Prediction of Complications and Prognostication in Perioperative Medicine: A Systematic Review and PROBAST Assessment of Machine Learning Tools

BACKGROUND

The utilization of artificial intelligence and machine learning as diagnostic and predictive tools in perioperative medicine holds great promise. Indeed, many studies have been performed in recent years to explore the potential. The purpose of this systematic review is to assess the current state of machine learning in perioperative medicine, its utility in prediction of complications and prognostication, and limitations related to bias and validation.

METHODS

A multidisciplinary team of clinicians and engineers conducted a systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Multiple databases were searched, including Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, PubMed, Medline, Embase, and Web of Science. The systematic review focused on study design, type of machine learning model used, validation techniques applied, and reported model performance on prediction of complications and prognostication. This review further classified outcomes and machine learning applications using an ad hoc classification system. The Prediction model Risk Of Bias Assessment Tool (PROBAST) was used to assess risk of bias and applicability of the studies.

RESULTS

A total of 103 studies were identified. The models reported in the literature were primarily based on single-center validations (75%), with only 13% being externally validated across multiple centers. Most of the mortality models demonstrated a limited ability to discriminate and classify effectively. The PROBAST assessment indicated a high risk of systematic errors in predicted outcomes and artificial intelligence or machine learning applications.

CONCLUSIONS

The findings indicate that the development of this field is still in its early stages. This systematic review indicates that application of machine learning in perioperative medicine is still at an early stage. While many studies suggest potential utility, several key challenges must be first overcome before their introduction into clinical practice.

EDITOR’S PERSPECTIVE

Fixation of Distal Radius Fractures Under Wide-Awake Local Anesthesia: A Systematic Review

BACKGROUND

The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events.

METHODS

Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion.

RESULTS

Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients.

CONCLUSIONS

A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.

Efficacy of remote ischaemic preconditioning on outcomes following non-cardiac non-vascular surgery: a systematic review and meta-analysis

BACKGROUND

Remote ischaemic preconditioning (RIPC) has been investigated as a simple intervention to potentially mitigate the ischaemic effect of the surgical insult and reduce postoperative morbidity. This review systematically evaluates the effect of RIPC on morbidity, including duration of hospital stay and parameters reflective of cardiac, renal, respiratory, and hepatic dysfunction following non-cardiac non-vascular (NCNV) surgery.

METHODS

The electronic databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from their inception date to November 2021. Studies investigating the effect of local preconditioning or postconditioning were excluded. Methodological quality and risk of bias were determined according to the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Calculation of the odds ratios and a random effects model was used for dichotomous outcomes and mean differences or standardised mean differences as appropriate were used for continuous outcomes. The primary outcomes of interest were cardiac and renal morbidity, and the secondary outcomes included other organ function parameters and hospital length of stay.

RESULTS

A systematic review of the published literature identified 36 randomised controlled trials. There was no significant difference in postoperative troponin or acute kidney injury. RIPC was associated with lower postoperative serum creatinine (9 studies, 914 patients, mean difference (MD) - 3.81 µmol/L, 95% confidence interval (CI) - 6.79 to - 0.83, p = 0.01, I² = 5%) and lower renal stress biomarker (neutrophil gelatinase-associated lipocalin (NGAL), 5 studies, 379 patients, standardized mean difference (SMD) - 0.66, 95% CI - 1.27 to - 0.06, p = 0.03, I² = 86%). RIPC was also associated with improved oxygenation (higher P_aO₂/F_iO₂, 5 studies, 420 patients, MD 51.51 mmHg, 95% CI 27.32 to 75.69, p < 0.01, I² = 89%), lower biomarker of oxidative stress (malondialdehyde (MDA), 3 studies, 100 patients, MD - 1.24 µmol/L, 95% CI - 2.4 to - 0.07, p = 0.04, I² = 91%)) and shorter length of hospital stay (15 studies, 2110 patients, MD - 0.99 days, 95% CI - 1.75 to - 0.23, p = 0.01, I² = 88%).

