Preoperative cardiac evaluation does not improve or predict perioperative or late survival in asymptomatic diabetic patients undergoing elective infrainguinal arterial reconstruction

OBJECTIVE: Patients undergoing infrainguinal arterial reconstruction frequently have increased cardiac risk factors. Diabetic patients are often asymptomatic despite advanced cardiac disease. This study investigates whether preoperative cardiac testing improves the outcome in diabetic patients at risk for cardiac disease. METHODS: We retrospectively reviewed all patients undergoing lower-extremity arterial reconstructions in a 32-month period from July 1999 to February 2002. Of the 433 patients identified undergoing 539 procedures, 295 had diabetes mellitus and considered in this study. The patients were stratified into two groups according to the present American College of Cardiology, American Heart Association (ACC/AHA) algorithm. We identified 140 patients with two or more of ACC (Eagle) criteria who met the inclusion criteria for a preoperative cardiac evaluation. These patients were separated into two groups: those undergoing a cardiac work-up (WU) according to the ACC/AHA algorithm and those not undergoing the recommended work-up (NWU). Outcomes included perioperative mortality, postoperative myocardial infarction, congestive heart failure, arrhythmia, and length of hospitalization. Significance of association was assessed by the Fisher exact test. Length of hospitalization was compared using the Kruskal-Wallis rank sum test. Survival data was analyzed with the Kaplan-Meier method. RESULTS: One hundred forty patients met the criteria for moderate risk. There were 61 patients in the NWU group and 79 in the WU group. Ten patients in the WU group underwent preoperative coronary revascularization (6 had percutaneous transluminal coronary angioplasty, 4 underwent coronary artery bypass grafting). There was no difference between perioperative mortality (WU, 1%; NWU, 2%; P = 1.00) or in postoperative cardiac morbidity, including myocardial infarction, congestive heart failure, and arrhythmia requiring treatment (WU, 5%; NWU, 6%; P = .71). There were no perioperative deaths and one episode of congestive heart failure in the group that had preoperative coronary revascularization. Median length of hospitalization was 10 days in the WU group and 8 days in the NWU group ( P = .11). Patient survival at 12 months for the NWU, WU, and revascularized groups was 85.3%, 78.5%, and 80.0%, respectively; 36-month survival was 73.6%, 62.9%, and 80.0%, respectively. The three survival curves did not differ significantly ( P = .209). CONCLUSIONS: Preoperative cardiac evaluation, as defined by the ACC/AHA algorithm, does not predict or improve postoperative morbidity, mortality, or 36-month survival in asymptomatic, diabetic patients undergoing elective lower-extremity arterial reconstruction. These data do not support the current ACC/AHA recommendations as a standard of care for diabetic patients with an intermediate clinical predictor who undergo peripheral arterial reconstruction, a high-risk surgical procedure.     

Predictors of mortality following symptomatic pulmonary embolism in patients undergoing noncardiac surgery

PURPOSE: To determine 30-day mortality and predictors of mortality following perioperative pulmonary embolism (PE). METHODS: We searched both the Mayo Clinic electronic medical records and Autopsy Registry, between January 1, 1998 and December 31, 2001, for patients who developed PE within 30 days after noncardiac surgery performed under general or neuraxial anesthesia. Medical records of all identified patients were reviewed using standardized data collection forms. The association between risk factors for PE and 30-day post-PE mortality was assessed using t tests, exact binomial tests, and logistic regression. RESULTS: We identified 158 patients with probable or definite perioperative PE. The overall 30-day mortality from the day of PE was 25.3%, i.e., 40 patients died. Hypotension requiring treatment, need for mechanical ventilation, and intensive care unit admission were the prominent univariate predictors of 30-day mortality (all P 相似文献   

Surgical morbidity and mortality among American Indian and Alaska Native veterans: a comparative analysis

BACKGROUND: Few studies have examined surgical risk factors and outcomes in American Indians and Alaska Natives (AI/ANs). My colleagues and I sought to determine if prevalence of preoperative risk factors for morbidity and mortality differed between male AI/AN and Caucasian surgical patients, and to determine if AI/ANs had an increased risk of surgical morbidity or mortality. STUDY DESIGN: We obtained data from the Veterans Affairs National Surgical Quality Improvement Program on major, noncardiac, surgical procedures performed between 1991 and 2002 for all AI/AN men (n = 2,155) and a random sample of Caucasian men (n = 2,264), matched by facility. Chi-square and t-test analyses were used to assess differences in preoperative risk factors between the two groups. Logistic regression was used to determine whether AI/AN race was independently associated with 30-day morbidity (defined as 1 or more of 21 postoperative complications) or 30-day all cause mortality after adjustment for major risk factors. RESULTS: Prevalence of major preoperative risk factors for morbidity and mortality often differed between the groups. Compared with Caucasians, AI/AN race did not predict morbidity (adjusted odds ratio, 0.92; 95% CI, 0.75-1.13), but AI/ANs were at higher risk for 30-day all cause postoperative mortality (adjusted odds ratio, 1.56; 95% CI, 1.04-2.35). CONCLUSIONS: Our results add postoperative mortality to health disparities experienced by AI/ANs. Future research should be conducted to identify other factors that contribute to this disparity.     

Analysis of early mortality and related risk factors in maintenance hemodialysis patients

Objective To analyze the early mortality and related risk factors of new hemodialysis patients in Zhejiang province, and provide basis for reducing the death risk of hemodialysis patients. Methods The early mortality and related factors of new hemodialysis patients from January 1, 2010 to June 30, 2018 were retrospectively analyzed using the database of Zhejiang province hemodialysis registration. The early mortality was defined as death within 90 days of dialysis. Cox regression model was used to analyze the related risk factors of the early mortality in hemodialysis patients. Results The mortality was the highest in the first month after dialysis (46.40/100 person year), and gradually stabilized after three months. The early mortality was 25.33/100 person year. The mortality within 120 days and 360 days were 21.40/100 person year and 11.37/100 person year, respectively. The elderly (≥65 years old, HR=1.981, 95%CI 1.319-2.977, P＜0.001), primary tumor (HR=3.308, 95%CI 1.137-5.624, P=0.028), combined with tumors (not including the primary tumor, HR=2.327, 95%CI 1.200-4.513, P=0.012), temporary catheter (the initial dialysis pathway, HR=3.632, 95%CI 1.806-7.307, P＜0.001), lower albumin (＜30 g/L, HR=2.181, 95%CI 1.459-3.260, P＜0.001), lower hemoglobin (every 0.01 g/L increase, HR=0.861, 95%CI 0.793-0.935, P=0.001), lower high density lipoprotein (＜0.7 mmol/L, HR=1.796, 95%CI 1.068-3.019, P=0.027) and higher C reactive protein (≥40 mg/L, HR=1.889, 95%CI 1.185-3.012, P=0.008) were the risk factors of early death for hemodialysis patients. Conclusions The early mortality of hemodialysis patients is high after dialysis, and gradually stable after 3 months. The elderly, primary tumor, combined with tumors, the initial dialysis pathway, lower albumin, lower hemoglobin, lower high density lipoprotein and higher C reactive protein are the risk factors of early death for hemodialysis patients.     

Limitations in the cardiac risk reduction provided by coronary revascularization prior to elective vascular surgery

