The Risk of Adverse #Pregnancy Outcomes Following Nonobstetric #Surgery During Pregnancy: Estimates From a Retrospective Cohort Study of 6.5 Million Pregnancies.

http://mobile.journals.lww.com/annalsofsurgery/_layouts/15/oaks.journals.mobile/articleviewer.aspx?year=9000&issue=00000&article=96410

Conclusions: Although we have no means of disentangling the effect of the surgery from the effect of the underlying condition, we found that the risk associated with nonobstetric surgery was relatively low, confirming that surgical procedures during pregnancy are generally safe. We believe that our findings improve upon previous research, and are useful reference points for any discussion of risk with prospective patients.

Withholding versus Continuing #Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac #Surgery

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2572372

Conclusions: Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

Relationship between high-sensitivity #Troponin T measurements and 30-day mortality after noncardiac #surgery
http://www.crtonline.org/presentation-detail/relationship-between-high-sensitivity-troponin-t-m

Slides link

#Daytime variation of perioperative myocardial injury in cardiac #surgery and its prevention by Rev-Erbα antagonism: a single-centre propensity-matched cohort study and a randomised study
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32132-3/fulltext?elsca1=tlpr

On-pump cardiac surgery provokes a predictable perioperative myocardial ischaemia–reperfusion injury which is associated with poor clinical outcomes. We determined the occurrence of time-of-the-day variation in perioperative myocardial injury in patients undergoing aortic valve replacement and its molecular mechanisms Ex-vivo analysis of human myocardium revealed an intrinsic morning–afternoon variation in hypoxia–reoxygenation tolerance, concomitant with transcriptional alterations in circadian gene expression with the nuclear receptor Rev-Erbα being highest in the morning. In a mouse Langendorff model of hypoxia–reoxygenation myocardial injury, Rev-Erbα gene deletion or antagonist treatment reduced injury at the time of sleep-to-wake transition, through an increase in the expression of the ischaemia–reperfusion injury modulator CDKN1a/p21.

Interpretation
Perioperative myocardial injury is transcriptionally orchestrated by the circadian clock in patients undergoing aortic valve replacement, and Rev-Erbα antagonism seems to be a pharmacological strategy for cardioprotection. Afternoon surgery might provide perioperative myocardial protection and lead to improved patient outcomes compared with morning surgery

#Aspirin in Patients With Previous Percutaneous #Coronary Intervention Undergoing Noncardiac #Surgery
http://annals.org/aim/article-abstract/2663288/aspirin-patients-previous-percutaneous-coronary-intervention-undergoing-noncardiac-surgery

Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery

In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% 95% CI, 0.4% to 10.5%; hazard ratio HR, 0.50 CI, 0.26 to 0.95; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% CI, 1.0% to 10.8%; HR, 0.44 CI, 0.22 to 0.87; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% CI, −2.6% to 5.2%). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% CI, 0.1% to 1.6%; HR, 1.22 CI, 1.01 to 1.48; P for interaction = 0.50)

Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI

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Risk and Risk Factors Associated With Recurrent Venous #Thromboembolism Following #Surgery in Patients With History of Venous Thromboembolism

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2733182

Of the 3741 patients, 580 (15.5%) underwent surgery and 601 (16.1%) developed a recurrent thrombotic event. The 1-month cumulative incidence of recurrent VTE for all surgery types was 2.1% (95% CI, 1.2%-3.6%), which increased to 3.3% (95% CI, 2.1%-5.1%) at 3 months and 4.6% (95% CI, 3.1%-6.6%) at 6 months. At 6 months, risk of recurrent VTE ranged from 2.3% to 9.3%, depending on surgery type. In addition to surgery type, factor V Leiden mutation (HR, 3.4; 95% CI, 1.6-7.4) and male sex (HR, 2.7; 95% CI, 1.3-5.8) were associated with increased risk of recurrent VTE.

Conclusions and Relevance Surgery was associated with an increased risk of recurrent VTE in patients with a history of VTE; risk remained high for up to 6 months after the procedure. This study suggests that high-risk individuals may be identified based on surgery type, sex, and the presence of factor V Leiden mutation.

These findings stress the need for revision of the current thromboprophylactic approach to prevent recurrence in these patients

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Association of #Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient #Surgery

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734068

length of stay (LOS)

.. In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk RR, 2.1; 95% CI, 2.0-2.3; LOS ≥ 1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS = 0, 22.8%; LOS ≥ 1, 29.3%).

Conclusions and Relevance These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.

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Adjunctive #liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic #surgery (GRAVITAS): a randomised, double-blind, placebo-controlled trial

https://www.thelancet.com/journals/landia/article/PIIS2213-8587(19)30157-3/fulltext

In a multivariable linear regression analysis, with baseline HbA 1c levels and surgery type as covariates, liraglutide treatment was associated with a difference of −13·3 mmol/mol (−1·22%, 95% CI −19·7 to −7·0; p=0·0001) in HbA 1c change from baseline to 26 weeks, compared with placebo. Type of surgery had no significant effect on the outcome. 24 (45%) of 53 patients assigned to liraglutide and 11 (41%) of 27 assigned to placebo reported adverse effects: these were mainly gastrointestinal and in line with previous experience with liraglutide. There was one death during the study in a patient assigned to the placebo group, which was considered unrelated to study treatment.

Interpretation
These findings support the use of adjunctive liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic surgery

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Association between #complications and death within 30 days after noncardiac #surgery

http://www.cmaj.ca/content/191/30/E830

Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2–3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9–2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6–6.8; AF 12.0%).

INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality.

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American Academy of #Pediatrics – Section on #Surgery
Five Things Physicians and Patients Should Question

. Avoid the routine use of whole-body computed tomography (CT) scanning (pan-scanning) in pediatric trauma patients.

. Avoid using computed tomography (CT scan) as the first-line imaging modality in the evaluation of suspected appendicitis in children. Ultrasound should be done first with a CT scan or magnetic resonance imaging (MRI) considered in equivocal cases.

. Avoid performing antireflux operations (fundoplications) during gastrostomy insertion in most children who are otherwise growing and thriving with gastric feedings.

 . Avoid referring most children with umbilical hernias to a pediatric surgeon until around age 4-5 years.

. Reduce post-operative opioid requirements in pediatric patients by administering acetaminophen and/or non-steroidal anti-inflammatory medications in the perioperative period.

 http://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on-surgery/

Association of New-Onset Atrial #Fibrillation After Noncardiac #Surgery With Subsequent #Stroke and Transient Ischemic Attack
https://2medical.news/2020/09/04/association-of-new-onset-atrial-fibrillation-after-noncardiac-surgery-with-subsequent-stroke-and-transient-ischemic-attack/

Outcomes of postoperative atrial fibrillation (AF) after noncardiac surgery are not well defined.. ..The median age of the 452 matched patients was 75 years (IQR, 67-82 years) and 51.8% of patients were men. Patients with postoperative AF had significantly higher CHA2DS2-VASc scores than those in the no AF group (median, 4 [IQR, 2-5] vs 3 [IQR, 2-5]; P < .001). Over a median follow-up of 5.4 years …