How to better identify patients at high risk of postoperative complications?

This review summarizes historical and more recent scoring systems for predicting patients with increased morbidity and mortality in the postoperative period | Current Opinion in Critical Care

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Purpose of review: Preoperative risk assessment and perioperative factors may help identify patients at increased risk of postoperative complications and allow postoperative management strategies that improve patient outcomes.

Recent findings: Most prediction scores predict postoperative mortality with, at best, moderate accuracy. Scores that incorporate surgery-specific and intraoperative covariates may improve the accuracy of traditional scores. Traditional risk factors including increased ASA physical status score, emergent surgery, intraoperative blood loss and hemodynamic instability are consistently associated with increased mortality using most scoring systems.

Summary: Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk calculators are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative hemodynamic instability, blood loss, extent of surgical excision and volume of resection.

Full reference: . & Kelly, B. (2017) How to better identify patients at high risk of postoperative complications? Current Opinion in Critical Care: Published online: 17 August 2017

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The Confusion Assessment Method for the ICU-7 Delirium Severity Scale

Khan, B.A. et al. (2017) Critical Care Medicine. 45(5) pp. 851–857

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Objectives: Delirium severity is independently associated with longer hospital stays, nursing home placement, and death in patients outside the ICU. Delirium severity in the ICU is not routinely measured because the available instruments are difficult to complete in critically ill patients. We designed our study to assess the reliability and validity of a new ICU delirium severity tool, the Confusion Assessment Method for the ICU-7 delirium severity scale.

Conclusions: Our results suggest that Confusion Assessment Method for the ICU-7 is a valid and reliable delirium severity measure among ICU patients. Further research comparing it to other delirium severity measures, its use in delirium efficacy trials, and real-life implementation is needed to determine its role in research and clinical practice.

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Preoperative risk stratification of critically ill patients

Copeland, C.C. et al. (2017) The Journal of Clinical Anesthesia. 39 (June) pp. 122–127

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Highlights:

  • Preoperative assessment of critically ill patients is challenging and understudied.
  • ASA class, RCRI, and SOFA score were studied to predict survival to discharge.
  • One in four ICU patients did not survive to discharge after an intervention.
  • Available scores inadequately discriminated between survivors and non-survivors.
  • SOFA score (AUC = 0.68) outperformed ASA class (AUC = 0.59).

Read the full abstract here

Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care

Heiberg, J. et al. (2016). Anaesthesia. Volume 71(9). pp. 1091–1100

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Image source: Patrick J. Lynch, medical illustrator – Wikipedia // CC BY 2.5

Image shows illustration of transesophageal echocardiography ultrasound diagram

Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management.

We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.

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The National Early Warning Score: Translation, testing and prediction in a Swedish setting

Spångfors, M. et al. Intensive and Critical Care Nursing. Published online: July 4 2016

The National Early Warning Score – NEWS is a “track and trigger” scale designed to assess in-hospital patients’ vital signs and detect clinical deterioration. In this study the NEWS was translated into Swedish and its association with the need of intensive care was investigated.

A total of 868 patient charts, recorded by the medical emergency team at a university hospital, containing the parameters needed to calculate the NEWS were audited. The NEWS was translated into Swedish and tested for inter-rater reliability with a perfect agreement (weighted κ = 1.0) among the raters.

The median score for patients admitted to the ICU were higher than for those who were not (10 vs. 8, p < 0.0001). AUROC for discriminating admittance to the ICU was 0.68 (95% CI: 0.622–0.739, p < 0.0001). A regression analysis showed that lower oxygen saturation and a lower level of consciousness were significantly associated with ICU admission (OR 1.27 [1.06–1.52], p = 0.01 and OR 1.77 [1.12–2.82], p = 0.02) and may predict admission to the ICU better than the other parameters.

The Swedish translated NEWS seems to have excellent inter-rater reliability and can be used without risk of linguistic misinterpretation. High scores for the parameters oxygen saturation and level of consciousness in the NEWS may predict admission to the ICU.

Read the abstract here