Multivariable Predictors of Postoperative Cardiac Adverse Events after General and Vascular Surgery: Results from the Patient Safety in Surgery Study

Transfers and anesthesia-related postoperative outcomes after 3361 same-day cancer surgeries at a freestanding surgery center: An observational retrospective study

BACKGROUND AND OBJECTIVES

Expanding outpatient surgery to the increasing number of procedures and patient populations warrants continuous evaluation of postoperative outcomes to ensure the best care and safety. We describe adverse postoperative outcomes and transfer rates related to anesthesia in a large sample of patients who underwent same-day cancer surgery at a freestanding ambulatory surgery center.

METHODS

Between January 2017 and June 2021, 3361 cancer surgeries, including breast and plastic, head and neck, gynecology, and urology, were performed. The surgeries were indicated for diagnosis, staging, and/or treatment. We report the incidence of transfers and adverse postoperative outcomes related to anesthesia.

RESULTS

Breast and plastic surgeries were the most common (1771, 53%), followed by urology (1052, 31%), gynecology (410, 12%), and head and neck surgeries (128, 4%). Based on patients' first procedure, comorbidity levels were highest for urology (75% American Society of Anesthesiologists physical status score 3, 1.7% score 4) and lowest for breast surgeries (31% score 3, 0.2% score 4). Most gynecology surgeries used general anesthesia (97.6%), whereas breast surgeries used the least (38%). A total of seven patients (0.2%; 95% CI: 0.08%-0.4%) were immediately transferred to an outside hospital; four due to anesthesia-related reasons. Only 7 (0.2%) patients needed additional postoperative care related to anesthesia-related adverse events, specifically cardiac events (4), difficult intubations (2), desaturation (1), and agitation, nausea, and headache (1).

CONCLUSIONS

The incidence of anesthesia-related adverse postoperative outcomes is low in cancer patients undergoing outpatient surgeries at our freestanding ambulatory surgery center. This suggests that carefully selected cancer patients, including patients with metastatic cancer, can undergo anesthesia for same-day surgery, making cancer care accessible locally and reducing stress associated with travel for treatment. More research investigating complication rates related to surgery and to cancer disease trajectory are needed to establish a complete evaluation of safety for outpatient cancer surgery.

Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model

BACKGROUND

The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance.

METHODS

Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed.

RESULTS

Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%.

CONCLUSIONS

Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.

Surgery and Anesthesia in Patients with Pulmonary Hypertension

Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.

Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture

INTRODUCTION

Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance.

METHODS

The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded.

RESULTS

Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up.

DISCUSSION

Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.

Unrecognized Pulmonary Hypertension in Non-Cardiac Surgical Patients: At-Risk Populations, Preoperative Evaluation, Intraoperative Management and Postoperative Complications

Pulmonary hypertension is a well-established independent risk factor for perioperative complications after elective non-cardiac surgery. Patients undergoing cardiac surgery are routinely evaluated for the presence of pulmonary hypertension in the preoperative period. Better monitoring in the postoperative critical care setting leads to more efficient management of potential complications. Data among patients with pulmonary hypertension undergoing elective non-cardiac surgery are scant. Moreover, the condition may be unidentified at the time of surgery. Also, monitoring after non-cardiac surgery can be very limited in the PACU setting, as opposed to the critical care setting. All these factors can result in a higher postoperative complication rate and poor outcomes.

An ethnographic study on the impact of a novel telemedicine-based support system in the operating room

OBJECTIVE

The Anesthesiology Control Tower (ACT) for operating rooms (ORs) remotely assesses the progress of surgeries and provides real-time perioperative risk alerts, communicating risk mitigation recommendations to bedside clinicians. We aim to identify and map ACT-OR nonroutine events (NREs)-risk-inducing or risk-mitigating workflow deviations-and ascertain ACT's impact on clinical workflow and patient safety.

MATERIALS AND METHODS

We used ethnographic methods including shadowing ACT and OR clinicians during 83 surgeries, artifact collection, chart reviews for decision alerts sent to the OR, and 10 clinician interviews. We used hybrid thematic analysis informed by a human-factors systems-oriented approach to assess ACT's role and impact on safety, conducting content analysis to assess NREs.

RESULTS

Across 83 cases, 469 risk alerts were triggered, and the ACT sent 280 care recommendations to the OR. 135 NREs were observed. Critical factors facilitating ACT's role in supporting patient safety included providing backup support and offering a fresh-eye perspective on OR decisions. Factors impeding ACT included message timing and ACT and OR clinician cognitive lapses. Suggestions for improvement included tailoring ACT message content (structure, timing, presentation) and incorporating predictive analytics for advanced planning.

DISCUSSION

ACT served as a safety net with remote surveillance features and as a learning healthcare system with feedback/auditing features. Supporting strategies include adaptive coordination and harnessing clinician/patient support to improve ACT's sustainability. Study insights inform future intraoperative telemedicine design considerations to mitigate safety risks.

CONCLUSION

Incorporating similar remote technology enhancement into routine perioperative care could markedly improve safety and quality for millions of surgical patients.

[Outcomes of patients experiencing cardiovascular adverse events within 1 year following craniotomy for intracranial aneurysm clipping: a retrospective cohort study]

OBJECTIVE

To investigate the impact of postoperative serious cardiovascular adverse events (CAE) on outcomes of patients undergoing craniotomy for intracranial aneurysm clipping.

METHODS

This retrospective cohort study was conducted among the patients undergoing craniotomy for intracranial aneurysm clipping during the period from December, 2016 to December, 2017, who were divided into CAE group and non-CAE group according to the occurrence of Clavien-Dindo grade ≥II CAEs after the surgery. The perioperative clinical characteristics of the patients, complications and neurological functions during hospitalization, and mortality and neurological functions at 1 year postoperatively were evaluated. The primary outcome was mortality within 1 year after the surgery. The secondary outcomes were Glasgow outcome scale (GOS) score at 1 year, lengths of postoperative hospital and intensive care unit (ICU) stay, and Glasgow coma scale (GCS) score at discharge.

