Publications by authors named "Roop Kaw"

56 Publications

Obesity and Obesity Hypoventilation, Sleep Hypoventilation, and Postoperative Respiratory Failure.

Anesth Analg 2021 05;132(5):1265-1273

Department of Medicine, University of Chicago, Chicago, Illinois.

Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ≥30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.
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http://dx.doi.org/10.1213/ANE.0000000000005352DOI Listing
May 2021

Is regular oxygen supplementation safe for obese postoperative patients?

Cleve Clin J Med 2020 11 23;87(12):723-727. Epub 2020 Nov 23.

Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.

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http://dx.doi.org/10.3949/ccjm.87a.19051DOI Listing
November 2020

Obesity Hypoventilation: Traditional Versus Nontraditional Populations.

Sleep Med Clin 2020 Dec 26;15(4):449-459. Epub 2020 Sep 26.

Quebec National Program for Home Ventilatory Assistance, Respiratory Division and Sleep Laboratory, McGill University Health Centre, 1001 Decarie Boulevard, Montreal, Quebec H4A 3J1, Canada.

Obesity hypoventilation syndrome is the most frequent cause of chronic hypoventilation and is increasingly more common with rising obesity rates. It leads to considerable morbidity and mortality, particularly when not recognized and treated adequately. Long-term nocturnal noninvasive ventilation is the mainstay of treatment but evidence suggests that CPAP may be effective in stable patients. Specific perioperative management is required to reduce complications. Some unique syndromes associated with obesity and hypoventilation include rapid-onset obesity with hypoventilation, hypothalamic, autonomic dysregulation (ROHHAD), and Prader-Willi syndrome. Congenital central hypoventilation syndrome (early or late-onset) is a genetic disorder resulting in hypoventilation. Several acquired causes of chronic central hypoventilation also exist. A high level of clinical suspicion is required to appropriately diagnose and manage affected patients.
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http://dx.doi.org/10.1016/j.jsmc.2020.08.001DOI Listing
December 2020

Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial.

Anesth Analg 2020 10;131(4):1012-1024

Trident Anesthesia Group, LLC, Charleston, South Carolina.

Background: Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring.

Methods: PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping.

Results: One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring.

Conclusions: A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
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http://dx.doi.org/10.1213/ANE.0000000000004788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467153PMC
October 2020

Letter to the Editor: Preoperative Dobutamine Stress Echocardiography and Clinical Factors for Assessment of Cardiac Risk after Noncardiac Surgery.

Authors:
Roop Kaw

J Am Soc Echocardiogr 2020 10 22;33(10):1293-1294. Epub 2020 Jul 22.

Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.echo.2020.06.005DOI Listing
October 2020

Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2019 08;200(3):e6-e24

The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: ) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, ) stable ambulatory patients with OHS receive positive airway pressure (PAP), ) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, ) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2-3 mo), and ) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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http://dx.doi.org/10.1164/rccm.201905-1071STDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6680300PMC
August 2019

Use of adaptive servo ventilation therapy as treatment of sleep-disordered breathing and heart failure: a systematic review and meta-analysis.

Sleep Breath 2020 Mar 3;24(1):49-63. Epub 2019 Jul 3.

Department of Hospital Medicine and Anesthesiology Outcomes Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.

Purpose: Adaptive servoventilation (ASV) has been reported to show improvement in patients with sleep-disordered breathing (SDB) and heart failure (HF); however, its role as a second-line or adjunctive treatment is not clear. We conducted a systematic review and meta-analysis of new existing data including cardiac mechanistic factor, geometry, and cardiac biomarkers.

Methods: We systematically searched for randomized controlled trials (RCTs) and cohort studies that assessed the efficacy or effectiveness of ASV compared to conventional treatments for SDB and HF in five research databases from their inception to November 2018. Random-effects meta-analyses using the inverse variance method and stratified by study design were performed.

Results: We included 15 RCTs (n = 859) and 5 cohorts (n = 162) that met our inclusion criteria. ASV significantly improved left ventricular ejection fraction (LVEF) in cohorts (MD 6.96%, 95% CI 2.58, 11.34, p = 0.002), but not in RCTs. Also, the ASV group had significantly lower apnea-hypopnea index (AHI) in both cohorts (MD - 26.02, 95% CI - 36.94, - 15.10, p < 0.00001) and RCTs (MD - 21.83, 95% CI - 28.17, - 15.49, p < 0.00001). ASV did not significantly decrease the E/e' ratio in RCTs or in cohorts. Finally, ASV significantly decreased brain natriuretic peptide (BNP) in the cohorts (SMD - 121.99, CI 95% - 186.47, - 57.51, p = 0.0002) but not in RCTs. ASV did not have a significant effect on systolic blood pressure, diastolic blood pressure, and cardiac diameters.

Conclusions: ASV therapy is associated with improvements of AHI in comparison to alternative treatments in patients with SDB and HF. ASV did not improve LVEF or E/e' ratios in randomized trials; other intermediate outcomes did not improve significantly.
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http://dx.doi.org/10.1007/s11325-019-01882-8DOI Listing
March 2020

Pulmonary infarction due to pulmonary embolism.

