Preoperative serum potassium predicts the clinical outcome after non-cardiac surgery

Temporal trends and risk factors of perioperative cardiac events in patients over 80 years old with coronary artery disease undergoing noncardiac surgery: a high-volume single-center experience, 2014-2022

BACKGROUND

Temporal trends and risk factors of perioperative cardiac events (PCEs) in patients over 80 years old with coronary artery disease (CAD) undergoing noncardiac surgery are still unclear.

METHODS

We retrospectively reviewed 1478 patients over 80 years old, with known CAD undergoing selective noncardiac surgery in a single center (2014-2022). Patients were divided into three equal time groups based on the discharge date (2014-2016, 2017-2019, and 2020-2022), with 367, 473, and 638 patients in Groups 1-3, respectively. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCEs intraoperatively or during hospitalization postoperatively, defined as any of the following events: myocardial infarction, heart failure, nonfatal cardiac arrest, and death.

RESULTS

PCEs occurred in 180 (12.2%) patients. Eight independent risk factors were associated with PCEs, including four clinical factors (body mass index < 22 kg/m2, history of myocardial infarction, history of heart failure, and general anesthesia) and four preoperative laboratory results (hemoglobin < 110 g/L, albumin < 40 g/L, creatinine > 120 μmol/L, and potassium <3.6 mmol/L). Significant rising trends were seen over the 9-year study period in the incidence of PCEs and independent risk factors including history of myocardial infarction, history of heart failure, general anesthesia, preoperative hemoglobin < 110 g/L, preoperative albumin < 40 g/L, and preoperative creatinine > 120 μmol/L (P for trend <0.05).

CONCLUSION

The incidence and independent risk factors of PCEs in patients over 80 years old with CAD undergoing noncardiac surgery showed significant rising trends over the last 9-year period.

Prediction of postoperative hypokalemia in patients with oral cancer undergoing en bloc cancer resection: a retrospective cohort study

BACKGROUND

The factors associated with postoperative hypokalemia in patients with oral cancer remain unclear. We determined the preoperative factors associated with postoperative hypokalemia in patients with oral cancer following en bloc cancer resection and established a nomogram for postoperative hypokalemia prediction.

METHODS

Data from 381 patients with oral cancer who underwent en bloc cancer resection were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the risk factors for postoperative hypokalemia. We used receiver operating characteristic (ROC) curves to quantify the factors' effectiveness. A nomogram was created to show each predictor's relative weight and the likelihood of postoperative hypokalemia development. The multinomial regression model's effectiveness was also evaluated.

RESULTS

Preoperative factors, including sex, preoperative serum potassium level, and preoperative platelet-to-lymphocyte ratio (PLR), were significantly associated with postoperative hypokalemia. Based on the ROC curve, the preoperative serum potassium and PLR cut-off levels were 3.98 mmol/L and 117, respectively. Further multivariate analysis indicated that female sex, preoperative serum potassium level < 3.98 mmol/L, and preoperative PLR ≥ 117 were independently associated with postoperative hypokalemia. We constructed a predictive nomogram with all these factors for the risk of postoperative hypokalemia with good discrimination and internal validation.

CONCLUSIONS

The predictive nomogram for postoperative hypokalemia risk constructed with these factors had good discrimination and internal validation. The developed nomogram will add value to these independent risk factors that can be identified at admission in order to predict postoperative hypokalemia.

Risk factors for hypokalemia and its association with postoperative recovery in patients scheduled for radical gastrectomy: a retrospective study

BACKGROUND

Hypokalemia is common in patients of various operations, especially gastrointestinal surgery, which seriously affects the safety and enhanced recovery after surgery. Our study aims to explore the risk factors of preoperative hypokalemia of radical gastrectomy for gastric cancer and analyze its impact on postoperative recovery.

METHODS

A total of 122 patients scheduled for radical gastrectomy from September, 2022 to December, 2022 were retrospectively analyzed. According to the serum potassium level before skin incision, patients were divided into hypokalemia group (n = 64) and normokalemia group (n = 58). Factors including age, gender, BMI, ASA classification, glutamic pyruvic transaminase (ALT), glutamic oxaloacetic transaminase (AST), creatinine, blood urea nitrogen (BUN), albumin, hypertension history, whether taking calcium channel blockers, β-receptor blockers, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor antagonist (ARB), thiazide diuretics and other drugs, anemia history, diabetes mellitus history, inability to eat or intestinal obstruction, vomiting, diarrhea, hypokalemia on admission and whether under cooperation with clinical nurse specialist were compared between groups. Univariate logistic regression analysis was used to determine risk factors for hypokalemia with p < 0.2 included as a cutoff. Multivariate logistic regression was used to analyze the influencing factors of preoperative hypokalemia for the indicators with differences. A receiver operating characteristic (ROC) curve was used to evaluate the efficacy of the regression model. Primary exhaust time and defecation time after surgery were compared between the two groups.