RESULTS

A total of 361 patients were enrolled in the final analysis, including 20 (5.5%) patients in CAE group and 341 in the non-CAE group. No significant differences were found in the patients' demographic characteristics, clinical history, or other postoperative adverse events between the two groups. The 1-year mortality was significantly higher in CAE group than in the non-CAE group (20.0% vs 5.6%, P=0.01). Logistics regression analysis showed that when adjusted for age, gender, emergency hospitalization, subarachnoid hemorrhage, volume of bleeding, duration of operation, aneurysm location, and preoperative history of cardiovascular disease, postoperative CAEs of Clavien-Dindo grade≥II was independently correlated with 1-year mortality rate of the patients with an adjusted odds ratio of 3.670 (95% CI: 1.037-12.992, P=0.04). The patients with CEA also had a lower GOS score at 1 year after surgery than those without CEA (P=0.002). No significant differences were found in the occurrence of other adverse events, postoperative hospital stay, ICU stay, or GCS scores at discharge between the two groups (P > 0.05).

CONCLUSION

Postoperative CAEs may be a risk factor for increased 1-year mortality and disability in patients undergoing craniotomy for intracranial aneurysms.

Characterization of Baseline Temperature Characteristics Using Thermography in The Clinical Setting

BACKGROUND

Thermography is a diagnostic method based on the ability to record infrared radiation emitted by the skin and is unique in its ability to accurately show physiological and/or pathological cutaneous temperature changes in a non-invasive way. This method can be used to indirectly assess changes or impairments in cutaneous perfusion. Significant technological advancements have allowed thermography to be more commonly utilized by clinicians, yet a basic consensus of patient characteristics that may affect temperature recordings is not established.

MATERIALS AND METHODS

We evaluated cutaneous temperature in a cohort of outpatients to understand what factors, including tobacco use and other high-risk characteristics, contribute to cutaneous tissue perfusion as measured by thermography. Participants were prospectively enrolled if they were a combustible cigarette smoker, an electronic cigarette (e-cigarette) user, or a never smoker. Standardized thermographic images of the subject's facial profiles, forearms, and calves were taken and demographic characteristics, medical comorbidities, and tobacco product use were assessed. These variables were statistically tested for associations with temperature at each anatomic site.

RESULTS

We found that gender had a significant effect on thermographic temperature that differed by anatomic site, and we found a lack of significant difference in thermographic temperature by race. Our regression analysis did not support significant differences in thermographic temperatures across smoking groups, while there was a trend for decreased perfusion in smokers relative to non-smokers and e-cigarette users relative to non-smokers.

CONCLUSION

Thermographic imaging is a useful tool for clinical and research use with consideration of sex and other perfusion-affecting characteristics.

Exploring patient perspectives on telemedicine monitoring within the operating room

BACKGROUND

Clinical decision support systems and telemedicine for remote monitoring can together support clinicians' intraoperative decision-making and management of surgical patients' care. However, there has been limited investigation on patient perspectives about advanced health information technology use in intraoperative settings, especially an electronic OR (eOR) for remote monitoring and management of surgical patients.

PURPOSE

Our study objectives were: (1) to identify participant-rated items contributing to patient attitudes, beliefs, and level of comfort with eOR monitoring; and (2) to highlight barriers and facilitators to eOR use.

METHODS

We surveyed 324 individuals representing surgical patients across the United States using Amazon Mechanical Turk, an online platform supporting internet-based work. The structured survey questions examined the level of agreement and comfort with eOR for remote patient monitoring. We calculated descriptive statistics for demographic variables and performed a Wilcoxon matched-pairs signed-rank test to assess whether participants were more comfortable with familiar clinicians from local hospitals or health systems monitoring their health and safety status during surgery than clinicians from hospitals or health systems in other regions or countries. We also analyzed open-ended survey responses using a thematic approach informed by an eight-dimensional socio-technical model.

RESULTS

Participants' average age was 34.07 (SD = 10.11). Most were white (80.9%), male (57.1%), and had a high school degree or more (88.3%). Participants reported a higher level of comfort with clinicians they knew monitoring their health and safety than clinicians they did not know, even within the same healthcare system (z = -4.012, p < .001). They reported significantly higher comfort levels with clinicians within the same hospital or health system in the United States than those in a different country (z = -10.230, p < .001). Facilitators and barriers to eOR remote monitoring were prevalent across four socio-technical dimensions: 1) organizational policies, procedures, environment, and culture; 2) people; 3) workflow and communication; and 4) hardware and software. Facilitators to eOR use included perceptions of improved patient safety through a safeguard system and perceptions of streamlined care. Barriers included fears of incorrect eOR patient assessments, decision-making conflicts between care teams, and technological malfunctions.

CONCLUSIONS

Participants expressed significant support for intraoperative telemedicine use and greater comfort with local telemedicine systems instead of long-distance telemedicine systems. Reservations centered on organizational policies, procedures, environment, culture; people; workflow and communication; and hardware and software. To improve the buy-in and acceptability of remote monitoring by an eOR team, we offer a few evidence-based guidelines applicable to telemedicine use within the context of OR workflow. Guidelines include backup plans for technical challenges, rigid care, and privacy standards, and patient education to increase understanding of telemedicine's potential to improve patient care.

The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System

The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.

Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement

BACKGROUND

The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death.

METHODS

A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research.

RESULTS

Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning.

CONCLUSIONS

With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.

