Purpose
Acute kidney injury (AKI) is a recognised risk factor for adverse outcomes in critical illness and hospitalised patients in general. To understand the incidence and associations of AKI as a ...peri-operative complication of major abdominal surgery, we conducted a systematic literature review and meta-analysis.
Methods
Using a systematic strategy, we searched the electronic reference databases for articles describing post-operative renal outcomes using consensus criteria for AKI diagnosis (RIFLE, AKIN or KDIGO) in the setting of major abdominal surgery. Pooled incidence of AKI and, where reported, pooled relative risk of death after post-operative AKI were estimated using random effects models.
Results
From 4287 screened titles, 19 articles met our inclusion criteria describing AKI outcomes in 82,514 patients undergoing abdominal surgery. Pooled incidence of AKI was 13.4 % (95 % CI 10.9–16.4 %). In eight studies that reported the short-term mortality, relative risk of death in the presence of post-operative AKI was 12.6 fold (95 % CI, 6.8–23.4). Where reported, length of stay was greater and non-renal post-operative complications were also more frequent in patients experiencing AKI.
Conclusions
Using modern consensus definitions, AKI is a common complication of major abdominal surgery that is associated with adverse patient outcomes including death. While a causative role for AKI cannot be concluded from this analysis, as an important signal of peri-operative harm, AKI should be regarded as an important surgical outcome measure and potential target for clinical interventions.
Despite evidence of high activity, the number of surgical procedures performed in UK hospitals, their cost and subsequent mortality remain unclear.
Time-trend ecological study using hospital episode ...data from England, Scotland, Wales and Northern Ireland. The primary outcome was the number of in-hospital procedures, grouped using three increasingly specific categories of surgery. Secondary outcomes were all-cause mortality, length of hospital stay and healthcare costs according to standard National Health Service tariffs.
Between April 1, 2009 and March 31, 2014, 39 631 801 surgical patient episodes were recorded. There was an annual average of 7 926 360 procedures (inclusive category), 5 104 165 procedures (intermediate category) and 1 526 421 procedures (restrictive category). This equates to 12 537, 8073 and 2414 procedures per 100 000 population per year, respectively. On average there were 85 181 deaths (1.1%) within 30 days of a procedure each year, rising to 178 040 deaths (2.3%) after 90 days. Approximately 62.8% of all procedures were day cases. Median length of stay for in-patient procedures was 1.7 (1.3–2.0) days. The total cost of surgery over the 5 yr period was £54.6 billion ($104.4 billion), representing an average annual cost of £10.9 billion (inclusive), £9.5 billion (intermediate) and £5.6 billion (restrictive). For each category, the number of procedures increased each year, while mortality decreased. One-third of all mortalities in national death registers occurred within 90 days of a procedure (inclusive category).
The number of surgical procedures in the UK varies widely according to definition. The number of procedures is slowly increasing whilst the number of deaths is decreasing.
Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as ...reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury.
We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L−1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals.
Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 OR: 2.56 (1.92–3.41); P<0.0001. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count OR 1.80 (1.50–2.17); P<0.0001 and higher absolute preoperative monocyte count OR 1.93 (1.12–3.30); P=0.017. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03).
Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury.
NCT01842568.
Age of patients undergoing surgery Fowler, A. J.; Abbott, T. E. F.; Prowle, J. ...
British journal of surgery,
July 2019, 2019-07-00, 20190701, Letnik:
106, Številka:
8
Journal Article
Recenzirano
Odprti dostop
Background
Advancing age is independently associated with poor postoperative outcomes. The ageing of the general population is a major concern for healthcare providers. Trends in age were studied ...among patients undergoing surgery in the National Health Service in England.
Methods
Time trend ecological analysis was undertaken of Hospital Episode Statistics and Office for National Statistics data for England from 1999 to 2015. The proportion of patients undergoing surgery in different age groupings, their pooled mean age, and change in age profile over time were calculated. Growth in the surgical population was estimated, with associated costs, to the year 2030 by use of linear regression modelling.
Results
Some 68 205 695 surgical patient episodes (31 220 341 men, 45·8 per cent) were identified. The mean duration of hospital stay was 5·3 days. The surgical population was older than the general population of England; this gap increased over time (1999: 47·5 versus 38·3 years; 2015: 54·2 versus 39·7 years). The number of people aged 75 years or more undergoing surgery increased from 544 998 (14·9 per cent of that age group) in 1999 to 1 012 517 (22·9 per cent) in 2015. By 2030, it is estimated that one‐fifth of the 75 years and older age category will undergo surgery each year (1·49 (95 per cent c.i. 1·43 to 1·55) million people), at a cost of €3·2 (3·1 to 3·5) billion.
