scholarly journals Cumulative Duration of “Triple Low” State of Low Blood Pressure, Low Bispectral Index, and Low Minimum Alveolar Concentration of Volatile Anesthesia Is Not Associated with Increased Mortality

2014 ◽  
Vol 121 (1) ◽  
pp. 18-28 ◽  
Author(s):  
Miklos D. Kertai ◽  
William D. White ◽  
Tong J. Gan
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Bispectral Index ◽  
Cox Regression ◽  
Minimum Alveolar Concentration ◽  
Risk Index ◽  
Noncardiac Surgery ◽  
Arterial Blood ◽  
Volatile Anesthesia ◽  
Cumulative Duration

Abstract Background: Mortality after noncardiac surgery has been associated with the “triple low state,” a combination of low mean arterial blood pressure (<75 mmHg), low bispectral index (<45), and low minimum alveolar concentration of volatile anesthesia (<0.70). The authors set out to determine whether duration of a triple low state and aggregate risk associated with individual diagnostic and procedure codes are independently associated with perioperative and intermediate-term mortality. Methods: The authors studied 16,263 patients (53 ± 16 yr) who underwent noncardiac surgery at Duke University Medical Center between January 2006 and December 2009. Multivariable logistic and Cox regression analyses were used to determine whether perioperative factors were independently associated with perioperative and intermediate-term all-cause mortality. Results: The 30-day mortality rate was 0.8%. There were statistically significant associations between 30-day mortality and various perioperative risk factors including age, American Society of Anesthesiologists Physical Status, emergency surgery, higher Cleveland Clinic Risk Index score, and year of surgery. Cumulative duration of triple low state was not associated with 30-day mortality (multivariable odds ratio, 0.99; 95% CI, 0.92 to 1.07). The clinical risk factors for 30-day mortality remained predictors of intermediate-term mortality, whereas cumulative duration of triple low was not associated with intermediate-term mortality (multivariable hazard ratio, 0.98; 95% CI, 0.97 to 1.01). The multivariable logistic regression (c-index = 0.932) and Cox regression (c-index = 0.860) models showed excellent discriminative abilities. Conclusion: The authors found no association between cumulative duration of triple low state and perioperative or intermediate-term mortality in noncardiac surgery patients.

scholarly journals Bispectral Index Monitoring, Duration of Bispectral Index Below 45, Patient Risk Factors, and Intermediate-term Mortality after Noncardiac Surgery in the B-Unaware Trial

2011 ◽  
Vol 114 (3) ◽  
pp. 545-556 ◽  
Author(s):  
Miklos D. Kertai ◽  
Ben J. A. Palanca ◽  
Nirvik Pal ◽  
Beth A. Burnside ◽  
Lini Zhang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Bispectral Index ◽  
Cox Regression ◽  
Postoperative Mortality ◽  
Noncardiac Surgery ◽  
Volatile Agent ◽  
Discriminative Ability ◽  
Cox Regression Analysis ◽  
Cumulative Duration ◽  
End Tidal

Background Postoperative mortality has been associated with cumulative anesthetic duration below an arbitrary processed electroencephalographic threshold (bispectral index [BIS] <45). This substudy of the B-Unaware Trial tested whether cumulative duration of BIS values lower than 45, cumulative anesthetic dose, comorbidities, or intraoperative events were independently associated with postoperative mortality. Methods The authors studied 1,473 patients (mean ± SD age, 57.9 ± 14.4 yr; 749 men) who underwent noncardiac surgery at Barnes-Jewish Hospital in St. Louis, Missouri. Multivariable Cox regression analysis was used to determine whether perioperative factors were independently associated with all-cause mortality. Results A total of 358 patients (24.3%) died during a follow-up of 3.2 ± 1.1 yr. There were statistically significant associations among various perioperative risk factors, including malignancy and intermediate-term mortality. BIS-monitored patients did not have lower mortality than unmonitored patients (24.9 vs. 23.7%; difference = 1.2%, 95% CI, -3.3 to 5.6%). Cumulative duration of BIS values less than 45 was not associated with mortality (multivariable hazard ratio, 1.03; 95% CI, 0.93-1.14). Increasing mean and cumulative end-tidal anesthetic concentrations were not associated with mortality. The multivariable Cox regression model showed a good discriminative ability (c-index = 0.795). Conclusions This study found no evidence that either cumulative BIS values below a threshold of 40 or 45 or cumulative inhalational anesthetic dose is injurious to patients. These results do not support the hypothesis that limiting depth of anesthesia either by titration to a specific BIS threshold or by limiting end-tidal volatile agent concentrations will decrease postoperative mortality.

scholarly journals The cumulative duration of bispectral index less than 40 concurrent with hypotension is associated with 90-day postoperative mortality: a retrospective study

2020 ◽  
Author(s):  
Soohyuk Yoon ◽  
Seokha Yoo ◽  
Min Hur ◽  
Sun-Kyung Park ◽  
Hyung-Chul Lee ◽  
...  
Keyword(s):  
Risk Factors ◽  
Retrospective Study ◽  
Bispectral Index ◽  
Odds Ratio ◽  
Postoperative Mortality ◽  
Anesthetic Depth ◽  
Intraoperative Hypotension ◽  
Cumulative Duration ◽  
The Relationship ◽  
Cumulative Time

Abstract Background The relationship between intraoperative low bispectral index (BIS) values and poor clinical outcomes has been controversial. Intraoperative hypotension is associated with postoperative complication. The purpose of this study was to investigate the influence of intraoperative low BIS values and hypotension on postoperative mortality in patients undergoing major abdominal surgery. Methods This retrospective study analyzed 1,862 cases of general anesthesia. We collected the cumulative time of BIS values below 20 and 40 as well as electroencephalographic suppression and documented the incidences in which these states were maintained for at least 5 minutes. Durations of intraoperative mean arterial pressures (MAP) less than 50 mmHg were also recorded. Multivariable logistic regression was used to evaluate the association between suspected risk factors and postoperative mortality. Results Ninety-day mortality and 180-day mortality were 1.5% and 3.2% respectively. The cumulative time in minutes for BIS values falling below 40 coupled with MAP falling below 50 mmHg was associated with 90-day mortality (odds ratio, 1.26; 95% confidence interval, 1.04-1.53; P = .019). We found no association between BIS related values and 180-day mortality. Conclusions Delicate adjustment of anesthetic depth is important to avoid excessive brain suppression and hypotension, which could be associated with postoperative mortality.

Cardiovascular Risk Factors and their Relationship with Endothelial Dysfunction in Rural and Urban South African Children

2020 ◽  
Author(s):  
Edna N. Matjuda ◽  
Godwill Azeh Engwa ◽  
Samuel Nkeh Chungag Anye ◽  
Benedicta N. Nkeh Chungag ◽  
Nandu Goswami
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Cardiovascular Risk ◽  
Endothelial Dysfunction ◽  
Cardiovascular Risk Factors ◽  
High Blood Pressure ◽  
Urban Children ◽  
Urban Settings ◽  
Arterial Blood ◽  
Rural And Urban

Abstract Background: Endothelial dysfunction is known to be an initiator to the development and progression of atherosclerotic cardiovascular disease (CVD). However, there is paucity o knowledge on its relationship with cardiovascular risk factors in children. More so, some of these cardiovascular risk factors are known to be influenced by feeding habits and life style changes which often vary between rural and urban settings. This study was aimed to investigate the relationship between cardiovascular risk factors and endothelial function in rural and urban children. Methods: A cross-sectional study on 6-9 years old children in randomly selected rural and urban schools of the Eastern Cape Province of South Arica was conducted. General anthropometric indices were measured followed by blood pressure (BP) measurements. The pulse wave velocity (PWV) was measured using a Vicorder. Urine sample was collected for the determination of albumin, creatinine, asymmetric dimethylarginine (ADMA), 8-hydroxy-2deoxyguanosine (8-OHdG) and thiobarbituric acid reactive substance (TBARS). Albumin to creatinine ratio (ACR) was calculated.Results: Children from urban settings (10.8%) had a higher prevalence of overweight/obesity than their rural counterparts (8.5%) while the prevalence of elevated/high blood pressure was higher in rural children (23.2%) than in urban children (19.0%). Diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) significantly (p<0.005) increased with increasing quartiles of PWV. ADMA positively associated with HR in rural girls and showed a weak risk for elevated SBP and MAP. Body mass index (BMI) increased with increasing PWV and predicted endothelial dysfunction. 8-OHdG significantly (p<0.005) increased with increasing quartiles of ADMA and positively correlated with ADMA. Creatinine, albumin and ACR significantly (p<0.005) increased with increasing ADMA and ADMA associated positively with creatinine. Conclusion: Endothelial dysfunction was associated with obesity, high blood pressure, oxidative stress and microalbuminuria in children, and this relationship varied between rural and urban children.

