Background
Acute SARS‐COVID‐19 infection may increase readmission risk compared to other respiratory infections. We assessed the 1‐year readmission and inhospital death rates of hospitalized ...SARS‐COVID‐19 patients compared to patients hospitalized with other types of pneumonia.
Methods
We determined the 1‐year readmission and inhospital death rate of adult patients initially hospitalized with a positive SARS‐COVID‐19 result, and subsequently discharged, between March 2020 and August 2021, at a Netcare private hospital in South Africa, and compared this to all hospitalized adult pneumonia patients in the 3 years prior to the COVID‐19 pandemic (2017–2019).
Results
The 1‐year readmission rate in COVID‐19 patients was 6.6% (328/50,067) versus 8.5% in pneumonia patients (4699/55,439; p < 0.001), with an inhospital mortality rate of 7.7% (n = 251) and 9.7% (n = 454; p = 0.002) for COVID‐19 and pneumonia patients, respectively.
Intraoperative hypotension may contribute to postoperative acute kidney injury (AKI) and myocardial injury, but what blood pressures are unsafe is unclear. The authors evaluated the association ...between the intraoperative mean arterial pressure (MAP) and the risk of AKI and myocardial injury.
The authors obtained perioperative data for 33,330 noncardiac surgeries at the Cleveland Clinic, Ohio. The authors evaluated the association between intraoperative MAP from less than 55 to 75 mmHg and postoperative AKI and myocardial injury to determine the threshold of MAP where risk is increased. The authors then evaluated the association between the duration below this threshold and their outcomes adjusting for potential confounding variables.
AKI and myocardial injury developed in 2,478 (7.4%) and 770 (2.3%) surgeries, respectively. The MAP threshold where the risk for both outcomes increased was less than 55 mmHg. Compared with never developing a MAP less than 55 mmHg, those with a MAP less than 55 mmHg for 1-5, 6-10, 11-20, and more than 20 min had graded increases in their risk of the two outcomes (AKI: 1.18 95% CI, 1.06-1.31, 1.19 1.03-1.39, 1.32 1.11-1.56, and 1.51 1.24-1.84, respectively; myocardial injury 1.30 1.06-1.5, 1.47 1.13-1.93, 1.79 1.33-2.39, and 1.82 1.31-2.55, respectively.
Even short durations of an intraoperative MAP less than 55 mmHg are associated with AKI and myocardial injury. Randomized trials are required to determine whether outcomes improve with interventions that maintain an intraoperative MAP of at least 55 mmHg.
The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of ...blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).
Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.
After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio OR, 1.27 1.07-1.50; P < .01), myocardial infarction (OR, 1.34 1.05-1.70; P = .02), and mortality (OR, 2.65 2.06-3.41; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 1.05-1.39; P = .01) and mortality (OR, 1.81 1.39-2.37; P < .01), but not myocardial infarction (OR, 1.21 0.98-1.49; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 1.01-1.34; P = .04) and myocardial infarction (OR, 1.34 1.09-1.64; P = .01) but, paradoxically, reduced mortality (OR, 0.76 0.58-0.99; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 0.59-0.82; P < .01), myocardial infarction (OR, 0.75 0.58-0.97; P = .03), and mortality (OR, 0.58 0.41-0.81; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 1.15-1.76; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 1.03-1.40; P = .02).
Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.
Phenylephrine infusions are considered as standard management for obstetric spinal hypotension, but there remains reluctance to implement them in resource-limited contexts. This prospective, ...alternating intervention study of patients undergoing elective or urgent cesarean delivery under spinal anesthesia compared a vasopressor bolus strategy to fixed-rate, low-dose prophylactic phenylephrine infusion with supplemental boluses. The primary outcome was the incidence of severe hypotension (mean arterial pressure <70% baseline or systolic blood pressure <80 mm Hg). Fewer patients receiving prophylactic phenylephrine infusions had severe hypotension (47.4% n = 120/253 vs 62.1% n = 157/253, P = .001, estimated relative risk 0.84, 95% confidence interval, 0.69-1.02), with no significant difference in the rate of hypertension (15% n = 39/253 vs 11% n = 27/253, P = .11, estimated relative risk 1.39, confidence interval 0.87-2.20). Guidelines for resource-constrained settings should consider a fixed, low-dose phenylephrine infusion in combination with rescue vasopressor bolus therapy.
Acute cardiac events are a frequent cause of morbidity after vascular surgery. The impact of early evidence-based treatment for patients with an acute cardiac event after vascular surgery on ...long-term postoperative outcomes has not been extensively studied. We hypothesized that providing appropriate evidence-based treatment to patients with elevated postoperative cardiac troponin levels may limit long-term mortality.
We conducted a study of 667 consecutive major vascular surgery patients with an elevated postoperative troponin I level. We then determined which of these patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina. All patients with troponin elevation were then matched with 2 control patients without postoperative troponin elevation. Matching was done using logistic regression and nearest-neighbor matching methods. The primary study end point was 12 months survival without a major cardiac event (i.e., death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization).
