Pub Date : 2025-06-01DOI: 10.1016/j.bpa.2025.08.005
Ludmil V. Mitrev , Kathirvel Subramaniam , Mathew Patteril
{"title":"Reimagining cardiac surgery—the emerging role of prehabilitation and risk optimization","authors":"Ludmil V. Mitrev , Kathirvel Subramaniam , Mathew Patteril","doi":"10.1016/j.bpa.2025.08.005","DOIUrl":"10.1016/j.bpa.2025.08.005","url":null,"abstract":"","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 2","pages":"Pages 71-73"},"PeriodicalIF":2.8,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145340950","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-01DOI: 10.1016/j.bpa.2025.09.003
Levi Mulladzhanov , Siddhi Desai , Erin Pukenas
Preoperative anemia is a significant risk factor for perioperative morbidity and mortality in surgical patients in general, and particularly for cardiac surgery patients. Simple correction of hemoglobin via blood transfusion is not ideal because of the various complications of blood transfusion, as well as loss of intrinsic iron stores that are not addressed with this strategy. As such, anemia prior to cardiac surgery is best handled with a systems-based preoperative blood management approach that includes preoperative screening, and addressing both anemia and iron deficiency (with or without anemia) by administering iron, and/or using erythropoietin stimulating agents. Here we review anemia subtypes, testing helpful for the perioperative clinician to delineate the etiology, and management and optimization strategies for iron deficiency with or without anemia in cardiac surgical patients.
{"title":"Avoiding anemia in cardiac surgery patients—strategies and protocols","authors":"Levi Mulladzhanov , Siddhi Desai , Erin Pukenas","doi":"10.1016/j.bpa.2025.09.003","DOIUrl":"10.1016/j.bpa.2025.09.003","url":null,"abstract":"<div><div>Preoperative anemia is a significant risk factor for perioperative morbidity and mortality in surgical patients in general, and particularly for cardiac surgery patients. Simple correction of hemoglobin via blood transfusion is not ideal because of the various complications of blood transfusion, as well as loss of intrinsic iron stores that are not addressed with this strategy. As such, anemia prior to cardiac surgery is best handled with a systems-based preoperative blood management approach that includes preoperative screening, and addressing both anemia and iron deficiency (with or without anemia) by administering iron, and/or using erythropoietin stimulating agents. Here we review anemia subtypes, testing helpful for the perioperative clinician to delineate the etiology, and management and optimization strategies for iron deficiency with or without anemia in cardiac surgical patients.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 2","pages":"Pages 103-108"},"PeriodicalIF":2.8,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145340839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-01DOI: 10.1016/j.bpa.2025.10.001
Ettienne Coetzee, Chian-Jia Eden Chiu, Justiaan LC. Swanevelder
Background
Prehabilitation, incorporating personalized physical, nutritional, and psychological interventions before cardiac surgery, has gained recognition for enhancing patient resilience and improving surgical outcomes, particularly for high-risk populations. Among these populations, patients with substance use disorders (SUDs), including alcohol, tobacco, and other substance misuse, present unique challenges for anesthetic management.
Objectives
This review aims to highlight the most recent evidence on preoperative preparation strategies focused on minimizing perioperative risks in patients with SUDs undergoing cardiac surgery. The goal is to understand how tailored approaches to preoperative care can improve outcomes in this vulnerable group.
The review emphasizes the importance of thorough history-taking, comprehensive clinical evaluation, and optimized perioperative management specific to patients with SUDs. Collaboration among anesthetists, cardiologists, surgeons, and other healthcare professionals is essential to providing holistic care. Active patient engagement in preoperative optimization is highlighted as a crucial factor in improving surgical outcomes.
Specialized preoperative strategies, including the management of substance withdrawal, optimization of cardiovascular function, and enhancement of psychological well-being, are essential for improving surgical outcomes in patients with SUDs. Effective collaboration with multidisciplinary teams ensures a comprehensive, patient-centered approach. Evidence suggests that preoperative optimization, alongside tailored anesthetic techniques, plays a critical role in minimizing perioperative risks and improving recovery.
Conclusion
Prehabilitation strategies, when adapted for patients with SUDs, offer significant benefits in minimizing perioperative complications and enhancing recovery in cardiac surgery. The success of these strategies depends on a comprehensive, multidisciplinary approach, with active patient participation in preoperative optimization. Continued research and standardized protocols are needed to further refine these strategies for this high-risk population.
