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Barber RL, Fletcher SN. A review of echocardiography in anaesthetic and peri-operative practice. Part 1: impact and utility. Anaesthesia 2014; 69:764-76. [DOI: 10.1111/anae.12663] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 12/11/2022]
Affiliation(s)
| | - S. N. Fletcher
- St George's Hospital and Honorary Senior Lecturer; St George's University of London; London UK
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Tu CP, Tsai CH, Tsai CC, Huang TS, Cheng SP, Liu TP. Postoperative Ileus in the Elderly. INT J GERONTOL 2014. [DOI: 10.1016/j.ijge.2013.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Cloyd JM, Ma Y, Morton JM, Kurella Tamura M, Poultsides GA, Visser BC. Does chronic kidney disease affect outcomes after major abdominal surgery? Results from the National Surgical Quality Improvement Program. J Gastrointest Surg 2014; 18:605-12. [PMID: 24241964 DOI: 10.1007/s11605-013-2390-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/07/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The impact of chronic kidney disease (CKD) and end-stage renal disease on outcomes following major abdominal surgery is not well defined. MATERIALS AND METHODS The 2008 NSQIP database was queried to identify adult patients undergoing complex abdominal surgery (major colorectal, hepatobiliary, pancreatic, gastric, and esophageal operations). Thirty-day morbidity and mortality in patients on hemodialysis (HD) versus patients not on HD were compared. The impact of preoperative renal insufficiency, measured by glomerular filtration rate (GFR), on morbidity and mortality was then assessed in non-dialysis patients. RESULTS Of 24,572 patients who underwent major abdominal operations, excluding emergency cases, only 149 (0.6%) were on HD preoperatively. Thirty-day mortality in the HD group was 12.8% compared to 1.8% for those not on HD (p < 0.0001). Overall complication rate was 23.5 versus 12.3% (p < 0.0001). In particular, rates of pneumonia (6.7 vs 3.0%, p < 0.05) and sepsis (12.8 vs 5.3%, p < 0.001) were higher in patients on HD. In patients not on HD, GFR was significantly predictive of postoperative mortality after controlling for age, gender, race, emergency status, and comorbidities. Compared to patients with normal preoperative kidney function (GFR, 75-90 ml/min/1.73 m(2)), even modest CKD (GFR, 45-60 ml/min/1.73 m(2)) was associated with increased postoperative mortality (odds ratio (OR), 1.62). With greater impairment in kidney function, postoperative mortality was even more marked (GFR, 30-45 ml/min/1.73 m(2) and OR, 2.84; GFR, 15-30 ml/min/1.73 m(2) and OR, 5.56). In addition, CKD was independently associated with increased postoperative complications. CONCLUSION Any degree of preoperative kidney impairment, even mild asymptomatic disease, is associated with clinically significant increases in 30-day postoperative morbidity and mortality following major abdominal surgery.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, Stanford University, 300 Pasteur Dr, MC5641, Stanford, CA, 94305, USA,
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Lim S, Jordan SW, Jain U, Kim JYS. Predictors and causes of unplanned re-operations in outpatient plastic surgery: a multi-institutional analysis of 6749 patients using the 2011 NSQIP database. J Plast Surg Hand Surg 2014; 48:270-5. [PMID: 24533745 DOI: 10.3109/2000656x.2013.871287] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Studies that evaluate the predictors and causes of unplanned re-operation in outpatient plastic surgery. This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all plastic surgery outpatient cases performed in 2011. Multiple logistic regression analysis was utilised to identify independent risk factors and causes of unplanned reoperations. Of the 6749 outpatient plastic surgery cases identified, there were 125 (1.9%) unplanned re-operations (UR). Regression analysis demonstrated that body mass index (BMI, OR = 1.041, 95% CI = 1.019-1.065), preoperative open wound/wound infection (OR = 3.498, 95% CI = 1.593-7.678), American Society of Anesthesiologists (ASA) class 3 (OR = 2.235, 95% CI = 1.048-4.765), and total work relative value units (RVU, OR = 1.014, 95% CI = 1.005-1.024) were significantly predictive of UR. Additionally, the presence of any complication was significantly associated with UR (OR = 15.065, 95% CI = 5.705-39.781). In an era of outcomes-driven medicine, unplanned re-operation is a critical quality indicator for ambulatory plastic surgery facilities. The identified risk factors will aid in surgical planning and risk adjustment.
