부산대학교 도서관

To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1016/S0140-6736(18)31131-0 Byline: Duminda N Wijeysundera, PhD (a,c,e,f), Prof Rupert M Pearse, MD (k), Mark A Shulman, MPH (o,p), Tom E F Abbott, PhD (k), Elizabeth Torres, BMSc (b), Althea Ambosta, MA (b), Bernard L Croal, MD (l), Prof John T Granton, MD (d,g,i), Kevin E Thorpe, MMath (a,b,h), Prof Michael P W Grocott, MD (m,n), Catherine Farrington, BAppSc (o,p), Prof Paul S Myles, DSc (o,p), Prof Brian H Cuthbertson, MD [brian.cuthbertson@sunnybrook.ca] (e,f,j,*), Sophie Wallace, Bruce Thompson, Mathew Ellis, Brigette Borg, Ross K Kerridge, Jeanene Douglas, John Brannan, Jeff Pretto, Guy Godsall, Nicola Beauchamp, Sandra Allen, Ann Kennedy, Ewan Wright, Johan Malherbe, Hilmy Ismail, Bernhard Riedel, Andrew Melville, Harry Sivakumar, Andrew Murmane, Kay Kenchington, Yesim Kirabiyik, Usha Gurunathan, Chris Stonell, Kate Brunello, Katherine Steele, Oystein Tronstad, Philip Masel, Annette Dent, Emma Smith, Alanna Bodger, Miriam Abolfathi, Pal Sivalingam, Adrian Hall, Thomas W Painter, Simon Macklin, Adrian Elliott, Anna Maria Carrera, Nico CS Terblanche, Simon Pitt, Joanne Samuel, Chris Wilde, Kate Leslie, Andrew MacCormick, David Bramley, Anne Marie Southcott, John Grant, Hugh Taylor, Samantha Bates, Miriam Towns, Anna Tippett, Fiona Marshall, C David Mazer, Janarthanee Kunasingam, Anmol Yagnik, Charmagne Crescini, Sanjay Yagnik, Colin JL McCartney, Priya Somascanthan, Stephen Choi, Kathrina Flores, Shelly Au, W Scott Beattie, Keyvan Karkouti, Hance A Clarke, Angela Jerath, Stuart A McCluskey, Marcin Wasowicz, Lauren Day, Janneth Pazmino-Canizares, Paul Oh, Rene Belliard, Leanna Lee, Karen Dobson, Vincent Chan, Richard Brull, Noam Ami, Matthew Stanbrook, Katherine Hagen, Douglas Campbell, Timothy Short, Joreline Van Der Westhuizen, Kushlin Higgie, Helen Lindsay, Ryan Jang, Chris Wong, Davina McAllister, Marlynn Ali, Jonathan Kumar, Ellen Waymouth, Chang Joon Kim, Julian Dimech, Michael Lorimer, Joyce Tai, Reuben Miller, Rachel Sara, Andrew Collingwood, Sue Olliff, Sharon Gabriel, Helen Houston, Paul Dalley, Sally Hurford, Anna Hunt, Lynn Andrews, Leanlove Navarra, Adelaide Jason-Smith, Helen Thompson, Natalie McMillan, Geraldine Back, Mark Lum, Daniel Martin, Sarah James, Helder Filipe, Manuel Pinto, Stephen Kynaston, Mandeep Phull, Christian Beilstein, Pheobe Bodger, Kirsty Everingham, Ying Hu, Edyta Niebrzegowska, Carmen Corriea, Thais Creary, Marta Januszewska, Tahania Ahmad, Jan Whalley, Richard Haslop, Jane McNeil, Alistair Brown, Neil MacDonald, Mari Liis Pakats, Kathryn Greaves, Shaman Jhanji, Ravishanar Raobaikady, Ethel Black, Martin Rooms, Helen Lawrence, Maria Koutra, Katrina Pirie, Michelle Gertsman, Sandy Jack, Michael Celinski, Denny Levett, Mark Edwards, Karen Salmon, Clare Bolger, Lisa Loughney, Leanne Seaward, Hannah Collins, Bryony Tyrell, Natasha Tantony, Kim Golder, Gareth L Ackland, RCM Stephens, Laura Gallego-Paredes, Anna Reyes, Ana Gutierrez del Arroyo, Ashok Raj, Rhiannon Lifford, Magda Melo, Muhammad Mamdani, Graham Hillis, Harindra C Wijeysundera Summary Background Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. Methods We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. Findings Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19*2% sensitivity (95% CI 14*2--25) and 94*7% specificity (93*2--95*9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0*96, 95% CI 0*83--0*99; p=0*03). Interpretation Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University. Author Affiliation: (a) Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada (b) Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada (c) Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada (d) Department of Medicine, University Health Network, Toronto, ON, Canada (e) Department of Anesthesia, University of Toronto, Toronto, ON, Canada (f) Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada (g) Department of Medicine, University of Toronto, Toronto, ON, Canada (h) Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (i) Department of Medicine, Sinai Health System, Toronto, ON, Canada (j) Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (k) Queen Mary University of London, London, UK (l) NHS Grampian, Aberdeen, UK (m) University Hospital Southampton, Southampton, UK (n) University of Southampton, Southampton, UK (o) Alfred Hospital, Melbourne, VIC, Australia (p) Monash University, Melbourne, VIC, Australia * Correspondence to: Prof Brian H Cuthbertson, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada