Comparing Charlson Comorbidity Index Scores between Anesthesiologists, Patients, and Administrative Data: A Prospective Observational Study.

(1) Background: Patients' comorbidities play an immanent role in perioperative risk assessment. It is unknown how Charlson Comorbidity Indices (CCIs) from different sources compare. (2) Methods: In this prospective observational study, we compared the CCIs of patients derived from patients' self-reports and from physicians' assessments with hospital administrative data. (3) Results: The data of 1007 patients was analyzed. Agreement between the CCI from patients' self-report compared to administrative data was fair (kappa 0.24 [95%CI 0.2-0.28]). Agreement between physicians' assessment and the administrative data was also fair (kappa 0.28 [95%CI 0.25-0.31]). Physicians' assessment and patients' self-report had the best agreement (kappa 0.33 [95%CI 0.30-0.37]). The CCI calculated from the administrative data showed the best predictability for in-hospital mortality (AUROC 0.86 [95%CI 0.68-0.91]), followed by equally good prediction from physicians' assessment (AUROC 0.80 [95%CI 0.65-0.94]) and patients' self-report (AUROC 0.80 [95%CI 0.75-0.97]). (4) Conclusions: CCIs derived from patients' self-report, physicians' assessments, and administrative data perform equally well in predicting postoperative in-hospital mortality.

Association between chronic obstructive pulmonary disease and in-hospital mortality after percutaneous coronary intervention: a retrospective cohort study in Germany.

Chronic obstructive pulmonary disease (COPD) is one of the leading chronic diseases worldwide. However, the impact of COPD on outcome after percutaneous coronary intervention (PCI) remains unclear. In this retrospective cohort study, we analyzed the data of hospitalized patients undergoing PCI in Germany between 2015 and 2019. We compared in-hospital mortality, hospital length of stay and peri-interventional ventilation time (VT) in patients with and without COPD, including different COPD severity grades, COPD with exacerbation (COPDe) and infection (COPDi). We analyzed the data of 3,464,369 cases undergoing PCI. A total of 291,707 patients (8.4%) suffered from COPD. Patients suffering from COPD died more often (2.4% vs. 2.0%; p < 0.001), stayed longer hospitalized (5 days (2-10) vs. 3 days (1-6); p < 0.001), were more frequent (7.2% vs. 3.2%) and longer ventilated (26 h (7-88) vs. 23 h (5-92); p < 0.001). Surprisingly, COPD was associated with a 0.78-fold odds of in-hospital mortality and with reduced VT (- 1.94 h, 95% CI, - 4.34 to 0.43). Mild to severe COPD was associated with a lower risk of in-hospital mortality and reduced VT, whereas very severe COPD, COPDe and COPDi showed a higher risk of in-hospital mortality. We found a paradoxical association between mild to severe COPD and in-hospital mortality, whereas very severe COPD, COPDe and COPDi were associated with higher in-hospital mortality. Further investigations should illuminate, whether comorbidities affect these associations.

A Longer Tpeak-Tend Interval Is Associated with a Higher Risk of Death: A Meta-Analysis.

A noninvasive tool for cardiovascular risk stratification has not yet been established in the clinical routine analysis. Previous studies suggest a prolonged Tpeak-Tend interval (the interval from the peak to the end of the T-wave) to be predictive of death. This meta-analysis was designed to systematically evaluate the association of the Tpeak-Tend interval with mortality outcomes. Medline (via PubMed), Embase and the Cochrane Library were searched from 1 January 2008 to 21 July 2020 for articles reporting the ascertainment of the Tpeak-Tend interval and observation of all-cause-mortality. The search yielded 1920 citations, of which 133 full-texts were retrieved and 29 observational studies involving 23,114 patients met the final criteria. All-cause deaths had longer Tpeak-Tend intervals compared to survivors by a standardized mean difference of 0.41 (95% CI 0.23-0.58) and patients with a long Tpeak-Tend interval had a higher risk of all-cause death compared to patients with a short Tpeak-Tend interval by an overall odds ratio of 2.33 (95% CI 1.57-3.45). Heart rate correction, electrocardiographic (ECG) measurement methods and the selection of ECG leads were major sources of heterogeneity. Subgroup analyses revealed that heart rate correction did not affect the association of the Tpeak-Tend interval with mortality outcomes, whereas this finding was not evident in all measurement methods. The Tpeak-Tend interval was found to be significantly associated with all-cause mortality. Further studies are warranted to confirm the prognostic value of the Tpeak-Tend interval.

