Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

Genderen et al. Critical Care Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults Michel E van Genderen 0 3 Jorden Paauwe 0 3 Jeroen de Jonge 2 Ralf JP van der Valk 1 4 Alexandre Lima 0 3 Jan Bakker 0 3 Jasper van Bommel 0 3 0 Department of Intensive Care, Erasmus MC , 's Gravendijkwal 230, 3015 CE Rotterdam , the Netherlands 1 Department of Epidemiology, Erasmus MC - Sophia's Children Hospital , Wytemaweg 80, 3015 CN Rotterdam , the Netherlands 2 Department of Surgery, Erasmus MC , 's Gravendijkwal 230, 3015 CE Rotterdam , the Netherlands 3 Department of Intensive Care, Erasmus MC , 's Gravendijkwal 230, 3015 CE Rotterdam , the Netherlands 4 Department of Paediatrics, Erasmus MC , Wytemaweg 80, 3015 CN Rotterdam , the Netherlands Introduction: Altered peripheral perfusion is strongly associated with poor outcome in critically ill patients. We wanted to determine whether repeated assessments of peripheral perfusion during the days following surgery could help to early identify patients that are more likely to develop postoperative complications. Methods: Haemodynamic measurements and peripheral perfusion parameters were collected one day prior to surgery, directly after surgery (D0) and on the first (D1), second (D2) and third (D3) postoperative days. Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (Tskin-diff). Generalized linear mixed models were used to predict severe complications within ten days after surgery based on Clavien-Dindo classification. Results: We prospectively followed 137 consecutive patients, from among whom 111 were included in the analysis. Severe complications were observed in 19 patients (17.0%). Postoperatively, peripheral perfusion parameters were significantly altered in patients who subsequently developed severe complications compared to those who did not, and these parameters persisted over time. CRT was altered at D0, and PPI and Tskin-diff were altered on D1 and D2, respectively. Among the different peripheral perfusion parameters, the diagnostic accuracy in predicting severe postoperative complications was highest for CRT on D2 (area under the receiver operating characteristic curve = 0.91 (95% confidence interval (CI) = 0.83 to 0.92)) with a sensitivity of 0.79 (95% CI = 0.54 to 0.94) and a specificity of 0.93 (95% CI = 0.86 to 0.97). Generalized mixed-model analysis demonstrated that abnormal peripheral perfusion on D2 and D3 was an independent predictor of severe postoperative complications (D2 odds ratio (OR) = 8.4, 95% CI = 2.7 to 25.9; D2 OR = 6.4, 95% CI = 2.1 to 19.6). Conclusions: In a group of patients assessed following major abdominal surgery, peripheral perfusion alterations were associated with the development of severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion-targeted resuscitation following major abdominal surgery. - Introduction Despite reductions in postoperative mortality, the occurrence of severe complications remains high [1]. The development of postoperative complications affects the prognosis of surgical patients and substantially increases the utilization of resources and the cost of care [1-3]. Early recognition of patients more likely to develop postoperative complications is therefore of prime importance. Because postoperative complications better predict short- and long-term mortality than preoperative and intraoperative factors [3-5], recent research has been focused on identifying preoperative factors that predispose patients to postoperative complications. Several scoring systems, such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the American Society of Anesthesiologists (ASA) score and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score can be applied in a general surgery population. These scores are based on preoperative and perioperative variables specific to different types of surgery. Despite the great number of identified predictors, these scores do not take into consideration the individual patients postoperative situation, are difficult to calculate [6], cannot be calculated over time and are still doubted for their specific predictive value for assessing the individual high-risk surgery patient [7]. Therefore, in clinical practice, a simple, easy-to-use approach is needed to recognize patients at risk for severe complications and to ensure timely initiation of interventions to improve outcomes. There is increasing evidence that altered tissue perfusion in high-risk surgical patients could be helpful for the detection of those at risk for complications [8,9] and optimally improve outcomes [10]. In this regard, the success of early, goal-directed haemodynamic therapy has demonstrated the importance of maintaining and improving tissue oxygenation and has shown that early detection and correction of altered tissue perfusion reduce postoperative complications [2,11]. Accordingly, their importance is also the basis for stressing the need to monitor postoperative early warning signals for occult tissue hypoperfusion [2,12]. Likewise, lactate level, a potential marker of occult hypoperfusion, is used as a resuscitation target, although its relationship with regional circulation is still not clear [13,14]. Therefore, early recognition of regional tissue perfusion abnormalities remains important to avoid further organ damage and improve outcomes following major surgery. Postoperative monitoring is still based on conventional haemodynamic variables, which are known to be insensitive to determination of the presence of regional tissue hypoperfusion. Recently, we and others have shown that assessment of perfusion of the peripheral circulation enables the identification of patients who will have unfavourable outcomes. In critically ill patients [15], after out-of-hospital cardiac arrest [16] and during septic shock [17], impaired peripheral perfusion has been shown to be associated with organ failure and increased mortality. By use of the capillary refill time (CRT), the peripheral perfusion index (PPI) (Masimo SET Radical-7 pulse oximeter on a rainbow and SatShare platform; Masimo UK, Basingstoke, UK) and the forearm-to-fingertip body temperature gradient (Tskin-diff ), peripheral perfusion can easily and noninvasively be evaluated at the bedside and may thus be a more simple and generally useful tool for identifying patients at risk for postoperative complications [18]. In this context, we were interested in determining whether repeated assessment of the peripheral circulation in the days following surgery could help in the early identification of patient (...truncated)