OBJECTIVE: The objective of this study was to evaluate the proposed cardiac protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) before elective major arterial surgery. METHOD: Preoperative cardiac risk stratification using American College of Cardiology/American Heart Association (ACC/AHA) guidelines was done on 425 consecutive patients undergoing 481 elective major vascular operations at an academic VA Medical Center. The algorithm assumed asymptomatic patients with prior coronary revascularization (CABG, <5 year; PTCA, <2 year) were low cardiac risk. Coronary angiography was done for recurrent symptoms with secondary intervention when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of vascular surgery were compared between patients with and without previous CABG or PTCA by contingency table and logistic regression analyses. RESULTS: Coronary revascularization was classified as recent (CABG, <1 year; PTCA, <6 months) in 35 cases (7%), prior (1 year < or = CABG < 5 year, 6 months < or = PTCA < 2 year) in 45 cases (9%), and remote (CABG, > or = 5 year; PTCA, > or = 2 year) in 48 cases (10%). A larger fraction of patients with previous revascularization possessed pathologic cardiac risk variables and were stratified as high-risk preoperatively than their nonrevascularized counterparts. Outcomes in patients with previous PTCA were similar to those after CABG (P =.7). Significant differences in adverse cardiac events (P =.01) and mortality (P =.05) were found between patients with CABG done within 5 years or PTCA within 2 years (6.3%, 1.3%, respectively), individuals with remote revascularization (10.4%, 6.3%), and nonrevascularized patients stratified at high risk (13.3%, 3.3%) or intermediate/low (2.8%, 0.9%) risk. De novo or recurrent 3-vessel coronary disease by angiography, but not the presence or timing of previous revascularization, was an independent predictor of cardiac events after vascular operations, whereas remote revascularization was associated with fatal outcomes by multivariate analysis. CONCLUSIONS: Previous coronary revascularization (CABG, <5 years; PTCA, <2 years) may provide only modest protection against adverse cardiac events and mortality following major arterial reconstruction.     

Critical appraisal of cardiac risk stratification before elective vascular surgery

This study was undertaken to evaluate the efficacy of the cardiac risk stratification protocol proposed by the American College of Cardiology/American Heart Association (ACC/AHA) in predicting cardiac morbidity and mortality associated with elective, major arterial surgery. Cardiac risk stratification using ACC/AHA guidelines was done on 425 consecutive patients before 481 elective cerebrovascular (n = 146), aortic/inflow (n = 166), or infrainguinal (n = 169) procedures at an academic Veterans Affairs Medical Center. Cardiac risk was stratified as low, intermediate, or high based on clinical risk factors, such as, Eagle criteria, history of cardiac intervention, patient functional status, results of noninvasive cardiac stress testing, and coronary angiography with coronary revascularization performed when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of surgery were compared between the various risk stratification groups. Univariate and multivariate analyses were used to identify clinically useful prognostic variables from the preoperative cardiac evaluation algorithm. Overall mortality (1.7%), cardiac death (0.4%), and adverse cardiac event (4.8%) rates were low, but cardiac death and morbidity were increased (p < 0.05) in high-risk stratified patients (3.4%, 11.9%) compared to intermediate (0%, 2.8%) and low (0%, 4.0%) cardiac risk groups. The presence of 3-vessel angiographic coronary artery occlusive disease was an independent predictor of cardiac morbidity, while inducible ischemia by cardiac stress imaging was not. Previous coronary revascularization was associated with increased mortality as was the development of a non-cardiac complication. Cardiac risk assessment identified 78 (18%) patients with indications for coronary angiography. Angiographic findings resulted in coronary artery intervention (9-angioplasty; 4-bypass grafting) in 13 (3%) patients who experienced no adverse cardiac events after the planned vascular surgery (15 procedures). Cardiac risk stratification using ACC/AHA guidelines can predict adverse cardiac events associated with elective vascular surgery; however, protocol modification by increased reliance on Eagle criteria and less use of cardiac stress testing can improve identification of the "highest risk" patients who may benefit from prophylactic coronary intervention.     

Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery

Background

American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that patients with an ejection fraction (EF) of 30% or less should not undergo mitral valve replacement for mitral regurgitation (MR). We sought to establish, using a national cardiac surgery database, whether patients with left ventricular dysfunction may safely undergo mitral valve surgery for MR, and if so, which ones.

