Risk Of 30-day Postoperative Mortality Research Articles

Influence of elevated liver enzyme level on 30-day mortality rates in patients undergoing nonemergency orthopedic surgery

BackgroundThe effect of elevated preoperative liver enzyme levels on postoperative outcomes is a topic of concern to clinicians. This study explored the association between elevated preoperative liver enzyme levels and surgical outcomes in patients undergoing orthopedic surgery.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database, we obtained data on adult patients who received nonemergency orthopedic surgery under general anesthesia between 2011 and 2021.ResultsWe evaluated the data of 477,524 patients, of whom 6.1% (24 197 patients) had elevated preoperative serum glutamic oxaloacetic transaminase (SGOT) levels. An elevated SGOT level was significantly associated with 30-day postoperative mortality (adjusted hazard ratio, 1.62; 95% confidence interval, 1.39 to 1.90). We determined that the mortality rate rose with SGOT levels. The results remained unchanged after propensity score matching.ConclusionElevated preoperative SGOT levels constitute an independent risk factor for 30-day postoperative mortality and are proportionately associated with the risk of 30-day postoperative mortality.

Development and external validation of a novel score for predicting postoperative 30‑day mortality in tumor craniotomy patients: A cross‑sectional diagnostic study.

The identification of patients with craniotomy at high risk for postoperative 30-day mortality may contribute to achieving targeted delivery of interventions. The present study aimed to develop a personalized nomogram and scoring system for predicting the risk of postoperative 30-day mortality in such patients. In this retrospective cross-sectional study, 18,642 patients with craniotomy were stratified into a training cohort (n=7,800; year of surgery, 2012-2013) and an external validation cohort (n=10,842; year of surgery, 2014-2015). The least absolute shrinkage and selection operator (LASSO) model was used to select the most important variables among the candidate variables. Furthermore, a stepwise logistic regression model was established to screen out the risk factors based on the predictors chosen by the LASSO model. The model and a nomogram were constructed. The area under the receiver operating characteristic (ROC) curve (AUC) and calibration plot analysis were used to assess the model's discrimination ability and accuracy. The associated risk factors were categorized according to clinical cutoff points to create a scoring model for postoperative 30-day mortality. The total score was divided into four risk categories: Extremely high, high, intermediate and low risk. The postoperative 30-day mortality rates were 2.43 and 2.58% in the training and validation cohort, respectively. A simple nomogram and scoring system were developed for predicting the risk of postoperative 30-day mortality according to the white blood cell count; hematocrit and blood urea nitrogen levels; age range; functional health status; and incidence of disseminated cancer cells. The ROC AUC of the nomogram was 0.795 (95% CI: 0.764 to 0.826) in the training cohort and it was 0.738 (95% CI: 0.7091 to 0.7674) in the validation cohort. The calibration demonstrated a perfect fit between the predicted 30-day mortality risk and the observed 30-day mortality risk. Low, intermediate, high and extremely high risk statuses for 30-day mortality were associated with total scores of (-1.5 to -1), (-0.5 to 0.5), (1 to 2) and (2.5 to 9), respectively. A personalized nomogram and scoring system for predicting postoperative 30-day mortality in adult patients who underwent craniotomy were developed and validated, and individuals at high risk of 30-day mortality were able to be identified.

Palliative Non-Operative Management in Geriatric Hip Fracture Patients: When Would Surgeons Abstain from Surgery?

Background: For hip fracture patients with a limited life expectancy, operative and palliative non-operative management (P-NOM) can yield similar quality of life outcomes. However, evidence on when to abstain from surgery is lacking. The aim of this study was to quantify the influence of patient characteristics on surgeons' decisions to recommend P-NOM. Methods: Dutch surgical residents and orthopaedic trauma surgeons were enrolled in a conjoint analysis and structured expert judgement (SEJ). The participants assessed 16 patient cases comprising 10 clinically relevant characteristics. For each case, they recommended either surgery or P-NOM and estimated the 30-day postoperative mortality risk. Treatment recommendations were analysed using Bayesian logistic regression, and perceived risks were pooled with equal and performance-based weights using Cooke's Classical Model. Results: The conjoint analysis and SEJ were completed by 14 and 9 participants, respectively. Participants were more likely to recommend P-NOM to patients with metastatic carcinomas (OR: 4.42, CrI: 2.14-8.95), severe heart failure (OR: 4.05, CrI: 1.89-8.29), end-stage renal failure (OR: 3.54, CrI: 1.76-7.35) and dementia (OR: 3.35, CrI: 1.70-7.06). The patient receiving the most P-NOM recommendations (12/14) had a pooled perceived risk of 30-day mortality between 50.8 and 62.7%. Conclusions: Overall, comorbidities had the strongest influence on participants' decisions to recommend P-NOM. Nevertheless, practice variation and heterogeneity in risk perceptions were substantial. Hence, more decision support for considering P-NOM is needed.

