Myocardial injury and long-term oncological outcomes in patients undergoing surgery for colorectal cancer.

PURPOSE: Myocardial injury after noncardiac surgery (MINS) is associated with increased mortality and postoperative complications. In patients with colorectal cancer (CRC), postoperative complications are a risk factor for cancer recurrence and disease-free survival. This study investigates the association between MINS and long-term oncological outcomes in patients with CRC in an ERAS setting. METHODS: This retrospective cohort study was conducted at Zealand University Hospital, Denmark, between June 2015 and July 2017. Patients undergoing CRC surgery were included if troponin was measured twice after surgery. Outcomes were all-cause mortality, recurrence, and disease-free survival within five years of surgery. RESULTS: Among 586 patients, 42 suffered MINS. After five years, 36% of patients with MINS and 26% without MINS had died, p = 0.15. When adjusted for sex, age and UICC, the hazard ratio (aHR) for 1-year all-cause mortality, recurrence, and disease-free survival were 2.40 [0.93-6.22], 1.47 [0.19-11.29], and 2.25 [0.95-5.32] for patients with MINS compared with those without, respectively. Further adjusting for ASA status, performance status, smoking, and laparotomies, the aHR for 3- and 5-year all-cause mortality were 1.05 [0.51-2.15] and 1.11 [0.62-1.99], respectively. Similarly, the aHR for 3- and 5-year recurrence were 1.38 [0.46-4.51], and 1.49 [0.56-3.98] and for 3- and 5-year disease-free survival the aHR were 1.19 [0.63-2.23], and 1.19 [0.70-2.03]. CONCLUSION: In absolute numbers, we found no difference in all-cause mortality and recurrence in patients with and without MINS. In adjusted Cox regression analyses, the hazard was increased for all-cause mortality, recurrence, and disease-free survival in patients with MINS without reaching statistical significance.

Myocardial injury after non-cardiac surgery and per operative fibrin metabolism in patients undergoing hip-fracture surgery: an observational study.

Myocardial injury after non-cardiac surgery (MINS) is associated with a 2-3-fold increased risk of subsequent major cardiovascular events and postoperative mortality. The pathological mechanism behind MINS is not fully uncovered. We hypothesized that patients with MINS following hip fracture surgery would have an altered haemostatic balance pre- and postoperative compared with patients without MINS. This was investigated in a prospective single-centre observational study including patients consecutively. The outcomes were changes in thrombin generation, fibrinogen/fibrin turnover, tissue plasminogen activator, plasminogen activator inhibitor-1 and fibrin structure measurements in patients developing MINS and patients who did not. Outcomes were measured preoperatively and two hours postoperatively. Seventy-two patients were included whereof 26 (36%) patients developed MINS. D-dimer delta values were significantly higher in patients developing MINS than in patients who did not (p = 0.01). After adjusting for age, sex, smoking, alcohol abuse, atrial fibrillation, anticoagulant medication preoperative CRP, preoperative creatinine and duration of surgery, the association remained significant (p = 0.04). There were no significant changes in thrombin generation, in markers of fibrinogen/fibrin turnover besides D-dimer, or in fibrin structure measurements pre- and postoperatively between patients with and without MINS. As such, a relationship between the coagulative and fibrinolytic activity and MINS cannot be ruled out in patients with MINS after hip fracture surgery. Registration: The study was an observational sub-study to a multicentre randomised clinical trial registered at ClinicalTrials.gov (NCT02344797).

Acute kidney injury following major emergency abdominal surgery - a retrospective cohort study based on medical records data.

BACKGROUND: Acute Kidney Injury (AKI) is a frequent and serious postoperative complication in trauma or critically ill patients in the intensive care unit. We aimed to estimate the risk of AKI following major emergency abdominal surgery and the association between AKI and 90-day postoperative mortality. METHODS: In this retrospective cohort study, we included patients undergoing major emergency abdominal surgery at the Department of Surgery, Zealand University Hospital, Denmark, from 2010 to 2016. The primary outcome was the occurrence of AKI within postoperative day seven (POD7). AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO)-criteria. The risk of AKI was analysed with a multivariable logistic regression. The association between AKI and 90-day mortality was analysed with a multivariable survival analysis. RESULTS: In the cohort, 122 out of 703 (17.4%) surgical patients had AKI within POD7. Of these, 82 (67.2%) had AKI stage 1, 26 (21.3%) had AKI stage 2, and 14 (11.5%) had AKI stage 3. Fifty-eight percent of the patients who developed postoperative AKI did so within the first 24 h of surgery. Ninety-day mortality was significantly higher in patients with AKI compared with patients without AKI (41/122 (33.6%) versus 40/581 (6.9%), adjusted hazard ratio 4.45 (95% confidence interval 2.69-7.39, P < 0.0001)), and rose with increasing KDIGO stage. Pre-existing hypertension and intraoperative peritoneal contamination were independently associated with the risk of AKI. CONCLUSIONS: The risk of AKI is high after major emergency abdominal surgery and is independently associated with the risk of death within 90 days of surgery.

