Adriana D. Oprea

ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly

From the Department of Anesthesiology, Yale University, New Haven, CT. Address reprint requests to Adriana Dana Oprea, MD, Department of Anesthesiology, Yale University, 333 Cedar Street TMP 3, PO Box 208051, New Haven, CT 06520-8051. E-mail: adriana.oprea@yale.edu & 2013 Elsevier Inc. All rights reserved. 1053-0770/2601-0001

P2Y12 Receptor Inhibitors in Acute Coronary Syndromes: What Is New on the Horizon?

36.00/0 http://dx.doi.org/10.1053/j.jvca.2012.11.014

Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy.

Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor represents the cornerstone therapy for patients with acute coronary syndromes or undergoing percutaneous interventions, leading to a reduction of subsequent ischemic events. Variable response to clopidogrel has received close attention, and pharmacokinetic, pharmacodynamic, and pharmacogenomic factors have been identified as culprits. This led to the introduction of newer, potentially safer, and more effective antiplatelet agents (prasugrel and ticagrelor). Additionally, several point-of-care assays of platelet function have been developed in recent years to rapidly screen individuals on antiplatelet therapy. While the routine use of platelet function testing is uncertain and not currently recommended, it may be useful in instances when the degree of platelet inhibition may be uncertain such as high-risk patients undergoing percutaneous coronary intervention or when there may be a suspected pharmacodynamic interaction with other drugs. The current paper focuses on the P2Y12 receptor inhibitors and their pharmacogenetics and indications in patients with acute coronary syndromes or receiving percutaneous coronary interventions as well as the applicability of platelet function testing in this clinical context.

Baseline pulse pressure, acute kidney injury, and mortality after noncardiac surgery

As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.

Comparison Between the 2007 and 2014 American College of Cardiology/American Heart Association Guidelines on Perioperative Evaluation for Noncardiac Surgery.

BACKGROUND:Increased pulse pressure (PP) is an important independent predictor of cardiovascular outcome and acute kidney injury (AKI) after cardiac surgery. The objective of this study was to determine whether elevated baseline PP is associated with postoperative AKI and 30-day mortality after noncardiac surgery. METHODS:We evaluated 9125 adult patients who underwent noncardiac surgery at Duke University Medical Center between January 2006 and December 2009. Baseline arterial blood pressure was defined as the mean of the first 5 measurements recorded by the automated record keeping system before inducing anesthesia. Multivariable logistic regression analysis was performed to determine whether baseline PP adjusted for other perioperative risk factors was independently associated with postoperative AKI and 30-day mortality. RESULTS:Of the 9125 patients, the baseline PP was <40 mm Hg in 1426 (15.6%), 40–80 mm Hg in 6926 (75.9%), and >80 mm Hg in 773 (8.5%) patients. The incidence of AKI was 19.8%, which included 8.4% (151 patients) and 4.2% (76 patients) who experienced stage II and III AKI, respectively. In the risk-adjusted model for postoperative AKI, elevated baseline PP was associated with higher odds for postoperative AKI (adjusted odds ratio [OR] for every 20 mm Hg increase in PP, 1.17; 95% confidence interval [CI], 1.10–1.25; P < .0001). Also elevated baseline preoperative PP was significantly associated with mild (stage I; OR, 1.19; 95% CI, 1.11–1.27; P < .0001), but not with more advanced stages of postoperative AKI or with an incremental risk for 30-day mortality. CONCLUSIONS:We found a significant association between elevated baseline PP and postoperative AKI in patients who underwent noncardiac surgery. However, elevated PP was not significantly associated with more advanced stages of postoperative AKI or 30-day mortality in these patients.

A case of adjustable pressure-limiting (APL) valve failure

ARDIOVASCULAR COMPLICATIONS are the major causes of perioperative morbidity and mortality, with myocardial infarctions occurring in 1% to 3% of unselected patients undergoing major noncardiac surgery. 1 The prevalence of perioperative cardiovascular complications correlates with the high frequency of underlying coronary artery disease (CAD) and is associated with major healthcare costs. 2,3 With the increased incidences of cardiac disease and comorbidities in older patients, preoperative optimization is essential to decrease postoperative major adverse cardiac events (MACE). 4 Recommendations for perioperative cardiovascular risk assessment for noncardiac surgery patients can be based on the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Evaluation for Noncardiac Surgery. These guidelines were developed to help perioperative physicians evaluate and manage cardiovascular risk for noncardiac surgery. 5,6 The ACC/AHA guidelines provide a suitable framework for evaluating cardiac risk based on the presence of potentially serious cardiac disorders including CAD, congestive heart failure, valvular heart disease, and arrhythmias. 5,6 The preoperative cardiac evaluation for noncardiac surgery also emphasizes the patient’s functional status and understanding the surgical risk. This risk assessment allows physicians to assign a clinical risk profile to an individual patient, which allows cardiologists, anesthesiologists, and surgeons to make informed treatment decisions that may influence short-term and long-term cardiovascular outcomes. 7–9 Regularly updated evidence-based guidelines ensure the best possible patient care. The purpose of this review is to highlight changes in the 2014 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery and to compare the new recommendations with the 2007 ACC/AHA guidelines. To achieve this objective, the authors evaluated the work-up of a patient who underwent an esophagectomy and had numerous risk factors due to coexisting cardiovascular disease. Where necessary, other relevant expert opinions and guidelines have been incorporated. For the purpose of this review, intraoperative and postoperative management are not discussed in detail.

Malignant Hyperthermia as a Complication of Maxillofacial Surgery

The adjustable pressure-limiting (APL) valve controls airway pressure during manual ventilation. Failure of the APL valve during induction of anesthesia may occur, and the anesthesiologist must be aware of solutions for this occurrence.

Left ventricular ejection fraction and left ventricular end-diastolic volume in patients with diastolic dysfunction.

Malignant hyperthermia (MH) is a rare anesthetic complication. This chapter will discuss the prevalence, pathophysiology, and manifestations of the condition. The surgeon must be familiar as to how to work up and manage a patient who is at risk or has a diagnosis or family history of malignant hyperthermia. Offices in which agents associated with malignant hyperthermia are used must be appropriately equipped and supplied to monitor and intervene as the patient can rapidly deteriorate once the process begins.