A systematic review of risk prediction models for perioperative mortality after thoracic surgery

OBJECTIVESGuidelines advocate that patients being considered for thoracic surgery should undergo a comprehensive preoperative risk assessment. Multiple risk prediction models to estimate the risk of mortality after thoracic surgery have been developed, but their quality and performance has not been reviewed in a systematic way. The objective was to systematically review these models and critically appraise their performance.Open in a separate windowMETHODSThe Cochrane Library and the MEDLINE database were searched for articles published between 1990 and 2019. Studies that developed or validated a model predicting perioperative mortality after thoracic surgery were included. Data were extracted based on the checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies.RESULTSA total of 31 studies describing 22 different risk prediction models were identified. There were 20 models developed specifically for thoracic surgery with two developed in other surgical specialties. A total of 57 different predictors were included across the identified models. Age, sex and pneumonectomy were the most frequently included predictors in 19, 13 and 11 models, respectively. Model performance based on either discrimination or calibration was inadequate for all externally validated models. The most recent data included in validation studies were from 2018. Risk of bias (assessed using Prediction model Risk Of Bias ASsessment Tool) was high for all except two models.CONCLUSIONSDespite multiple risk prediction models being developed to predict perioperative mortality after thoracic surgery, none could be described as appropriate for contemporary thoracic surgery. Contemporary validation of available models or new model development is required to ensure that appropriate estimates of operative risk are available for contemporary thoracic surgical practice.     

A novel preoperative model to predict 90-day surgical mortality in patients considered for renal cell carcinoma surgery

Introduction

Surgical benefits for renal cell carcinoma must be weighed against competing causes of mortality, especially in the elderly patient population. We used a large cancer registry to evaluate the impact of patient and cancer-specific factors on 90-day mortality (90DM). A nomogram to predict the odds of short-term mortality was created.

A 10-year retrospective review of perioperative mortality in pediatric general surgery at Ile-Ife Hospital,Nigeria

Background/Purpose

The analysis of perioperative mortality as well as surgery- and anesthesia-related death in pediatric patients may serve as a potential tool to improve outcome. The aim of this study is to report the 24-h and 30-day overall, and surgery and anesthesia-related, mortality in a tertiary hospital.

消化道疾病患者951例围术期死亡病例调查

目的分析我院胃肠外科患者同术期死亡的高危因素,探讨降低同术期死亡率的方法。方法回顾性研究2005年1月至2010年1月收治的951例手术患者的临床资料,对其中19例嗣术期死亡病例的临床资料进行统计学分析。结果951例手术患者同术期死亡率为2．0％,主要影响凶素是高龄、恶性肿瘤、术前高血压及冠心病以及术后低蛋白血症、呼吸系统衰竭及肾功能不全。并且低体温、代谢性酸中毒和凝血功能障碍严重影响术后生存率。结论强化围术期患者高危因素的积极处理并结合损伤控制外科理念,对于降低死亡率具有重要的意义。     

多模式围术期处理在小儿加速康复外科中的应用

目的通过术前心理干预,采用合理的禁食禁饮方案,适当的麻醉前用药,优化麻醉方式,术后早期进食等一系列措施,研究多模式围术期处理在小儿加速康复外科(enhanced recovery after surgery,ERAS)中的应用。方法择期腹腔镜下行腹股沟区手术患儿127例,男111例,女16例,年龄1~3岁,ASAⅠ级。随机分为对照组(C组,n=59)和多模式组(M组,n=68)。C组常规术前访视,予以一般麻醉处理。M组进行术前亲善宣教、细致访视,术前禁食4~6h,术前2h予以5%葡萄糖5ml/kg,术前1h在以手术切口处皮肤为中心2cm范围内涂抹一层厚约2mm的复方利多卡因乳膏,上盖密封敷膜,术前30 min静脉注射咪达唑仑0.02 mg/kg,缝皮时切口局部浸润0.25%罗哌卡因2ml,术后PACU内安慰,术后2h根据患儿恢复情况早期进食。记录患儿与父母分离时的镇静评分、诱导时的面罩接受程度评分,术中全麻药的用量、拔喉罩时间、意识恢复时间、麻醉恢复时间,术后Ramsay镇静评分、苏醒期躁动评分,术后随访并记录患儿家长的满意度以及患儿不良反应发生情况。结果 M组患儿与父母分离时的镇静评分、诱导时面罩接受程度评分明显高于C组(P0.05),术中丙泊酚、瑞芬太尼总量明显少于C组(P0.05或P0.01),拔喉罩时间、意识恢复时间以及麻醉恢复时间明显短于C组(P0.05或P0.01),术后Ramsay镇静评分明显高于C组(P0.01),苏醒期躁动评分明显低于C组(P0.01),术后家长满意度评分明显高于C组(P0.05)。结论多模式围术期处理在小儿ERAS中有应用价值且安全可行。     

