Background: Hyperglycemia has shown a negative association with cognitive dysfunction. We analyzed patients with high preoperative blood glucose level and hemoglobin A1c (HbA1c) level to determine the prevalence of postoperative delirium.Methods: We reviewed a database of 23,532 patients with diabetes who underwent non-cardiac surgery. Acute hyperglycemia was defined as fasting blood glucose > 140 mg/dl or random glucose > 180 mg/dl within 24 h before surgery. Chronic hyperglycemia was defined as HbA1c level above 6.5% within three months before surgery. The incidence of delirium was compared according to the presence of acute and chronic hyperglycemia.Results: Of the 23,532 diabetic patients, 21,585 had available preoperative blood glucose level within 24 h before surgery, and 18,452 patients reported levels indicating acute hyperglycemia. Of the 8,927 patients with available HbA1c level within three months before surgery, 5,522 had levels indicating chronic hyperglycemia. After adjustment with inverse probability weighting, acute hyperglycemia was related to higher incidence of delirium (hazard ratio: 1.33, 95% CI [1.10,1.62], P = 0.004 for delirium) compared with controls without acute hyperglycemia. On the other hand, chronic hyperglycemia did not correlate with postoperative delirium.Conclusions: Preoperative acute hyperglycemia was associated with postoperative delirium, whereas chronic hyperglycemia was not significantly associated with postoperative delirium. Irrespective of chronic hyperglycemia, acute glycemic control in surgical patients could be crucial for preventing postoperative delirium.

The cardioprotective effects of volatile anesthetics versus total intravenous anesthesia (TIVA) are controversial, especially in patients undergoing non-cardiac surgery. Using current generation high-sensitivity cardiac troponin (hs-cTn), we aimed to evaluate the effect of anesthetics on the occurrence of myocardial injury after non-cardiac surgery (MINS). From February 2010 to December 2016, 3555 patients without preoperative hs-cTn elevation underwent non-cardiac surgery under general anesthesia. Patients were grouped according to anesthetic agent; 659 patients were classified into a propofol-remifentanil total intravenous anesthesia (TIVA) group, and 2896 patients were classified into a volatile group. To balance the use of remifentanil between groups, a balanced group (n = 1622) was generated with patients who received remifentanil infusion in the volatile group, and two separate comparisons were performed (TIVA vs. volatile and TIVA vs. balanced). The primary outcome was occurrence of MINS, defined as rise of hs-cTn I ≥ 0.04 ng/mL within postoperative 48 hours. The secondary outcomes were 30-day mortality, postoperative acute kidney injury (AKI), and adverse events during hospital stay (mortality, type I myocardial infarction (MI), and new-onset arrhythmia). In propensity-matched analyses, the occurrence of MINS was lower in the TIVA group compared to the volatile group (OR 0.642; 95% CI 0.450–0.914; p = 0.014). However, after balancing the use of remifentanil, there was no difference between groups in the risk of MINS (OR 0.832; 95% CI 0.554–1.251; p-value = 0.377). There were no significant associations between the two groups in type 1 MI, new-onset atrial fibrillation, in-hospital and 30-day mortality before and after balancing the use of remifentanil. However, the incidence of postoperative AKI was lower in the TIVA group (OR 0.362; 95% CI 0.194–0.675; p-value = 0.001). After balancing the use of remifentanil, volatile anesthesia and TIVA showed comparable effects on MINS in patients undergoing non-cardiac surgery without preoperative myocardial injury. Further studies are needed on the benefit of remifentanil infusion.

The objective of this study was to investigate the usefulness of fibrinogen-to-albumin ratio (FAR) as a prognostic marker in patients admitted to an intensive care unit (ICU) compared with Sequential Organ Failure Assessment (SOFA) score, a widely used prognostic scoring system. An inverse probability weighting (IPW) was used to control for selection bias and confounding factors. After IPW adjustment, the high FAR group showed significantly higher risk of 1-year compared with low FAR group (36.4% vs. 12.4%, adjust hazard ratio = 1.72; 95% confidence interval (CI): 1.59–1.86; p < 0.001). In the receiver-operating characteristic curve analysis associated with the prediction of 1-year mortality, there was no significant difference between the area under the curve of FAR on ICU admission (C-statistic: 0.684, 95% CI: 0.673–0.694) and that of SOFA score on ICU admission (C-statistic: 0.679, 95% CI: 0.669–0.688) (p = 0.532). In this study, FAR and SOFA score at ICU admission were associated with 1-year mortality in patients admitted to an ICU. Especially, FAR was easier to obtain in critically ill patients than SOFA score. Therefore, FAR is feasible and might help predict long-term mortality in these patients.

Prediction of fluid responsiveness has been considered an essential tool for modern fluid management. However, most studies in this field have focused on patients in intensive care unit despite numerous research throughout several decades. Therefore, the present narrative review aims to show the representative method’s feasibility, advantages, and limitations in predicting fluid responsiveness, focusing on the operating room environments. Firstly, we described the predictors of fluid responsiveness based on heart-lung interaction, including pulse pressure and stroke volume variations, the measurement of respiratory variations of inferior vena cava diameter, and the end-expiratory occlusion test and addressed their limitations. Subsequently, the passive leg raising test and mini-fluid challenge tests were also mentioned, which assess fluid responsiveness by mimicking a classic fluid challenge. In the last part of this review, we pointed out the pitfalls of fluid management based on fluid responsiveness prediction, which emphasized the importance of individualized decision-making. Understanding the available representative methods to predict fluid responsiveness and their associated benefits and drawbacks through this review will aid anesthesiologists in choosing the most reliable methods for optimal fluid administration in each patient during anesthesia in the operating room.

Background: Perioperative adverse cardiac events (PACE), a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, and stroke during 30-day postoperative period, is associated with long-term mortality, but with limited clinical evidence. We compared long-term mortality with PACE using data from nationwide multicenter electronic health records.Methods: Data from 7 hospitals, converted to Observational Medical Outcomes Partnership Common Data Model, were used. We extracted records of 277,787 adult patients over 18 years old undergoing non-cardiac surgery for the first time at the hospital and had medical records for more than 180 days before surgery. We performed propensity score matching and then an aggregated meta‑analysis.Results: After 1:4 propensity score matching, 7,970 patients with PACE and 28,807 patients without PACE were matched. The meta‑analysis showed that PACE was associated with higher one-year mortality risk (hazard ratio [HR]: 1.33, 95% CI [1.10, 1.60], P = 0.005) and higher three-year mortality (HR: 1.18, 95% CI [1.01, 1.38], P = 0.038). In subgroup analysis, the risk of one-year mortality by PACE became greater with higher-risk surgical procedures (HR: 1.20, 95% CI [1.04, 1.39], P = 0.020 for low-risk surgery; HR: 1.69, 95% CI [1.45, 1.96], P < 0.001 for intermediate-risk; and HR: 2.38, 95% CI [1.47, 3.86], P = 0.034 for high-risk).Conclusions: A nationwide multicenter study showed that PACE was significantly associated with increased one-year mortality. This association was stronger in high-risk surgery, older, male, and chronic kidney disease subgroups. Further studies to improve mortality associated with PACE are needed.

Background: We compared the prognostic value of the C-reactive protein (CRP)-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and modified Glasgow prognostic score (mGPS) with the Sequential Organ Failure Assessment (SOFA) score in an intensive care unit (ICUs). Methods: This study used the data of 53,877 adult patients admitted to an ICU between June 2013 and May 2022. Using the CAR, NLR, and mGPS values, as well as the SOFA score from the ICU, we conducted multivariable logistic regression analysis and used the receiver operating characteristic (ROC) curve to compare the predictive value for 28-day and 1-year mortality. Results: A total of 2419 patients (4.5%) died within 28 days, and 6209 (11.5%) patients died within 1 year. After an adjustment, all predictors were found to be independent risk factors for 28-day mortality (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.29–1.33, p < 0.001 for the SOFA score; OR 1.05, 95% CI 1.03–1.07, p < 0.001 for CAR; OR 1.01, 95% CI 1.00–1.02, p < 0.001 for the NLR; and OR 1.19, 95% CI 1.08–1.30, p < 0.001 for the mGPS). This trend persisted for the 1-year mortality. In ROC curve analysis, the CAR showed better predictability than the NLR and mGPS. Furthermore, the predictive power of the CAR was significantly higher than that of the SOFA score for 1-year mortality. Conclusions: The CAR, NLR, and mGPS values at ICU admission were independent risk factors of mortality after ICU admission. The predictive value of CAR was higher than that of the SOFA score for 1-year mortality. CAR assessment at ICU admission may be a feasible predictor of long-term mortality.