Noncardiac Surgery Patients Research Articles

Effect of different durations of preoperative computerised cognitive training on postoperative delirium in older patients undergoing cardiac surgery: a study protocol for a prospective, randomised controlled trial

IntroductionPostoperative delirium (POD) is a common neurological complication after surgery among older patients, characterised by acute disturbances in consciousness, attention and cognition, usually occurring within 24–72 hours after surgery. POD...

Relationship between sST2 and NT-proBNP levels and postoperative atrial fibrillation in patients having non-cardiac surgery.

We explored the link between sST2 and NT-proBNP levels and postoperative atrial fibrillation (POAF) incidence in non-cardiac surgery patients in this study. The research involved 302 participants over 40 years old who underwent medium and/or high-risk non-cardiac surgeries. These patients were divided into two groups: those who developed POAF and those who did not. The study cohort consisted of a total of 302 patients, with 14 (4.6%) experiencing POAF. POAF was more common in patients with previous heart failure, a high Left Atrial Volume Index (LAVI), and elevated ASA and RCRI scores (all P<0.05). LAVI, sST2, NT-proBNP, and RCRI scores were found to be independent predictors of POAF in patients undergoing non-cardiac surgeries (all P<0.05). The area under the curve (AUC) for sST2 and NT-proBNP in predicting POAF was 0.707 (95% CI 0.544-0.869; P=0.009) and 0.727 (95% CI 0.598-0.857; P=0.004), respectively. Combined elevation of sST2 and NT-proBNP increased the likelihood of developing POAF by approximately 8.5 times (OR: 8.65, CI 95% 1.06-35.3, P=0.044). sST2 and NT-proBNP are valuable predictors of POAF in patients undergoing non-cardiac surgery. Identifying these predictors can help in recognizing high-risk patient groups for POAF.

Boston Naming Test as a Screening Tool for Early Postoperative Cognitive Dysfunction in Elderly Patients After Major Noncardiac Surgery.

The Boston naming test (BNT), as a simple, fast, and easily administered neuropsychological test, was demonstrated to be useful in detecting language function. In this study, BNT was investigated whether it could be a screening tool for early postoperative cognitive dysfunction (POCD). This prospective observational cohort study included 132 major noncardiac surgery patients and 81 nonsurgical controls. All participants underwent a mini-mental state examination (MMSE) and BNT 1 day before and 7 days after surgery. Early POCD was assessed by reliable change index and control group results. Seven days after surgery, among 132 patients, POCD was detected in 30 (22.7%) patients (95% CI, 15.5%-30.0%) based on MMSE, and 45 (34.1%) patients (95% CI, 26.3%-41.9%) were found with postoperative language function decline based on BNT and MMSE. Agreement between the BNT spontaneous naming and MMSE total scoring was moderate (Kappa .523), and the sensitivity of BNT spontaneous naming for detecting early POCD was .767. Further analysis showed that areas under receiver operating characteristics curves (AUC) did not show statistically significant differences when BNT spontaneous naming (AUC .862) was compared with MMSE language functional subtests (AUC .889), or non-language functional subtests (AUC .933). This study indicates the feasibility of implementing the BNT spontaneous naming test to screen early POCD in elderly patients after major noncardiac surgery.

Defining Postinduction Hemodynamic Instability With an Automated Classification Model.

Postinduction hypotension (PIH) may be associated with increased morbidity and mortality. In earlier studies, the definition of PIH is solely based on different absolute or relative thresholds. However, the time-course (eg, how fast blood pressure drops during induction) is rarely incorporated, whereas it might represent the hemodynamic instability of a patient. We propose a comprehensive model to distinguish hemodynamically unstable from stable patients by combining blood pressure thresholds with the magnitude and speed of decline. This prospective study included 375 adult elective noncardiac surgery patients. Noninvasive blood pressure was continuously measured between 5 minutes before up to 15 minutes after the first induction agent had been administered. An expert panel rated whether the patient experienced clinically relevant hemodynamic instability or not. Interrater correlation coefficient and intraclass correlation were computed to check for consistency between experts. Next, an automated classification model for clinically relevant hemodynamic instability was developed using mean, maximum, minimum systolic, mean, diastolic arterial blood pressure (SAP, MAP, and DAP, respectively) and their corresponding time course of decline. The model was trained and tested based on the hemodynamic instability labels provided by the experts. In total 78 patients were classified as having experienced hemodynamic instability and 279 as not. The hemodynamically unstable patients were significantly older (7 years, 95% confidence interval (CI), 4-11, P < .001), with a higher prevalence of chronic obstructive pulmonary disease (COPD) (3% higher, 95% CI, 1-8, P = .036). Before induction, hemodynamically unstable patients had a higher SAP (median (first-third quartile): 161 (145-175) mm Hg vs 150 (134-166) mm Hg, P < .001) compared to hemodynamic stable patients. Interrater agreement between experts was 0.92 (95% CI, 0.89-0.94). The random forest classifier model showed excellent performance with an area under the receiver operating curve (AUROC) of 0.96, a sensitivity of 0.84, and specificity of 0.94. Based on the high sensitivity and specificity, the developed model is able to differentiate between clinically relevant hemodynamic instability and hemodynamic stable patients. This classification model will pave the way for future research concerning hemodynamic instability and its prevention.

