Background Massive transfusion is associated with high morbidity and mortality, yet existing reports of massive transfusion are limited. Our primary aim was to determine the incidence of complications and 30-day mortality among patients who received massive transfusions and to explore risk factors associated with 30-day mortality.Methods We evaluated 971,455 patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We assessed the associations between 30-day mortality and baseline, intraoperative, and postoperative factors among 5,143 patients who received massive transfusions and for whom complete data were available. Results The crude 30-day postoperative mortality of the non-transfused, low transfusion (1-4 units), and massive transfusion (C 5 units) patients in the NSQIP was 1.2%, 8.9%, and 21.5%, respectively. Of the 5,143 massive transfusion patients with non-missing covariable data, 17% (95% confidence interval [CI] 16% to 18%) died within 30 days of surgery, while 54% (95% CI 53% to 56%) had at least one non-fatal major complication. The following baseline and intraoperative variables were independently associated with 30-day mortality after adjusting for multiple testing: age, American Society of Anesthesiologists (ASA) physical status, emergency case, surgical types, coma [ 24 hr before surgery, systemic sepsis, preoperative international normalized ratio of prothrombin time, the number of intraoperative transfusions, and requirement of postoperative transfusion. Conclusion Massive transfusion is associated with substantial risk for respiratory and infectious complications and for mortality. Patients who died within 30 days of a massive perioperative transfusion were generally older, more likely to have vascular surgical procedure and abnormal international normalized ratio of prothrombin time, higher ASA physical status, preoperative coma and sepsis, and higher postoperative bleeding requiring transfusion, and they were likely given more intraoperative red cell units. RésuméContexte Les transfusions massives sont associées à des taux élevés de morbidité et de mortalité; toutefois, les Presented in part at the Foundation for Anesthesia Education and Research session at the

Treatment of intraoperative hyperglycemia should account for the hyperglycemic surgical stress response trend depending on the stage of surgery as well as the added effects of steroid administration. Denying steroid prophylaxis for postoperative nausea and vomiting for fear of hyperglycemic response should be reconsidered given the limited effect of steroids on intraoperative blood glucose concentrations.

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Minimum perioperative peripheral tissue oxygenation predicted a composite of major complications and mortality from major non-cardiac surgery. This is an observational association and whether clinical interventions to augment tissue oxygenation will improve outcomes remains to be determined.

Among our three interventions, dexamethasone alone reduced inflammation. However, no intervention reduced the risk of major morbidity or 1 yr mortality. TRIAL REGISTRATION IDENTIFIER: NCT00433251 at www.clinicaltrials.gov.

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Summary Patient characteristics may affect patients' response to insulin. We examined the impact of body weight, and presence of diabetes on the response to insulin during non-cardiac surgery. We studied 202 patients who were enrolled in the DeLiT Trial and received intraoperative intravenous insulin. Univariable and multivariable analyses (Bonferroni-corrected) assessed the relationship between patient's response to the initial intraoperative bolus of regular insulin and the factors of interest. Blood glucose concentrations decreased 8.3 ±10 mg dl-1 (0.46 ± 0.56 mmol litre-1) per unit of insulin in 30 minutes. The response to insulin was similar in patients with or without diabetes [adjusted mean difference (97.5% CI): 0.2 (-3.9, 4.2) mg dl-1, 0.01 (-0.22, 0.24) mmol litre-1, P = 0.93]. No relationship was found between insulin response and body weight. Our results suggest that adjustment for body weight and the presence of diabetes may not improve intraoperative insulin treatment algorithms.

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