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Affiliation(s)
- Seokchun Lim
- Rosalind Franklin University of Medicine and Science, Chicago Medical School , North Chicago, IL , USA
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Glasgow RE, Hawn MT, Hosokawa PW, Henderson WG, Min SJ, Richman JS, Tomeh MG, Campbell D, Neumayer LA. Comparison of prospective risk estimates for postoperative complications: human vs computer model. J Am Coll Surg 2014; 218:237-45.e1-4. [PMID: 24440066 PMCID: PMC3904017 DOI: 10.1016/j.jamcollsurg.2013.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/23/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk. STUDY DESIGN This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes. RESULTS The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity. CONCLUSIONS Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.
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Affiliation(s)
| | - Mary T Hawn
- Department of Surgery, University of Alabama, Birmingham, AL
| | | | | | - Sung-Joon Min
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Majed G Tomeh
- University of Colorado Health Outcomes Program, Aurora, CO
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Kabarriti AE, Pietzak EJ, Canter DJ, Guzzo TJ. The Relationship Between Age and Perioperative Complications. CURRENT GERIATRICS REPORTS 2014. [DOI: 10.1007/s13670-013-0069-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Waist circumference and waist/hip ratio are better predictive risk factors for mortality and morbidity after colorectal surgery than body mass index and body surface area. Ann Surg 2013; 258:722-30. [PMID: 24096768 DOI: 10.1097/sla.0b013e3182a6605a] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine whether body fat distribution, measured by waist circumference (WC) and waist/hip ratio (WHR), is a better predictor of mortality and morbidity after colorectal surgery than body mass index (BMI) or body surface area (BSA). BACKGROUND Obesity measured by BMI is not a consistent risk factor for postoperative mortality and morbidity after abdominal surgery. Studies in metabolic and cardiovascular diseases have shown WC and WHR to be better outcome predictors than BMI. METHODS A prospective multicenter international study was conducted among patients undergoing elective colorectal surgery. The WHR, BMI, and BSA were derived from body weight, height, and waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify risk factors for postoperative outcomes. RESULTS A total of 1349 patients (754 men) from 38 centers in 11 countries were included. Increasing WHR significantly increased the risk of conversion [odds ratio (OR) = 15.7, relative risk (RR) = 4.1], intraoperative complications (OR = 11.0, RR = 3.2), postoperative surgical complications (OR = 7.7, RR = 2.0), medical complications (OR = 13.2, RR = 2.5), anastomotic leak (OR = 13.7, RR = 3.3), reoperations (OR = 13.3, RR = 2.9), and death (OR = 653.1, RR = 21.8). Both BMI (OR = 39.5, RR = 1.1) and BSA (OR = 4.9, RR = 3.1) were associated with an increased risk of abdominal wound complication. In multivariate analysis, the WHR predicted intraoperative complications, conversion, medical complications, and reinterventions, whereas BMI was a risk factor only for abdominal wall complications; BSA did not reach significance for any outcome. CONCLUSIONS The WHR is predictive of adverse events after elective colorectal surgery. It should be used in routine clinical practice and in future risk-estimating systems.