A comparison between invasive and noninvasive measurement of the Hypotension Prediction Index: A post hoc analysis of a prospective cohort study.

Clinical trials and validation studies demonstrate promising hypotension prediction capability by the Hypotension Prediction Index (HPI). Most studies that evaluate HPI derive it from invasive blood pressure readings, but a direct comparison with the noninvasive alternative remains undetermined. Such a comparison could provide valuable insights for clinicians in deciding between invasive and noninvasive monitoring strategies. Evaluating predictive differences between HPI when obtained through noninvasive versus invasive blood pressure monitoring. Post hoc analysis of a prospective observational study conducted between 2018 and 2020. Single-centre study conducted in an academic hospital in the Netherlands. Adult noncardiac surgery patients scheduled for over 2 h long elective procedures. After obtaining informed consent, 91 out of the 105 patients had sufficient data for analysis. The primary outcome was the difference in area under the receiver-operating characteristics (ROC) curve (AUC) obtained for HPI predictions between the two datasets. Additionally, difference in time-to-event estimations were calculated. AUC (95% confidence interval (CI)) results revealed a nonsignificant difference between invasive and noninvasive HPI, with areas of 94.2% (90.5 to 96.8) and 95.3% (90.4 to 98.2), respectively with an estimated difference of 1.1 (-3.9 to 6.1)%; P = 0.673. However, noninvasive HPI demonstrated significantly longer time-to-event estimations for higher HPI values. Noninvasive HPI is reliably accessible to clinicians during noncardiac surgery, showing comparable accuracy in HPI probabilities and the potential for additional response time. Clinicaltrials.gov (NCT03795831) on 10 January 2019. https://clinicaltrials.gov/study/NCT03795831.

Team dynamics after implementation of guidelines for anaesthesia for children with CHD.

Guidelines were created at our single centrer institution for which anesthesiology team should care for pediatric cardiac patients for noncardiac surgery. The goal of the survey was to assess inter-team dynamics after the implementation of guidelines and revealed that practice behaviour can quickly change but a sustained change in team dynamics and workplace culture takes time.

Association of preoperative red blood cell width and postoperative 30-day mortality in patients undergoing non-cardiac surgery: a retrospective cohort study using propensity-score matching

BackgroundIn terms of predicting surgery mortality, it is controversial whether red blood cell width works independently. In non-cardiac surgery patients older than 18 years, we intend to examine the relationship between red blood cell width and postoperative 30-day mortality.MethodsIn this retrospective cohort study, 90,785 Singapore General Hospital patients were matched by propensity score between January 1, 2012 and October 31, 2016. It was determined that red blood cell width at baseline and mortality within 30 days after surgery were the independent and dependent variables. We used a non-parametric multivariate logistic regression to balance the confounders among 7807 patients with high RDW and 7807 patients with non-high RDW in the propensity score matching. We investigated the association between RDW and 30-day mortality after surgery using the doubly robust estimation method.ResultsCohorts matched according to propensity score, the risk of 30-day mortality after surgery increased by 114.6.0% among the high RDW group (OR = 2.146, 95% CI 1.645–2.799, P < 0.00001). In the crude model, there was a significant association between RDW and 30-day mortality after surgery (OR = 1.877, 95% CI 1.476–2.388, P < 0.00001). In the propensity-score adjusted model, the risk of 30-day mortality after surgery in the high RDW group compared to the control group was not as high as in the non-adjusted model (OR = 1.867, 95% CI 1.467–2.376, P < 0.00001). Compared to non-high RDW group, the risk of 30-day mortality after surgery increased by 117.0% and 127.7% among high RDW group in the original cohort (OR 2.170, 95% CI 1.754–2.683, P < 0.00001) and the weighted cohort (OR 2.272, 95% CI 2.009–2.580, P < 0.00001), respectively.ConclusionsAccording to the results of this observational, propensity score-matched cohort study, uncontrolled high RDW before surgery is associated with an increased risk of death within 30 days after surgery, that is to say, patients over the age of 18 with high preoperative RDW who undergo non-cardiac surgery have a worse postoperative prognosis than those with normal RDW.