Methods

We queried the Society of Thoracic Surgeons (STS) National Database to identify patients who had isolated mitral valve replacement or repair for MR between 1998 and 2001. Mortality and morbidity outcomes were compared by EF category (≤ 30% vs > 30%), and observed mortality compared by EF group, stratified by predicted risk for mortality. A classification and regression tree (CART) model was then used to determine which patient characteristics contributed most to designate the high-risk patient.

Results

Of the 14,582 patients who had mitral valve surgery, 727 had an EF of 30% or less and 13,855 had an EF of more than 30%. Observed mortality rates were higher for patients with an EF of 30% or less (5.4% vs 3.1%). However, for low-risk to medium-risk patients, mortality rates remained fairly constant across levels of EF. Mortality is notably increased in the high-risk patients (predicted risk > 10%). A classification tree identifies three key characteristics for high risk: age more than 75 years, renal failure, and emergent or salvage procedure.

Conclusions

When the predicted mortality risk is less than 10%, EF has minimal impact on operative mortality for mitral regurgitation. In contrast to the ACC/AHA Guidelines, our data show that operative risk for mitral valve surgery is not prohibitive for most patients with ventricular dysfunction.     

Mortality and risk factors for surgical lung biopsy in patients with idiopathic interstitial pneumonia

Background: The overall safety of surgical lung biopsy in patients with idiopathic interstitial pneumonia (IIP) remains controversial. This study was performed to investigate the mortality and complication rate and identify the risk factors for surgical lung biopsy in patients with IIP. Methods: A total of 200 patients with IIP who underwent surgical lung biopsy at the Asan Medical Center, Korea, from April 1990 to August 2003, were enrolled. Complications and mortality were analyzed retrospectively. Results: (1) The mortality rate 30 days after the surgical lung biopsy was 4.3%, which was significantly higher than the control group. Biopsy performed at the time of acute exacerbation (AE) resulted in higher 30-day mortality (28.6%) compared to non-AE (3.0%; p < 0.05). AE was followed by biopsy itself in three cases. (2) Univariate analysis indicated that lower FVC, lower DL_CO, and presence of AE were significant risk factors for 30-day mortality (p < 0.05). However, multivariate analysis revealed that only AE (OR: 11.334, 95% CI: 1.727–74.365, p = 0.011) was an independent risk factor. (3) The patients with low DL_CO (<50% predicted) had higher mortality and complication rate than high DL_CO group. Conclusion: Our data suggested that the presence of acute exacerbation at the time of biopsy and lower DL_CO were predictors of higher mortality after the surgical lung biopsy.     

Effect of acute kidney injury on short-and long-term mortality of patients with acute myocardial infarction

Objective To evaluate the role of acute kidney injury (AKI) in predicting the early (30-day) and late (30-day to 5-year) mortality of acute myocardial infarction (AMI) patients during hospitalization. Methods A total of 1371 adult patients diagnosed with AMI in the First People's Hospital of Changzhou from January 2008 to December 2012 were analyzed retrospectively with collecting their relevant clinical data from the hospital's database. AKI was categorized according to the 2012 KDIGO AKI criteria. To compare between death group and non-death group in AMI patients during 30-day and 30-day to 5-year. Different AKI stages of patients were compared, and their all-cause mortality were analyzed by Kaplan-Meier. Using multivariate COX regression analysis with two models to assess the factors for AMI patients in 30-day to 5-year. Results The prevalence of AKI after AMI in death group was higher than that in non-death group (the 30-day prevalence was 72.7% vs 27.4%, P＜0.001; the 5-year prevalence was 36.3% vs 26.2%, P=0.013). In both early (30-day) and late (30-day to 5-year) follow up, the KDIGO grading distribution of AKI was different between death group and non-death group (P＜0.001 in 30-day follow up and P=0.002 in 30-day to 5-year follow up). Among the 1371 AMI patients,410 (29.9%) developed AKI during the hospital stay. The 30-day and 30-day to 5-year mortality rates were 5.6% (77/1371) and 11.3% (146/1294) respectively. All-cause mortality and cardiovascular mortality were significantly higher in patients with AKI-Ⅰstage, AKI-Ⅱ stage and AKI-Ⅲ stage than those with non-AKI (all P＜0.001), especially in patients with AKI-Ⅲ stage. Further stroke history (HR=3.122, P=0.012), AKI severity (AKI-Ⅰstage HR=3.034, P=0.028; AKI-Ⅱ stage HR=7.832, P＜0.001; AKI -Ⅲ stage HR=9.919, P＜0.001), and β-blocker therapy (HR=0.591, P=0.040) were independent predictors of 30-day mortality, while aging (HR=1.061, P＜0.001), albumin (HR=0.943, P=0.023), AKI -Ⅲ stage (HR=3.944, P=0.007), β-blocker therapy (HR=0.660, P=0.041) and percutaneous coronary intervention (HR=0.256, P＜0.001) were independent predictors of 30-day to 5-year mortality. Both at early (30-day) and late (30-day to 5-year) follow-up, AKI with or without baseline renal dysfunction were independent predictors of death in patients with AMI (all P＜0.05). Conclusions AKI strongly correlated with short- and long-term all-cause mortality of AMI patients, regardless of the baseline renal impairment. Specifically, the more severe AKI, the higher short-term mortality AMI patients have.     