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Dover M, Tawfick W, Hynes N, Sultan S. Cardiac Risk Assessment, Morbidity Prediction, and Outcome in the Vascular Intensive Care Unit. Vasc Endovascular Surg 2013; 47:585-94. [DOI: 10.1177/1538574413502551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives: The aim of this study is to examine the predictive value of the Lee revised cardiac risk index (RCRI) for a standard vascular intensive care unit (ICU) population as well as assessing the utility of transthoracic echocardiography and the impact of prior coronary artery disease (CAD) and coronary revascularization on patient outcome. Design: This is a retrospective review of prospectively maintained Vascubase and prospectively collected ICU data. Materials and Methods: Data from 363 consecutive vascular ICU admissions were collected. Findings were used to calculate the RCRI, which was then correlated with patient outcomes. All patients were on optimal medical therapy (OMT) in the form of cardioselective β-blocker, aspirin, statin, and folic acid. Results: There was no relationship found between a reduced ejection fraction and patient outcome. Mortality was significantly increased for patients with left ventricular hypertrophy (LVH) as identified on echo (14.9% vs 6.5%, P = .028). The overall complication rates were significantly elevated for patients with valvular dysfunction. Discrimination for the RCRI on receiver–operating characteristic analysis was poor, with an area under the receiver–operating characteristic curve of .621. Model calibration was reasonable with an Hosmer-Lemeshow Ĉ statistic of 2.726 ( P = .256). Of those with known CAD, 41.22% of the patients receiving best medical treatment developed acute myocardial infarction (AMI) compared to 35.3% of those who previously underwent percutaneous cardiac intervention and 23.5% of those who had undergone coronary artery bypass grafting. There was 3-fold increase in major adverse clinical events in patients with troponin rise and LVH. Conclusions: The RCRI’s discriminatory capacity is low, and this raises difficulties in assessing cardiac risk in patients undergoing vascular intervention. The AMI is highest in the OMT group without prior cardiac intervention, which mandates protocols to identify patients requiring cardiac intervention prior to vascular procedures.
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Affiliation(s)
- Mary Dover
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Wael Tawfick
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland
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Biccard BM, Rodseth RN. What evidence is there for intraoperative predictors of perioperative cardiac outcomes? A systematic review. Perioper Med (Lond) 2013; 2:14. [PMID: 24472327 PMCID: PMC3964323 DOI: 10.1186/2047-0525-2-14] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 05/10/2013] [Indexed: 01/06/2023] Open
Abstract
Background Patients undergo cardiac preoperative evaluation to identify those at risk of adverse perioperative cardiac events. The Revised Cardiac Risk index is commonly used for this task, although it is unable to accurately risk stratify in all patients. This may be partly a result of intraoperative events which significantly modify preoperative risk. Methods We conducted a systematic review to identify independent intraoperative predictors of adverse cardiac events in patients undergoing non-cardiac surgery. Four databases (Ovid Healthstar 1966 to Jan 2012, Ovid Medline 1946 to 6 March 2012, EMBASE 1974 to March 05 2012 and The Cochrane Library to March 06 2012) were searched. Results Fourteen eligible studies were identified. The need for intraoperative blood transfusion (odds ratio (OR), 2.3; 95% confidence interval (CI), 1.4-3.3), vascular surgery (OR, 2.3; 95% CI, 1.2-3.4) and emergent/urgent surgery (OR, 2.3; 95% CI, 1.1-3.5) were the only independent intraoperative risk predictors identified in more than study. Other independent intraoperative factors identified included a >20 mmHg fall in mean arterial blood pressure for > 60 min (OR, 3.0; 95% CI, 1.8-4.9), >30% increase in baseline systolic pressure (OR, 8.0; 95% CI, 1.3-50), tachycardia in the recovery room (>30 beats per min (bpm) from baseline for >5 min) (OR, 7; 95% CI, 1.9-26), new onset atrial fibrillation (OR, 6.6; 95% CI, 2.5-20), hypothermia (OR, 2.2; 95% CI, 1.1-5) and remote ischemic preconditioning (OR, 0.22; 95% CI, 0.07-0.67). Other markers of surgical complexity were not independently associated with postoperative adverse cardiac outcomes. None of these studies controlled for blood transfusion. Conclusions Intraoperative events significantly increase the risk for postoperative cardiac complications, although only intraoperative blood transfusion has strong evidence supporting this finding. It is possible that modification of these intraoperative risk factors by anesthetists and surgeons may reduce postoperative cardiac events and improve outcome. The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study will add important information to understanding intraoperative risk factors for adverse cardiac events.
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Affiliation(s)
- Bruce M Biccard
- Perioperative Research Group, Department of Anaesthetics, Nelson R, Mandela School of Medicine, University of KwaZulu-Natal, Private Bag 7, Congella 4013, South Africa.
