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

more

Transfusion associated with worse outcomes in acute MI

January 29th, 2013

Meta analysis has its limitations.  This one in today’s JAMA seems to condemn transfusion in acute MI.  Interesting, that in the perioperative arena, blood loss is associated with increased CV complications.

“What are this month’s perioperative beta blockade guidelines?”

December 16th, 2012

I lectured at the NY State Society of Anesthesiologists annual meeting (aka, “PGA”) on a panel on care of the cardiac patient for noncardiac surgery.  That meant I didn’t see as much of SantaCon as I might have liked.

Click here for PDF of PowerPoint slide set:  2012_12_15 PGA 2012 John Ellis Beta blockade handout

 

Annual Scientific Meeting in Anesthesiology 2012 Hong Kong

December 10th, 2012

I gave several lectures at this year’s ASM meeting in Hong Kong. Below are some of the lecture slides.

Continue, stop, or start ACE inhibitors before cardiac surgery?

July 17th, 2012

Keep your neo/vasopressin handy and deal with it!

A new retrospective study of 4000+ cardiac surgery patients shows that the periop use of ACE-I is associated with reduced morbid events; the primary outcome of the study was defined as the composite outcome of the cardiac, cerebral, and renal events and in-hospital mortality:

“CONCLUSIONS: Our study suggests that withdrawal of ACEI treatment after CABG surgery is associated with non-fatal in-hospital ischemic events. Further, continuation of ACEI or de novo ACEI therapy early after cardiac surgery is associated with improved in-hospital outcomes.”

So, keep your neo/vasopressin handy and deal with it!

Figure 2.

Kaplan–Meier survival analysis of event-free status by angiotensin-converting enzyme inhibitor (ACEI) therapy. The curves show data of 30-day in-hospital composite event-free status. The P value shown is for the comparison of Kaplan–Meier survival function among the 4 groups. The P value was calculated from the log-rank

Monitoring for CEA – 2012 Society of Cardiovascular Anesthesia 20 min lecture video and PDF of slides

July 15th, 2012

ELLIS 2012 SCA CEA SLIDES HANDOUTS

 

 

Hemorrhage increases periop Q wave MI and stroke following noncardiac surgery

July 10th, 2012

A new article in Circulation reviews hundreds of thousdands of patients in the NSQIP database.  They excluded cardiac, transplant, trauma, and neurosurgery patients. They find that approximately 1% of patients have >4 U RBC transfusion.  These patients have a 3-4 fold increase in rate of periop Q wave MI and/or stroke (approx 1% each).  No surprises there.  Patients undergoing vascular surgery were significantly over-represented in the hemorrhage category.

This retrospective study does not address the relationship of preexisting anticoagulant or antiplatelet drug use in these patients.  The reporting did not include routine ROMI (rule-out MI), suggesting under-reporting of PMI; we know that troponin increases, even in the absence of Q waves, are associated with poor long-term outcome after vascular surgery.

 

The authors and the editorial below discuss that perioperative strokes are usually ischemic, not hemorrhagic; and that hypotension is probably more important that anemia (low oxygen carrying capacity) perse in contributing to periop stroke.

In an accompanying editorial, Lee Goldman points out a number of limitations and suggestions for future research:

Most studies suggest a ~ 5:1 ratio of PMI:stroke, not the 1:1 ratio seen here.

In the Carson study, the ratio was 5.5 postoperative MIs for each postoperative stroke. So, NSQIP, which may well have missed some small postoperative strokes, undoubtedly missed 80% of postoperative MIs by modern diagnostic criteria. As a result, Kamel and colleagues clearly have substantially underestimated the absolute risk of postoperative MI attributable to perioperative hemorrhage and may also have substantially underestimated the relative risk resulting from postoperative hemorrhage.

He then goes on to criticize the present evidence base and guidelines for perioperative management of antiplatelet and anticoagulant therapy.

The American College of Chest Physicians publishes evidenced-based clinical practice guidelines for the perioperative management of antithrombotic therapy, the last of which was published in 2012.12 Although each iteration of these guidelines is logical and consensus-driven, each is based on weak data, essentially none from randomized trials…

As noted by Kamel and colleagues, this problem cries out for better data, which can be obtained only from placebo-controlled randomized trials. And the problem is getting even more important… we really do not know at all how best to manage these patients through noncardiac surgery…  It simply is not appropriate for us to keep tap dancing with recommendations whose scientific basis is no more sound than a variety of treatment guidelines…

He suggests three large RCTs to address the following questions:

  1. How best to manage patients who are on aggressive antiplatelet therapy after coronary stenting
  2. How best to manage patients who are treated long-term with aspirin or other antiplatelet agents for the secondary prevention of myocardial infarction or ischemic cerebrovascular events
  3. How best to manage patients who have atrial fibrillation and are receiving prophylactic anticoagulation to prevent embolic stroke.

 

Screening (and Some Rescreening) for Aortic Aneurysms Found Cost Effective

July 6th, 2012
BMJ 2012; 345 doi: 10.1136/bmj.e4276 (Published 5 July 2012)

Cite this as: BMJ 2012;345:e4276

Objective To assess the cost effectiveness of different screening strategies for abdominal aortic aneurysm in men, from the perspective of a national health service.

Setting Screening units at regional hospitals.

Participants Hypothetical cohort of 65 year old men from the general population.

Main outcome measures Costs (£ in 2010) and effect on health outcomes (quality adjusted life years (QALYs)).

Results Screening seems to be highly cost effective compared with not screening. The model estimated a 92% probability that some form of screening would be cost effective at a threshold of £20 000 (€24 790; $31 460).

NEJM “Porcelain Aorta” – Great video of fluoroscopy

June 29th, 2012

IMAGES IN CLINICAL MEDICINE

IMAGES IN CLINICAL MEDICINE Porcelain Aorta Min-Kyung Kang, M.D., and Jong-Won Ha, M.D., Ph.D. N Engl J Med 2012; 366:e40June 28, 2012

Porcelain Aorta
Min-Kyung Kang, M.D., and Jong-Won Ha, M.D., Ph.D.
N Engl J Med 2012; 366:e40June 28, 2012

Anesthesia Camp, Grand Cayman BWI. Jan 30 – Feb 2 2013

June 5th, 2012

Anesthesia Camp, Laguna Beach CA, Sept 20-22, 2012

May 15th, 2012

Register here

Course details here