P6143Body-mass index, blood pressure, diabetes and cardiovascular mortality in Cuba: prospective cohort study of 146,665 participants

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
B W H Lacey ◽  
N Armas ◽  
J A Burrett ◽  
R Peto ◽  
A Duenas ◽  
...  
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Cohort Study ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Cox Regression ◽  
Metabolic Risk Factors ◽  
Metabolic Risk ◽  
Reverse Causality ◽  
Cvd Mortality

Abstract Background Cardiovascular disease (CVD) is a leading cause of premature death in Cuba, accounting for about one third of all deaths under age 70 years. Substantial uncertainty remains, however, about the relevance of major metabolic risk factors to CVD mortality in this population. Purpose To relate body-mass index (BMI), systolic blood pressure (SBP), and diabetes to risk of CVD death in Cuba. Methods In a prospective cohort study, 146,665 adults were recruited from the general population in five areas of Cuba between 1996 and 2002. Participants were interviewed, measured (height, weight and blood pressure) and followed up by electronic linkage to Cuban national death registries to Jan 1 2017; 24,345 participants were resurveyed between 2006 and 2008. After excluding all with missing data or chronic disease at recruitment or, to further limit reverse causality, those who died in the first 5 years, Cox regression (adjusted for age, sex, education, smoking, alcohol and, where appropriate, BMI) was used to relate mortality rate ratios (RRs) at ages 35–79 years to BMI, SBP and diabetes. Correlations of baseline and resurvey values were used to corrected RRs for regression dilution, and thereby estimate associations with long-term average (“usual”) levels of SBP and BMI. Results After exclusions, there were 117,008 participants age 35–79 (mean age 52 [SD 12]; 55% women). At recruitment, mean SBP was 124 mm Hg (SD 15), mean BMI was 24.2 kg/m2 (SD 3.6) and 5% had diabetes; mean SBP and diabetes prevalence were both strongly related to BMI. Correlations of resurvey and baseline measurements were 0.48 for SBP and 0.60 for BMI. At ages 35–79 years, there were 3780 CVD deaths (1871 ischaemic heart disease [IHD], 766 stroke, and 1143 other). CVD mortality was positively associated with BMI (down to about 22–23 kg/m2; figure), SBP and diabetes: 10 kg/m2 higher usual BMI approximately doubled CVD mortality (RR 1.90, 95% CI 1.61–2.24), as did 20 mmHg higher usual SBP (2.03, 1.88–2.20), and a prior diagnosis of diabetes (2.18, 1.97–2.42). The associations were similar in men and women. Given these associations, about one quarter (27%) of CVD deaths in this study were attributable to these metabolic risk factors combined. Conclusion These associations differ to those reported from other parts of Latin America, and are more consistent with studies in Europe and North America, highlighting the need for many more large-scale prospective studies in low and middle income countries. This study provides direct evidence for the expected benefit on CVD mortality of addressing major metabolic risk factors in Cuba. As the levels of these metabolic risk factors are increasing in Cuba, so too is their importance as determinants of premature CVD death. Acknowledgement/Funding Medical Research Council, British Heart Foundation, Cancer Research UK

scholarly journals The Use of Lee and Co-Workers’ Index to Assist a Risk Adjusted Audit of Perioperative Cardiac Outcome

2008 ◽  
Vol 36 (2) ◽  
pp. 167-173 ◽  
Author(s):  
P. J. Moran ◽  
T. Ghidella ◽  
G. Power ◽  
A. S. Jenkins ◽  
D. Whittle
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Positive Result ◽  
Cardiac Event ◽  
Risk Index ◽  
Cardiac Risk ◽  
Noncardiac Surgery ◽  
Frequent Use ◽  
Cardiac Outcome ◽  
The Impact