Myocardial Injury After Colorectal Cancer Surgery and Postoperative 90-Day Mortality and Morbidity: A Retrospective Cohort Study.

BACKGROUND: Myocardial injury after noncardiac surgery is a strong predictor of 30-day mortality and morbidity. OBJECTIVE: The purpose of this study was to examine the incidence of myocardial injury in patients undergoing colorectal cancer surgery in an enhanced recovery after surgery protocol and its association with 90-day mortality and morbidity. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at Zealand University Hospital, Denmark, between June 2015 and July 2017. PATIENTS: Adult patients undergoing colorectal cancer surgery were included if troponin was measured at least twice during the first 7 days after surgery. The patients were followed for 90 days. MAIN OUTCOME MEASURES: Myocardial injury was defined as an elevated troponin I measurement (>45 ng/L) without evidence of a nonischemic origin causing the elevation. Ninety-day mortality and complications were assessed. RESULTS: A total of 586 patients were included of which 42 were diagnosed with myocardial injury. Thirteen patients (2%) died within 90 days of surgery. There was no significant difference in 90-day mortality between patients with and without myocardial injury (5% (2/42) versus 2% (11/544); p = 0.24). We found a higher incidence of postoperative complications within 90 days of surgery in the myocardial injury group than in the nonmyocardial injury group (43% (18/42) versus 20% (107/544); p < 0.01). We found a significant difference between the myocardial injury group and nonmyocardial injury group in terms of medical complications (33% (14/42) versus 9% (50/544); p < 0.01) but not surgical complications (19% (8/42) versus 16% (85/544); p = 0.56). Myocardial injury was an independent predictor of postoperative complications within 90 days of surgery (adjusted OR, 2.69; 95% CI, 1.31-5.55). LIMITATIONS: This study was limited by its retrospective design. CONCLUSION: Myocardial injury occurs frequently in patients undergoing colorectal cancer surgery in an enhanced recovery after surgery protocol. Patients with myocardial injury did not have a significantly higher 90-day mortality but had higher risk of 90-day postoperative complications than patients without myocardial injury. Future research should examine the prevention and treatment of myocardial injury. See Video Abstract at http://links.lww.com/DCR/B692. LESIN MIOCRDICA DESPUS DE LA CIRUGA DE CNCER COLORRECTAL Y MORTALIDAD Y MORBILIDAD POSOPERATORIAS A LOS DAS UN ESTUDIO DE COHORTE RETROSPECTIVE: ANTECEDENTES:La lesión del miocardio después de una cirugía no cardíaca es un fuerte predictor de mortalidad y morbilidad a los 30 días.OBJETIVO:El propósito fue examinar la incidencia de lesión miocárdica en pacientes sometidos a cirugía de cáncer colorrectal en un protocolo de recuperación mejorada después de la cirugía y su asociación con la mortalidad y morbilidad a los 90 días.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Realizado en el Hospital Universitario de Zelanda, Dinamarca, entre junio de 2015 y julio de 2017.PACIENTES:Se incluyeron pacientes adultos sometidos a cirugía de cáncer colorrectal, si la troponina se midió al menos dos veces durante los primeros siete días después de la cirugía. Los pacientes fueron seguidos durante 90 días.PRINCIPALES MEDIDAS DE RESULTADO:La lesión miocárdica se definió como una medición de troponina I elevada (> 45 ng / l) sin evidencia de una etiología no isquémica que causara la elevación. Se evaluaron la mortalidad y las complicaciones a los noventa días.RESULTADOS:Se incluyeron un total de 586 pacientes, de los cuales 42 fueron diagnosticados de lesión miocárdica. Trece pacientes (2%) murieron dentro de los 90 días posteriores a la cirugía. No hubo diferencias significativas en la mortalidad a 90 días entre los pacientes con y sin lesión del miocardio, 5% [2/42] versus 2% [11/544], p = 0,24. Encontramos una mayor incidencia de complicaciones posoperatorias dentro de los 90 días de la cirugía en el grupo de lesión miocárdica en comparación con el grupo de lesión no miocárdica, 43% [18/42] versus 20% [107/544], p <0,01. Encontramos una diferencia significativa entre el grupo de lesión miocárdica y el grupo de lesión no miocárdica en términos de complicaciones médicas (33% [14/42] versus 9% [50/544]; p <0,01) pero no complicaciones quirúrgicas (19% [8/42] versus 16% [85/544]; p = 0,56). La lesión miocárdica fue un predictor independiente de complicaciones posoperatorias dentro de los 90 días posteriores a la cirugía (razón de probabilidades ajustada: 2,69; intervalo de confianza del 95%: 1,31 - 5,55).LIMITACIONES:Limitado por su diseño retrospectivo.CONCLUSIÓN:La lesión del miocardio ocurre con frecuencia en pacientes sometidos a cirugía de cáncer colorrectal en un protocolo de recuperación mejorada después de la cirugía. Los pacientes con lesión miocárdica no tuvieron una mortalidad significativamente mayor a los 90 días, pero tuvieron un mayor riesgo de complicaciones posoperatorias a los 90 días en comparación con los pacientes sin lesión miocárdica. Las investigaciones futuras deben examinar la prevención y el tratamiento de la lesión miocárdica. Consulte Video Resumen en http://links.lww.com/DCR/B692.

