Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study.

BACKGROUND: The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to characterise the association of preoperative DASI scores with postoperative death or complications. METHODS: The analysis included 1546 participants (≥40 yr of age) at an elevated cardiac risk who had inpatient noncardiac surgery. The primary outcome was 30-day death or myocardial injury. The secondary outcomes were 30-day death or myocardial infarction, in-hospital moderate-to-severe complications, and 1 yr death or new disability. Multivariable logistic regression modelling was used to characterise the adjusted association of preoperative DASI scores with outcomes. RESULTS: The DASI score had non-linear associations with outcomes. Self-reported functional capacity better than a DASI score of 34 was associated with reduced odds of 30-day death or myocardial injury (odds ratio: 0.97 per 1 point increase above 34; 95% confidence interval [CI]: 0.96-0.99) and 1 yr death or new disability (odds ratio: 0.96 per 1 point increase above 34; 95% CI: 0.92-0.99). Self-reported functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00-1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01-1.05). CONCLUSIONS: A DASI score of 34 represents a threshold for identifying patients at risk for myocardial injury, myocardial infarction, moderate-to-severe complications, and new disability.

Cardiopulmonary exercise testing as a risk assessment method in non cardio-pulmonary surgery: a systematic review.

This study reviews the predictive value of maximum oxygen consumption (VO2max) and anaerobic threshold, obtained through cardiopulmonary exercise testing, in calculating peri-operative morbidity and mortality in non-cardiopulmonary thoraco-abdominal surgery. A literature review provided nine studies that investigated either one or both of these two variables across a wide range of surgical procedures. Six of the seven studies that reported sufficiently detailed results on peak oxygen consumption and four of the six studies that reported sufficiently detailed results on anaerobic threshold found them to be significant predictors. We conclude that peak oxygen consumption and possibly anaerobic threshold are valid predictors of peri-operative morbidity and mortality in non-cardiopulmonary thoraco-abdominal surgery. These indicators could potentially provide a means of allocating increased care to high-risk patients.

Effect-site targeted patient-controlled sedation with propofol: comparison with anaesthetist administration for colonoscopy.

Patient-controlled sedation (PCS) allows patients to match their sedation requirement to perceived discomfort. The significant delay in onset of sedation may be overcome with effect-site steered target controlled infusion, but previously only trials in volunteers have been carried out. We therefore conducted a randomised, double-blind controlled trial comparing effect-site steered propofol PCS with anaesthetist-administered propofol sedation in 40 patients presenting for colonoscopy. The initial effect-site target in the PCS group was 0.8 microg.ml(-1), increment was 0.1 microg.ml(-1) and lockout was 3 min. Patient and endoscopist satisfaction and operating conditions were similar between the two groups. PCS patients were sedated more slowly (13 [7.1] vs. 3 [1.1] min; p < 0.0001) and less deeply (minimum BIS value: 71 [16] vs. 58 [15]; p = 0.13) than anaesthetist-administered propofol sedation patients. More of the latter patients were hypotensive, but all patients had similar recollection of events during the procedure and similar quality of recovery.

Tracheobronchopathia osteoplastica: incidental finding at tracheal intubation.

Subglottic papillomatous growths were observed on routine tracheal intubation for a scheduled colorectal procedure. Fibreoptic bronchoscopy revealed that the lesions extended down to the carina and into the main bronchi. The diagnosis of tracheobronchopathia osteoplastica was made after subsequent bronchoscopy and biopsy in the post-operative period. A brief review of this rare benign condition is given.