{"title":"Optimizing patients with substance use disorder for cardiac surgery","authors":"Ettienne Coetzee, Chian-Jia Eden Chiu, Justiaan LC. Swanevelder","doi":"10.1016/j.bpa.2025.10.001","DOIUrl":"10.1016/j.bpa.2025.10.001","url":null,"abstract":"<div><h3>Background</h3><div>Prehabilitation, incorporating personalized physical, nutritional, and psychological interventions before cardiac surgery, has gained recognition for enhancing patient resilience and improving surgical outcomes, particularly for high-risk populations. Among these populations, patients with substance use disorders (SUDs), including alcohol, tobacco, and other substance misuse, present unique challenges for anesthetic management.</div></div><div><h3>Objectives</h3><div>This review aims to highlight the most recent evidence on preoperative preparation strategies focused on minimizing perioperative risks in patients with SUDs undergoing cardiac surgery. The goal is to understand how tailored approaches to preoperative care can improve outcomes in this vulnerable group.</div><div>The review emphasizes the importance of thorough history-taking, comprehensive clinical evaluation, and optimized perioperative management specific to patients with SUDs. Collaboration among anesthetists, cardiologists, surgeons, and other healthcare professionals is essential to providing holistic care. Active patient engagement in preoperative optimization is highlighted as a crucial factor in improving surgical outcomes.</div><div>Specialized preoperative strategies, including the management of substance withdrawal, optimization of cardiovascular function, and enhancement of psychological well-being, are essential for improving surgical outcomes in patients with SUDs. Effective collaboration with multidisciplinary teams ensures a comprehensive, patient-centered approach. Evidence suggests that preoperative optimization, alongside tailored anesthetic techniques, plays a critical role in minimizing perioperative risks and improving recovery.</div></div><div><h3>Conclusion</h3><div>Prehabilitation strategies, when adapted for patients with SUDs, offer significant benefits in minimizing perioperative complications and enhancing recovery in cardiac surgery. The success of these strategies depends on a comprehensive, multidisciplinary approach, with active patient participation in preoperative optimization. Continued research and standardized protocols are needed to further refine these strategies for this high-risk population.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 2","pages":"Pages 138-146"},"PeriodicalIF":2.8,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145340867","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bpa.2025.04.004
Simone Lindau, Andrea U. Steinbicker
Anemia is common in cancer patients and linked to higher mortality, longer hospital stays, and reduced survival. Iron deficiency and the second most common form of anemia, anemia of chronic disease caused by elevated hepcidin levels, limit iron availability. Although red blood cell (RBC = transfusions quickly raise hemoglobin levels, they are associated with increased risks of tumor recurrence, infections, and reduced cancer-specific survival. Intravenous iron therapy and/or erythropoiesis-stimulating agents (ESAs) are effective alternatives to manage anemia. Patient Blood Management (PBM) offers a structured strategy to reduce transfusions by multiple approaches such as preoperative iron therapy, restrictive transfusion strategy and conserving blood during surgery. Clinical studies have shown that PBM significantly reduced transfusion rates, lowered infection risks, and shortened hospital stays without compromising safety. An individualized therapeutic approach seems beneficial in oncologic patients.
{"title":"Blood transfusion and patient blood management in cancer patients","authors":"Simone Lindau, Andrea U. Steinbicker","doi":"10.1016/j.bpa.2025.04.004","DOIUrl":"10.1016/j.bpa.2025.04.004","url":null,"abstract":"<div><div>Anemia is common in cancer patients and linked to higher mortality, longer hospital stays, and reduced survival. Iron deficiency and the second most common form of anemia, anemia of chronic disease caused by elevated hepcidin levels, limit iron availability. Although red blood cell (RBC = transfusions quickly raise hemoglobin levels, they are associated with increased risks of tumor recurrence, infections, and reduced cancer-specific survival. Intravenous iron therapy and/or erythropoiesis-stimulating agents (ESAs) are effective alternatives to manage anemia. Patient Blood Management (PBM) offers a structured strategy to reduce transfusions by multiple approaches such as preoperative iron therapy, restrictive transfusion strategy and conserving blood during surgery. Clinical studies have shown that PBM significantly reduced transfusion rates, lowered infection risks, and shortened hospital stays without compromising safety. An individualized therapeutic approach seems beneficial in oncologic patients.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 1","pages":"Pages 50-56"},"PeriodicalIF":4.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144239544","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bpa.2025.03.009
Carlos E. Guerra-Londono , Alexander Schreck , Arun Muthukumar , Juan J. Guerra-Londono
In the cancer survivorship journey, many patients require both medical and surgical oncologic treatments to improve survival. The return to intended oncologic treatment (RIOT) is a relatively new concept addressing the continuity of cancer treatment after surgery. While general definitions have been published, thresholds and minimal clinically important differences (MCID) have not been standardised. For many cancers, a threshold for delayed RIOT is 6–8 weeks, while the MCID in colorectal cancer may approximate 4 weeks. Studies addressing RIOT have shown multiple demographics, socioeconomic, institutional, surgical, and postoperative factors associated with a difference in rate and time to RIOT. The most influential of these variables is the surgical approach. While research on the effect of enhanced recovery after surgery on RIOT has increased, the literature is still in its early stages. Finally, the effect of anaesthetic interventions on RIOT has been largely unexplored.