Patient perceptive focus on recovery: An exploratory study on follow-up after major emergency abdominal surgery.

BACKGROUND: Optimal recovery can be defined as the adequate in-hospital length of stay with minimal postoperative complications and readmissions. The quality of recovery beyond the immediate postoperative period after major emergency abdominal surgery is yet to be fully described. We hypothesized that long-term measures of overall recovery were affected after surgery. The study aimed to investigate patient-focused recovery-related parameters 1 year after major emergency abdominal surgery. METHOD: This is a prospective study including patients undergoing major emergency abdominal surgery at a Danish secondary referral center. Three questionnaires were answered regarding the recovery following the procedure; Activities Assessment Scale (AAS); Quality of Recovery-15 (QoR-15), and Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). All questionnaires were answered at postoperative days (PODs) 14, 30, 90, and 365. RESULTS: Eighty-two patients were included, and 68 were available for follow-up until 1 year after surgery. The response rates differed between the follow-up time points, with a response rate of 85% (n = 59) at POD30 and 50% (n = 36) at POD365. A decrease in the level of physical function following surgery was observed in 60% of the patients at POD14, which improved to 36% at POD365. Twenty-four patients (48%) reported postoperative pain at POD14, which declined to 9 (26%) at POD365. The maximum overall recovery was reached at POD30, which remained stable throughout the study period. CONCLUSION: One in three patients reported physical functional impairment, and one in four patients reported pain 1 year after their surgical procedure.

The effect of remote ischaemic preconditioning on endothelial function after hip fracture surgery.

BACKGROUND: Endothelial dysfunction seems to play a role in the pathophysiology of myocardial injury after surgery. The aim of this randomised clinical trial was to examine whether remote ischaemic preconditioning in relation to hip fracture surgery ameliorates post-operative systemic endothelial dysfunction. METHODS: This was a planned single-centre pilot sub-study of a multicentre, randomised clinical trial. Patients ≥45 years with a cardiovascular risk factor were randomised to remote ischaemic preconditioning (RIPC) or control (standard treatment) performed in relation with their hip fracture operation. RIPC consisted of four cycles of 5 minutes forearm ischaemia and reperfusion. The procedure was performed non-invasively with a tourniquet. The endothelial function was assessed with non-invasive digital pulse amplitude tonometry on post-operative day 1 and expressed as the reactive hyperaemia index (RHI). Endothelial dysfunction was defined as RHI < 1.22. RESULTS: Between February 2015 and December 2016, 18 patients were allocated to the RIPC group and 20 patients to the control group. The endothelial function was impaired in both groups on post-operative day 1. RHI did not differ between the groups, 1.47 (95% CI 1.20-1.75) in the RIPC group vs. 1.54 (95% CI 1.17-1.91) in the control group, P = .76. Endothelial dysfunction was present in 3/18 patients (16.7%) in the RIPC group and 8/20 patients (40%) in the control group, P = .11. CONCLUSION: No beneficial effect of remote ischaemic preconditioning on the systemic endothelial dysfunction, assessed at a single time point on post-operative day one, was detected after hip fracture surgery.

Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery.

PURPOSE: The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery. METHODS: An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge. RESULTS: A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake. CONCLUSIONS: The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery.

BACKGROUND: In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis. METHODS: Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control. RESULTS: In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009). CONCLUSION: In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

The risk of post-operative myocardial injury after major emergency abdominal surgery: A retrospective cohort study.

BACKGROUND: The aim was to examine the risk of post-operative myocardial injury after major emergency abdominal surgery and identify pre- and intra-operative risk factors of post-operative myocardial injury. Moreover, the study aimed to examine the association between post-operative myocardial injury and clinical outcomes. METHODS: This was a retrospective cohort study including patients undergoing major emergency abdominal surgery from February 2017 to January 2019. Troponin I was assessed on post-operative days 1-3. Post-operative myocardial injury was defined as a cardiac troponin I ≥ 45 ng per litre. Post-operative clinical outcomes included in-hospital myocardial infarction, in-hospital major adverse cardiovascular events, reoperation, admission to the intensive care unit, lengths of stay, 30- and 90-day all-cause mortality. RESULTS: 98 out of 401 patients (24.4%) sustained a post-operative myocardial injury within the third post-operative day. Increasing age was an independent risk factor of post-operative myocardial injury (age per 10 years adjusted odds ratio 2.2 [95% CI 1.7-2.9], P < .0001). Patients with post-operative myocardial injury had an increased risk of major adverse cardiovascular events, a higher admission rate to the intensive care unit, a longer median post-operative length of stay and a higher 30- and 90-day all-cause mortality compared with patients without myocardial injury. CONCLUSION: One in four patients suffered a post-operative myocardial injury within the third post-operative day. Post-operative myocardial injury was a risk factor of adverse cardiac and non-cardiac clinical outcomes. Troponin monitoring could potentially improve the post-operative risk stratification in this cohort of high-risk surgical patients.

Endothelial dysfunction and myocardial injury after major emergency abdominal surgery: a prospective cohort study.

BACKGROUND: Preoperative endothelial dysfunction is a predictor of myocardial injury and major adverse cardiac events. Non-cardiac surgery is known to induce acute endothelial changes. The aim of this explorative cohort study was to assess the extent of systemic endothelial dysfunction after major emergency abdominal surgery and the potential association with postoperative myocardial injury. METHODS: Patients undergoing major emergency abdominal surgery were included in this prospective cohort study. The primary outcome was the change in endothelial function expressed as the reactive hyperemia index from 4-24 h after surgery until postoperative day 3-5. The reactive hyperemia index was assessed by non-invasive digital pulse tonometry. Secondary outcomes included changes in biomarkers of nitric oxide metabolism and bioavailability. All assessments were performed at the two separate time points in the postoperative period. Clinical outcomes included myocardial injury within the third postoperative day and major adverse cardiovascular events within 30 days of surgery. RESULTS: Between October 2016 and June 2017, 83 patients were included. The first assessment of the endothelial function, 4-24 h, was performed 15.8 (SD 6.9) hours after surgery and the second assessment, postoperative day 3-5, was performed 83.7 (SD 19.8) hours after surgery. The reactive hyperemia index was suppressed early after surgery and did not increase significantly; 1.64 (95% CI 1.52-177) at 4-24 h after surgery vs. 1.75 (95% CI 1.63-1.89) at postoperative day 3-5, p = 0.34. The L-arginine/ADMA ratio, expressing the nitric oxide production, was reduced in the perioperative period and correlated significantly with the reactive hyperemia index. A total of 16 patients (19.3%) had a major adverse cardiovascular event, of which 11 patients (13.3%) had myocardial injury. The L-arginine/ADMA ratio was significantly decreased at 4-24 h after surgery in patients suffering myocardial injury. CONCLUSION: This explorative pathophysiological study showed that acute systemic endothelial dysfunction was present early after major emergency abdominal surgery and remained unchanged until day 3-5 after the procedure. Early postoperative disturbances in the nitric oxide bioavailability might add to the pathogenesis of myocardial injury. This pathophysiological link should be confirmed in larger studies. TRIAL REGISTRATION: clinicaltrials.gov no. NCT03010969.

Postoperative atrial fibrillation following emergency noncardiothoracic surgery: A systematic review.

BACKGROUND: Postoperative atrial fibrillation (POAF) occurs frequently following cardiothoracic surgery and is associated with a higher mortality and a longer hospital stay. The condition is less studied following noncardiothoracic surgery as well as emergency surgery. OBJECTIVE: The aim of this systematic review was to investigate the occurrence of atrial fibrillation following emergency noncardiothoracic surgery and associated risk factors and mortality. DESIGN: We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Observational studies and randomised controlled trials were assessed for risk of bias using the Downs and Black checklist and Cochrane Handbook for Systematic reviews of intervention. DATA SOURCES: A systematic literature search of PubMed, EMBASE and Scopus was carried out in August 2019. No publication date- or source restrictions were imposed. ELIGIBILITY CRITERIA: Observational and randomised controlled trials were included if data on POAF occurring after an emergency, noncardiothoracic, surgical intervention on adult patients could be extracted. RESULTS: We identified 15 studies eligible for inclusion covering orthopaedic-, abdominal-, vascular-, neuro- and miscellaneous noncardiothoracic surgery. The occurrence of POAF after emergency noncardiothoracic surgery ranged from 1.5 to 12.2% depending on type of surgery and intensity of cardiac monitoring. Studies that investigated risk factors and associated mortality found emergency surgery and increasing age to be associated with risk of POAF. Moreover, POAF was generally associated with an increase in long-term and short-term mortality. CONCLUSION: In this study, atrial fibrillation occurred frequently, especially following emergency orthopaedic, vascular and neurosurgery. Emergency surgery and age were independent risk factors for developing atrial fibrillation. POAF seems to be related to a higher risk of postoperative complications and mortality, though further studies with long-term follow-up are needed. TRIAL REGISTRATION: CRD42019112090.

Postoperative mortality after a hip fracture over a 15-year period in Denmark: a national register study.

Background and purpose - In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods - The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results - 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8-25) to 8 (IQR 5-11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation - Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014.

The impact of blood type on transfusion after major emergency abdominal surgery.

BACKGROUND: ABO dependent variation in von Willebrand factor (vWF) and factor VIII have an impact on hemostasis. Several contradictory studies have investigated the influence of ABO blood type in surgical hemorrhage. Emergency surgery is associated with an increased risk of perioperative hemorrhage leading to inferior clinical outcomes. The aim of this study was to investigate if patients with blood type O received more transfusions with blood components compared with non-O patients after major emergency abdominal surgery. STUDY DESIGN AND METHODS: This retrospective observational study combined perioperative data including hemoglobin with transfusion data in patients undergoing emergency surgery at a university hospital between January 2010 and October 2016. The primary outcome was postoperative transfusion stratified into early transfusion, within 24 hours after surgery, and late transfusion from 24 hours to 7 days (POD7) after surgery. RESULTS: A total of 869 patients were included, 363 patients with blood type O (42.0%) and 501 (58.0%) with blood type non-O. We found no difference in the need for transfusion with 42 (11.6%) patients with blood type O and 66 (13.2%) patients with blood type non-O receiving early transfusion and 39 (13.4%) and 48 (11.9%) of O and non-O patients, respectively, receiving late transfusion. Multivariate logistic regression analysis showed an adjusted OR of 0.915 (95% CI 0.569-1.471) for early transfusion and an adjusted OR of 1.307 (95% CI 0.788-2.169) for late transfusion in patients with blood type O. Likewise, no difference was seen with respect to the change in hemoglobin levels before and after surgery as well as transfused volume. CONCLUSION: We did not find an association between transfusion or perioperative changes in hemoglobin with respect to blood type ABO.

The Effect of Perioperative Iron Therapy in Acute Major Non-cardiac Surgery on Allogenic Blood Transfusion and Postoperative Haemoglobin Levels: A Systematic Review and Meta-analysis.