Cleve Clin J Med 2018 11;85(11):848-852

Departments of Hospital Medicine and Outcomes Research Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.3949/ccjm.85a.17132DOI Listing
November 2018

Obstructive Sleep Apnea and Risk of Postcardiac Surgery Atrial Fibrillation.

Anesth Analg 2018 11;127(5):e87-e88

Departments of Hospital Medicine and Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, Ohio, Center for Sleep Disorders, Respiratory Institute, Heart and Vascular Institute, Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1213/ANE.0000000000003749DOI Listing
November 2018

The role of B-type natriuretic peptide in diagnosing acute decompensated heart failure in chronic kidney disease patients.

Arch Med Sci 2018 Aug 13;14(5):1003-1009. Epub 2018 Aug 13.

Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Introduction: Chronic kidney disease (CKD) and congestive heart failure (CHF) patients have higher serum B-type natriuretic peptide (BNP), which alters the test interpretation. We aim to define BNP cutoff levels to diagnose acute decompensated heart failure (ADHF) in CKD according to CHF subtype: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).

Material And Methods: We reviewed 1,437 charts of consecutive patients who were admitted for dyspnea. We excluded patients with normal kidney function, without measured BNP, echocardiography, or history of CHF. BNP cutoff values to diagnose ADHF for CKD stages according to CHF subtype were obtained for the highest pair of sensitivity (Sn) and specificity (Sp). We calculated positive and negative likelihood ratios (LR+ and LR-, respectively), and diagnostic odds ratios (DOR), as well as the area under the receiver operating characteristic curves (AUC) for BNP.

Results: We evaluated a cohort of 348 consecutive patients: 152 had ADHF, and 196 had stable CHF. In those with HFpEF with CKD stages 3-4, BNP < 155 pg/ml rules out ADHF (Sn90%, LR- = 0.26 and DOR = 5.75), and BNP > 670 pg/ml rules in ADHF (Sp90%, LR+ = 4 and DOR = 6), with an AUC = 0.79 (95% CI: 0.71-0.87). In contrast, in those with HFrEF with CKD stages 3-4, BNP < 412.5 pg/ml rules out ADHF (Sn90%, LR- = 0.19 and DOR = 9.37), and BNP > 1166.5 pg/ml rules in ADHF (Sp87%, LR+ = 3.9 and DOR = 6.97) with an AUC = 0.78 (95% CI: 0.69-0.86). All LRs and DOR were statistically significant.

Conclusions: BNP cutoff values for the diagnosis of ADHF in HFrEF were higher than those in HFpEF across CKD stages 3-4, with moderate discriminatory diagnostic ability.
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http://dx.doi.org/10.5114/aoms.2018.77263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6111357PMC
August 2018

Predictive Value of Stress Testing, Revised Cardiac Risk Index, and Functional Status in Patients Undergoing Noncardiac Surgery.

J Cardiothorac Vasc Anesth 2019 04 24;33(4):927-932. Epub 2018 Jul 24.

Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada.

Objective: Patients undergoing noncardiac surgery are at risk for postoperative cardiovascular complications. Literature regarding the ability of the Revised Cardiac Risk Index (RCRI), functional capacity, and stress testing to predict perioperative cardiac events is scarce. The authors examined the association of these parameters with perioperative cardiac events and their additive ability to predict these outcomes.

Design: This was a single-center retrospective study conducted at the Cleveland Clinic.

Setting: Hospital.

Participants: Patients undergoing noncardiac surgery.

Intervention: Patients underwent stress testing.

Measurements And Main Results: The primary outcome of interest was major adverse cardiac events (MACE). The study cohort included 509 patients with a predominantly good functional status, as defined by estimated metabolic equivalents (METSe), which was ≥4 in 83% of the patients. The addition of preoperative stress testing, when indicated based on the RCRI and functional class limitation, only modestly improved discrimination of risk for postoperative outcomes (METSe + RCRI + positive stress test-C statistic 0.77 for MACE; 0.84 for 1-year mortality) compared with the combination of functional capacity (METSe) and RCRI (C statistic 0.70 for MACE; 0.79 for 1-year mortality). A surprisingly high prevalence of false negative stress tests (negative stress tests in patients who later had presence of obstructive coronary disease on angiography) was noted, but the C statistic for MACE remained unchanged, even when no false negative results were assumed.

Conclusions: In a cohort of patients with predominantly good functional status and intermediate-to-high RCRI scores, addition of a preoperative stress test was of only moderate value in predicting postoperative cardiovascular outcomes compared with a combination of functional class and RCRI.
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http://dx.doi.org/10.1053/j.jvca.2018.07.020DOI Listing
April 2019

Knowledge Gaps in the Perioperative Management of Adults with Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome. An Official American Thoracic Society Workshop Report.

Ann Am Thorac Soc 2018 02;15(2):117-126

The purpose of this workshop was to identify knowledge gaps in the perioperative management of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). A single-day meeting was held at the American Thoracic Society Conference in May, 2016, with representation from many specialties, including anesthesiology, perioperative medicine, sleep, and respiratory medicine. Further research is urgently needed as we look to improve health outcomes for these patients and reduce health care costs. There is currently insufficient evidence to guide screening and optimization of OSA and OHS in the perioperative setting to achieve these objectives. Patients who are at greatest risk of respiratory or cardiac complications related to OSA and OHS are not well defined, and the effectiveness of monitoring and other interventions remains to be determined. Centers involved in sleep research need to develop collaborative networks to allow multicenter studies to address the knowledge gaps identified below.
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http://dx.doi.org/10.1513/AnnalsATS.201711-888WSDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850745PMC
February 2018

Sleep disordered breathing and post-cardiac surgery atrial fibrillation.

J Thorac Dis 2017 Sep;9(9):E867-E868

Sleep Disorders Center, Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, USA.

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http://dx.doi.org/10.21037/jtd.2017.08.105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708439PMC
September 2017

Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis of Comparative Studies.

Anesth Analg 2017 12;125(6):2030-2037

Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Obstructive sleep apnea (OSA) is a common comorbidity in patients undergoing cardiac surgery and may predispose patients to postoperative complications. The purpose of this meta-analysis is to determine the evidence of postoperative complications associated with OSA patients undergoing cardiac surgery.

Methods: A literature search of Cochrane Database of Systematic Reviews, Medline, Medline In-process, Web of Science, Scopus, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL until October 2016 was performed. The search was constrained to studies in adult cardiac surgical patients with diagnosed or suspected OSA. All included studies must report at least 1 postoperative complication. The primary outcome is major adverse cardiac or cerebrovascular events (MACCEs) up to 30 days after surgery, which includes death from all-cause mortality, myocardial infarction, myocardial injury, nonfatal cardiac arrest, revascularization process, pulmonary embolism, deep venous thrombosis, newly documented postoperative atrial fibrillation (POAF), stroke, and congestive heart failure. Secondary outcome is newly documented POAF. The other exploratory outcomes include the following: (1) postoperative tracheal intubation and mechanical ventilation; (2) infection and/or sepsis; (3) unplanned intensive care unit (ICU) admission; and (4) duration of stay in hospital and ICU. Meta-analysis and meta- regression were conducted using Cochrane Review Manager 5.3 (Cochrane, London, UK) and OpenBUGS v3.0, respectively.

Results: Eleven comparative studies were included (n = 1801 patients; OSA versus non-OSA: 688 vs 1113, respectively). MACCEs were 33.3% higher odds in OSA versus non-OSA patients (OSA versus non-OSA: 31% vs 10.6%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.38-4.2; P = .002). The odds of newly documented POAF (OSA versus non-OSA: 31% vs 21%; OR, 1.94; 95% CI, 1.13-3.33; P = .02) was higher in OSA compared to non-OSA. Even though the postoperative tracheal intubation and mechanical ventilation (OSA versus non-OSA: 13% vs 5.4%; OR, 2.67; 95% CI, 1.03-6.89; P = .04) were significantly higher in OSA patients, the length of ICU stay and hospital stay were not significantly prolonged in patients with OSA compared to non-OSA. The majority of OSA patients were not treated with continuous positive airway pressure therapy. Meta-regression and sensitivity analysis of the subgroups did not impact the OR of postoperative complications for OSA versus non-OSA groups.

Conclusions: Our meta-analysis demonstrates that after cardiac surgery, MACCEs and newly documented POAF were 33.3% and 18.1% higher odds in OSA versus non-OSA patients, respectively.
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http://dx.doi.org/10.1213/ANE.0000000000002558DOI Listing
December 2017

Do HCAHPS Doctor Communication Scores Reflect the Communication Skills of the Attending on Record? A Cautionary Tale from a Tertiary-Care Medical Service.

J Hosp Med 2017 06;12(6):421-427

Center for Value-based Care Research, Cleveland Clinic Medicine Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores measure patient satisfaction with hospital care. It is not known if these reflect the communication skills of the attending physician on record. The Four Habits Coding Scheme (4HCS) is a validated instrument that measures bedside physician communication skills according to 4 habits, namely: investing in the beginning, eliciting the patient's perspective, demonstrating empathy, and investing in the end.

Objective: To investigate whether the 4HCS correlates with provider HCAHPS scores.

Methods: Using a cross-sectional design, consenting hospitalist physicians (n = 28), were observed on inpatient rounds during 3 separate encounters. We compared hospitalists' 4HCS scores with their doctor communication HCAHPS scores to assess the degree to which these correlated with inpatient physician communication skills. We performed sensitivity analysis excluding scores returned by patients cared for by more than 1 hospitalist.

Results: A total of 1003 HCAHPS survey responses were available. Pearson correlation between 4HCS and doctor communication scores was not significant, at 0.098 (-0.285, 0.455; P = 0.619). Also, no significant correlations were found between each habit and HCAHPS. When including only scores attributable to 1 hospitalist, Pearson correlation between the empathy habit and the HCAHPS respect score was 0.515 (0.176, 0.745; P = 0.005). Between empathy and overall doctor communication, it was 0.442 (0.082, 0.7; P = 0.019).

Conclusion: Attending-of-record HCAHPS scores do not correlate with 4HCS. After excluding patients cared for by more than 1 hospitalist, demonstrating empathy did correlate with the doctor communication and respect HCAHPS scores. Journal of Hospital Medicine 2017;12:421-427.
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http://dx.doi.org/10.12788/jhm.2743DOI Listing
June 2017

Obesity as an Effect Modifier in Sleep-Disordered Breathing and Postcardiac Surgery Atrial Fibrillation.

