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1.  Comparative evaluation of ASA classification and ACE-27 index as morbidity scoring systems in oncosurgeries 
Indian Journal of Anaesthesia  2010;54(3):219-225.
The primary intention of the study was to find out whether Adult Comorbidity Evaluation Index (ACE-27) was better than the American Society of Anaesthesiologists’ (ASA) risk classification system in predicting postoperative morbidity in head and neck oncosurgery. Another goal was to identify other risk factors for complications which are not included in these indexes. Univariate and multivariate analyses were performed on 250 patients to determine the impact of seven variables on morbidity-ACE-27 grade, ASA class, age, sex, duration of anaesthesia, chemotherapy and radiotherapy. In univariate analysis ACE-27 index, ASA score, duration of anaesthesia, radiotherapy and chemotherapy were significant. As both comorbidity scales were significant in univariate analysis they were analyzed together and separately in multivariate analysis to illustrate their individual strength. In the first multivariate analysis (excluding ACE-27 grade) ASA class, duration of anaesthesia, radiotherapy and chemotherapy were significant. The positive predictive value (PPV) of this model to predict morbidity was 60.86% and negative predictive value (NPV) was 77.9%. The sensitivity was 75% and specificity 62.2%. In the second multivariate analysis (excluding ASA class) ACE-27 grade, duration of anaesthesia and radiotherapy were significant. The PPV of this model to predict morbidity was 62.1% and NPV was 76.5%. The sensitivity was 61.6% and specificity 70.9%. In the third multivariate analysis which included both ACE-27 grade and ASA class only ASA class, duration of anaesthesia, radiotherapy and chemotherapy remained significant. In conclusion, ACE-27 grade and ASA class were reliable predictors of major complications but ASA class had more impact on complications than ACE-27 grade.
doi:10.4103/0019-5049.65366
PMCID: PMC2933480  PMID: 20885868
Morbidity prediction; perioperative complications; surgery
2.  “Timed Up & Go”: A Screening Tool for Predicting 30-Day Morbidity in Onco-Geriatric Surgical Patients? A Multicenter Cohort Study 
PLoS ONE  2014;9(1):e86863.
Objective
To determine the predictive value of the “Timed Up & Go” (TUG), a validated assessment tool, on a prospective cohort study and to compare these findings to the ASA classification, an instrument commonly used for quantifying patients’ physical status and anesthetic risk.
Background
In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population.
Methods
280 patients ≥70 years undergoing elective surgery for solid tumors were prospectively recruited. Primary endpoint was 30-day morbidity. Pre-operatively TUG was administered and ASA-classification was registered. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Absolute risks and area under the receiver operating characteristic curves (AUC’s) were calculated.
Results
180 (64.3%) patients (median age: 76) underwent major surgery. 55 (20.1%) patients experienced major complications. 50.0% of patients with high TUG and 25.6% of patients with ASA≥3 experienced major complications (absolute risks). TUG and ASA were independent predictors of the occurrence of major complications (TUG:OR 3.43; 95%-CI = 1.14–10.35. ASA1 vs. 2:OR 5.91; 95%-CI = 0.93–37.77. ASA1 vs. 3&4:OR 12.77; 95%-CI = 1.84–88.74). AUCTUG was 0.64 (95%-CI = 0.55–0.73, p = 0.001) and AUCASA was 0.59 (95%-CI = 0.51–0.67, p = 0.04).
Conclusions
Twice as many onco-geriatric patients at risk of post-operative complications, who might benefit from pre-operative interventions, are identified using TUG than when using ASA.
doi:10.1371/journal.pone.0086863
PMCID: PMC3901725  PMID: 24475186
3.  Prediction of early postoperative major cardiac events after elective orthopedic surgery: the role of B-type natriuretic peptide, the revised cardiac risk index, and ASA class 
BMC Anesthesiology  2014;14:20.
Background
The aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date.
Methods
The study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge.
Results
MACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82.
Conclusions
Both pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.
doi:10.1186/1471-2253-14-20
PMCID: PMC3998048  PMID: 24655733
Brain natriuretic peptide; Orthopedic surgery; Preoperative care
4.  Predictive factors of hospital length of stay in patients with operatively treated ankle fractures 
Background
Operative fixation of ankle fractures is common. However, as reimbursement plans evolve with the potential for bundled payments, it is critical that orthopedic surgeons better understand factors influencing the postoperative length of stay (LOS) in patients undergoing these procedures to negotiate appropriate reimbursement. We sought to identify factors influencing the postoperative LOS in patients with operatively treated ankle fractures.
Materials and methods
Six hundred twenty-two patients with ankle fractures between January 1st, 2004 and December 31st, 2010 were identified retrospectively. Charts were reviewed for gender, length of operative procedure, method of fixation, American Society of Anesthesiologists (ASA) physical status score, medical comorbidities, and postoperative LOS. Both univariate and multivariate models were developed to determine predictors of patient LOS. Financial data for an average 24-h inpatient stay were obtained from financial services.
Results
Six hundred twenty-two patients were included. In a linear regression analysis, a statistically significant relationship was demonstrated between ASA status and LOS (P < 0.001). Multiple regression analysis further characterized the relationship between ASA and LOS: a 1-U increase in ASA classification conferred a 3.42-day increase in LOS on average (P < 0.001). Based on an average per-day inpatient cost of $4,503, each unit increase in ASA status led to a $15,490 increase in cost.
Conclusions
Our study demonstrates that ASA status is a powerful predictor of LOS in patients undergoing operative fixation of ankle fractures. More complete understanding of these factors will lead to better risk adjustment models for measuring outcomes, determining fair reimbursement, and potential improvements to the efficiency of patient care.
Level of Evidence
Level III retrospective comparative study regressing length of stay with many variables, including ASA physical status.
Electronic supplementary material
The online version of this article (doi:10.1007/s10195-013-0280-9) contains supplementary material, which is available to authorized users.
doi:10.1007/s10195-013-0280-9
PMCID: PMC4244567  PMID: 24337780
Ankle fracture; Postoperative length of stay; ASA score; Payment and reimbursement model; Surgical outcomes; Healthcare costs
5.  The Waterlow score for risk assessment in surgical patients 
Introduction
Perioperative scoring systems aim to predict outcome following surgery and are used in preoperative counselling to guide management and to facilitate internal or external audit. The Waterlow score is used prospectively in many UK hospitals to stratify the risk of decubitus ulcer development. The primary aim of this study was to assess the potential value of this existing scoring system in the prediction of mortality and morbidity in a general surgical and vascular cohort.
Methods
A total of 101 consecutive moderate to high risk emergency and elective surgical patients were identified through a single institution database. The preoperative Waterlow score and outcome data pertaining to that admission were collected. The discriminatory power of the Waterlow score was compared against that of the American Society of Anesthesiologists (ASA) grade and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM).