Postoperative Outcomes After Gastrointestinal Surgery in Patients Receiving Chronic Kidney Replacement Therapy: A Population-based Cohort Study.

This study evaluated the postoperative mortality and morbidity outcomes following the different subtypes of gastrointestinal (GI) surgery over a 15-year period. Patients receiving chronic kidney replacement therapy (KRT) experience higher rates of general surgery compared with other surgery types. Contemporary data on the types of surgeries and their outcomes are lacking. KRT was defined as patients requiring chronic dialysis (hemodialysis or peritoneal dilaysis) or having a functioning kidney transplant long-term. All incident and prevalent patients aged greater than 18 years identified in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry as receiving chronic KRT were linked with jurisdictional hospital admission datasets between January 1, 2000 until December 31, 2015. Patients were categorized by their KRT modality [hemodialysis (HD), peritoneal dialysis (PD), home hemodialysis (HHD), and kidney transplant (KT)]. GI surgeries were categorized as upper gastrointestinal (UGI), bowel (small and large bowel), anorectal, hernia surgery, cholecystectomy, and appendicectomy. The primary outcome was the rates of the different surgeries, estimated using Poisson models. Secondary outcomes were risks of 30-day/in-hospital postoperative mortality risk and nonfatal outcomes and were estimated using logistic regression. Independent predictors of 30-day mortality were examined using comorbidity-adjusted Cox models. Overall, 46,779 patients on chronic KRT were linked to jurisdictional hospital datasets, and 9,116 patients were identified as having undergone 14,540 GI surgeries with a combined follow-up of 76,593 years. Patients on PD had the highest rates of GI surgery (8 per 100 patient years), with hernia surgery being the most frequent. Patients on PD also had the highest risk of 30-day postoperative mortality following the different types of GI surgery, with the risk being more than 2-fold higher after emergency surgery compared with elective procedures. Infective postoperative complications were more common than cardiac complications. This study also observed a U-shaped association between body mass index (BMI) and mortality, with a nadir in the 30 to 35kg/m 2 group. Patients on chronic KRT have high rates of GI surgery and morbidity, particularly in those who receive PD, are older, or are either underweight or moderately obese.

Improved postoperative outcomes in pediatric major surgery: evidence from hospital volume analysis.

This study aimed to examine the association between hospital volume and postoperative outcomes in pediatric major surgery using a nationwide database. The study included pediatric patients who underwent first major elective inpatient surgery and hospitalization for more than 1day. The results showed no significant difference in the risk of 30-day postoperative mortality based on hospital volume. However, patients in the middle- and high-volume groups had significantly lower rates of 30-day major complications, particularly deep wound infection. In terms of 90-day postoperative outcomes, patients in the high-volume group had a significantly lower risk of mortality and lower rates of major complications, particularly deep wound infection, pneumonia, and septicemia. Conclusions: The study suggests that pediatric patients undergoing major surgery in high and middle-volume groups have better outcomes in terms of major complications compared to the low-volume group. What is Known: • Limited evidence exists on the connection between hospital volume and pediatric surgery outcomes. What is New: • A Taiwan-based study, using national data, found that high and middle hospital-volume groups experienced significantly lower rates of major complications within 30 and 90 days after surgery. • High-volume hospitals demonstrated a substantial decrease in the risk of 90-day postoperative mortality. • The study underscores the importance of specialized pediatric surgical centers and advocates for clear guidelines for hospital selection, potentially improving outcomes and informing future health policies.

