The impact of the incorporation of a feasible postoperative mortality model at the Post-Anaesthestic Care Unit (PACU) on postoperative clinical deterioration: A pragmatic trial with 5,353 patients

Background Practical use of risk predictive tools and the assessment of their impact on outcome reduction is still a challenge. This pragmatic study of quality improvement (QI) describes the preoperative adoption of a customised postoperative death probability model (SAMPE model) and the evaluation of the impact of a Postoperative Anaesthetic Care Unit (PACU) pathway on the clinical deterioration of high-risk surgical patients. Methods A prospective cohort of 2,533 surgical patients compared with 2,820 historical controls after the adoption of a quality improvement (QI) intervention. We carried out quick postoperative high-risk pathways at PACU when the probability of postoperative death exceeded 5%. As outcome measures, we used the number of rapid response team (RRT) calls within 7 and 30 postoperative days, in-hospital mortality, and non-planned Intensive Care Unit (ICU) admission. Results Not only did the QI succeed in the implementation of a customised risk stratification model, but it also diminished the postoperative deterioration evaluated by RRT calls on very high-risk patients within 30 postoperative days (from 23% before to 14% after the intervention, p = 0.05). We achieved no survival benefits or reduction of non-planned ICU. The small group of high-risk patients (13% of the total) accounted for the highest proportion of RRT calls and postoperative death. Conclusion Employing a risk predictive tool to guide immediate postoperative care may influence postoperative deterioration. It encouraged the design of pragmatic trials focused on feasible, low-technology, and long-term interventions that can be adapted to diverse health systems, especially those that demand more accurate decision making and ask for full engagement in the control of postoperative morbi-mortality.

Development and Validation of a Novel Nomogram for Preoperative Prediction of In-Hospital Mortality After Coronary Artery Bypass Grafting Surgery in Heart Failure With Reduced Ejection Fraction

Background and Aims: Patients with heart failure with reduced ejection fraction (HFrEF) are among the most challenging patients undergoing coronary artery bypass grafting surgery (CABG). Several surgical risk scores are commonly used to predict the risk in patients undergoing CABG. However, these risk scores do not specifically target HFrEF patients. We aim to develop and validate a new nomogram score to predict the risk of in-hospital mortality among HFrEF patients after CABG.Methods: The study retrospectively enrolled 489 patients who had HFrEF and underwent CABG. The outcome was postoperative in-hospital death. About 70% (n = 342) of the patients were randomly constituted a training cohort and the rest (n = 147) made a validation cohort. A multivariable logistic regression model was derived from the training cohort and presented as a nomogram to predict postoperative mortality in patients with HFrEF. The model performance was assessed in terms of discrimination and calibration. Besides, we compared the model with EuroSCORE-2 in terms of discrimination and calibration.Results: Postoperative death occurred in 26 (7.6%) out of 342 patients in the training cohort, and in 10 (6.8%) out of 147 patients in the validation cohort. Eight preoperative factors were associated with postoperative death, including age, critical state, recent myocardial infarction, stroke, left ventricular ejection fraction (LVEF) ≤35%, LV dilatation, increased serum creatinine, and combined surgery. The nomogram achieved good discrimination with C-indexes of 0.889 (95%CI, 0.839–0.938) and 0.899 (95%CI, 0.835–0.963) in predicting the risk of mortality after CABG in the training and validation cohorts, respectively, and showed well-fitted calibration curves in the patients whose predicted mortality probabilities were below 40%. Compared with EuroSCORE-2, the nomogram had significantly higher C-indexes in the training cohort (0.889 vs. 0.762, p = 0.005) as well as the validation cohort (0.899 vs. 0.816, p = 0.039). Besides, the nomogram had better calibration and reclassification than EuroSCORE-2 both in the training and validation cohort. The EuroSCORE-2 underestimated postoperative mortality risk, especially in high-risk patients.Conclusions: The nomogram provides an optimal preoperative estimation of mortality risk after CABG in patients with HFrEF and has the potential to facilitate identifying HFrEF patients at high risk of in-hospital mortality.

Preoperative mechanical large bowel preparation in colorectal cancer surgery

Objective: to analyze literature data on the effectiveness of preoperative mechanical bowel preparation (MBP), and on the basis of our own data to perform a comparative analysis of immediate MBP results in patients operated on right-sided colon cancer.Materials and methods. We reviewed literature data relevant to the use of MBP and performed a retrospective analysis of the immediate results of surgical interventions on right-sided colon cancer in 349 patients having undergone MBP with polyethylene glycol (PEG) compounds (n = 186) and without the use of PEG (n = 163).Results. The incidence rates of complications in the patients of groups I and II were 6.7 % and 9.8 % (P>0.05), anastomotic leak rates were 0.6 % and 1.6 % (P>0.05), postoperative death rates — 1.2 % and 1.6 % (P>0.05), the average durations of the postoperative period were 14.9 and 12.1 days, respectively (P>0.05).Conclusion. The use of preoperative MBP with PEG compounds does not result in enhancing the immediate results of the surgical treatment of patients with right-sided cancer.

Mortality after treatment of intracranial aneurysms with the Pipeline Embolization Device

BackgroundThe Pipeline Embolization Device (PED) is reported to be a safe treatment tool for aneurysms. However, mortality occurs in a few cases, and this has not been clearly studied. We conducted a multicenter study to retrospectively evaluate the causes of, and risk factors for, mortality in patients with intracranial aneurysms treated with the PED.MethodsWe retrospectively reviewed the prospectively maintained databases of patients with intracranial aneurysms treated by PED placement at 14 academic institutions from 2014 to 2019. Patients’ data, including clinical and radiographic information, were analyzed with an emphasis on mortality-related complications.ResultsA total of 1171 consecutive patients underwent 1319 PED procedures to treat 1322 intracranial aneurysms. The mortality rate was 1.5% (17/1171), and in 1.3% of the patients (15/1171), deaths were caused by delayed aneurysmal rupture, distal intraparenchymal hemorrhage, and neurological compression symptoms associated with PED procedures. Multivariate analysis showed that previous treatment (OR, 12.657; 95% CI, 3.189 to 50.227; P<0.0001), aneurysm size ≥10 mm (OR, 4.704; 95% CI, 1.297 to 17.068; P=0.019), aneurysm location (basilar artery) (OR, 10.734; 95% CI, 2.730 to 42.207; P=0.001), and current subarachnoid hemorrhage (OR, 4.505; 95% CI, 0.991 to 20.474; P=0.051) were associated with neurological complications resulting in mortality.ConclusionsDelayed aneurysm rupture, distal intraparenchymal hemorrhage, and neurological compression were the main causes of mortality in patients with intracranial aneurysms treated with the PED. Large basilar aneurysms are associated with an increased risk of postoperative death and require increased attention and caution.

Correlation analysis of adjuvant chemotherapy duration and postoperative death in Chinese patients with colorectal cancer: a retrospective cohort study

IntroductionIt is not known whether adjuvant chemotherapy duration is non-linearly associated with postoperative mortality risk. This study was designed to examine this relationship in Chinese patients with colorectal cancer.Material and methodsThis cohort study was conducted in 1171 participants with stage III and high-risk stage II colorectal cancer, who were treated in China between July 1, 2011, and September 1, 2018. The target independent variable was adjuvant chemotherapy duration, and the dependent variable was postoperative death.ResultsAfter adjusting for confounding factors, an increase in adjuvant chemotherapy duration was negatively correlated with the risk of postoperative death (hazard ratio (HR) = 0.95, 95% confidence interval (CI): 0.900.99). However, a non-linear relationship between therapy duration and postoperative death was observed in the group with bolus and infused fluorouracil with oxaliplatin (FOLFOX). In this group, the incidence of death decreased only when chemotherapy duration was more than 14 weeks (HR = 0.78, 95% CI: 0.630.97). A stronger association between adjuvant chemotherapy duration and postoperative death was detected in the capecitabine and oxaliplatin (CAPOX) group (HR = 0.71, 95% CI: 0.55–0.94) compared with the FOLFOX group (HR = 0.96, 95% CI: 0.92–1.01).ConclusionsThe duration of adjuvant chemotherapy with the FOLFOX regimen is associated with a non-linear reduction in postoperative deaths, which is only apparent after at least 14 weeks of treatment. However, patients with colorectal cancer may receive CAPOX adjuvant treatment for a longer duration.

Postoperative mortality in New Zealand following general anaesthetic: demographic patterns and temporal trends

ObjectivesIn this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017.Design, participants and settingWe use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period.Results and conclusionA total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3–6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.