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Farzi S, Stojakovic T, Marko T, Sankin C, Rehak P, Gumpert R, Baumann A, Höfler B, Metzler H, Mahla E. Role of N-terminal pro B-type natriuretic peptide in identifying patients at high risk for adverse outcome after emergent non-cardiac surgery. Br J Anaesth 2013; 110:554-60. [DOI: 10.1093/bja/aes454] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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62
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63
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Boitano LT, Wang EC, Kibbe MR. Differential effect of nutritional status on vascular surgery outcomes in a Veterans Affairs versus private hospital setting. Am J Surg 2012; 204:e27-37. [DOI: 10.1016/j.amjsurg.2012.07.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 05/23/2012] [Accepted: 07/11/2012] [Indexed: 11/28/2022]
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Anderson JE, Lassiter R, Bickler SW, Talamini MA, Chang DC. Brief tool to measure risk-adjusted surgical outcomes in resource-limited hospitals. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 2012; 147:798-803. [PMID: 22987164 PMCID: PMC4282492 DOI: 10.1001/archsurg.2012.699] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To develop and validate a risk-adjusted tool with fewer than 10 variables to measure surgical outcomes in resource-limited hospitals. DESIGN All National Surgical Quality Improvement Program (NSQIP) preoperative variables were used to develop models to predict inpatient mortality. The models were built by sequential addition of variables selected based on their area under the receiver operator characteristic curve (AUROC) and externally validated using data based on medical record reviews at 1 hospital outside the data set. SETTING Model development was based on data from the NSQIP from 2005 to 2009. Validation was based on data from 1 nonurban hospital in the United States from 2009 to 2010. PATIENTS A total of 631 449 patients in NSQIP and 239 patients from the validation hospital. MAIN OUTCOME MEASURES The AUROC value for each model. RESULTS The AUROC values reached higher than 90% after only 3 variables (American Society of Anesthesiologists class, functional status at time of surgery, and age). The AUROC values increased to 91% with 4 variables but did not increase significantly with additional variables. On validation, the model with the highest AUROC was the same 3-variable model (0.9398). CONCLUSIONS Fewer than 6 variables may be necessary to develop a risk-adjusted tool to predict inpatient mortality, reducing the cost of collecting variables by 95%. These variables should be easily collectable in resource-poor settings, including low- and middle-income countries, thus creating the first standardized tool to measure surgical outcomes globally. Research is needed to determine which of these limited-variable models is most appropriate in a variety of clinical settings.
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Affiliation(s)
- Jamie E Anderson
- Department of Surgery, University of California, San Diego, 200 W Arbor Dr, Ste 8400, San Diego, CA 92103, USA.
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65
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Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg 2012; 215:453-66. [PMID: 22917646 DOI: 10.1016/j.jamcollsurg.2012.06.017] [Citation(s) in RCA: 513] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 05/29/2012] [Accepted: 06/11/2012] [Indexed: 01/10/2023]
Affiliation(s)
- Warren B Chow
- American College of Surgeons National Surgical Quality Improvement Program, Chicago, IL 60611-3211, USA.
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Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward Prospective Identification of High-Risk Surgical Patients. Am Surg 2012. [DOI: 10.1177/000313481207800713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: “low” risk corresponding to the bottom quartile, “average” to the middle two quartiles, and “high” to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of “high-risk” patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.