3-Factor versus 4-Factor Prothrombin Complex Concentrates for the Reversal of Vitamin K Antagonist-Associated Coagulopathy: A Systematic Review and Meta-analysis.

Long-term anticoagulation is used worldwide to prevent or treat thrombotic events. Anticoagulant therapy using vitamin K antagonists (VKAs) is well established; however, anticoagulants carry an increased risk of potentially life-threatening bleeding. In cases of bleeding or need for surgery, patients require careful management, balancing the need for rapid anticoagulant reversal with risk of thromboembolic events. Prothrombin complex concentrates (PCCs) replenish clotting factors and reverse VKA-associated coagulopathy. Two forms of PCC, 3-factor (3F-PCC) and 4-factor (4F-PCC), are available. Using PRISMA methodology, we systematically reviewed whether 4F-PCC is superior to 3F-PCC for the reversal of VKA-associated coagulopathy. Of the 392 articles identified, 48 full texts were reviewed, with 11 articles identified using criteria based on the PICOS format. Data were captured from 1,155 patients: 3F-PCC, n = 651; 4F-PCC, n = 504. ROBINS-I was used to assess bias. Nine studies showed international normalized ratio (INR) normalization to a predefined goal, ranging from ≤1.5 to ≤1.3, following PCC treatment. Meta-analysis of the data showed that 4F-PCC was favorable compared with 3F-PCC overall (odds ratio [OR]: 3.50; 95% confidence interval [CI]: 1.88-6.52, p < 0.0001) and for patients with a goal INR of ≤1.5 or ≤1.3 (OR: 3.45; 95% CI: 1.42-8.39, p = 0.006; OR: 3.25; 95% CI: 1.30-8.13, p = 0.01, respectively). However, heterogeneity was substantial (I 2 = 62%, I 2 = 70%, I 2 = 64%). Neither a significant difference in mortality (OR: 0.72; 95% CI: 0.42-1.24, p = 0.23) nor in thromboembolisms was reported. These data suggest that 4F-PCC is better suited than 3F-PCC for the treatment of patients with VKA-associated coagulopathy, but further work is required for a definitive recommendation.

Incidence and Predictive Factors of Acute Kidney Injury After Off-pump Lung Transplantation.

OBJECTIVES: To determine the incidence and predictive factors of acute kidney injury (AKI) after off-pump lung transplantation. DESIGN: A retrospective cohort study. SETTING: The operating room and intensive care unit. PARTICIPANTS: Adult patients who underwent lung transplant without cardiopulmonary bypass or extracorporeal membrane oxygenator between 2006 and 2016 at the Vanderbilt University Medical Center. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of postoperative AKI was assessed by the Kidney Disease: Improving Global Outcomes criteria in the first seven postoperative days. Multivariate logistic regression analysis was used to determine the independent predictive factors of AKI. One hundred forty-eight patients were included in the final analysis, of whom 63 (42.6%) subsequently developed AKI: 43 (29.0%) stage 1, ten (6.8%) stage 2, and ten (6.8%) stage 3. Patients who had AKI had a longer hospital length of stay (12 days [interquartile range (IQR): 10-17] vs ten days [IQR: 8-12], p < 0.001). For every one-year increase in age, the odds of AKI decreased by 8% (odds ratio [OR] 0.92, 95% confidence interval [CI]: 0.87-0.98, p = 0.008). The odds of having AKI in patients with bilateral lung transplant was lower than patients with unilateral transplant (OR 0.09, 95% CI: 0.01-0.63, p = 0.015). Additionally, a diagnosis of chronic obstructive pulmonary disease increased the odds of AKI by four-fold compared with a diagnosis of idiopathic pulmonary fibrosis (OR 4.73, 95% CI: 1.44-15.56, p = 0.011). CONCLUSIONS: AKI is a common complication after off-pump lung transplantation and is associated with increased hospital length of stay. Younger age, unilateral lung transplant, and diagnosis of chronic obstructive pulmonary disease are independently associated with AKI.