Conclusion
The population having surgery in England is ageing at a faster rate than the general population. Healthcare policies must adapt to ensure that provision of surgical treatments remains safe and sustainable.
The surgical population of England is ageing more quickly than the general population. More than 1·4 million patients aged over 75 years will have surgery each year by 2030.
Worrying prediction
Retrospective studies suggest that preoperative anaemia is associated with poor outcomes after surgery. The objective of this study was to describe mortality rates and patterns of intensive care ...resource use for patients with anaemia undergoing non-cardiac and non-neurological in-patient surgery.
We performed a secondary analysis of a large prospective study describing perioperative care and survival in 28 European nations. Patients at least 16 yr old undergoing in-patient surgery during a 7 day period were included in the study. Data were collected for in-hospital mortality, duration of hospital stay, admission to intensive care, and intensive care resource use. Multivariable logistic regression analysis was performed to understand the effects of preoperative haemoglobin (Hb) levels on in-hospital mortality.
We included 39 309 patients in the analysis. Preoperative anaemia had a high prevalence in both men and women (31.1% and 26.5%, respectively). Multivariate analysis showed that patients with severe odds ratio 2.82 (95% confidence interval 2.06–3.85) or moderate 1.99 (1.67–2.37) anaemia had higher in-hospital mortality than those with normal preoperative Hb concentrations. Furthermore, hospital length of stay (P<0.001) and postoperative admission to intensive care (P<0.001) were greater in patients with anaemia than in those with normal Hb concentrations.
Anaemia is common among non-cardiac and non-neurological surgical patients, and is associated with poor clinical outcome and increased healthcare resource use.
NCT01203605 (ClinicalTrials.gov).
Variations in patient outcomes between providers have been described for emergency admissions, including general surgery. The aim of this study was to investigate whether differences in modifiable ...hospital structures and processes were associated with variance in mortality, amongst patients admitted for emergency colorectal laparotomy, peptic ulcer surgery, appendicectomy, hernia repair and pancreatitis.
Adult emergency admissions in the English NHS were extracted from the Hospital Episode Statistics between April 2005 and March 2010. The association between mortality and structure and process measures including medical and nursing staffing levels, critical care and operating theatre availability, radiology utilization, teaching hospital status and weekend admissions were investigated.
There were 294 602 emergency admissions to 156 NHS Trusts (hospital systems) with a 30-day mortality of 4.2%. Trust-level mortality rates for this cohort ranged from 1.6 to 8.0%. The lowest mortality rates were observed in Trusts with higher levels of medical and nursing staffing, and a greater number of operating theatres and critical care beds relative to provider size. Higher mortality rates were seen in patients admitted to hospital at weekends OR 1.11 (95% CI 1.06–1.17) P<0.0001, in Trusts with fewer general surgical doctors 1.07 (1.01–1.13) P+0.019 and with lower nursing staff ratios 1.07 (1.01–1.13) P+0.024.
Significant differences between Trusts were identified in staffing and other infrastructure resources for patients admitted with an emergency general surgical diagnosis. Associations between these factors and mortality rates suggest that potentially modifiable factors exist that relate to patient outcomes, and warrant further investigation.
The optimal perioperative use of intensive care unit (ICU) resources is not yet defined. We sought to determine the effect of ICU admission on perioperative (30 day) and long-term mortality.
This was ...an observational study of all surgical patients in Scotland during 2005–7 followed up until 2012. Patient, operative, and care process factors were extracted. The primary outcome was perioperative mortality; secondary outcomes were 1 and 4 yr mortality. Multivariable regression was used to construct a risk prediction model to allow standard-risk and high-risk groups to be defined based on deciles of predicted perioperative mortality risk, and to determine the effect of ICU admission (direct from theatre; indirect after initial care on ward; no ICU admission) on outcome adjusted for confounders.
There were 572 598 patients included. The risk model performed well (c-index 0.92). Perioperative mortality occurred in 1125 (0.2%) in the standard-risk group (n=510 979) and in 3636 (6.4%) in the high-risk group (n=56 785). Patients with no ICU admission within 7 days of surgery had the lowest perioperative mortality (whole cohort 0.7%; high-risk cohort 5.3%). Indirect ICU admission was associated with a higher risk of perioperative mortality when compared with direct admission for the whole cohort (20.9 vs 12.1%; adjusted odds ratio 2.39, 95% confidence interval 2.01–2.84; P<0.01) and for high-risk patients (26.2 vs 17.8%; adjusted odds ratio 1.64, 95% confidence interval 1.37–1.96; P<0.01). Compared with direct ICU admission, indirectly admitted patients had higher severity of illness on admission, required more organ support, and had an increased duration of ICU stay.