Optimizing anesthesia management based on early identification of electroencephalogram burst suppression risk in non-cardiac surgery patients: a visualized dynamic nomogram

Background Burst suppression (BS) is a specific electroencephalogram (EEG) pattern that may contribute to postoperative delirium and negative outcomes. Few prediction models of BS are available and some factors such as frailty and intraoperative hypotension (IOH) which have been reported to promote the occurrence of BS were not included. Therefore, we look forward to creating a straightforward, precise, and clinically useful prediction model by incorporating new factors, such as frailty and IOH. Materials and methods We retrospectively collected 540 patients and analyzed the data from 418 patients. Univariate analysis and backward stepwise logistic regression were used to select risk factors to develop a dynamic nomogram model, and then we developed a web calculator to visualize the process of prediction. The performance of the nomogram was evaluated in terms of discrimination, calibration, and clinical utility. Results According to the receiver operating characteristic (ROC) analysis, the nomogram showed good discriminative ability (AUC = 0.933) and the Hosmer–Lemeshow goodness-of-fit test demonstrated the nomogram had good calibration (p = 0.0718). Age, Clinical Frailty Scale (CFS) score, midazolam dose, propofol induction dose, total area under the hypotensive threshold of mean arterial pressure (MAP_AUT), and cerebrovascular diseases were the independent risk predictors of BS and used to construct nomogram. The web-based dynamic nomogram calculator was accessible by clicking on the URL: https://eegbsnomogram.shinyapps.io/dynnomapp/ or scanning a converted Quick Response (QR) code. Conclusions Incorporating two distinctive new risk factors, frailty and IOH, we firstly developed a visualized nomogram for accurately predicting BS in non-cardiac surgery patients. The model is expected to guide clinical decision-making and optimize anesthesia management.

Outcomes after noncardiac surgery in patients with left ventricular assist devices: a systematic review.

The number of patients living with left ventricular assist devices (LVADs) has gradually increased in the past decade. Non-cardiac surgery (NCS) in patients with LVAD poses a unique situation with its inherent challenges. We conducted a comprehensive review to investigate the perioperative complications and mortality associated with emergent or elective NCS in patients with LVAD. A comprehensive literature search for any papers referring to continuous LVAD patients with NCS. All publications with at least five durable LVAD patients who had NCS were eligible for inclusion. Twenty articles matching our criteria were found and included in our study. This systematic review included 6,476 LVAD patients who underwent 6,824 NCS. There were 5-3,216 LVAD patients with NCS in each study. The median age was between 39 and 65 years, and most of the patients (78.8%) were male. Thirty-day postoperative mortality ranged from 0% to 60%. Eight studies reported no death within the 30 days of the operation. Common complications include gastrointestinal (GI) bleeding, intracranial bleeding, infection, acute kidney injury (AKI), urinary tract infection (UTI), stroke, sepsis, pneumonia, and VAD exchange. Emergent abdominal surgery had the highest (up to 60%) mortality rate, and vascular and neurological operations had the highest complication rates. Due to the diverse range of patients in each publication and the combination of outcomes presented in various publications, a meta-analysis was not conducted. In LVAD patients, noncardiac surgery may be performed effectively and safely. LVAD patients who undergo non-cardiac surgery may require more transfusions due to their complex coagulopathies. However, perioperative management of LVAD patients undergoing emergent NCS should be optimized to reduce mortality. https://osf.io/fetsb/.

Perioperative surveillance of myocardial injury after non-cardiac surgery in patients with hip fracture: A retrospective cohort study.