BACKGROUND: Perioperative anaemia in relation to surgery is associated with adverse clinical outcomes. In an elective surgical setting, it is possible to optimize patients prior to surgery, often by iron supplementation with correction of anaemia. Possibilities for optimization prior to and during acute surgical procedures are limited. This review investigates whether iron treatment initiated perioperatively improves outcomes in patients undergoing major acute non-cardiac surgery. METHOD: This systematic review was performed using PubMed, EMBASE (Ovid) and Scopus to identify current evidence on iron supplementation in acute surgery. Primary outcomes were allogenic blood transfusion (ABT) rate and changes in haemoglobin. Secondary outcomes were postoperative mortality, length of stay (LOS), and postoperative complications. Iron was administered at latest within 24 h after end of surgery. RESULTS: Of the 5413 studies screened, four randomized controlled trials and nine observational cohort studies were included. Ten studies included patients with hip fractures. A meta-analysis of seven studies showed a risk reduction of transfusion (OR = 0.35 CI 95% (0.20-0.63), p = 0.0004, I2 = 66%). No influence on plasma haemoglobin was found. Postoperative mortality was reduced in the iron therapy group in a meta-analysis of four observational studies (OR 0.50 (CI 95% 0.26-0.96) p = 0.04). No effect was found on LOS, but a reduction in postoperative infection was seen in four studies. CONCLUSIONS: This review examined perioperative iron therapy in acute major non-cardiac surgery. IV iron showed a lower 30-day mortality, a reduction in postoperative infections and a reduction in ABT largely due to the observational studies. The review primarily consisted of small observational studies and does not have the power to formally recommend this practice.

Short- and long-term mortality in major non-cardiac surgical patients admitted to the intensive care unit.

BACKGROUND: The aim of this register-based cohort study was to characterize patients admitted to the intensive care unit (ICU) following non-cardiac surgery and identify risk factors associated with 30-days, 90-days and 1-year mortality after ICU admission. METHODS: Patients aged 18+ years admitted to the intensive care unit within 30-days of non-cardiac surgery at four Capital Region hospitals in Denmark between January 2005 and December 2014 were included. Patients were identified through the Danish National Patient Register. The outcomes were 30-days, 90-days and 1-year mortality after ICU admission. Unadjusted and multivariate logistic regression analyses were performed to identify independent risk factors of mortality. RESULTS: The study included 3311 ICU patients. Gastrointestinal surgery accounted for 71.3%, orthopaedic surgery for 18.4% and urologic surgery for 10.2% of the population. For the total population, the median length of stay in hospital was 18 days (9-36, 25th-75th percentile) and 2 days (1-4, 25th-75th percentile) in the ICU. Thirty-days, 90-days and 1-year mortality were 37.8%, 44.5% and 51.2% respectively. Mortality within the ICU was 22.3% while the post-ICU in-hospital mortality was 19.4%. Higher age, comorbidity, delayed ICU admission, acute surgery, and gastrointestinal and orthopaedic surgery increased 30-days, 90-days and 1-year mortality. CONCLUSIONS: Short- and long-term mortality in non-cardiac surgical patients admitted to the ICU is very high, especially among the elderly comorbid patients undergoing acute surgery. Future research should focus on targeting clinically modifiable risk factors and performing tailored treatment for these high-risk patients.

Peri-operative endothelial dysfunction in patients undergoing minor abdominal surgery: An observational study.

BACKGROUND: Myocardial injury after noncardiac surgery is common and associated with major adverse cardiac events. Surgery induces acute endothelial dysfunction, which might be central in the pathophysiology of myocardial injury; however, the relationship between surgical stress and endothelial function remains incompletely understood. OBJECTIVES: This study aimed to assess the acute peri-operative changes in endothelial function after minor elective abdominal surgery. DESIGN: A prospective, observational, single-centre study. SETTING: A university hospital from February 2016 to January 2017. PATIENTS: Sixty patients undergoing elective minor abdominal surgery. MAIN OUTCOME MEASURES: The change in endothelial function, expressed as the reactive hyperaemia index (RHI), was assessed by non-invasive digital pulse tonometry. RHI, biomarkers of nitric oxide bioavailability and oxidative stress were assessed prior to and 4 h after surgery. RESULTS: RHI decreased significantly from 1.93 [95% confidence interval (95% CI 1.78 to 2.09)] before surgery to 1.76 (95% CI 1.64 to 1.90), P = 0.03, after surgery. The nitric oxide production, L-arginine/asymmetric dimethylarginine, decreased significantly from a ratio of 213.39 (95% CI 188.76 to 241.2) to a ratio of 193.3 (95% CI 171.82 to 217.54), P = 0.03. Plasma biopterins increased significantly after surgery, while the ratio between tetrahydrobiopterin and dihydrobiopterin was unchanged. Total ascorbic acid decreased significantly after surgery (P < 0.001), while its oxidation ratio was unchanged. CONCLUSION: Elective minor abdominal surgery impaired systemic endothelial function early after surgery. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02690233.