Results
The inpatient mortality rate was 17% and the 30-day morbidity rate was 29%. A statistically significant association was demonstrated between the preoperative Waterlow score and inpatient mortality (p<0.0001) and 30-day morbidity (p=0.0002). Using a threshold Waterlow score of 20 to dichotomise risk, accuracies of 0.84 and 0.76 for prediction of mortality and morbidity were demonstrated. In comparison with P-POSSUM, the preoperative Waterlow score performed well on receiver operating characteristic analysis. With respect to mortality, the area under the curve was 0.81 (0.80–0.85) and for morbidity it was 0.72 (0.69–0.76). The ASA grade achieved a similar level of discrimination.
Conclusions
The Waterlow score is collected routinely by nursing staff in many hospitals and might therefore be an attractive means of predicting postoperative morbidity and mortality. It might also function to stratify perioperative risk for comparison of surgical outcome data. A prospective study comparing these risk prediction scores is required to support these findings.
doi:10.1308/003588413X13511609954770
PMCID: PMC3964640  PMID: 23317729
General surgery; Risk assessment; Mortality; Morbidity
6.  Reliability of the American Society of Anesthesiologists physical status scale in clinical practice 
BJA: British Journal of Anaesthesia  2014;113(3):424-432.
Background
Previous studies, which relied on hypothetical cases and chart reviews, have questioned the inter-rater reliability of the ASA physical status (ASA-PS) scale. We therefore conducted a retrospective cohort study to evaluate its inter-rater reliability and validity in clinical practice.
Methods
The cohort included all adult patients (≥18 yr) who underwent elective non-cardiac surgery at a quaternary-care teaching institution in Toronto, Ontario, Canada, from March 2010 to December 2011. We assessed inter-rater reliability by comparing ASA-PS scores assigned at the preoperative assessment clinic vs the operating theatre. We also assessed the validity of the ASA-PS scale by measuring its association with patients' preoperative characteristics and postoperative outcomes.
Results
The cohort included 10 864 patients, of whom 5.5% were classified as ASA I, 42.0% as ASA II, 46.7% as ASA III, and 5.8% as ASA IV. The ASA-PS score had moderate inter-rater reliability (κ 0.61), with 67.0% of patients (n=7279) being assigned to the same ASA-PS class in the clinic and operating theatre, and 98.6% (n=10 712) of paired assessments being within one class of each other. The ASA-PS scale was correlated with patients' age (Spearman's ρ, 0.23), Charlson comorbidity index (ρ=0.24), revised cardiac risk index (ρ=0.40), and hospital length of stay (ρ=0.16). It had moderate ability to predict in-hospital mortality (receiver-operating characteristic curve area 0.69) and cardiac complications (receiver-operating characteristic curve area 0.70).
Conclusions
Consistent with its inherent subjectivity, the ASA-PS scale has moderate inter-rater reliability in clinical practice. It also demonstrates validity as a marker of patients' preoperative health status.
doi:10.1093/bja/aeu100
PMCID: PMC4136425  PMID: 24727705
anaesthesiology; health status; reliability and validity
7.  Postresectional lung injury in thoracic surgery pre and intraoperative risk factors: a retrospective clinical study of a hundred forty-three cases 
Introduction
Acute respiratory dysfunction syndrome (ARDS), defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, is a major cause of morbidity and mortality after pulmonary resection. The aim of the study was to determine the pre and intraoperative factors associated with ARDS after pulmonary resection retrospectively.
Methods
Patients undergoing elective pulmonary resection at Adnan Menderes University Medical Faculty Thoracic Surgery Department from January 2005 to February 2010 were included in this retrospective study. The authors collected data on demographics, relevant co-morbidities, the American Society of Anesthesiologists (ASA) Physical Status classification score, pulmonary function tests, type of operation, duration of surgery and intraoperative fluid administration (fluid therapy and blood products). The primary outcome measure was postoperative ARDS, defined as the need for continuation of mechanical ventilation for greater than 48-hours postoperatively or the need for reinstitution of mechanical ventilation after extubation. Statistical analysis was performed with Fisher exact test for categorical variables and logistic regression analysis for continuous variables.
Results
Of one hundred forty-three pulmonary resection patients, 11 (7.5%) developed postoperative ARDS. Alcohol abuse (p = 0.01, OR = 39.6), ASA score (p = 0.001, OR: 1257.3), resection type (p = 0.032, OR = 28.6) and fresh frozen plasma (FFP)(p = 0.027, OR = 1.4) were the factors found to be statistically significant.
Conclusion
In the light of the current study, lung injury after lung resection has a high mortality. Preoperative and postoperative risk factor were significant predictors of postoperative lung injury.
doi:10.1186/1749-8090-5-62
PMCID: PMC2936288  PMID: 20716368
8.  The Palliative Index: Predicting Outcomes of Emergent Surgery in Patients with Cancer 
Journal of Palliative Medicine  2014;17(1):37-42.
Abstract
Background: The role of emergent palliative surgery in the setting of advanced malignancy remains a subject of controversy.
Objective: The purpose of this study was to identify clinical predictors of outcome in patients with cancer who undergo nonelective abdominal surgery.
Setting/Subjects: Individuals who underwent urgent and emergent abdominal operations between 2006 and 2010 at a tertiary cancer center were identified.
Measurements: Analyses were performed to identify predictors of 30-day morbidity and mortality as well as overall survival (OS). A risk score was derived from predictors of OS.
Results: Of 143 patients, 93 (65%) had active disease (AD; defined as evidence of malignancy at time of surgery). Thirty-day morbidity and mortality were 36.4% and 9.8%, respectively. Independent predictors of 30-day mortality included ASA score >3 (p=0.009) and albumin <2.8 (p=0.040). Median OS was 5.4 months in patients with AD and was not reached in patients without AD (p<0.001). Independent predictors of decreased OS included AD; ASA >3; creatinine >1.3; and a tumor-related indication (i.e., bleeding, obstructing, or perforating tumor). A risk or palliative index (PI) score stratified patients into groups with discreet outcomes.
Conclusions: Although AD did not predict 30-day morbidity, it was the dominant independent predictor of postoperative OS. In cancer patients undergoing emergency abdominal surgery, outcome is anticipated by disease status and other independent predictors of OS.
doi:10.1089/jpm.2013.0235
PMCID: PMC3887430  PMID: 24410420
9.  Small Airway Impairment and Bronchial Hyperresponsiveness in Asthma Onset 
Purpose
Our study tried to find a relationship between baseline FEF25-75% and airway hyperresponsiveness (AHR) and whether a greater FEF25-75% impairment may be a marker of a more severe hyperresponsiveness in subjects with normal FEV1 and FEV1/FVC and suggestive asthma symptoms. Besides, we tried to asses a FEF25-75% cut-off value to identify hyper-reactive subjects.