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture

IntroductionWe conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD.MethodsThis study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality.ResultsThe 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD.ConclusionsIn elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.     

Aggregate risk score for predicting mortality after surgical biopsy for interstitial lung disease

In order to develop a practical risk score for 90-day mortality following surgical lung biopsy (SLB) for interstitial lung disease (ILD) we reviewed 311 consecutive patients undergoing SLB for ILD between 2002 and 2009. Postoperative complication, 30-day and 90-day mortality rates were 11.5%, 9% and 10.6% respectively. Univariable and multivariable analyses, validated by bootstrap statistics, were used to identify factors associated with 90-day mortality. A scoring system was developed by proportionally weighting the regression coefficients of the significant predictors of 90-day mortality: age >67 (P < 0.0001, weighted score 1.5), preoperative intensive care unit (ICU) admission (P = 0.006, weighted score 2), immunosuppressive treatment (P = 0.004, weighted score 1.5) and open surgery (P = 0.03, weighted score 1). Patients were grouped in four classes showing incremental risk of death at 90 days: class A, score 0 (2%); class B, score 1-2 (12%); class C, score 2.5-3 (40%); class D, score >3 (86%); P <0.0001). SLB entails a considerable surgical risk with an overall 90-day mortality around 10%. We were able to develop a practical risk score which, if validated by other independent studies, can be easily used to stratify the risk of SLB candidates and assess the cost-effectiveness of this procedure.     

Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study

BACKGROUND: Venous thromboembolism (VTE) is a potentially preventable postoperative complication. Accurate risk prediction is an essential first step toward limiting serious, and sometimes fatal, postoperative VTE. We sought to develop and test a model to predict patients at high risk for postoperative VTE. STUDY DESIGN: Data from the Patient Safety in Surgery (PSS) Study were used to develop and test a predictive model of VTE using multiple logistic regression analyses. RESULTS: VTE occurred in 1,162 of 183,069 (0.63%) patients undergoing vascular and general surgical procedures. The 30-day mortality in patients who suffered a VTE was 11.19%. Fifteen variables independently associated with increased risk of VTE included patient factors (female gender, higher American Society of Anesthesiologists class, ventilator dependence, preoperative dyspnea, disseminated cancer, chemotherapy within 30 days, and > 4 U packed red blood cell transfusion in the 72 hours before operation), preoperative laboratory values (albumin < 3.5 mg/dL, bilirubin > 1.0 mg/dL, sodium > 145 mmol/L, and hematocrit < 38%), and operative characteristics (type of surgical procedure, emergency operation, work relative value units, and infected/contaminated wounds). These variables were used to develop a predictive model for postoperative VTE (c-index = 0.7647) and a risk score that can be used in the preoperative assessment of patients undergoing major operations. CONCLUSIONS: Venous thromboembolic events after noncardiac operations are relatively infrequent but highly lethal. Important multivariable risk factors for VTE in this setting were identified in the large PSS database. The risk-prediction scoring system, developed by using the logistic regression odds ratios, helps to identify patients at risk for postoperative VTE and to institute appropriate perioperative prophylactic measures.     