Association between Postoperative Complications and Reoperation for Patients Undergoing Geriatric Surgery and the Effect of Reoperation on Mortality

Elderly patients have greater risk for postoperative adverse events (PAEs). The study examines the rates of reoperation, the association between PAEs and reoperation, and the effect of reoperation on mortality for patients 65 years of age or older undergoing colorectal resections (CRRs), pancreatic resections (PRs), and lower extremity bypass (LEB) in 2010 American College of Surgeons National Surgical Quality Improvement Program. The models evaluating associations between reoperation and preoperative factors, PAEs, and mortality were developed using multiple logistic regression. The reoperation rates were 6.41 per cent for CRR (n = 11,084), 6.79 per cent for PR (n = 1,606), and 15.04 per cent for LEB (n = 4,170). Preoperative factors predicting reoperation included indications for surgery, procedure category, emergency status, and systemic sepsis. The PAEs most strongly associated with reoperation were wound dehiscence for CRR (odds ratio [OR], 15.286; 95% confidence interval [CI], 11.035 to 21.175) and for PR (OR, 19.656; 8.677 to 44.531) and for LEB, graft failure (OR, 28.151; 18.030 to 43.954) and organ space surgical site infection (OR, 15.753; 6.938 to 35.711). Higher rates of mortality occurred with reoperation for patients undergoing CRR (16.88 vs 5.45%, P < 0.0001), PR (28.44 vs 2.14%, P < 0.0001), and LEB (6.22 vs 3.05%, P < 0.0001). For elderly patients undergoing general and vascular surgery, reoperation occurs frequently, is strongly associated with other PAEs, and may elevate risk of mortality for this vulnerable population.

Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices

OBJECTIVE

To conduct a systematic review of published cardiac risk indices relevant to patients undergoing noncardiac surgery and to provide clinically meaningful recommendations to physicians regarding the use of these indices.

METHODS

A literature search of articles published from January 1, 1999, through December 28, 2018, was conducted in Ovid (MEDLINE), PubMed, Embase, CINAHL, and Web of Science. Publications describing models predicting risk of cardiac complications after noncardiac surgery were included and citation chaining was used to identify additional studies for inclusion.

RESULTS

Eleven risk indices involving 2,910,297 adult patients were included in this analysis. Studies varied in size, population, quality, risk of bias, outcome event definitions, risk factors identified, index outputs, accuracy, and clinical usefulness. Studies considered 6 to 83 variables to develop their models. Among the identified models, the factors with the highest predictiveness for adverse cardiac outcomes included congestive heart failure, type of surgery, creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. Substantial data from the large studies also supports advancing age, American Society of Anesthesiology physical status classification, functional status, and hypertension as additional risks.

CONCLUSION

The risk indices identified generally fell into two groups - those with higher accuracy for predicting a narrow range of cardiac outcomes and those with lower accuracy for predicting a broader range of cardiac outcomes. Using one index from each group may be the most clinically useful approach. Risk factors identified varied widely among studies. In addition to judicious use of predictive indices, reasoned clinical judgment remains indispensable in assessing perioperative cardiac risk.

The association of endothelial injury and systemic inflammation with perioperative myocardial infarction

Background

Major surgery predisposes to endothelial glycocalyx injury. Endothelial glycocalyx injury associates with cardiac morbidity, including spontaneous myocardial infarction. However, the relation between endothelial glycocalyx injury and the development of perioperative myocardial infarction remains unknown.

Methods

Fifteen perioperative myocardial infarction patients and 60 propensity-matched controls were investigated in this prospective study. The diagnosis of perioperative myocardial infarction was based on repeated cardiac troponin T measurements, electrocardiographs and recordings of ischaemic signs and symptoms. We measured endothelial glycocalyx markers – soluble thrombomodulin, syndecan-1 and vascular adhesion protein 1 – and an inflammatory marker, namely interleukin-6, preoperatively and 6 h and 24 h postoperatively. We calculated the areas under the receiver operating characteristics curves (AUCs) to compare the performances of the different markers in predicting perioperative myocardial infarction. The highest value of each marker was used in the analysis.

Results

The interleukin-6 concentrations of perioperative myocardial infarction patients were significantly higher preoperatively and 6 and 24 h postoperatively ( P =  0.002, P =  0.002 and P =  0.001, respectively). The AUCs (95% confidence intervals) for the detection of perioperative myocardial infarction were 0.51 (0.34–0.69) for soluble thrombomodulin, 0.63 (0.47–0.79) for syndecan-1, 0.54 (0.37–0.70) for vascular adhesion protein 1 and 0.69 (0.54–0.85) for interleukin-6.

Conclusions

Systemic inflammation, reflected by interleukin-6, associates with cardiac troponin T release and perioperative myocardial infarction. Circulating interleukin-6 demonstrated some potential to predict perioperative myocardial infarction, whereas endothelial glycocalyx markers did not.

Preoperative Long-Acting Opioid Use Is Associated with Increased Length of Stay and Readmission Rates After Elective Surgeries

Objectives To compare postoperative outcomes in patients prescribed long-acting opioids vs opioid-naïve patients who underwent elective noncardiac surgeries.

Design Retrospective cohort study.

Setting Single urban academic institution.

Methods and Subjects We retrospectively compared postoperative outcomes in long-acting opioid users vs opioid-naïve patients who underwent elective noncardiac surgeries. Inpatient and ambulatory surgery cohorts were separately analyzed. Preoperative medication lists were queried for the presence of long-acting opioids or absence of opioids. Multivariable logistic regression was performed to analyze the impact of long-acting opioid use on readmission rate, respiratory failure, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used to examine length of stay.

Results After exclusions, there were 93,644 adult patients in the study population, 23,605 of whom underwent inpatient surgeries and 70,039 of whom underwent ambulatory surgeries. After adjusting for potential confounders and inpatient surgeries, preoperative long-acting opioid use was associated with increased risk of prolonged length of stay (incidence rate ratio = 1.1, 99% confidence interval [CI] = 1.0–1.2, P &lt; 0.01) but not readmission. For ambulatory surgeries, preoperative long-acting opioid use was associated with increased risk of all-cause as well as pain-related readmission (odds ratio [OR] = 2.1, 99% CI = 1.5–2.9, P &lt; 0.001; OR = 2.0, 99% CI = 0.85–4.2, P = 0.02, respectively). There were no significant differences for respiratory failure or adverse cardiac events.

Conclusions The use of preoperative long-acting opioids was associated with prolonged length of stay for inpatient surgeries and increased risk of all-cause and pain-related readmission for ambulatory surgeries. Timely interventions for patients on preoperative long-acting opioids may be needed to improve these outcomes.

Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis

Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.

The effects of anesthetic drug choice on heart rate variability in dogs

Objective:

The objective of this study was to assess the effects of anesthetic drugs on heart rate (HR) and heart rate variability (HRV) in dogs.

Materials and Methods:

Twelve healthy client-owned dogs of various breeds, including five females and seven males were used for elective surgery in this study. The dogs were pre-medicated with four protocols; (1) alfaxalone [at 3 mg/kg body weight (bwt)], (2) zolazepam + tiletamine (Zoletil) (at 5 mg/kg bwt), (3) diazepam (at 0.3 mg/kg bwt) + ketamine (at 5 mg/kg bwt), and (4) diazepam (at 0.3 mg/kg bwt) + propofol (at 5 mg/kg bwt). The HR and HRV of 12 dogs were recorded 20 min before and after the administration of the anesthetic drugs. Doppler was used to obtain systolic, diastolic, and mean blood pressures.

Results:

After anesthetic drug administration, the dogs pre-medicated and inducted with alfaxalone had the lowest HR values as compared with those of other protocols. The HRV low frequency and high frequency power ratio decreased in the dogs pre-medicated and intubated with alfaxalone.

Conclusion:

This study demonstrates that alfaxalone preserves the cardiovascular function; and hence, is considered as safe to use for the surgical applicability in dogs.

Risk factors contributing to cardiac events following general and vascular surgery

Background

Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes.

Study design

This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE.

Results

Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5–16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7–5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4–16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4–6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2–12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7–6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8–5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1–8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9–4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4–5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7–4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7–6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3–6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1–8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups.

Conclusion

Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management.

•

Cardiac events following general and vascular surgery were associated with a mortality rate of 55%.

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Underlying risk factors for cardiac events following general and vascular surgery include COPD, hypertension on medication, and renal failure.

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Return to the OR, deep wound infection, unplanned intubation and ventilator dependence are also associated with a post-op cardiac event.

Outcomes of Kidney Donors over 60 Years Old: A Single-Center Cohort Study

AIM

To evaluate outcomes and post-donation kidney function of older living kidney donors (LKD).

METHODS

Retrospective analysis of prospective database including all consecutive LKD undergoing laparoscopic nephrectomy in a single center (09/1998-12/2013). LKD aged ≥60 years were compared to younger LKD. Renal function assessed by creatinine levels and estimated glomerular filtration rates (eGFR). Surgical complications classified according to the Clavien-Dindo classification. Bivariate and multivariate analyses using linear mixed effect models were performed to determine factors (age, gender, hypertension status, BMI, choice of better functioning kidney for donation) that might impinge on renal function after donation.

RESULTS

213 LKD were identified: 49 older (median age: 66 years, range: 60-79) and 164 younger (median age: 46, range: 25-59). Mean operative time (149 vs. 152 min, p = 0.69), conversion to laparotomy (n = 1 vs. 3, p = 0.92), grade III-IV complications (n = 4 vs. 2, p = 0.36) were similar. Older had more grade I-II complications (n = 18 vs. 4, p < 0.001). Despite similar pre-donation eGFR (80 vs. 84 ml/min/1.73 m²), older donors presented significantly lower eGFR during inpatient period (46 vs. 51 ml/min/1.73 m², p = 0.0003), at 1 month (51 vs. 58 ml/min/1.73 m², p = 0.002) and at 1 year (54 vs. 62 ml/min/1.73 m², p = 0.001). Multivariate analysis adjusted to gender, hypertension status, BMI and choice of better functioning kidney for donation showed that at 1 year, age ≥60 affected renal function by a coefficient of 0.91 (p < 0.001).

CONCLUSION

Despite renal function improvement after discharge, LKD ≥ 60 years presented lower eGFR than younger at one year and had more grade I-II surgical complications.

A systematic review on risk factors associated with sepsis in patients admitted to intensive care units

OBJECTIVE

We sought to systematically review data on the risk factors influencing the incidence of sepsis in patients admitted to intensive care units (ICUs).

REVIEW METHODS

An electronic search was undertaken in PubMed, MEDLINE, Scopus, and the Cochrane Library for studies reporting the risk factors of sepsis from the earliest available date up to December 30, 2016.

RESULTS

Among the 2978 articles, 14 studies met the inclusion criteria with a total of 56 164 participants from nine countries. The extracted risk factors were from the following categories: demographic, critical care interventions, surgery-related factors, pre-existing comorbidities, severity of organ injury, and biomarkers and biochemical and molecular indicators. From demographic factors, older age and male gender were associated with an increased risk of sepsis among ICU-admitted patients.

CONCLUSION

Our analysis comprehensively summarised the risk factors of sepsis in patients admitted to medical, surgical, neurologic, trauma, and general ICUs. Age, sex, and comorbidities were non-modifiable risk factors; however, critical care interventions and surgery-related factors were modifiable factors and suggest that improving the care of surgical patients and effective management of critical care interventions may play a key role in decreasing the development of sepsis in patients admitted to the ICUs.

Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments

Background

Current preoperative cardiac risk stratification practices group operations into broad categories, which might inadequately consider the intrinsic cardiac risks of individual operations. We sought to define the intrinsic cardiac risks of individual operations and to demonstrate how grouping operations might lead to imprecise estimates of perioperative cardiac risk.

