Special Issue "Anesthesia for the High-Risk Patient"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Anesthesiology".

Deadline for manuscript submissions: closed (31 December 2019) | Viewed by 19229

Special Issue Editor

Prof. Dr. Benedikt Preckel
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Guest Editor
Professor of Anesthesiology, Department of Anesthesiology, Amsterdam University Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
Interests: cardiovascular anesthesia; organ protection; perioperative diabetes treatment; patient safety; cognitive aids; sedation outside the operating room; simulation
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Special Issue Information

Dear Colleagues,

During the last few years, the practice of anesthesiology has changed significantly, with anesthesiologist no longer only taking over the task of applying safe anesthesia and analgesia during surgical and diagnostic procedures but also being involved in pre-operative patient evaluation and improvement, as well as post-operative surveillance, especially in the increasing patient population with significant co-morbidities. Identifying and managing patient- and procedure-related risk factors plays a key role in daily clinical work. Adopting anesthesia practices in the rapidly changing and developing practice of surgical and nonsurgical medicine challenges anesthesiologists to choose the most adequate and safe treatment on an individual patient basis.

In this Special Issue of Journal of Clinical Medicine, original and review papers concerning relevant topics of anesthesia, intensive care, emergency care, and pain therapy in patients with clinically significant co-morbidities shall help anesthesiologists and intensivists to come to the most appropriate treatment of their patients in daily clinical practice.

Prof. Dr. Benedikt Preckel

Guest Editor

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Keywords

  • Cardiac compromised patients
  • Pulmonary compromised patients
  • Patients with endocrine disorders
  • Patients with liver or renal failure
  • Anesthesia in the extremes of age

Published Papers (11 papers)

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Research

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Article
Nebulized Heparin in Burn Patients with Inhalation Trauma—Safety and Feasibility
J. Clin. Med. 2020, 9(4), 894; https://doi.org/10.3390/jcm9040894 - 25 Mar 2020
Cited by 3 | Viewed by 1342
Abstract
Background: Pulmonary hypercoagulopathy is intrinsic to inhalation trauma. Nebulized heparin could theoretically be beneficial in patients with inhalation injury, but current data are conflicting. We aimed to investigate the safety, feasibility, and effectiveness of nebulized heparin. Methods: International multicenter, double-blind, placebo-controlled randomized clinical [...] Read more.
Background: Pulmonary hypercoagulopathy is intrinsic to inhalation trauma. Nebulized heparin could theoretically be beneficial in patients with inhalation injury, but current data are conflicting. We aimed to investigate the safety, feasibility, and effectiveness of nebulized heparin. Methods: International multicenter, double-blind, placebo-controlled randomized clinical trial in specialized burn care centers. Adult patients with inhalation trauma received nebulizations of unfractionated heparin (25,000 international unit (IU), 5 mL) or placebo (0.9% NaCl, 5 mL) every four hours for 14 days or until extubation. The primary outcome was the number of ventilator-free days at day 28 post-admission. Here, we report on the secondary outcomes related to safety and feasibility. Results: The study was prematurely stopped after inclusion of 13 patients (heparin N = 7, placebo N = 6) due to low recruitment and high costs associated with the trial medication. Therefore, no analyses on effectiveness were performed. In the heparin group, serious respiratory problems occurred due to saturation of the expiratory filter following nebulizations. In total, 129 out of 427 scheduled nebulizations were withheld in the heparin group (in 3 patients) and 45 out of 299 scheduled nebulizations were withheld in the placebo group (in 2 patients). Blood-stained sputum or expected increased bleeding risks were the most frequent reasons to withhold nebulizations. Conclusion: In this prematurely stopped trial, we encountered important safety and feasibility issues related to frequent heparin nebulizations in burn patients with inhalation trauma. This should be taken into account when heparin nebulizations are considered in these patients. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Association between Cerebral Oxygen Saturation with Outcome in Cardiac Surgery: Brain as an Index Organ
J. Clin. Med. 2020, 9(3), 840; https://doi.org/10.3390/jcm9030840 - 19 Mar 2020
Cited by 8 | Viewed by 1438
Abstract
While both baseline regional cerebral oxygen saturation (rSO2) and intraoperative rSO2 decreases have prognostic importance in cardiac surgery, evidence is limited in patients who received interventions to correct rSO2 decreases. The primary aim was to examine the association between [...] Read more.
While both baseline regional cerebral oxygen saturation (rSO2) and intraoperative rSO2 decreases have prognostic importance in cardiac surgery, evidence is limited in patients who received interventions to correct rSO2 decreases. The primary aim was to examine the association between rSO2 values (both baseline rSO2 and intraoperative decrease in rSO2) with the composite of morbidity endpoints. We retrospectively analyzed 356 cardiac surgical patients having continuously recorded data of intraoperative rSO2 values. Per institutional guidelines, patients received interventions to restore the rSO2 value to ≥80% of the baseline value. Analyzed rSO2 variables included baseline value, and area under the threshold below an absolute value of 50% (AUT50). Their association with outcome was analyzed with multivariable logistic regression. AUT50 (odds ratio, 1.05; 95% confidence interval; 1.01–1.08; p = 0.015) was shown to be an independent risk factor (along with age, chronic kidney disease, and cardiopulmonary bypass time) of adverse outcomes. In cardiac surgical patients who received interventions to correct decreases in rSO2, increased severity of intraoperative decrease in rSO2 as reflected by AUT below an absolute value of 50% was associated with a composite of adverse outcomes, implicating the importance of cerebral oximetry to monitor the brain as an index organ. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Anesthetic Agents and Cardiovascular Outcomes of Noncardiac Surgery after Coronary Stent Insertion
J. Clin. Med. 2020, 9(2), 429; https://doi.org/10.3390/jcm9020429 - 05 Feb 2020
Cited by 4 | Viewed by 1196
Abstract
Patients undergoing noncardiac surgery after coronary stent implantation are at an increased risk of thrombotic complications. Volatile anesthetics are reported to have organ-protective effects against ischemic injury. Propofol has an anti-inflammatory action that can mitigate ischemia-reperfusion injury. However, the association between anesthetic agents [...] Read more.
Patients undergoing noncardiac surgery after coronary stent implantation are at an increased risk of thrombotic complications. Volatile anesthetics are reported to have organ-protective effects against ischemic injury. Propofol has an anti-inflammatory action that can mitigate ischemia-reperfusion injury. However, the association between anesthetic agents and the risk of major adverse cardiovascular and cerebral event (MACCE) has never been studied before. In the present study, a total of 1630 cases were reviewed. Four different propensity score matchings were performed to minimize selection bias (propofol-based total intravenous anesthesia (TIVA) vs. volatile anesthetics; TIVA vs. sevoflurane; TIVA vs. desflurane; and sevoflurane vs. desflurane). The incidence of MACCE in these four propensity score-matched cohorts was compared. As a sensitivity analysis, a multivariable logistic regression analysis was performed to identify independent predictors for MACCE during the postoperative 30 days both in total and matched cohorts (TIVA vs. volatile agent). MACCE occurred in 6.0% of the patients. Before matching, there was a significant difference in the incidence of MACCE between TIVA and sevoflurane groups (TIVA 5.1% vs. sevoflurane 8.2%, p = 0.006). After matching, there was no significant difference in the incidence of MACCE between the groups of any pairs (TIVA 6.5% vs. sevoflurane 7.7%; p = 0.507). The multivariable logistic regression analysis revealed no significant association of the volatile agent with MACCE (odds ratio 1.48, 95% confidence interval 0.92–2.37, p = 0.104). In conclusion, the choice of anesthetic agent for noncardiac surgery did not significantly affect the development of MACCE in patients with previous coronary stent implantation. However, further randomized trials are needed to confirm our results. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Biomarker-Based Preoperative Risk Stratification for Patients Undergoing Non-Cardiac Surgery