Methods
4,172 subjects (2,042 M; mean age: 38.3±14.9; mean FEV1 % predicted: 100.5±12.7 and FEV1/FVC: 85.4±6.8) were examined after performing a methacholine (Mch) test. All subjects reported a symptom onset within 3 years before the test. Subjects with PD20<400 or >400 µg were arbitrarily considered affected by moderate/severe and borderline AHR, respectively.
Results
PD20 values were 213 (IQR:86-557), 340 (IQR:157-872) and 433 (IQR:196-1032) µg in subjects with baseline FEF25-75≤50%, FEF25-75 between 50 and 70% and FEF25-75>70% respectively (P<0.0001). Only in moderate/severe hyper-reactive subjects (excluded borderlines), PD20 was lower in the FEF25-75≤50% subgroup than in the 1 with FEF25-75>70%. The hyperreactive subjects percentage, was higher in those with FEF25-75≤50% and lower in those with FEF25-75>70% (P<0.0001). FEF25-75<50% (compared to FEF25-75>70%) was a higher AHR risk factor, especially in subjects with moderate/severe AHR (OR: 2.18 [IQR:1.41-3.37]; P<0.0001). Thresholds yielding the highest combined sensitivity/specificity for FEF25-75% were 75.19 (area under curve [AUC]: 0.653) and 74.95 (AUC:0.688) in subjects with PD20<2,400 and <400 µg respectively. FEV1, FVC, and FEV1/FVC measured in subjects with different FEF25-75≤50%, FEF25-75>50 and ≤70% or FEF25-75>70% levels were similar both in normoreactive and hyperreactive subjects.
Conclusions
At asthma onset, reduced baseline FEF25-75 values with normal FEV1 and FEV1/FVC may predict AHR. Detectable predictive cut-off values do not exist because even normoreactive subjects can show lower FEF25-75 values. Furthermore, a greater FEF25-75 reduction may be associated to a more severe AHR, suggesting a possible FEF25-75 role in the management of asthma when FEV1 and FEV1/FVC are normal.
doi:10.4168/aair.2014.6.3.242
PMCID: PMC4021243  PMID: 24843800
Airway hyperresponsiveness; small airways; methacholine test; asthma; FEF25-75; diagnosis
10.  Prediction of Postoperative Pain using Path Analysis in Older Patients 
Journal of anesthesia  2011;26(1):1-8.
Purpose
Effective postoperative pain management is important for older surgical patients since pain affects perioperative outcomes. A prospective cohort study was conducted to describe the direct and indirect effects of patient risk factors and pain treatment in explaining levels of postoperative pain in older surgical patients.
Methods
We studied patients who were 65 years of age or older and were scheduled for major non-cardiac surgery with a postoperative hospital stay of at least 2 days. The numeric rating scale (0 = no pain, 10 = worst possible pain) was used to measure pain levels before surgery and once daily for 2 days after surgery. Path analysis was performed to examine the association between predictive variables and postoperative pain levels.
Results
Three hundred fifty patients were studied. The results reveal that preoperative pain level, use of preoperative opioids, female gender, higher ASA physical status, and postoperative pain control methods were the strongest predictors of postoperative pain as measured the first day after surgery. Younger age, greater preoperative symptoms of depression and lower cognitive function also contributed to higher postoperative pain levels. Pain levels on the second day after surgery were strongly predicted by preoperative pain level, use of preoperative opioids, surgical risk, and pain and opioid dose on postoperative day 1. However, younger age, female gender, higher ASA physical status, greater preoperative symptoms of depression, lower cognitive function and postoperative pain control methods indirectly contributed to pain levels on the second day after surgery.
Conclusion
Although preoperative pain and use of preoperative opioids have the strongest effects on postoperative pain, clinicians should be aware that other factors such as age, gender, surgical risk, preoperative cognitive impairment and depression also contribute to reported postoperative pain. Based on significant statistical correlations, these study results can contribute to more effective postoperative care for those patients having the risk factors studied here. Preoperative treatment/intervention based in part on factors such as preoperative pain, use of preoperative opioids and depression may improve postoperative pain management.
doi:10.1007/s00540-011-1249-6
PMCID: PMC3720127  PMID: 22012171
aged; 80 and over; aging; pain; postoperative
11.  Prediction of post-operative pain following arthroscopic subacromial decompression surgery: an observational study 
F1000Research  2013;2:31.
Background: Arthroscopic shoulder surgery is increasingly performed as a day case procedure. Optimal post-operative pain relief remains a challenge due to considerable variations in the level of pain experienced between individuals. Our aim was to examine whether the preoperative electrical pain threshold was a strong predictor of elevated postoperative pain levels following arthroscopic subacromial decompression (ASD) surgery. Methods: Forty consenting patients with American Society of Anesthesiologists (ASA) grade 1-2 presenting for elective ASD surgery were recruited. Patients’ electrical pain thresholds were measured preoperatively using a PainMatcher® (Cefar Medical AB, Lund, Sweden) device. Following surgery under general anaesthesia, the maximum pain experienced at rest and movement was recorded using a visual analogue scale until the end of postoperative day four. Results: In univariate analyses (t-test), the postoperative pain experienced (Area Under Curve) was significantly greater in patients with a low pain threshold as compared with a high pain threshold at both rest (mean 12.5, S.E. 1.7 v mean 6.5, S.E.1.2. P=0.008) and on movement (mean 18.7, S.E. 1.5 v mean 14.1, S.E.1.4. P=0.031). In multivariate analyses, adjusting for additional extra analgesia, the pain experienced postoperatively was significantly greater in the low pain threshold group both at rest (mean difference 4.9, 95% CI 1.5 to 8.4, P=0.007) and on movement (mean difference 4.1, 95%CI 0.03 to 8.2, P=0.049). Conclusions: Preoperative pain threshold can predict postoperative pain level following ASD of the shoulder. Trial registration: Clinicaltrials.gov identifier: NCT01351363 Level of Evidence: II
doi:10.12688/f1000research.2-31.v1
PMCID: PMC3790597  PMID: 24358863
12.  Outcome after osteosynthesis of hip fractures in nonagenarians 
Background
Hip fractures in the elderly population are associated with high morbidity and mortality. However, there is still a lack of information on mortality and loss of independence in extremely elderly people with a hip fracture.
Objective
To study functional outcomes and mortality after osteosynthesis of hip fractures in very old patients in our clinic.
Patients and methods
Hospital charts of all patients over 90 years old who were operated for a hip fracture between January 2007 and December 2011 were reviewed. Outcome measures were mortality, preoperative and postoperative mobility, and loss of independence.
Results
A total of 149 patients were included; 132 (89%) women, median age 93.5±2.45 years. Thirty-six (24%) patients were classified as American Society of Anesthesiologists (ASA) grade 2, 104 (70%) as ASA grade 3, and nine (6%) as ASA grade 4. The Charlson comorbidity index (CCI) score was 2 or less in 115 (77%) patients and 34 (23%) patients scored 3 or more points. Short-term survival was 91% and 77% at 30 days and 3 months, respectively. Long-term survival was 64%, 42%, and 18% at 1, 3, and 5 years after surgery, respectively. Survival was significantly better in patients with lower ASA scores (P=0.005). No significant difference in survival was measured between patients according to CCI score (P=0.13). Fifty-one percent of patients had to be accommodated in an institution with more care following treatment, and 57% were less mobile after osteosynthesis of a hip fracture.
Conclusion
Our study shows that short-term mortality rates in very elderly patients with a hip fracture are high and there is no clear predictive value for mortality. ASA classification is the best predictive value for overall mortality. A large proportion of these patients lost their independence after osteosynthesis of a hip fracture.
doi:10.2147/CIA.S52083
PMCID: PMC3872008  PMID: 24379658
hip fracture; osteosynthesis; very elderly people; mortality; loss of independence
13.  Comorbidity and nutritional indices as predictors of morbidity after transurethral procedures: A prospective cohort study 
Canadian Urological Association Journal  2014;8(9-10):E600-E604.
Introduction:
Preoperative scores are widely used predictors of complications after major surgery. These scores, however, are not widely used in transurethral procedures. The aim of this study was to assess the value of the Charlson Comorbidity Index (CCI), the age-adjusted CCI, the American Society of Anesthesiologist score (ASA) and the Nutritional Risk Score (NRS) in predicting early morbidity after transurethral urological procedures.
Methods:
Consecutive patients undergoing transurethral resection of the bladder or the prostate were prospectively enrolled. The scores were calculated preoperatively; 30-day complications were prospectively recorded according to the Dindo-Clavien classification. Univariate logistic regression was performed to investigate the value of each score and of other factors (i.e., age, sex, body mass index, anemia, smoking habit, type of operation and anaesthesia) as predictors of complications. A multivariate model was then calculated using these predictors.
Results:
Overall, 197 patients were included. The mean age was 72 (standard deviation ± 10). In total, 26.9% patients had at least 1 complication. Using univariate analysis, we found that each score significantly predicted complications. In multivariate analysis, only the ASA (odds ration [OR] 2.11; 95% confidence interval [CI] 1.01–4.43) and the NRS (OR 2.42; 95% CI 1.56–3.74) remained independent predictors. The best model incorporated ASA, NRS and gender, and predicted morbidity with an area under the curve of 76%. Our study’s main limitations are population heterogeneity and limited sample size.
Conclusion:
The ASA and the NRS are important and independent determinants of early morbidity after transurethral procedures. The use of these indices may assist clinicians in the decision-making process to balance the possible benefits of transurethral procedures with the potential risks.
doi:10.5489/cuaj.1848
PMCID: PMC4164546  PMID: 25295129
14.  Is ASA classification useful in risk stratification for endoscopic procedures? 
Gastrointestinal endoscopy  2013;77(3):10.1016/j.gie.2012.11.039.
Background
The American Society of Anesthesiologists’ (ASA) physical status classification is a measurement of co-morbidity and is a predictor of peri-operative morbidity and mortality.
Objective
To assess the predictive ability of the ASA class for peri-endoscopic adverse events
Design
retrospective cohort analysis
Setting
74 sites in the USA comprised of academic, community/HMO and VA/Military practices affiliated with the Clinical Outcomes Research Initiative (CORI) database
Patients
≥ 18 years who underwent an endoscopic procedure between 2000–2008
Interventions
EGD, colonoscopy, flexible sigmoidoscopy, ERCP
Main outcome measurements
immediate adverse event requiring an unplanned intervention
Results
A total of 1,590,648 endoscopic procedures were performed on 1,318,495 unique patients. The majority of patients were designated as ASA class I or II (I: 27%, II: 63%). An immediate adverse events occurred in 0.35% of all endoscopic procedures (n=5,596) and was proportionally highest for ERCPs (1.84%). Increasing ASA class was associated with higher prevalence and a stepwise increase in the odds ratio of serious adverse events for EGD (II: 1.54 [95% CI 1.31–1.82]; III: 3.90 [95% CI 3.27–4.64]; IV/V: 12.02 [95% CI 9.62–15.01]); and colonoscopy COL (II: 0.92 [95% CI 0.85–1.01]; III: 1.66 [95% CI 1.46–1.87]; IV/V: 4.93 [95% CI 3.66–66.3]). This trend was not significant for FS and ERCP.
Limitations
retrospective, end point is a surrogate for peri-procedure morbidity
Conclusions
ASA class is associated with increased risk of adverse events at endoscopy, particularly for EGD and colonoscopy. It is useful in endoscopic risk stratification and is an important quality indicator for endoscopy.
doi:10.1016/j.gie.2012.11.039
PMCID: PMC3816502  PMID: 23410699
ASA class; endoscopy; adverse events; complications; risk stratification; CORI
15.  A Comparative Study of Postoperative Pulmonary Complications Using Fast Track Regimen and Conservative Analgesic Treatment: A Randomized Clinical Trial 
Tanaffos  2011;10(3):12-19.
Background
Postoperative pulmonary complications and pain are important causes of postoperative morbidity following thoracotomy. This study aimed to compare the effects of fast track and conservative treatment regimens on patients undergoing thoracotomy.
Materials and Methods
In this randomized controlled clinical trial, we recruited 60 patients admitted to the thoracic ICU of Imam Reza Hospital in two matched groups of 30 patients each. Group 1 patients received fast track regimen randomly; whereas, group 2 cases randomly received conservative analgesic regimen after thoracotomy and pulmonary resection. The outcome was determined based on the incidence of pulmonary complications and reduction of post-thoracotomy pain in all patients with forced expiratory volume in one second (FEV1) <75% predicted value which was measured while the patients were in ICU. The length of ICU stay, thoracotomy pain, morbidity, pulmonary complications and mortality were compared in two groups.
Results
A total of 60 patients, 45 (75%) males and 15(25%) females with ASA class I-III were recruited in this study. Postoperative pulmonary complications were observed in 5 (16.7%) patients in group 1 versus 17 (56.7%) patients in group 2. There were statistically significant differences in development of postoperative pulmonary complications such as atelectasis and prolonged air leak between both groups (P< 0.001 and P = 0.003). There was also a statistically significant difference in the rate of preoperative FEV1 (p = 0.001) and ASA scoring (p = 0.01) and value of FEV1 < 75% predicted in the two groups. The difference in length of ICU stay in two groups was statistically significant (P= 0.003 and P = 0.017 in FEV1 < 75% group). Four patients in group 1 and 9 patients in group 2 had FEV1reduced to less than 75% of predicted value (p = 0.03).
Conclusion
Using fast track regimen reduced postoperative pain and incidence of some pulmonary complications significantly when compared to the conservative regimen following thoracotomy and various lung surgeries.
