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Purpose: To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure. Methods: A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST). Results: Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice. Conclusions: A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made.

Background Health related quality of life (HRQL) is an important outcome measure in geriatric oncology. Surgery is the main treatment for colorectal cancer (CRC) but has been associated with a loss of HRQL in older patients. This study aimed to identify determinants for a decreased HRQL at three months after CRC diagnosis. Method This multi-centre observational cohort study ( NCT04443816 ) included 273 patients aged ≥70 years diagnosed with non-metastatic CRC. A multi-domain frailty screening was performed in each patient. A decreased HRQL was defined as a mean difference ≥ 10 on the EORTC QLQ-C30 questionnaire between baseline and three months after CRC diagnosis. Determinants of a decreased HRQL were analysed using multivariable logistic regression. Results A decrease in HRQL occurred in 63 patients (23.1%). Non-surgical patients had the highest risk of decreased HRQL three months after diagnosis (adjusted odds ratio (OR) 6.4 (95% confidence interval (CI) 2.0–19.8)). The Charlson Comorbidity Index (CCI) (aOR 2.3 (95% (CI) 1.2–4.2)), the American Association of Anesthesiologists class (aOR 2.6 (95%CI 1.4–4.9)), impaired daily functioning (aOR 2.7 (95%CI 1.3–5.6)) and dependent living (aOR 1.9 (95%CI 1.1–4.5)) were associated with a decreased HRQL, mainly caused by non-surgical patients. In surgical patients, a major postoperative complication was a strong determinant of decreased HRQL and was associated with preoperative comorbidity and cognitive impairment (aOR 4.0 (95%CI 1.9–8.8)). Conclusion Frailty characteristics are highly prevalent in older patients at time of CRC diagnosis but not strongly associated with a decreased HRQL after three months. Non-surgical patients and patients with major postoperative complications had the highest risk of decreased HRQL. Registered at clinicaltrials.gov trial number: NCT04443816

ImportanceCurrent fasting guidelines for procedures under anesthesia are poorly implemented, leading to negative metabolic sequelae. Recent studies in children showed support of liberal clear fluid intake; adult physiology can support clear fluid intake, but implementation studies are lacking.ObjectiveTo evaluate the successfulness of implementation of a liberal clear fluid policy with regard to fasting duration, well-being, and safety in adults scheduled for anesthesia.Design, Setting, and ParticipantsThis was a quality improvement study conducted from January 2016 to July 2021 at a tertiary referral hospital in the Netherlands. Adults scheduled for nonemergency procedures under anesthesia were included in the study. Patients undergoing obstetrics procedures or those who were intubated preoperatively were excluded.InterventionsStepwise introduction of a liberal fluid fasting policy, allowing for ingestion of clear fluids until arrival at the operating room.Main Outcomes and MeasuresThe primary outcome was change in fasting duration. Secondary outcomes were patient well-being, measured as preoperative thirst, amount of fluid ingested, postoperative nausea and vomiting (PONV), and administration of antiemetics. Safety was measured as incidence of regurgitation and aspiration (pneumonia).ResultsOf the 76 451 patients (mean [SD] age, 56 [17] years; 39 530 male individuals [52%] 36 921) included in the study, 59 036 (78%) followed the standard policy, and 16 815 (22%) followed the liberal policy. Time series analysis showed an estimated fasting duration decrease of 3:07 hours (IQR, 1:36-7:22; P P P P Conclusions and RelevanceResults of this quality improvement study suggest that a liberal fasting policy was associated with a clinically relevant reduction in fasting duration and improved patient well-being with regard to preoperative thirst and PONV. Although a slightly higher incidence of regurgitation could not be ruled out, wider implementation of such a policy may be advocated as results are still within the clinically accepted risks margins. Results suggest that surgical procedures in patients who drink clear fluids within 2 hours before anticipated anesthesia should not be postponed or canceled.

