstat, Haque, Azim and Makaryus
Eastern Pavillion, Setauket
|Knees and Hips
Dr. Eisenstat gave a very good presentation on the Price, et al. article. She reviewed POCD. The study found that executive and memory declines occur in nondemented adults who had orthopedic surgery. Dr. Haque gave a nice review of the Moja et al. article. He reviewed pertinent info on mortality. Mortality in elderly is 10% at 1 month, 20% at 4 months, and 30% at 1 year. Surgical delay is associated with increase risk of death in this frail population. This study did have similar results to studies done in the past (Shiga 2008, Khan 2009, etc). It is advocated to have early hip fracture surgery and that patients should be stabilized as quickly as possible within 24-48 hours. We also learned about the status of delay time to surgery at Stony Brook. Dr. Azim and Dr. Benveniste have data. Delay varies by the day of the week of admission to SB. Interestingly the longest delay occurs for a Tuesday admittance. We hope that this will be addressed by a focus group. Guidelines should be established so that patients at Stony Brook get expedited surgery.
* Price CC, et al. A pilot study evaluating presurgery neuroanatomical biomarkers for postoperative cognitive decline after total knee arthroplasty in older adults. Anesthesiology. 2014 Mar;120(3):601-13 [Abstract]
* Moja L, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One. 2012;7(10):e46175. doi: 10.1371/journal.pone.0046175 [Abstract]