Myocardial injury after non-cardiac surgery is due to ischaemia either during non-cardiac surgery or within 30 days after it. Our surveillance protocol includes hip fracture template and high-sensitivity troponin stratification, as recommended in European countries. Our retrospective study cohort included surgical patients for hip fracture at our hospital in Japan. The primary outcome was the rate of myocardial injury after non-cardiac surgery in comparison to patients managed with (213) and without (176) hip fracture template. The hip fracture template was used more in patients with myocardial injury after non-cardiac surgery than those without myocardial injury after non-cardiac surgery. When hip fracture template was used, patients had a higher likelihood of myocardial injury after non-cardiac surgery after adjusting for age, time to operation, diabetes mellitus, and chronic kidney disease (odds ratio 41.3; 95% confidence interval: 12.1, 259.6). Patients with myocardial injury after non-cardiac surgery had higher in-hospital mortality than those without myocardial injury after non-cardiac surgery, even in adjusted analysis. There was a high detection rate of myocardial injury after non-cardiac surgery when patients with hip fractures were managed with hip fracture template. Myocardial injury after non-cardiac surgery was associated with in-hospital mortality.

Prediction of intraoperative hypotension using deep learning models based on non-invasive monitoring devices.

Intraoperative hypotension is associated with adverse outcomes. Predicting and proactively managing hypotension can reduce its incidence. Previously, hypotension prediction algorithms using artificial intelligence were developed for invasive arterial blood pressure monitors. This study tested whether routine non-invasive monitors could also predict intraoperative hypotension using deep learning algorithms. An open-source database of non-cardiac surgery patients ( https://vitadb.net/dataset ) was used to develop the deep learning algorithm. The algorithm was validated using external data obtained from a tertiary Korean hospital. Intraoperative hypotension was defined as a systolic blood pressure less than 90 mmHg. The input data included five monitors: non-invasive blood pressure, electrocardiography, photoplethysmography, capnography, and bispectral index. The primary outcome was the performance of the deep learning model as assessed by the area under the receiver operating characteristic curve (AUROC). Data from 4754 and 421 patients were used for algorithm development and external validation, respectively. The fully connected model of Multi-head Attention architecture and the Globally Attentive Locally Recurrent model with Focal Loss function were able to predict intraoperative hypotension 5min before its occurrence. The AUROC of the algorithm was 0.917 (95% confidence interval [CI], 0.915-0.918) for the original data and 0.833 (95% CI, 0.830-0.836) for the external validation data. Attention map, which quantified the contributions of each monitor, showed that our algorithm utilized data from each monitor with weights ranging from 8 to 22% for determining hypotension. A deep learning model utilizing multi-channel non-invasive monitors could predict intraoperative hypotension with high accuracy. Future prospective studies are needed to determine whether this model can assist clinicians in preventing hypotension in patients undergoing surgery with non-invasive monitoring.

Aspirin Monotherapy vs No Antiplatelet Therapy in Stable Patients With Coronary Stents Undergoing Low-to-Intermediate Risk Noncardiac Surgery.

Current guidelines recommend the perioperative continuation of aspirin in patients with coronary drug-eluting stents (DES) undergoing noncardiac surgery. However, supporting evidence is limited. This study aimed to compare continuing aspirin monotherapy vs temporarily holding all antiplatelet therapy before noncardiac surgery in patients with previous DES implantation. We randomly assigned patients who had received a DES >1 year previously and were undergoing elective noncardiac surgery either to continue aspirin or to discontinue all antiplatelet agents 5days before noncardiac surgery. Antiplatelet therapy was recommended to be resumed no later than 48 hours after surgery, unless contraindicated. The primary outcome was a composite of death from any cause, myocardial infarction, stent thrombosis, or stroke between 5days before and 30days after noncardiac surgery. A total of 1,010 patients underwent randomization. Among 926 patients in the modified intention-to-treat population (462 patients in aspirin monotherapy group and 464 patients in the no-antiplatelet therapy group), the primary composite outcome occurred in 3 patients (0.6%) in the aspirin monotherapy group and 4 patients (0.9%) in the no antiplatelet group (difference, -0.2 percentage points; 95%CI:-1.3 to 0.9; P > 0.99). There was no stent thrombosis in either group. The incidence of major bleeding did not differ significantly between groups (6.5% vs 5.2%; P=0.39), whereas minor bleeding was significantly more frequent in the aspirin group (14.9% vs 10.1%; P = 0.027). Among patients undergoing low-to-intermediate risk noncardiac surgery >1 year after stent implantation primarily with a DES, in the setting of lower-than-expected event rates, we failed to identify a significant difference between perioperative aspirin monotherapy and no antiplatelet therapy with respect to ischemic outcomes or major bleeding. (Perioperative Antiplatelet Therapy in Patients With Drug-eluting Stent Undergoing Noncardiac Surgery [ASSURE-DES]; NCT02797548).