J. Clin. Med. 2020, 9(2), 351; https://doi.org/10.3390/jcm9020351 - 27 Jan 2020
Cited by 4 | Viewed by 1790
Abstract
Perioperative morbidity and mortality remains a substantial problem and is strongly associated with patients’ cardiac comorbidities. Guidelines for the cardiovascular assessment and management of patients at risk of cardiac issues while undergoing non-cardiac surgery are traditionally based on the exclusion of active or [...] Read more.
Perioperative morbidity and mortality remains a substantial problem and is strongly associated with patients’ cardiac comorbidities. Guidelines for the cardiovascular assessment and management of patients at risk of cardiac issues while undergoing non-cardiac surgery are traditionally based on the exclusion of active or unstable cardiac conditions, determination of the risk of surgery, the functional capacity of the patient, and the presence of cardiac risk factors. In the last two decades, strong evidence showed an association between cardiac biomarkers and adverse cardiac events, with newer guidelines incorporating this knowledge. This review describes a biomarker-based risk-stratification pathway and discusses potential treatment strategies for patients suffering from postoperative myocardial injury or infarction. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Intraoperative Anesthetic Management of Patients with Chronic Obstructive Pulmonary Disease to Decrease the Risk of Postoperative Pulmonary Complications after Abdominal Surgery
J. Clin. Med. 2020, 9(1), 150; https://doi.org/10.3390/jcm9010150 - 06 Jan 2020
Cited by 5 | Viewed by 2800
Abstract
Patients with chronic obstructive pulmonary disease (COPD) exhibit airflow limitation and suboptimal lung function, and they are at high risk of developing postoperative pulmonary complications (PPCs). We aimed to determine the factors that would decrease PPC risk in patients with COPD. We retrospectively [...] Read more.
Patients with chronic obstructive pulmonary disease (COPD) exhibit airflow limitation and suboptimal lung function, and they are at high risk of developing postoperative pulmonary complications (PPCs). We aimed to determine the factors that would decrease PPC risk in patients with COPD. We retrospectively analyzed 419 patients with COPD who were registered in our institutional PPC database and had undergone an abdominal surgery under general anesthesia. PPCs comprised respiratory failure, pleural effusion, atelectasis, respiratory infection, and bronchospasm; the presence or type of PPC was diagnosed by respiratory physicians and recorded in the database before this study. Binary logistic regression was used for statistical analysis. Of the 419 patients, 121 patients (28.8%) experienced 200 PPCs. Multivariable analysis showed three modifiable anesthetic factors that could decrease PPC risk: low tidal volume ventilation, restricted fluid infusion, and sugammadex-induced neuromuscular blockade reversal. We found that the 90-day mortality risk was significantly greater in patients with PPC than in those without PPC (5.8% vs. 1.3%; p = 0.016). Therefore, PPC risk in patients with COPD can be decreased if low tidal volume ventilation, restricted fluid infusion, and sugammadex-induced reversal during abdominal surgery are efficiently managed, as these factors result in decreased postoperative mortality. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
The Extended Postoperative Care-Score (EXPO-Score)—An Objective Tool for Early Identification of Indication for Extended Postoperative Care
J. Clin. Med. 2019, 8(10), 1666; https://doi.org/10.3390/jcm8101666 - 12 Oct 2019
Cited by 2 | Viewed by 1109
Abstract
Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early [...] Read more.
Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early prediction of admission to extended care in surgical patients. This prospective observational study was divided into two periods (Period 1: Extended Postoperative Care-Score (EXPO)-Score generation; Period 2: EXPO-Score validation) and it was performed at a tertiary university center in Germany. A total of 4042 (Period 1) and 2198 (Period 2) adult patients ≥ 18 years old receiving elective or emergency surgery were included in this study. After identifying patient- and surgery-related risk factors by an expert panel, the EXPO-Score was developed through logistic regression from data of Period 1 and validated in Period 2. Three risk factors are sufficient for generating a reliable predictive EXPO-Score: (1) the American Society of Anesthesiologists’ (ASA) physical status, (2) cardiopulmonary physical exercise status expressed in metabolic equivalents (MET), and (3) the type of surgery. The score threshold (0.23) has a sensitivity of 0.87, a specificity of 0.91, and an accuracy of 0.90 for predicting indication for extended postoperative care. The EXPO-Score provides a validated, early collectable, and easy-to-use tool for predicting indication of extended postoperative care in adult surgical patients. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Low Muscle Mass as a Prognostic Factor for Early Postoperative Outcomes in Pediatric Patients Undergoing the Fontan Operation: A Retrospective Cohort Study