Background Acute kidney injury (AKI) is associated with mortality after cardiac surgery. Novel risk factors may improve identification of patients at risk for renal injury. The authors evaluated the association between preoperative biomarkers that reflect cardiac, inflammatory, renal, and metabolic disorders and cardiac surgery-associated AKI (CSA-AKI) in elderly patients. Methods This was a secondary analysis of the 2-center prospective cohort study "Anesthesia Geriatric Evaluation." Twelve biomarkers were determined preoperatively in 539 patients. Primary outcome was CSA-AKI. The association between biomarkers and CSA-AKI was investigated with multivariable logistic regression analysis. Secondary outcomes were 1-year mortality and patient-reported disability and were assessed with relative risks (RR) between patients with and without CSA-AKI. Results CSA-AKI occurred in 88 (16.3%) patients and was associated with increased risk of mortality (RR, 6.70 [95% confidence interval {CI}, 3.38-13.30]) and disability (RR, 2.13 [95% CI, 1.53-2.95]). Preoperative concentrations of N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitive C-reactive protein (hs-CRP), hemoglobin, and magnesium had the strongest association with CSA-AKI. Identification of patients with CSA-AKI improved when a biomarker panel was used (area under the curve [AUC] 0.75 [95% CI, 0.69-0.80]) compared to when only clinical risk factors were used (European System for Cardiac Operative Risk Evaluation [EuroSCORE II] AUC 0.67 [95% CI, 0.62-0.73]). Conclusions Preoperative cardiac, inflammatory, renal, and metabolic biomarkers are associated with CSA-AKI and may improve identification of patients at risk.

Background: Postoperative anaemia is common in older cardiac surgery patients and often caused by iron deficiency. Anaemia may negatively affect recovery after cardiac surgery. This study aims to determine the efficacy of treatment of postoperative iron deficiency anaemia (IDA) with intravenous iron (IVI) on disability 90 days after cardiac surgery in older patients. Methods: This is a randomized placebo-controlled double blind multi-centre trial. In total, 310 patients aged ≥70 years with moderate IDA on postoperative day 1 (haemoglobin 85 - 110 g/L and ferritin concentration < 100 μg/L or iron saturation Discussion: The results of this study will demonstrate whether early treatment of postoperative IDA with IVI improves disability at 90 days in older cardiac surgery patients. Trial registration: Registered at ClinicalTrials.gov as NCT04913649 at June 4th, 2021.

Background Chronic pain after cardiac surgery, whether or not related to the operation, is common and has negative impact on health related quality of life (HRQL). Frailty is a risk factor for adverse surgical outcomes, but its relationship with chronic pain after cardiac surgery is unknown. This study aimed to address the association between frailty and chronic pain following cardiac surgery. Methods This sub-study of the Anesthesia Geriatric Evaluation study included 518 patients ≥ 70 years undergoing elective cardiac surgery. Pain was evaluated with the Short-Form 36 questionnaire prior to and one year after surgery. Associations between chronic postoperative pain and frailty domains, including medication use, nutritional status, mobility, physical functioning, cognition, HRQL, living situation and educational level, were investigated with multivariable regression analysis. Results Chronic pain one year after cardiac surgery was reported in 182 patients (35%). Medication use, living situation, mobility, gait speed, Nagi’s physical functioning and preoperative HRQL were frailty domains associated with chronic pain after surgery. For patients with chronic pain physical HRQL after one year was worse compared to patients without chronic pain (β –10.37, 99% CI –12.57 – –8.17). Conclusions Preoperative polypharmacy, living alone, physical frailty and lower mental HRQL are associated with chronic pain following cardiac surgery. Chronic postoperative pain is related to worse physical HRQL one year after cardiac surgery. These findings may guide future preoperative interventions to reduce chronic pain and poor HRQL after cardiac surgery in older patients. Trial Registration This trial has been registered before initiation under number NCT02535728 at clinicaltrials.gov.