Time to surgery and 30-day morbidity and mortality of periprosthetic hip fractures

Background and aim

The management of femoral periprosthetic fractures following hip replacement surgery is a complex and challenging situation. Whilst the early complications for both primary hip arthroplasty and proximal femoral fracture surgery have been widely documented, there is a paucity of published data regarding early outcomes following periprosthetic fracture surgery.Delay to surgery for native proximal femoral fractures has been clearly documented as a predictor towards adverse outcome. This study therefore aims to correlate the timing of operative intervention with the complication rate following periprosthetic fracture surgery. In addition, the study aims to identify further factors in the perioperative period that positively predict a poor postoperative outcome.

Methods

Sixty patients who were operatively managed for a femoral implant periprosthetic fracture were identified and each case assessed retrospectively.

Results and conclusion

There was an overall complication rate of 45% including a 30-day mortality of 10%. An abbreviated mental test score of 8 out of 10 or less and a delay to surgery of >72 h were found to be significant risk factors for adverse outcome. Both the patient cohort in this study and the predictors for poor postoperative outcome were comparable to those for native proximal femoral fractures.     

Predictive value of perioperative peripheral blood cells counts for bacteremia and 90-day mortality in severe burn patients

ObjectiveBurn bacteremia is related to immune barrier damage, but whether the level of circulating immune cells predicts outcomes in severe burns is still not clear. This study aimed to explore the predictive value of perioperative blood cells of the first surgery after burn for bacteremia and 90-day death.MethodsData from severe burn patients treated at the First Affiliated Hospital of Sun Yat-sen University from 2011 to 2020 were retrospectively analyzed. Data on monocytes (M), lymphocytes (L), white blood cell-to-platelet ratio (WPR), neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and changes in temperature (T-37) were collected at one day before(X0), the first day after (X1) and the third day after (X3) the primary surgery.Univariate and multivariate logistic regression were used to identify the independent risk factors of bacteremia and death within 90 days, which were used to establish the risk prediction models (xbac and x90d-m) in severely burned patients. Severe burn cases from two other burn centers were selected to verify the prediction models.ResultsWe analyzed 169 severe burn cases in the training dataset, with a 90-day mortality of 21.3% (36/169); 56 (33.1%) patients experienced burn bacteremia. Higher M0, WPR0, NLR0, NLR3, T3–37, ∆M (M0-M3) and lower M3, L3 were associated with higher risk of bacteremia (P < 0.05). Multivariate regression analysis showed that SOFA0, WPR0, M3, and T3–37 were independently associated with bacteremia. The prediction model for bacteremia Xbac = 0.1809 × SOFA0 + 6.532 × WPR0–1.171 × M3 + 0.6987 × T3–37- 2.297. TBSAB, SOFA0, and ∆M (M0-M3) were independently correlated with 90-day mortality. The risk prediction model X90d-m= 0.055 × TBSAB + 0.301 ×SOFA0 + 1.508 × ∆M - 7.196. External validation suggested that the specificity, sensitivity and AUC of the prediction model Xbac was 90.7%, 62.5% and 0.797, respectively; of the prediction model X90d-m was 69.2%, 90.0% and 0.873, respectively.ConclusionPeripheral M3, WPR0 and ∆M (M0-M3) during the primary surgery has reasonable predictive ability for bacteremia and 90-day mortality in severe burn patients, which could inform clinical antimicrobial judgment and prognostication.     

术前甲状腺功能异常对老年髋部骨折患者术后30 d内病死率及并发症的影响研究

目的:探讨术前甲状腺功能异常对老年髋部骨折患者术后30 d内病死率及并发症发生率的影响。方法:回顾性分析2018年1月至2019年12月期间首都医科大学附属北京潞河医院创伤骨科收治的349例老年髋部骨折患者资料。男108例,女241例;平均年龄为76.3岁（60~104岁）;骨折类型：股骨转子间骨折190例,股骨颈骨折...     

Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review

Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.     

Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture

ObjectiveThis study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors for mortality in the management of geriatric hip fractures.MethodsA total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60–108] years) with AO/OTA 31A2.2 intertrochanteric fractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. The treatment type was decided by the responsible surgeon according to the patients’ pre-injury activity level, bone quality, and features of the fracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time to surgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-year mortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified the possible risk factors for mortality.ResultsA total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS, 2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 with hemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the 30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus 0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advanced age (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality.ConclusionWe demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated with higher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factors in the management of intertrochanteric hip fractures in the geriatric population.Level of EvidenceLevel IV, Prognostic Study     

30-Day, 90-day and 1-year mortality after emergency colonic surgery

Purpose

Emergency surgery is an independent risk factor in colonic surgery resulting in high 30-day mortality. The primary aim of this study was to report 30-day, 90-day and 1-year mortality rates after emergency colonic surgery, and to report factors associated with 30-day, 90-day and 1-year mortality. Second, the aim was to report 30-day postoperative complications and their relation to in-hospital mortality.

Methods

All patients undergoing acute colonic surgery in the period from May 2009 to April 2013 at Copenhagen University Hospital Herlev, Denmark, were identified. Perioperative data was collected from medical journals.

Results

30-day, 90-day and 1-year mortality was 21, 30 and 41%, respectively. Age >70 years, Performance status ≥3 and resection with stoma were independent factors associated with 30-day mortality. Age >70 years, Performance status ≥3, resection with stoma and malignant disease were independent risk factors associated with 90-day mortality. Age >70 years, Performance status ≥3, resection with stoma and malignant disease were independent factors associated with 1-year mortality. Overall, 30-day complication rate was 63%, with cardiopulmonary complications leading to most postoperative deaths.

Conclusion

Mortality and complication rates after emergency colonic surgery are high and associated with patient related risk factors that cannot be modified, but also treatment related outcomes that are modifiable. An increased focus on medical and other preventive measures should be explored in the future.

     

Hip fracture: effectiveness of early surgery to prevent 30-day mortality

To estimate the effect of delay to surgery for hip fracture on 30-day mortality using a risk adjustment strategy to control for the effect of demographic and clinical confounders. This observational study was carried out on all patients admitted with a hip fracture and discharged between January 2004 and December 2007 from a teaching hospital. Gender, age, time to surgery, mortality and medical comorbidities were derived from hospital discharge records (SDO), while International Normalised Ratio (INR) and American Society of Anaesthesiologists (ASA) score were retrieved from clinical records. Backward stepwise logistic regression was used to identify potential confounders in the relationship between time to surgery and mortality. A final multivariate logistic regression analysis was carried out controlling for the effect of confounders. In the 1320 patients who underwent surgery (mean age = 83 years, % female = 76.8%), time to surgery was two days or less in 746 (56.5%) patients and 30-day mortality was 3.5%. The interventions included partial or total hip replacement (N=820, 62.1%) and reduction and internal fixation (N=500, 37.9%). Multivariate logistic regression analysis showed that patients with a time to surgery greater than two days had a 2-fold increase in 30-day mortality after adjusting for age, gender, and comorbidity (OR=1.992, 95% CI 1.065-3.725). In a second model also including ASA score the odd ratio decreased to 1.839 (95% CI 0.971-3.486). Patients with a hip fracture should have surgery within two days from admission in order to reduce 30-day mortality.     

Effect of preoperative beta-blockade on perioperative mortality in coronary surgery

Background. Many preoperative factors can influence perioperativemortality in cardiac surgery. Because the perioperative useof ß-blocking agents may reduce perioperative cardiaccomplications in non-cardiac surgery, we considered the possibilitythat ß-blocking agents could improve survival in coronarysurgery patients. Methods. In a retrospective study on 1586 patients undergoingcoronary bypass surgery, the relative risk of 30-day mortalitywas determined in relation to preoperative risk factors andmedication. Factors included patient characteristics, pre-existingillness, specific cardiovascular risk factors, cardiac statusand urgency of surgery. Treatment with ß-blockingagents, calcium antagonists, angiotensin-converting enzyme inhibitors,nitrates, anti-arrhythmic agents, diuretics and antithromboticagents was taken into account. Results. Sex, age, chronic obstructive pulmonary disease, urgencyand the preoperative use of diuretics and chronic ß-blockingtherapy were found to be linked to mortality (P<0.05). Backwardstepwise regression testing identified age, urgency and ß-blockingtherapy as independent factors that could predict mortality. Conclusions. Increasing age and urgency of surgery are associatedwith greater mortality, whereas preoperative ß-blockingtherapy is associated with less mortality. The characteristicsof patients who received chronic ß-blockade did notdiffer significantly from those of patients who did not. Theresults suggest that chronic preoperative ß-blockertherapy reduces 30-day mortality in coronary surgery. Br J Anaesth 2003; 90: 27–31