Daily Anesthesiology Research Analysis

IMPORTANCE: Perioperative cardiac arrest and cardiopulmonary resuscitation (CPR) are associated with significant morbidity and mortality. Despite a growing focus on goal-concordant surgical care and longstanding emphasis on preoperative code status discussions, clinicians lack tools to individualize risk estimates and inform shared decision-making (SDM) regarding perioperative CPR. OBJECTIVE: To generate and internally validate predictive models for 30-day mortality and nonhome discharge using routinely available preoperative data. DESIGN, SETTING, AND PARTICIPANTS: A prospective, multicenter, prognostic study of patients within the American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP), including nearly 700 participating hospitals in the US, from January 1, 2012, through December 31, 2023. Follow-up duration was 30 days. Seven machine learning models were developed using 10-fold cross validation. Participants were patients aged 18 years or older undergoing noncardiac surgery who underwent CPR on the day of surgery. EXPOSURES: Thirty-three preoperative sociodemographic, clinical, laboratory, and procedural variables were evaluated for their association with 30-day mortality and nonhome discharge. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day mortality following CPR. The secondary outcome was nonhome discharge among survivors admitted from home. Performance was evaluated using area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and calibration (Brier score and calibration curves). Clinical utility was evaluated using Shapley additive values (SHAP) decision curve analysis (DCA). RESULTS: Among 6405 patients (median [IQR] age 69 [60-78], 3572 [55.8%] men, 860 [13.4%] Black, 4343 [67.8%] White, and 261 [4.1%] another racial category, including American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander), 3710 (57.9%) died within 30 days. The extreme gradient boosting model (CPR Outcome Prediction for Arrest in Surgical Settings [COMPASS]) achieved the best performance (AUROC for mortality = 0.80; 95 % CI, 0.78-0.82; accuracy = 0.73; 95% CI, 0.71-0.75; sensitivity = 0.77; 95% CI, 0.74-0.79; specificity = 0.68; 95% CI, 0.65-0.71; Brier score = 0.18). Among 2478 survivors admitted from home, 822 (33.2%) were discharged to a facility. For nonhome discharge, extreme gradient boosting demonstrated an AUROC of 0.78 (95 % CI, 0.74-0.82), accuracy of 0.76; and Brier score of 0.17. SHAP analysis identified American Society of Anesthesiologists status, case urgency, and frailty as key predictors. DCA indicated greater net benefit of extreme gradient boosting over default strategies (ie, treat all or treat none) across wide threshold ranges. CONCLUSIONS AND RELEVANCE: In this prospective prognostic study of outcomes following perioperative CPR, extreme gradient boosting generated individualized predictions of outcomes following perioperative CPR that may inform prevention strategies and goal-concordant surgical care.

BACKGROUND: Pain is a common yet underaddressed issue in surgical inpatients. Inadequate pain control in patients with hip fractures can lead to adverse hemodynamic changes, potentially increasing the risk of myocardial ischemia. The authors aim to investigate whether perioperative pain is associated with the development of myocardial ischemic events in patients undergoing hip fracture surgery. METHODS: HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) was a multicenter international randomized controlled trial comparing the effects of accelerated surgical repair of hip fracture versus standard of care. The authors included patients enrolled in the HIP ATTACK trial who had at least one troponin measurement and a pain score measurement. Pain was assessed daily on hospital admission using the 0 to 10 numeric rating scale. The primary analysis included all available pain scores averaged (then categorized as mild [numeric rating scale 0 to 3], moderate [4 to 7], and severe [8 to 10] pain) before and on the day of the first troponin elevation. The primary outcome was troponin elevation from any cause, with secondary outcomes of myocardial injury (due to an ischemic etiology), myocardial infarction, and then a composite of myocardial injury and myocardial infarction. Multivariable regression models adjusting for potential confounders were used to identify an association between pain categories and outcomes. RESULTS: The authors included 2,430 (82%) from the initial HIP ATTACK cohort (n = 2,970). Forty-five percent of patients (1,098) suffered a troponin elevation from any cause. In the adjusted models, moderate (odds ratio, 3.90; 95% CI, 3.02 to 5.05) and severe pain (odds ratio, 29.24; 95% CI, 17.7 to 48.29) were associated with a troponin elevation of any cause. Similarly, moderate (odds ratio, 2.09; 95% CI, 1.71 to 2.57) and severe pain (odds ratio, 6.04, 95% CI, 4.49 to 8.12) were associated with myocardial injury, whereas only severe pain was associated with myocardial infarction (odds ratio, 2.33; 95% CI, 1.35 to 3.99). Both moderate and severe pain were associated with the composite outcome. CONCLUSIONS: Increased pain may be associated with myocardial ischemic events in the perioperative period in hip fracture patients. Future research is needed to confirm and further clarify this relationship and to determine whether analgesic interventions can reduce the risk of perioperative myocardial ischemia.

OBJECTIVE: Postoperative delirium (POD) frequently occurs among elderly patients following surgery, yet effective preventive measures remain insufficiently established. This study aimed to investigate whether perioperative intranasal insulin (INI) administration could reduce the incidence of POD and modulate inflammatory marker levels in elderly patients undergoing hip fracture surgery under general anesthesia (GA). METHODS: From June to December 2024, a total of 96 elderly patients scheduled for hip fracture surgery with GA were enrolled and randomly assigned to two groups (48 per group). Patients in the insulin group received INI (20 units in 0.5 mL) twice daily, beginning two days preoperatively and continuing for five days. Patients in the control group received an equivalent volume of saline (0.5 mL) with the same dosing regimen. The primary outcome was POD incidence within five postoperative days, evaluated using the 3D-CAM-CN assessment tool. Secondary outcomes included serum levels of interleukin-6 (IL-6) and C-reactive protein (CRP), measured at baseline (T0; before intervention) and postoperative day 1 (T1) using immunofluorescence quantitative assays. RESULTS: Ninety-two patients completed the study, with an overall POD incidence rate of 20.7%. Patients treated with INI showed a significantly lower incidence of POD within the 5-day postoperative period (10.9% vs. 30.4%, P = 0.020). On postoperative day 3 (T2), the incidence of POD was notably reduced in the insulin group (2.2% vs. 19.6%, P = 0.007). No significant differences in POD incidence were observed on postoperative days 1 (T1) or 5 (T3). Serum IL-6 and CRP levels at T1 were lower in the insulin group compared to controls (P < 0.001), although both groups experienced significant elevations in these markers at T1 compared to baseline (T0) (P < 0.001). No adverse events related to interventions occurred during the study. CONCLUSION: Perioperative INI administration reduced the incidence of POD and decreased postoperative inflammatory markers (IL-6 and CRP) in elderly patients undergoing hip fracture surgery with GA. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Register (registration no. ChiCTR2400085627, registration date on 14/6/2024).