BACKGROUND: Delirium is a frequent complication after surgery in older adults and is associated with an increased risk of long-term cognitive impairment and dementia. Disturbances in functional brain networks were previously reported during delirium. We hypothesised that alterations in functional brain networks persist after remission of postoperative delirium and that functional brain network alterations are associated with long-term cognitive impairment. METHODS: In this prospective, multicentre, observational cohort study, we included older patients who underwent clinical assessments (including the Trail Making Test B [TMT-B]) and resting-state functional MRI (rs-fMRI) before and 3 months after elective surgery. Delirium was assessed on the first seven postoperative days. RESULTS: Of the 554 enrolled patients, 246 remained after strict motion correction, of whom 38 (16%) developed postoperative delirium. The rs-fMRI functional connectivity strength increased 3 months after surgery in the total study population (β=0.006; 95% confidence interval [CI]: 0.001-0.011; P=0.013), but it decreased after postoperative delirium (β=-0.015; 95% CI: -0.028 to 0.002; P=0.023). No difference in TMT-B scores was found at follow-up between patients with and without postoperative delirium. Patients with decreased functional connectivity strength declined in TMT-B scores compared with those who did not (β=11.04; 95% CI: 0.85-21.2; P=0.034). CONCLUSIONS: Postoperative delirium was associated with decreased brain functional connectivity strength after 3 months, suggesting that delirium has a long-lasting impact on brain networks. The decreased connectivity strength was associated with significant cognitive deterioration after major surgery. CLINICAL TRIAL REGISTRATION: NCT02265263.

Frailty increases risk for morbidity and mortality after cardiac surgery. Its influence on functional outcome is largely unknown. We studied the association of frailty with health-related quality of life and disability after cardiac surgery.A prospective 2-center observational cohort of 555 patients aged 70 years or more undergoing cardiac surgery. A comprehensive frailty assessment was performed before surgery based on 11 individual assessments in physical, mental, and social domains. Frailty was defined as at least 1 positive test in each domain. The primary outcome was health-related quality of life over 1 year, and the secondary outcomes were severe in-hospital complications and disability over 1 year. Adverse functional outcome was defined as the composite of a decreased health-related quality of life and disability.Physical frailty was most common (91%) compared with mental (39%) or social frailty (42%). Adverse functional outcome occurred in 257 patients (46%) and consisted of decreased physical health-related quality of life in 134 (24%), decreased mental health-related quality of life in 141 (25%), and disability in 120 (22%). Frailty was more common in patients with adverse functional outcome (29%) compared with patients without adverse functional outcome (16%, P .001). Poor mobility, malnutrition, and polypharmacy were associated with a decreased health-related quality of life over time, whereas impaired physical functioning and higher self-rated health were related to increased health-related quality of life. Disability after cardiac surgery was associated with poor mobility, polypharmacy, dependent living, living alone, and lower self-rated mental health before surgery.Mobility, nutrition, medication use, physical functioning, and self-rated health before surgery are associated with health-related quality of life in elderly patients 1 year after cardiac surgery.

BackgroundDelirium is a frequent complication of elective surgery in elderly patients, associated with an increased risk of long-term cognitive impairment and dementia. Disturbances in the functional brain network were previously reported during delirium. We hypothesized persisting alterations in functional brain networks three months after elective surgery in patients with postoperative delirium, and hypothesized that postoperative brain connectivity changes (irrespective of delirium) are related to cognitive decline.MethodsElderly patients (N=554) undergoing elective surgery underwent clinical assessments (including Trail Making Test B (TMT-B) and resting-state functional magnetic resonance imaging (rs-fMRI) before and three months after surgery. Delirium was assessed on the first seven postoperative days. After strict motion correction, rs-fMRI connectivity strength and network characteristics were calculated in 246 patients (130 patients underwent scans at both timepoints), of whom 38 (16%) developed postoperative delirium.ResultsRs-fMRI functional connectivity strength increased after surgery in the total study population (β=0.006, 95%CI=0.000–0.012, p=0.021), but decreased after postoperative delirium (β=-0.014, 95%CI=0.000–0.012, p=0.026). No difference in TMT-B scores was found at follow-up between patients with and without postoperative delirium. Patients who decreased in functional connectivity strength declined in TMT-B scores compared to the group that did not (β=11.04, 95%CI=0.85-21.2, p=0.034).ConclusionsDelirium was associated with decreased functional connectivity strength three months after the syndrome was clinically resolved, which implies that delirium has lasting impact on brain networks. Decreased connectivity strength was associated with statistically significant (but not necessarily clinically relevant) cognitive deterioration after major surgery, which was not specifically related to delirium.Summary statementDelirium was associated with decreased resting-state fMRI functional connectivity strength three months after the syndrome was clinically resolved. Irrespective of delirium, decreased connectivity strength after major surgery was associated with a statistically significant cognitive deterioration.