CONCLUSIONS

This meta-analysis did not show an improvement in the primary outcomes of interest with the use of RIPC. RIPC was associated with a small improvement in certain surrogate parameters of organ function and small reduction in hospital length of stay. Our results should be interpreted with caution due to the limited number of studies addressing individual outcomes and the considerable heterogeneity identified.

TRIAL REGISTRATION

PROSPERO CRD42019129503.

Development, implementation and evaluation of high-quality virtual preoperative anaesthetic assessment during COVID-19 and beyond: a quality improvement report

BACKGROUND

Preoperative risk factor identification and optimisation are widely accepted as the gold standard of care for elective surgery and are essential for reducing morbidity and mortality. COVID-19 public health restrictions required a careful balance between ensuring best medical practices and maintaining safety by minimising patient face-to-face attendance in the hospital. Based on the successful implementation of telemedicine (TM) in other medical specialties and its feasibility in the preoperative context, this study aimed to develop, implement and evaluate a high-quality virtual preoperative anaesthetic assessment process.

METHODS

The three-step model for improvement was used. The specific, measurable, actionable, relevant, time aim (step 1) and measures for improvement (step 2) were defined at the onset of the project. The plan-do-study-act tool was used for the structured implementation of improvement interventions (step 3) in three phases. Data relating to virtual and in-person referrals, assessments, did-not-attend (DNA) rate, consultation time, day of surgery delays and cancellations, and service-user and provider experience surveys were recorded prospectively.

RESULTS

A total of 2805 patients were assessed in the preoperative anaesthetic assessment clinic between July 2020 and March 2021. The mean rate of virtual preoperative assessments was 50% (SD ±10) (1390/2805). 0.1% (30/2805) were inappropriately referred on the alternative pathway. The DNA rate was 0.4% (8/1398) and 3% (43/1458) for virtual and in-person pathways, respectively. The mean consultation times for virtual and in-person attendance were 19 (SD ±7) and 31 (SD ±13) min, respectively. There were five same-day surgery cancellations and one delay due to medical reasons. When asked about their experience with the virtual assessment, both service users and providers reported high satisfaction, minimal technical difficulties and shared concerns about limited opportunities for physical examination.

CONCLUSION

This is one of the first implementational studies to comprehensively outline the feasibility of TM in preoperative anaesthetic assessment during COVID-19.

Prognostic value of combined preoperative phase angle and handgrip strength in cardiac surgery

OBJECTIVES

Phase angle (PA) constitutes a bioelectrical impedance measurement, indicating cell membrane health and integrity, hydration, and nutritional status. Handgrip strength (HS) has been also associated with body composition, nutritional status, inflammation, and functional ability in several chronic diseases. Although their prognostic significance as independent biomarkers has been already investigated regarding the outcomes of a cardiac surgery, our study is the first one to assess the combined predictive value of preoperative PA and HS.

DESIGN AND METHODS

HS and PA measurements were performed preoperativelyin 195 patients undergoing cardiac surgery. The association ofthe combination of HS and PAwith all-cause mortality rates was the primary study outcome, while its association with the intensive care unit (ICU) length of stay (LOS) was the secondary one.

RESULTS

PA was positively correlated with HS (r = 0.446, p < 0.005) and negatively with EuroSCORE II (r = - 0.306 p < 0.005). The combination of PA < 5.15 and HS < 25.5 was associated with higher one-year all-cause mortality (OR = 9.28; 95% CI 2.50-34.45; p = 0.001) compared to patients with PA > 5.15 and HS > 25.5, respectively. Patients with combined lower values of PA and HS (PA < 5.15 and HS < 30.7) were at higher risk of prolonged ICU LOS (OR = 4.02; 95% CI 1.53-10.56; p = 0.005) compared to those with higher PA-HS (PA > 5.15-HS > 30.7). The combination of PA-HS was also significantly linked with EuroSCORE II.

CONCLUSION

The combination of low preoperative PA and HS values was significantly associated with higher risk of all-cause mortality at 12 months and prolonged ICU LOS; thereby it might serve as a clinically useful prognostic biomarker after cardiac surgery procedures.