Effect of Aprotinin on Liver Injury after Transplantation of Extended Criteria Donor Grafts in Humans: A Retrospective Propensity Score Matched Cohort Analysis.

The number of patients awaiting liver transplantation still widely exceeds the number of donated organs available. Patients receiving extended criteria donor (ECD) organs are especially prone to an aggravated ischemia reperfusion syndrome during liver transplantation leading to massive hemodynamic stress and possible impairment in organ function. Previous studies have demonstrated aprotinin to ameliorate reperfusion injury and early graft survival. In this single center retrospective analysis of 84 propensity score matched patients out of 274 liver transplantation patients between 2010 and 2014 (OLT), we describe the association of aprotinin with postreperfusion syndrome (PRS), early allograft dysfunction (EAD: INR 1,6, AST/ALT > 2000 within 7-10 days) and recipient survival. The incidence of PRS (52.4% vs. 47.6%) and 30-day mortality did not differ (4.8 vs. 0%; p = 0.152) but patients treated with aprotinin suffered more often from EAD (64.3% vs. 40.5%, p = 0.029) compared to controls. Acceptable or poor (OR = 3.3, p = 0.035; OR = 9.5, p = 0.003) organ quality were independent predictors of EAD. Our data do not support the notion that aprotinin prevents nor attenuates PRS, EAD or mortality.

Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans.

BACKGROUND: The goal of cardiac evaluation of patients awaiting orthotopic liver transplantation (OLT) is to identify the patients at risk for cardiovascular events (CVEs) in the peri- and postoperative periods by opportunistic evaluation of coronary artery calcium (CAC) in non-gated abdominal computed tomographs (CT). METHODS: We hypothesized that in patients with OLT, a combination of Lee's revised cardiac index (RCRI) and CAC scoring would improve diagnostic accuracy and prognostic impact compared to non-invasive cardiac testing. Therefore, we retrospectively evaluated 169 patients and compared prediction of CVEs by both methods. RESULTS: Standard workup identified 22 patients with a high risk for CVEs during the transplant period, leading to coronary interventions. Eighteen patients had a CVE after transplant and a CAC score > 0. The combination of CAC and RCRI ≥ 2 had better negative (NPV) and positive predictive values (PPV) for CVEs (NPV 95.7%, PPV 81.6%) than standard non-invasive stress tests (NPV 92.0%, PPV 54.5%). CONCLUSION: The cutoff value of CAC > 0 by non-gated CTs combined with RCRI ≥ 2 is highly sensitive for identifying patients at risk for CVEs in the OLT population.

Catastrophic Cardiac Events During Transcatheter Aortic Valve Replacement.

BACKGROUND: Perioperative complications of transcatheter aortic valve replacement (TAVR) are decreasing but can be catastrophic when they occur. Systematic reports of the nature of these events are lacking in the contemporary era. Our study aimed to report the incidence, outcomes, and perioperative management of catastrophic cardiac events in patients undergoing TAVR and to propose a working strategy to address these complications. METHODS: This is a retrospective cohort study of patients who developed catastrophic cardiac events during or immediately after TAVR between 2015 and 2019 at a single academic centre. RESULTS: Of 2102 patients who underwent TAVR, 51 (2.5%) developed catastrophic cardiac events. The causes included cardiac perforation and tamponade (n = 19, 37.3%), acute left- ventricular failure (n = 10, 19.6%), coronary artery obstruction (n = 10, 19.6%), aortic-root disruption (n = 7, 13.7%), and device embolization (n = 5, 9.8%). Twenty-four patients (47.0%) with catastrophic cardiac events required stabilization by either intra-aortic balloon counter-pulsation or extracorporeal membrane oxygenation. The in-hospital mortality rate increased by 11.7-fold for patients with catastrophic cardiac events compared with those without (25.5% vs 2.0%, P < 0.001). Patients who developed aortic root disruption had the highest mortality rate (42.8%) compared with the others. The incidence of catastrophic cardiac events remained stable over a 5-year period, but the associated mortality decreased from 38.5% in 2015 to 9.1% in 2019. CONCLUSIONS: Catastrophic cardiac events during TAVR are rare, but they account for a dramatic increase in perioperative mortality. Early recognition and development of a standardized perioperative team approach can help manage patients experiencing these complications.

