John E. Ellis, MD
Dr. Ellis is Vice President of the Society of Cardiovascular Anesthesiologists Research Foundation. He has served as Consultant to FDA panels of Anesthetic and Life Support and Cardiorenal Drugs and Special Emphasis Panel Grant Reviewer for the Centers for Disease Control. He was formerly Professor in the Department of Anesthesia and Critical Care at the University of Chicago, and is currently Adjunct Professor in Department of Anesthesiology and Critical Care in the School of Medicine of the University of Pennsylvania. He served on the Editorial Board of the Journal of Cardiothoracic and Vascular Anesthesia and is a frequent ad hoc reviewer for Anesthesiology
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Our perioperative beta blockade review. Published Dec 2011, before Poldermans misconduct allegations
January 6th, 2012Risk for Postoperative Respiratory Failure
November 30th, 2011Calculator Estimates Risk for Postoperative Respiratory Failure
Five strong predictors for PRF emerged from evaluation of the data:
- surgery type,
- The riskiest surgeries were those of the brain, aorta, and foregut/hepatopancreatobiliary region.
- emergency case,
- dependent functional status,
- preoperative sepsis,
- higher American Society of Anesthesiologists class.
“PRF develops in approximately 3% of patients, and more than 25% of them die within 30 days. Up to 40% of postoperative complications after abdominal and vascular surgeries are pulmonary in nature.
The study, from Himani Gupta, MD and colleagues from the University of Pittsburgh in Pennsylvania and Creighton University in Omaha, Nebraska, considers all surgeries and distinguishes PRF from other pulmonary complications. Data are from the American College of Surgeons’ National Surgical Quality Improvement Program, which represents more than 180 hospitals.”
Don Poldermans, of DECREASE beta blocker trials, fired.
November 29th, 2011I’ve always been concerned about the generalizability of Poldermans’ work. A PubMed search of his name and “vascular surgery” returns over 150 references. His work has continued to support perioperative beta blockade while other studies, such as POISE, have found adverse outcomes. He is lead author of the European Society of Cardiologists Perioperative Guidelines for Noncardiac Surgery.
Now, Prof Poldermans has been fired by Erasmus University, among allegations:
The professor is accused of faking academic data and compromising patient trust, the paper says. In particular, he failed to obtain patient consent for carrying out research and recorded results ‘which cannot be resolved to patient information,’ the university said.
Don Poldermans has spent years researching the risk of complications during cardio-vascular surgery and has some 500 publications to his name.
A spokesman for Poldermans told the paper he admitted not keeping to research protocols but denied faking data.
In its statement, the ESC said that the society is reviewing this document “in order to decide if these need to be re-examined in the light of recent events. A new statement will be issued by the ESC once a decision has been reached.”
Will medical therapy replace surgery for thoracic aneurysms?
October 13th, 2011Recent epidemiologic studies have shown lower rates of AAA. Many ascribe this to better chronic treatment of hypertension.
Now Danyi et al have written a review article highlighting the potential for medical therapy to replace some surgery for thoracic aneurysms.
Specifically, they describe molecular mechanisms that may lead to aneurysm formation, and how:
- Angiotensin receptor blockers (ARBs) are thought to inhibit the above pathways via inhibition of the AT1 receptors.
- Angiotensin-converting enzyme inhibitors (ACEIs) block angiotensin II.
- Statins block the NADH/NADPH system;
- tetracyclines and macrolides reduce MMP activity. β-Blockers reduce shear stress on the vessel.
Given the high M&M of thoracic aortic surgery, even with endovascular and hybrid approaches, these are hopeful advances.
Fig. 2. MRI parasagittal gated image showing a saccular aneurysm of the aortic isthmus just distal to the left subclavian artery (white arrow). The cine-gradient echo image signal intensity in the aneurysm is inhomogeneous because of the intraluminal turbulence.
“Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study”
October 6th, 2011Preoperative anaemia and postoperative outcomes in non-cardiac surgery- a retrospective cohort study
www.thelancet.com Published online October 6, 2011 DOI:10.1016/S0140-6736(11)61381-0
“Methods We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons’ National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) eff ect of anaemia, which was defi ned as mild (haematocrit concentration >29–<39% in men and >29–<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes.
Interpretation Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery.”
Vascular patients were more anemic than others (no surprise there). Any anemia in vascular surgery patients had OR for mortality = 1·44 (1·24–1·68) for morbidity 1·24 (1·14–1·35).
In all patient groups (by level of anemia or not), transfused patients did NOT have increase mortality or morbidity. Go figure.
Succinct review suggests that medical management is superior to CEA for asymptomatic carotid stenosis
September 16th, 2011
A few quotes from a review by — Allan S. Brett, MD:
Because medical therapy has improved since these trials were conducted, researchers have examined whether stroke rates in patients with ACS have declined during the past decade. In fact, rates have fallen to around 1% annually in medically treated patients.4,5
Thus, we must ask whether CEA has any role in patients with ACS. Recently, researchers have proposed several imaging findings that might identify high-risk subgroups — plaque echolucency, plaque ulceration, and embolic signals on transcranial Doppler ultrasound of the ipsilateral middle cerebral artery…
Thus, many asymptomatic patients who now undergo CEA (or carotid stenting, which is not safer than CEA) are likely risking harm without commensurate benefit. Use of embolic signals and plaque characteristics to identify candidates for CEA is promising but requires larger studies and assurance that the techniques are reliable in community settings.
I couldn’t agree more!
4. Marquardt L et al. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: A prospective, population-based study. Stroke 2010 Jan; 41:e11. (http://dx.doi.org/10.1161/STROKEAHA.109.561837)
- Original article (Subscription may be required)
- Medline abstract (Free)
5. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis.Stroke 2009 Oct; 40:e573. (http://dx.doi.org/10.1161/STROKEAHA.109.556068)
- Original article (Subscription may be required)
- Medline abstract (Free)
Does aggressive medical therapy trump cerebral revascularization?
September 8th, 2011
NEJM has just published an RCT of INTRAcranial stenting for symptomatic intracranial arterial stenosis vs. aggressive medical therapy. It showed WORSE outcomes for stenting.
For me, this begs the question of whether NASCET (symptomatic; published 1998) and ACAS (asymptomatic; published 1995) CEA trials need to be repeated, up against aggressive medical Rx.
How was aggressive medical Rx defined in the trial?
Aggressive Medical Management
The rationale for the medical-management regimen and details on the management of risk factors in the study patients have been published previously.21-23… we targeted a systolic blood pressure of less than 140 mm Hg (<130 mm Hg in the case of patients with diabetes) and an LDL cholesterol level of less than 70 mg per deciliter (1.81 mmol per liter). We provide the aspirin, clopidogrel, one drug from each major class of antihypertensive agents, rosuvastatin, and the lifestyle program to the study patients.
Medical therapy was probably less aggressive in the NASCET study:
Video: Aug 2011 lecture Anesthesia for Carotid Revascularization
August 23rd, 2011Medical University of South Carolina Grand Rounds
Dr. John E. Ellis
Video: Aug 2011 lecture Periop Myocardial Ischemia and Infarction
August 23rd, 2011Medical University of South Carolina Grand Rounds
Dr. John E. Ellis
Start watching video at 2:20
Periop MI continues to be lethal
July 22nd, 2011Data from the POISE trial shows that periop MI continues to carry 10-15% lethality, and that symptomatic MI may have worse outcome than symptomatic ones.
Also note that medical Rx after MI remains suboptimal. Our decision analysis years ago supports the routine use of troponin to screen patients after open AAA surgery.
A slide show of salient data follows below: