Jacek Cywinski - Academia.edu (original) (raw)

Papers by Jacek Cywinski

Anesthesiology

Background The relationship between intraoperative physiology and postoperative stroke is incompl... more Background The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. Methods We conducted a retrospective, case–control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmH...

Basic Sciences in Anesthesia, 2017

Key Points 1. Transfusion of blood products can be lifesaving, however, it is not risk free. Ther... more Key Points 1. Transfusion of blood products can be lifesaving, however, it is not risk free. Therefore it is the responsibility of the physician to use appropriate triggers for blood component therapy. 2. ABO and the Rh systems are the most important in the majority of blood transfusions, although human red cell membranes contain as many as 300 different antigenic determinants. 3. Indication for red blood cell (RBC) transfusion is the need to increase the oxygen-carrying capacity. 4. The US Food and Drug Administration (FDA) recommends avoiding HES in critically ill adult patients and septic patients requiring ICU care. 5. Transfusion-related acute lung injury (TRALI) is currently the leading cause of transfusion-related death. Clinical presentation of TRALI may be indistinguishable from acute respiratory distress syndrome (ARDS) and is characterized by acute onset, bilateral pulmonary infiltrates and hypoxia without evidence of congestive heart failure (CHF).

Cleveland Clinic Journal of Medicine, 2022

A ttention to the heart before, during, and after liver transplantation can pay off in terms of b... more A ttention to the heart before, during, and after liver transplantation can pay off in terms of better outcomes. This, even though today's liver transplant patients are older than those in the past and more likely to have fatty liver disease as the cause of their liver failure, and even though liver failure, the transplant procedure, and the posttransplant regimen can all predispose to heart disease. The changing demographics of patients receiving liver transplants and the unique cardiac pathophysiology of patients with advanced liver disease pose signifi cant challenges in managing these patients perioperatively, as we will discuss in the following sections.

Journal of Clinical Anesthesia, 2022

STUDY OBJECTIVE To measure the possible association between subhypnotic propofol infusion during ... more STUDY OBJECTIVE To measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV. DESIGN Retrospective Cohort Analysis Using Propensity Score Matching. SETTING Postanesthesia care unit and inpatient unit. PATIENTS Patients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio. INTERVENTIONS None. MEASUREMENTS The primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay. MAIN RESULTS A total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion. CONCLUSIONS Our study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.

Anesthesiology, 2020

Background The Hypotension Prediction Index is a commercially available algorithm, based on arter... more Background The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. Methods We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were...

Journal of Clinical Anesthesia, 2021

STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care u... more STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards. DESIGN A prediction study using data from two randomized controlled trials. SETTING Operating room, post-anesthesia care unit, and surgical ward. PATIENTS 550 adult patients having abdominal surgery with ASA physical status I-IV. INTERVENTIONS Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively. MEASUREMENTS The primary predictors were minimum mean arterial pressure (<60, <65, <70 and < 80 mmHg) and minimum systolic blood pressure (<70, <75, <80, <85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure < 70 mmHg or systolic pressure < 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75. MAIN RESULTS Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure < 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure < 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure < 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity. CONCLUSIONS Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.

Anesthesiology, 2018

EDITOR’S PERSPECTIVE What We Already Know about This Topic Intraoperative triple-low events (mean... more EDITOR’S PERSPECTIVE What We Already Know about This Topic Intraoperative triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction of anesthetic less than 0.8) have been found to be associated with increased risk of mortality What This Article Tells Us That Is New A randomized electronic alert of triple-low events to treating clinicians did not reduce 90-day mortality The alerts minimally influenced clinician responses, assessed as vasopressor administration or reduction in end-tidal volatile anesthetic partial pressure, and there was no association between response to alerts and mortality Triple-low events predict mortality but do not appear to be causally related Background Triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction less than 0.8) are associated with mortality but may not be causal. This study tested the hypothesis that providing triple-lo...

Anesthesia and analgesia, Jan 14, 2018

Intraoperative hypotension is associated with postoperative mortality. Early detection of hypoten... more Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension. Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared usin...

European journal of anaesthesiology, Jan 11, 2017

Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes... more Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. Retrospective cohort analysis. Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or...

Archives of Medical Science, 2017

Introduction: Haemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in sy... more Introduction: Haemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in systemic inflammatory response syndrome (SIRS), a recognised cause of late mortality in this case. The aim of this study was to analyse the impact of fluid resuscitation, using two Ringer solutions, on the microcirculation changes that take place during experimentally induced haemorrhagic shock. Material and methods: A model of the rat cremaster muscle was used to assess microcirculation in vivo. The experimental groups (n = 10 each) included: control (CTRL); shock (HSG); Ringer's acetate (RAG); and Ringer's lactate (RLG). Microhaemodynamic parameters were measured during the experiment. Results: A statistically significantly higher level of leukocytes, both those attached to the endothelium and those located in the extravascular space (p < 0.05), was reported in the LR (Lactate Ringer) group compared with the AR group. There were significant differences in the activity of A3 arterioles compared with A1 and A2 arterioles. Ringer's lactate solution seemed to the inflammation response during fluid resuscitation from haemorrhagic shock. A3 arterioles are likely to play a role as a pre-capillary sphincter in the skeletal muscle. Conclusions: The present study revealed that fluid resuscitation with Ringer's lactate solution exacerbates inflammation in the skeletal muscle. It is worth noting that Ringer's acetate solution reduces local inflammation and could therefore be recommended as the "first line" crystalloid of the fluid resuscitation during haemorrhagic shock.

Heart, 2016

Objective Due to their unique pathophysiological profile, patients with hypertrophic cardiomyopat... more Objective Due to their unique pathophysiological profile, patients with hypertrophic cardiomyopathy (HCM) undergoing non-cardiac surgery require additional attention to perioperative management. We sought to compare perioperative outcomes of patients with HCM undergoing non-cardiac surgery with a matched group patients without HCM. Methods This observational cohort study conducted at a tertiary care centre included patients with HCM (n=92, age 67 years, 54% men) undergoing intermediate-risk and high-risk non-cardiac surgeries between 1/2007 and 12/2013 (excluding <18 years, prior septal myectomy/ alcohol ablation, low-risk surgery) who were 1:2 matched (based on age, gender, type and time of noncardiac surgery) with patients without HCM (n=184, median age 65 years, 53% men). A composite endpoint (30-day postoperative death, myocardial infarction, stroke, in-hospital decompensated congestive heart failure (CHF) and rehospitalisation within 30 days) and postoperative atrial fibrillation (AF) were recorded. Results There was a significantly lower incidence of intraoperative hypotension/tachycardia in patients with HCM versus those without HCM (p<0.001). At 30 days postoperatively, 42 (15%) patients had composite events. Rates of 30-day death, MI or stroke were very low in patients with HCM (5%). However, a significantly higher proportion of patients with HCM met the composite endpoint versus patients without HCM (20 (22%) vs 22 (12%), p=0.03), driven by decompensated CHF. On logistic regression, HCM, high-risk non-cardiac surgery, high anaesthesia risk score and intraoperative duration of hypotension were independently associated with 30-day composite events (p<0.05). Conclusions Patients with HCM undergoing high-risk and intermediate-risk non-cardiac surgeries have a low perioperative event rate, at an experienced centre. However, they have a higher risk of composite events versus matched patients without HCM.

Canadian journal of anaesthesia = Journal canadien d'anesthesie, Jan 29, 2015

Serum creatinine is the most commonly used indicator of renal function, but its derivative, estim... more Serum creatinine is the most commonly used indicator of renal function, but its derivative, estimated glomerular filtration rate (eGFR), has been shown to be superior in non-surgical settings. It remains unknown if eGFR better predicts postoperative mortality in non-cardiac surgical patients. We thus tested the hypothesis that eGFR predicts 30-day mortality after non-cardiac surgery better than serum creatinine. We evaluated patients who had inpatient non-cardiac surgery of at least one hour duration during January 2006 to December 2011 at the Cleveland Clinic Main Campus and whose preoperative serum creatinine was measured within 30 days before surgery. The eGFR was calculated using the Chronic Kidney Disease-Epidemiology Collaboration equation. Preoperative eGFR was compared in a multivariable analysis with preoperative serum creatinine (both assessed as continuous variables) on the ability to predict 30-day mortality in all patients. Secondarily, the comparison was made within su...