Perioperative Acute Kidney Injury.

Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improving timely detection and prognosis for acute kidney injury. However, specificity and timing of biomarker release continue to present challenges to their integration into existing diagnostic regimens. Despite many clinical trials using various pharmacologic or nonpharmacologic interventions, reliable means to prevent or reverse acute kidney injury are still lacking. Nevertheless, several recent randomized multicenter trials provide new insights into renal replacement strategies, composition of intravenous fluid replacement, goal-directed fluid therapy, or remote ischemic preconditioning in their impact on perioperative acute kidney injury. This review provides an update on the latest progress toward the understanding of disease mechanism, diagnosis, and managing perioperative acute kidney injury, as well as highlights areas of ongoing research efforts for preventing and treating acute kidney injury in surgical patients.

Utilization, Safety, and Technical Performance of a Telemedicine System for Prehospital Emergency Care: Observational Study.

BACKGROUND: As a consequence of increasing emergency medical service (EMS) missions requiring an EMS physician on site, we had implemented a unique prehospital telemedical emergency service as a new structural component to the conventional physician-based EMS in Germany. OBJECTIVE: We sought to assess the utilization, safety, and technical performance of this telemedical emergency service. METHODS: We conducted a retrospective analysis of all primary emergency missions with telemedical consultation of an EMS physician in the City of Aachen (250,000 inhabitants) during the first 3 operational years of our tele-EMS system. Main outcome measures were the number of teleconsultations, number of complications, and number of transmission malfunctions during teleconsultations. RESULTS: The data of 6265 patients were analyzed. The number of teleconsultations increased during the run-in period of four quarters toward full routine operation from 152 to 420 missions per quarter. When fully operational, around the clock, and providing teleconsultations to 11 mobile ambulances, the number of teleconsultations further increased by 25.9 per quarter (95% CI 9.1-42.6; P=.009). Only 6 of 6265 patients (0.10%; 95% CI 0.04%-0.21%) experienced adverse events, all of them not inherent in the system of teleconsultations. Technical malfunctions of single transmission components occurred from as low as 0.3% (95% CI 0.2%-0.5%) during two-way voice communications to as high as 1.9% (95% CI 1.6%-2.3%) during real-time vital data transmissions. Complete system failures occurred in only 0.3% (95% CI 0.2%-0.6%) of all teleconsultations. CONCLUSIONS: The Aachen prehospital EMS is a frequently used, safe, and technically reliable system to provide medical care for emergency patients without an EMS physician physically present. Noninferiority of the tele-EMS physician compared with an on-site EMS physician needs to be demonstrated in a randomized trial.

Golgin A4 in CSF and granulovacuolar degenerations of patients with Alzheimer disease.

OBJECTIVE: To isolate and identify a new, as yet unknown molecule in CSF that could serve as marker for Alzheimer disease. METHODS: We immunized mice with human CSF and fused hybridomas for monoclonal antibodies and screened these antibodies for their capacity to discriminate CSF of patients with Alzheimer disease from CSF of controls. We then chromatographically isolated the antigen to the best discriminating antibody and identified the antigen using mass spectrometric methods. Thereafter, we quantified the CSF concentration of the antigen in a new cohort of patients with Alzheimer disease and controls and performed immunohistochemistry of postmortem brain tissue derived from patients with Alzheimer disease and controls. RESULTS: We generated >200 hybridomas and selected 1 antibody that discriminated CSF from patients with Alzheimer disease from that of controls. We identified golgin A4 as the antigen detected by this antibody. Golgin A4 concentration was significantly higher in CSF from patients with Alzheimer disease than in CSF of controls (145 [interquartile range 125-155] vs 115 [ 99-128] pg/mL, p < 0.001) and demonstrated a substantial discriminative power (area under the receiver operating characteristic curve 0.80, 95% confidence interval 0.67-0.94). Immunohistochemistry of postmortem brain sections from patients with Alzheimer disease revealed a significant accumulation of golgin A4 in granulovacuolar degeneration bodies (GVBs). CONCLUSIONS: These results support the notion that golgin A4 could serve as a diagnostic marker in Alzheimer disease. For validation of this notion, prospective multicenter diagnostic studies will evaluate golgin A4 as diagnostic marker for Alzheimer disease. Furthermore, it has to be determined whether the association of golgin A4 with GVBs is an epiphenomenon or whether golgin A4 plays a more direct role in Alzheimer disease, allowing it to serve as a target in therapeutic treatment strategies. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that elevated CSF golgin A4 levels identify patients with Alzheimer disease.