Remote Ischaemic Preconditioning in Intra-Abdominal Cancer Surgery (RIPCa): A Pilot Randomised Controlled Trial

There is limited evidence on the effect of remote ischaemic preconditioning (RIPC) following non-cardiac surgery. The aim of this study was to investigate the effect of RIPC on morbidity following intra-abdominal cancer surgery. We conducted a double blinded pilot randomised controlled trial that included 47 patients undergoing surgery for gynaecological, pancreatic and colorectal malignancies. The patients were randomized into an intervention (RIPC) or control group. RIPC was provided by intermittent inflations of an upper limb tourniquet. The primary outcome was feasibility of the study, and the main secondary outcome was postoperative morbidity including perioperative troponin change and the urinary biomarkers tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 (TIMP-2*IGFBP-7). The recruitment target was reached, and the protocol procedures were followed. The intervention group developed fewer surgical complications at 30 days (4.5% vs. 33%), 90 days (9.5% vs. 35%) and 6 months (11% vs. 41%) (adjusted p 0.033, 0.044 and 0.044, respectively). RIPC was a significant independent variable for lower overall postoperative morbidity survey (POMS) score, OR 0.79 (95% CI 0.63 to 0.99) and fewer complications at 6 months including pulmonary OR 0.2 (95% CI 0.03 to 0.92), surgical OR 0.12 (95% CI 0.007 to 0.89) and overall complications, OR 0.18 (95% CI 0.03 to 0.74). There was no difference in perioperative troponin change or TIMP2*IGFBP-7. Our pilot study suggests that RIPC may improve outcomes following intra-abdominal cancer surgery and that a larger trial would be feasible.

Derivation and validation of a national multicenter mortality risk stratification model - the ExCare model: a study protocol

Introduction

Surgical care is essential for proper management of various diseases. However, it can result in unfavorable outcomes. In order to identify patients at higher risk of complications, several risk stratification models have been developed. Ideally, these tools should be simple, reproducible, accurate, and externally validated. Unfortunately, none of the best-known risk stratification instruments have been validated in Brazil. In this sense, the Ex-Care model was developed by retrospective data analysis of surgical patients in a major Brazilian university hospital. It consists of four independent predictors easily collected in the preoperative evaluation, showing high accuracy in predicting death within 30 days after surgery.

Objectives

To update and validate a Brazilian national-based model of postoperative death probability within 30 days based on the Ex-Care model. Also, to develop an application for smartphones that allows preoperative risk stratification by Ex-Care model.

Methods

Ten participating centers will collect retrospective data from digital databases. Variables age, American Society of Anesthesiologists (ASA) physical status, surgical severity (major or non-major) and nature (elective or urgent) will be evaluated as predictors for in-hospital mortality within 30 postoperative days, considered the primary outcome.

Expected results

We believe that the Ex-Care model will present discriminative capacity similar to other classically used scores validated for surgical mortality prediction. Furthermore, the mobile application to be developed will provide a practical and easy-to-use tool to the professionals enrolled in perioperative care.

Clinical and economic burden of postsurgical complications of high-risk surgeries: a cohort study in Thailand

BACKGROUND

This study aimed to understand the clinical and economic burden associated with postsurgical complications in high-risk surgeries in Thailand.

METHODS

A cost and outcome study was conducted using a retrospective cohort database from four tertiary hospitals. All patients with high-risk surgeries visiting the hospitals from 2011 to 2017 were included. Outcomes included major postsurgical complications, length of stay (LOS), in-hospital death, and total healthcare costs. Multivariate regression analyses were performed to identify risk factors of postsurgical outcomes.

