Complications linked to 30-day postsurgical mortality

By Bianca Nogrady
Major bleeding, sepsis and myocardial injury are the greatest contributors to 30-day mortality after noncardiac surgery, an international study has found.

Writing in the Canadian Medical Association Journal, researchers reported the outcomes of a prospective cohort study in 40,004 patients aged 45 years and older undergoing inpatient noncardiac surgery at 28 centres in 14 countries, who were followed for 30 days.

The overall mortality rate was 1.8%, representing 715 patients. Of those, only five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery while the patient was still in hospital and the remaining 210 deaths (29.4%) occurred after discharge.

Eight complications were independently and significantly associated with 30-day mortality.

Major bleeding, which occurred in 15.6% of patients, was associated with a 2.6-fold higher mortality rate compared with patients without major bleeding, whereas sepsis, which occurred in 4.5% of cases, was associated with a 5.6-fold higher risk of 30-day mortality.

Myocardial injury was seen in 13% of patients, and was associated with a 2.2-fold higher rate of 30-day mortality.

The median time to major bleeding was on the same day as surgery, whereas myocardial injury occurred a median of one day after surgery, and sepsis occurred a median of six days after surgery.

‘The median time to these events provides insight about when monitoring for each complication is likely to have the greatest effect,’ the researchers wrote.

Other complications associated with mortality were infection without sepsis, acute kidney injury with new dialysis, stroke, venous thromboembolism and congestive heart failure.

Commenting, Professor Guy Maddern, Professor of Surgery at the University of Adelaide, said the study was impressive in being able to obtain 30-day mortality data for such a large group of patients, and it confirmed the significant role that sepsis, myocardial injury and bleeding played in postsurgical mortality.

‘Overwhelming sepsis is a huge problem that you can only deal with, largely, by operating to manage a septic focus or with antibiotics in the postoperative period,’ said Professor Maddern, also Chair of the Australian and New Zealand Audit of Surgical Mortality of the Royal Australian College of Surgeons.

He noted that the deaths from myocardial injury often reflected patients who were not physically able to cope with the trauma of surgery.

Professor Maddern also told Medicine Today that surgical mortality rates had been dropping steadily for years, probably as a result of better surgical selection and fewer operations that were likely to be futile.
CMAJ 2019; 191: E830-7; doi: 10.1503/cmaj.190221.