Visual quality assessment of the liver graft by the transplanting surgeon predicts postreperfusion syndrome after liver transplantation: a retrospective cohort study.

BACKGROUND: The discrepancy between demand and supply for liver transplants (LT) has led to an increased transplantation of organs from extended criteria donors (ECD). METHODS: In this single center retrospective analysis of 122 cadaveric LT recipients, we investigated predictors of postreperfusion syndrome (PRS) including transplant liver quality categorized by both histological assessment of steatosis and subjective visual assessment by the transplanting surgeon using multivariable regression analysis. Furthermore, we describe the relevance of PRS during the intraoperative and postoperative course of LT recipients. RESULTS: 53.3% (n = 65) of the patients suffered from PRS. Risk factors for PRS were visually assessed organ quality of the liver grafts (acceptable: OR 12.2 [95% CI 2.43-61.59], P = 0.002; poor: OR 13.4 [95% CI 1.48-121.1], P = 0.02) as well as intraoperative norepinephrine dosage before reperfusion (OR 2.2 [95% CI 1.26-3.86] per 0.1 µg kg- 1 min- 1, P = 0.01). In contrast, histological assessment of the graft was not associated with PRS. LT recipients suffering from PRS were hemodynamically more instable after reperfusion compared to recipients not suffering from PRS. They had lower mean arterial pressures until the end of surgery (P < 0.001), received more epinephrine and norepinephrine before reperfusion (P = 0.02 and P < 0.001, respectively) as well as higher rates of continuous infusion of norepinephrine (P < 0.001) and vasopressin (P = 0.02) after reperfusion. Postoperative peak AST was significantly higher (P = 0.001) in LT recipients with PRS. LT recipients with intraoperative PRS had more postoperative adverse cardiac events (P = 0.05) and suffered more often from postoperative delirium (P = 0.04). CONCLUSIONS: Patients receiving ECD liver grafts are especially prone to PRS. Anesthesiologists should keep these newly described risk factors in mind when preparing for reperfusion in patients receiving high-risk organs.

Risk perception of blood transfusions - a comparison of patients and allied healthcare professionals.

BACKGROUND: Due to an increasing demand in health care services plans to substitute selective physician-conducted medical activities have become attractive. Because administration of a blood transfusion is a highly standardized procedure, it might be evaluated if obtaining a patient's consent for a blood transfusion can be delegated to allied healthcare professionals. Physicians and patients perceive risks of transfusions differently. However, it is unknown how allied healthcare professionals perceive risks of transfusion-associated adverse events. METHODS: Patients (n = 506) and allied healthcare professionals (n = 185) of an academic teaching hospital were asked to quantify their concerns about transfusions including five predefined transfusion-associated risks and their incidences. RESULTS: Blood transfusions were considered to be generally harmful by 10.9% of patients and 14.6% of caregivers (P = 0.180). Among all surveyed patients, 36.8% were worried about infection-transmissions (caregivers: 27.6%; P = 0.024). Compared to 5.4% of caregivers, 13.6% of patients believed infection-transmission was a frequent complication (P = 0.003). Caregivers ranked the risks of receiving an AB0-mismatch transfusion (caregivers: 29.7% vs. PATIENTS: 19.2%, P = 0.003) or a transfusion-associated allergic reaction (caregivers: 17.3% vs. PATIENTS: 11.1%, P = 0.030) significantly higher than patients and were aware of the high incidence of transfusion-associated fever (caregivers: 17.8% vs. PATIENTS: 8.3%, P < 0.001). CONCLUSION: A significant part of interviewees perceived transfusions as a general health hazard. Patients perceived infection-transmissions as the most frequent and greatest transfusion-associated threat while caregivers focused on fatal AB0-mismatch transfusions and allergic reactions. Understanding the patients' main concerns about blood transfusions and considering that these concerns might differ from the view of healthcare professionals might improve the process of shared decision making.

Closed-loop mechanical ventilation for lung injury: a novel physiological-feedback mode following the principles of the open lung concept.