PMCID: PMC4153159  PMID: 25191370
Fast track regimen; Pulmonary complications; Thoracotomy; Pain
16.  Using Machine-Learned Bayesian Belief Networks to Predict Perioperative Risk of Clostridium Difficile Infection Following Colon Surgery 
Background
Clostridium difficile (C-Diff) infection following colorectal resection is an increasing source of morbidity and mortality.
Objective
We sought to determine if machine-learned Bayesian belief networks (ml-BBNs) could preoperatively provide clinicians with postoperative estimates of C-Diff risk.
Methods
We performed a retrospective modeling of the Nationwide Inpatient Sample (NIS) national registry dataset with independent set validation. The NIS registries for 2005 and 2006 were used for initial model training, and the data from 2007 were used for testing and validation. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were used to identify subjects undergoing colon resection and postoperative C-Diff development. The ml-BBNs were trained using a stepwise process. Receiver operating characteristic (ROC) curve analysis was conducted and area under the curve (AUC), positive predictive value (PPV), and negative predictive value (NPV) were calculated.
Results
From over 24 million admissions, 170,363 undergoing colon resection met the inclusion criteria. Overall, 1.7% developed postoperative C-Diff. Using the ml-BBN to estimate C-Diff risk, model AUC is 0.75. Using only known a priori features, AUC is 0.74. The model has two configurations: a high sensitivity and a high specificity configuration. Sensitivity, specificity, PPV, and NPV are 81.0%, 50.1%, 2.6%, and 99.4% for high sensitivity and 55.4%, 81.3%, 3.5%, and 99.1% for high specificity. C-Diff has 4 first-degree associates that influence the probability of C-Diff development: weight loss, tumor metastases, inflammation/infections, and disease severity.
Conclusions
Machine-learned BBNs can produce robust estimates of postoperative C-Diff infection, allowing clinicians to identify high-risk patients and potentially implement measures to reduce its incidence or morbidity.
doi:10.2196/ijmr.2131
PMCID: PMC3626137  PMID: 23611947
Clostridium difficile; Bayesian belief network; pseudomembranous colitis; colectomy; NIS
17.  PREDICTION OF MALIGNANT BREAST LESIONS FROM MRI FEATURES: A COMPARISON OF ARTIFICIAL NEURAL NETWORK AND LOGISTIC REGRESSION TECHNIQUES 
Academic radiology  2009;16(7):842-851.
Rationale and Objectives
Dynamic contrast enhanced MRI (DCE-MRI) is a clinical imaging modality for detection and diagnosis of breast lesions. Analytical methods were compared for diagnostic feature selection and performance of lesion classification to differentiate between malignant and benign lesions in patients.
Materials and Methods
The study included 43 malignant and 28 benign histologically-proven lesions. Eight morphological parameters, ten gray level co-occurrence matrices (GLCM) texture features, and fourteen Laws’ texture features were obtained using automated lesion segmentation and quantitative feature extraction. Artificial neural network (ANN) and logistic regression analysis were compared for selection of the best predictors of malignant lesions among the normalized features.
Results
Using ANN, the final four selected features were compactness, energy, homogeneity, and Law_LS, with area under the receiver operating characteristic curve (AUC) = 0.82, and accuracy = 0.76. The diagnostic performance of these 4-features computed on the basis of logistic regression yielded AUC = 0.80 (95% CI, 0.688 to 0.905), similar to that of ANN. The analysis also shows that the odds of a malignant lesion decreased by 48% (95% CI, 25% to 92%) for every increase of 1 SD in the Law_LS feature, adjusted for differences in compactness, energy, and homogeneity. Using logistic regression with z-score transformation, a model comprised of compactness, NRL entropy, and gray level sum average was selected, and it had the highest overall accuracy of 0.75 among all models, with AUC = 0.77 (95% CI, 0.660 to 0.880). When logistic modeling of transformations using the Box-Cox method was performed, the most parsimonious model with predictors, compactness and Law_LS, had an AUC of 0.79 (95% CI, 0.672 to 0.898).
Conclusion
The diagnostic performance of models selected by ANN and logistic regression was similar. The analytic methods were found to be roughly equivalent in terms of predictive ability when a small number of variables were chosen. The robust ANN methodology utilizes a sophisticated non-linear model, while logistic regression analysis provides insightful information to enhance interpretation of the model features.
doi:10.1016/j.acra.2009.01.029
PMCID: PMC2832583  PMID: 19409817
18.  Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy 
AIM: To determine predictors of clinically relevant pancreatic fistulas (CRPF) by measuring drain fluid amylase (DFA) in the early postoperative period.
METHODS: This prospective clinical study included 382 patients with periampullary tumors that were surgically resected at our department between March 2005 and October 2012. A cephalic duodenopancreatectomy (DP) was performed on all patients. Two closed suction drains were placed at the end of the surgery. The highest postoperative DFA value was recorded and analyzed during the first three postoperative days and on subsequent days if the drains were kept longer. Pancreatic fistula (PF) was classified according to the International Study Group of Pancreatic Fistula (ISGPF) criteria. Postoperative complications were defined according to the Dindo-Clavien classification. All data were statistically analyzed. The optimal thresholds of DFA levels on the first, second and third postoperative days were estimated by constructing receiver operating curves, generated by calculating the sensitivities and specificities of the DFA levels. The DFA level limits were used to differentiate between the group without PF and the groups with biochemical pancreatic fistula (BPF) and CRPF.
RESULTS: Pylorus-preserving duodenopancreatectomy was performed on 289 (75.6%) patients, while the remaining patients underwent a classic Whipple procedure (CW). The total incidence of PF was 37.7% (grade A 22.8%, grade B 11.0% and grade C 3.9%). Soft pancreatic texture (SPT) was present in 58.3% of patients who developed PF. Mortality was 4.2%. The median DFA value on the first postoperative day (DFA1) in patients who developed PF was 4520 U/L (range 350-99000 U/L) for grade A fistula (BPF) with a SPT and a diameter of the main pancreatic duct (MPD) of ≤ 3 mm. For grade B/C (CRPF), the median DFA1 value was 8501 U/L (range 377-92060 U/L) with a SPT and MPD of ≤ 3 mm. These values were significantly higher when compared to the patients who did not have PF (122; range 5-37875 U/L). The upper limit of DFA values for the first 3 postoperative days in the examined stages of PF were: DFA1 1200 U/L for the BPF and CRPF; DFA3 350 U/L for BPF and DFA3 800 U/L for CRPF. The determined values were highly significant and demonstrated a reliable diagnostic test for both BPF and CRPF.
CONCLUSION: DFA1 ≥ 1200 U/L is an important predictive factor for PF of any degree. The trend of DFA3 (decrease of < 50%) compared to DFA1 is a significant factor in the differentiation of CRPF from transient BPF.
doi:10.3748/wjg.v20.i26.8691
PMCID: PMC4093722  PMID: 25024627
Cephalic duodenopancreatectomy; Periampullary tumors; Pancreatic fistula; Drain fluid amylase level; Prediction
19.  Biliary fistula after treatment for hydatid disease of the liver: When to intervene 
AIM: To determine the outcome of patients with biliary fistula (BF) after treatment for hydatid disease of the liver.