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Affiliation(s)
- Joshua S. Richman
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
- Division of General Surgery, Gastrointestinal Section, University of Alabama School of Medicine, Birmingham, Alabama
| | - Patrick W. Hosokawa
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
| | - Sung-Joon Min
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
| | | | | | | | - William G. Henderson
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
- Department of Biostatistics & Informatics, School of Public Health, University of Colorado Denver, Denver, Colorado
| | - Mary T. Hawn
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
- Division of General Surgery, Gastrointestinal Section, University of Alabama School of Medicine, Birmingham, Alabama
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Asopa A, Jidge S, Schermerhorn ML, Hess PE, Matyal R, Subramaniam B. Preoperative Pulse Pressure and Major Perioperative Adverse Cardiovascular Outcomes After Lower Extremity Vascular Bypass Surgery. Anesth Analg 2012; 114:1177-81. [DOI: 10.1213/ane.0b013e3182290551] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Elias ACGP, Matsuo T, Grion CMC, Cardoso LTQ, Verri PH. Incidence and risk factors for sepsis in surgical patients: A cohort study. J Crit Care 2012; 27:159-66. [DOI: 10.1016/j.jcrc.2011.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/01/2022]
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Biccard BM. Postoperative risk stratification for cardiovascular complications. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sabaté S, Mases A, Guilera N, Canet J, Castillo J, Orrego C, Sabaté A, Fita G, Parramón F, Paniagua P, Rodríguez A, Sabaté M. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth 2011; 107:879-90. [DOI: 10.1093/bja/aer268] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Tsang C, Palmer W, Bottle A, Majeed A, Aylin P. A Review of Patient Safety Measures Based on Routinely Collected Hospital Data. Am J Med Qual 2011; 27:154-69. [DOI: 10.1177/1062860611414697] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carmen Tsang
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
| | - William Palmer
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- National Audit Office, London, UK
| | - Alex Bottle
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
| | | | - Paul Aylin
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
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Biccard B, Rodseth R. Utility of clinical risk predictors for preoperative cardiovascular risk prediction. Br J Anaesth 2011; 107:133-43. [DOI: 10.1093/bja/aer194] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, Esterbrooks DJ, Hunter CB, Pipinos II, Johanning JM, Lynch TG, Forse RA, Mohiuddin SM, Mooss AN. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation 2011; 124:381-7. [PMID: 21730309 DOI: 10.1161/circulationaha.110.015701] [Citation(s) in RCA: 417] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Perioperative myocardial infarction or cardiac arrest is associated with significant morbidity and mortality. The Revised Cardiac Risk Index is currently the most commonly used cardiac risk stratification tool; however, it has several limitations, one of which is its relatively low discriminative ability. The objective of the present study was to develop and validate a predictive cardiac risk calculator. METHODS AND RESULTS Patients who underwent surgery were identified from the American College of Surgeons' 2007 National Surgical Quality Improvement Program database, a multicenter (>250 hospitals) prospective database. Of the 211 410 patients, 1371 (0.65%) developed perioperative myocardial infarction or cardiac arrest. On multivariate logistic regression analysis, 5 predictors of perioperative myocardial infarction or cardiac arrest were identified: type of surgery, dependent functional status, abnormal creatinine, American Society of Anesthesiologists' class, and increasing age. The risk model based on the 2007 data set was subsequently validated on the 2008 data set (n=257 385). The model performance was very similar between the 2007 and 2008 data sets, with C statistics (also known as area under the receiver operating characteristic curve) of 0.884 and 0.874, respectively. Application of the Revised Cardiac Risk Index to the 2008 National Surgical Quality Improvement Program data set yielded a relatively lower C statistic (0.747). The risk model was used to develop an interactive risk calculator. CONCLUSIONS The cardiac risk calculator provides a risk estimate of perioperative myocardial infarction or cardiac arrest and is anticipated to simplify the informed consent process. Its predictive performance surpasses that of the Revised Cardiac Risk Index.
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Affiliation(s)
- Prateek K Gupta
- Department of Surgery, Creighton University, 601 N 30th St, Omaha, NE 68131, USA.