Routine perioperative blood tests predict survival of resectable lung cancer

There is growing evidence that inflammatory, immunologic, and metabolic status is associated with cancer patients survival. Here, we built a simple algorithm to predict lung cancer outcome. Perioperative routine blood tests (RBT) of a cohort of patients with resectable primary lung cancer (LC) were analysed. Inflammatory, immunologic, and metabolic profiles were used to create a single algorithm (RBT index) predicting LC survival. A concurrent cohort of patients with resectable lung metastases (LM) was used to validate the RBT index. Charts of 2088 consecutive LC and 1129 LM patients undergoing lung resection were evaluated. Among RBT parameters, C-reactive protein (CRP), lymphocytes, neutrophils, hemoglobin, albumin and glycemia independently correlated with survival, and were used to build the RBT index. Patients with a high RBT index had a higher 5-year mortality than low RBT patients (adjusted HR 1.93, 95% CI 1.62–2.31). High RBT patients also showed a fourfold higher risk of 30-day postoperative mortality (2.3% vs. 0.5%, p 0.0019). The LM analysis validated the results of the LC cohort. We developed a simple and easily available multifunctional tool predicting short-term and long-term survival of curatively resected LC and LM. Prospective external validation of RBT index is warranted.

Association between intraoperative steroid and postoperative mortality in patients undergoing craniotomy for brain tumor.

Despite the widespread use of intraoperative steroids in various neurological surgeries to reduce cerebral edema and other adverse symptoms, there is sparse evidence in the literature for the optimal and safe usage of intraoperative steroid administration in patients undergoing craniotomy for brain tumors. We aimed to investigate the effects of intraoperative steroid administration on postoperative 30-day mortality in patients undergoing craniotomy for brain tumors. Adult patients who underwent craniotomy for brain tumors between January 2011 to January 2020 were included at West China Hospital, Sichuan University in this retrospective cohort study. Stratified analysis based on the type of brain tumor was conducted to explore the potential interaction. This study included 8,663 patients undergoing craniotomy for brain tumors. In patients with benign brain tumors, intraoperative administration of steroids was associated with a higher risk of postoperative 30-day mortality (adjusted OR 1.98, 95% CI 1.09-3.57). However, in patients with malignant brain tumors, no significant association was found between intraoperative steroid administration and postoperative 30-day mortality (adjusted OR 0.86, 95% CI 0.55-1.35). Additionally, administration of intraoperative steroids was not associated with acute kidney injury (adjusted OR 1.11, 95% CI 0.71-1.73), pneumonia (adjusted OR 0.89, 95% CI 0.74-1.07), surgical site infection (adjusted OR 0.78, 95% CI 0.50-1.22) within 30 days, and stress hyperglycemia (adjusted OR 1.05, 95% CI 0.81-1.38) within 24 h after craniotomy for brain tumor. In patients undergoing craniotomy for benign brain tumors, intraoperative steroids were associated with 30-day mortality, but this association was not significant in patients with malignant brain tumors.

Preoperative renal insufficiency predicts postoperative adverse outcomes in a mixed surgical population: a retrospective matched cohort study using the NSQIP database.

The incidence of chronic kidney disease is increasing, but most cases are not diagnosed until the accidental finding of abnormal laboratory data or the presentation of severe symptoms. Patients with chronic kidney disease are reported to have an increased risk of postoperative mortality and morbidities, but previous studies mainly targeted populations undergoing cardiovascular surgery. The authors aimed to evaluate the risk of postoperative mortality and complications in a surgical population with preoperative renal insufficiency (RI). This retrospective cohort study used data from the National Surgical Quality Improvement Program database between 2013 and 2018 to evaluate the risk of postoperative morbidity and mortality in the surgical population. Patients with estimated glomerular filtration rate less than 60ml/min/1.73m2 were defined as the RI group. Propensity score matching methods and multivariate logistic regression were used to calculate the risk of postoperative morbidity and mortality. After propensity score matching, 502281 patients were included in the RI and non-RI groups. The RI group had a higher risk of 30-day in-hospital mortality (odds ratio: 1.54, 95% CI: 1.49-1.58) than the non-RI group. The RI group was associated with a higher risk of postoperative complications, including myocardial infarction, stroke, pneumonia, septic shock, and postoperative bleeding. The RI group was also associated with an increased risk of prolonged ventilator use for over 48h, readmission, and reoperation. Patients with preoperative RI have an increased risk of postoperative 30-day mortality and complications. RI group patients with current dialysis, estimated glomerular filtration rate less than or equal to 30ml/min/1.73m2 or concomitant anemia had an elevated risk of postoperative mortality.