Intraoperative clinical application of hemodynamic monitoring in noncardiac surgery patients

The current S1guidelines on the intraoperative clinical application of hemodynamic monitoring in patients scheduled for noncardiac surgery are presented based on a case report under the aspect of an optimized intraoperative anesthesiological management. The S1 guidelines were developed with the aim of identifying the questions on the intraoperative hemodynamic monitoring and management which are important for the routine daily clinical practice, to discuss them in a guideline group and to answer them based on the current state of scientific knowledge. The guidelines were written under the auspices of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and published by the AWMF in 2023 under the register number 001/049.

High body mass index is associated with elevated risk of perioperative ischemic stroke in patients who underwent noncardiac surgery: A retrospective cohort study.

Body mass index (BMI) serves as a global metric for assessing obesity and overall health status. However, the impact of BMI, treated as a continuous variable, on the risk of perioperative stroke remains poorly understood. This retrospective cohort study aimed to elucidate the association between BMI and the risk of perioperative ischemic stroke in patients undergoing non-cardiovascular surgery. A cohort of 223,415 patients undergoing noncardiac surgery at the First Medical Center of Chinese PLA General Hospital between January 1, 2008 and August 31, 2019 was screened. Preoperative high BMI, defined as BMI >22.64 kg/m2, was the primary exposure, and the outcome of interest was the new diagnosis of perioperative ischemic stroke within 30 days post-surgery. Robust controls for patient and intraoperative factors were implemented to minimize residual confounding. Logistic regression and propensity score matching were employed, and patients were stratified into subgroups for further investigation. The overall incidence of perioperative ischemic stroke was 0.23% (n = 525) in the cohort. After adjusting for patient-related variables (OR 1.283; 95% CI, 1.04-1.594; p < 0.05), surgery-related variables (OR 1.484; 95% CI, 1.2-1.849; p < 0.001), and all confounding variables (OR 1.279; 95% CI, 1.025-1.607; p < 0.05), patients with BMI >22.64 kg/m2 exhibited a significantly increased risk of perioperative ischemic stroke. This association persisted in the propensity score matched cohort (OR 1.577; 95% CI, 1.203-2.073; p < 0.01). Subgroup analyses indicated that preoperative BMI >22.64 kg/m2 correlated with an elevated risk of perioperative ischemic stroke in female patients, those with coronary heart disease, peripheral vascular diseases, and individuals undergoing neurosurgery. We first identified BMI >22.64 kg/m2 as a substantial and independent risk factor for perioperative ischemic stroke in Chinese noncardiac surgery patients. Normal BMI may not suffice as a universal preventive standard. Instead, a more stringent perioperative weight management approach is recommended, particularly for specific subgroups such as female patients, those with coronary heart disease and peripheral vascular disease, and individuals scheduled for neurosurgery.

Predicting perioperative myocardial injury/infarction after noncardiac surgery in patients under surgical and medical co-management: a prospective cohort study

BackgroundPerioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model.MethodsA prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated.Results613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34–14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67–0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81–0.93).ConclusionsThe incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery.

Effect of home-based prehabilitation on objectively measured physical activity in patients undergoing elective major cardiac and non-cardiac surgery. Data from a randomized controlled trial