Two cases of preceded aortic valve replacement for severe aortic stenosis before the cancer operations

We report two cases of aortic valve replacement (AVR) for severe aortic stenosis (AS) before the cancer operations. Severe AS poses a great risk for noncardiac surgery. In the ACC/AHA 2007 Guideline on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery, if the AS is symptomatic, elective noncardiac surgery should generally be postponed or canceled. Such patients require AVR before elective noncardiac surgery. On the other hand, in patients with severe AS who refuse cardiac surgery, noncardiac surgery can be performed with a mortality risk of approximately 10%. In our cases, severe AS was found in the preoperative examination. We informed them about necessary AVR before noncardiac surgery, and patients consented to our suggestion. AVR was performed around 7 days after this consent, and cancer operation was performed around 30 days after the AVR. However, there are no clear guidelines for this interval between AVR and cancer operation. In our cases the patients underwent the cardiac surgery and noncardiac surgery in a short period without serious complication in the perioperative management. It is very important to discuss among surgeon, cardiovascular surgeon, cardiologist and anesthesiologist. Especially anesthesiologist should take an important role in organizing these departments for such patients.     

The risk factors of mortality in peritoneal dialysis patients in different periods

Objective To explore the risk factors and characteristics in patients with peritoneal dialysis who died in different periods. Methods The clinical data of new peritoneal dialysis patients in the Department of Nephrology and Peritoneal Dialysis Center of the First Affiliated Hospital of Nanchang University from November 1, 2005 to February 28, 2017 was retrospectively analyzed. The patients were divided into two groups according to the time of death: those who died within one year and died after one year. The risk factors of mortality between the two groups were analyzed by Cox regression model. Results A total of 997 patients were enrolled and 244 patients died. There were 69 patients (28.3%) died within one year and 175 patients (71.7%) died after one year. Cardiovascular and cerebrovascular disease was the dominating reason of death in both groups, accounting for 59.4% (died within one year group) and 51.4% (died after one year group) respectively. Cox regression analysis showed that for died within one year group, old age (HR=1.035, 95%CI: 1.016-1.055, P＜0.001), low blood total calcium (HR=0.167, 95%CI: 0.053-0.529, P=0.002), low albumin (HR=0.899, 95%CI: 0.856-0.943, P＜0.001) and low apolipoprotein A1 (HR=0.274, 95%CI: 0.095-0.789, P=0.016) were risk factors associated with mortality. However, for died after one year group, old age (HR=1.053, 95%CI: 1.038-1.069, P＜0.001), combined with diabetes (HR=2.181, 95%CI: 1.445-3.291, P＜0.001) and hypertriglyceride (HR=1.204, 95%CI: 1.065-1.362, P=0.003) were risk factors associated with mortality. Conclusions The risk factors of mortality for peritoneal dialysis patients of different periods were not exactly the same. For died within one year patients, old age, low blood total calcium, low albumin and low apolipoprotein A1 were independent risk factors for mortality.However, for died after one year patients, old age, combined with diabetes, and high triglycerides were independent risk factors for mortality.     

Surgery for esophageal cancer complicate with cardiovascular disease

A risk of cardiac complications is one of the most significant risks to patient undergoing major surgery. Especially, for the patients with cancer, the preoperative management can be complex. The direct effect of cancer and side effect of prior chemotherapy or radiation therapy should be considered. The 2007 American College of Cardiology/American Heart Association( ACC/AHA) guidelines on perioperative cardiovascular evaluation for noncardiac surgery concluded that 3 elements must be assessed to determine the risk of cardiac event. The preoperative risk in a patient is initially assessed by the presence or absence of clinical predictors of increased perioperative cardiovascular risk, the patient's level of cardiac function, and the underlying risk of the surgical procedure. Here we will provide an overview of issue that are relevant to patients with esophageal cancer.     