Adherence to low tidal volume (VT) ventilation and selected positive end-expiratory pressures are low during mechanical ventilation for treatment of the acute respiratory distress syndrome. Using a pig model of severe lung injury, we tested the feasibility and physiological responses to a novel fully closed-loop mechanical ventilation algorithm based on the "open lung" concept. Lung injury was induced by surfactant washout in pigs (n = 8). Animals were ventilated following the principles of the "open lung approach" (OLA) using a fully closed-loop physiological feedback algorithm for mechanical ventilation. Standard gas exchange, respiratory- and hemodynamic parameters were measured. Electrical impedance tomography was used to quantify regional ventilation distribution during mechanical ventilation. Automatized mechanical ventilation provided strict adherence to low VT-ventilation for 6 h in severely lung injured pigs. Using the "open lung" approach, tidal volume delivery required low lung distending pressures, increased recruitment and ventilation of dorsal lung regions and improved arterial blood oxygenation. Physiological feedback closed-loop mechanical ventilation according to the principles of the open lung concept is feasible and provides low tidal volume ventilation without human intervention. Of importance, the "open lung approach"-ventilation improved gas exchange and reduced lung driving pressures by opening atelectasis and shifting of ventilation to dorsal lung regions.

Proteomic-Biostatistic Integrated Approach for Finding the Underlying Molecular Determinants of Hypertension in Human Plasma.

Despite advancements in lowering blood pressure, the best approach to lower it remains controversial because of the lack of information on the molecular basis of hypertension. We, therefore, performed plasma proteomics of plasma from patients with hypertension to identify molecular determinants detectable in these subjects but not in controls and vice versa. Plasma samples from hypertensive subjects (cases; n=118) and controls (n=85) from the InGenious HyperCare cohort were used for this study and performed mass spectrometric analysis. Using biostatistical methods, plasma peptides specific for hypertension were identified, and a model was developed using least absolute shrinkage and selection operator logistic regression. The underlying peptides were identified and sequenced off-line using matrix-assisted laser desorption ionization orbitrap mass spectrometry. By comparison of the molecular composition of the plasma samples, 27 molecular determinants were identified differently expressed in cases from controls. Seventy percent of the molecular determinants selected were found to occur less likely in hypertensive patients. In cross-validation, the overall R2 was 0.434, and the area under the curve was 0.891 with 95% confidence interval 0.8482 to 0.9349, P<0.0001. The mean values of the cross-validated proteomic score of normotensive and hypertensive patients were found to be -2.007±0.3568 and 3.383±0.2643, respectively, P<0.0001. The molecular determinants were successfully identified, and the proteomic model developed shows an excellent discriminatory ability between hypertensives and normotensives. The identified molecular determinants may be the starting point for further studies to clarify the molecular causes of hypertension.

[Postoperative acute kidney injury: confounder or causal link for surgical outcome?] / Akute Nierenschädigung - Postoperatives Begleitphänomen oder kausaler Risikofaktor für das operative Behandlungsergebnis?

Demographic change and increase of complexity of diagnostic and surgical procedures lead to an increasing relevance of acute kidney injury as postoperative complication. Postoperative acute kidney injury is associated with higher mortality, morbidity and treatment costs. It has not yet been unequivocally proven that postoperative acute kidney injury is in fact causally linked with worse treatment outcome in surgical patients. This article aims to give an overview of the phenomenon postoperative acute kidney injury, to discuss problems of demonstrating causal relations in biomedical research, and to present arguments for and against the hypothesis that postoperative acute kidney injury is causally linked to worse surgical outcome.

Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients.