METHODS: Between January 2000 and December 2010, out of 301 patients with a diagnosis of hydatid cyst of the liver, 282 patients who underwent treatment [either surgery or puncture, aspiration, injection and reaspiration (PAIR) procedure] were analysed. Patients were grouped according to the presence or absence of postoperative biliary fistula (PBF) (PBF vs no-PBF groups, respectively). Preoperative clinical, radiological and laboratory characteristics, operative characteristics including type of surgery, peroperative detection of BF, postoperative drain output, morbidity, mortality and length of hospital stays of patients were compared amongst groups. Multivariate analysis was performed to detect factors predictive of PBF. Receiver operative characteristics (ROC) curve analysis were used to determine ideal cutoff values for those variables found to be significant. A comparison was also made between patients whose fistula closed spontaneously (CS) and those with intervention in order to find predictive factors associated with spontaneous closure.
RESULTS: Among 282 patients [median (range) age, 23 (16-78) years; 77.0% male]; 210 (74.5%) were treated with conservative surgery, 33 (11.7%) radical surgery and 39 (13.8%) underwent percutaneous drainage with PAIR procedure A PBF developed in 46 (16.3%) patients, all within 5 d after operation. The maximum cyst diameter and preoperative alkaline phosphatase levels (U/L) were significantly higher in the PBF group than in the no-PBF group [10.5 ± 3.7 U/L vs 8.4 ± 3.5 U/L (P < 0.001) and 40.0 ± 235.1 U/L vs 190.0 ± 167.3 U/L (P = 0.02), respectively]. Hospitalization time was also significantly longer in the PBF group than in the no-PBF group [37.4 ± 18.0 d vs 22.4 ± 17.9 d (P < 0.001)]. A preoperative high alanine aminotransferase level (> 40 U/L) and a peroperative attempt for fistula closure were significant predictors of PBF development (P = 0.02, 95%CI: -0.03-0.5 and P = 0.001, 95%CI: 0.1-0.4), respectively. Comparison of patients whose PBF CS or with biliary intervention (BI) revealed that the mean diameter of the cyst was not significantly different between CS and BI groups however maximum drain output was significantly higher in the BI group (81.6 ± 118.1 cm vs 423.9 ± 298.4 cm, P < 0.001). Time for fistula closure was significantly higher in the BI group (10.1 ± 3.7 d vs 30.7 ± 15.1 d, P < 0.001). The ROC curve analysis revealed cut-off values of a maximum bilious drainage < 102 mL and a waiting period of 5.5 postoperative days for spontaneous closure with the sensitivity and specificity values of (83.3%-91.1%, AUC: 0.90) and (97%-91%, AUC: 0.95), respectively. The multivariate analysis demonstrated a PBF drainage volume < 102 mL to be the only statistically significant predictor of spontaneous closure (P < 0.001, 95%CI: 0.5-1.0).
CONCLUSION: Patients with PBF after hydatid surgery often have complicated postoperative course with serious morbidity. Patients who develop PBF with an output < 102 mL might be managed expectantly.
doi:10.3748/wjg.v19.i3.355
PMCID: PMC3554819  PMID: 23372357
Hydatid disease; Biliary fistula; Postoperative complications; Surgery
20.  Evaluation of Four Risk-Scoring Methods to Predict Long-Term Outcomes in Patients Undergoing Aorto-Bifemoral Bypass for Aorto-Iliac Occlusive Disease 
This study was done to determine the usefulness of the American Society of Anesthesiologists (ASA) classification, the comorbidity Charlson index unadjusted (CCIu),the comorbidity Charlson index adjusted by age (CCIa), and the Glasgow aneurysm score (GAS) for postoperative morbimortality and survival in patients treated with aorto-bifemoral bypass (AFB) for aorto-iliac occlusive disease (AIOD). A series of 278 patients who underwent AFB were restrospectively studied. For the CCIu, CCIa, ASA, and GAS, receiver operating characteristics curve analysis for prediction of morbidity showed area under the curves of 0.61 (p = 0.004), 0.59 (p = 0.026), 0.569 (p = 0.087), and 0.63 (p = 0.001), respectively. Additionally, univariate analysis showed that CCIa (p = 0.016) and GAS (p = 0.006) were associated significantly with an increased risk of developing complications. Furthermore, CCIa (p < 0.001) and GAS (p = 0.001) showed a significant association with survival. Finally, the variable age was related to morbidity (p = 0.004), mortality (p = 0.038), and survival (p < 0.001). The comorbididity and the age should be taken in account in clinical treatment decisions for patients with AIOD. The CCIa and GAS may play a role as predictive factors for postoperative morbidity and survival after AFB.
doi:10.1055/s-0032-1302434
PMCID: PMC3444032  PMID: 23450270
atherosclerosis; peripheral arterial disease; risk factors; risk-scoring methods
21.  Determinants of Length of Stay in Surgical Ward after Coronary Bypass Surgery: Glycosylated Hemoglobin as a Predictor in All Patients, Diabetic or Non-Diabetic 
Background:
Reports on the determinants of morbidity in coronary artery bypass graft surgery (CABG) have focused on outcome measures such as length of postoperative stay in the Intensive Care Unit (ICU). We proposed that major comorbidities in the ICU hampered the prognostic effect of other weaker but important preventable risk factors with effect on patients’ length of hospitalization. So we aimed at evaluating postoperative length of stay in the ICU and surgical ward separately.
Methods:
We studied isolated CABG candidates who were not dialysis dependent. Preoperative, operative, and postoperative variables as well as all classic risk factors of coronary artery disease were recorded. Using multivariate analysis, we determined the independent predictors of length of stay in the ICU and in the surgical ward.
Results:
Independent predictors of extended length of stay in the surgical ward ( > 3 days) were a history of peripheral vascular disease, total administered insulin during a 24-hour period after surgery, glycosylated hemoglobin (HbA1c), last fasting blood sugar of the patients before surgery, and inotropic usage after cardiopulmonary bypass. The area under the Receiver Operating Characteristic Curve (AUC) was found to be 0.71 and Hosmer-Lemeshow (HL) goodness of fit statistic p value was 0.88. Independent predictors of extended length of stay in the ICU ( > 48 hours) were surgeon category, New York Heart Association functional class, intra-aortic balloon pump, postoperative arrhythmias, total administered insulin during a 24-hour period after surgery, and mean base excess of the first 6 postoperative hours (AUC = 0.70, HL p value = 0.94).
Conclusion:
This study revealed that the indices of glycemic control were the most important predictors of length of stay in the ward after cardiac surgery in all patients, diabetic or non-diabetic. However, because HbA1c level did not change under the influence of perioperative events, it could be deemed a valuable measure in predicting outcome in CABG candidates.
