To assess whether preoperative statin therapy is associated with the risk of postoperative infection in patients undergoing cardiac surgery.520 patients undergoing cardiac surgery in 2010 were retrospectively examined. Data regarding statin and antibiotic use prior to and after surgery were available from the hospital pharmacy information system. Cultures and clinical data of patients on postoperative antibiotics other than standard prophylactic therapy were studied to identify postoperative infections up to 30 days from day of surgery.370 (71.2 %) patients were on preoperative statin therapy. Overall, 82 patients (15.8 %) suffered from postoperative infection of which 11 were surgical site infections. In multivariable regression analysis, statin therapy was associated with a reduced risk of postoperative infection (adjusted odds ratio: 0.329, 95 %: CI 0.19-0.57; P < 0.001).Preoperative statin use was associated with a considerable reduced risk of postoperative infections following cardiac surgery. Randomised controlled trials are required to clarify the role of statin therapy in the prevention of postoperative infections.
Differences in socioeconomic status (SES) may influence long-term physical, psychological, and cognitive health outcomes of ICU survivors. However, the relationship between SES and these three long-term health outcomes is rarely studied. The aim of this study was to investigate associations between SES and the occurrence of long-term outcomes 1-year post-ICU. Prospective cohort study. Seven Dutch ICUs. Patients 16 years old or older and admitted for greater than or equal to 12 hours to the ICU between July 2016 and March 2020 completed questionnaires, or relatives if patients could not complete them themselves, at ICU admission and 1 year after ICU admission. None. Validated scales were used for the outcomes: physical problems (fatigue or ≥ 3 new physical symptoms), psychological problems (anxiety, depression, or post-traumatic stress), cognitive impairment, and a composite score. Occurrence of outcomes were calculated for: origin, education level, employment status, income, and household structure. Adjusted odds ratios (aORs) were calculated with covariates age, gender, admission type, severity-of-illness, and pre-ICU health status. Of the 6555 patients included, 3246 (49.5%) completed the questionnaires at admission and after 1 year. Low education level increased the risk of having health problems in the composite score 1-year post-ICU (aOR 1.84; 95% CI, 1.39-2.44; p < 0.001). Pre-ICU unemployment increased the risk of having physical problems (aOR 1.98; 95% CI, 1.31-3.01; p = 0.001). Migrants and low income was associated with more psychological problems (aOR 2.03; 95% CI, 1.25-3.24; p < 0.01; aOR 1.54; 95% CI, 1.10-2.16; p = 0.01, respectively), and unpaid work with less psychological (aOR 0.26; 95% CI, 0.08-0.73; p = 0.02) and cognitive (aOR 0.11; 95% CI, 0.01-0.59; p = 0.04) problems. Indicators of lower SES, including low education level, low income, unemployment and migrants were associated with an increased risk of post-ICU health problems. Gaining insight into the complex relationship between SES and long-term health problems is necessary to decrease disparities in healthcare.
Rettig, Thijs C. D. MD; Verwijmeren, Lisa MD; Van de Garde, Ewoudt M. W. PharmD, PhD; Boerma, Djamilla MD, PhD; Noordzij, Peter G. MD, PhD Author Information
To assess the association of systemic inflammation and outcome after major abdominal surgery.Major abdominal surgery carries a high postoperative morbidity and mortality rate. Studies suggest that inflammation is associated with unfavorable outcome.Levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-α and the systemic inflammatory response syndrome (SIRS) were assessed in 137 patients undergoing major abdominal surgery. Blood samples were drawn on days 0, 1, 3, and 7, and SIRS was scored during 48 hours after surgery. Primary outcome was a composite of mortality, pneumonia, sepsis, anastomotic dehiscence, wound infection, noncardiac respiratory failure, atrial fibrillation, congestive heart failure, myocardial infarction, and reoperation within 30 days of surgery.An IL-6 level more than 432 pg/mL on day 1 was associated with an increased risk of complications (adjusted odds ratio: 3.3; 95% confidence interval [CI]: 1.3-8.5) and a longer median length of hospital stay (7 vs 12 days, P < 0.001). As a single test, an IL-6 cut-off level of 432 pg/mL on day 1 yielded a specificity of 70% and a sensitivity of 64% for the prediction of complications (area under the curve: 0.67; 95% CI: 0.56-0.77). Levels of CRP started to discriminate from day 3 onward with a specificity of 87% and a sensitivity of 58% for a cut-off level of 203 mg/L (AUC: 0.73; 95% CI: 0.63-0.83).A high IL-6 level on day 1 is associated with postoperative complications. Levels of IL-6 help distinguish between patients at low and high risk for complications before changes in levels of CRP.
