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Perioperative Stroke and Associated Mortality After Noncardiac, Nonneurologic Surgery

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Perioperative Stroke and Associated Mortality After Noncardiac, Nonneurologic Surgery PERIOPERATIVE MEDICINE Perioperative Stroke and Associated Mortality after Noncardiac, Nonneurologic Surgery George A. Mashour, M.D., Ph.D.,* Amy M. Shanks, M.S.,† Sachin Kheterpal, M.D., M.B.A.‡ Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/114/6/1289/254230/0000542-201106000-00014.pdf by guest on 26 September 2021 This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue. ABSTRACT What We Already Know about This Topic • Stroke is a potentially devastating perioperative complication, Background: Stroke is a leading cause of morbidity and even after surgeries not involving the heart or great vessels mortality in the United States and occurs in the perioper- ative period. The authors studied the incidence, predic- tors, and outcomes of perioperative stroke using the What This Article Tells Us That Is New American College of Surgeons National Surgical Quality Improvement Program. • Perioperative stroke in the low-risk population varies with sur- gical procedure, has a number of independent predictors in- Methods: Data on 523,059 noncardiac, nonneurologic pa- cluding history of stroke or transient ischemic attack, and is tients in the American College of Surgeons National Surgical associated with an eight-fold increase in mortality Quality Improvement Program database were analyzed for the current study. The incidence of perioperative stroke was identified. Logistic regression was applied to a derivation cardial infarction within 6 months before surgery, acute renal cohort of 350,031 patients to generate independent predic- failure, history of stroke, dialysis, hypertension, history of tors of stroke and develop a risk model. The risk model was transient ischemic attack, chronic obstructive pulmonary subsequently applied to a validation cohort of 173,028 pa- disease, current tobacco use, and body mass index 35–40 2 tients. The role of perioperative stroke in 30-day mortality kg/m (protective). These risk factors were confirmed in the was also assessed. validation cohort. Surgical procedure also influenced the in- Results: The incidence of perioperative stroke in both the cidence of stroke. Perioperative stroke was associated with an derivation and validation cohorts was 0.1%. Multivariate 8-fold increase in perioperative mortality within 30 days analysis revealed the following independent predictors of (95% CI, 4.6–12.6). stroke in the derivation cohort: age Ն62 yr, history of myo- Conclusions: Noncardiac, nonneurologic surgery carries a risk of perioperative stroke, which is associated with higher mortality. The models developed in this study may be infor- * Assistant Professor of Anesthesiology and Neurosurgery and Di- rector, Division of Neuroanesthesiology, † Clinical Research Coordina- mative for clinicians and patients regarding risk and preven- tor, Department of Anesthesiology, ‡ Assistant Professor of Anesthesi- tion of this complication. ology and Director, Center for Perioperative Outcomes Research, University of Michigan Medical School, Ann Arbor, Michigan. Received from the Division of Neuroanesthesiology, Depart- TROKE is a leading cause of morbidity and mortality in ment of Anesthesiology, University of Michigan Medical School, S the United States and is known to occur in the periop- Ann Arbor, Michigan. Submitted for publication May 12, 2010. erative period.1 Perioperative stroke is primarily associated Accepted for publication February 4, 2011. Support was provided 2 solely from institutional and/or departmental sources. with major cardiovascular procedures but has also been re- 3,4 Address correspondence to Dr. Mashour: Division of Neuroan- ported after general surgery. A recent study of acute isch- esthesiology, Department of Anesthesiology, University of Michigan emic stroke in the noncardiovascular population using an Medical School, 1H247 UH/SPC-5048, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-5048. [email protected]. This article may be accessed for personal use at no charge through ᭜ This article is accompanied by an Editorial View. Please see: the Journal Web site, www.anesthesiology.org. McDonagh DL, Mathew JP: Perioperative stroke: Where do Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott we go from here? ANESTHESIOLOGY 2011; 114:1263–4. Williams & Wilkins. Anesthesiology 2011; 114:1289–96 Anesthesiology, V 114 • No 6 1289 June 2011 Perioperative Stroke administrative database found an incidence of 0.7% after audits performed if a site fails an audit. The audit process hemicolectomy, 0.2% after hip replacement, and 0.6% after consists of a manual