RESULTS

A total of 14,930 patients were identified with an average age of 57.7 ± 17.0 years and 34.9% being male. Gastrointestinal (GI) procedures were the most common high-risk procedures, accounting for 54.9% of the patients, followed by cardiovascular (CV) procedures (25.2%). Approximately 27.2% of the patients experienced major postsurgical complications. The top three complications were respiratory failure (14.0%), renal failure (3.5%), and myocardial infarction (3.4%). In-hospital death was 10.0%. The median LOS was 9 days. The median total costs of all included patients were 2,592 US$(IQR: 1,399-6,168 US$). The patients, who received high-risk GI surgeries and experienced major complications, had significantly increased risk of in-hospital death (OR: 4.53; 95%CI: 3.81-5.38), longer LOS (6.53 days; 95%CI: 2.60-10.46 days) and higher median total costs (2,465 US$; 95%CI: 1,945-2,984 US$), compared to those without major complications. Besides, the patients, who underwent high-risk CV surgeries and developed major complications, resulted in significantly elevated risk of in-hospital death (OR: 2.22; 95%CI: 1.74-2.84) and increased median total costs (2,719 US$; 95%CI: 2,129-3,310 US$), compared to those without major complications.

CONCLUSIONS

Postsurgical complications are a serious problem in Thailand, as they are associated with worsening mortality risk, LOS, and healthcare costs. Clinicians should develop interventions to prevent or effectively treat postsurgical complications to mitigate such burdens.

Pre-operative frailty is predictive of adverse post-operative outcomes in colorectal cancer patients

BACKGROUND

An increasing number of elderly patients are presenting for elective surgery. Pre-operative risk assessment in this population is inexact due to the complex interplay between age, comorbidity and functional status. Frailty assessment may provide a surrogate measure of a patient's physiological reserve and aid operative decision-making. The aim of this study is to determine the association between pre-operative frailty, as assessed using the Edmonton Frail Scale, and post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery.

METHODS

A prospective analysis of 86 patients over the age of 65 undergoing elective colorectal cancer surgery at a tertiary centre between October 2017 and October 2018 was performed. Frailty assessment was conducted pre-operatively using the Edmonton Frail Scale. Primary outcomes included length of stay and post-operative complication rates. Multivariable logistic regression analyses were used to determine the influence of frailty on post-operative outcomes including mortality, prolonged hospital admission, complication rates and quality of life.

RESULTS

Of 86 patients, 12 (14.0%) were identified as frail. Frailty was associated with a significantly increased median length of stay (20 days versus 6 days, incidence rate ratio 2.83, P < 0.01) and a significantly increased risk of major post-operative complications (50.0% versus 6.7%, odds ratio 13.8, P < 0.01). Frailty was not associated with a significant reduction in quality of life scores at 30 and 90 days post-operatively.

CONCLUSION

Frailty is associated with adverse post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery. Frailty assessment is an important component of pre-operative risk assessment and may identify targets for pre-operative optimisation.

Documentation of individualized preoperative risk assessment: a multi-center study

Background

Individual surgical risk assessment (ISRA) enhances patient care experience and outcomes by informing shared decision-making, strengthening the consent process, and supporting clinical management. Neither the use of individual pre-surgical risk assessment tools nor the rate of individual risk assessment documentation is known. The primary endpoint of this study was to determine the rate of physician documented ISRAs, with or without a named ISRA tool, within the records of patients with poor outcomes. Secondary endpoints of this work included the effects of age, sex, race, ASA class, and time and type of surgery on the rate of documented presurgical risk.

Methods

The records of non-obstetric surgical patients within 22 community-based private hospitals in Arizona, Colorado, Nebraska, Nevada, and Wyoming, between January 1 and December 31, 2017, were evaluated. A two-sample proportion test was used to identify the difference between surgical documentation and anesthesiology documentation of risk. Logistic regression was used to analyze both individual and group effects associated with secondary endpoints.