Association between preoperative hematocrit and postoperative 30-day mortality in adult patients with tumor craniotomy.

The purpose of this research was to synthesize the American College of Surgeons National Surgical Quality Improvement Program database to investigate the link between preoperative hematocrit and postoperative 30-day mortality in patients with tumor craniotomy. A secondary retrospective analysis of electronic medical records of 18,642 patients with tumor craniotomy between 2012 and 2015 was performed. The principal exposure was preoperative hematocrit. The outcome measure was postoperative 30-day mortality. We used the binary logistic regression model to explore the link between them and conducted a generalized additive model and smooth curve fitting to investigate the link and its explicit curve shape. We conducted sensitivity analyses by converting a continuous HCT into a categorical variable and calculated an E-value. A total of 18,202 patients (47.37% male participants) were included in our analysis. The postoperative 30-day mortality was 2.5% (455/18,202). After adjusting for covariates, we found that preoperative hematocrit was positively associated with postoperative 30-day mortality (OR = 0.945, 95% CI: 0.928, 0.963). A non-linear relationship was also discovered between them, with an inflection point at a hematocrit of 41.6. The effect sizes (OR) on the left and right sides of the inflection point were 0.918 (0.897, 0.939) and 1.045 (0.993, 1.099), respectively. The sensitivity analysis proved that our findings were robust. The subgroup analysis demonstrated that a weaker association between preoperative hematocrit and postoperative 30-day mortality was found for patients who did not use steroids for chronic conditions (OR = 0.963, 95% CI: 0.941-0.986), and a stronger association was discovered in participants who used steroids (OR = 0.914, 95% CI: 0.883-0.946). In addition, there were 3,841 (21.1%) cases in the anemic group (anemia is defined as a hematocrit (HCT) <36% in female participants and <39% in male participants). In the fully adjusted model, compared with the non-anemic group, patients in the anemic group had a 57.6% increased risk of postoperative 30-day mortality (OR = 1.576; 95% CI: 1.266, 1.961). This study confirms that a positive and nonlinear association exists between preoperative hematocrit and postoperative 30-day mortality in adult patients undergoing tumor craniotomy. Preoperative hematocrit was significantly associated with postoperative 30-day mortality when the preoperative hematocrit was <41.6.

A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients

IntroductionHip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study’s aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients.MethodsThis retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum.ResultsA total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0–2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18–30%, p < 0.001], compared to BBt- patients within the same stratum.ConclusionBeta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients

IntroductionAlthough two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). Materials and methodsWe studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was “Not Needed” (medical management preferred) or “Not Recommended” (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. ResultsWe included 204 patients (60% female, median age 75 y), for whom an operation was “Not Needed” in 81% and “Not Recommended” in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the “Not Recommended” cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. ConclusionsNonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Association between preoperative platelet and 30-day postoperative mortality of adult patients undergoing craniotomy for brain tumors: data from the American College of Surgeons National Surgical Quality Improvement Program database

Evidence regarding the relationship between preoperative platelet and 30-day postoperative mortality of intracranial tumor patients undergoing craniotomy is still limited. Therefore, the present research was conducted to explore the link of the platelet and 30-day postoperative mortality. Electronic medical records of 18,642 adult patients undergoing craniotomy for brain tumors from 2012 to 2015 in the American College of Surgeons National Surgical Quality Improvement Program, were subject to secondary retrospective analysis. A binary logistic regression model evaluated the independent association between preoperative platelet and 30-day postoperative mortality. A generalized additive model and smooth curve fitting was conducted to explore the exact shape of the curve between them. Additionally, We also conducted sensitivity analyses to test the robustness of the results, and performed subgroup analyses. Eighteen thousand sixty-three patients were included in this study analysis. Of these, 47.49% were male. The mean preoperative platelet value was (244.12 ± 76.77) × 109/L. The 30-day postoperative mortality of included participants was 2.5% (452/18,063). After adjusting covariates, the results showed that preoperative platelet was positively associated with 30-day postoperative mortality (OR = 0.999, 95%CI: 0.997, 1.000). There was also a nonlinear relationship between preoperative platelet and 30-day postoperative mortality, and the inflection point of the platelet was 236. The effect sizes (OR) on the right and left sides of the inflection point were 1.002 (1.000, 1.004) and 0.993 (0.990, 0.995), respectively. And sensitive analysis demonstrated the robustness of the results. Subgroup analysis showed a stronger association between preoperative platelet and 30-day postoperative mortality in non-emergency surgery patients when preoperative platelet value is less than 235 × 109/L. This research demonstrates a positive and non-linear relationship between preoperative platelet and 30-day postoperative mortality in U.S. adult brain tumor patients undergoing craniotomy. Preoperative platelet is strongly related to 30-day postoperative mortality when the platelet is less than 235 × 109/L. Proper preoperative management of platelet and maintenance of platelet near inflection point (235) could reduce risk of 30-day postoperative mortality in these cases.