Clinical and experimental otorhinolaryngology, 2014

Premedication with clonidine has been found to reduce the bleeding during endoscopic sinus surger... more Premedication with clonidine has been found to reduce the bleeding during endoscopic sinus surgery (ESS), therefore lowering the risk of surgical complications. Premedication is an essential part of pre-surgical care and can potentially affect magnitude of systemic stress response to a surgical procedure. The aim of this study was to compare the efficacy of premedication with clonidine and midazolam in patients undergoing sinus surgery. Forty-four patients undergoing ESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or midazolam as a premedication before receiving propofol/remifentanil total intravenous anesthesia. The effect of this premedication choice on anesthetic requirements, intraoperative hemodynamic profile, preoperative anxiety and sedation as well as postoperative pain and shivering were examined in each premedication group. Total intraoperative remifentanil requirement was lower in the clonidine group as comp...

Rhinology, 2013

During functional endoscopic sinus surgery (FESS), intraoperative bleeding can significantly comp... more During functional endoscopic sinus surgery (FESS), intraoperative bleeding can significantly compromise visualization of the surgical field. Clonidine constricts peripheral blood vessels and reduces systemic blood pressure, which in combination decrease nasal mucosa blood flow. This dual effect can potentially reduce bleeding during FESS and stabilize the intraoperative hemodynamic profile of the patient. The aim of this prospective study was to assess if the quality of the surgical field visualization during FESS was improved when clonidine was used as a premedication agent. A group of 44 patients undergoing FESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or midazolam as preoperative premedication. During the operation, the quality of the surgical field was assessed and graded by the operating surgeon using the scale proposed by Boezaart. The evaluations were done during surgery at 15 minutes (K1), 30 minutes (K2), 6...

Orthopedics, 2012

The purpose of this study was to evaluate the effects of intraoperative fluid therapy on length o... more The purpose of this study was to evaluate the effects of intraoperative fluid therapy on length of hospital stay and pulmonary complications in patients undergoing spine surgery. A total of 1307 patients were analyzed. Sixteen pulmonary complications were observed. Patients with a higher volume of administered crystalloids, colloids, and total intravenous fluids were more likely to have postoperative respiratory complications: the odds of postoperative respiratory complications increased by 30% with an increase of 1000 mL of crystalloid administered. The best cutoff point for total fluids was 4165 mL, with a sensitivity of 0.8125 and specificity of 0.7171, for postoperative pulmonary complications. A direct correlation existed between fluids and length of stay: patients who received >4165 mL of total fluids had an average length of stay of 3.88±4.66 days vs 2.3±3.9 days for patients who received <4165 mL of total fluids ( P <.0001). This study should be considered as hypoth...

Pharmacological Reports, 2012

Target controlled infusion (TCI) devices are increasingly used in clinical practice. These device... more Target controlled infusion (TCI) devices are increasingly used in clinical practice. These devices unquestionably aid optimization of drug dosage. However, it still remains to be determined if they sufficiently address differences in pharmacological make up of individual patients. The algorithms guiding TCI pumps are based on pharmacological data obtained from a relatively small number of healthy volunteers, which are then extrapolated, on the basis of sophisticated pharmacokinetic and pharmacodynamic modeling, to predict plasma concentrations of the drug and its effect on general population. One has to realize the limitation of this approach: these models may be less accurate when applied to patients in extreme clinical conditions: in intensive care units, with a considerable loss of blood, severe hypothermia or temporary changes in the composition of plasma, e.g., hypoalbuminemia. In the future, data obtained under these extreme clinical circumstances, may be used to modify the dosage algorithms of propofol TCI systems to match the clinical scenario.

Liver Transplantation, 2013

Obesity is among the great health problems facing Americans today. More than 32% of the US popula... more Obesity is among the great health problems facing Americans today. More than 32% of the US population is considered obese on the basis of a body mass index (BMI) exceeding 30 kg/m 2. Obesity increases the risk for numerous perioperative complications, but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplantation performed at the Cleveland Clinic between April 2005 and June 2011 in 2 groups: obese patients with a BMI 38 kg/m 2 and lean patients with a BMI between 20 and 26 kg/m 2. We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting with the inverse propensity score. After we controlled for observed confounding, no significant differences were observed in graft/patient survival between obese and lean patients (P 5 0.30). The estimated hazard ratio for obese patients to experience graft failure or death was 1.19 [95% confidence interval (CI) 5 0.85-1.67]. There were 134 patients who had follow-up for more than 3 years, and they included 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome were significantly greater for obese patients (46%) versus lean patients (21%; odds ratio 5 4.76, 99.5% CI 5 1.66-13.7, P < 0.001). However, no significant association between obesity and any other long-term adverse outcomes was found. In conclusion, this study shows that transplant outcomes were comparable for lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplantation.