Chest 2017 06 12;151(6):1279-1287. Epub 2017 Mar 12.

Sleep Disorders Center, Neurologic Institute, Cleveland Clinic, Cleveland, OH; Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; Respiratory Institute and Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

Background: Because the interrelationships of objectively ascertained sleep-disordered breathing (SDB), postcardiac surgery atrial fibrillation (PCSAF), and obesity remain unclear, we aimed to further investigate the interrelationships in a clinic-based cohort.

Methods: Patients with polysomnography and cardiac surgery (coronary artery bypass surgery and/or valvular surgery) within 3 years, from January 2009 to January 2014, were identified, excluding those with preexisting atrial fibrillation. Logistic models were used to determine the association of SDB (apnea hypopnea index [AHI] per 5-unit increase) and secondary predictors (central sleep apnea [CSA] [central apnea index ≥ 5] and oxygen desaturation index [ODI]) with PCSAF. Models were adjusted for age, sex, race, BMI, and hypertension. Statistical interaction and stratification by median BMI was performed. ORs and 95% CIs are presented.

Results: There were 190 patients who comprised the analytic sample (mean age, 60.6 ± 11.4 years; 36.1% women; 80% white; BMI, 33.3 ± 7.5 kg/m; 93.2% had an AHI ≥ 5; 30% had PCSAF). Unlike unadjusted analyses (OR, 1.06; 95% CI, 1.01-1.1), in the adjusted model, increasing AHI was not significantly associated with increased odds of PCSAF (OR, 1.04; 95% CI, 0.98-1.1). Neither CSA nor ODI was associated with PCSAF. A significant interaction with median BMI was noted (P = .015). Effect modification by median BMI was observed; those with a higher BMI > 32 kg/m had 15% increased odds of PCSAF (OR, 1.15; 95% CI, 1.05-1.26; P < .003).

Conclusions: SDB was significantly associated with PCSAF in unadjusted analyses, but not after taking into account obesity; those with both SDB and obesity may represent a vulnerable subgroup to target to reduce PCSAF and its associated morbidity.
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http://dx.doi.org/10.1016/j.chest.2017.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026256PMC
June 2017

Spectrum of postoperative complications in pulmonary hypertension and obesity hypoventilation syndrome.

Authors:
Roop K Kaw

Curr Opin Anaesthesiol 2017 Feb;30(1):140-145

Departments of Hospital Medicine and Anesthesiology Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA.

Purpose Of Review: The purpose of this review is to identify chronic pulmonary conditions which may often not be recognized preoperatively especially before elective noncardiac surgery and which carry the highest risk of perioperative morbidity and mortality.

Recent Findings: This review discusses some of the most recent studies that highlight the perioperative complications, and their prevention and management strategies.

Summary: Pulmonary hypertension is a well recognized risk factor for postoperative complications after cardiac surgery but the literature surrounding noncardiac surgery is sparse. Pulmonary hypertension was only recently classified as an independent risk factor for postoperative complications in the American Heart Association/American College of Cardiology Foundation Practice Guideline for noncardiac surgery. Spinal anesthesia should be avoided in most surgeries on patients with pulmonary hypertension because of it's rapid sympatholytic effects. The presence of significant right ventricle dysfunction and marked hypoxemia should prompt re-evaluation of the need for elective surgery. Obesity hypoventilation syndrome is even harder to recognize preoperatively as arterial blood gases are generally not obtained prior to elective noncardiac surgery. Amongst patients with obstructive sleep apnea this group of patients carries much higher risk of postoperative respiratory and congestive heart failure.
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http://dx.doi.org/10.1097/ACO.0000000000000420DOI Listing
February 2017

Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea.

Anesth Analg 2016 08;123(2):452-73

From the *Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York; ‡Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; §Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph's Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph's Health care, Western University, London, Ontario, Canada; ‖Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care, Salzburg, Austria; ¶Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College New York, New York; #Department of Anesthesia, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; **Department of Medicine, University of California San Diego, San Diego, California; ††Sparrow Hospital, Lansing, Michigan; ‡‡Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Texas; §§Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada; ‖‖University of British Columbia, Vancouver, BC, Canada; ¶¶Department of Medicine, Emory University, Atlanta, Georgia; ##Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California; ***Department of Anesthesia, Critical Care and Pain Medicine, Harvard University, Cambridge, Massachusetts; †††Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; ‡‡‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; §§§Department of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, Minnesota; ‖‖‖School of Medicine, Universidad Peruana de Ciencias Apl

The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients' conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.
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http://dx.doi.org/10.1213/ANE.0000000000001416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4956681PMC
August 2016

Effect of diastolic dysfunction on postoperative outcomes after cardiovascular surgery: A systematic review and meta-analysis.

J Thorac Cardiovasc Surg 2016 10 7;152(4):1142-53. Epub 2016 Jun 7.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.

Objective: The objective of this study was to investigate the effect of preoperative diastolic dysfunction on postoperative mortality and morbidity after cardiovascular surgery.

Methods: We systematically searched for articles that assessed the prognostic role of diastolic dysfunction on cardiovascular surgery in PubMed, Cochrane Library, Web of Science, Embase, and Scopus until February 2016. Twelve studies (n = 8224) met our inclusion criteria. Because of the scarcity of outcome events, fixed-effects meta-analysis was performed via the Mantel-Haenszel method.

Results: Preoperative diagnosis of diastolic dysfunction was associated with greater postoperative mortality (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.54-3.71; P < .0001), major adverse cardiac events (OR, 2.07; 95% CI, 1.55-2.78; P ≤ .0001), and prolonged mechanical ventilation (OR, 2.08; 95% CI, 1.04-4.16; P = .04) compared with patients without diastolic dysfunction among patients who underwent cardiovascular surgery. The odds of postoperative myocardial infarction (OR, 1.29; 95% CI, 0.82-2.05; P = .28) and atrial fibrillation (OR, 2.67; 95% CI, 0.49-14.43; P = .25) did not significantly differ between the 2 groups. Severity of preoperative diastolic dysfunction was associated with increased postoperative mortality (OR, 21.22; 95% CI, 3.74-120.33; P = .0006) for Grade 3 diastolic dysfunction compared with patients with normal diastolic function. Inclusion of left ventricular ejection fraction (LVEF) <40% accompanying diastolic dysfunction did not further impact postoperative mortality (P = .27; I(2) = 18%) compared with patients with normal LVEF and diastolic dysfunction.

Conclusions: Presence of preoperative diastolic dysfunction was associated with greater postoperative mortality and major adverse cardiac events, regardless of LVEF. Mortality was significantly greater in grade III diastolic dysfunction.
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http://dx.doi.org/10.1016/j.jtcvs.2016.05.057DOI Listing
October 2016

Does Obstructive Sleep Apnea Influence Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-Disordered Breathing.

Anesth Analg 2016 May;122(5):1321-34

From the *Department of Anesthesiology, Hospital for Special Surgery, New York, New York; †Department of Anesthesiology, Paracelsus Medical University, Salzburg, Austria; ‡Department of Surgical Sciences, University of Parma, Parma, Italy; §Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois; ‖Departments of Hospital Medicine and Anesthesia Outcomes Research, Cleveland Clinic, Cleveland, Ohio; ¶Division of Pulmonary, Critical Care, and Sleep Medicine, Metro Health Medical Center, Case Western Reserve Hospital, Cleveland, Ohio; and #Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.

Obstructive sleep apnea (OSA) is a commonly encountered problem in the perioperative setting even though many patients remain undiagnosed at the time of surgery. The objective of this systematic review was to evaluate whether the diagnosis of OSA has an impact on postoperative outcomes. We performed a systematic review of studies published in PubMed-MEDLINE, MEDLINE In-Process, and other nonindexed citations, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Health Technology Assessment up to November 2014. Studies of adult patients with a diagnosis of OSA or high risk thereof, published in the English language, undergoing surgery or procedures under anesthesia care, and reporting ≥1 postoperative outcome were included. Overall, the included studies reported on 413,304 OSA and 8,556,279 control patients. The majority reported worse outcomes for a number of events, including pulmonary and combined complications, among patients with OSA versus the reference group. The association between OSA and in-hospital mortality varied among studies; 9 studies showed no impact of OSA on mortality, 3 studies suggested a decrease in mortality, and 1 study reported increased mortality. In summary, the majority of studies suggest that the presence of OSA is associated with an increased risk of postoperative complications.
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http://dx.doi.org/10.1213/ANE.0000000000001178DOI Listing
May 2016

Determinants of Wake Pco2 and Increases in Wake Pco2 over Time in Patients with Obstructive Sleep Apnea.

Ann Am Thorac Soc 2016 Feb;13(2):259-64

4 Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute.

Rationale: The progression from obesity and obstructive sleep apnea to obesity with hypoventilation and daytime hypercapnia may relate to features of sleep-disordered breathing events that affect loading and unloading of carbon dioxide.

Objectives: To determine whether the wake Pco2 increases over time in untreated obstructive sleep apnea, and whether that increase is explained by changes in sleep-disordered breathing event duration, interevent duration, or postevent ventilation amplitude.

Methods: We selected 14 adults who had two polysomnographic studies more than 1 year apart because of untreated or suboptimally treated moderate to severe obstructive sleep apnea. Demographic and polysomnographic data were reviewed for both sets of studies, including the evening wake end-tidal CO2, the ratio of mean event to mean interevent duration (subsuming apneas and hypopneas), and the ratio of mean post- to preevent breath amplitude.

Measurement And Main Results: The mean (SD) wake end-tidal Pco2 increased between studies from 35.9 (4.2) to 39.5 (3.9) mm Hg (P < 0.005). The wake end-tidal CO2 correlated inversely with the post- to pre-event breath amplitude and positively with the ratio of mean event to mean interevent duration and with body mass index. However, those three variables were not significantly changed between the two studies. The wake end-tidal CO2 did not correlate with the apnea-hypopnea index or age. There was a significant increase in bicarbonate level between studies (median, 24.0-26.5 mmol/L; P = 0.01).