J. Clin. Med. 2019, 8(8), 1257; https://doi.org/10.3390/jcm8081257 - 19 Aug 2019
Cited by 5 | Viewed by 1512
Abstract
The impact of low muscle mass on pediatric cardiac patients remains unclear. We investigated the impact of low muscle mass on early postoperative outcomes in patients undergoing the Fontan operation. The electronic medical records of 74 patients (aged <18 years) who underwent the [...] Read more.
The impact of low muscle mass on pediatric cardiac patients remains unclear. We investigated the impact of low muscle mass on early postoperative outcomes in patients undergoing the Fontan operation. The electronic medical records of 74 patients (aged <18 years) who underwent the Fontan operation were retrospectively reviewed. The cross-sectional areas of the erector spinae and pectoralis muscles were measured using preoperative chest computed tomography (CT), normalized to the body surface area, and combined to obtain the total skeletal muscle index (TSMI). Low muscle mass was defined as a TSMI value lower than the median TSMI for the second quintile. The incidence of major postoperative complications was higher in patients with low muscle mass than in those with high muscle mass (48% (15/31) versus 14% (6/43); P = 0.003). Multivariable analyses revealed that a higher TSMI was associated with a lower likelihood of an increased duration of intensive care unit (>5 days) and hospital stay (>14 days) (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.77–0.96; P = 0.006 and OR 0.92; 95% CI 0.85–0.99; P = 0.035 per 1 cm2/m2 increase in TSMI) and incidence of major postoperative complications (OR 0.90; 95% CI 0.82–0.99; P = 0.039 per 1 cm2/m2 increase in TSMI). Preoperative low muscle mass was associated with poor early postoperative outcomes in pediatric patients undergoing the Fontan operation. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Serum Alkaline Phosphatase as a Predictor of Cardiac and Cerebrovascular Complications after Lumbar Spinal Fusion Surgery in Elderly: A Retrospective Study
J. Clin. Med. 2019, 8(8), 1111; https://doi.org/10.3390/jcm8081111 - 26 Jul 2019
Cited by 7 | Viewed by 1069
Abstract
We retrospectively enrolled 1395 patients aged > 65 years undergoing posterior lumbar spinal fusion surgery and classified them into tertiles based on serum Alkaline Phosphatase (ALP) levels (<63, 63–79, >79 IU/L). The primary outcome was the incidence of 30-day major adverse cardiac and [...] Read more.
We retrospectively enrolled 1395 patients aged > 65 years undergoing posterior lumbar spinal fusion surgery and classified them into tertiles based on serum Alkaline Phosphatase (ALP) levels (<63, 63–79, >79 IU/L). The primary outcome was the incidence of 30-day major adverse cardiac and cerebrovascular events (MACCE; composite endpoint defined as the occurrence of ≥1 of the following events: new-onset myocardial infarction, stroke, or cardiovascular mortality). The incidence of the composite endpoint was the highest in the third serum ALP tertile (0.4% vs. 0.2% vs. 2.2% in the first, second, and third tertile, respectively, p = 0.003). Multivariate analysis showed that the third serum ALP tertile was an independent predictor of the composite endpoint of MACCE (odds ratio 4.507, 95% confidence interval 1.378–14.739, p = 0.013). The optimal cut-off value of preoperative serum ALP showing the best discriminatory capacity to predict postoperative MACCE (measured by receiver-operating characteristic curve analysis) was 83 IU/L (area under curve 0.694, 95% confidence interval 0.574–0.813, p = 0.016). Preoperative serum ALP levels were independently associated with the composite endpoint of postoperative 30-days MACCE. We suggest that serum ALP can be used as a biomarker to predict cardiac and cerebrovascular complications following lumbar spinal fusion surgery in elderly patients. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Article
Impact of Remote Ischemic Preconditioning Conducted in Living Kidney Donors on Renal Function in Donors and Recipients Following Living Donor Kidney Transplantation: A Randomized Clinical Trial
J. Clin. Med. 2019, 8(5), 713; https://doi.org/10.3390/jcm8050713 - 20 May 2019
Cited by 7 | Viewed by 1511
Abstract
Although remote ischemic preconditioning (RIPC) has been shown to have renoprotective effects, few studies have assessed the effects of RIPC on renal function in living kidney donors. This study investigated whether RIPC performed in living kidney donors could improve residual renal function in [...] Read more.
Although remote ischemic preconditioning (RIPC) has been shown to have renoprotective effects, few studies have assessed the effects of RIPC on renal function in living kidney donors. This study investigated whether RIPC performed in living kidney donors could improve residual renal function in donors and outcomes in recipients following kidney transplantation. The donors were randomized into a control group (n = 85) and a RIPC group (n = 85). The recipients were included according to the matched donors. Serum creatinine (sCr) concentrations and estimated glomerular filtration rate (eGFR) were compared between control and RIPC groups in donors and recipients. Delayed graft function, acute rejection, and graft failure within one year after transplantation were evaluated in recipients. sCr was significantly increased in the control group (mean, 1.13; 95% confidence interval (CI), 1.07–1.18) than the RIPC group (1.01; 95% CI, 0.95–1.07) (p = 0.003) at discharge. Donors with serum creatinine >1.4 mg/dL at discharge had higher prevalence of chronic kidney disease (n = 6, 26.1%) than donors with a normal serum creatinine level (n = 8, 5.4%) (p = 0.003) after one year. sCr concentrations and eGFR were similar in the RIPC and control groups of recipients over the one-year follow-up period. Among recipients, no outcome variables differed significantly in the RIPC and control groups. RIPC was effective in improving early renal function in kidney donors but did not improve renal function in recipients. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Review

