Cardiac events remain the leading cause of peri-operative morbidity and mortality, and patients undergoing major surgery are exposed to significant risks which may be preventable and modifiable. Proper assessment and management of various cardiac conditions in the peri-operative period by anaesthetists can markedly improve patient safety, especially in high-risk patient populations. This involves understanding and applying current evidence-based practice and international guidelines on the main aspects of cardiac optimisation, including management of patients with hypertension, chronic heart failure, valvular heart diseases and cardiac implantable electronic devices. Peri-operative management of antihypertensive drugs in keeping with the current best evidence is discussed. Pre-operative cardiac risk assessment and cardiac biomarkers can be used to help predict and quantify peri-operative adverse cardiac events. There is an increasing need for anaesthetist-led services, including focused transthoracic echocardiography and management of implantable cardiac electronic devices. Anaesthetists should be encouraged to play a proactive role in pre-operative risk stratification and make timely multidisciplinary referrals if necessary. A personalised approach to pre-operative cardiac optimisation enables a safer peri-operative journey for at-risk patients undergoing major surgery.
Background
Current ways to diagnose citrate accumulation (CA) in patients receiving regional citrate anticoagulation (RCA) continuous renal replacement therapy (CRRT) are confounded by various clinical factors. Serum citrate measurement emerges as a more direct way to diagnose CA, but its clinical utility and optimal cut-off values remain undefined. This study examined serum citrate kinetics and its diagnostic performance for CA in patients receiving RCA CRRT.
Methods
A multi-center prospective study carried out in 2 tertiary referral center ICUs in Hong Kong with serum citrate levels measured at baseline, 2-, 6-, 12-, 24-, 36-, 48- and 72-hours after initiation of RCA CRRT and their relationships with development of CA examined.
Results
Amongst the 133 patients analyzed, 18 patients (13.5%) developed CA. The serum citrate levels at baseline, 2-, 6- and 12-hours after initiation of RCA CRRT in patients who had CA were significantly higher than the non-CA group (P < 0.001, for all). The CA group also had higher serum citrate levels than the non-CA group [median (IQR): 0.93(0.81–1.16) mmol/L vs. 0.37(0.26–0.57) mmol/L, P < 0.001]. Using a cut-off of 0.85 mmol/L, serum citrate level had a sensitivity (SN) of 0.77 and a specificity (SP) 0.96 for the diagnosis of CA (AUROC 0.90, P < 0.001). The 2-hr and 6-hr serum citrate levels had good discriminatory abilities for predicting subsequent development of CA (AUROC 0.86 and 0.83 for 2-hr and 6-hr citrate levels using cut-off values of 0.34 and 0.63 mmol/L respectively; P < 0.001).
Conclusion
Serum citrate levels were significantly higher in patients with CA compared with patients without CA. Serum citrate levels showed good performance in diagnosing and predicting the development of CA.
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