Incidence and prediction of intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation and 30-day mortality in non-cardiac surgical patients.

BACKGROUND The incidence, prediction and mortality outcomes of intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR) in surgical patients are under investigated and have not been studied concurrently in a single study. METHODS A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program data between 2008 and 2012. Firth's penalized logistic regression was used to study the incidence and identify risk factors for intra- and postoperative CPR and 30-day mortality. simplified prediction model was constructed and internally validated to predict the studied outcomes. RESULTS Among about 1.86 million non-cardiac operations, the incidence rate of intraoperative CPR was 0.03%, and for postoperative CPR was 0.33%. The 30-day mortality incidence rate was 1.25%. The incidence rate of events decreased overtime between 2008-2012. Of the 29 potential predictors, 14 were significant for intraoperative CPR, 23 for postoperative CPR, and 25 for 30-day mortality. The five strongest predictors (highest odd ratios) of intraoperative CPR were the American Society of Anesthesiologists (ASA) physical status, Systemic Inflammatory Response Syndrome (SIRS)/sepsis, surgery type, urgent/emergency case and anesthesia technique. Intraoperative CPR, ASA, age, functional status and end stage renal disease were the most significant predictors for postoperative CPR. The most significant predictors of 30-day mortality were ASA, age, functional status, SIRS/sepsis, and disseminated cancer. The predictions with the simplified five-factor model performed well and was comparable to the full prediction model. Postoperative cardiac arrest requiring CPR, compared to intraoperative, was associated with much higher mortality. CONCLUSIONS The incidence of cardiac arrest requiring CPR in surgical patients decreased overtime. Risk factors for intraoperative CPR, postoperative CPR and perioperative mortality are overlapped. We proposed a simplified approach compromised of five-factor model to identify patients at high risk. Postoperative, compare to intraoperative, cardiac arrest requiring CPR was associated with much higher mortality

Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study

BACKGROUND Many orthopaedic surgical procedures can be performed with either regional or general anesthesia. We hypothesized that total hip arthroplasty with regional anesthesia is associated with less postoperative morbidity and mortality than total hip arthroplasty with general anesthesia. METHODS This retrospective propensity-matched cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database included patients who had undergone total hip arthroplasty from 2007 through 2011. After matching, logistic regression was used to determine the association between the type of anesthesia and deep surgical site infections, hospital length of stay, thirty-day mortality, and cardiovascular and pulmonary complications. RESULTS Of 12,929 surgical procedures, 5103 (39.5%) were performed with regional anesthesia. The adjusted odds for deep surgical site infections were significantly lower in the regional anesthesia group than in the general anesthesia group (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.20 to 0.72; p 0.05). The adjusted odds for cardiovascular complications (OR = 0.61; 95% CI = 0.44 to 0.85) and respiratory complications (OR = 0.51; 95% CI = 0.33 to 0.81) were all lower in the regional anesthesia group. CONCLUSIONS Compared with general anesthesia, regional anesthesia for total hip arthroplasty was associated with a reduction in deep surgical site infection rates, hospital length of stay, and rates of postoperative cardiovascular and pulmonary complications. These findings could have an important medical and economic impact on health-care practice

Contaminated heparin and outcomes after cardiac surgery: a retrospective propensity-matched cohort study.

During 2007 and 2008 it is likely that millions of patients in the US received heparin contaminated (CH) with oversulfated chondroitin sulfate, which was associated with anaphylactoid reactions. We tested the hypothesis that CH was associated with serious morbidity, mortality, intensive care unit (ICU) stay and heparin-induced thrombocytopenia following adult cardiac surgery.We conducted a single center, retrospective, propensity-matched cohort study during the period of CH and the equivalent time frame in the three preceding or the two following years. Perioperative data were obtained from the institutional record of the Society of Thoracic Surgeons National Database, for which the data collection is prospective, standardized and performed by independent investigators. After matching, logistic regression was performed to evaluate the independent effect of CH on the composite adverse outcome (myocardial infarction, stroke, pneumonia, dialysis, cardiac arrest) and on mortality. Cox regression was used to determine the association between CH and ICU length of stay. The 1∶5 matched groups included 220 patients potentially exposed to CH and 918 controls. There were more adverse outcomes in the exposed cohort (20.9% versus 12.0%; difference  =  8.9%; 95% CI 3.6% to 15.1%, P < 0.001) with an odds ratio for CH of 2.0 (95% CI, 1.4 to 3.0, P < 0.001). In the exposed group there was a non-significant increase in mortality (5.9% versus 3.5%, difference = 2.4%; 95% CI, -0.4 to 3.5%, P  =  0.1), the median ICU stay was longer by 14.1 hours (interquartile range -26.6 to 79.8, S = 3299, P = 0.0004) with an estimated hazard ratio for CH of 1.2 (95% CI, 1.0 to 1.4, P = 0.04). There was no difference in nadir platelet counts between cohorts.The results from this single center study suggest the possibility that contaminated heparin might have contributed to serious morbidity following cardiac surgery

Proportional Hazards Model of ICU-LOS during Heparin Contamination.

<p>ICU-LOS indicates length of stay on the intensive care unit; SE, standard error; HR, hazard ratio; CI, confidence interval; CH, contaminated heparin; LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass time; TXA, tranexamic acid.</p><p>Proportional Hazards Model of ICU-LOS during Heparin Contamination.</p

Logistic Regression Model of Composite Outcome^* during Heparin Contamination.

<p>SE indicates standard error; OR, odds ratio; CI, confidence interval; CH, contaminated heparin; #, number of comorbidities; LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass time; TXA, tranexamic acid. Overall fit: 2 Log likelihood ratio = 65.9, P<0.0001; Wald F = 5.8 on 12 and 906 degrees of freedom, P<0.0001; Hosmer-Lemeshow: X² = 4.9, Degrees of freedom = 8, P = 0.87.</p><p>*Composite outcome is any postoperative myocardial infarction, stroke, pneumonia, dialysis or cardiac arrest.</p><p>Logistic Regression Model of Composite Outcome^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0106096#nt104" target="_blank">*</a>} during Heparin Contamination.</p

Summary Statistics of Unadjusted Patient Outcome Before and After PS Matching during Heparin Contamination.

<p>PS indicates propensity score; n, number of patients; %, number of patients in percent of total per group; M, median; IQR, interquartile range; MI, myocardial infarction; ICU LOS, length of stay on the intensive care unit.</p><p>*Composite outcome is any postoperative myocardial infarction, stroke, pneumonia, renal failure with dialysis or cardiac arrest during hospitalization.</p><p>Summary Statistics of Unadjusted Patient Outcome Before and After PS Matching during Heparin Contamination.</p

Subgroup Analysis of ACEI and ARB: Regular versus Potentially Contaminated Heparin.

<p>ACEI indicates angiotensin-converting-enzyme inhibitor; ARB, angiotensin-receptor blocker.</p><p>*Events of composite outcome.</p><p>Subgroup Analysis of ACEI and ARB: Regular versus Potentially Contaminated Heparin.</p