Performance of prognostic scores in prediction of 30-day postoperative mortality in COVID-19 patients after emergency surgery: A retrospective cohort study.

Background: : Risk assessment with prognostic scoring, though important, is scarcely studied in emergency surgical patients with COVID-19 infection. Methods and Material: We conducted a retrospective cohort study on adult emergency surgical patients with COVID-19 infection in our institute from 1 May 2020 to 31 October 2021 to find the 30-day postoperative mortality and predictive accuracy of prognostic scores. We assessed the demographic data, prognostic risk scores (American Society of Anesthesiologists-Physical Classification (ASA-PS), Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores), surgical and anesthetic factors. We assessed the postoperative morbidity using the Clavien-Dindo scale and recorded the 30-day mortality. Correlation of prognostic scores and mortality was evaluated using Univariate Cox proportional hazards regression, receiver operating characteristic curve (ROC), Youden's index and Hosmer- Lemeshow goodness of fit model. Results: Emergency surgery was performed in 67 COVID-19 patients with postoperative complication and 30-day mortality rate of 33% and 19%, respectively. A positive qSOFA and ASAPS IIIE/IVE had a 9.03- and 12.7-times higher risk of mortality compared to a negative qSOFA and ASA-PS IE/IIE (P < 0.001), respectively. Every unit increase of SOFA, POSSUM and P-POSSUM scores was associated with a 50%, 18% and 17% higher risk of mortality, respectively. SOFA, POSSUM and P-POSSUM AUCROC curves showed good discrimination between survivors and non-survivors (AUC 0.8829, 0.85 and 0.86, respectively). Conclusions: SOFA score has a higher sensitivity to predict 30-day postoperative mortality as compared to POSSUM and P-POSSUM. However, in absence of a control group of non-COVID-19 patients, actual risk attributable to COVID-19 infection could not be determined.

Remote Ischaemic Preconditioning in Intra-Abdominal Cancer Surgery (RIPCa): A Pilot Randomised Controlled Trial.

There is limited evidence on the effect of remote ischaemic preconditioning (RIPC) following non-cardiac surgery. The aim of this study was to investigate the effect of RIPC on morbidity following intra-abdominal cancer surgery. We conducted a double blinded pilot randomised controlled trial that included 47 patients undergoing surgery for gynaecological, pancreatic and colorectal malignancies. The patients were randomized into an intervention (RIPC) or control group. RIPC was provided by intermittent inflations of an upper limb tourniquet. The primary outcome was feasibility of the study, and the main secondary outcome was postoperative morbidity including perioperative troponin change and the urinary biomarkers tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 (TIMP-2*IGFBP-7). The recruitment target was reached, and the protocol procedures were followed. The intervention group developed fewer surgical complications at 30 days (4.5% vs. 33%), 90 days (9.5% vs. 35%) and 6 months (11% vs. 41%) (adjusted p 0.033, 0.044 and 0.044, respectively). RIPC was a significant independent variable for lower overall postoperative morbidity survey (POMS) score, OR 0.79 (95% CI 0.63 to 0.99) and fewer complications at 6 months including pulmonary OR 0.2 (95% CI 0.03 to 0.92), surgical OR 0.12 (95% CI 0.007 to 0.89) and overall complications, OR 0.18 (95% CI 0.03 to 0.74). There was no difference in perioperative troponin change or TIMP2*IGFBP-7. Our pilot study suggests that RIPC may improve outcomes following intra-abdominal cancer surgery and that a larger trial would be feasible.