Conclusions: In our study cohort, wake end-tidal CO2 correlated with body mass index and features of sleep apnea that influence the balance of loading and unloading of CO2. However, those features remained fixed over time, even as the wake Pco2 and bicarbonate levels increased with untreated sleep apnea.
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http://dx.doi.org/10.1513/AnnalsATS.201508-563OCDOI Listing
February 2016

Postoperative Outcomes in Obstructive Sleep Apnea: Matched Cohort Study.

Authors:
Roop Kaw

Anesthesiology 2015 Jul;123(1):229-30

Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1097/ALN.0000000000000683DOI Listing
July 2015

Prevalence of Undetected Sleep Apnea in Patients Undergoing Cardiovascular Surgery and Impact on Postoperative Outcomes.

J Clin Sleep Med 2015 Oct 15;11(10):1083-9. Epub 2015 Oct 15.

Cleveland Medical Devices Inc., Cleveland, OH.

Study Objective: We examined the prevalence of obstructive sleep apnea (OSA) among patients undergoing cardiac surgery and its impact on postoperative outcomes.

Methods: Subjects were recruited from inpatient cardiovascular surgery units at two tertiary care centers. Crystal Monitor 20-H recorded polysomnograms preoperatively. Regression analyses were performed to explore associations between OSA using different apnea-hypopnea index (AHI) cutoffs and postoperative outcomes adjusting for key covariates. Prevalence of postoperative outcomes was compared among groups defined by AHI and left ventricle ejection fraction (LVEF) median cutoffs.

Results: Of 107 participants, the AHI was ≥ 5 in 79 (73.8%), ≥ 10 in 63 (58.9%), ≥ 15 in 51(47.7%), and ≥ 30 in 29 (27.1%). Patients with AHI ≥ 15 had significantly lower LVEF (p < 0.001). Logistic regression analyses with OSA cutoffs as above adjusting for age, gender, race, BMI, and LVEF found no significant increase in odds for any postoperative outcomes. No significant differences were found in %Total sleep time (TST) with SpO2 < 90% between AHI or LVEF groups, or by presence/absence of complications. Patients with any amount of TST with SpO2 < 90% had greater BMI, longer OR tube time, and greater prevalence of prolonged intubation (p = 0.007, 0.035, 0.038, respectively).

Conclusions: OSA is highly prevalent in patients undergoing cardiovascular surgery. It could not be shown that OSA was significantly associated with adverse postoperative outcomes, but this may have been due to an insufficient number of subjects. AHI ≥ 15 was associated with lower LVEF. Larger samples are required to explore the impact of OSA on key postoperative outcomes that have clinical and economic importance in the care of cardiovascular surgery populations.

Commentary: A commentary on this article appears in this issue on page 1081.
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http://dx.doi.org/10.5664/jcsm.5076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4582049PMC
October 2015

Postoperative Complications in Patients With Unrecognized Obesity Hypoventilation Syndrome Undergoing Elective Noncardiac Surgery.

Chest 2016 Jan 6;149(1):84-91. Epub 2016 Jan 6.

Respiratory Institute, Cleveland Clinic, Cleveland, OH.

Background: Among patients with OSA, a higher number of medical morbidities are known to be associated with those who have obesity hypoventilation syndrome (OHS) compared with OSA alone. OHS can pose a higher risk of postoperative complications after elective noncardiac surgery (NCS) and often is unrecognized at the time of surgery. The objective of this study was to retrospectively identify patients with OHS and compare their postoperative outcomes with those of patients with OSA alone.

Methods: Patients meeting criteria for OHS were identified within a large cohort with OSA who underwent elective NCS at a major tertiary care center. We identified postoperative outcomes associated with OSA and OHS as well as the clinical determinants of OHS (BMI, apnea-hypopnea index [AHI]). Multivariable logistic and linear regression models were used for dichotomous and continuous outcomes, respectively.

Results: Patients with hypercapnia from definite or possible OHS and overlap syndrome are more likely to experience postoperative respiratory failure (OR, 10.9; 95% CI, 3.7-32.3; P < .0001), postoperative heart failure (OR, 5.4; 95% CI, 1.9-15.7; P = .002), prolonged intubation (OR, 3.1; 95% CI, 0.6-15.3; P = .2), postoperative ICU transfer (OR, 10.9; 95% CI, 3.7-32.3; P < .0001), and longer ICU (?-coefficient, 0.86; SE, 0.32; P = .009) and hospital (?-coefficient, 2.94; SE, 0.87; P = .0008) lengths of stay compared with patients with OSA. Among the clinical determinants of OHS, neither BMI nor AHI showed associations with any postoperative outcomes in univariable or multivariable regression.

Conclusions: Better emphasis is needed on preoperative recognition of hypercapnia among patients with OSA or overlap syndrome undergoing elective NCS.
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http://dx.doi.org/10.1378/chest.14-3216DOI Listing
January 2016

The Effects of Continuous Positive Airway Pressure on Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Surgery: A Systematic Review and Meta-analysis.

