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Top 9 updates in perioperative medicine from 2014

BOSTON – The top 9 studies published in 2014 in the area of perioperative medicine provided important data on perioperative cardiac medicine, perioperative beta-blockers, perioperative pulmonary medicine, venous thromboembolism prevention, and perioperative medication management.

“In selecting the 9 articles to highlight, we used the predetermined criteria of clinical relevance to internal medicine physicians, potential for practice change, and strength of the evidence,” the researchers said in an ACP press release. “We gave priority to practice guidelines or meta-analyses that addressed clinical questions important to perioperative care."

Summaries of the selected studies appeared in the Annals of Internal Medicine as part of its Summaries of the Year’s Most Important Studies Pertaining to the Practice of Internal Medicine. The summaries of the studies, which were chosen for their contribution to the advancement of various aspects of internal medicine, were published to coincide with the 100th annual ACP Internal Medicine Meeting here.

The following are the top 9 updates from 2014 in the field of perioperative medicine.

1. An algorithmic approach to preoperative cardiac risk assessment should be utilized determine the necessity of cardiac stress testing.

This American College of Cardiology (ACC)/American Heart Association (AHA) guideline also addresses preoperative risk assessment, cardiovascular testing, pharmacologic management during surgery, the timeline of surgery after percutaneous intervention and perioperative monitoring of patients undergoing noncardiac surgery who are at risk for, or are currently affected by cardiovascular disease.

“Clinicians who provide perioperative care should familiarize themselves with this guideline,” the researchers wrote.

2. When considering perioperative beta-blockers, careful patient selection is essential.
In the systematic review of 89 randomized clinical trials, researchers found that perioperative use of beta blockers may confer less risk and more potential benefit in cardiac surgery patients.

“There is also potential risk reduction with regard to perioperative acute MI and cardiac ischemia in noncardiac surgery patients, but this must be carefully weighed against the possible increased risk for mortality, stroke and hemodynamic instability,” the researchers wrote.

3. Postoperative elevations in troponin levels may be predictive of myocardial injury after noncardiac surgery.

In this international, prospective cohort study, researchers found that independent of ischemic characteristics, postoperative increases in troponin T  is fairly prevalent, and may increase the risk of 30-day mortality.

“The significant number of patients with myocardial injury after noncardiac surgery, and the associated 10-fold increase in 30-day mortality, calls into question the current practice of clinically dismissing minor elevations of the troponin T level in the postoperative period,” the researchers wrote.

4. Long-term outcomes from postoperative elevated troponin levels are likely improved through guideline-based medical management.

In a case-control study, researchers found that in patients undergoing elective major vascular surgery who had elevated troponin I levels, postoperative therapeutic intensification of cardiovascular treatment was associated with 1-year major event-free survival: “Although no definite practice recommendations should be based on these observations, this is the first evidence to suggest that intensive treatment of a postoperative elevated troponin level with evidence-based medical management of acute coronary syndrome might improve long-term cardiac outcomes,” the researchers wrote.

5. In patients undergoing noncardiac surgery, neither aspirin nor clonidine appears to decrease the risk of death or nonfatal MI.

Data from the POISE-2 Trial found that found that neither perioperative aspirin nor clonidine decreased risk of perioperative MI or death, but did elevate the risk of significant side effects.

“Initiating therapy with either drug just before surgery should be done with caution and individualized to both the patient and surgery type, with increased vigilance for side effects,” the researchers wrote.

6. In patients undergoing cardiothoracic or upper abdominal surgery, postoperative pulmonary complications can be reduced through preoperative inspiratory training.

In a systematic review and meta-analysis, researchers found that in cardiothoracic and upper abdominal surgery patients, 4 weeks of preoperative inspiratory muscle training can significantly reduce postoperative pulmonary complications and their associated health care costs.

“If this relatively simple intervention can reduce postoperative pulmonary complications by one half, it will have a substantial effect,” the researchers wrote.

7. The risk of postoperative cardiovascular complications can be reduced by preoperative diagnosis of obstructive sleep apnea and treatment with continuous positive airway pressure (CPAP).

In a matched cohort study, researchers found a correlation between obstructive sleep apnea and surgical outcomes, but noted that CPAP may decrease the risk of postoperative cardiovascular complications.

“Administrative data did not enable identification of all important confounders or adherence to CPAP,” the researchers wrote.

8. In patients undergoing major surgery, a combination of compression and anticoagulation appears to be superior to either modality alone in the prevention of postoperative deep venous thrombosis.

This systematic review and meta-analysis, researchers found that in patients at high risk for deep venous thrombosis (DVT), a combination treatment with compression and anticoagulation was more effective than either approach alone.

9. In certain patients, the preoperative discontinuation of ACE inhibitors and angiotensin receptor blocker treatment may be safe.

In a randomized clinical trial, researchers found that in some patients undergoing ambulatory or same-day surgery, it may be safe to discontinue the use of ACE inhibitors or ARBs.

Disclosure: The researchers report no relevant disclosures.