Effect of High Inspiratory Oxygen Fraction on Endothelial Function in Healthy Volunteers: A Randomized Controlled Crossover Pilot Study.

It has been suggested that high inspiratory oxygen concentrations during anesthesia may be associated with higher postoperative mortality due to endothelial dysfunction. A randomized controlled crossover study was conducted with 25 healthy male volunteers. They inhaled an oxygen concentration of 30% and 80%. The endothelial function was assessed using noninvasive digital pulse amplitude tonometry (EndoPAT) supported by endothelial biomarkers. The difference in endothelial function between the 2 treatments was 0.05 (95% confidence interval, -0.36 to 0.27; P = .77). Endothelial biomarkers were unaffected. Inhalation of a high oxygen fraction in healthy volunteers did not result in a significant reduction of endothelial function.

Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study.

PURPOSE: Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery. METHODS: This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days. RESULTS: From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission. CONCLUSION: Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.

Association between reduced physical performance measures and short-term consequences after major emergency abdominal surgery: a prospective cohort study.

BACKGROUND: Major emergency abdominal surgery is associated with high morbidity with outcomes worse than for similar elective surgery, including complicated physical recovery, increased need for rehabilitation, and prolonged hospitalisation. PURPOSE: To investigate whether low physical performance test scores were associated with an increased risk of postoperative complications, and, furthermore, to investigate the feasibility of postoperative performance tests in patients undergoing major emergency abdominal surgery. We hypothesize that patients with low performance test scores suffer more postoperative complications. METHODS: The study is a prospective observational cohort study including all patients who underwent major abdominal surgery at the Department of Surgery at Zealand University Hospital between 1st March 2017 and 31st January 2019. Patients were evaluated with De Morton Mobility Index (DEMMI) score, hand grip strength, and 30-s chair-stand test. RESULTS: The study included 488 patients (median age 69, 50.6% male). Physiotherapeutic evaluation including physical performance tests with DEMMI and hand grip strength in the immediate postoperative period were feasible in up to 68% of patients undergoing major emergency abdominal surgery. The 30-s chair-stand test was less viable in this population; only 21% of the patients could complete the 30-s chair-stand test during the postoperative period. In logistic regression models low DEMMI score (< 40) and ASA classification and low hand grip strength (< 20 kg for women, < 30 kg for men were independent risk factors for the development of postoperative severe complications Clavien-Dindo (CD) grade ≥ 3. CONCLUSIONS: In patients undergoing major emergency surgery low performance test scores (DEMMI and hand grip strength), were independently associated with the development of significant postoperative complications CD ≥ 3.

Effect of Remote Ischaemic Preconditioning on Perioperative Endothelial Dysfunction in Non-Cardiac Surgery: A Randomised Clinical Trial.

Endothelial dysfunction result from inflammation and excessive production of reactive oxygen species as part of the surgical stress response. Remote ischemic preconditioning (RIPC) potentially exerts anti-oxidative and anti-inflammatory properties, which might stabilise the endothelial function after non-cardiac surgery. This was a single centre randomised clinical trial including 60 patients undergoing sub-acute laparoscopic cholecystectomy due to acute cholecystitis. Patients were randomised to RIPC or control. The RIPC procedure consisted of four cycles of five minutes of ischaemia and reperfusion of one upper extremity. Endothelial function was assessed as the reactive hyperaemia index (RHI) and circulating biomarkers of nitric oxide (NO) bioavailability (L-arginine, asymmetric dimethylarginine (ADMA), L-arginine/ADMA ratio, tetra- and dihydrobiopterin (BH4 and BH2), and total plasma biopterin) preoperative, 2-4 h after surgery and 24 h after surgery. RHI did not differ between the groups (p = 0.07). Neither did levels of circulating biomarkers of NO bioavailability change in response to RIPC. L-arginine and L-arginine/ADMA ratio was suppressed preoperatively and increased 24 h after surgery (p < 0.001). The BH4/BH2-ratio had a high preoperative level, decreased 2-4 h after surgery and remained low 24 h after surgery (p = 0.01). RIPC did not influence endothelial function or markers of NO bioavailability until 24 h after sub-acute laparoscopic cholecystectomy. In response to surgery, markers of NO bioavailability increased, and oxidative stress decreased. These findings support that a minimally invasive removal of the inflamed gallbladder countereffects reduced markers of NO bioavailability and increased oxidative stress caused by acute cholecystitis.