Results

Seven hundred fifty-six of 140,756 inpatient charts met inclusion criteria (0.54%, 95% CI 0.50 to 0.58%). ISRAs were documented by 16.08% of surgeons and 4.76% of anesthesiologists (p < 0.0001, 95% CI −0.002 to 0.228). Cardiac surgeons documented ISRAs more frequently than non-cardiac surgeons (25.87% vs 16.15%) [p = 0.0086, R-squared = 0.970%]. Elective surgical patients were more likely than emergency surgical patients (19.57 vs 12.03%) to have risk documented (p = 0.023, R-squared = 0.730%). Patients over the age of 65 were more likely than patients under the age of 65 to have ISRA documentation (20.31 vs 14.61%) [p = 0.043, R-squared = 0.580%]. Only 10 of 756 (1.3%) records included documentation of a named ISRA tool.

Conclusions

The observed rate of documented ISRA in our sample was extremely low. Surgeons were more likely than anesthesiologists to document ISRA. As these individualized risk assessment discussions form the bedrock of perioperative informed consent, the rate and quality of risk documentation must be improved.

The association between low pre-operative step count and adverse post-operative outcomes in older patients undergoing colorectal cancer surgery

Background

Multiple tools exist estimating perioperative risk. With an ageing surgical demographic, frailty is becoming an increasingly important concept in perioperative medicine due to its association with adverse post-operative outcomes. Reduced physical activity is a hallmark of frailty, and we postulate that a low pre-operative step count may be an objective measure of frailty. This study aimed to determine the association between low pre-operative step count and post-operative outcomes in patients undergoing elective colorectal cancer surgery.

Methods

A prospective analysis of 85 older patients undergoing major elective colorectal surgery was performed at a tertiary centre between October 2017 and October 2018. Patients aged 65 years and over who met inclusion criteria were provided with an activity tracker to wear for 14 days prior to planned surgery. Their median daily step count was measured and a cut-off of < 2500 steps/day was used to define a reduced step count. Primary outcomes included length of stay and 30-day post-operative complication rate. Multivariable logistic regression analyses were used to analyze the influence of low pre-operative step count and other preoperative variables, on post-operative outcomes including mortality, prolonged hospital admission, and complication rates.

Results

Of 85 patients, 17 (20%) were identified as having a low pre-operative step count. A low pre-operative step count was associated with a significantly increased length of stay (14 vs. 6 days, IRR 2.09, 95% CI 1.55–2.83, p ≤ 0.01) and rate of major post-operative complications (29.4% vs. 8.8%, OR 3.34, 95% CI 1.03–14.3, p = 0.04). It was also associated with significantly increased rates of discharge to care facilities (p < 0.01) and requiring support on discharge (p = 0.03).

Conclusion

Low pre-operative step count (< 2500 steps/day) is predictive of an increased risk of post-operative morbidity in patients undergoing elective colorectal surgery. Accurate preoperative identification may allow for treatment modification and tailored perioperative care. The possibility of using a wearable activity tracker as a simple but powerful pre-habilitation tool is raised as an important avenue for future study.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12618000045213).

Frailty assessment and postoperative outcomes among patients undergoing general surgery

BACKGROUND

Frailty is an emerging concept in modern general surgery because of its correlation with adverse outcomes. More frail older patients are undergoing general surgery due to the rapid aging of the population and the effect of the "baby boom" generation. However, there is no consensus on the definition of frailty and on ways to assess its severity and effect.

PURPOSE

To describe the definition and epidemiology, measurement tools, and the effect of frailty on postoperative outcomes after general surgery.

METHODS

PubMed and Google Scholar databases were comprehensively searched.

RESULTS

Frailty is a syndrome defined as increased vulnerability to stressors due to a decline in physiological function and reserve among organ systems, resulting in adverse outcomes. Numerous tools have been described and tested for frailty measurement, but the ideal clinical tool has not been found yet. The evidence from cohort studies and meta-analyses shows associations between preoperative frailty and adverse perioperative outcomes after general surgery.

CONCLUSION

Frailty is an essential concept in general surgery. However, further studies have to identify the optimal way to preoperatively assess frailty and risk-stratify older patients.

Frailty in surgical patients

OBJECTIVE

To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice.

BACKGROUND

Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome.

METHODS

Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases.

RESULTS

Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients.

CONCLUSION

Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.