PMCID: PMC3537203  PMID: 23323078
Coronary artery bypass; Treatment outcome; Hemoglobin A, glycosylated; Length of stay
22.  Prognostic Accuracy of WHO Growth Standards to Predict Mortality in a Large-Scale Nutritional Program in Niger 
PLoS Medicine  2009;6(3):e1000039.
Background
Important differences exist in the diagnosis of malnutrition when comparing the 2006 World Health Organization (WHO) Child Growth Standards and the 1977 National Center for Health Statistics (NCHS) reference. However, their relationship with mortality has not been studied. Here, we assessed the accuracy of the WHO standards and the NCHS reference in predicting death in a population of malnourished children in a large nutritional program in Niger.
Methods and Findings
We analyzed data from 64,484 children aged 6–59 mo admitted with malnutrition (<80% weight-for-height percentage of the median [WH]% [NCHS] and/or mid-upper arm circumference [MUAC] <110 mm and/or presence of edema) in 2006 into the Médecins Sans Frontières (MSF) nutritional program in Maradi, Niger. Sensitivity and specificity of weight-for-height in terms of Z score (WHZ) and WH% for both WHO standards and NCHS reference were calculated using mortality as the gold standard. Sensitivity and specificity of MUAC were also calculated. The receiver operating characteristic (ROC) curve was traced for these cutoffs and its area under curve (AUC) estimated. In predicting mortality, WHZ (NCHS) and WH% (NCHS) showed AUC values of 0.63 (95% confidence interval [CI] 0.60–0.66) and 0.71 (CI 0.68–0.74), respectively. WHZ (WHO) and WH% (WHO) appeared to provide higher accuracy with AUC values of 0.76 (CI 0.75–0.80) and 0.77 (CI 0.75–0.80), respectively. The relationship between MUAC and mortality risk appeared to be relatively weak, with AUC = 0.63 (CI 0.60–0.67). Analyses stratified by sex and age yielded similar results.
Conclusions
These results suggest that in this population of children being treated for malnutrition, WH indicators calculated using WHO standards were more accurate for predicting mortality risk than those calculated using the NCHS reference. The findings are valid for a population of already malnourished children and are not necessarily generalizable to a population of children being screened for malnutrition. Future work is needed to assess which criteria are best for admission purposes to identify children most likely to benefit from therapeutic or supplementary feeding programs.
Rebecca Grais and colleagues assess the accuracy of WHO growth standards in predicting death among malnourished children admitted to a large nutritional program in Niger.
Editors' Summary
Background.
Malnutrition causes more than a third of child deaths worldwide. The World Health Organization (WHO) estimates there are 178 million malnourished children globally, all of whom are vulnerable to disease and 20 million of whom are at risk of death. Poverty, rising food prices, food scarcity, and natural disasters all contribute significantly to malnutrition, but children's lives can be saved if aid agencies are able to identify and treat acute malnutrition early. This can be done by comparing a child's body measurements to those of healthy children.
In 1977 the US National Center for Health Statistics (NCHS) introduced child growth reference charts describing how US children grow. The charts enable the height of a child of a given age to be compared with the set of “percentile curves,” which show, for example, whether the child is on the 90th or the 10th centile—that is, whether taller than 90% or 10% of their peers. These NCHS reference charts were subsequently adopted by the WHO for international use. In 2006, the WHO began to use new growth charts, based on children from a variety of countries raised in optimal environments for healthy growth. These provide a standard for how all children should grow, regardless of ethnic background or wealth.
Why Was This Study Done?
It is known that the WHO standards and the NCHS reference differ in how they identify malnutrition. Estimates of malnutrition are higher with the WHO standard than the NCHS reference. This affects the cost of international programs to treat malnutrition, as more children will be diagnosed and treated when the WHO standards are used. However, it is not known how the different growth measures differ in predicting which children's lives are at risk from malnutrition. The researchers saw that the data in their nutritional program could help provide this information.
What Did the Researchers Do and Find?
The researchers examined data on the body measurements of over 60,000 children aged between 6 mo and 5 y enrolled in a Médecins sans Frontières (MSF) nutritional programme in Maradi, Niger during 2006. Children were assessed as having acute malnutrition (wasting) and enrolled in the feeding program if their weight-for-height was less than 80% of the NCHS average, if their mid-upper arm circumference (MUAC) was under 110 mm (for children 65–110 cm), or they had swelling in both feet.
The authors evaluated three measures to see which was most accurate at predicting that children would die under treatment: low weight-for-height as measured against each of the WHO standard and NCHS reference, and low MUAC. For each measure, they compared the proportion of correct predictions of death (sensitivity) and the proportion of correct predictions of survival (specificity) for a range of possible cutoffs (or thresholds) for diagnosis.
They found that the WHO standard gave more accurate predictions than the NCHS reference or the MUAC of which children would die under treatment. The results were similar when the children were grouped by age or sex.
What Do these Findings Mean?
The results suggest that, at least in this population, the WHO standards are a more accurate predictor of death following malnutrition. This agrees with what might be expected, as the WHO standard is more up-to-date as well as aiming to show how healthy children from a range of settings should grow.
Nevertheless, an important limitation is that the children in the study had already been diagnosed as malnourished and were receiving treatment. As a result, the authors cannot say definitively which measure is better at predicting what children in the general population are acutely malnourished and would benefit most from treatment.
It should also be noted that children were predominantly entered into the feeding program by the weight-for-height indicator rather than by the MUAC. This may be a reason why the MUAC appears worse at predicting death than weight-for-height. Missing and inaccurate data, for instance on the exact ages of some children, also limit the findings.
In addition, the findings do not provide guidance on the cutoffs that should be used in deciding whether to enter a child into a feeding program. Different cutoffs represent a trade-off between treating more children needlessly in order to catch all in need, and treating fewer children and missing some in need. The study also cannot be used to advise on whether weight-for-height or the MUAC is more appropriate in a given context. In certain crisis situations, for instance, some authorities suggest it may be more practical to use the MUAC, as it requires less equipment or training.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000039.
The UN Standing Committee on Nutrition homepage publishes international briefings on nutrition as a foundation for development
The US National Center for Health Statistics provides background information on its 1977 growth charts and how they were developed in the context of explaining how they differ from revised charts produced in 2000
The World Heath Organization publishes country profile information on its child growth standards and also on Niger
Médecins sans Frontières also provides information on its work in Niger
The EC-FAO Food Security Information for Action Programme is funded by the European Commission (EC) and implemented by the Food and Agriculture Organization of the United Nations (FAO). It aims to help nations formulate more effective anti-hunger policies and provides online materials, including a guide to nutritional status assessment and analysis, which includes information on the contexts in which different indicators are useful
doi:10.1371/journal.pmed.1000039
PMCID: PMC2650722  PMID: 19260760
23.  Prognostic factors for death and survival with or without complications in cardiac arrest patients receiving CPR within 24 hours of anesthesia for emergency surgery 
Purpose
To determine prognostic factors for death and survival with or without complications in cardiac arrest patients who received cardiopulmonary resuscitation (CPR) within 24 hours of receiving anesthesia for emergency surgery.