review of 12–15 ACS NSQIP records at lobectomy or segmental lung resection.5 In the population each site. A site visitor from the central ACS NSQIP offices 65 yr and older, the incidence rose to 1.0%, 0.3%, and 0.8%, reviews approximately 106 variables for each of these records respectively. Importantly, perioperative stroke was associated and abstracts the data per ACS NSQIP definitions. Disagree- with increased mortality. ments between the visitor abstracted data and the site’s sub- Risk factors for perioperative stroke include renal disease, mitted data are identified. In 2008, the overall disagreement atrial fibrillation, valvular disease, congestive heart failure, rate for the 140,132 variables audited was 1.36%.14 hypertension, carotid disease, history of tobacco use, and The ACS NSQIP participant use data file is a compilation history of stroke.3–8 However, the assessment of risk factors of operations from 250 participating U.S. medical centers for Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/114/6/1289/254230/0000542-201106000-00014.pdf by guest on 26 September 2021 for perioperative stroke has been restricted to case series,9,10 the 4-yr period 2005–2008. It contains data from 211 non- case-control studies,1,11 or large retrospective studies,7 in- Veterans Administration hospitals in the private sector and cluding those using administrative data.5 Prospective studies includes data from academic medical centers, large non- have been limited because of the low incidence of the event in teaching hospitals, and community hospitals.§ To maintain the noncardiovascular, nonneurosurgical population.12 institutional, provider, and patient anonymity, no site- or Thus, the objective of the current study was to assess the region-specific data elements are included in the participant incidence and predictors of perioperative stroke and its role use data file. Sites with interrater reliability audit scores dem- in mortality in a broad range of noncardiac, nonneurosurgi- onstrating Ն5% disagreement are excluded from the ACS cal cases using a large, prospectively gathered clinical data set NSQIP participant use data file. derived from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). ACS NSQIP Study Population and Variables Analyzed Inclusion and Exclusion Criteria. General surgery, orthope- Materials and Methods dics, urology, otolaryngology, plastics, thoracic, minor vas- cular, and gynecology cases were included in this study as General ACS NSQIP Methodology representative of being at low risk for perioperative stroke; Institutional Review Board approval (University of Michi- cardiac, major vascular, and neurosurgical procedures were gan, Ann Arbor) was obtained for the analysis of these pro- excluded as high risk. We also excluded patients who had spectively collected data, which are deidentified and publicly disseminated cancer, a body mass index (BMI) less than 18.5 available. The ACS NSQIP methodology has been described 2 kg/m , or a documented 10% weight loss because this pop- 13 and is summarized here. Operations requiring elsewhere ulation represents high risk for stroke (due to hypercoagula- general, epidural, or spinal anesthesia are prospectively di- bility), brain metastasis with hemorrhage, and mortality. vided into 8-day cycles. At most institutions, the first 40 Outcomes. Postoperative stroke and 30-day mortality were general surgery and vascular surgery operations within each analyzed as the primary and secondary outcomes of interest, 8-day cycle are included. At some ACS NSQIP institutions, respectively. “Postoperative stroke” is defined by ACS additional cases outside of the general and vascular popula- NSQIP as an embolic, thrombotic, or hemorrhagic cerebro- tion may be analyzed. Procedures performed by cardiac, neu- vascular event with patient motor, sensory, or cognitive dys- rosurgery, orthopedic, urology, otolaryngology, plastics, tho- function that persists for 24 h or more and occurs within 30 racic, and gynecology services are a minority of the overall days of an operation. Thirty-day mortality can be from any patient enrollment at these institutions. mechanism of death, and the cause of death is not reported. For each operation, a trained surgical clinical reviewer, Patient Variables. Basic demographic data were analyzed, typically a registered nurse, prospectively collects preopera- including age, sex, race, BMI, and American Society of An- tive patient demographics, preoperative comorbidities, oper- esthesiologists physical classification status. Patient charac- ative information, selected intraoperative elements, labora- teristics included diabetes mellitus (oral or insulin therapy), tory values, and postoperative adverse events occurring as current tobacco use, history of chronic
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