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

Modern hydroxyethyl starch and acute kidney injury after cardiac surgery: a prospective multicentre cohort

Background: Recent trials have shown hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients. It is uncertain whether these adverse effects also affect surgical patients. We sought to determine the renal safety of modern tetrastarch (6% HES 130/0.4) use in cardiac surgical patients. Methods: In this multicentre prospective cohort study, 1058 consecutive patients who underwent cardiac surgery from 15th September 2012 to 15th December 2012 were recruited in 23 Spanish hospitals. Results: We identified 350 patients (33%) administered 6% HES 130/0.4 intraoperatively and postoperatively, and 377 (36%) experienced postoperative AKI (AKI Network criteria). In-hospital death occurred in 45 (4.2%) patients. Patients in the non-HES group had higher Euroscore and more comorbidities including unstable angina, preoperative cardiogenic shock, preoperative intra-aortic balloon pump use, peripheral arterial disease, and pulmonary hypertension. The non-HES group received more intraoperative vasopressors and had longer cardiopulmonary bypass times. After multivariable risk-adjustment, 6% HES 130/0.4 use was not associated with significantly increased risks of AKI (adjusted odds ratio 1.01, 95% CI 0.71–1.46, P=0.91). These results were confirmed by propensity score-matched pairs analyses. Conclusions: The intraoperative and postoperative use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with increased risks of AKI and dialysis after cardiac surgery in our multicentre cohor

The relationship between patient data and pooled clinical management decisions

A strong relationship between patient data and preoperative clinical decisions could potentially be used to support clinical decisions in preoperative management. The aim of this exploratory study was to determine the relationship between key patient data and pooled clinical opinions on management. Ina previous study, panels of anaesthetists compared the quality of computer-assisted patient health assessments with outpatient consultations and made decisions on the need for preoperative tests, no preoperative outpatient assessment, possible postoperative intensive care unit/high dependency unit requirements and aspiration prophylaxis. In the current study, the relationship between patient data and these decisions was examined using binomial logistic regression analysis. Backward stepwise regression was used to identify independent predictors of each decision (at P <0.15), which were then incorporated into a predictive model. The number of factors related to each decision varied: blood picture (four factors), biochemistry (six factors), coagulation studies (three factors), electrocardiography (eight factors), chest X-ray (seven factors), preoperative outpatient assessment (17 factors), intensive care unit requirement (eight factors) and aspiration prophylaxis (one factor). The factor types also varied, but included surgical complexity, age, gender, number of medications or comorbidities, body mass index, hypertension, central nervous system condition, heart disease, sleep apnoea, smoking, persistent pain and stroke. Models based on these relationships usually demonstrated good sensitivity and specificity, with receiver operating characteristics with the following areas under curve: blood picture (0.75), biochemistry (0.86), coagulation studies (0.71), electrocardiography (0.90), chest X-ray (0.85), outpatient assessment (0.85), postoperative intensive care unit requirement (0.88) and aspiration prophylaxis (0.85). These initial results suggest modelling of patient data may have utility supporting clinicians' preoperative decisions.G. L. Ludbrook, E. J. O'loughlin, C. Grant, T B. Corcora

Myocardial Infarction in Major Noncardiac Surgery: Epidemiology, Pathophysiology and Prevention

The number of subjects undergoing major noncardiac surgery who are at risk for perioperative myocardial infarction (MI) is growing worldwide. It has been estimated that 500,000 to 900,000 patients suffer major perioperative cardiovascular complications every year, with consequent heavy, long-term prognostic implications and costs. It is well known that perioperative MIs don’t share the same pathophysiology as nonsurgical MIs but the relative role of the different, potential triggers has not been completely clarified. Many aspects of the perioperative management, including risk-stratification and prophylactic or postoperative interventions have also not been completely defined. Throughout recent years many resources have been invested to clarify these aspects and experts have developed indices and algorithm-based strategies to better assess the cardiac risk and to guide the perioperative management. The scope of the present review is to discuss the main aspects of perioperative MI in noncardiac surgery, with particular regard to epidemiology, pathophysiology, preoperative risk stratification, prophylaxis and therapy