Abstract
IntroductionAltered peripheral perfusion is strongly associated with poor outcome in critically ill patients. We wanted to determine whether repeated assessments of peripheral perfusion during the days following surgery could help to early identify patients that are more likely to develop postoperative complications.MethodsHaemodynamic measurements and peripheral perfusion parameters were collected one day prior to surgery, directly after surgery (D0) and on the first (D1), second (D2) and third (D3) postoperative days. Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (Tskin-diff). Generalized linear mixed models were used to predict severe complications within ten days after surgery based on Clavien-Dindo classification.ResultsWe prospectively followed 137 consecutive patients, from among whom 111 were included in the analysis. Severe complications were observed in 19 patients (17.0%). Postoperatively, peripheral perfusion parameters were significantly altered in patients who subsequently developed severe complications compared to those who did not, and these parameters persisted over time. CRT was altered at D0, and PPI and Tskin-diff were altered on D1 and D2, respectively. Among the different peripheral perfusion parameters, the diagnostic accuracy in predicting severe postoperative complications was highest for CRT on D2 (area under the receiver operating characteristic curve = 0.91 (95% confidence interval (CI) = 0.83 to 0.92)) with a sensitivity of 0.79 (95% CI = 0.54 to 0.94) and a specificity of 0.93 (95% CI = 0.86 to 0.97). Generalized mixed-model analysis demonstrated that abnormal peripheral perfusion on D2 and D3 was an independent predictor of severe postoperative complications (D2 odds ratio (OR) = 8.4, 95% CI = 2.7 to 25.9; D2 OR = 6.4, 95% CI = 2.1 to 19.6).ConclusionsIn a group of patients assessed following major abdominal surgery, peripheral perfusion alterations were associated with the development of severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion–targeted resuscitation following major abdominal surgery.
Highlights
Altered peripheral perfusion is strongly associated with poor outcome in critically ill patients
Several scoring systems, such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the American Society of Anesthesiologists (ASA) score and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score can be applied in a general surgery population
Operative blood loss tended to be greater in patients who developed severe complications compared to patients who developed nonsevere complications, this difference was not significant (P = 0.245)
Summary
Altered peripheral perfusion is strongly associated with poor outcome in critically ill patients. Because postoperative complications better predict short- and long-term mortality than preoperative and intraoperative factors [3,4,5], recent research has been focused on identifying preoperative factors that predispose patients to postoperative complications. Several scoring systems, such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the American Society of Anesthesiologists (ASA) score and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score can be applied in a general surgery population. In clinical practice, a simple, easy-to-use approach is needed to recognize patients at risk for severe complications and to ensure timely initiation of interventions to improve outcomes
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