RESULTS

The use of ACEI or ARB [OR 0.08, 95% CI (0.01 to 0.58), p = 0.012] and thiazide diuretics [OR 8.31, 95% CI (1.31 to 52.68), p = 0.025], inability to eat for more than 3 days or intestinal obstruction [OR 17.96, 95% CI (2.16 to 149.43), p = 0.008], diarrhea for more than 48 h [OR 6.21, 95% CI (1.18 to 32.61), p = 0.031] and hypokalemia on admission [OR 8.97, 95% CI (1.05 to 77.04), p = 0.046] were independent influencing factors of hypokalemia before skin incision. Primary postoperative exhaust time and defecation time was significantly longer in the hypokalemia group than in the normokalemia group, no matter after laparoscopic radical gastrectomy (p = 0.044, p = 0.045, respectively) or open radical gastrectomy (p = 0.033, p = 0.019, respectively).

CONCLUSION

Early attention and management of serum potassium in patients undergoing radical gastrectomy can better reduce perioperative adverse reactions and promote recovery of gastrointestinal function.

Association between preoperative hypokalemia and postoperative complications in elderly patients: a retrospective study

Background

Hypokalemia is a common form of electrolyte disorder, which has a higher incidence in hospitalized patients and is closely related to perioperative complications and prognosis. Due to decreased skeletal muscle mass which causes total body potassium reduction, and increased comorbidities, the elderly are more susceptible to hypokalemia.

Objective

To investigate preoperative hypokalemia in elderly patients and its effect on postoperative complications.

Methods

Data were retrospectively collected from the elderly patients who underwent elective surgery from April 2018 to March 2019 and had preoperative blood gas data available. Patients, with age 60 to 100 years, were divided into hypokalemia group (potassium level < 3.5 mmol/L) and normokalemia group (potassium level between 3.5 and 5.5 mmol/L) according to preoperative blood gas analysis. Hypokalemia can be divided into mild (potassium level 3.0 to 3.5 mmol/L), moderate (potassium level 2.5 to 3.0 mmol/L) and severe (potassium level < 2.5 mmol/L), respectively. The risk factors of preoperative hypokalemia and its impact on postoperative complications and prognosis were primary outcomes. Secondary outcomes included postanesthesia care unit (PACU) stay time and hospital length of stay (LOS).

Results

Of 987 participants, 436 (44.17%) developed preoperative hypokalemia, among them 357 (81.88%) mild, 87 (16.74%) moderate and 6 (1.38%) severe. Multivariate logistic regression showed that female gender (OR, 1.851; 95% CI, 1.415–2.421), pre-existing hypokalemia at admission (OR, 4.498; 95% CI, 2.506–8.071), and oral laxative twice or more (OR, 1.823; 95% CI, 1.266–2.624) are risk factors of preoperative hypokalemia. Gynecological and biliopancreatic surgery were more common in hypokalemia group than normokalemia group (P <  0.001, P <  0.05). There was no significant difference in postoperative complications, PACU stay time, LOS, and 30-day mortality between the two groups (all P >  0.05).

Conclusions

Female gender, pre-existing hypokalemia at admission, and oral laxative twice or more are independent risk factors for preoperative hypokalemia in elderly patients. However, postoperative complications and 30-day mortality were not increased, which may be related to monitoring blood gas analysis and prompt correction of potassium levels during surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03445-1.

Preoperative hypokalemia can increase complications after colorectal cancer surgery: a propensity score matching analysis

Background

Whether hypokalemia can affect the short-term outcomes of CRC patients after radical surgery remains unclear. The purpose of this study was to investigate the impact of preoperative hypokalemia on the short-term outcomes for colorectal cancer (CRC) patients who underwent radical CRC surgery using propensity score matching (PSM).

Methods

We retrospectively enrolled consecutive CRC patients from Jan 2011 to Dec 2021 in a single-center hospital. Hypokalemia was defined as a serum potassium concentration < 3.5 mmol/L. The short-term outcomes were compared between the hypokalemia group and the normal blood potassium group. In addition, univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for overall complications.

