Associations between intraoperative hypotension (IOH) and postoperative complications have been reported. We examined whether using different methods to model IOH affected the association with ...postoperative myocardial injury (POMI) and acute kidney injury (AKI).
This two-centre cohort study included 10 432 patients aged ≥50 yr undergoing non-cardiac surgery. Twelve different methods to statistically model IOH representing presence, depth, duration, and area under the threshold (AUT) were applied to examine the association with POMI and AKI using logistic regression analysis. To define IOH, eight predefined thresholds were chosen.
The incidences of POMI and AKI were 14.9% and 14.8%, respectively. Different methods to model IOH yielded effect estimates differing in size and statistical significance. Methods with the highest odds were absolute maximum decrease in blood pressure (BP) and mean episode AUT, odds ratio (OR) 1.43 99% confidence interval (CI): 1.15–1.77 and OR 1.69 (99% CI: 0.99–2.88), respectively, for the absolute mean arterial pressure 50 mm Hg threshold. After standardisation, the highest standardised ORs were obtained for depth-related methods, OR 1.12 (99% CI: 1.05–1.20) for absolute and relative maximum decrease in BP. No single method always yielded the highest effect estimate in every setting. However, methods with the highest effect estimates remained consistent across different BP types, thresholds, outcomes, and centres.
In studies on IOH, both the threshold to define hypotension and the method chosen to model IOH affects the association of IOH with outcome. This makes different studies on IOH less comparable and hampers clinical application of reported results.
To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance.
Marked ...reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues.
This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity.
After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio OR 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively.
Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.
Diagnostic and prognostic prediction models often perform poorly when externally validated. We investigate how differences in the measurement of predictors across settings affect the discriminative ...power and transportability of a prediction model.
Differences in predictor measurement between data sets can be described formally using a measurement error taxonomy. Using this taxonomy, we derive an expression relating variation in the measurement of a continuous predictor to the area under the receiver operating characteristic curve (AUC) of a logistic regression prediction model. This expression is used to demonstrate how variation in measurements across settings affects the out-of-sample discriminative ability of a prediction model. We illustrate these findings with a diagnostic prediction model using example data of patients suspected of having deep venous thrombosis.
When a predictor, such as D-dimer, is measured with more noise in one setting compared to another, which we conceptualize as a difference in “classical” measurement error, the expected value of the AUC decreases. In contrast, constant, “structural” measurement error does not impact on the AUC of a logistic regression model, provided the magnitude of the error is the same among cases and noncases. As the differences in measurement methods between settings (and in turn differences in measurement error structures) become more complex, it becomes increasingly difficult to predict how the AUC will differ between settings.
When a prediction model is applied to a different setting to the one in which it was developed, its discriminative ability can decrease or even increase if the magnitude or structure of the errors in predictor measurements differ between the two settings. This provides an important starting point for researchers to better understand how differences in measurement methods can affect the performance of a prediction model when externally validating or implementing it in practice.
A recent overview of all CVD models applicable to diabetes patients is not available.
To review the primary prevention studies that focused on the development, validation and impact assessment of a ...cardiovascular risk model, scores or rules that can be applied to patients with type 2 diabetes.
Systematic review.
Medline was searched from 1966 to 1 April 2011.
A study was eligible when it described the development, validation or impact assessment of a model that was constructed to predict the occurrence of cardiovascular disease in people with type 2 diabetes, or when the model was designed for use in the general population but included diabetes as a predictor.
A standardized form was sued to extract all data of the CVD models.
45 prediction models were identified, of which 12 were specifically developed for patients with type 2 diabetes. Only 31% of the risk scores has been externally validated in a diabetes population, with an area under the curve ranging from 0.61 to 0.86 and 0.59 to 0.80 for models developed in a diabetes population and in the general population, respectively. Only one risk score has been studied for its effect on patient management and outcomes. 10% of the risk scores are advocated in national diabetes guidelines.
Many cardiovascular risk scores are available that can be applied to patients with type 2 diabetes. A minority of these risk scores has been validated and tested for its predictive accuracy, with only a few showing a discriminative value of ≥0.80. The impact of applying these risk scores in clinical practice is almost completely unknown, but their use is recommended in various national guidelines.
Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical ...practice is unknown. To improve postoperative pain therapy and develop procedure-specific, optimized pain-treatment protocols, types of surgery that may result in severe postoperative pain in everyday practice must first be identified.
This study considered 115,775 patients from 578 surgical wards in 105 German hospitals. A total of 70,764 patients met the inclusion criteria. On the first postoperative day, patients were asked to rate their worst pain intensity since surgery (numeric rating scale, 0-10). All surgical procedures were assigned to 529 well-defined groups. When a group contained fewer than 20 patients, the data were excluded from analysis. Finally, 50,523 patients from 179 surgical groups were compared.
The 40 procedures with the highest pain scores (median numeric rating scale, 6-7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many "minor" surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of "major" abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia.
Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain. To reduce the number of patients suffering from severe pain, patients undergoing so-called minor surgery should be monitored more closely, and postsurgical pain treatment needs to comply with existing procedure-specific pain-treatment recommendations.
Many studies have analyzed risk factors for the development of severe postoperative pain with contradictory results. To date, the association of risk factors with postoperative pain intensity among ...different surgical procedures has not been studied and compared.
The authors selected precisely defined surgical groups (at least 150 patients each) from prospectively collected perioperative data from 105 German hospitals (2004-2010). The association of age, sex, and preoperative chronic pain intensity with worst postoperative pain intensity was studied with multiple linear and logistic regression analyses. Pooled data of the selected surgeries were studied with random-effect analysis.
Thirty surgical procedures with a total number of 22,963 patients were compared. In each surgical procedure, preoperative chronic pain intensity and younger age were associated with higher postoperative pain intensity. A linear decline of postoperative pain with age was found. Females reported more severe pain in 21 of 23 surgeries. Analysis of pooled surgical groups indicated that postoperative pain decreased by 0.28 points (95% CI, 0.26 to 0.31) on the numeric rating scale (0 to 10) per decade age increase and postoperative pain increased by 0.14 points (95% CI, 0.13 to 0.15) for each higher score on the preoperative chronic pain scale. Females reported 0.29 points (95% CI, 0.22 to 0.37) higher pain intensity.
Independent of the type and extent of surgery, preoperative chronic pain and younger age were associated with higher postoperative pain. Females consistently reported slightly higher pain scores regardless of the type of surgery. The clinical significance of this small sex difference has to be analyzed in future studies.
Increasing evidence indicates that harmful effects are associated with the use of physical restraint.
To characterize the use of physical restraint in intensive care units. Prevalence, adherence to ...protocols, and correlates of the use of physical restraint were determined. For comparisons between ICUs, adjustments were made for differences in patients' characteristics.
A prospective, cross-sectional, observational multicenter study with a representative sample (n = 25) of all Dutch intensive care units, ranging from local hospitals to academic centers. Each unit was visited twice, and all 379 patients admitted during these visits were included and were examined for use of physical restraint.
Physical restraint was used in 23% of all patients (range, 0%-56% for different units). Of all 346 nurses interviewed, 31% reported using a protocol when applying physical restraint. When corrections were made for clustering within units, the risk for use of physical restraint was increased in patients with delirium or coma, in patients who could not communicate verbally, and in patients receiving psychoactive or sedative medications. Sex, severity of illness, and nurse to patient ratio were not independently related to use of physical restraint. In 11 units (44%), use of physical restraint was more frequent than expected on the basis of patients' characteristics, although this finding was not significant.
Physical restraint is frequently used in Dutch intensive care units. The differences in frequency between units suggest that opportunities exist to limit the use of physical restraint.
The inflammatory response to surgery varies considerably between individual patients. Age might be a substantial factor in this variability. Our objective was to examine the association of patient ...age and other potential risk factors with the occurrence of a postoperative systemic inflammatory response syndrome, during the first 24 h after cardiac surgery.
This was a retrospective cohort study, using linked data from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Database and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database. Data from patients who underwent coronary artery bypass grafting and/or valve surgery were used. The association between age and postoperative SIRS was analysed using Poisson regression, and corrected for other risk factors. Restricted cubic splines were used to determine relevant age categories. Results are expressed as risk ratios (RR) with 95% confidence intervals (CI).
Data from 28 513 patients were used. In both univariable and multivariable models, increased patient age was strongly associated with reduced postoperative SIRS prevalence. Using 73–83 yr as the reference category, the RRs (95% CI) for the age categories were 1.38 (1.28–1.49) for ≤43 yr, 1.15 (1.09–1.20) for 44–63 yr, 1.05 (1.00–1.09) for 64–72 yr, and 1.03 (0.94–1.12) for >83 yr, respectively. The predictive value for postoperative SIRS of the final model, however, was moderate (c-statistic: 0.61).
We have demonstrated that advanced patient age is associated with a decreased risk of postoperative SIRS among cardiac surgery patients, where patients aged over 72 yr had the lowest risk.
Postoperative stroke is a rare but major complication after surgery. The most often proposed mechanism is an embolus originating from the heart or great vessels. The role of intraoperative ...hypotension in the occurrence and evolution of postoperative stroke is largely unknown.
A case-control study was conducted among 48,241 patients who underwent noncardiac and nonneurosurgical procedures in the period from January 2002 to June 2009. A total of 42 stroke cases (0.09%) were matched on age and type of surgery to 252 control patients. Conditional logistic regression analysis was used to estimate the effect of the duration of intraoperative hypotension (defined according to a range of blood pressure thresholds) on the occurrence of an ischemic stroke within 10 days after surgery, adjusted for potential confounding factors.
After correction for potential confounders and multiple testing, the duration that the mean blood pressure was decreased more than 30% from baseline remained statistically significantly associated with the occurrence of a postoperative stroke.
Intraoperative hypotension might play a role in the development of postoperative ischemic stroke. Especially for mean blood pressure values decreasing more than 30% from baseline blood pressure, an association with postoperative ischemic stroke risks was observed.
Background
The goal is to estimate the additional value of ultrasonographic optic nerve sheath diameter (ONSD) measurement on days 1–3, on top of electroencephalography (EEG), pupillary light ...reflexes (PLR), and somatosensory evoked potentials (SSEP), for neurological outcome prediction of comatose cardiac arrest patients. We performed a prospective longitudinal cohort study in adult comatose patients after cardiac arrest. ONSD was measured on days 1–3 using ultrasound. Continuous EEG, PLR, and SSEP were acquired as standard care. Poor outcome was defined as cerebral performance categories 3–5 at 3–6 months. Logistic regression models were created for outcome prediction based on the established predictors with and without ONSD. Additional predictive value was assessed by increase in sensitivity for poor (at 100% specificity) and good outcome (at 90% specificity).
Results
We included 100 patients, 54 with poor outcome. Mean ONSD did not differ significantly between patients with good and poor outcome. Sensitivity for predicting poor outcome increased by adding ONSD to EEG and SSEP from 25% to 41% in all patients and from 27% to 50% after exclusion of patients with non-neurological death.
Conclusions
ONSD on days 1–3 after cardiac arrest holds potential to add to neurological outcome prediction.
Trial
registration
: clinicaltrials.gov, NCT04084054. Registered 10 September 2019,
https://www.clinicaltrials.gov/study/NCT04084054
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