Methods

Elective operations (based on Common Procedural Terminology codes) performed from January 1, 2010 to December 31, 2015 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program were studied. A composite measure of perioperative adverse cardiac events was defined as either cardiac arrest requiring cardiopulmonary resuscitation or acute myocardial infarction. Operations’ intrinsic cardiac risks were derived from mixed-effects models while controlling for patient mix. Resultant risks were sorted into low-, intermediate-, and high-risk categories, and the most commonly performed operations within each category were identified. Intrinsic operative risks were also examined using a representative grouping of operations to portray within-group variation.

Results

Sixty-six low, 30 intermediate, and 106 high intrinsic cardiac risk operations were identified. Excisional breast biopsy had the lowest intrinsic cardiac risk (overall rate, 0.01%; odds ratio, 0.11; 95% CI, 0.02 to 0.25) relative to the average, whereas aorto-bifemoral bypass grafting had the highest (overall rate, 4.1%; odds ratio, 6.61; 95% CI, 5.54 to 7.90). There was wide variation in the intrinsic cardiac risks of operations within the representative grouping (median odds ratio, 1.40; interquartile range, 0.88 to 2.17).

Conclusions

A continuum of intrinsic cardiac risk exists among operations. Grouping operations into broad categories inadequately accounts for the intrinsic cardiac risk of individual operations.

Preoperative Screening

Older adults undergoing elective surgical procedures suffer higher rates of morbidity and mortality than younger patients. A geriatric-focused preoperative evaluation can identify risk factors for complications and opportunities for health optimization and care coordination. Key components of a geriatric preoperative evaluation include (1) assessments of function, mobility, cognition, and mental health; (2) reviews of medical conditions and medications; and (3) discussion of risks, preferences, and goals of care. A geriatric-focused, team-based approach can improve surgical outcomes and patient experience.

Pleiotropic effects of statins in the perioperative setting

Statins belong to a specific group of drugs that have been described for their ability to control hyperlipidemia as well as for other pleiotropic effects such as improving vascular endothelial function, inhibition of oxidative stress pathways, and anti-inflammatory actions. Accumulating clinical evidence strongly suggests that statins also have a beneficial effect on perioperative morbidity and mortality. Therefore, this review aims to present all recent and pooled data on statin treatment in the perioperative setting as well as to highlight considerations regarding their indications and therapeutic application.

Hypoalbuminemia Predicts Perioperative Morbidity and Mortality after Infrainguinal Lower Extremity Bypass for Critical Limb Ischemia

BACKGROUND

Poor nutritional status has been associated with a higher risk of morbidity and mortality in general surgery patients; however, outcomes in vascular surgery patients are unclear. Our goal was to determine the effect of poor nutritional status on perioperative morbidity and mortality after lower extremity bypass (LEB).

METHODS

The 2005-2012 National Surgical Quality Improvement Program was analyzed to determine associated complications, mortality, length of stay (LOS), and readmissions for patients with hypoalbuminemia (serum albumin <3.5 g/dL and <2.8 g/dL) undergoing infrainguinal lower extremity bypass for critical limb ischemia. Multivariable analyses were performed to assess associated risk factors while adjusting for possible confounders.

RESULTS

There were 5,110 LEB identified with an albumin level recorded. There were 2,327 (45.5%) patients with a low preoperative albumin. Patients with a low albumin were more likely to have diabetes, chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, renal failure, dialysis dependence, hypertension, history of transient ischemic attack or stroke, steroid use, impaired functional status, dyspnea at rest, anemia, prior operations within 30 days, preoperative wounds or infections, and a tibial target (P < 0.05). Multivariable analyses showed that low albumin was independently associated with increased mortality (odds ratio [OR]: 1.8, 95% confidence interval [95% CI]: 1.3-2.6, P = 0.001), return to the operating room (OR: 1.4, 95% CI: 1.2-1.6, P < 0.001), and increased LOS (MR: 1.2, 95% CI: 1.1-1.2, P < 0.001). When compared with patients with normal albumin, patients with more severe hypoalbuminemia, less than 2.8 g/dL, showed further increased risk of mortality (OR: 2.5, 95% CI: 1.6-3.8), return to the operating room (OR: 1.6, 95% CI: 1.3-2.0), and prolonged LOS (MR: 1.2, 95% CI: 1.2-1.3).

CONCLUSIONS

Poor preoperative hypoalbuminemia is associated with morbidity and mortality after infrainguinal lower extremity bypass for critical limb ischemia. Evaluation and optimization of nutritional status should be performed preoperatively in this high risk population.

Preoperative Assessment of Geriatric Patients

Geriatric patients are over-represented in hospitalizations, surgeries, and perioperative complications. Special consideration is required for this patient group in the perioperative period because of the prevalence of comorbid diseases, functional impairments, and other deficits. A comprehensive preoperative evaluation strategy is recommended to identify and address these issues. Systematic, multidomain assessments should be performed and paired with risk reduction efforts. A shared understanding of patient function and long-term health goals is also important for providing patient-centered care of the geriatric surgical patient.

Postoperative Cardiac Ischemia Detection by Continuous 12-Lead Electrocardiographic Monitoring in Vascular Surgery Patients: A Prospective, Observational Study

OBJECTIVES

Elderly patients undergoing vascular surgery are at major risk for perioperative cardiac complications. The authors investigated continuous electrocardiographic Holter monitoring in a postoperative setting to determine the degree of postoperative ischemic load and its possible associations with perioperative myocardial infarction.

DESIGN

A prospective, observational study.

SETTING

One university hospital.

PARTICIPANTS

The study comprised 51 patients aged 65 years or older undergoing peripheral arterial surgery.