Anesth Analg 2015 May;120(5):1013-23

From the *Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; †Department of Medicine, Sleep Disorders Center and the Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois; ‡Department of Anesthesiology, Toronto Western Hospital, University Health, Toronto, Ontario, Canada; §Department of Hospital Medicine and Department of Outcomes Research (Anesthesiology), Cleveland Clinic, Cleveland, Ohio; and ║Department of Anesthesia, Toronto Western Hospital, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Obstructive sleep apnea (OSA) is a commonly encountered comorbid condition in patients undergoing surgery and is associated with a greater risk of postoperative adverse events. Our objective in this review was to investigate the effectiveness of continuous positive airway pressure (CPAP) in reducing the risk of postoperative adverse events in patients with OSA undergoing surgery, the perioperative Apnea-Hypopnea Index (AHI), and the hospital length of stay (LOS).

Methods: We performed a systematic search of the literature databases. We reviewed the studies that included the following: (1) adult surgical patients (>18 years old) with information available on OSA; (2) patients using either preoperative and/or postoperative CPAP or no-CPAP; (3) available reports on postoperative adverse events, preoperative and postoperative AHI, and LOS; and (4) all published studies in English including case series.

Results: Six studies that included 904 patients were eligible for the meta-analysis. The meta-analysis for postoperative adverse events was performed in 904 patients (CPAP: n = 471 vs no-CPAP: n = 433; adverse events: 134 vs 133; P = 0.19). There was no significant difference in the postoperative adverse events between the 2 groups. The preoperative baseline AHI without CPAP was reduced significantly with postoperative use of CPAP (preoperative AHI versus postoperative AHI, 37 ± 19 vs 12 ± 16 events per hour, P < 0.001). LOS showed a trend toward significance in the CPAP group versus the no-CPAP group (4.0 ± 4 vs 4.4 ± 8 days, P = 0.05).

Conclusions: Our review suggests that there was no significant difference in the postoperative adverse events between CPAP and no-CPAP treatment. Patients using CPAP had significantly lower postoperative AHI and a trend toward shorter LOS. There may be potential benefits in the use of CPAP during the perioperative period.
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http://dx.doi.org/10.1213/ANE.0000000000000634DOI Listing
May 2015

Comparative efficacy and safety of anticoagulants and aspirin for extended treatment of venous thromboembolism: A network meta-analysis.

Thromb Res 2015 May 4;135(5):888-96. Epub 2015 Mar 4.

Medical School, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru, Health Outcomes and Clinical Epidemiology Section, Dept. of Quantitative Health Sciences, Lerner, Research Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Objective: To systematically review the literature and to quantitatively evaluate the efficacy and safety of extended pharmacologic treatment of venous thromboembolism (VTE) through network meta-analysis (NMA).

Methods: A systematic literature search (MEDLINE, Embase, Cochrane CENTRAL, through September 2014) and searching of reference lists of included studies and relevant reviews was conducted to identify randomized controlled trials of patients who completed initial anticoagulant treatment for VTE and then randomized for the extension study; compared extension of anticoagulant treatment to placebo or active control; and reported at least one outcome of interest (VTE or a composite of major bleeding or clinically relevant non-major bleeding). A random-effects Frequentist approach to NMA was used to calculate relative risks with 95% confidence intervals.

Results: Ten trials (n=11,079) were included. Risk of bias (assessed with the Cochrane tool) was low in most domains assessed across the included trials. Apixaban (2.5mg and 5mg), dabigatran, rivaroxaban, idraparinux and vitamin K antagonists (VKA) each significantly reduced the risk of VTE recurrence compared to placebo, ranging from a 73% reduction with idraparinux to 86% with VKAs. With exception of idraparinux, all active therapies significantly reduced VTE recurrence risk versus aspirin, ranging from a 73% reduction with either apixaban 2.5mg or rivaroxaban to 80% with VKAs. Apixaban and aspirin were the only therapies that did not increase composite bleeding risk significantly compared to placebo. All active therapies except aspirin increased risk of composite bleeding by 2 to 4-fold compared to apixaban 2.5mg, with no difference found between the two apixaban doses.

Conclusion: Extended treatment of VTE is a reasonable approach to provide continued protection from VTE recurrence although bleeding risk is variable across therapeutic options. Our results indicate that apixaban, dabigatran, rivaroxaban, idraparinux and VKAs all reduced VTE recurrence when compared to placebo. Apixaban appears to have a more favorable safety profile compared to other therapies.
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http://dx.doi.org/10.1016/j.thromres.2015.02.032DOI Listing
May 2015

Inferior vena cava filters and postoperative outcomes in patients undergoing bariatric surgery: a meta-analysis.

Surg Obes Relat Dis 2014 Jul-Aug;10(4):725-33. Epub 2014 Apr 18.

Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Postgraduate and Medical Schools, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; Unidad de Análisis y Generación de Evidencias en Salud Pública (UNAGESP), Instituto Nacional de Salud, Lima, Peru.