Results

A total of 6183 CRC patients who underwent radical surgery were included in this study, of whom 390 (6.3%) patients were diagnosed with hypokalemia before surgery. After 1:1 ratio PSM, there were 390 patients in the hypokalemia group and in the normal potassium group. No significant difference was found between the two groups after PSM in terms of baseline information (p > 0.05). Regarding short-term outcomes, the hypokalemia group had a longer hospital stay (p = 0.028), a higher proportion of overall complications (p = 0.048) and a higher incidence of postoperative pneumonia (p = 0.008) after PSM. Moreover, hypokalemia (p = 0.036, OR = 1.291, 95% CI = 1.017–1.639) was an independent risk factor for overall complications.

Conclusion

Preoperative hypokalemia could increase complications after CRC surgery and prolong the hospital stay. Moreover, preoperative hypokalemia was an independent risk factor for overall complications.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Development and outcomes of hyperkalemia in hospitalized patients: potential implications for care

INTRODUCTION

While severe hyperkalemia is commonly encountered, its manifestation in hospitalized patients and related outcomes are unclear. We aimed to examine development of hyperkalemia in hospitalized patients and associated outcomes.

METHODS

Data from a county hospital electronic health record were used to assess all inpatient admissions, 2012-2016, for non-dialysis-dependent patients with ≥1 K value for development of hyperkalemia. Unadjusted odds ratios (ORs) were calculated for associations of the maximum K value with in-hospital mortality and adjusted ORs were calculated for death associated with hyperkalemia.

RESULTS

In 47,018 individual patient hospitalizations, 1.3% had a maximum K ≥6.0 mEq/L and 4.2% <3.5 mEq/L. Fifth and 95th percentiles for maximum K values were 3.5 and 5.3 mEq/L. For high-K patients with a prior K value, the mean (SD) of the immediate pre-maximum K value was 5.0 ± 1.0 mEq/L, and the mean difference in K values (immediate pre-maximum to maximum) was 1.5 ± 1.1 mEq/L; mean duration between these two K tests was 10.7 ± 14.9 hours. Compared with maximum K values 3.5 to 4.0 mEq/L, ORs for death were 37.1 (95% confidence intervals, 25.8-53.3) for K 6.0 to <6.5, 88.6 (56.8-138.2) for K ≥7.0, and 18.9 (4.3-82.2) for K <3.0 mEq/L. In adjusted models, the OR for death for K ≥6.0 mEq/L was 4.9 (3.7-6.4).

DISCUSSION/CONCLUSIONS

Peak K values ≥6.0 mEq/L were associated with mortality. Values tended to increase rapidly, limiting opportunities for detection and treatment. Systems-based approaches to detect life-threatening hyperkalemia should be studied.

Clinical Characteristics and Risk Factors for Mortality in Older Patients with Dialysis-Receiving Community-Acquired Acute Kidney Injury

Introduction

Older people in community are susceptible to acute kidney injury (AKI) and hemodialysis is the most important supportive measure used in the management of severe AKI. This study aims to investigate the clinical characteristics, outcomes and risk factors for mortality in older patients with dialysis-receiving-community-acquired AKI (CA-AKI).

Methods

A total of 1953 CA-AKI patients aged 65 years old and above were recruited from 2013 to 2016. Among which, 200 patients received hemodialysis. Clinical characteristics, outcomes, suspected nephrotoxic drug use after CA-AKI and risk factors for mortality in older CA-AKI patients with dialysis were analyzed.

Results

The percentage of CA-AKI patients receiving hemodialysis was 10.2%. Compared with non-dialysis patients, dialysis-receiving patients had more comorbidity, and worse renal function. The types of suspected nephrotoxic drugs used in dialysis patients were more than those in non-dialysis patients. Moreover, dialysis-receiving patients had worse outcomes, including complete recovery of renal function (42.0% vs 71.6%), intensive care unit (ICU) (69.0% vs 15.3%) transfer and in-hospital mortality (50.5% vs 5.6%) (P<0.01). Age, moderate/severe liver disease, beta lactam antibiotics, glycopeptide antibiotics, antifungal agents, drugs for anti-heart failure, category of suspected nephrotoxic drugs, hyperkalemia, increased leucocyte count, ICU transfer, multiple organ dysfunction (MODS), cardiogenic shock and cardio-pulmonary resuscitation (CPR) were risk factors for mortality by univariate logistic regression analysis. After adjusting for confounding factors, the independent risk factors were glycopeptide antibiotics, drugs for anti-heart failure, ICU transfer, MODS and CPR.