INTERVENTIONS

Continuous electrocardiographic monitoring with a Holter device was started postoperatively and continued for 72 hours or until discharge. Postural changes were recorded using a 3-axis accelerometer. Standard 12-lead electrocardiography, high-sensitive troponin T measurements, and an inquiry of ischemic symptoms were performed 4 times perioperatively.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were ischemic load (area under the function of ischemic ST-segment deviation and ischemic time) and perioperative myocardial infarction. During 3,262.7 patient-hours of monitoring, 17 patients (33.3%) experienced 608 transient ischemic events, all denoted by ST-segment depression. Of these 17 patients, 5 experienced perioperative myocardial infarction. The mean ischemic load in all patients was 913.2±2,797.3 µV×minute. Ischemic load predicted perioperative myocardial infarction, with an area under receiver operating characteristics curve (95% confidence interval) of 0.87 (0.75-0.99). Ischemic changes occurred most frequently during hours 24 to 60 of monitoring. Ischemia was asymptomatic in 14 of 17 patients (82.4%).

CONCLUSION

Postoperative myocardial ischemia was common in peripheral vascular surgery patients and may progress to perioperative myocardial infarction. Ischemic load was a good predictor of perioperative myocardial infarction. Ambulatory electrocardiographic monitoring solutions for continuous postoperative ischemia detection are warranted in the surgical ward.

Perioperative Myocardial Infarction in Non-Cardiac Surgery Patients: A Prospective Observational Study

Background and Aims:

Perioperative myocardial infarction is an underdiagnosed complication causing morbidity, mortality, and considerable costs. However, evidence of preventive and therapeutic options is scarce. We investigated the incidence and outcome of perioperative myocardial infarction in non-cardiac surgery patients in order to define a target population for future interventional trials.

Material and Methods:

We conducted a prospective single-center study on non-cardiac surgery patients aged 50 years or older. High-sensitivity troponin T and electrocardiograph were obtained five times perioperatively. Perioperative myocardial infarction diagnosis required a significant troponin T release and an ischemic sign or symptom. Perioperative risk calculator was used for risk assessment.

Results:

Of 385 patients with systematic ischemia screening, 27 patients (7.0%) had perioperative myocardial infarction. The incidence was highest in vascular surgery—19 of 172 patients (11.0%). The 90-day mortality was 29.6% in patients with perioperative myocardial infarction and 5.6% in non–perioperative myocardial infarction patients ( p <  0.001). Perioperative risk calculator predicted perioperative myocardial infarction with an area under curve of 0.73 (95% confidence interval: 0.64–0.81).

Conclusion:

Perioperative myocardial infarction is a common complication associated with a 90-day mortality of 30%. The ability of the perioperative risk calculator to predict perioperative myocardial infarction was fair supporting its routine use.

Risk factors for postoperative complications in robotic general surgery

The feasibility and safety of robotically assisted procedures in general surgery have been reported from various groups worldwide. Because postoperative complications may lead to longer hospital stays and higher costs overall, analysis of risk factors for postoperative surgical complications in this subset of patients is clinically relevant. The goal of this study was to identify risk factors for postoperative morbidity after robotic surgical procedures in general surgery. We performed an observational monocentric retrospective study. All consecutive robotic surgical procedures from November 2001 to December 2013 were included. One thousand consecutive general surgery patients met the inclusion criteria. The mean overall postoperative morbidity and major postoperative morbidity (Clavien >III) rates were 20.4 and 6 %, respectively. This included a conversion rate of 4.4 %, reoperation rate of 4.5 %, and mortality rate of 0.2 %. Multivariate analysis showed that ASA score >3 [OR 1.7; 95 % CI (1.2-2.4)], hematocrit value <38 [OR 1.6; 95 % CI (1.1-2.2)], previous abdominal surgery [OR 1.5; 95 % CI (1-2)], advanced dissection [OR 5.8; 95 % CI (3.1-10.6)], and multiquadrant surgery [OR 2.5; 95 % CI (1.7-3.8)] remained independent risk factors for overall postoperative morbidity. It also showed that advanced dissection [OR 4.4; 95 % CI (1.9-9.6)] and multiquadrant surgery [OR 4.4; 95 % CI (2.3-8.5)] remained independent risk factors for major postoperative morbidity (Clavien >III). This study identifies independent risk factors for postoperative overall and major morbidity in robotic general surgery. Because these factors independently impacted postoperative complications, we believe they could be taken into account in future studies comparing conventional versus robot-assisted laparoscopic procedures in general surgery.

Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery

Transthoracic and transoesophageal echocardiography are increasingly used as tools to improve clinical assessment following cardiac surgery. However, most physicians are not trained in echocardiography, and there is no widespread agreement on the feasibility, indications or effect on outcome of transthoracic or transoesophageal echocardiography for patients after cardiac surgery. We performed a systematic review of electronic databases for focused transthoracic and transoesophageal echocardiography after cardiac surgery which revealed 15 full-text articles. They consistently reported that echocardiography is feasible, whether performed by a novice or expert, and frequently resulted in important changes in diagnosis of cardiac abnormalities and their management. However, most were observational studies and there were no well-designed trials investigating the impact of echocardiography on outcome. We conclude that both transthoracic and transoesophageal echocardiography are useful following cardiac surgery.

An efficient risk adjustment model to predict inpatient adverse events after surgery

BACKGROUND

Risk adjustment is an important component of surgical outcomes and quality analyses. Current models include numerous preoperative variables; however, the relative contribution of these variables may be limited. This research seeks to identify a model with the fewest number of variables necessary to perform an adequate risk adjustment to predict any inpatient adverse event for use in resource-limited settings.

METHODS

All patients from the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2010 were included. Outcomes were inpatient mortality or any surgical complication captured by NSQIP. Models were built by sequential addition of preoperative risk variables selected by their area under the receiver operator characteristic curve (AUC).