Abstract Background Low functional capacity in patients undergoing major elective surgery is associated with postoperative complications. Prehabilitation aims to increase functional capacity by increasing preoperative physical activity. Low functional capacity in patients eligible for major surgery is associated with high age and comorbid burden. In this population, center-based prehabilitation is a barrier for participation. Therefore, we developed a multimodal home-based prehabilitation intervention. Data regarding the effectiveness of a home-based prehabilitation intervention to increase physical activity before surgery is limited. We hypothesize that home-based prehabilitation leads to an increase in physical activity in patients undergoing major cardiac and non-cardiac surgery. Methods We included patients aged over 65 with a proven low functional capacity and/or ventilatory efficiency measured by preoperative cardiopulmonary exercise testing. Patients were randomized to either standard of care or intervention. The intervention group received a home-based prehabilitation intervention 2-4 weeks before surgery. As part of the multimodal intervention, patients were prescribed a walking regimen according to the physical activity guidelines published by the World Health Organization (WHO). Patients were followed-up with weekly telephone calls by a physiotherapist to increase adherence and motivation. All patients were provided a wrist-worn tri-axial accelerometer at the baseline visit. The accelerometer was collected at the ward once the patient entered the hospital for surgery. Physical activity was estimated by calculating the average Euclidean norm minus one (ENMO, milligravity [mg]) per day. Baseline characteristics were tested by Wilcoxon rank-sum test and a linear model for the primary outcome was performed to adjust for confounders. Data analysis was performed using R Studio. Results 37 patients scheduled for cardiac and 62 for non-cardiac surgery were included (Table 1). Mean group difference of daily physical activity levels in non-cardiac surgery patients was 3.01 mg (p = 0.03, 95% CI [0.3, 5.6]). Mean group difference of daily physical activity levels in cardiac surgery patients was 0.27 mg (p = 0.95, 95% CI [-4.1, 5.0]) (Figure 1). Patients undergoing cardiac surgery had higher overall activity levels compared to non-cardiac also when adjusted for age. Conclusion Home-based prehabilitation increases preoperative physical activity levels in patients undergoing major non-cardiac surgery, but not in patients undergoing major cardiac surgery. Higher activity levels in cardiac surgery patients was unexpected, but may be explained by previous inclusion of patients with cardiac diseases in exercise-based rehabilitation and physical activity recommendations at routine cardiac follow-up visits. Table 1 Figure 1

Association between Complications and Death within 30 days after General Surgery

Objective: To determine the epidemiology of post-operative complications among general surgery patients, inform their relationships with 30-day mortality, and determine the attributable fraction of death of each postoperative complication. Background: The contemporary causes of post-operative mortality among general surgery patients are not well characterized. Methods: VISION is a prospective cohort study of adult non-cardiac surgery patients across 28 centres in 14 countries, who were followed for 30 days after surgery. For the subset of general surgery patients, a cox proportional hazards model was used to determine associations between various surgical complications and post-operative mortality. The analyses were adjusted for preoperative and surgical variables. Results were reported in adjusted hazard ratios (HR) with 95% confidence intervals (CI). Results: Among 7950 patients included in the study, 240 (3.0%) patients died within 30 days of surgery. Five post-operative complications (myocardial injury after non-cardiac surgery [MINS], major bleeding, sepsis, stroke, and acute kidney injury resulting in dialysis) were independently associated with death. Complications associated with the largest attributable fraction (AF) of post-operative mortality (i.e., percentage of deaths in the cohort that can be attributed to each complication, if causality were established) were major bleeding (n=1454, 18.3%, HR 2.49 95%CI 1.87-3.33, P&lt;0.001, AF 21.2%), sepsis (n=783, 9.9%, HR 6.52, 95%CI 4.72-9.01, P&lt;0.001, AF 15.6%), and MINS (n=980, 12.3%, HR 2.00, 95%CI 1.50-2.67, P&lt;0.001, AF 14.4%). Conclusion: The complications most associated with 30-day mortality following general surgery are major bleeding, sepsis, and MINS. These findings may guide the development of mitigating strategies, including prophylaxis for perioperative bleeding.

Association between preoperative albumin and length of hospital stay in non-cardiac surgery patients with pulmonary hypertension: A secondary retrospective analysis.