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Lobo SM, Rezende E, Knibel MF, Silva NB, Páramo JA, Nácul FE, Mendes CL, Assunção M, Costa RC, Grion CC, Pinto SF, Mello PM, Maia MO, Duarte PA, Gutierrez F, Silva JM, Lopes MR, Cordeiro JA, Mellot C. Early Determinants of Death Due to Multiple Organ Failure After Noncardiac Surgery in High-Risk Patients. Anesth Analg 2011; 112:877-83. [DOI: 10.1213/ane.0b013e3181e2bf8e] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Subramaniam B, Meroz Y, Talmor D, Pomposelli FB, Berlatzky Y, Landesberg G. A long-term survival score improves preoperative prediction of survival following major vascular surgery. Ann Vasc Surg 2011; 25:197-203. [PMID: 21315231 DOI: 10.1016/j.avsg.2010.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Revised: 03/26/2010] [Accepted: 09/22/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND In a previous study it has been shown that a long-term survival score (LTSS), composed of Lee's Revised Cardiac Risk Index (RCRI) criteria supplemented by age, preoperative electrocardiography (EKG) features, and all types of diabetes to the RCRI criteria, predicts long-term (3-15 years) survival after major vascular surgery. The present study aimed to investigate the performance of LTSS in predicting earlier survival (3 months-3 years) as compared with the RCRI. METHODS Data from 921 consecutive patients undergoing major vascular surgery (624 patients at Hadassah Medical Center [HMC] and 296 patients in Beth Israel Deaconess Medical Center [BIDMC]) were collected retrospectively. The LTSS was seven points that included the five RCRI factors as well as age >65 years and ST-segment depression on preoperative EKG. Logistic regression and receiver operating characteristic curve (ROC) curve analyses were used to compare the 3 months-3 years mortality between the RCRI and LTSS. RESULTS The Beth Israel Deaconess Medical Center patients were sicker than the Hadassah Medical Center patients, with higher RCRI (1.2 ± 1.0 vs. 0.81 ± 0.83, p < 0.001) and LTSS (2.6 ± 1.4 vs. 1.7 ± 1.2, p < 0.001) and higher 3-years mortality (36.3% vs. 20.7%, p = 0.005). The LTSS predicted mortality better than RCRI as measured by the area under the ROC curves at all time points between 6 months (0.66 ± 0.03 vs. 0.57 ± 0.04, p = 0.02) and 3 years (0.70 ± 0.02 vs. 0.61 ± 0.02, p < 0.0001) in both institutions, but not 3-months mortality. The LTSS also provided better discrimination between each adjacent two-risk score than the RCRI. CONCLUSIONS Age >65 years, ST-segment depression on preoperative 12-lead EKG, and all types of diabetes added to the RCRI significantly improved the preoperative prediction of mortality after 6 months following major vascular surgery.
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Nafiu OO, Kheterpal S, Moulding R, Picton P, Tremper KK, Campbell DA, Eliason JL, Stanley JC. The Association of Body Mass Index to Postoperative Outcomes in Elderly Vascular Surgery Patients. Anesth Analg 2011; 112:23-9. [DOI: 10.1213/ane.0b013e3181fcc51a] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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77
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Henke PK, Kubus J, Englesbe MJ, Harbaugh C, Campbell DA. A statewide consortium of surgical care: A longitudinal investigation of vascular operative procedures at 16 hospitals. Surgery 2010; 148:883-89; discussion 889-92. [DOI: 10.1016/j.surg.2010.07.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 07/07/2010] [Indexed: 11/16/2022]
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Missing Data in the American College of Surgeons National Surgical Quality Improvement Program Are Not Missing at Random: Implications and Potential Impact on Quality Assessments. J Am Coll Surg 2010; 210:125-139.e2. [DOI: 10.1016/j.jamcollsurg.2009.10.021] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 10/16/2009] [Accepted: 10/23/2009] [Indexed: 11/22/2022]
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79
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Itani KM. Fifteen years of the National Surgical Quality Improvement Program in review. Am J Surg 2009; 198:S9-S18. [DOI: 10.1016/j.amjsurg.2009.08.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 08/04/2009] [Indexed: 12/22/2022]
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80
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Sun P, Gu J, Maze M, Ma D. Is xenon a future neuroprotectant? FUTURE NEUROLOGY 2009. [DOI: 10.2217/fnl.09.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Acute neuronal injury has devastating consequences with increased risks of morbidity and mortality. Among its survivors, neurological deficit is associated with loss of function, independence and quality of life. Currently, there is a distinctive lack of effective clinical strategies to obviate this problem. Xenon, a noble gas with anesthetic properties, exhibits neuroprotective effects. It is efficacious and nontoxic and has been used safely in clinical settings involving both anesthetic and imaging applications in patients of all ages. Xenon blocks the NMDA subtype of the glutamate receptor, a pivotal step in the pathway towards neuronal death. The preclinical data obtained from animal models of stroke, neonatal asphyxia and global ischemia induced by cardiac arrest, as well as recent data of traumatic brain injury, revealed that xenon is a potentially ideal candidate as a neuroprotectant. In addition, recent studies demonstrated that xenon can uniquely prevent anesthetic-induced neurodegeneration in the developing brain. Thus, clinical studies are urgently required to investigate the neuroprotective effects of xenon in the clinical setting of brain damage.