Patients and methods
A retrospective cohort study approved by the Maharaj Nakorn Chiang Mai University Hospital Ethical Committee. Data used were taken from records of 751 cardiac arrest patients who received their first CPR within 24 hours of anesthesia for emergency surgery between January 1, 2003 and October 31, 2011. The reviewed data included patient characteristics, surgical procedures, American Society of Anesthesiologist (ASA) physical status classification, anesthesia information, the timing of cardiac arrest, CPR details, and outcomes at 24 hours after CPR. Univariate and polytomous logistic regression analyses were used to determine prognostic factors associated with the outcome variable. P-values of less than 0.05 were considered statistically significant.
Results
The outcomes at 24 hours were death (638/751, 85.0%), survival with complications (73/751, 9.7%), and survival without complications (40/751, 5.3%). The prognostic factors associated with death were: age between 13–34 years (OR =3.08, 95% CI =1.03–9.19); ASA physical status three and higher (OR =6.60, 95% CI =2.17–20.13); precardiopulmonary comorbidity (OR =3.28, 95% CI =1.09–9.90); the condition of patients who were on mechanical ventilation prior to receiving anesthesia (OR =4.11, 95% CI =1.17–14.38); surgery in the upper abdominal site (OR =14.64, 95% CI =2.83–75.82); shock prior to cardiac arrest (OR =6.24, 95% CI =2.53–15.36); nonshockable electrocardiography (EKG) rhythm (OR =5.67, 95% CI =1.93–16.62); cardiac arrest occurring in postoperative period (OR =7.35, 95% CI =2.89–18.74); and duration of CPR more than 30 minutes (OR =4.32, 95% CI =1.39–13.45). The prognostic factors associated with survival with complications were being greater than or equal to 65 years of age (OR =4.30, 95% CI =1.13–16.42), upper abdominal site of surgery (OR =10.86, 95% CI =1.99–59.13), shock prior to cardiac arrest (OR =3.62, 95% CI =1.30–10.12), arrhythmia prior to cardiac arrest (OR =4.61, 95% CI =1.01–21.13), and cardiac arrest occurring in the postoperative period (OR =3.63, 95% CI =1.31–10.02).
Conclusion
The mortality and morbidity in patients who received anesthesia for emergency surgery within 24 hours of their first CPR were high, and were associated with identifiable patient comorbidity, age, shock, anatomic site of operation, the timing of cardiac arrest, EKG rhythm, and the duration of CPR. EKG monitoring helps to identify cardiac arrest quickly and diagnose the EKG rhythm as a shockable or nonshockable rhythm, with CPR being performed as per the American Heart Association (AHA) CPR Guidelines 2010. The use of the fast track system in combination with an interdisciplinary team for surgery, CPR, and postoperative care helps to rescue patients in a short time.
doi:10.2147/RMHP.S68797
PMCID: PMC4218906  PMID: 25378961
CPR; cardiac arrest; emergency surgery; prognostic factors; death; survival; survival with complications; mortality; morbidity
24.  A randomised controlled trial to evaluate and optimize the use of antiplatelet agents in the perioperative management in patients undergoing general and abdominal surgery- the APAP trial (ISRCTN45810007) 
BMC Surgery  2011;11:7.
Background
Due to the increase of cardiovascular diseases acetylsalicylic acid (ASA) has become one of the most frequently prescribed drugs these days. Despite the rising number of patients with ASA medication presenting for elective general and abdominal surgery and the potentially increased risk of hemorrhage in these patients, there are no clear, evidence-based guidelines for the perioperative use of antiplatelet agents. The present randomised controlled trial was designed to evaluate the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery.
Methods/Design
This is a two-arm, monocenter randomised controlled trial. Patients scheduled for elective surgical treatment (i.e. inguinal hernia repair, cholecystectomy and colorectal resections) with ASA as a permanent medication are randomised equally to perioperative continuation or discontinuation of ASA. Patients who are randomised in the discontinuation group stop the administration of ASA five days prior to surgical treatment and start intake of ASA on postoperative day 5. Fifty-two patients will be enrolled in this trial. The primary outcome is the incidence of postoperative bleeding and cardiovascular events at 30 days after surgery. In addition a set of general as well as surgical variables are analysed.
Discussion
This is a randomised controlled two-group parallel trial designed to assess the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery. The results of this pilot study build the basis for a confirmative randomised controlled trial that may help to clarify the use and potential risk/benefits of perioperative ASA medication in patients undergoing elective surgery.
Trial registration
The trial is registered with Current Controlled Trials ISRCTN45810007.
doi:10.1186/1471-2482-11-7
PMCID: PMC3056734  PMID: 21371292
25.  Predictors of in-hospital mortality and complications in very elderly patients undergoing emergency surgery 
Introduction
With the increasing aging population demographics and life expectancies the number of very elderly patients (age ≥ 80) undergoing emergency surgery is expected to rise. This investigation examines the outcomes in very elderly patients undergoing emergency general surgery, including predictors of in-hospital mortality and morbidity.
Methods
A retrospective study of patients aged 80 and above undergoing emergency surgery between 2008 and 2010 at a tertiary care facility in Canada was conducted. Demographics, comorbidities, surgical indications, and perioperative risk assessment data were collected. Outcomes included length of hospitalization, discharge destination, and in-hospital mortality and morbidity. Multivariable logistic regression was used to identify predictors of in-hospital mortality and complications.
Results
Of the 170 patient admissions, the mean age was 84 years and the in-hospital mortality rate was 14.7%. Comorbidities were present in 91% of this older patient population. Over 60% of the patients required further services or alternate level of care on discharge. American Society of Anesthesiologist Physical Status (ASA) Classification (OR 5.30, 95% CI 1.774-15.817, p = 0.003) and the development of an in-hospital complications (OR 2.51, 95% CI 1.210-5.187, p = 0.013) were independent predictors of postoperative mortality. Chronological age or number of comorbidities was not predictive of surgical outcome.
Conclusions
Mortality, complication rates and post-discharge care requirements were high in very elderly patients undergoing emergency general surgery. Advanced age and medical comorbidities alone should not be the limiting factors for surgical referral or treatment. This study illustrates the importance of preventing an in-hospital complication in this very vulnerable population. ASA class is a robust tool which is predictive of mortality in the very elderly population and can be used to guide patient and family counseling in the emergency setting.
doi:10.1186/1749-7922-9-43
PMCID: PMC4105124  PMID: 25050133
Elderly; Acute care; Emergency; Surgery; Morbidity; Mortality

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