Abstract
Background:
Potassium disorders have been linked to adverse outcomes in various medical conditions. However, the association of preoperative serum potassium with postoperative outcome is not well established. We aimed to examine the association between preoperative potassium with a 30-day mortality and adverse cardiovascular event (MACE).
Methods:
We conducted a cohort study using a prospectively collected database of patients, undergoing surgical procedures from 1998 to 2013 in the VA Western New York Healthcare System, which are reported to the Veterans Affairs Surgical Quality Improvement Program (VASQIP). The patients were categorized into three groups based on their documented preoperative potassium concentrations. Hypokalemia was defined as serum potassium concentration <4 mmol/L and hyperkalemia was defined as serum potassium concentrations >5.5 mmol/L. The values within the range of 4.0–5.5 mmol/L were considered as normokalemia and used as the control group. Statistical analyses included Chi-square test, analysis of variance and multivariate logistic regression to estimate the risk of MACE within 30 days of surgery.
Results:
Study included 5959 veterans who underwent surgery between 1998 and 2013. The patients in the hyperkalemics group had lower kidney function compared to the other two groups. The frequency of MACE was 13.6% in hypokalemics and 21.9% in hyperkalemics that were both significantly higher than 4.9% in controls. In multivariate logistic regression the hazard risk (HR) ratios of MACE were (2.17, 95% CI 1.75–2.70) for hypokalemics and (3.23, 95% CI 2.10–4.95) for hyperkalemics when compared to normokalemic controls.
Conclusions:
Preoperative hypokalemia and hyperkalemia are both independent predictors of MACE within 30 days.
Acknowledgments
This study was performed at the VA Western NY Healthcare system using the database for VA Surgical Quality Improvement Program (VASQIP). However, VA does not claim any responsibility for its accuracy and validity.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Leung AA, McAlister FA, Rogers SO Jr, Pazo V, Wright A, Bates DW. Preoperative hyponatremia and perioperative complications. Arch Intern Med 2012;172:1474–81.10.1001/archinternmed.2012.3992Search in Google Scholar
2. Crestanello JA, Phillips G, Firstenberg MS, Sai-Sudhakar C, Sirak J, Higgins R, et al. Preoperative hyponatremia predicts outcomes after cardiac surgery. J Surg Res 2013;181:60–6.10.1016/j.jss.2012.06.004Search in Google Scholar
3. Berne RM, Sperelakis N. American Physiological Society (1887-Present). The cardiovascular system. Bethesda, MD.: American Physiological Society; distributed by Williams and Wilkins Co., 1981, 4 v 6.Search in Google Scholar
4. Committee on S, Practice P, Apfelbaum JL, Connis RT, Nickinovich DG, American Society of Anesthesiologists Task Force on Preanesthesia E, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012;116:522–38.10.1097/ALN.0b013e31823c1067Search in Google Scholar
5. Dzankic S, Pastor D, Gonzalez C, Leung JM. The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesth Analg 2001;93:301–8, 2nd contents page.10.1213/00000539-200108000-00013Search in Google Scholar
6. Narr BJ, Hansen TR, Warner MA. Preoperative laboratory screening in healthy Mayo patients: cost-effective elimination of tests and unchanged outcomes. Mayo Clin Proc 1991;66:155–9.10.1016/S0025-6196(12)60487-XSearch in Google Scholar
7. Wahr JA, Parks R, Boisvert D, Comunale M, Fabian J, Ramsay J, et al. Preoperative serum potassium levels and perioperative outcomes in cardiac surgery patients. Multicenter Study of Perioperative Ischemia Research Group. J AmMed Assoc 1999;281:2203–10.10.1001/jama.281.23.2203Search in Google Scholar PubMed
8. American Society of Anesthesiologists A. ASA Physical Status Classification System 1995-2013. Available from: http://www.asahq.org/Home/For-Members/Clinical-Information/ASA-Physical-Status-Classification-System.Search in Google Scholar
9. Afshar AH, Virk N, Porhomayon J, Pourafkari L, Dosluoglu HH, Nader ND. The validity of the VA surgical risk tool in predicting postoperative mortality among octogenarians. Am J Surg 2015;209:274–9.10.1016/j.amjsurg.2014.07.005Search in Google Scholar PubMed
10. Sohn MW, Arnold N, Maynard C, Hynes DM. Accuracy and completeness of mortality data in the Department of Veterans Affairs. Popul Health Metr 2006;4:2.10.1186/1478-7954-4-2Search in Google Scholar PubMed PubMed Central
11. National Center for Health Statistics (U.S.). Vital and health statistics. Series 16, Compilations of advance data from vital and health statistics. DHHS publication no (PHS). Hyattsville, Md.: U.S. Dept. of Health and Human Services, Centers for Disease Control, National Center for Disease Statistics; 1989.Search in Google Scholar
12. Messerli FH, Nunez BD, Nunez MM, Garavaglia GE, Schmieder RE, Ventura HO. Hypertension and sudden death. Disparate effects of calcium entry blocker and diuretic therapy on cardiac dysrhythmias. Arch Intern Med 1989;149:1263–7.10.1001/archinte.149.6.1263Search in Google Scholar PubMed
13. Hoes AW, Grobbee DE, Lubsen J, Man in ’t Veld AJ, van der Does E, Hofman A. Diuretics, beta-blockers, and the risk for sudden cardiac death in hypertensive patients. Ann Intern Med 1995;123:481–7.10.7326/0003-4819-123-7-199510010-00001Search in Google Scholar PubMed
14. Siscovick DS, Raghunathan TE, Psaty BM, Koepsell TD, Wicklund KG, Lin X, et al. Diuretic therapy for hypertension and the risk of primary cardiac arrest. N Engl J Med 1994;330:1852–7.10.1056/NEJM199406303302603Search in Google Scholar
15. Hollifield JW. Potassium and magnesium abnormalities: diuretics and arrhythmias in hypertension. Am J Med 1984;77:28–32.10.1016/S0002-9343(84)80005-4Search in Google Scholar
16. Torlen K, Kalantar-Zadeh K, Molnar MZ, Vashistha T, Mehrotra R. Serum potassium and cause-specific mortality in a large peritoneal dialysis cohort. Clin J Am Soc Nephrol 2012;7:1272–84.10.2215/CJN.00960112Search in Google Scholar PubMed PubMed Central
17. Vitez TS, Soper LE, Wong KC, Soper P. Chronic hypokalemia and intraoperative dysrhythmias. Anesthesiology 1985;63:130–3.10.1097/00000542-198508000-00002Search in Google Scholar PubMed
18. Hirsch IA, Tomlinson DL, Slogoff S, Keats AS. The overstated risk of preoperative hypokalemia. Anesth Analg 1988;67:131–6.10.1213/00000539-198802000-00005Search in Google Scholar
19. Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. Can Med Assoc J 2005;173:627–34.10.1503/cmaj.050011Search in Google Scholar PubMed PubMed Central
20. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043–9.10.1161/01.CIR.100.10.1043Search in Google Scholar PubMed
21. Kumar R, McKinney WP, Raj G, Heudebert GR, Heller HJ, Koetting M, et al. Adverse cardiac events after surgery: assessing risk in a veteran population. J Gen Intern Med 2001;16:507–18.10.1046/j.1525-1497.2001.016008507.xSearch in Google Scholar PubMed PubMed Central
22. Ashton CM, Petersen NJ, Wray NP, Kiefe CI, Dunn JK, Wu L, et al. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Annal Intern Med 1993;118:504–10.10.7326/0003-4819-118-7-199304010-00004Search in Google Scholar PubMed
23. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW. Myocardial infarction after noncardiac surgery. Anesthesiology 1998;88:572–8.10.1097/00000542-199803000-00005Search in Google Scholar PubMed