Objectives: Accurate preoperative transfusion risk stratification may serve to better manage older patients undergoing cardiac surgery. Therefore, the aim of the present study was to externally validate the existing Association of Cardiothoracic Anesthetists perioperative risk of blood transfusion (ACTA-PORT) score in a population ≥70 years of age scheduled for cardiac surgery. Furthermore, the study authors investigated the additional prognostic value of individual frailty variables to this transfusion risk score. Design: A retrospective analysis. Setting: At a tertiary-care hospital. Participants: Five hundred seven patients aged ≥70 years undergoing elective cardiac surgery from July 2015 to August 2017. Interventions: None. Measurements and Main Results: The primary outcome was the administration of a perioperative blood transfusion. Frailty domains were assessed in a preanesthesia geriatric assessment, and a priori selection of biomarkers derived from blood was determined. The original ACTA-PORT score resulted in a c-statistic of 0.78 (95% confidence interval 0.74-0.82), with moderate calibration in predicting perioperative allogeneic transfusion in older patients undergoing cardiac surgery. Model updating, using the closed testing procedure, resulted in model revision with a higher discriminatory performance (c-statistic of 0.83, 95% confidence interval 0.79-0.86) and corrected calibration slope. Iron deficiency, impaired nutritional status, and physical impairment were associated with perioperative transfusions. The addition of individual frailty variables to the updated ACTA-PORT model did not result in improved predictive performance. Conclusions: External validation of the original ACTA-PORT score showed good discrimination and moderate calibration in older patients at risk of frailty undergoing cardiac surgery. Updating the original ACTA-PORT improved the predictive performance. Careful evaluation of additional frailty domains did not add prognostic value to the ACTA-PORT score.

Aims: Identifying preoperative risk factors in older patients becomes more important to reduce adverse functional outcome. This study investigated the association between preoperative medication use and functional decline in elderly cardiac surgery patients and compared polypharmacy as a preoperative screening tool to a clinical frailty assessment.Methods: This sub-study of the Anaesthesia Geriatric Evaluation study included 518 patients aged ≥70 years undergoing elective cardiac surgery. The primary outcome was functional decline, defined as a worse health-related quality of life or disability 1 year after surgery. The association between polypharmacy (i.e. ≥5 prescriptions and Results: Functional decline was reported in 284 patients (55%) and preoperative polypharmacy and excessive polypharmacy showed higher risks (adjusted relative risk 1.57, 95% confidence interval [CI] 1.23-1.98 and 1.93, 95% CI 1.48-2.50, respectively). Besides cardiovascular medication, proton-pump inhibitors and central nervous system medication were significantly associated with functional decline. Discrimination between models with polypharmacy or frailty was similar (area under the curve 0.67, 95% CI 0.61-0.72). The net reclassification index improved when including polypharmacy to the basic model (17%, 95% CI 0.06-0.27).Conclusion: Polypharmacy is associated with functional decline in elderly cardiac surgery patients. A preoperative medication review is easily performed and could be used as screening tool to identify patients at risk for adverse outcome after cardiac surgery.

Acute kidney injury (AKI) is associated with mortality after cardiac surgery. Novel risk factors may improve identification of patients at risk for renal injury. The authors evaluated the association between preoperative biomarkers that reflect cardiac, inflammatory, renal, and metabolic disorders and cardiac surgery-associated AKI (CSA-AKI) in elderly patients.This was a secondary analysis of the 2-center prospective cohort study "Anesthesia Geriatric Evaluation." Twelve biomarkers were determined preoperatively in 539 patients. Primary outcome was CSA-AKI. The association between biomarkers and CSA-AKI was investigated with multivariable logistic regression analysis. Secondary outcomes were 1-year mortality and patient-reported disability and were assessed with relative risks (RR) between patients with and without CSA-AKI.CSA-AKI occurred in 88 (16.3%) patients and was associated with increased risk of mortality (RR, 6.70 [95% confidence interval {CI}, 3.38-13.30]) and disability (RR, 2.13 [95% CI, 1.53-2.95]). Preoperative concentrations of N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitive C-reactive protein (hs-CRP), hemoglobin, and magnesium had the strongest association with CSA-AKI. Identification of patients with CSA-AKI improved when a biomarker panel was used (area under the curve [AUC] 0.75 [95% CI, 0.69-0.80]) compared to when only clinical risk factors were used (European System for Cardiac Operative Risk Evaluation [EuroSCORE II] AUC 0.67 [95% CI, 0.62-0.73]).Preoperative cardiac, inflammatory, renal, and metabolic biomarkers are associated with CSA-AKI and may improve identification of patients at risk.

OBJECTIVES Older patients have a higher cardiac surgery-associated acute kidney injury (CSA-AKI) related mortality. Low oxygen delivery (DO2) during cardiopulmonary bypass (CPB) is a risk factor for CSA-AKI, but critical DO2 thresholds for older patients are unknown. This study investigated critical DO2 thresholds for CSA-AKI in patients ≥70 years undergoing on-pump cardiac surgery. METHODS Patients were enrolled from July 2015 until August 2017. CPB data from 432 patients were collected, and DO2 values were calculated per minute. The primary outcome was CSA-AKI. The association between DO2 and CSA-AKI was analysed with multivariable regression analysis. Multiple DO2 thresholds were analysed. The association between CSA-AKI and the area below the DO2 thresholds (DO2 deficit) was evaluated, as was the association between frailty and CSA-AKI. RESULTS CSA-AKI occurred in 63 (14.6%) patients. Mean and nadir (lowest) DO2 values were lower in patients with CSA-AKI (283 vs 312 ml/min/m2; P-value CONCLUSIONS Low DO2 increased the risk for CSA-AKI in older patients who had cardiac surgery. A critical DO2 threshold of 270 ml/min/m2 was applicable for frail and non-frail patients. The efficacy of a DO2 >270 ml/min/m2 to reduce CSA-AKI in older patients needs further evaluation.

Background: Advanced glycation end products (AGEs) are a potential biomarker of biological age. Skin Auto Fluorescence (SAF) can assess AGEs non-invasively. We evaluated the association of SAF levels with frailty and its predictive ability for adverse outcomes in elderly cardiac surgery patients. Methods & Results: We measured SAF level in cardiac surgery patients aged ≥70 and analyzed the correlation with frailty diagnosed with geriatric assessment. A decision algorithm for frailty screening was developed using Conditional Interference Tree analysis and compared with the Frailty Phenotype (FP), a validated frailty assessment tool. We evaluated the association of SAF level with severe postoperative complications and a composite endpoint of one-year disability (defined by WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire) and mortality with Poisson regression analyses. Among 555 enrolled patients, 122 (22%) were classified as frail. Of all frailty characteristics, SAF level was most strongly associated with dependent living status (aRR 2.61 (95% CI 1.23-5.53) and handgrip strength (aRR 1.72 (95% CI 1.28-2.32). A decision algorithm including SAF level, sex, prescription drugs, preoperative hemoglobin and EuroSCORE II resulted in a C-statistic of 0.72 (95% CI 0.67-0.77) vs 0.66 (95% CI 0.61-0.71) for the FP. SAF level was also associated with disability/death after one year (aRR 1.18 (95% CI 1.06-1.30). The RR for severe complications was 1.32 (95% CI 0.99-1.75). Conclusion: Higher SAF level is associated with frailty in elderly cardiac surgery patients, as well as an increased risk of death and disability. This biomarker could potentially optimize preoperative screening for cardiac surgery.

BackgroundCardiac and inflammatory biomarkers have been associated with adverse outcome after major abdominal surgery. Remote ischemic preconditioning (RIPC) may protect organs from ischemic insults during and after cardiac surgery, but the effect in major abdominal surgery is largely unknown.ObjectiveTo study the effect of RIPC on cardiac and inflammatory biomarkers in patients undergoing pancreatic resection.MethodsSingle-center, double-blind, randomized controlled trial in ninety patients undergoing elective pancreatic resection between March 2017 and February 2019. Three cycles of upper-limb ischemia and reperfusion (each 5 minutes) were applied before surgery. The primary endpoint was the maximum postoperative high-sensitive cardiac troponin (hs-cTn) T concentration within 48 hours after surgery. Secondary endpoints were postoperative myocardial injury (PMI, defined as a postoperative hs-cTnT ≥14 ng L-1), the maximum concentration of interleukin (IL)-6 within 48 hours after surgery, and postoperative complications within 30-days of surgery.ResultsRIPC did not reduce the maximum hs-cTnT concentration after surgery (12.6 ng L-1 vs 16.6 ng L-1 in the control group (P=0.23), nor did it lessen the incidence of PMI (15 (33.3%) patients in the RIPC group versus 19 (42.2%) controls, P=0.93). The maximum postoperative IL-6 concentration was 239 pg mL-1 [115-360] in the RIPC group, as compared to 317 pg mL-1 [174-909] in the control group (P=0.13). A postoperative complication occurred in 23 (51%) RIPC patients and 24 (53%) controls.ConclusionsRemote ischemic preconditioning did not reduce the maximum postoperative hs-cTnT concentration. Postoperative myocardial injury, IL-6 concentrations and postoperative complications were not statistically different between RIPC patients and controls.Trial RegistrationClinicaltrials.gov identifier NCT03460938FundingFunding for biomarker analysis was provided by Roche Diagnostics. Roche Diagnostics had no role in design and conduct of the study, analysis and interpretation of the data, preparation and approval of the manuscript.Article summaryStrengths and limitations of this studyWell-designed clinical trial in a selected group of high-risk abdominal surgery patients.Serial assessment of high-sensitive cardiac troponin T and interleukin-6 concentrations.Postoperative cardiac biomarker concentrations were relatively low.This trial was not primarily designed to detect differences in IL-6 concentrations and postoperative complications.

Background An elevated cardiac troponin level after noncardiac surgery is associated with both morbidity and mortality. Guidelines suggest routine troponin monitoring in high-risk patients. We implemented a dedicated anesthesia team to conduct follow-up on patients with postoperative troponin elevation. We hypothesized that these visits would facilitate early detection of complications. Therefore, the aim of this study was to evaluate the effect of postoperative visits by dedicated anesthesiologists on early detection of complications and care utility. Methods This retrospective observational study included patients aged ≥ 60 years with an elevated troponin within the first 3 days after noncardiac surgery. Troponin elevation was detected by routine biomarker monitoring. The primary outcome was early detected myocardial infarctions by the dedicated anesthesiologist. Other outcomes were overall detected complications, additional diagnostic tests and treatment advised by the anesthesiologist, consultation of another medical specialist, and advised postoperative follow-up at the outpatient cardiac clinic within 1 week after surgery. Results Of the 811 patients, 509 (63%) received a postoperative consultation by the anesthesiologist. Anesthesiologists were involved in the early detection of 59% of all myocardial infarctions and in 12% of all complications. Besides cardiac ischemia, patients were also often diagnosed with noncardiac complications, including respiratory failure (8.9%), pneumonia (13.2%), and acute kidney injury (17.5%) within 1 week after surgery. In 75% of patients, anesthesiologists ordered additional diagnostics, most frequently existing of electrocardiograms and additional cardiac enzyme testing. Additionally, change in treatment was advised, most often a medication change, in 16% of patients. Conclusions Standard consultation of a dedicated anesthesiologist resulted in an early detection of 59% of all myocardial infarctions and involved a change in treatment in a considerable number of patients with postoperative troponin elevation. Whether this may improve patient outcomes remains to be elucidated.

This is a protocol for a Cochrane Review (Prognosis). The objectives are as follows: The primary objective of this Cochrane Review is to quantify the added predictive value of several biomarkers to the Revised Cardiac Risk Index (RCRI) and to estimate the predictive performance of biomarkers compared to the RCRI alone to predict major adverse cardiac events (MACEs) and all-cause mortality in patients undergoing noncardiac surgery. Table 1 represents the PICOTS of the review based on the CHARMS checklist (Moons 2014). Table 1. PICOTS of the review based on the CHARMS checklist Population targeted Patients undergoing noncardiac surgery Intervention (index model) Prognostic model; Revised Cardiac Risk Index (RCRI) Comparator model Addition of biomarkers to the RCRI or comparison of biomarkers alone to the RCRI Outcome(s) to be predicted Major adverse cardiac events (MACEs) and all-cause mortality Time span of the prediction All time spans Setting (intended role and use of the model) To inform physicians preoperatively of the patient's risk of developing events after noncardiac surgery Investigation of sources of heterogeneity between studies We will assess sources of heterogeneity based on the population, outcome definitions and prediction horizons. The RCRI was originally developed for a noncardiac, nonvascular surgical population to predict in-hospital MACEs. However, the RCRI has also been externally validated in vascular surgical patients (Gillmann 2014; Scrutinio 2014), in which the predictive performance was found to be moderate (Ford 2010). In addition, prediction horizons vary between studies from in-hospital to long-term events (e.g. postoperative 1-year all-cause mortality). Finally, the composition of items that defines MACEs varies among different studies.

Background Associations between intraoperative hypotension (IOH) and postoperative complications have been reported. We examined whether using different methods to model IOH affected the association with postoperative myocardial injury (POMI) and acute kidney injury (AKI). Methods This two-centre cohort study included 10 432 patients aged ≥50 yr undergoing non-cardiac surgery. Twelve different methods to statistically model IOH [representing presence, depth, duration, and area under the threshold (AUT)] were applied to examine the association with POMI and AKI using logistic regression analysis. To define IOH, eight predefined thresholds were chosen. Results The incidences of POMI and AKI were 14.9% and 14.8%, respectively. Different methods to model IOH yielded effect estimates differing in size and statistical significance. Methods with the highest odds were absolute maximum decrease in blood pressure (BP) and mean episode AUT, odds ratio (OR) 1.43 [99% confidence interval (CI): 1.15–1.77] and OR 1.69 (99% CI: 0.99–2.88), respectively, for the absolute mean arterial pressure 50 mm Hg threshold. After standardisation, the highest standardised ORs were obtained for depth-related methods, OR 1.12 (99% CI: 1.05–1.20) for absolute and relative maximum decrease in BP. No single method always yielded the highest effect estimate in every setting. However, methods with the highest effect estimates remained consistent across different BP types, thresholds, outcomes, and centres. Conclusions In studies on IOH, both the threshold to define hypotension and the method chosen to model IOH affects the association of IOH with outcome. This makes different studies on IOH less comparable and hampers clinical application of reported results.