Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S50

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVD); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop …

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2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(08)61560-3.pdf

Perioperative β blockers in patients having non-cardiac surgery: a meta-analysis

Perioperative β blockers in patients having non-cardiac surgery : a meta-analysis. Commentary

Background
Central venous catheters (CVCs) can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed with as few attempts as possible. Traditionally, anatomical ‘landmarks’ on the body surface were used to find the correct place in which to insert catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain ‘two-dimensional’ ultrasound.

Objectives
The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional (imaging ultrasound (US) or ultrasound Doppler (USD)) guided puncture techniques for insertion of central venous catheters via the internal jugular vein in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.

Our secondary objectives were to assess whether the effect differs between US and USD; whether the effect differs between ultrasound used throughout the puncture ('direct') and ultrasound used only to identify and mark the vein before the start of the puncture procedure (indirect'); and whether the effect differs between different groups of patients or between different levels of experience among those inserting the catheters.

Search methods
We searched the Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013 ), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with identified studies of interest when we update the review.

Selection criteria
We included randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound with an anatomical 'landmark' technique during insertion of internal jugular venous catheters in both adults and children.

Data collection and analysis
Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. A priori, we aimed to perform subgroup analyses, when possible, for adults and children, and for experienced operators and inexperienced operators.

Main results
Of 735 identified citations, 35 studies enrolling 5108 participants fulfilled the inclusion criteria. The quality of evidence was very low for most of the outcomes and was moderate at best for four of the outcomes. Most trials had an unclear risk of bias across the six domains, and heterogeneity among the studies was significant.

Use of two-dimensional ultrasound reduced the rate of total complications overall by 71% (14 trials, 2406 participants, risk ratio (RR) 0.29, 95% confidence interval (CI) 0.17 to 0.52; P value < 0.0001, I² = 57%), and the number of participants with an inadvertent arterial puncture by 72% (22 trials, 4388 participants, RR 0.28, 95% CI 0.18 to 0.44; P value < 0.00001, I² = 35%). Overall success rates were modestly increased in all groups combined at 12% (23 trials, 4340 participants, RR 1.12, 95% CI 1.08 to 1.17; P value < 0.00001, I² = 85%), and similar benefit was noted across all subgroups. The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I² = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.

Use of Doppler ultrasound increased the chance of success at the first attempt by 58% (four trials, 199 participants, RR 1.58, 95% CI 1.02 to 2.43; P value 0.04, I² = 57%). No evidence showed a difference for the total numbers of perioperative and postoperative complications/adverse events (three trials, 93 participants, RR 0.52, 95% CI 0.16 to 1.71; P value 0.28), the overall success rate (seven trials, 289 participants, RR 1.09, 95% CI 0.95 to 1.25; P value 0.20), the total number of attempts until success (two trials, 69 participants, MD -0.63, 95% CI -1.92 to 0.66; P value 0.34), the overall number of participants with an arterial puncture (six trials, 213 participants, RR 0.61, 95% CI 0.21 to 1.73; P value 0.35) and time to successful cannulation (five trials, 214 participants, each using a different definition for this outcome; MD 62.04 seconds, 95% CI -13.47 to 137.55; P value 0.11) when Doppler ultrasound was used. It was not possible to perform analyses for the other outcomes because they were reported in only one trial.

Authors' conclusions
Based on available data, we conclude that two-dimensional ultrasound offers gains in safety and quality when compared with an anatomical landmark technique. Because of missing data, we did not compare effects with experienced versus inexperienced operators for all outcomes (arterial puncture, haematoma formation, other complications, success with attempt number one), and so the relative utility of ultrasound in these groups remains unclear and no data are available on use of this technique in patients at high risk of complications. The results for Doppler ultrasound techniques versus anatomical landmark techniques are also uncertain.

Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization.

Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients: A Randomized Controlled Trial

Background Use of ultrasound-guided techniques to facilitate central venous cannulation (CVC) may reduce the risk of misplacement and complications. A meta-analysis was conducted to compare real-time two-dimensional ultrasound (RTUS) guidance technique with anatomical landmark technique for CVC to determine whether RTUS has any advantages. Methods Randomized studies comparing outcomes in patients undergoing CVC with either RTUS or landmark technique were retrieved from PubMed, ISI Web of Knowledge, EMBASE, and OVID EBM Reviews from their inception to March 2012. Results Twenty-six studies involving 4,185 CVC procedures met the inclusion criteria. Compared with landmark technique, patients with RTUS had a pooled relative risk (RR) of 0.18 (95% CI: 0.10-0.32) for cannulation failure, 0.25 (95% CI: 0.15-0.42) for arterial puncture, 0.30 (95% CI: 0.19-0.46) for hematoma, 0.21 (95% CI: 0.06-0.73) for pneumothorax, and 0.10 (95% CI: 0.02-0.54) for hemothorax from random-effects models. However, RTUS did not show a reduction in the risk of cannulation failure (RR = 0.26, 95% CI: 0.03-2.55), arterial puncture (RR = 0.34, 95% CI: 0.05-2.60), hematoma (RR = 0.13, 95% CI: 0.01-2.42), pneumothorax (RR = 0.40, 95% CI: 0.02-9.61), and hemothorax (RR = 0.40, 95% CI: 0.02-9.61) in children or infants when the limited data were analyzed. Conclusions Among adults receiving CVC, RTUS was associated with decreased risks of cannulation failure, arterial puncture, hematoma, and hemothorax. Additional data of randomized studies are necessary to evaluate these outcomes in pediatric patients.

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Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis.

BACKGROUND OBJECTIVE: The elderly esophageal cancer patients undergoing esophagectomy are increasing now. How to protect their cardiac functions and reduce perioperative mortality and morbidity of cardiac events is an urgent problem to be solved. Prophylactic β-blockers have been recently applied during surgery. This study was to evaluate the beneficial effects of metoprolol on perioperative cardiac function of elderly esophageal cancer patients. METHODS: The esophageal cancer patients, no less than 65 years old, scheduled for elective esophagectomy were enrolled, and randomized into metoprolol group and control group. The patients of metoprolol group received metoprolol to control heart rate from anesthesia induction to 72 h after operation. Perioperative hemodynamic data were recorded at time points of baseline, drug administration, 2 min after induction, intubation, 4 min after intubation, incision, thoracic exposure, 60 min after incision, 10 min before the completion of operation, the completion of operation, extubation, and 15 min after extubation. The serum level of cardiac troponin T (cTnT), the occurrence of perioperative cardiac events and postoperative sinus tachycardia were also recorded. RESULTS: Compared with preoperative values, systolic arterial pressure was significantly higher at intubation (P0.05), heart rate was significantly faster at intubation and extubation (P0.05) in control group; while the hemodynamic data had no obvious changes in metoprolol group (P0.05). The serum level of cTnT was elevated in 3 patients of control group within 3 days after operation, and remained normal in all patients of metoprolol group (P=0.237); cardiac events occurred in 6 patients of control group (including 2 cases of myocardial ischemia and 4 cases of atrial fibrillation), but didn't occur in metoprolol group (P=0.024). No myocardial infarction and death occurred in the 2 groups during operation. The occurrence rate of tachycardia was significantly higher in control group than in metoprolol group (15 cases vs. 6 cases, P0.05). CONCLUSION: Metoprolol can reduce the occurrence of perioperative cardiac events and postoperative tachycardia in the elderly esophageal cancer patients undergoing esophagectomy, and restrain the effects of tracheal intubation or extubation on heart rate and blood pressure.

Beneficial effects of metoprolol on perioperative cardiac function of elderly esophageal cancer patients

Real-Time Two-Dimensional Ultrasound Guidance for Central Venous Cannulation: A Meta-Analysis

BACKGROUND & OBJECTIVE Morphine is a widely used analgesic in management of postoperative pain with well documented analgesic properties and side effects. Tramadol, a new synthetic mu-opioid receptor agonist, little is known about its efficacy and side effects when administered in epidural for pain relief. The aim of this study is to compare the efficacy and side effects of tramadol, morphine versus their combination for postoperative analgesia. METHODS One hundred and twenty patients undergoing abdominal cancer surgery were assigned to one of three groups randomly, tramadol group (Group T, n = 40), morphine group(Group M, n = 40) and combination of tramadol and morphine group(group T + M, n = 40), for postoperative analgesia. In group T, 12 mg/kg tramadol and 0.125% bupivacaine 100 ml were used for 48 h postoperative analgesia. In group M, 0.12 mg/kg morphine and 0.125% bupivacaine 100 ml; and in group T + M, 6 mg/kg tramadol, 0.12 mg/kg morphine and 0.125%. Bupivacaine 100 ml were used for postoperative analgesia. Efficacy was assessed by comparing visual analogue scale(VAS), Bruggman comfort score (BCS), global satisfaction score (GSS) at several time points over 48 hours. Possile adverse events were recorded. RESULTS There is no significant difference among three groups in VAS, but in group T, there are more patients whose VAS > 5 score than those in group M and group T + M. BCS; GSS in group T + M are lower than that in group T and group M. The occurrence rate of nausea and vomiting in group T + M are lower than that in group M. CONCLUSIONS The efficacy of tramadol in epidural postoperative analgesia is similar to that of morphine, but varied from patient to patient, so the dose of tramadol should be individualized. Combination of tramadol and morphine can provide effective analgesia for postoperative pain and cause little adverse effect, especially reduce the occurrence rate of nausea and vomiting.

[Comparison of postoperative analgesia with tramadol, morphine versus their combination in patients undergoing abdominal cancer surgery].

BACKGROUND AND OBJECTIVE Midazolam is a useful drug used preoperatively because it can produce anxiolysis and sedation. This study compared the propofol requirements and haemodynamic effects during anaesthetic induction using propofol with premedication of midazolam or luminal. METHODS Thirty patients (aged 20-65, ASA I-II) undergoing tumor surgery were randomly assigned into 2 groups (group M and group L): group M, receiving 0.5 mg atropine and 0.05 mg/kg midazolam; group L, receiving atropine and 2 mg/kg phenobarbital sodium 30 min before induction as premedication. Anesthesia was induced with propofol at the rate of 30 mg.kg-1.h-1 to achieve enough depth of anesthesia to intubate. Induction time, total propofol dosage, blood pressure, heart rate were recorded before and after induction, and after intubation. Awaken time was also recorded. RESULTS The time of induction and the propofol dosage in group M (2.8 +/- 0.37 min and 79.9 +/- 15.3 mg) were significantly (P < 0.05) less than that in group L (3.3 +/- 0.54 min and 98.9 +/- 17.4 mg). Blood pressure was unchanged in M group after propofol induction and after the intubation. Heart rate change was much less in group M (P < 0.05). CONCLUSIONS The results indicate that midazolam compered to phenobarbital sodium as premedication could reduce the usage of propofol, and also provide stable cardiovascular state during propofol induction.

Wei an Zeng

Papers

Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis.

Beneficial effects of metoprolol on perioperative cardiac function of elderly esophageal cancer patients

Real-Time Two-Dimensional Ultrasound Guidance for Central Venous Cannulation: A Meta-Analysis

[Comparison of postoperative analgesia with tramadol, morphine versus their combination in patients undergoing abdominal cancer surgery].

Effects of midazolam premedication on induction doses of propofol and hemodynamic changes during tumor patient induction