Journal of Cardiothoracic and Vascular Anesthesia, 2009

The aim of this study was to identify predictors of delayed endotracheal extubation defined as th... more The aim of this study was to identify predictors of delayed endotracheal extubation defined as the need for postoperative ventilatory support after open thoracotomy for lung resection. Design: An observational cohort investigation. Setting: A tertiary referral center. Participants: The study population consisted of 2,068 patients who had open thoracotomy for pneumonectomy, lobectomy, or segmental lung resection between January 1996 and December 2005. Interventions: Not applicable. Measurements and Main Results: Preoperative and intraoperative variables were collected concurrently with the patient's care. Risk factors were identified using logistic regression with stepwise variable selection procedure on 1,000 bootstrap resamples, and a bagging algorithm was used to summarize the results. Intraoperative red blood cell transfusion , higher preoperative serum creatinine level, absence of a thoracic epidural catheter, more extensive surgical resection, and lower preoperative FEV 1 were associated with an increased risk of delayed extubation after lung resection. Conclusion: Most predictors of delayed postoperative extubation (ie, red blood cell transfusion, higher preoperative serum creatinine, lower preoperative FEV 1 , and more extensive lung resection) are difficult to modify in the perioperative period and probably represent greater severity of underlying lung disease and more advanced comorbid conditions. However, thoracic epidural anesthesia and analgesia is a modifiable factor that was associated with reduced odds for postoperative ventilatory support. Thus, the use of epidural analgesia may reduce the need for post-thoracotomy mechanical ventilation.

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose A safe and effective insulin infusion algorithm that achieves rigorous intraoperative gly... more Purpose A safe and effective insulin infusion algorithm that achieves rigorous intraoperative glycemic control in noncardiac surgery has yet to be formally characterized and evaluated. We therefore report the validation of the DeLit Trial insulin infusion algorithm. Methods Patients scheduled for major noncardiac surgery were randomized to a target intraoperative blood glucose concentration of 4.4-6.1 mmoLÁL-1 (80-110 mgÁdL-1) intensive group or 10-11.1 mmoLÁL-1 (180-200 mgÁdL-1) conventional group. Glucose was managed with a dynamic intravenous insulin infusion algorithm. We compared the randomized groups on glucose time-weighted average (TWA), Preliminary results were presented at the Annual Meeting of the American Society of Anesthesiologists, October 2008.

British Journal of Anaesthesia, 2010

† Maintenance of temperature during major surgery can be a challenge. † Circulating-water garment... more † Maintenance of temperature during major surgery can be a challenge. † Circulating-water garments (CWGs) have been suggested to be effective. † This study compared CWG with forced-air combined with a circulating-water mattress during upperabdominal surgery. † Both methods were comparably effective in maintaining core temperatures. Background. A recent heat-balance study in volunteers suggested that greater efficacy of circulating-water garments (CWGs) results largely from increased heat transfer across the posterior skin surface since heat transfer across the anterior skin surface was similar with circulating-water and forced-air. We thus tested the hypothesis that the combination of a circulating-water mattress (CWM) and forced-air warming prevents core temperature reduction during major abdominal surgery no worse than a CWG does. Methods. Fifty adult patients aged between 18 and 85 yr old, undergoing major abdominal surgery, were randomly assigned to intraoperative warming with a combination of forcedair and a CWM or with a CWG (Allon ThermoWrap). Core temperature was measured in the distal oesophagus. Non-inferiority of the CWM to the CWG on change from baseline to median intraoperative temperature was assessed using a one-tailed Student's t-test with an equivalency buffer of 20.58C. Results. Data analysis was restricted to 16 CWG and 20 CWM patients who completed the protocol. Core temperature increased in both groups during the initial hours of surgery. We had sufficient evidence (P¼0.001), to conclude that the combination of a CWM and forcedair warming was non-inferior to a CWG in preventing temperature reduction, with mean (95% CI) difference in the temperature change between the CWM and the CWG groups (CWM2CWG) of 0.468C (20.098C, 1.008C). Conclusions. The combination of a CWM and forced-air warming is significantly non-inferior in maintaining intraoperative core temperature than a CWG. Trial registry: This trial has been registered at clinical trials.gov, identifier: NCT 00651898.