Background: Pulmonary embolism(PE)accounts for almost 40% of perioperative deaths after bariatric surgery.Placement of prophylactic inferior vena cava(IVC) filter before bariatric surgery to improve outcomes has shown varied results. We performed a meta-analysis to evaluate post- operative outcomes associated with the preoperative placement of IVC filters in these patients. Methods: A systematic review was conducted by three investigators independently in PubMed, EMBASE, the Web of Science and Scopus until February 28,2013.Our search was restricted to studies in adult patients undergoing bariatric surgery with and without IVC filters. Primary outcomes were postoperative deep vein thrombosis(DVT),pulmonary embolism (PE),and postoperative mortality. Meta-analysis used random effects models to account for heterogeneity,and Sidik- Jonkman method to account for scarcity of outcomes and studies. Associations are shown as Relative Risks(RR) and 95% Confidence Intervals(CI). Results: Seven observational studies were identified (n=102,767), with weighted average inci- dences of DVT(0.9%),PE(1.6%),and mortality(1.0%)for a follow-up ranging from 3 weeks to 3 months. Use of IVC filters was associated with an approximately 3-fold higher risk of DVT and death that was nominally significant for the former outcome, but not the latter (RR2.81,95%CI 1.33-5.97, p=0.007; and RR 3.27,95%CI0.78-13.64, p=0.1, respectively);there was no difference in the risk of PE(RR1.02,95%CI0.31-3.77,p=0.9). Moderate to high heterogeneity of effects was noted across studies. Conclusions: Placement of IVC filter before bariatric surgery Is associated with higher risk of postoperative DVT and mortality. A similar risk of PE inpatients with and without IVC filter placement cannot exclude a benefit, given the potential large imbalance in risk at baseline.Ran- domized trials are needed before IVC placement can be recommended. (SurgObesRelatDis 2015;11:268-269.) r 2015 American Society for Metabolic and Bariatric Surgery.
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http://dx.doi.org/10.1016/j.soard.2014.04.008DOI Listing
May 2015

Prognostic implications of diastolic dysfunction in patients with acute pulmonary embolism.

BMC Res Notes 2014 Sep 6;7:610. Epub 2014 Sep 6.

Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Avenue, M2-Annex, Cleveland, OH 44195, USA.

Background: A history of congestive heart failure has been used to determine the prognosis in patients with acute pulmonary embolism. Diastolic dysfunction is responsible for the half of congestive heart failure but has not been understood well.

Methods: A total of 205 patients were reported admitted with acute pulmonary embolism from January 2009 to July 2011. We excluded hemodynamically unstable patients who received thrombolytics or underwent thromboembolectomy. We included hemodynamically stable patients who underwent echocardiogram within 72 hours of diagnosis. We reviewed medical records of 107 patients to investigate whether diastolic dysfunction increases in-hospital mortality or adverse clinical outcomes.

Results: Out of 107 patients, 10 patients died during hospitalization with in-hospital mortality rate of 9.3%. Among 84 patients without diastolic dysfunction as assessed by echocardiogram, six patients died with in-hospital mortality rate of 7.1%. Meanwhile, among 23 patients with diastolic dysfunction, four patients died with in-hospital mortality rate of 17.4%. The multivariable adjusted odds ratio was calculated as 2.71, with 95% confidence interval of 0.59 - 12.44.

Conclusions: For hemodynamically stable patients with acute pulmonary embolism, diastolic dysfunction as assessed by echocardiogram could increase in-hospital mortality 2.71 fold, although this was not statistically significant. Further study with a large patient population is needed to determine the statistically significant implications of diastolic dysfunction in patients with acute pulmonary embolism.
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http://dx.doi.org/10.1186/1756-0500-7-610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167149PMC
September 2014

Factors predicting incremental administration of antihypertensive boluses during deep brain stimulator placement for Parkinson's disease.

J Clin Neurosci 2014 Oct 7;21(10):1790-5. Epub 2014 Jun 7.

Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA. Electronic address:

Hypertension is common in deep brain stimulator (DBS) placement predisposing to intracranial hemorrhage. This retrospective review evaluates factors predicting incremental antihypertensive use intraoperatively. Medical records of Parkinson's disease (PD) patients undergoing DBS procedure between 2008-2011 were reviewed after Institutional Review Board approval. Anesthesia medication, preoperative levodopa dose, age, preoperative use of antihypertensive medications, diabetes mellitus, anxiety, motor part of the Unified Parkinson's Disease Rating Scale score and PD duration were collected. Univariate and multivariate analysis was done between each patient characteristic and the number of antihypertensive boluses. From the 136 patients included 60 were hypertensive, of whom 32 were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), told to hold on the morning of surgery. Antihypertensive medications were given to 130 patients intraoperatively. Age (relative risk [RR] 1.01; 95% confidence interval [CI] 1.00-1.02; p=0.005), high Joint National Committee (JNC) class (p<0.0001), diabetes mellitus (RR 1.4; 95%CI 1.2-17; p<0.0001) and duration of PD >10 years (RR 1.2; 95%CI 1.1-1.3; p=0.001) were independent predictors for antihypertensive use. No difference was noted in the mean dose of levodopa (p=0.1) and levodopa equivalent dose (p=0.4) between the low (I/II) and high severity (III/IV) JNC groups. Addition of dexmedetomidine to propofol did not influence antihypertensive boluses required (p=0.38). Intraoperative hypertension during DBS surgery is associated with higher age group, hypertensive, diabetic patients and longer duration of PD. Withholding ACEI or ARB is an independent predictor of hypertension requiring more aggressive therapy. Levodopa withdrawal and choice of anesthetic agent is not associated with higher intraoperative antihypertensive medications.
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http://dx.doi.org/10.1016/j.jocn.2014.04.005DOI Listing
October 2014