Machine learning models to prognose 30-Day Mortality in Postoperative Disseminated Cancer Patients

Patients with disseminated cancer at higher risk for postoperative mortality see improved outcomes with altered clinical management. Being able to risk stratify patients immediately after their index surgery to flag high risk patients for healthcare providers is vital. The combination of physician uncertainty and a demonstrated optimism bias often lead to an overestimation of patient life expectancy which can precent proper end of life counseling and lead to inadequate postoperative follow up. In this cohort study of 167,474 postoperative patients with multiple types of disseminated cancer, patients at high risk of 30-day postoperative mortality were accurately identified using our machine learning models based solely on clinical features and preoperative lab values. Extreme Gradient Boosting, Random Forest, and Logistic Regression machine learning models were developed on the cohort. Among 167,474 disseminated cancer patients, 50,669 (30.3%) died within 30 days of their index surgery; After preprocessing, 28 features were included in the model development. The cohort was randomly divided into 133,979 patients (80%) for training the models and 33,495 patients (20%) for testing. The extreme gradient boosting model had an AUC of 0.93 (95% CI: 0.926–0.931), the random forest model had an AUC of 0.93 (95% CI: 0.930–0.934), and the logistic regression model had an AUC of 0.90 (95% CI: 0.900–0.906 the index operation. Ultimately, Machine learning models were able to accurately predict short-term postoperative mortality among a heterogenous population of disseminated cancer patients using commonly accessible medical features. These models can be included in electronic health systems to guide clinical judgements that affect direct patient care, particularly in low-resource settings.

Association Between Pre-operative BUN and Post-operative 30-Day Mortality in Patients Undergoing Craniotomy for Tumors: Data From the ACS NSQIP Database.

ObjectiveThere is limited evidence to clarify the specific relationship between pre-operative blood urea nitrogen (BUN) and post-operative 30-day mortality in patients undergoing craniotomy for tumors. Therefore, we aimed to investigate this relationship in detail.MethodsElectronic medical records of 18,642 patients undergoing craniotomy for tumors in the ACS NSQIP from 2012 to 2015 were subjected to secondary retrospective analysis. The principal exposure was pre-operative BUN. Outcome measures were post-operative 30-day mortality. We used binary logistic regression modeling to evaluate the association between them and conducted a generalized additive model and smooth curve fitting (penalized spline method) to explore the potential relationship and its explicit curve shape. We also conducted sensitivity analyses to ensure the robustness of the results and performed subgroup analyses.ResultsA total of 16,876 patients were included in this analysis. Of these, 47.48% of patients were men. The post-operative 30-day mortality of the included cases was 2.49% (420/16,876), and the mean BUN was 16.874 ± 6.648 mg/dl. After adjusting covariates, the results showed that pre-operative BUN was positively associated with post-operative 30-day mortality (OR = 1.020, 95% CI: 1.004, 1.036). There was also a non-linear relationship between BUN and post-operative 30-day mortality, and the inflection point of the BUN was 9.804. For patients with BUN < 9.804 mg/dl, a 1 unit decrease in BUN was related to a 16.8% increase in the risk of post-operative 30-day mortality (OR = 0.832, 95% CI: 0.737, 0.941); for patients with BUN > 9.804 mg/dl, a 1 unit increase in BUN was related to a 2.8% increase in the risk of post-operative 30-day mortality (OR = 1.028, 95% CI: 1.011, 1.045). The sensitivity analysis proved that the results were robust. The subgroup analysis revealed that all listed subgroups did not affect the relationship between pre-operative BUN and post-operative 30-day mortality (P > 0.05).ConclusionOur study demonstrated that pre-operative BUN (mg/dl) has specific linear and non-linear relationships with post-operative 30-day mortality in patients over 18 years of age who underwent craniotomy for tumors. Proper pre-operative management of BUN and maintenance of BUN near the inflection point (9.804 mg/dl) could reduce the risk of post-operative 30-day mortality in these cases.