Factors affecting early mortality in spontaneous rupture of hepatocellular carcinoma

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) is a catastrophic surgical emergency with high mortality rates. The aim of this study is to determine the factors associated with the prognosis and to assess the outcome of different management strategies. METHODS: A retrospective study of 34 consecutive patients with spontaneous rupture of HCC was conducted from January 1996 to January 2004. Clinical, biochemical and operative factors influencing 30-day mortality were analysed. RESULTS: In our study, 30-day mortality rate was 32% (n = 11). Presence of cirrhosis, Child's C status, shock on admission, higher blood transfusion requirement, raised alpha-fetoprotein, raised alkaline phosphatase, raised aspartate transaminase, and raised indocyanine green at 15 min were all associated with increased risk of 30-day mortality on univariate analysis (P < 0.05). On multivariate analysis, only shock on admission (P = 0.001) and higher blood transfusion requirement (P = 0.01) were significant independent factors affecting early mortality. Surgical intervention was associated with a better 30-day survival as compared with medical therapy or transarterial embolization. The median survival time of patients undergoing curative resection was significantly longer than that of patients who had surgery for haemostasis only (420 vs 205 days). The overall median survival was 161 days. CONCLUSIONS: Spontaneous rupture of HCC is a potentially salvageable complication of HCC. Poor prognosis is associated with poor liver reserve, advanced disease and severity of haemorrhage. Shock and blood transfusion requirement are the only independent factors affecting early mortality.     

Prolonged hospital stay after arthroplasty for geriatric femoral neck fractures is associated with increased early mortality risk after discharge

BackgroundRecent studies show increasing mortality rates of geriatric femoral neck fracture patients with delays in operative treatment greater than 48 hours from injury. A less extensively studied area in this population is the effect of length of inpatient hospital stay (LOS) on outcomes. The purpose of this study was to determine the association of LOS after arthroplasty for geriatric femoral neck fractures with 30-day mortality risk.MethodsThis study is a retrospective review using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a nationally validated, outcomes-based database incorporating data from over 700 geographically diverse medical centers. It included 9005 patients, 65 years of age or older, who underwent either hemiarthroplasty or total hip arthroplasty for a femoral neck fracture between 2011 and 2018. Using multivariate analysis, risk of 30-day mortality based on surgery-to-discharge time was determined, expressed as odds ratios (OR) with 95% confidence intervals (CI).ResultsAfter controlling for sex, BMI, age, surgical procedure, American Society of Anesthesiologists (ASA) classification, and discharge location, the risk of mortality after discharge was increased with longer post-surgical length of stay [OR 2.5, P < .001].ConclusionProlonged LOS after arthroplasty for geriatric femoral neck fractures is associated with increased 30-day mortality risk. Efforts made to target and mitigate modifiable risk factors responsible for delaying discharge may improve early outcomes in this population.     

