Postoperative systemic inflammation after major abdominal surgery: patient-centred outcomes

Abstract

Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient-centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient-centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high-risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. The co-primary endpoints were persistent disability or death up to 90 days after surgery, and quality of recovery using a 15-item quality of recovery score at days 3 and 30. Secondary endpoints included: 90-day and 1-year all-cause mortality; septic complications; acute kidney injury; unplanned admission to intensive care/high dependency unit; and total intensive care unit and hospital stays. Patients were assigned into quartiles of maximum postoperative C-reactive protein concentration up to day 3, after multiple imputations of missing values. The lowest (reference) group, quartile 1, C-reactive protein ≤ 85 mg.l^-1 , was compared with three inflammation groups: quartile 2 > 85 mg.l^-1 to 140 mg.l^-1 ; quartile 3 > 140 mg.l^-1 to 200 mg.l^-1 ; and quartile 4 > 200 mg.l^-1 to 587 mg.l^-1 . Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31-2.36), p < 0.001. Increased inflammation was associated with increasing decline in risk-adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being -14.4 (-17.38 to -10.71), p < 0.001 on day 3, and -5.94 (-8.92 to -2.95), p < 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery.

Keywords: anaesthesia; disability-free survival; major surgery; patient-reported outcomes; quality of recovery; systemic inflammation.

Figure 1

(a) The relationship between measured maximum postoperative C‐reactive protein (CRP) concentration (mg.l^‐1) up to day 3 and the probability of persistent disability or death up to day 90 after major abdominal surgery; (b) the relationship between maximum postoperative day CRP concentration (mg.l^‐1) up to day 3 and quality of recovery on day 3. The shaded bands are 95%CI.