Conclusion

The percentage of older CA-AKI patients receiving dialysis was high, and these patients had more comorbidity and worse prognosis. Glycopeptide antibiotics, drugs for anti-heart failure, ICU transfer, MODS and CPR were independent risk factors for mortality.

Trends and Predictors of Transcatheter Aortic Valve Implantation Related In-Hospital Mortality (From the National Inpatient Sample Database)

Existing surgical aortic valve replacement risk models accurately predict the post- surgical aortic valve replacement morbidity and mortality, but factors associated with post transcatheter aortic valve Implantation (TAVI) mortality are not well known. The National Inpatient Sample was queried to identify all cases of TAVI. The association of baseline comorbidities with in-hospital mortality was determined using a binary logistic regression model to obtain adjusted odds ratios (aOR). A total of 161,049 patients underwent TAVI between 2010 and 2017. Of these, 157,151 (97.6%) survived while 3,898 (2.4%) died during hospitalization. The baseline characteristics of TAVI-survivors and non-survivors showed a significant amount of variation, including age (80 vs 82 years, p ≤ 0.0001) and female sex (46% vs 52%, p ≤ 0.0001), respectively. The non-survivors had significantly higher adjusted odds of renal failure requiring hemodialysis (aOR 2.59, 95% CI 2.24 to 2.99, p ≤ 0.0001), history of mediastinal radiation (aOR 2.71, 95% CI 1.02 to 7.20, p = 0.05), liver disease (aOR 3.04, 95% CI 2.63 to 3.51, p ≤ 0.0001), pneumonia (aOR 2.47, 95% CI 2.15 to 2.83, p ≤ 0.0001), cardiogenic shock (aOR 9.83, 95% CI 8.93 to 10.82, p ≤ 0.0001), ventricular tachycardia (aOR 2.12, 95% CI 1.88 to 2.40, p ≤ 0.0001), acute ST-elevation myocardial infarction (aOR 7.38, 95% CI 5.53 to 9.84, p ≤ 0.0001), stroke (aOR 2.25, 95% CI 1.99 to 2.54, p ≤ 0.0001), and acute infective endocarditis (aOR 5.74, 95% CI 3.65 to 9.02, p ≤ 0.0001) compared to TAVI-survivors. The yearly trend of mortality showed an increase in the absolute number of TAVI procedures and mortality but the yearly rate showed a decline in mortality after an initial peak during 2012.Patients with renal failure on dialysis, ST-elevation myocardial infarction, cardiogenic shock, infective endocarditis, liver disease and pneumonia have a higher rate of in-hospital mortality post TAVI.

Preoperative risk factors including serum levels of potassium, sodium, and creatinine for early mortality after open abdominal surgery: a retrospective cohort study

Background

In hospitalized patients, abnormal plasma electrolyte concentrations are frequent and have been linked to poor outcomes following acute surgery. The aim of this study was to assess whether preoperative plasma levels of potassium, sodium, and creatinine at the time of admission were associated with 30-day mortality in patients following open abdominal surgery.

Methods

This was a single-center register-based retrospective study. By means of electronic search in a maintained surgery database, all patients (n = 4177) aged ≥ 60 years old undergoing open surgery in our department from January 2000 to May 2013 were identified. Plasma was assessed within 30 days prior to surgery. The primary endpoint was 30-day postoperative mortality. The association between mortality and plasma levels of potassium, sodium, and creatinine were examined using Cox proportional hazard models.

Results

A total of 3690 patients were included in the study cohort. The rates of abnormal preoperative plasma levels were 36, 41, and 38% for potassium, sodium, and creatinine, respectively. The overall 30 day mortality was 20%. A predictive algorithm for 30 day mortality following abdominal surgery was constructed by means of logistic regression showing excellent distinction between patients with and without a fatal postoperative outcome.

Conclusion

Apart from demographic factors (age, sex, and emergency surgery), preoperative imbalance in potassium, sodium and creatinine levels were significant independent predictors of early mortality following open abdominal surgery.

Prevalence and risk factors for hypokalemia in patients scheduled for laparoscopic colorectal resection and its association with post-operative recovery

Background

Perioperative serum potassium levels are closely associated with postoperative clinical outcomes after gastrointestinal surgery. The aim of our retrospective study was to identify the prevalence and risk factors for preoperative hypokalemia (before pneumoperitoneum) and to evaluate the influence of preoperative hypokalemia on the recovery of postoperative gastrointestinal function.

