Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance

Pavel S Roshanov; John W Eikelboom; Daniel I Sessler; Clive Kearon; Gordon H Guyatt; Mark Crowther; Vikas Tandon; Flavia Kessler Borges; Andre Lamy; Richard Whitlock; Bruce M Biccard; Wojciech Szczeklik; Mohamed Panju; Jessica Spence; Amit X Garg; Michael McGillion; 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.2020.06.051

Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance

Br J Anaesth. 2021 Jan;126(1):163-171. doi: 10.1016/j.bja.2020.06.051. Epub 2020 Aug 5.

Authors

Pavel S Roshanov¹, John W Eikelboom², Daniel I Sessler³, Clive Kearon⁴, Gordon H Guyatt⁵, Mark Crowther⁶, Vikas Tandon⁶, Flavia Kessler Borges², Andre Lamy⁷, Richard Whitlock⁸, Bruce M Biccard⁹, Wojciech Szczeklik¹⁰, Mohamed Panju⁶, Jessica Spence¹¹, Amit X Garg¹², Michael McGillion¹³, Tomas VanHelder¹⁴, Peter A Kavsak¹⁵, Justin de Beer¹⁶, Mitchell Winemaker¹⁶, Yannick Le Manach¹⁷, Tej Sheth⁶, Jehonathan H Pinthus¹⁶, Deborah Siegal⁶, Lehana Thabane¹⁸, Marko R I Simunovic⁷, Ryszard Mizera⁶, Sebastian Ribas⁶, Philip J Devereaux¹⁹

Affiliations

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

PMID: 32768179
DOI: 10.1016/j.bja.2020.06.051

Abstract

Background: We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS.

Methods: This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery.

Results: Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L^-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%.

Conclusions: Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery.

Clinical trial registration: NCT00512109.

Keywords: anaemia; mortality; noncardiac surgery; perioperative bleeding; postoperative outcome; transfusion.

MeSH terms

Aged
Cohort Studies
Female
Humans
Male
Middle Aged
Postoperative Hemorrhage / diagnosis*
Postoperative Hemorrhage / mortality*
Prognosis
Prospective Studies

Associated data

ClinicalTrials.gov/NCT00512109