The Presence of Diabetes and Higher HbA1c Are Independently Associated With Adverse Outcomes After Surgery.

OBJECTIVE: Limited studies have examined the association between diabetes and HbA1c with postoperative outcomes. We investigated the association of diabetes, defined categorically, and the association of HbA1c as a continuous measure, with postoperative outcomes. RESEARCH DESIGN AND METHODS: In this prospective, observational study, we measured the HbA1c of surgical inpatients age ≥54 years at a tertiary hospital between May 2013 and January 2016. Patients were diagnosed with diabetes if they had preexisting diabetes or an HbA1c ≥6.5% (48 mmol/mol) or with prediabetes if they had an HbA1c between 5.7 and 6.4% (39 and 48 mmol/mol). Patients with an HbA1c <5.7% (39 mmol/mol) were categorized as having normoglycemia. Baseline demographic and clinical data were obtained from hospital records, and patients were followed for 6 months. Random-effects logistic and negative binomial regression models were used for analysis, treating surgical units as random effects. We undertook classification and regression tree (CART) analysis to design a 6-month mortality risk model. RESULTS: Of 7,565 inpatients, 30% had diabetes, and 37% had prediabetes. After adjusting for age, Charlson comorbidity index (excluding diabetes and age), estimated glomerular filtration rate, and length of surgery, diabetes was associated with increased 6-month mortality (adjusted odds ratio [aOR] 1.29 [95% CI 1.05-1.58]; P = 0.014), major complications (1.32 [1.14-1.52]; P < 0.001), intensive care unit (ICU) admission (1.50 [1.28-1.75]; P < 0.001), mechanical ventilation (1.67 [1.32-2.10]; P < 0.001), and hospital length of stay (LOS) (adjusted incidence rate ratio [aIRR] 1.08 [95% CI 1.04-1.12]; P < 0.001). Each percentage increase in HbA1c was associated with increased major complications (aOR 1.07 [1.01-1.14]; P = 0.030), ICU admission (aOR 1.14 [1.07-1.21]; P < 0.001), and hospital LOS (aIRR 1.05 [1.03-1.06]; P < 0.001). CART analysis confirmed a higher risk of 6-month mortality with diabetes in conjunction with other risk factors. CONCLUSIONS: Almost one-third of surgical inpatients age ≥54 years had diabetes. Diabetes and higher HbA1c were independently associated with a higher risk of adverse outcomes after surgery.

Usefulness of N-terminal pro-brain natriuretic peptide to predict postoperative cardiac complications and long-term mortality after emergency lower limb orthopedic surgery.

After emergency orthopedic-geriatric surgery, cardiac complications are an important cause of morbidity and mortality. The utility of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) for the prediction of cardiac complications and mortality was evaluated. NT-pro-BNP was tested pre- and postoperatively in 89 patients >60 years of age. They were followed for 2 years for cardiac complications (defined as acute myocardial infarction, congestive cardiac failure, atrial fibrillation or major arrhythmia) or death. Receiver operating characteristic curves were constructed to determine the optimal discriminatory level for cardiac events and death using NT-pro-BNP. Twenty-three patients (25.8%) sustained an in-hospital postoperative cardiac complication. Total all-cause mortality was 3 of 89 (3.4%) in hospital, 21 of 89 (23.6%) at 1 year, and 27 of 89 (30.3%) at 2 years. Median preoperative and postoperative NT-pro-BNP levels were higher in patients who had an in-hospital cardiac event compared to those without (387 vs 1,969 pg/ml, p <0.001; and 676 vs 7,052 pg/ml, p <0.001 respectively). The optimal discriminatory level for preoperative NT-pro-BNP was 842 pg/ml and that for postoperative NT-pro-BNP was 1,401 pg/ml for the prediction of in-hospital cardiac events and 1- and 2-year mortality. Preoperative NT-pro-BNP >/=842 pg/ml (odds ratio 11.6, 95% confidence interval 2.1 to 65.0, p = 0.005) was an independent predictor of in-hospital cardiac complications using multivariate analysis and pre- and postoperative NT-pro-BNP levels were independent predictors of 2-year cardiovascular events. Patients who had preoperative NT-pro-BNP >/=842 pg/ml or postoperative NT-pro-BNP >/=1,401 pg/ml had significantly worse survival using log-rank testing (p <0.001) and these variables independently predicted 2-year mortality. In conclusion, increase pre- and postoperative NT-pro-BNP levels are independent predictors of in-hospital cardiac events and 1- and 2-year mortality in older patients undergoing emergency orthopedic surgery.

Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients.

OBJECTIVES: to determine the incidence of post-operative troponin I rises and its association with 1-year all-cause mortality and cardiac events after emergency orthopaedic-geriatric surgery, which has not been studied before. METHODS: one hundred and two patients over the age of 60 were recruited and followed up at 1 year. All consented to serial troponin I measurements peri-operatively. RESULTS: the incidence of a troponin I rise post-operatively was 52.9%. Post-operative acute myocardial infarction was diagnosed in 9.8% and at 1 year, 70% of these patients were dead. At 1 year, 32.4% (33/102) had sustained a cardiac event (myocardial infarction, congestive cardiac failure, atrial fibrillation or major arrhythmia) and using multivariate analysis, post-operative troponin rise (OR 3.9, 95% CI 1.4-10.7, P = 0.008) was an independent predictor of this. Half of the patients with a troponin rise had a cardiac event compared to 18.8% without a rise. All-cause mortality was 20.6% at 1 year; 37% with an associated post-operative troponin rise died versus 2.1% without a rise (P < 0.0001). Using multivariate analysis, only two factors were associated with 1-year all-cause mortality: post-operative troponin rise (OR 12.0, 95% CI 1.4-104.8, P = 0.025) and sustaining a post-operative in-hospital cardiac event (OR 6.6, 95% CI 1.7-25.6, P = 0.006). Furthermore, patients with higher troponin levels had significantly worse survival. CONCLUSIONS: there is a high incidence of post-operative troponin I rises in older patients undergoing emergency orthopaedic surgery with 1-year mortality and cardiac events being significantly increased in these patients. Future studies are needed to determine whether any intervention can improve outcome for these patients.