RESULTS

Among 863,349 patients, the single variable with the highest AUC was American Society of Anesthesiologists (ASA) classification (AUC = 0.7127). AUC values reached 0.7923 with five variables (ASA classification, wound classification, functional status prior to surgery, albumin, and age) and 0.7945 with six variables. The sixth variable was one of the following: alkaline phosphatase, weight loss, principal anesthesia technique, gender, or emergency status. The model with the highest discrimination that did not require laboratories included ASA classification, functional status prior to surgery, wound classification, and age (AUC = 0.7810). Including all 66 preoperative variables produced little additional gain (AUC = 0.8006).

CONCLUSIONS

Six variables are sufficient to develop a risk adjustment tool for inpatient surgical mortality and morbidity. This research has important implications for the field of surgical outcomes research by improving efficiency of data collection. This limited model can aid the expansion of risk-adjusted analyses to resource-limited settings worldwide.

Major adverse cardiac events in elderly patients with coronary artery disease undergoing noncardiac surgery: A multicenter prospective study in China

BACKGROUND

Major adverse cardiac events (MACEs) are important causes of perioperative morbidity and mortality for elderly patients undergoing non-cardiac surgery. Treatment and control rates for coronary artery disease (CAD) in Chinese patients are poorer than rates in western countries. However, no previous prospective study has focused on perioperative MACE in this population. Our aim was to ascertain the incidence and risk factors associated with MACEs in Chinese patients.

METHODS

Consecutive CAD patients, aged ≥60 years, who underwent non-cardiac surgery at five medical centers in China, were prospectively enrolled. Clinical variables, including electrocardiogram and troponin I levels, were evaluated to estimate MACEs. The main outcome was occurrence of at least one perioperative MACE from admittance to 30 days after surgery, defined as any of the following complications: cardiac death, nonfatal cardiac arrest, acute myocardial infarction (MI), congestive heart failure (CHF), and angina. MACE independent risk factors were based on the Andersen-Gill multiplicative intensity model.

RESULTS

Of the 1422 patients recruited, 129 (9.1%) developed at least one MACE, and cardiac death occurred in 11 patients (0.8%). The independent risk factors contributing to postoperative MACE included age ≥75 years, female gender, history of MI, history of hypertension, high-risk surgery, intraoperative hypotension, and intraoperative hypoxemia.

CONCLUSIONS

The incidence of MACE in Chinese elderly patients with CAD who underwent non-cardiac surgery was 9.1%. Seven independent risk factors for a perioperative MACE were identified. Preventing intraoperative hypoxemia and hypotension may reduce the occurrence of MACE in these high risk patients.

Kidney transplantation in patients with severe preoperative hypertension

BACKGROUND

Severe systemic hypertension (HTN) is a risk factor for perioperative cardiovascular complications; however, its impact at the time of kidney transplantation (KTX) is not well defined.

METHODS

A retrospective cohort study of adult kidney-only transplant recipients between October 2009 and December 2012 was performed to examine outcomes between patients with (n = 111) and without (n = 98) severe preoperative HTN defined as SBP > 180 or DBP > 110 mmHg.

RESULTS

Recipients with severe HTN were older (56.7 ± 13.0 vs. 53.5 ± 12.4 yr, p = 0.07) and significantly more likely to receive an expanded criteria donor kidney (32.7% vs. 12.2%, p = 0.02). No patients developed hypertensive crisis, intracranial hemorrhage, or life threatening ventricular arrhythmias within 30 d post-transplantation; however, three patients with severe HTN had cardiac events: two with demand ischemia and one with decompensate heart failure. Two patients in the control group had decompensated heart failure. There were no differences between the groups in terms of cardiac event (2.7% vs. 2.0%, p = 0.75), one-yr patient survival (98.2% vs. 98.0%, p = 0.90) or graft survival (90.1% vs. 92.9%, p = 0.48), nadir creatinine > 2 mg/dL (4.6% vs. 6.2%, p = 0.62), length of stay > 6 d (37.8% vs. 35.7%, p = 0.75), and DGF (52.3% vs. 63.3%, p = 0.11).

CONCLUSIONS

Our results suggest that severe preoperative HTN should not be considered an absolute contraindication to kidney transplant in patients who are otherwise clinically stable.

Risk Factors of Postoperative Myocardial Infarction after Colorectal Surgeries

There are limited data regarding the specific risk factors of postoperative myocardial infarction (MI) in patients undergoing colorectal resectional surgery. We sought to identify risk factors of acute MI after colorectal resection operations. The National Inpatient Sample database was used to identify patients who had postoperative MI after colorectal resection operations between 2002 and 2010. Statistical analysis was performed to identify factors predictive of postoperative MI. We sampled a total of 2,513,124 patients undergoing colorectal resection, of whom 38,317 (1.5%) sustained a postoperative MI. Patients with postoperative MI had associated 28.5 per cent in-hospital mortality. Risk factors identified include ( P < 0.01): history of congestive heart failure (odds ratio [OR], 8.18), chronic renal failure (OR, 3.86), age 70 years or older (OR, 3.68), peripheral vascular disorders (OR, 2.93), fluid and electrolyte disorders (OR, 2.69), emergency admission (OR, 2.56), preoperative weight loss (OR, 2.49), cardiac valvular disease (OR, 2.46), chronic lung disease (OR, 1.75), deficiency anemia (OR, 1.22), colorectal cancer (OR, 1.77), and hypertension (OR, 1.14). Postoperative MI occurs in less than 2 per cent of colorectal resections. However, patients sustaining postoperative MI are over six times more likely to die. Congestive heart failure and chronic renal failure are the strongest predictors of postoperative MI.

Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database

OBJECT

This study evaluates the impact of resident presence in the operating room on postoperative outcomes in neurosurgery.

METHODS

The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all cases treated in a neurosurgery service in 2011. Propensity scoring analysis and multiple logistic regression models were used to reduce patient bias and to assess independent effect of resident involvement.