24. Mangano DT, Browner WS, Hollenberg M, Li J, Tateo IM. Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group. J Am Med Assoc 1992;268:233–9.10.1001/jama.268.2.233Search in Google Scholar
25. Goldman L, Caldera DL, Southwick FS, Nussbaum SR, Murray B, O’Malley TA, et al. Cardiac risk factors and complications in non-cardiac surgery. Medicine 1978;57:357–70.10.1097/00005792-197807000-00006Search in Google Scholar
26. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–50.10.1056/NEJM197710202971601Search in Google Scholar
27. Gilbert K, Larocque BJ, Patrick LT. Prospective evaluation of cardiac risk indices for patients undergoing noncardiac surgery. Annal Intern Med 2000;133:356–9.10.7326/0003-4819-133-5-200009050-00011Search in Google Scholar
28. Schouten O, Shaw LJ, Boersma E, Bax JJ, Kertai MD, Feringa HH, et al. A meta-analysis of safety and effectiveness of perioperative beta-blocker use for the prevention of cardiac events in different types of noncardiac surgery. Coron Artery Dis 2006;17:173–9.10.1097/00019501-200603000-00012Search in Google Scholar
29. POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008;371:1839–47.10.1016/S0140-6736(08)60601-7Search in Google Scholar
30. Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet 2008;372:1962–76.10.1016/S0140-6736(08)61560-3Search in Google Scholar
31. Schouten O, Boersma E, Hoeks SE, Benner R, van Urk H, van Sambeek MR, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med 2009;361:980–9.10.1056/NEJMoa0808207Search in Google Scholar PubMed
32. Dosluoglu HH, Davari-Farid S, Pourafkari L, Harris LM, Nader ND. Statin use is associated with improved overall survival without affecting patency and limb salvage rates following open or endovascular revascularization. Vascu Med 2014;19:86–93.10.1177/1358863X14528271Search in Google Scholar PubMed
33. Kapoor AS, Kanji H, Buckingham J, Devereaux PJ, McAlister FA. Strength of evidence for perioperative use of statins to reduce cardiovascular risk: systematic review of controlled studies. Br Med J 2006;333:1149.10.1136/bmj.39006.531146.BESearch in Google Scholar PubMed PubMed Central
34. Bauer SM, Cayne NS, Veith FJ. New developments in the preoperative evaluation and perioperative management of coronary artery disease in patients undergoing vascular surgery. J Vasc Surg 2010;51:242–51.10.1016/j.jvs.2009.08.087Search in Google Scholar PubMed
35. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795–804.10.1056/NEJMoa041905Search in Google Scholar PubMed
36. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007;116:1971–96.10.1161/CIRCULATIONAHA.107.185700Search in Google Scholar PubMed
37. Brown MJ, Brown DC, Murphy MB. Hypokalemia from beta2-receptor stimulation by circulating epinephrine. N Engl J Med 1983;309:1414–9.10.1056/NEJM198312083092303Search in Google Scholar PubMed
38. Nordrehaug JE, Johannessen KA, von der Lippe G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction. Circulation 1985;71:645–9.10.1161/01.CIR.71.4.645Search in Google Scholar
39. Goyal A, Spertus JA, Gosch K, Venkitachalam L, Jones PG, Van den Berghe G, et al. Serum potassium levels and mortality in acute myocardial infarction. J Am Med Assoc 2012;307:157–64.10.1001/jama.2011.1967Search in Google Scholar PubMed
40. Grossman AN, Opie LH, Beshansky JR, Ingwall JS, Rackley CE, Selker HP. Glucose-insulin-potassium revived: current status in acute coronary syndromes and the energy-depleted heart. Circulation 2013;127:1040–8.10.1161/CIRCULATIONAHA.112.130625Search in Google Scholar PubMed
41. ECC Committee S, Task Forces of the American Heart A. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(24 Suppl):IV1–203.Search in Google Scholar
©2017 Walter de Gruyter GmbH, Berlin/Boston