Indirect ICU admission was associated with increased mortality and increased requirement for organ support.
UKCRN registry no. 15761.
Background
Numerous published studies have explored associations between anaemia and adverse outcomes after surgery. However, there are no evidence syntheses describing the impact of preoperative ...anaemia on postoperative outcomes.
Methods
A systematic review and meta‐analysis of observational studies exploring associations between preoperative anaemia and postoperative outcomes was performed. Studies investigating trauma, burns, transplant, paediatric and obstetric populations were excluded. The primary outcome was 30‐day or in‐hospital mortality. Secondary outcomes were acute kidney injury, stroke and myocardial infarction. Predefined analyses were performed for the cardiac and non‐cardiac surgery subgroups. A post hoc analysis was undertaken to evaluate the relationship between anaemia and infection. Data are presented as odds ratios (ORs) with 95 per cent c.i.
Results
From 8973 records, 24 eligible studies including 949 445 patients were identified. Some 371 594 patients (39·1 per cent) were anaemic. Anaemia was associated with increased mortality (OR 2·90, 2·30 to 3·68; I2 = 97 per cent; P < 0·001), acute kidney injury (OR 3·75, 2·95 to 4·76; I2 = 60 per cent; P < 0·001) and infection (OR 1·93, 1·17 to 3·18; I2 = 99 per cent; P = 0·01). Among cardiac surgical patients, anaemia was associated with stroke (OR 1·28, 1·06 to 1·55; I2 = 0 per cent; P = 0·009) but not myocardial infarction (OR 1·11, 0·68 to 1·82; I2 = 13 per cent; P = 0·67). Anaemia was associated with an increased incidence of red cell transfusion (OR 5·04, 4·12 to 6·17; I2 = 96 per cent; P < 0·001). Similar findings were observed in the cardiac and non‐cardiac subgroups.
Conclusion
Preoperative anaemia is associated with poor outcomes after surgery, although heterogeneity between studies was significant. It remains unclear whether anaemia is an independent risk factor for poor outcome or simply a marker of underlying chronic disease. However, red cell transfusion is much more frequent amongst anaemic patients.
Associated with poor outcome
Trials suggest that the use of i.v. hydroxyethyl starch (HES) solutions is associ-ated with increased risk of death and acute kidney injury (AKI) in critically ill patients. It is uncertain whether ...similar adverse effects occur in surgical patients.
Systematic review and meta-analysis of trials in which patients were randomly allocated to 6% HES solutions or alternative i.v. fluids in patients undergoing surgery. Ovid Medline, Embase, Cinhal, and Cochrane Database of Systematic Reviews were searched for trials comparing 6% HES with clinically relevant non-starch comparator. The primary end-point was hospital mortality. Secondary endpoints were requirement for renal replacement therapy (RRT) and author-defined AKI. Pre-defined subgroups were cardiac and non-cardiac surgery.
Four hundred and fifty-six papers were identified; of which 19 met the inclusion criteria. In total, 1567 patients were included in the analysis. Dichotomous outcomes were expressed as a difference of proportions risk difference (RD). There was no difference in hospital mortality RD 0.00, 95% confidence interval (CI) −0.02, 0.02, requirement for RRT (RD −0.01, 95% CI −0.04, 0.02), or AKI (RD 0.02, 95% CI −0.02 to 0.06) between compared arms overall or in predefined subgroups.
We did not identify any differences in the incidence of death or AKI in surgical patients receiving 6% HES. Included studies were small with low event rates and low risk of heterogeneity. Narrow CIs suggest that these findings are valid. Given the absence of demonstrable benefit, we are unable to recommend the use of 6% HES solution in surgical patients.
SUMMARY POINTS Non-cardiac surgery has a low overall mortality but is associated with a large number of deaths because so many procedures are performed Most deaths occur in a group of patients who ...are at high risk because of advanced age, comorbid disease, or major surgery (hospital mortality rate 12%) More effective systems can improve quality of perioperative care and may improve survival while reducing healthcare costs Further research is needed to identify the most effective approaches to perioperative medicine for high risk patients Routine audit of outcomes after all non-cardiac surgery is urgently needed
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