Lee and co-workers’ revised cardiac risk index was used to study the perioperative cardiac outcome of 296 patients. The index uses a history of ischaemic heart disease, congestive cardiac failure, diabetes treated with insulin, a creatinine greater than 180 μmol/l, cerebrovascular disease and high risk surgery as the risk factors involved in predicting a perioperative cardiac event. It was derived on the basis of data from patients over the age of 50 years undergoing elective, noncardiac surgery with an expected inpatient stay of two or more days. The presence of one, two and three or more risk factors predicted a risk of a major cardiac event of 1.3% (95% confidence interval [CI] 0.7 to 2.1), 3.6% (95% CI 2.1 to 5.6) and 9% (95% CI 5.5 to 13.8) respectively in Lee's derivation group of 2,893 patients. In our audit of 296 patients we observed a cardiac event rate of 0.8% (95% CI 0 to 2.3%), 6.7% (95% CI 1.6 to 10%) and 2% (95% CI 0 to 5.9%), in patients with one, two and three or more risk factors respectively. The more frequent use of ECGs and troponin levels in the routine postoperative care of high risk patients undergoing major noncardiac surgery is recommended on the basis of the frequency of a positive result and the impact of a positive result on a patient's management.

All IPI Factors Are Equal, but LDH Is More Equal Than Others.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1913-1913
Author(s):  
Gustaaf W. van Imhoff ◽  
W. Graveland ◽  
B. Van der Holt ◽  
M. Van Glabbeke ◽  
L. F. Verdonck ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cox Regression ◽  
Risk Index ◽  
Elevated Serum ◽  
Continuous Variable ◽  
Prognostic Impact ◽  
Prognostic Information ◽  
Curative Intent ◽  
Non Hodgkin Lymphoma ◽  
The Individual

Abstract The International Prognostic Risk Index (IPI) offers the most important prognostic information in patients with aggressive non-Hodgkin Lymphoma (NHL). Risk classification is based on presence or absence of age >60 yr, stage III or IV, more than one extranodal site, performance score 2–4, or elevated serum LDH above the upper limit of normal (ULN). Because each factor confers a more or less equal independent risk for treatment outcome, they are summed to generate a final IPI risk score (Shipp model). Dichotomization of the continuous variable age is practical, as treatment for patients >60 yr often differs from younger ones. However, as LDH also is a continuous variable we wondered if risk based on actual LDH, especially in patients with highly elevated levels, would have additional prognostic impact. IPI risk factors including actual serum LDH at diagnosis were retrieved from 1286 patients (28% >60 yr) with advanced aggressive NHL and treated with curative intent in 6 clinical trials conducted by HOVON (5 trials) and EORTC (1 trial). All LDH ULNs from the participating centers were verified. LDH levels were divided by the ULN of each center to generate normalized ratios. Six % of patients had LDH >5 times ULN, 8% 3–5 times, 11% 2–3 times, 34% 1–2 times, 20% 0.75–1 times and 20% had levels below 0.75 of ULN. In a multivariate Cox regression model similar independent hazard ratios (HR) ranging from 1.6 to 2.6 were found for the individual dichotomized risk factors according to the Shipp model except for the number of extranodal sites which turned out to be non-significant. This factor was with a HR of 1.4 also the least predictive factor in the Shipp model. In contrast to the dichotomized LDH variable (normal versus elevated), risk for inferior outcome increased linearly with actual LDH levels. Five year OS estimates were 71% for patients with LDH <0.75 x ULN; 53% for 0.75–1; 49% for 1–2; 37% for 2–3; 31% for 3–5; and 25% for LDH >5 x ULN. The HR for these groups were respectively 0.54, 1, 1.45, 2.46, 2.54 and 5.15. This analysis using actual LDH values gave a better discrimination as compared to the HR of 2.6 (95% CI 2.1–3.1) for the dichotomized LDH (i.e. normal versus elevated) in multivariate analysis. Interestingly, the 235 patients with very low LDH (<0.75 x ULN) had much better outcomes with a HR of 0.54 as compared with patients with an LDH-ratio between 0.75 and 1. In conclusion, highly elevated LDH levels in aggressive NHL confer a worse prognosis and suggest the application of a modified IPI risk index adding extra risk points for patients with highly elevated LDH levels.

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