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Affiliation(s)
- Pamela Sun
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Jianteng Gu
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, Chelsea and Westminster Hospital, London, UK and, Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Mervyn Maze
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Daqing Ma
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London SW10 9NH, UK
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Effect of subjective preoperative variables on risk-adjusted assessment of hospital morbidity and mortality. Ann Surg 2009; 249:682-9. [PMID: 19300217 DOI: 10.1097/sla.0b013e31819eda21] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine the influence of American Society of Anesthesiologists Physical Status Classification (ASA) and preoperative Functional Health Status (FHS) variables on risk-adjusted estimates of surgical quality and to assess whether classifications are inflated at some hospitals. BACKGROUND ASA and FHS are influential in risk-adjusted comparisons of surgical quality. However, because ASA and FHS are subjective they can be inflated, making patients appear more ill than they actually are, and crediting hospitals for a sicker patient population. METHODS We identified 28,751 colorectal surgery patients at 170 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program (ACS NSQIP) during 2006 to 2007. Logistic regression models were developed for morbidity and mortality with and without inclusion of ASA and FHS. Hospital quality rankings from the different models were compared. RESULTS Morbidity and mortality rates were 24.3% and 3.9%, respectively. Percents of patients in ASA classes I through V were 3.3%, 46.4%, 41.5%,8.3%, and 0.7% and that were independent or partially or totally dependent were 89.2%, 7.2%, and 3.6%, respectively. Models that included ASA and FHS exhibited slightly better fit (Hosmer-Lemshow statistic) and discrimination(c-statistic) than models without both these variables, though magnitudes of differences were consistent with chance. There was inconsistent evidence for improper assignment of ASA and FHS. CONCLUSIONS The small improvements in model quality when both ASA and FHS are present versus absent, suggest that they make a unique contribution to assessing severity of preoperative risk. With little indication that these subjective variables are subject to an important level of institutional bias, it is appropriate that they be used to assess risk-adjusted surgical quality. Periodic monitoring for inappropriate inflation of ASA status is warranted.
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Sear JW. Perioperative control of hypertension: when will it adversely affect perioperative outcome? Curr Hypertens Rep 2009; 10:480-7. [PMID: 18959836 DOI: 10.1007/s11906-008-0090-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Much has been published about the impact of treatment on adverse outcomes in patients with cardiovascular diseases. Hypertension is an extremely common condition affecting a significant percentage of the world population. Although care guidelines exist for the medical patient with raised blood pressure, there are no accepted guidelines for the preoperative evaluation and perioperative care of the patient with hypertension who undergoes noncardiac surgery. Of particular importance are defining at-risk groups of patients, and the indications for cancellation to treat and hence reduce this risk. This review examines the interactions between hypertension, drug therapies, anesthesia, and adverse outcomes in these patients. Recommendations for identifying patients at greatest risk of adverse cardiovascular events and cardiac mortality have been developed through evaluation of available data. Based on these findings, the only patients in whom cancellation may be justified and the level of hypertension treated prior to surgery are those with stage 2 hypertension and accompanying target-organ damage, or stage 3 hypertension (blood pressure > 180/> 110 mm Hg).
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Affiliation(s)
- John W Sear
- Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, UK.
