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1.  Survival after postoperative morbidity: a longitudinal observational cohort study† 
BJA: British Journal of Anaesthesia  2014;113(6):977-984.
Background
Previous studies have suggested that there may be long-term harm associated with postoperative complications. Uncertainty exists however, because of the need for risk adjustment and inconsistent definitions of postoperative morbidity.
Methods
We did a longitudinal observational cohort study of patients undergoing major surgery. Case-mix adjustment was applied and morbidity was recorded using a validated outcome measure. Cox proportional hazards modelling using time-dependent covariates was used to measure the independent relationship between prolonged postoperative morbidity and longer term survival.
Results
Data were analysed for 1362 patients. The median length of stay was 9 days and the median follow-up time was 6.5 yr. Independent of perioperative risk, postoperative neurological morbidity (prevalence 2.9%) was associated with a relative hazard for long-term mortality of 2.00 [P=0.001; 95% confidence interval (CI) 1.32–3.04]. Prolonged postoperative morbidity (prevalence 15.6%) conferred a relative hazard for death in the first 12 months after surgery of 3.51 (P<0.001; 95% CI 2.28–5.42) and for the next 2 yr of 2.44 (P<0.001; 95% CI 1.62–3.65), returning to baseline thereafter.
Conclusions
Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complications.
doi:10.1093/bja/aeu224
PMCID: PMC4235571  PMID: 25012586
complications; complications, morbidity; complications, neurological; surgery, non-cardiac
2.  Revised cardiac risk index and postoperative morbidity after elective orthopaedic surgery: a prospective cohort study 
BJA: British Journal of Anaesthesia  2010;105(6):744-752.
Background
The revised cardiac risk index (RCRI) is associated strongly with increased cardiac ischaemic risk and perioperative death. Associations with non-cardiac morbidity in non-cardiac surgery have not been explored. In the elective orthopaedic surgical population, morbidity is common but preoperative predictors are unclear. We hypothesized that RCRI would identify individuals at increased risk of non-cardiac morbidity in this surgically homogenous population.
Methods
Five hundred and sixty patients undergoing elective primary (>90%) and revision hip and knee procedures were studied. A modified RCRI (mRCRI) score was calculated, weighting intermediate and low risk factors. The primary endpoint was the development of morbidity, collected prospectively using the Postoperative Morbidity Survey, on postoperative day (POD) 5.
Results
Morbidity on POD 5 was more frequent in patients with mRCRI ≥3 {relative risk 1.7, [95% confidence interval (CI): 1.4–2.1]; P<0.001}. Time to hospital discharge was delayed in patients with mRCRI score ≥3 (log-rank test, P=0.0002). Pulmonary (P<0.001), infectious (P=0.001), cardiovascular (P=0.0003), renal (P<0.0001), wound (P=0.02), and neurological (P=0.002) morbidities were more common in patients with mRCRI score ≥3. Pre/postoperative haematocrit, anaesthetic/analgesic technique, and postoperative temperature were similar across mRCRI groups. There were significant associations with hospital stay, as measured by the area under the receiver-operating characteristic curves for mRCRI 0.64 (95% CI: 0.58–0.70) and POSSUM 0.70 (95% CI: 0.63–0.75).
Conclusions
mRCRI score ≥3 is associated with increased postoperative non-cardiac morbidity and prolonged hospital stay after elective orthopaedic procedures. mRCRI can contribute to objective risk stratification of postoperative morbidity.
doi:10.1093/bja/aeq245
PMCID: PMC2982697  PMID: 20876700
assessment, preanaesthetic; complications, morbidity; surgery, non-cardiac; surgery, orthopaedic
6.  Median nerve injury: an underrecognised complication of brachial artery cardiac catheterisation? 
OBJECTIVE—To describe the local neurological complications associated with cardiac catheterisation via the right brachial artery.
METHODS—A follow up study to determine the mechanism of injury and outcome of patients who sustained a high median nerve palsy after this procedure. Five right handed patients were identified in a 24 month period. Each was assessed clinically and electrophysiologically at presentation. All were followed up initally (range six to 22months) clinically, electrophysiologically, and using components from the Chessington occupational therapy neurological assessment battery (COTNAB) functional hand assessment.
RESULTS—The incidence of this complication was between 0.2 and 1.4%. Three mechanisms of injury were identified. These included direct nerve compression due to formation of antecubital fossa haematoma, direct nerve trauma, and ischaemia secondary to brachial artery occlusion. The initial neurological and nerve conduction deficits improved with time. However, all cases had persistent disability in hand function as documented clinically and on the dexterity and stereognosis subcomponent of the COTNAB test.
CONCLUSION—This is an uncommon, but probably underrecognised complication. Those performing cardiac catheterisation via the right brachial artery should be aware of the potential risks of damage to the median nerve. They should evaluate hand function after the procedure and take prompt action if median nerve dysfunction is noted. Damage to the median nerve results in appreciable long term disability, which may have medicolegal relevance.


PMCID: PMC2169787  PMID: 9343143

Results 1-6 (6)