[show abstract][hide abstract] ABSTRACT: BACKGROUND: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. METHODS: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. RESULTS: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. CONCLUSION: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.
[show abstract][hide abstract] ABSTRACT: BACKGROUND:Acute kidney injury (AKI) is a common complication of noncardiac surgery and is associated with excess morbidity and mortality. Perioperative hemoglobin concentrations are strongly associated with surgical mortality, but little is known about their relationship with AKI. We studied hemoglobin concentration before and 24 hours after surgery and its association with AKI.METHODS:We performed a single-center observational cohort study using clinical and administrative data from the Cleveland Clinic, Cleveland, OH. In patients with normal preoperative renal function, we examined the association between the outcome of AKI and the exposures of preoperative hemoglobin concentration and decrements in hemoglobin concentration in the first 24 hours after surgery using logistic regression and controlling for important confounding variables.RESULTS:We included 27,381 patients who had 33,330 noncardiac surgeries. AKI developed in 2478 (7.4%) surgeries. Preoperative hemoglobin concentrations were <12.0 g/dL in 9566 (29%) patients. Hemoglobin concentrations decreased by >4.0 g/dL in 10,808 (32%) patients. Compared with patients with a preoperative hemoglobin >12.0 g/dL, the adjusted odds ratio (OR) for AKI was 2.01 (95% confidence interval [CI], 1.8-2.3) for those with a preoperative hemoglobin between 10.1 and 12.0 g/dL and was 3.7 (95% CI, 2.6-5.4) for those with a preoperative hemoglobin <8.0 g/dL. Compared with patients who did not have a decrease in postoperative hemoglobin, a decrement of 1.1 to 2.0 g/dL was associated with an adjusted OR of 1.51 (95% CI, 1.15-1.98), and a decrement of >4.0 g/dL with an OR of 4.7 (95% CI, 3.6-6.2) for AKI.CONCLUSIONS:Low preoperative and early postoperative decrements in hemoglobin concentrations are strongly associated with postoperative AKI in a graded manner. Given the frequency of low perioperative hemoglobin and decreases in hemoglobin concentration, research is needed to determine whether there are safe treatment strategies to mitigate the risk of AKI.
Anesthesia and analgesia 09/2013; · 3.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: Preoperative chemotherapy is frequently given to shrink or decrease the chance of metastasis. However, chemotherapy has well-recognized side effects that may complicate the perioperative period. We therefore tested the hypotheses that chemotherapy within 30 days before cancer surgery is associated with an increased risk of mortality and with a composite of major morbidities within 30 postoperative days.
We evaluated 971,455 patients from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were defined as having chemotherapy when they were given any chemotherapy for malignancy within 30 days before surgery. We successfully matched 1,348 pairs of chemotherapy recipients and non-recipients.
Twenty-one of the 1,348 (1.6%) non-chemotherapy patients died within 30 days after surgery compared with 30 of the 1,348 (2.2%) chemotherapy patients. The odds of mortality were not statistically different between groups based on our logistic regression model [odds ratio (OR) = 1.47; 95% confidence interval (CI) 0.82 to 2.64; P = 0.19]. The most common complication observed was wound infection in 13.1% of non-chemotherapy patients compared with 14.2% of the chemotherapy patients. There was similarly no difference between groups for the collapsed composite of major morbidities [OR = 1.17; 95% CI 0.97 to 1.42; P = 0.09].
Preoperative use of neoadjuvant chemotherapy in cancer patients undergoing resection surgeries was not associated with a higher rate of early postoperative complications or mortality.
Canadian Anaesthetists? Society Journal 05/2012; 59(8):758-65. · 2.31 Impact Factor