Methods

In this retrospective study, patients scheduled for laparoscopic colorectal resection from November 11 2014 to October 20 2016, were considered for inclusion. A blood potassium level between 3.5 and 5.5 mmol/L was defined as normal, with levels between 3.0 to 3.5 mmol/L, 2.5 to 3.0 mmol/L and < 2.5 mmol/L considered as slight, moderate, and severe level of hypokalemia. The factors including age, gender, ASA grade, BMI, hypertension, diabetes, anti-hypertension drugs, lactose oral soluble, oral cathartics, oral cathartics, cathartic enemas, and blood potassium level before gastrointestinal preparation which might be associated with blood potassium level before pneumoperitoneum were analysed. The time to postoperative first flatus (FFL) and first feces (FFE) was compared between patients with and without hypokalemia.

Results

The final analysis was based on the data of 108 patients. Hypokalemia was identified in 70.37% patients, with the following distribution of blood potassium levels before pneumoperitoneum: slight, 49 (45.37%) patients; moderate, 23 (21.30%); and severe, 4 (3.70%) patients. Hypokalemia was significantly associated with hypertension and the use of ≥2 types of oral cathartics for preoperative gastrointestinal preparation. With treatment, potassium levels recovered to normal levels in all patients within 48 h postoperatively. Hypokalemia was associated with a longer postoperative time to first feces, compared to patients with a normal potassium level before pneumoperitoneum.

Conclusions

Our findings underlie the importance of early monitoring and management of serum potassium levels in these patients.

The Utility of Preoperative Laboratory Testing Before Urogynecologic Surgery

OBJECTIVES

National guidelines for preoperative laboratory testing are based on limited, low-quality evidence. The role of age as a risk factor for testing is unclear. We sought to compare the prevalence of abnormal preoperative laboratory results in older vs younger urogynecologic surgical patients.

METHODS

In this retrospective cohort study of women undergoing urogynecologic surgery, we compared older (age, ≥65 years) with younger (age, 50-64 years) women. Our primary outcome was the prevalence of an abnormal preoperative laboratory result.

RESULTS

We included 317 women, with 167 (52.7%) in the older cohort (ages, 65-91 years; mean, 73.3 ± 5.6 years) and 150 (47.3%) in the younger cohort (ages, 50-64 years; mean, 57.3 ± 4.1 years). Overall, 18.3% of participants had at least one abnormal preoperative laboratory, with older women more likely to have an abnormal result (28.7% vs 10.7%, P < 0.001). Compared with the younger cohort, older women had higher rates of abnormal hemoglobin (13.8% vs 6.0%, P = 0.02) and creatinine values (10.8% vs 2.7%, P = 0.005), with no significant differences for platelets (3.0% vs 1.3%, P = 0.53), sodium (3.0% vs 0.7%, P = 0.22), or potassium (6.0% vs 3.3%, P = 0.27). After adjusting for potential confounders, older age remained associated with an abnormal preoperative result (odds ratio, 3.6; 95% confidence interval, 1.9-7.1).

CONCLUSIONS

In our sample, women 65 years or older had a greater than 25% chance of having an abnormal preoperative laboratory result and were at higher risk compared with younger women. Age 65 years or greater should be considered as a criterion for preoperative laboratory testing in urogynecologic patients.

Hyperkalemia is Associated with Increased 30-Day Mortality in Hip Fracture Patients

Abnormal plasma concentrations of potassium in the form of hyper- and hypokalemia are frequent among hospitalized patients and have been linked to poor outcomes. In this study, we examined the prevalence of hypo- and hyperkalemia in patients admitted with a fractured hip as well as the association with 30-day mortality in these patients. A total of 7293 hip fracture patients (aged 60 years or above) with admission plasma potassium measurements were included. Data on comorbidity, medication, and death was retrieved from national registries. The association between plasma potassium and mortality was examined using Cox proportional hazards models adjusted for age, sex, and comorbidities. The prevalence of hypo- and hyperkalemia on admission was 19.8% and 6.6%, respectively. The 30-day mortality rates were increased for patients with hyperkalemia (21.0%, p < 0.0001) compared to normokalemic patients (9.5%), whereas hypokalemia was not significantly associated with mortality. After adjustment for age, sex, and individual comorbidities, hyperkalemia was still associated with increased risk of death 30 days after admission (HR = 1.93 [1.55-2.40], p < 0.0001). After the same adjustments, hypokalemia remained non-associated with increased risk of 30-day mortality (HR = 1.06 [0.87-1.29], p = 0.6). Hyperkalemia, but not hypokalemia, at admission is associated with increased 30-day mortality after a hip fracture.