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83
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TEE for managing a patient with mitral valve disease undergoing clipping of intracranial aneurysm. J Neurosurg Anesthesiol 2008; 21:70-1. [PMID: 19098635 DOI: 10.1097/ana.0b013e31818fe6b7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The unresolved issues with risk stratification and management of patients with coronary artery disease undergoing major vascular surgery. Can J Anaesth 2008; 55:542-56. [PMID: 18676390 DOI: 10.1007/bf03016675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The purpose of this article, with a specific focus on patients undergoing vascular surgery, is to review controversial issues related to mechanisms of perioperative myocardial infarction (MI), coronary artery disease detection, and strategies to reduce perioperative complications. We propose explanations for the many conflicting results that have recently emerged in the literature.Source documents: We searched MEDLINE and reviewed all relevant manuscripts and scientific statements regarding management of patients undergoing non-cardiac surgery. PRINCIPAL FINDINGS Identification and prevention of ischemia in patients undergoing vascular surgery remains controversial. While the identification of preoperative ischemia is a marker of a higher perioperative risk, the value of identifying such ischemia has been questioned. We believe this may be, at least in part, due to our limited understanding of perioperative MI. Appropriate management of patients, based on the results of such testing, is likely the key to improving outcomes, and deserves further investigation. Efforts aimed at reducing the ischemic consequences of severe coronary plaques (by revascularization or beta-blocker therapy) have yielded conflicting results. The use of high doses of preoperative beta-blocker therapy may be harmful. Some studies suggest a promising role for statin therapy. Benefits of acetylsalicylic acid must be weighted against the risk of bleeding. CONCLUSION Many questions remain unanswered about the impact of detecting inducible ischemia, and the role of revascularization or beta-blockers in patients undergoing vascular surgery. A better understanding of the pathophysiology of perioperative MI is critical, in order to identify the best approach to improve cardiac outcomes in these patients.
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Bishop MJ, Souders JE, Peterson CM, Henderson WG, Domino KB. Factors Associated with Unanticipated Day of Surgery Deaths in Department of Veterans Affairs Hospitals. Anesth Analg 2008; 107:1924-35. [DOI: 10.1213/ane.0b013e31818af8f3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. OBJECTIVE To assess, synthesize, and discuss implementation of "fast-track" recovery programs. DATA SOURCES Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. DATA SYNTHESIS Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. CONCLUSION Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.
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Mittnacht AJC, Fanshawe M, Konstadt S. Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery. Semin Cardiothorac Vasc Anesth 2008; 12:33-59. [DOI: 10.1177/1089253208316442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as βblockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.
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Affiliation(s)
| | | | - Steven Konstadt
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn New York
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Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA, Fink AS, Mentzer RM, Steeger JE. The Patient Safety in Surgery Study: Background, Study Design, and Patient Populations. J Am Coll Surg 2007; 204:1089-102. [PMID: 17544068 DOI: 10.1016/j.jamcollsurg.2007.03.028] [Citation(s) in RCA: 290] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Accepted: 03/16/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this article is to describe the background, design, and patient populations of the Patient Safety in Surgery Study, as a preliminary to the articles in this journal that will report the results of the Study. STUDY DESIGN The Patient Safety in Surgery Study was a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in patients undergoing major general and vascular operations at 128 Veterans Affairs (VA) medical centers and 14 selected university medical centers between October 1, 2001 and September 30, 2004. An Internet-based data collection system was used to input data from the different private medical centers. Semiannual feedback of observed to expected mortality and morbidity ratios was provided to the participating medical centers. RESULTS During the 3-year study, total accrual in general surgery was 145,618 patients, including 68.5% from the VA and 31.5% from the private sector. Accrual in vascular surgery totaled 39,225 patients, including 77.8% from the VA and 22.2% from the private sector. VA patients were older and included a larger proportion of male patients and African Americans and Hispanics. The VA population included more inguinal, umbilical, and ventral hernia repairs, although the private-sector population included more thyroid and parathyroid, appendectomy, and operations for breast cancer. Preoperative comorbidities were similar in the two populations, but the rates of comorbidities were higher in the VA. American Society of Anesthesiologists classification tended to be higher in the VA. CONCLUSIONS The National Surgical Quality Improvement Program methodology was successfully implemented in the 14 university medical centers. The data from the study provided the basis for the articles in this issue of the Journal of the American College of Surgeons.
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Affiliation(s)
- Shukri F Khuri
- VA Boston Healthcare System, West Roxbury, MA 02132, USA.
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Abstract
In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.
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