BACKGROUND: Surgical patients frequently experience postoperative increases in creatinine levels. The authors hypothesized that even small increases in postoperative creatinine levels are associated with adverse outcomes. METHODS: The authors examined the association of postoperative changes from preoperative baseline creatinine with all-cause in-hospital mortality and hospital length of stay (HLOS) in a retrospective analysis of surgical patients at a single tertiary care center between January 2006 and June 2012. RESULTS: The data of 39,369 surgical patients (noncardiac surgery n = 37,345; cardiac surgery n = 2,024) were analyzed. Acute kidney injury (AKI)-by definition of the Kidney Disease: Improving Global Outcome group-was associated with a five-fold higher mortality (odds ratio [OR], 4.8; 95% CI, 4.1 to 5.7; P < 0.001) and a longer HLOS of 5 days (P < 0.001) after adjusting for age, sex, comorbidities, congestive heart failure, preoperative hemoglobin, preoperative creatinine, exposure to radiocontrast agent, type of surgery, and surgical AKI risk factors. Importantly, even minor creatinine increases (Δcreatinine 25 to 49% above baseline but < 0.3 mg/dl) not meeting AKI criteria were associated with a two-fold increased risk of death (OR, 1.7; 95% CI, 1.3 to 2.4; P < 0.001) and 2 days longer HLOS (P < 0.001). This was more pronounced in noncardiac surgery patients. Patients with minor creatinine increases had a five-fold risk of death (OR, 5.4; 95% CI, 1.5 to 20.3; P < 0.05) and a 3-day longer HLOS (P < 0.01) when undergoing noncardiac surgery. CONCLUSIONS: Even minor postoperative increases in creatinine levels are associated with adverse outcomes. These results emphasize the importance to find effective therapeutic approaches to prevent or treat even mild forms of postoperative kidney dysfunction to improve surgical outcomes.

Association of comorbidities with postoperative in-hospital mortality: a retrospective cohort study.

The purpose of this article is to evaluate the American Society of Anesthesiologists Physical Status (ASA PS) and the Charlson comorbidity index (CCI) for the prediction of postoperative mortality. The ASA PS has been suggested to be equally good as the CCI in predicting postoperative outcome. However, these scores have never been compared in a broad surgical population. We conducted a retrospective cohort study in a German tertiary care university hospital. Predictive accuracy was compared using the area under the receiver-operating characteristic curves (AUROC). In a post hoc approach, a regression model was fitted and cross-validated to estimate the association of comorbidities and intraoperative factors with mortality. This model was used to improve prediction by recalibrating the CCI for surgical patients (sCCIs) and constructing a new surgical mortality score (SMS). The data of 182,886 patients with surgical interventions were analyzed. The CCI was superior to the ASA PS in predicting postoperative mortality (AUROCCCI 0.865 vs AUROCASAPS 0.833, P < 0.001). Predictive quality further improved after recalibration of the sCCI and construction of the new SMS (AUROCSMS 0.928 vs AUROCsCCI 0.896, P < 0.001). The SMS predicted postoperative mortality especially well in patients never admitted to an intensive care unit. The newly constructed SMS provides a good estimate of patient's risk of death after surgery. It is capable of identifying those patients at especially high risk and may help reduce postoperative mortality.

End-of-life decisions in intensive care medicine-shared decision-making and intensive care unit length of stay.

BACKGROUND: Most deaths on the intensive care unit (ICU) occur after end-of-life decisions (EOLD) have been made. During the decision-making process, responsibility is often shared within the caregiver team and with the patients' surrogates. The intensive care unit length of stay (ICU-LOS) of surgical ICU-patients depends on the primary illness as well as on the past medical history. Whether an increasing ICU-LOS affects the process of EOLD making is unknown. METHODS: A retrospective analysis was conducted on all deceased patients (n = 303) in a 22-bed surgical ICU of a German university medical center. Patient characteristics were compared between surgical patients with an ICU-LOS up to 1 week and those with an ICU-LOS of more than 7 days. RESULTS: Deceased patients with a long ICU-LOS received more often an EOLD (83.2% vs. 63.6%, p = 0.001). Groups did not differ in urgency of admission. Attending intensivists participated in every EOLD. Participation of surgeons was significantly higher in patients with a short ICU-LOS (24.1%, p = 0.003), whereas nurses and the patients' surrogates were involved more frequently in patients with a long ICU-LOS (18.8%, p = 0.021 and 18.9%, p = 0.018, respectively). CONCLUSION: EOLDs of surgical ICU-patients are associated with the ICU-LOS. Reversal of the primary illness leads the early ICU course, while in prolonged ICU-LOS, the patients' predicted will and the expected post-ICU-quality of life gain interest. Nurses and the patients' surrogates participate more frequently in EOLDs with prolonged ICU-LOS. To improve EOLD making on surgical ICUs, the ICU-LOS associated participation of the different decision makers needs further prospective analysis.