Editor, A reduced renal blood flow because of intraoperative hypotension may contribute to acute kidney injury. Recently, two retrospective studies showed that intraoperative hypotension was associated with an increased risk of acute kidney injury after noncardiac surgery.1,2 Pre and postoperative serum creatinine values were not routinely measured, however, and this may have introduced bias. Also, the use of the estimated glomerular filtration (eGFR) rate may provide a more accurate assessment of renal function than serum creatinine.3 The aim of this study was to determine whether intraoperative hypotension is associated with a change in eGFR in patients undergoing abdominal surgery with routine perioperative creatinine measurements. The local Medical Research Ethics Committee (trial number W15.032) approved this secondary analysis of the prospective observational Myocardial Injury and Complications after major abdominal surgery (MICOLON) study (ClinicalTrials.gov Identifier NCT02150486). In the MICOLON study, the association between high-sensitive cardiac troponin T levels and noncardiac complications after major abdominal surgery was investigated in patients at risk for coronary artery disease.4 Serum creatinine was routinely measured on the day of surgery and on the first, third and seventh postoperative day. eGFR was calculated using the Modification of Diet in Renal Disease 4 equation.3 Primary outcome was change in eGFR, defined as the difference between baseline eGFR and lowest postoperative eGFR, expressed as a percentage of baseline eGFR value. In the sensitivity analysis we used the change in creatinine as the outcome variable. Intraoperative hypotension was expressed as the total duration below several absolute and relative mean arterial pressure (MAP) threshold values and the area under the curve, combining depth and duration, for several MAP threshold values. MAP was recorded every minute in case of invasive blood pressure (BP) monitoring, and every 1 to 3 min in case of noninvasive monitoring. When the MAP was not measured or in case of an artefact, the prior MAP was carried forward to the next MAP measurement. Linear regression analysis was used to assess the relation of intraoperative hypotension with change in eGFR, before and after adjustment for potential confounders. Potential confounders for the association of intraoperative hypotension and change in eGFR were age, sex, renin–angiotensin–aldosterone system inhibitors, congestive heart failure, American Society of Anesthesiologists classification, type of surgery, duration of surgery and blood loss.2,5 Effect estimates are expressed as unstandardised coefficients (βs) with their accompanying 99% confidence interval (CI). As multiple thresholds are compared, we used a more stringent level of significance of P < 0.01 and hence present effective estimates with 99% CIs. For statistical analyses IBM SPSS, Chicago, IL version 22 was used. In total, 202 patients were included in the analysis. Creatinine was available in all 202 patients at baseline, and in 99% (201/202), 96% (181/188) and 88% (106/121) of hospitalised patients on the first, third and seventh postoperative day, respectively. Invasive BP monitoring was performed in 120 patients (59%). In the univariable analysis, intraoperative hypotension, defined as a MAP below 75 mmHg, was associated with a change in eGFR (eGFR decreased with 0.05% for each minute spent below a MAP of 75 mmHg, 99% CI: −0.09 to −0.00, P = 0.009; Fig. 1a). A similar association was observed for intraoperative hypotension defined as a decrease in MAP of 20% (−0.05%, 99% CI: −0.10 to −0.01, P = 0.004) and 25% from baseline (−0.05%, 99% CI: −0.09 to −0.01, P = 0.004, Fig. 1b). The area under the curve for intraoperative hypotension thresholds was not associated with a change in eGFR (Fig. 1c). In the multivariable analysis, none of the intraoperative hypotension definitions were associated with change in eGFR (Fig. 1d, e and f). In the sensitivity analysis with a change in creatinine as the outcome variable, similar results were found.Fig. 1: Uni (a, b, c) and multivariable (d, e, f) analysis of absolute and relative MAP threshold values and AUC for MAP thresholds and change in eGFR. AUC, area under the curve; eGFR, estimated glomerular filtration; MAP, mean arterial pressure.The potential influence of intraoperative arterial perfusion pressure on organ function preservation is an ongoing debate. Walsh et al.2 and Sun et al.1 found, in two retrospective studies, that intraoperative hypotension, defined as a MAP below 55 mmHg, was associated with acute kidney injury. In contrast to these studies, we had highly detailed information on perioperative renal function for our study patients. Instead of using creatinine values that were requested by treating physicians on medical indication (potentially leading to confounding by indication and information bias), creatinine measurements were systematically conducted. In doing this, we may however, have missed the ‘peak’ creatinine value, potentially leading to an underestimation of the true incidence of acute kidney injury. We used eGFR as the outcome variable because it represents renal function better than creatinine.3 A drawback of the eGFR, however, is that it has not been validated for patients with unstable creatinine values. However, the perioperative use of eGFR is recommended by others and the use of a change in creatinine as the outcome variable showed similar results.6 Typically, a decline in renal function is dichotomised at a creatinine level of 1.5 to 1.9 times baseline or an increase of at least 0.3 mg dl−1 (≥26.5 μmol l−1). Although categorisation of continuous variables is often done to simplify statistical analysis, dichotomising a continuous variable increases the chance of a type 1 error (‘false positive’).7 By including the outcome as a continuous variable we increased statistical power to detect a true association. Still, our study may be underpowered to find an association between intraoperative hypotension and change in eGFR. For example, the change in eGFR we found in patients with MAP less than 55 mmHg (−0.074% for each minute below this threshold, 99% CI: −0.228 to 0.079) would have required the inclusion of 876 patients to reach statistical significance. A closer investigation of the effect estimates suggests a trend towards renal injury as BP declines, which may become statistically significant in larger sample sizes. In summary, we did not observe an association between intraoperative hypotension and change in eGFR, although we cannot exclude that our study was underpowered. Nevertheless, the effect estimates of change in eGFR per minute intraoperative hypotension had not been studied before and could serve as a basis for sample size calculations in future studies. Acknowledgements relating to this article Assistance with the study: none. Financial support and sponsorship: support was provided from institutional and departmental sources. Conflict of interest: none.
Purpose Postoperative complications increase mortality, disability and costs. Advanced understanding of the risk factors for postoperative complications is needed to improve surgical outcomes. This paper discusses the rationale and profile of the BIGPROMISE (biomarkers to guide perioperative management and improve outcome in high-risk surgery) cohort, that aims to investigate risk factors, pathophysiology and outcomes related to postoperative complications. Participants Adult patients undergoing major surgery in two tertiary teaching hospitals. Clinical data and blood samples are collected before surgery, at the end of surgery and on the first, second and third postoperative day. At each time point a panel of cardiovascular, inflammatory, renal, haematological and metabolic biomarkers is assessed. Aliquots of plasma, serum and whole blood of each time point are frozen and stored. Data on severe complications are prospectively collected during 30 days after surgery. Functional status is assessed before surgery and after 120 days using the WHO Disability Assessment Schedule (WHODAS) 2.0. Mortality is followed up until 2 years after surgery. Findings to date The first patient was enrolled on 8 October 2021. Currently (1 January 2024) 3086 patients were screened for eligibility, of whom 1750 (57%) provided informed consent for study participation. Median age was 66 years (60; 73), 28% were female, and 68% of all patients were American Society of Anaesthesiologists (ASA) physical status class 3. Most common types of major surgery were cardiac (49%) and gastro-intestinal procedures (26%). The overall incidence of 30-day severe postoperative complications was 16%. Future plans By the end of the recruitment phase, expected in 2026, approximately 3000 patients with major surgery will have been enrolled. This cohort allows us to investigate the role of pathophysiological perioperative processes in the cause of postoperative complications, and to discover and develop new biomarkers to improve risk stratification for adverse postoperative outcomes. Trial registration number NCT05199025 .