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Review
Update for Anaesthetists on Clinical Features of COVID-19 Patients and Relevant Management
J. Clin. Med. 2020, 9(5), 1495; https://doi.org/10.3390/jcm9051495 - 15 May 2020
Cited by 7 | Viewed by 2938
Abstract
When preparing for the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the coronavirus infection disease (COVID-19) questions arose regarding various aspects concerning the anaesthetist. When reviewing the literature it became obvious that keeping up-to-date with all relevant publications is [...] Read more.
When preparing for the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the coronavirus infection disease (COVID-19) questions arose regarding various aspects concerning the anaesthetist. When reviewing the literature it became obvious that keeping up-to-date with all relevant publications is almost impossible. We searched for and summarised clinically relevant topics that could help making clinical decisions. This is a subjective analysis of literature concerning specific topics raised in our daily practice (e.g., clinical features of COVID-19 patients; ventilation of the critically ill COVID-19 patient; diagnostic of infection with SARS-CoV-2; stability of the virus; Covid-19 in specific patient populations, e.g., paediatrics, immunosuppressed patients, patients with hypertension, diabetes mellitus, kidney or liver disease; co-medication with non-steroidal anti-inflammatory drugs (NSAIDs); antiviral treatment) and we believe that these answers help colleagues in clinical decision-making. With ongoing treatment of severely ill COVID-19 patients other questions will come up. While respective guidelines on these topics will serve clinicians in clinical practice, regularly updating all guidelines concerning COVID-19 will be a necessary, although challenging task in the upcoming weeks and months. All recommendations during the current extremely rapid development of knowledge must be evaluated on a daily basis, as suggestions made today may be out-dated with the new evidence available tomorrow. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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Review
The Right Ventricle—You May Forget It, But It Will Not Forget You
J. Clin. Med. 2020, 9(2), 432; https://doi.org/10.3390/jcm9020432 - 05 Feb 2020
Cited by 13 | Viewed by 1974
Abstract
Right ventricular (RV) dysfunction and failure are common and often overlooked causes of perioperative deterioration and adverse outcomes. Due to its unique pathophysiologic underpinnings, RV failure often does not respond to typical therapeutic measures such as volume resuscitation and often worsens when therapy [...] Read more.
Right ventricular (RV) dysfunction and failure are common and often overlooked causes of perioperative deterioration and adverse outcomes. Due to its unique pathophysiologic underpinnings, RV failure often does not respond to typical therapeutic measures such as volume resuscitation and often worsens when therapy is escalated and mechanical ventilation is begun, with a danger of irreversible cardiovascular collapse and death. The single most important factor in improving outcomes in the context of RV failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation is set in motion, rapidly spiraling down into a state of shock culminating in multi-organ failure and ultimately death. Therapy of RV failure must focus on rapidly reestablishing RV coronary perfusion, lowering pulmonary vascular resistance and optimizing volemia. In parallel, underlying reversible causes should be sought and if possible treated. In all stages of diagnostics and therapy, echocardiography plays a central role. In severe cases of RV dysfunction there remains a role for the use of the pulmonary artery catheter. When these mostly simple measures are undertaken in a timely fashion, the spiral of death of RV failure can often be broken or even prevented altogether. Full article
(This article belongs to the Special Issue Anesthesia for the High-Risk Patient)
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