Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial

Ws, Beattie; Wijeysundera, Duminda N.; Chan, Matthew T. V.; Pj, Peyton; Leslie, Kate; Paech, Mike; Di, Sessler; Wallace, Sophia; Myles, Paul S.; Galagher, W; Farrington, C.; Ditoro, A.; Baulch, S.; Sidiropoulos, Sofia; Bulach, R; Bryant, Dianne; O’Loughlin, Edmond; Mitteregger,; Bolsin, Stephen; Osborne, Cameron S.; McRae, Rosemary; Bäckström, Martin; Cotter, R; March, Sonja; Silbert, Brendan; Said, Simone; Halliwell, Richard; Cope, Jennifer R.; Fahlbusch, D; Crump, Diane; Thompson, G.; Jefferies, Ann L; Reeves, Matthew J.; Buckley, Norman; Tidy, T; Schricker, Thomas; Lattermann, Ralph; Iannuzzi, Davide; Carroll, Jo; Jacka, Michael J.; Bryden, Courtney; Badner, N.; Mwy, Tsang; Bcp, Cheng; Acm, Fong; Lcy, Chu; Egy, Koo; Mohd, Nurulhuda; Le, Ming; Campbell, Doug; McAllister, Davina; Walker, Simon; Olliff, Sue; Kennedy, R; Eldawlatly, Abdelazeem; Alzahrani, Talal; Chua, Neil; Sneyd, J. R.; McMillan, Helen; Parkinson, Ian; Brennan, Andrew; Balaji, Packianathaswamy; Nightingale, J. J.; Kunst, Gudrun; Dickinson, Matthew; Subramaniam, Balachundhar; Banner-Godspeed,; Liu, Jing; Kurz, Andrea; Hesler, Brian D.; Ay, Fu; Egan, Cameron; An, Fiffick; Mt, Hutcherson; Turan, Alparslan; Naylor, Amanda J.; Obal, Detlef; Cooke, Emma

doi:10.1213/ane.0000000000003310

Cited by 49 publications

(32 citation statements)

References 34 publications

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“…The increases in troponin I (n = 11, 13% of patients) found in our study were primarily subclinical values below the clinical cut‐off of 45 ng.l −1 for myocardial ischaemia used at our centre. Only four patients had values above the clinical cut‐off, which is markedly lower than what is found in other studies, where it ranged from 18% to 19% . The VISION trial used a peak increase in troponin T well below the clinical cut‐off, and found an incidence of 11.6%, which is similar to our findings.…”

Section: Discussionsupporting

confidence: 74%

“…There may be an association between postoperative hypoxaemia and myocardial ischaemia. The study by Devereaux et al and subsequent studies have shown that an isolated troponin increase in the postoperative period is not only associated with increased 30‐day mortality and risk of ischaemic events, but also influences long‐term outcomes. Hypoxaemia is by definition reduced availability of oxygen in the tissues, which could lead to subclinical ischaemia.…”

Section: Introductionmentioning

confidence: 99%

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Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study

et al. 2019

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Episodic and ongoing hypoxaemia are well-described after surgery, but, to date, no studies have investigated the occurrence of episodic hypoxaemia following minimally-invasive colorectal surgery performed in an enhanced recovery setting. We aimed to describe the occurrence of postoperative hypoxaemia after minimally-invasive surgery in an enhanced recovery setting, and the association with morphine use, incision site, fluid intake and troponin increase. We performed a prospective observational study of 85 patients undergoing minimally-invasive surgery for colorectal cancer between 25 August 2016 and 17 August 2017. We applied a pulse oximeter with a measurement rate of 1 Hz immediately after surgery either until discharge or until two days after surgery, and recorded the oxygen saturation. We measured troponin I during the first four days after surgery, or until discharge. The median (IQR [range]) length of stay was 3 (2-4 [1-38]) days. Thirty-six percent of patients spent more than 1 h below an oxygen saturation of 90% (4.2% of the day), and with a median (IQR [range]) proportion of 1.3 (0.2-11.1 [0.0-21.4])% of the day spent with an oxygen saturation below 88%. We found no associations between time spent below an oxygen saturation of 88% and morphine use (p = 0.215), fluid intake (p = 0.446), complications (p = 0.808) or extraction site (p = 0.623). Postoperative increases in troponin I were associated both with time spent below an oxygen saturation of 88% (p = 0.026) and hypopnoea episodes (p = 0.003). Even with minimally-invasive surgery and enhanced recovery after surgery, episodic hypoxaemia and hypopnoea episodes are common, but are not associated with morphine use, fluid intake or incision site. Further studies should investigate the relationship between hypoxaemia and troponin increase.

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Section: Discussionsupporting

confidence: 74%

Section: Introductionmentioning

confidence: 99%

Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study

et al. 2019

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“…Fifth, because myocardial infarction was defined as a clinical diagnosis made by a cardiologist, the incidence of myocardial infarction may have been higher when it retrospectively would have been based on the 4 th universal definition (Thygesen et al 2018), as previously shown. (Beattie et al 2018;Devereaux et al 2011;van Waes et al 2016) Finally, only documented consultations by the anesthesiologist were recorded as consultation, which potentially explains why 37% of the patients did not receive a consultation. As part of the local protocol, anesthesiologists determined whether consultation was necessary based on clinical course reported in the electronic medical files and consultation of treating physicians by phone.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…However, troponin elevation has also been related to other disease entities including stroke, sepsis and pulmonary embolism. (Akkermans et al 2019;Beattie et al 2018;Noordzij et al 2015;van Waes et al 2016) We hypothesized a more general approach to assess postoperative troponin elevation, rather than an approach focusing on cardiac etiology, would be beneficial. As a result, in October 2016 we implemented routine postoperative consultations by a dedicated anesthesia team in patients detected with an elevated troponin in the surveillance program.…”

Section: Introductionmentioning

confidence: 99%

Postoperative visits by dedicated anesthesiologists in patients with elevated troponin: a retrospective cohort study evaluating postoperative care utility and early detection of complications

Akkermans

Vernooij

Klei

et al. 2020

Preprint

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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 three 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 one 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 one 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.

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“…12 Of note, both studies suggested decreases in both mortality and length of stay that were much greater than many specific therapeutic interventions. 4,5 These two studies also highlight the need to consider a range of outcomes. Mortality is relatively uncommon, but measurable and more frequent events include medical emergency response calls, 13 hypotension, 4 length of stay, 11,12 and events after hospital discharge.…”

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confidence: 99%

Hidden pandemic of postoperative complications—time to turn our focus to health systems analysis

Ludbrook

2018

British Journal of Anaesthesia

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Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial

Abstract: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.

Cited by 49 publications

References 34 publications

Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study

Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study

Postoperative visits by dedicated anesthesiologists in patients with elevated troponin: a retrospective cohort study evaluating postoperative care utility and early detection of complications

Hidden pandemic of postoperative complications—time to turn our focus to health systems analysis

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