Therapy was intensified in 43 of 66 patients (65%) who suffered a troponin I elevation after surgery. Patients with a troponin I elevation not receiving intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13-2.42; P = 0.004) for the primary study outcome as compared with the control group. In contrast, patients with a troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10-1.19; P = 0.45) for the primary outcome as compared with the control group. Patients with a troponin I elevation not receiving treatment intensification likely were at higher risk for a major cardiac event (HR, 2.80; 95% CI, 1.05-24.2; P = 0.04) compared with patients who did receive treatment intensification.
The main finding of this study was that in patients with elevated troponin I levels after noncardiac surgery, long-term adverse cardiac outcomes may likely be improved by following evidence-based recommendations for the medical management of acute coronary syndromes.
Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days.
To determine the relationship between the peak fourth-generation troponin T ...(TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality.
A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery.
Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death.
A total of 15,133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT ≤ 0.01 ng/mL): peak TnT of 0.02 ng/mL (adjusted hazard ratio aHR, 2.41; 95% CI, 1.33-3.77); 0.03 to 0.29 ng/mL (aHR, 5.00; 95% CI, 3.72-6.76); and 0.30 ng/mL or greater (aHR, 10.48; 95% CI, 6.25-16.62). Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without (C index = 0.85 vs 0.81; difference, 0.4; 95% CI, 0.2-0.5; P < .001 for difference between C index values). The net reclassification improvement with TnT was 25.0% (P < .001).
Among patients undergoing noncardiac surgery, the peak postoperative TnT measurement during the first 3 days after surgery was significantly associated with 30-day mortality.
Fluid therapy is one of the most ubiquitous medical therapeutic interventions. There is a debate over whether colloids or crystalloids are better for fluid resuscitation. Recent large trials and ...meta-analyses suggest no mortality benefit and possible harm with hydroxyethyl starch (HES) use. However, these trials were conducted in critically ill and septic patients and their applicability to perioperative patients has been challenged.
We aimed to evaluate the impact of HES use in scheduled and elective surgical patients.
Systematic review and meta-analysis of randomised controlled trials (RCTs).
Only RCTs comparing the use of the synthetic colloid HES with any crystalloid in adults undergoing noncardiac surgery (up to 24 h postop) were considered eligible. For each eligible trial, we extracted the outcomes of all-cause mortality within 90 days, length of hospital stay, major infectious complications, acute kidney injury (AKI) and renal replacement therapy (RRT).
We identified 1555 citations, selected 90 for full-text evaluation, and identified 13 eligible RCTs. Trials were small (n = 20 to 202) with low event rates. There was a trend to increased mortality with HES within 90 days 13/373 vs. 3/368; risk ratio 2.97; 95% confidence interval (95% CI) 0.96 to 9.19; I = 0%, no difference in AKI and RRT (risk ratio 1.11; 95% CI 0.26 to 4.69; I = 34%), and no difference in major infectious complications (risk ratio 1.19; 95% CI 0.59 to 2.39; I = 0%). Patients resuscitated with HES had a shorter length of hospital stay (mean difference -1.52 days; 95% CI -2.87 to -0.18), although heterogeneity was high (I = 90%).
This meta-analysis, based on small studies with low event rates, suggests that there are currently insufficient data to identify a difference in outcomes associated with crystalloids and HES in scheduled or elective noncardiac surgery.
The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide BNP and N-terminal fragment of proBNP NT-proBNP) ...enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured.
Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done.
We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery.
Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery.
Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.
The aims of this study were to perform an individual patient data meta-analysis of studies using B-type natriuretic peptides (BNPs) to predict the primary composite endpoint of cardiac death and ...nonfatal myocardial infarction (MI) within 30 days of vascular surgery and to determine: 1) the cut points for a natriuretic peptide (NP) diagnostic, optimal, and screening test; and 2) if pre-operative NPs improve the predictive accuracy of the revised cardiac risk index (RCRI).
NPs are independent predictors of cardiovascular events in noncardiac and vascular surgery. Their addition to clinical risk indexes may improve pre-operative risk stratification.
Studies reporting the association of pre-operative NP concentrations and the primary study endpoint, post-operative major adverse cardiovascular events (defined as cardiovascular death and nonfatal MI) in vascular surgery, were identified by electronic database search. Secondary study endpoints included all-cause mortality, cardiac death, and nonfatal MI.
Six data sets were obtained, 5 for BNP (n = 632) and 1 for N-terminal pro-BNP (n = 218). An NP level higher than the optimal cut point was an independent predictor for the primary composite endpoint (odds ratio: 7.9; 95% confidence interval: 4.7 to 13.3). BNP cut points were 30 pg/ml for screening (95% sensitivity, 44% specificity), 116 pg/ml for optimal (highest accuracy point; 66% sensitivity, 82% specificity), and 372 pg/ml for diagnostic (32% sensitivity, 95% specificity). Subsequent to revised cardiac risk index stratification, reclassification using the optimal cut point significantly improved risk prediction in all groups (net reclassification improvement 58%, p < 0.000001), particularly in the intermediate-risk group (net reclassification improvement 84%, p < 0.001).
Pre-operative NP levels can be used to independently predict cardiovascular events in the first 30 days after vascular surgery and to significantly improve the predictive performance of the revised cardiac risk index.
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