RESULTS

Of the 8748 neurosurgery cases identified, residents were present in 4529 cases. Residents were more likely to be involved in complex procedures with longer operative duration. The multivariate analysis found that resident involvement was not a statistically significant factor for overall complications (OR 1.116, 95% CI 0.961-1.297), surgical complications (OR 1.132, 95% CI 0.825-1.554), medical complications (OR 1.146, 95% CI 0.979-1.343), reoperation (OR 1.250, 95% CI 0.984-1.589), mortality (OR 1.164, 95% CI 0.780-1.737), or unplanned readmission (OR 1.148, 95% CI 0.946-1.393).

CONCLUSIONS

In this multicenter study, the authors demonstrated that resident involvement in the operating room was not a significant factor for postoperative complications in neurosurgery service. This analysis also showed that much of the observed difference in postoperative complication rates was attributable to other confounding factors. This is a quality indicator for resident trainees and current medical education. Maintaining high standards in postgraduate training is imperative in enhancing patient care and reducing postoperative complications.

A case-cohort study of postoperative myocardial infarction: impact of anemia and cardioprotective medications

OBJECTIVE

Postoperative myocardial infarction (poMI) is a serious and costly complication. Multiple risk factors for poMI are known, but the effect of anemia and cardioprotective medications have not been defined in real-world surgical practice.

METHODS

Patients undergoing inpatient elective surgery were assessed at 17 hospitals from 2008 to 2011 for the occurrence of poMI (American Heart Association definition). Non-MI control patients were chosen randomly on the basis of case type. Descriptive, univariable, and multivariable statistical analysis were performed for primary outcomes of poMI and death at 30 days.

RESULTS

Compared with controls (N = 304), patients with poMI (N = 222) were older (72 ± 11 vs 60 ± 17 years, P < .0001), had a lesser preoperative hematocrit (37 ± 6 vs 39 ± 5, P < .0001), more often were smokers, had a preoperative T-wave abnormality (21% vs 9%, P < .0001), and had a preoperative stress test with a fixed deficit (26% vs 3%; P < .001). Preoperative factors associated with poMI included peripheral vascular disease (odds ratio 2.6; 95% confidence interval 1.3-5.3), tobacco use (1.7; 1.01-2.9), history of percutaneous coronary angioplasty (2.8; 1.6-5.0), and age (1.05; 1.03-1.07), whereas hematocrit >35 (0.51; 0.32-0.82) and preoperative acetylsalicylic acid, ie, aspirin (0.59; 0.4-0.97) were protective. Preoperative β-blockade, statin, and use of angiotensin-converting enzyme inhibitors were not associated with lesser rates of poMI. Non-MI complication rates were 23-fold greater in the poMI group compared with the control group (P < .0001). Mortality with poMI within 30 days was 11% compared with 0.3% in non-MI control patients (P < .0001). In patients with poMI, factors independently associated with death included use of epidurals (3.5; 1.07-11.4) and bleeding (4.2; 1.1-16), whereas preoperative use of aspirin (0.29; 0.1-0.88), and postoperative β-blockade (0.18; 0.05-0.63) were protective. Cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass grafting after poMI was performed in 34% of those alive and 20% of those who died (P = .16).

CONCLUSION

In the current era, poMI patients have a markedly increased risk of death. This risk is decreased with preoperative use of acetylsalicylic acid and post MI β-blockade. Further study is warranted to explore the role of anemia and cardiac interventions after poMI.

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases.

METHODS

We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement.

RESULTS

Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles.

CONCLUSIONS

Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cardiac biomarkers in the prediction of risk in the non-cardiac surgery setting

B-Type natriuretic peptides and troponin measurements have potential in predicting risk in patients undergoing non-cardiac surgery. Using the American Heart Association framework for the evaluation of novel biomarkers, we review the current evidence supporting the peri-operative use of these two biomarkers. In patients having major non-cardiac surgery who are risk stratified using clinical risk scores, the measurement of natriuretic peptides and troponin, both before and after surgery, significantly improves risk stratification. However, only pre- and postoperative natriuretic peptide measurement and postoperative troponin measurement have shown clinical utility. It is now important for trials to be conducted to determine whether integrating pre- and postoperative natriuretic peptide and postoperative troponin measurement into clinical practice is able to improve clinical outcomes in patients undergoing non-cardiac surgery.

Predictors of readmission after outpatient otolaryngologic surgery

OBJECTIVES/HYPOTHESIS

Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery.

STUDY DESIGN

This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program (NSQIP) dataset.

METHODS

NSQIP was reviewed for outpatients with "Otolaryngology (ENT)" as their recorded surgical specialty. Readmission was tracked through the "Unplanned Readmission" variable. Patient characteristics and outcomes were compared using chi-square analysis and student t tests for categorical and continuous variables, respectively. Multivariate regression analysis investigated predictors of readmission.

RESULTS

A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (odds ratio [OR] 2.672, confidence interval [CI] 1.133-6.304, P = .025) and work relative value units (RVU) (OR .972, CI .944-1, P = .049) to be significant predictors of readmission.

CONCLUSION

Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work RVUs proved to be significant positive and negative risk factors, respectively, for readmission. These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations.

Anesthetic challenges of patients with cardiac comorbidities undergoing major urologic surgery

The cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. Number of this group of patients having to go through this procedure is constantly increasing, due to prolonged life, increased agressiveness of surgery and increased anesthesia's safety. The anesthesiologist usually has to deal with several problems of the patient, such as hypertension, chronic heart failure, coronary artery disease, rhythm disturbances, intraoperative hemodymanic changes, intraoperative bleeding, perioperative fluid imbalance, and metabolic disturbances. A cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. The scope of this review article is to present the most frequent issues encountered with this group of patients, and to synthetically discuss the respective strategies and maneuvers during perioperative period, which is the major challenge for the anesthesiologist.