{"title":"Return to intended oncologic treatment: Definitions, perioperative prognostic factors, and interventions","authors":"Carlos E. Guerra-Londono , Alexander Schreck , Arun Muthukumar , Juan J. Guerra-Londono","doi":"10.1016/j.bpa.2025.03.009","DOIUrl":"10.1016/j.bpa.2025.03.009","url":null,"abstract":"<div><div>In the cancer survivorship journey, many patients require both medical and surgical oncologic treatments to improve survival. The return to intended oncologic treatment (RIOT) is a relatively new concept addressing the continuity of cancer treatment after surgery. While general definitions have been published, thresholds and minimal clinically important differences (MCID) have not been standardised. For many cancers, a threshold for delayed RIOT is 6–8 weeks, while the MCID in colorectal cancer may approximate 4 weeks. Studies addressing RIOT have shown multiple demographics, socioeconomic, institutional, surgical, and postoperative factors associated with a difference in rate and time to RIOT. The most influential of these variables is the surgical approach. While research on the effect of enhanced recovery after surgery on RIOT has increased, the literature is still in its early stages. Finally, the effect of anaesthetic interventions on RIOT has been largely unexplored.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 1","pages":"Pages 14-22"},"PeriodicalIF":4.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144239667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bpa.2025.03.005
Nora Jahn , Philipp Metnitz , Robert Sucher , Robert Karitnig , Sven Laudi , Hans Michael Hau
Advancements in the treatment of cancers and organ failures have significantly improved survival rates and increased the number of cancer patients requiring and benefiting from intensive care unit (ICU) admission. As a result, critical care has become a vital component of modern cancer treatment. While, in many ways, intensive care for cancer patients is similar to that for other severely ill individuals, there are specific challenges unique to this group that require specialized expertise and knowledge. Effectively managing critically ill cancer patients requires proficiency in oncology, critical care, and palliative medicine. Therefore, cancer specialists must be well-versed in the essential aspects of intensive care for these patients. This review offers an overview of the latest approaches in the personalized management of critically ill cancer patients.
{"title":"Challenges of (postoperative) cancer patients in the ICU","authors":"Nora Jahn , Philipp Metnitz , Robert Sucher , Robert Karitnig , Sven Laudi , Hans Michael Hau","doi":"10.1016/j.bpa.2025.03.005","DOIUrl":"10.1016/j.bpa.2025.03.005","url":null,"abstract":"<div><div>Advancements in the treatment of cancers and organ failures have significantly improved survival rates and increased the number of cancer patients requiring and benefiting from intensive care unit (ICU) admission. As a result, critical care has become a vital component of modern cancer treatment. While, in many ways, intensive care for cancer patients is similar to that for other severely ill individuals, there are specific challenges unique to this group that require specialized expertise and knowledge. Effectively managing critically ill cancer patients requires proficiency in oncology, critical care, and palliative medicine. Therefore, cancer specialists must be well-versed in the essential aspects of intensive care for these patients. This review offers an overview of the latest approaches in the personalized management of critically ill cancer patients.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 1","pages":"Pages 57-70"},"PeriodicalIF":4.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144239663","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bpa.2025.03.007
Laura Smith , Ashly Mary Lal , Patrice Forget
Pain management in cancer patients is crucial, yet its implications on tumour progression and long-term outcomes remain an area of ongoing debate. Opioids, while effective for severe pain, may have immunomodulatory and tumour-promoting effects, whereas NSAIDs, particularly selective COX-2 inhibitors, could exert anti-tumour properties through modulation of inflammation and the tumour microenvironment. However, conflicting clinical evidence and methodological limitations hinder definitive conclusions. This review examines the current literature on the oncological effects of analgesics, highlighting the need for high-quality randomized controlled trials, biomarker-driven research, and a focus on patient-centred outcomes. Future studies should integrate advanced cancer subtyping and predictive modelling to optimize analgesic strategies while minimizing potential oncological risks. By addressing these gaps, clinicians can refine perioperative and long-term pain management approaches to improve both symptom control and cancer prognosis.
{"title":"Pain management in cancer patients: Could opioids or NSAIDs influence outcomes?","authors":"Laura Smith , Ashly Mary Lal , Patrice Forget","doi":"10.1016/j.bpa.2025.03.007","DOIUrl":"10.1016/j.bpa.2025.03.007","url":null,"abstract":"<div><div>Pain management in cancer patients is crucial, yet its implications on tumour progression and long-term outcomes remain an area of ongoing debate. Opioids, while effective for severe pain, may have immunomodulatory and tumour-promoting effects, whereas NSAIDs, particularly selective COX-2 inhibitors, could exert anti-tumour properties through modulation of inflammation and the tumour microenvironment. However, conflicting clinical evidence and methodological limitations hinder definitive conclusions. This review examines the current literature on the oncological effects of analgesics, highlighting the need for high-quality randomized controlled trials, biomarker-driven research, and a focus on patient-centred outcomes. Future studies should integrate advanced cancer subtyping and predictive modelling to optimize analgesic strategies while minimizing potential oncological risks. By addressing these gaps, clinicians can refine perioperative and long-term pain management approaches to improve both symptom control and cancer prognosis.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 1","pages":"Pages 45-49"},"PeriodicalIF":4.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144239543","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bpa.2025.03.001
Eduardo Nunez-Rodriguez , Juan P. Cata , Tobias Piegeler
Local anesthetics (LAs) have been widely used for over a century in perioperative care. Emerging evidence suggests that LAs impact on cancer cell biology through multiple mechanisms, including modulation of tumor cell proliferation, apoptosis, and metastasis, as well as in processes related to the tumor microenvironment such as angiogenesis and the immune response. These effects are attributed to LAs effect on membrane proteins, such as voltage gated sodium channels (VGSC) and caveolin-1, oncogenic pathways, such as PI3K/AKT/mTOR and RAS/MAPK/ERK axis, and gene transcription signaling regulation, including intermediates such as NF-κB and STAT3. Furthermore, LAs modulate cancer cells by promoting caspase activation and inducing oxidative stress, as well as regulating different organelle's function and structure. LAs role as adjuvant agents for stablished and experimental chemotherapeutic drugs have further been described in multiple in vitro experiments. In vivo models have also been used to demonstrate that LAs might be able to reduce tumor burden and metastasis in animals, highlighting their potential role in cancer treatment. However, despite promising preclinical findings, further research is needed to establish clinical relevance and optimize the use of LAs in oncological surgery. The aim of this review article is to summarize the currently available preclinical evidence of the effects of LAs and regional anesthesia on cancer spread.
{"title":"Local anesthetics, regional anesthesia and cancer biology","authors":"Eduardo Nunez-Rodriguez , Juan P. Cata , Tobias Piegeler","doi":"10.1016/j.bpa.2025.03.001","DOIUrl":"10.1016/j.bpa.2025.03.001","url":null,"abstract":"<div><div>Local anesthetics (LAs) have been widely used for over a century in perioperative care. Emerging evidence suggests that LAs impact on cancer cell biology through multiple mechanisms, including modulation of tumor cell proliferation, apoptosis, and metastasis, as well as in processes related to the tumor microenvironment such as angiogenesis and the immune response. These effects are attributed to LAs effect on membrane proteins, such as voltage gated sodium channels (VGSC) and caveolin-1, oncogenic pathways, such as PI3K/AKT/mTOR and RAS/MAPK/ERK axis, and gene transcription signaling regulation, including intermediates such as NF-κB and STAT3. Furthermore, LAs modulate cancer cells by promoting caspase activation and inducing oxidative stress, as well as regulating different organelle's function and structure. LAs role as adjuvant agents for stablished and experimental chemotherapeutic drugs have further been described in multiple <em>in vitro</em> experiments. <em>In vivo</em> models have also been used to demonstrate that LAs might be able to reduce tumor burden and metastasis in animals, highlighting their potential role in cancer treatment. However, despite promising preclinical findings, further research is needed to establish clinical relevance and optimize the use of LAs in oncological surgery. The aim of this review article is to summarize the currently available preclinical evidence of the effects of LAs and regional anesthesia on cancer spread.</div></div>","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 1","pages":"Pages 30-39"},"PeriodicalIF":4.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144239669","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bpa.2025.05.002
Juan P. Cata , Tobias Piegeler
{"title":"Perioperative care of the cancer patient","authors":"Juan P. Cata , Tobias Piegeler","doi":"10.1016/j.bpa.2025.05.002","DOIUrl":"10.1016/j.bpa.2025.05.002","url":null,"abstract":"","PeriodicalId":48541,"journal":{"name":"Best Practice & Research-Clinical Anaesthesiology","volume":"39 1","pages":"Pages 1-2"},"PeriodicalIF":4.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144239665","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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