P56: Morbidity and Mortality Associated with Intra-Aortic Counterpulsation Balloon Pump Use

Background: Postoperative acute limb ischemia (pALI) is a vascular emergency better prevented than treated. Knowledge of the predisposing factors is vital to prevention and early recognition. In this study, we examined the predictors and risk of 30-day postoperative mortality of pALI among patients who underwent open-heart surgery. Methods: We retrospectively analyzed data collected at a single university hospital as part of the Society of Thoracic Surgeons National Adult Cardiac Surgery database between January 2006 and January 2018. The primary outcome was pALI (coded in STS as CVaLbIsc) defined as any ischemic event of the arterial system of either upper or lower limbs. For this analysis transcatheter procedure and entries with the missing outcome variable were excluded. The final sample was divided into 2 groups based on the presence of pALI or not. Logistics regression model was used to assess for association between pALI and the preop variable. KM curves were plotted to compare survival probability between the 2 groups. Results: Among the 5231 records included in this analysis, there were 60 (1.15%) cases of pALI. Multivariate regression model adjusting for known risk factors of acute limb ischemia showed preop IABP use (OR 4.16(95%CI 2.22 - 7.80), p=<.0001); body surface area (OR 0.19 (95%CI 0.07 - 0.52), p= 0.001); emergent/urgent procedures (OR 2.57 (95%CI 1.32 - 4.98), p=0.005; history of PVD (OR 4.89 (95%CI 2.83 - 8.43), p=<.0001); preop IV steroid use (OR 3.07 (95%CI 1.32 - 7.16), p=0.009; history of infective endocarditis (OR 3.66 (95%CI 1.61 - 8.29), p=0.002; Cardiogenic shock (OR 2.86 (95%CI 1.41 - 5.78), p=0.003) are independent predictors of pALI. ROC curve AUC of final model= 0.83. Conclusion: A knowledge of the above risk factors may help identify at-risk individuals that may benefit from perioperative limb tissue oxygenation or perfusion monitoring thereby facilitating prompt diagnosis and intervention.

Body Mass Index Has a Nonlinear Association With Postoperative 30-Day Mortality in Patients Undergoing Craniotomy for Tumors in Men: An Analysis of Data From the ACS NSQIP Database.

BackgroundThe association between body mass index (BMI) and mortality is controversial. Thus, the purpose of our research was to survey the association between BMI and postoperative 30-day mortality in brain tumor patients undergoing craniotomy.MethodsThis study analyzed data collected in a multicenter, cross-sectional study that consecutively and nonselectively collected data from a total of 18,642 patients undergoing craniotomy for tumors in the ACS NSQIP from 2012 to 2015. We constructed three linear and non-linear binomial logistic models (the inflection point was set at 18.5) to evaluate the association between BMI and postoperative 30-day mortality, respectively. We also conducted subgroup analyses. Additionally, we compared non-linear models with vs. without interaction with sex.ResultsA total of 17,713 patients were included in this analysis. Of these, 47.38% were male. The postoperative 30-day mortality of the included cases was 2.39% (423/17,713), and the mean BMI was 28.41 ± 6.05 kg/m2. The linear logistic models suggested that after adjusting for the covariates, BMI was not associated with postoperative 30-day mortality (OR=0.999; 95% CI: 0.981, 1.017). The non-linear binomial logistic models suggested a nonlinear relationship between BMI and postoperative 30-day mortality. When BMI was < 18.5, we observed a stronger negative association between them after adjusting for covariates; the OR and 95% CI were 0.719, 0.576-0.896. When BMI was > 18.5, the relationship between them was not significant. We also found that a one-unit decrease in BMI for male patients with BMI < 18.5 kg/m2 was related to a 34.6% increase in the risk of postoperative 30-day mortality (OR=0.654, 95% CI (0.472, 0.907). There was no significant association between them in male patients with BMI > 18.5 kg/m2 or female patients.ConclusionsThis study demonstrates a non-linear relationship between BMI and the risk of postoperative death. Preoperative underweight (BMI < 18.5 kg/m2) would increase the risk of postoperative death in male patients (> 18 years old) undergoing craniotomy for brain tumors. Appropriate nutritional management prior to craniotomy for brain tumors may reduce the risk of postoperative 30-day mortality in underweight men.