Body mass index and outcome after coronary artery bypass surgery

AIM: Morbidity and mortality after surgical interventions are influenced by different preoperative factors. We investigated the impact of body mass index (BMI) on outcome after coronary artery bypass grafting (CABG). METHODS: A total of 4 749 CABG patients were divided into 4 groups: low BMI (or=35 kg/m(2), n=146). The incidence of severe perioperative complications (heart failure, renal failure or perioperative stroke), 30-day mortality, length of stay (LOS) and long-term survival were compared. A multivariate analysis with BMI, age, gender and Cleveland Clinic risk score as independent variables and 30-day mortality as dependent variable was performed. RESULTS: Compared to patients with normal BMI, low BMI patients had higher incidence of severe complications (12.5 vs 7.0%, P=0.039), higher 30-day mortality (6.2 vs 1.7 %, P=0.001) and inferior cumulative long-term survival (P=0.04). Patients with moderately increased BMI had longer LOS (10.8 vs 9.0 days, P=0.003) but no difference in incidence of severe complications or mortality. Patients with severely increased BMI had a higher incidence of severe complications (12.3 vs 7.0%, P=0.015, longer LOS (13.0 vs 9.0 days, P<0.001), but no significant difference in early or long-term mortality. Low but not high BMI was an independent predictor for 30-day mortality. CONCLUSIONS: The results suggest that low BMI is associated with increased morbidity and mortality after CABG. Overweight is associated with more postoperative complications and longer hospitalisation but not with an increased early or long-term mortality.     

An evaluation of existing risk stratification models as a tool for comparison of surgical performances for coronary artery bypass grafting between institutions

Objective: Risk stratification systems are used in cardiac surgery to estimate mortality risk for individual patients and to compare surgical performance between institutions or surgeons. This study investigates the suitability of six existing risk stratification systems for these purposes. Methods: Data on 5471 patients who underwent isolated coronary artery bypass grafting at two UK cardiac centres between 1993 and 1999 were extracted from a prospective computerised clinical data base. Of these patients, 184 (3.3%) died in hospital. In-hospital mortality risk scores were calculated for each patient using the Parsonnet score, the EuroSCORE, the ACC/AHA score and three UK Bayes models (old, new complex and new simple). The accuracy for predicting mortality at an institutional level was assessed by comparing total observed and predicted mortality. The accuracy of the risk scores for predicting mortality for a patient was assessed by the Hosmer-Lemeshow test. The receiver operating characteristic (ROC) curve was used to evaluate how well a system ranks the patient with respect to their risk of mortality and can be useful for patient management. Results: Both EuroSCORE and the simple Bayes model were reasonably accurate at predicting overall mortality. However predictive accuracy at the patient level was poor for all systems, although EuroSCORE was accurate for low to medium risk patients. Discrimination was fair with the following ROC areas: Parsonnet 0.73, EuroSCORE 0.76, ACC/AHA system 0.76, old Bayes 0.77, complex Bayes 0.76, simple Bayes 0.76. Conclusions: This study suggests that two of the scores may be useful in comparing institutions. None of the risk scores provide accurate risk estimates for individual patients in the two hospitals studied although EuroSCORE may have some utility for certain patients. All six systems perform moderately at ranking the patients and so may be useful for patient management. More results are needed from other institutions to confirm that the EuroSCORE and the simple Bayes model are suitable for institutional risk-adjusted comparisons.     

Predictors of Postoperative Acute Renal Failure after Noncardiac Surgery in Patients with Previously Normal Renal Function

Background: The authors investigated the incidence and risk factors for postoperative acute renal failure after major noncardiac surgery among patients with previously normal renal function.

Methods: Adult patients undergoing major noncardiac surgery with a preoperative calculated creatinine clearance of 80 ml/min or greater were included in a prospective, observational study at a single tertiary care university hospital. Patients were followed for the development of acute renal failure (defined as a calculated creatinine clearance of 50 ml/min or less) within the first 7 postoperative days. Patient preoperative characteristics and intraoperative anesthetic management were evaluated for associations with acute renal failure. Thirty-day, 60-day, and 1-yr all-cause mortality was also evaluated.

Results: A total of 65,043 cases between 2003 and 2006 were reviewed. Of these, 15,102 patients met the inclusion criteria; 121 patients developed acute renal failure (0.8%), and 14 required renal replacement therapy (0.1%). Seven independent preoperative predictors were identified (P < 0.05): age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy. Several intraoperative management variables were independent predictors of acute renal failure: total vasopressor dose administered, use of a vasopressor infusion, and diuretic administration. Acute renal failure was associated with increased 30-day, 60-day, and 1-yr all-cause mortality.