Perioperative beta-blocker and statin therapy

The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients

AIM

To investigate the association of the neutrophil to lymphocyte ratio (NLR) at admission with presence of fracture, comorbid conditions, and its prognostic value for short-term outcomes in orthogeriatric patients.

METHODS

On 415 consecutive patients (mean age 78.8 ±8.7[SD] years, 281 women, 255 with a non-vertebral bone fracture, including 167 with a hip fracture, HF) admitted to the Department of Orthopaedic Surgery at the Canberra hospital (2010 - 2011) data on clinical and laboratory characteristics were collected prospectively. The validation dataset included 294 consecutive patients (mean age 82.1 ± 8.0 years, 72.1% women) with HF.

RESULTS

Multivariate regression revealed four variables, presence of HF, hypoalbuminaemia (<33g/L), anaemia (<120g/L) and hyperparathyroidism (PTH>6.8 pmol/L), as independent determinants of admission NLR≥5.1. There was a dose-graded relationship between presence of fracture, especially HF, postoperative complications and levels of NLR categorized as tertiles. Compared to patients with NLR<5.1(first tertile), patients with NLR 5.1-8.5 (second tertile) had a 1.8-, 3.1-, 2.6-, and 2.5-fold higher risk for presence of any fracture, HF, developing postoperative myocardial injury (troponin I rise) and a high inflammatory response/infection (CRP>100mg/L after the 3rd postoperative day), respectively, while in subjects with NLR>8.5 (third tertile) these risks were 2.6-, 4.9-, 5.9- and 4.5-times higher, respectively; subjects with NLR>8.5 had a 9.7 times higher chance of dying in the hospital compared to patients with NLR 5.1-8.5; the NLR retained its significance on multivariate analyses. The NLR ≥5.1 predicted postoperative myocardial injury with an area under the curve (AUC) of 0.626, CRP>100mg/L with AUC of 0.631 and the NLR >8.5 predicted in-hospital mortality with an AUC of 0.793, showing moderately high sensitivity (86.7%, 80% and 90%, respectively) and negative predictive value (92.9%, 71.2%, 99.6%, respectively), but low specificity. Admission NLR was superior to other, except hypoalbuminaemia, prognostic markers; combined use of both NLR≥5.1 and albumin<33g/L only moderately increased the accuracy of prediction. The validation study confirmed the prognostic value of the admission NLR.

CONCLUSIONS

In orthogeriatric patients, high NLR on admission is an independent indicator of fracture presence, a significant risk factor and moderate predictor of postoperative myocardial injury, high inflammatory response/infection and in-hospital death.

Clinical Review: Is the Perioperative Use of β-Blockers Still Recommended? A Critical Review of Recent Controversies

The optimal role of β-adrenergic receptor blockade in the perioperative period remains unclear in patients at risk for cardiovascular events. Cardiovascular complications continue to be the most common cause of perioperative morbidity and mortality, and cardioprotective properties of β-blockers are widely recognized, yet the results of the clinical trials investigating the use of different β-blockers in the perioperative period are controversial. The discrepancy might be related to differences in the design of studies, use of different agents, administration by different routes, and continuation for different time intervals. Evidently, perioperative mortality and morbidity seem to be related to heart rate, and the majority of complications are related to β-blockers’ side effects. Based on the observations from different studies, we propose an algorithm for perioperative β blockade.

Preinjury statin use is associated with a higher risk of multiple organ failure after injury: a propensity score adjusted analysis

BACKGROUND

Recent studies suggest that statin use may improve outcome in critically ill patients. This has been attributed to the pleiomorphic effect and modulation of inflammatory mediators that occurs with statin use. We sought to determine whether preinjury statin (PIS) use was associated with improved outcome in severely injured blunt trauma patients.

METHODS

Data were obtained from a multicenter prospective cohort study evaluating outcomes in blunt injured adults with hemorrhagic shock. Patients aged 55 years and older were analyzed. Those with isolated traumatic brain injury, cervical cord injury, and those who survived <24 hours were excluded. A propensity score predicting statin use was created using logistic regression. Cox proportional hazard regression was then used to evaluate the effects of PIS use on mortality and the development of multiple organ failure (MOF, multiple organ dysfunction syndrome >5) and nosocomial infection (NI) after adjusting for important injury characteristics and the propensity of taking PISs.

RESULTS

Overall mortality and MOF rates for the study cohort (n = 295) were 21% and 50%, respectively. Over 24% of patients (n = 71) reported PIS use. Kaplan-Meier analysis revealed no difference in NI or mortality over time but did show a significant higher incidence of MOF in those with PIS use (p = 0.04). Regression analysis verified PIS was independently associated with an 80% higher risk of MOF (hazard ratio: 1.8; 95% confidence interval, 1.1-2.9) and was found to be one of the strongest independent risk factors for the development of MOF.

CONCLUSION

PIS use was independently associated with a higher risk of MOF postinjury. These results are contrary to previous analyses. The protective effect of statins may be lost in the severely injured, and modulation of the inflammatory response may result in higher morbidity. Further studies are required to better understand the impact and potential therapeutic utility of this commonly prescribed medication both before and after injury.