To explore the risk factors affecting the length of hospital stay (LOS) as well as to examine the relationship between preoperative serum albumin levels and LOS following non-cardiac, non-obstetric surgery in patients with pulmonary hypertension (PHTN). This study represents a secondary retrospective analysis based on 287 non-cardiac, non-obstetric procedures performed on 195 PTHN patients at a single institution in the USA between 2007 and 2013. The primary outcome was the LOS. We conducted a multiple logistic regression analysis to compare the LOS between the 2 groups, divided at a serum albumin level of 3.5 g/dL. After adjusting for multiple covariates, the ORs for the long length of stay (LOS > 7 days) for the high group(albumin > 3.5 g/dL) compared with the low group (albumin ≤ 3.5 g/dL) were 0.35 (95%CI: 0.21~0.6), 0.41 (95%CI: 0.22 ~0.76), 0.41 (95%CI: 0.18~0.94) from model 2 to model 4. The stratified analysis results indicate that these findings are stable (p for trend > 0.05). In this study, it was observed that low levels of preoperative albumin were associated with an increased risk of prolonged hospital stay after non-cardiac, non-obstetric surgery in patients with PHTN. This implies that optimizing preoperative nutrition could potentially reduce the LOS for non-cardiac, non-obstetric surgery in patients with PHTN.

The relative merits of using a high-sensitivity cardiac Troponin T assay compared to a nonhigh-sensitivity troponin T assay after noncardiac surgery

Troponin elevation after noncardiac surgery is associated with an elevated risk of 30-day mortality. Little is known about relative merit of using a high-sensitivity Troponin T (hsTnT), the fifth-generation assay, vs the nonhigh sensitivity Troponin T (non-hsTnT), the fourth-generation assay, in the noncardiac surgery setting. We aimed to identify whether hsTnT can identify additional patients at risk that would have gone undetected with non-hsTnT measurement. The VISION Study included 40,004 noncardiac surgery patients with postoperative troponin measurements. Among them, 1,806 patients had both fourth-generation non-hsTnT and fifth-generation hsTnT concomitant measurements (4,451 paired results). We compared the absolute concentrations, the timing, and the impact of different thresholds on predicting 30-day major cardiovascular complications (composite of death, nonfatal cardiac arrest, coronary revascularization, and congestive heart failure). Based on the manufacturers' threshold of 14 ng/L, 580 (32.1%) patients had postoperative hsTnT concentrations greater than the threshold, while their non-hsTnT concentrations were below the manufacturer's threshold. These 580 patients had higher risk of major cardiovascular events (OR 2.33; CI 95% 1.04-5.23; P = .049) than patients with hsTnT concentrations below the manufacturer threshold. Among patients with myocardial injury after noncardiac surgery, only 50% would be detected by the fourth-generation non-hsTnT assay at 6 to 12 hours postoperative as compared to 85% with the fifth-generation hsTnT assay (P-value < .001). Within the first 3 postoperative days, fifth-generation hsTnT identified at least 1 in 3 patients with troponin elevation that would have gone undetected by fourth-generation non-hsTnT using published thresholds in this setting. Furthermore, fifth-generation hsTnT identified patients with an elevation earlier than fourth-generation non-hsTnT, indicating potential to improve postoperative risk stratification.

Effect of Transcutaneous Electrical Acupoint Stimulation on Extubation-Related Stress Response in Noncardiac Surgery Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PurposeStress response is a common complication during extubation, mainly manifested by dramatic hemodynamic fluctuations. Transcutaneous electrical acupoint stimulation (TEAS) is widely applied in perioperative period. We performed this meta-analysis to evaluate whether the TEAS could relieve stress response during extubation in non-cardiac surgery patients. DesignA systematic review and meta-analysis of randomized controlled trials (RCTs). MethodsWe searched six databases (PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, CNKI and Wan Fang) for relevant literature. Risk of bias assessment was executed based on the Cochrane Criteria. We applied RevMan5.4.1 software to analyze data. When the chi-square test did not show heterogeneity, we adopted the fixed-effect model. Otherwise, the random-effect model was utilized. Findingsln total, twelve RCTs with 1347 participants were enrolled in this meta-analysis. Meta-analysis showed the heart rate and mean arterial pressure of the intervention group were significantly lower than the control group at immediately,5 min and 10 min after extubation. And the occurrence rate of emergency agitation (RR 0.39, 95% CI [0.26,0.60]) and postoperative delirium (RR 0.40, 95% CI [0.22, 0.72] were lower in TEAS group. The consumptions of propofol (SMD-0.47, 95% CI [-0.77, -0.18]) and remifentanil (SMD-1.49, 95%CI [-2.01, -0.96]) of the intervention group were also significantly reduced compared with the control group. ConclusionsTEAS was beneficial for improving stress response during extubation, emergence agitation, postoperative delirium and reduced the consumption of intraoperative propofol and remifentanil, but it was necessary to note the limitations of the current evidence.