Perioperative medicine and UK plc.

No abstract available

A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: A secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study

Background Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. Methods In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg −1 min −1 and peak oxygen consumption (VO 2 peak) >16 ml kg −1 min −1, cut-points that represent a reduced risk of postoperative complications. Results Five questions were identified to have dominance in predicting AT>11 ml kg −1 min −1 and VO 2 peak>16 ml.kg −1min −1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg −1.min −1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO 2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO 2 peak>16 ml.kg −1.min −1 and VO 2 peak<16 ml.kg −1.min −1. Conclusions The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management

Elevated preoperative heart rate is associated with cardiopulmonary and autonomic impairment in high-risk surgical patients

Background. Elevated preoperative heart rate (HR) is associated with perioperative myocardial injury and death. In apparently healthy individuals, high resting HR is associated with development of cardiac failure. Given that patients with overt cardiac failure have poor perioperative outcomes, we hypothesized that subclinical cardiac failure, identified by cardiopulmonary exercise testing, was associated with elevated preoperative HR > 87 beats min1 (HR > 87). / Methods. This was a secondary analysis of an observational cohort study of surgical patients aged 45 yr. The exposure of interest was HR > 87, recorded at rest before preoperative cardiopulmonary exercise testing. The predefined outcome measures were the following established predictors of mortality in patients with overt cardiac failure in the general population: ventilatory equivalent for carbon dioxide (V_ E=V_ co2) ratio 34, heart rate recovery �6 and peak oxygen uptake (V_ o2) �14 ml kg1 min1 . We used logistic regression analysis to test for association between HR > 87 and markers of cardiac failure. We also examined the relationship between HR > 87 and preoperative left ventricular stroke volume in a separate cohort of patients. / Results. HR > 87 was present in 399/1250 (32%) patients, of whom 438/1250 (35%) had V_ E=V_ co2 ratio 34, 200/1250 (16%) had heart rate recovery �6, and 396/1250 (32%) had peak V_ o2 �14 ml kg1 min1 . HR > 87 was independently associated with peak V_ o2 �14 ml kg1 min1 {odds ratio (OR) 1.69 [1.12–3.55]; P¼0.01} and heart rate recovery �6 (OR 2.02 [1.30–3.14]; P<0.01). However, HR > 87 was not associated with V_ E=V_ co2 ratio 34 (OR 1.31 [0.92–1.87]; P¼0.14). In a separate cohort, HR > 87 (33/ 181; 18.5%) was associated with impaired preoperative stroke volume (OR 3.21 [1.26–8.20]; P¼0.01). / Conclusions. Elevated preoperative heart rate is associated with impaired cardiopulmonary performance consistent with clinically unsuspected, subclinical cardiac failure. / Clinical trial registration. ISRCTN88456378

Revised cardiac risk index and postoperative morbidity after elective orthopaedic surgery: a prospective cohort study

The revised cardiac risk index (RCRI) is associated strongly with increased cardiac ischaemic risk and perioperative death. Associations with non-cardiac morbidity in non-cardiac surgery have not been explored. In the elective orthopaedic surgical population, morbidity is common but preoperative predictors are unclear. We hypothesized that RCRI would identify individuals at increased risk of non-cardiac morbidity in this surgically homogenous population.Five hundred and sixty patients undergoing elective primary (> 90%) and revision hip and knee procedures were studied. A modified RCRI (mRCRI) score was calculated, weighting intermediate and low risk factors. The primary endpoint was the development of morbidity, collected prospectively using the Postoperative Morbidity Survey, on postoperative day (POD) 5.Morbidity on POD 5 was more frequent in patients with mRCRI >= 3 {relative risk 1.7, [95% confidence interval (CI): 1.4-2.1]; P < 0.001}. Time to hospital discharge was delayed in patients with mRCRI score >= 3 (log-rank test, P=0.0002). Pulmonary (P < 0.001), infectious (P=0.001), cardiovascular (P=0.0003), renal (P < 0.0001), wound (P=0.02), and neurological (P=0.002) morbidities were more common in patients with mRCRI score >= 3. Pre/postoperative haematocrit, anaesthetic/analgesic technique, and postoperative temperature were similar across mRCRI groups. There were significant associations with hospital stay, as measured by the area under the receiver-operating characteristic curves for mRCRI 0.64 (95% CI: 0.58-0.70) and POSSUM 0.70 (95% CI: 0.63-0.75).mRCRI score >= 3 is associated with increased postoperative non-cardiac morbidity and prolonged hospital stay after elective orthopaedic procedures. mRCRI can contribute to objective risk stratification of postoperative morbidity