Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study

Pavel S Roshanov; Gordon H Guyatt; Vikas Tandon; Flavia K Borges; Andre Lamy; Richard Whitlock; Bruce M Biccard; Wojciech Szczeklik; Mohamed Panju; Jessica Spence; Amit X Garg; Michael McGillion; John W Eikelboom; Daniel I Sessler; Clive Kearon; Mark Crowther; Tomas VanHelder; Peter A Kavsak; Justin de Beer; Mitchell Winemaker; Yannick Le Manach; Tej Sheth; Jehonathan H Pinthus; Deborah Siegal; Lehana Thabane; Marko R I Simunovic; Ryszard Mizera; Sebastian Ribas; Philip J Devereaux

doi:10.1016/j.bja.2020.02.028

Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study

Br J Anaesth. 2021 Jan;126(1):172-180. doi: 10.1016/j.bja.2020.02.028. Epub 2020 Jul 24.

Authors

Pavel S Roshanov¹, Gordon H Guyatt², Vikas Tandon³, Flavia K Borges⁴, Andre Lamy⁵, Richard Whitlock⁶, Bruce M Biccard⁷, Wojciech Szczeklik⁸, Mohamed Panju³, Jessica Spence⁹, Amit X Garg¹⁰, Michael McGillion¹¹, John W Eikelboom⁴, Daniel I Sessler¹², Clive Kearon¹³, Mark Crowther³, Tomas VanHelder¹⁴, Peter A Kavsak¹⁵, Justin de Beer¹⁶, Mitchell Winemaker¹⁶, Yannick Le Manach¹⁷, Tej Sheth³, Jehonathan H Pinthus¹⁶, Deborah Siegal³, Lehana Thabane¹⁸, Marko R I Simunovic⁵, Ryszard Mizera³, Sebastian Ribas³, Philip J Devereaux¹⁹

Affiliations

¹ Division of Nephrology, London Health Science Centre, London, ON, Canada. Electronic address: [email protected].
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
³ Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁴ Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
⁵ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada.
⁶ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Surgery, McMaster University, Hamilton, ON, Canada.
⁷ Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Observatory, Cape Town, Western Cape, South Africa; University of Cape Town, Rondebosch, Cape Town, Western Cape, South Africa.
⁸ Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland.
⁹ Population Health Research Institute, Hamilton, ON, Canada.
¹⁰ Division of Nephrology, London Health Science Centre, London, ON, Canada; Institute for Clinical Evaluative Sciences at Western, London, ON, Canada.
¹¹ Population Health Research Institute, Hamilton, ON, Canada; School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
¹² Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
¹³ Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada.
¹⁴ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
¹⁵ Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
¹⁶ Department of Surgery, McMaster University, Hamilton, ON, Canada.
¹⁷ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
¹⁸ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada.
¹⁹ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.

PMID: 32718723
DOI: 10.1016/j.bja.2020.02.028

Abstract

Background: Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care.

Methods: In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L^-1.

Results: With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L^-1, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L^-1 alone.

Conclusions: BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery.

Clinical trial registration: NCT00512109.

Keywords: mortality; noncardiac surgery; perioperative bleeding; prediction; risk index; transfusion.

Publication types

Comment

MeSH terms

Blood Transfusion*
Hemorrhage*
Humans
Logistic Models
Prognosis
Prospective Studies

Associated data

ClinicalTrials.gov/NCT00512109