Preoperative internal medicine evaluation is associated with a reduction in 30-Day postoperative mortality risk in patients with cancer

BackgroundPatients commonly undergo evaluation by internists prior to surgery. However, the impact of preoperative internal medicine evaluations on the postoperative outcomes of patients with cancer is uncertain. MethodsWe conducted a retrospective cohort study of patients who had been included in the National Surgery Quality Improvement Program from 2011 to 2014 from a single hospital specializing in cancer care to determine the effect of an Internal Medicine Perioperative Assessment Center (IMPAC) evaluation (IMPAC group) on the risk of 30-day mortality compared to that of patients who proceeded directly to surgery (control group). ResultsOf the 11,577 participants, 3,589 underwent an IMPAC evaluation. The absolute 30-day mortality was 0.47% for the IMPAC group and 0.50% for the control group. After propensity matching, the odds ratio (OR) of 30-day mortality was 0.39 (95% CI=0.18–0.84) for the IMPAC group in comparison to the control group. ConclusionsOur findings demonstrate that a preoperative internal medicine evaluation was associated with lower 30-day mortality. Additional studies are needed to identify which patient populations are most likely to benefit and which attributes of the internal medicine evaluation are most beneficial.

The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients.

BACKGROUNDAn association between β-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery.METHODSAll patients older than 65 years who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008, and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality.RESULTSA total of 126,934 cases met the study inclusion criteria. β-Blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population (adjusted incidence rate ratio [95% confidence interval], 0.35 [0.32–0.38]; p < 0.001). The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of BB therapy was seen in patients with an RCRI score greater than 0.CONCLUSIONβ-Blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of BB therapy.LEVEL OF EVIDENCETherapeutic/care management, level II

Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study

ObjectivesThe Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to...

The Pathologic Fracture Mortality Index: A Novel Externally Validated Tool for Predicting 30-day Postoperative Mortality

Current mortality predictive tools, in the setting of completed or impending pathologic fractures, are nonspecific. Clinical decision making and mortality prediction in research would benefit from creation of a high-fidelity scoring system for calculating the risk of 30-day postoperative mortality. The purpose of this study is to develop a validated research and clinical tool that is superior to existing methods in estimating postoperative mortality risk after fixation of pathologic fractures. One thousand two hundred nineteen patients who underwent fixation for either completed or impending pathologic fractures in the National Surgical Quality Improvement Program (2012 to 2018) database were analyzed. Multivariable logistic regression with diagnostics was used to develop a predictive model in a derivation cohort and then validated in a validation cohort. Area under the curve (AUC) from receiver operator curve analysis was used to assess accuracy. A score was derived and compared with the American Society of Anesthesiologists classification and modified five-component frailty index (mF-I5). The score was validated in an exclusive cohort of patients who underwent fixation for pathologic fractures at a tertiary care center. Of 1,219, a total of 177 (15%) patients did not survive beyond 30 days postoperatively. AUC for our predictive model was 0.76 in the derivation and 0.75 in the validation National Surgical Quality Improvement Program cohorts. The derived Pathologic Fracture Morbidity Index included seven data points: anemia, alkaline phosphatase > 150 U/L, albumin < 3.5 mg/dL, pulmonary disease, recent weight loss, functional dependence, and white blood cell count >12,000. The PFMI (AUC = 0.75) was more accurate than ASA (AUC = 0.60) or mF-5 (AUC = 0.58) (P < 0.01). The AUC for PFMI in predicting 30-day mortality in the exclusive cohort (N = 39) was 0.74. The PFMI is a validated tool that may be used for predicting postoperative 30-day mortality after fixation of pathologic fractures, with higher level of accuracy compared with ASA or mF-I5.