Plating of Distal Radius Fracture Using the Wide-Awake Anesthesia Technique

Fractures of the distal radius are one of the most common types of injuries encountered in hand surgery. Plate osteosynthesis is recommended for unstable fractures. Because distal radius fracture fixation is usually performed under general or regional anesthesia with the use of a tourniquet, this exposes patients, especially elderly people with extensive comorbidities, to adverse effects commonly associated with these forms of anesthesia. As such, many of these patients are unable to undergo surgery in a timely manner until they are deemed medically fit for surgery or anesthesia, and some may still be treated nonsurgically. Injecting local anesthetic of lidocaine and epinephrine into the surgical field and without using a tourniquet is known to be advantageous for various surgical procedures of the hand. However, this approach, also known as wide-awake local anesthesia no tourniquet (WALANT), has not been used in the fixation of fractures beyond the wrist. Using the WALANT approach as an alternative anesthetic for plating of distal radius fractures may enable patients who are normally denied surgery owing to their age or medical comorbidities to undergo plate fixation for the fractures. This article outlines the WALANT approach used for a single case of fixation of distal end radius fracture with a detailed description of the technique of administering local anesthesia.

Nurse-led extubation in the post-anaesthesia care unit

Weaning of mechanical ventilation occurs in intensive care units by nurses, which stimulates the prospect of nurse-led extubation extending into the PACU environment for improved patient outcomes and reduced demand of hospital resources. Nurse-led patient extubation in the PACU, would involve specially trained nurses weaning mechanical ventilation via an established protocol for a specific patient group, prior to the patient being extubated by an anaesthetist or intensivist.

Anaesthesia: what a surgeon needs to know

Surgeons and anaesthetists work closely together, sometimes in challenging circumstances. To help surgeons cooperate with anaesthetists to deliver high quality care for patients, a working knowledge of modern anaesthetic practice is useful. The specialty of anaesthetics is developing rapidly, and periodic updating of this knowledge is likely to be required. This article provides an update of anaesthetic practice for surgeons, covering the varied roles of anaesthetists, preoperative assessment, management on the day of surgery (induction, maintenance and reversal of anaesthetic), general anaesthesia, the role of regional blocks and sedation. It also discusses safety issues, the management of frail patients and future challenges.

The Relation between Sarcopenia and Mortality in Patients at Intensive Care Unit

Background and Aim

Psoas muscle area (PMA) can reflect the status of skeletal muscle in the whole body. It has been also reported that decreased PMA was associated with postoperative mortality or morbidity after several surgical procedures. In this study, we aimed to investigate the relation between PMA and mortality in all age groups in intensive care unit (UNIT).

Materials and Method

The study consists of 362 consecutive patients. The demographic characteristics of patients, indications for ICU hospitalization, laboratory parameters, and clinical parameters consist of mortality and length of stay, and surgery history was obtained from intensive care archive records.

Results

The mean age was 61.2 ± 18.2 years, and the percentage of female was 33.3%. The mean duration of stay was 10.3 ± 24.4 days. Exitus ratio, partial healing, and healing were 25%, 70%, and 5%, respectively. The mean right, left, and total PMA were 8.7 ± 3.6, 8.9 ± 3.4, and 17.6 ± 6.9, respectively. The left and total PMA averages of the nonoperation patients were statistically significantly lower (p = 0.021  p = 0.043). The mean PMA between the ex and recovered patients were statistically significantly lower (p = 0.001, p = 0.001, p < 0.001). Dyspnoea, renal insufficiency, COPD, transfusion rate, operation rate, ventilator needy, and mean duration of hospitalization were statistically significant higher in patients with exitus. There is a significant difference in operation types, anesthesia type, and clinic rates.

Conclusion

Our data suggest that sarcopenia can be used to risk stratification in ICU patients. Future studies may use this technique to individualize postoperative interventions that may reduce the risk for an adverse discharge disposition related to critical illness, such as early mobilization, optimized nutritional support, and reduction of sedation and opioid dose.

Addressing the Global Burden of Trauma in Major Surgery

Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.