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Multistate models for predicting organ failure trajectories in the postoperative period of cardiac surgery
Alberto Garrido Callén1, Manuel Pérez Torres1, Dovami Vasco Castaño1
1Unidad de Cuidados Intensivos, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain.
Objective:
Developing a multistate model to predict clinical transitions and their associated risk factors during the ICU postoperative period following cardiac surgery (CS).
Design:
An observational, single-center, retrospective study from December 2021 to December 2023. 6 predefined transitions were considered: (T1) ICU admission → haemodynamic failure; (T2) admission → ICU discharge; (T3) haemodynamic failure → second organ failure; (T4) haemodynamic failure → ICU discharge; (T5) second organ failure → ICU discharge; and (T6) second organ failure → death.
Setting:
Postoperative period following CS.
Patients:
Adults undergoing surgery with cardiopulmonary bypass, excluding immediate postoperative mechanical circulatory support, prior cardiopulmonary arrest, minimally invasive surgery, or reintervention outside the index hospitalization.
Main Variables Of Interest:
Comorbidity, functional status, type of intervention, surgical characteristics, and pre- and postoperative haemodynamic status.
Results:
n = 197. The final model achieved a C-index = 0.63 (95% CI: 0.58-0.66). The following transition specific adjusted hazard ratios (95% CI) were obtained: in T1, urgent surgery 3.02 (1.85-4.93), age 1.02 (1.00 1.04), central venous pressure at admission 1.05 (1.00-1.10), and shock index (SI) at admission 4.11 (1.56 10.86); in T2, change in left ventricular ejection fraction 0.03 (0.00-0.27) and age 0.98 (0.97-1.00); in T3, aortic cross-clamp time 1.01 (1.00-1.01), number of defibrillations 1.27 (1.01-1.59), mean arterial pressure (MAP) at admission 0.96 (0.93-0.99), and urgent surgery 3.10 (1.19-8.10); in T4, Vasoactive-Inotropic Score at admission 0.97 (0.95-1.00), red blood cell units 0.53 (0.37-0.77), and improvement in right ventricular systolic function 1.61 (1.08-2.38); in T5, previous CS 0.30 (0.11-0.78), SI 0.06 (0.01-0.47), smoker 0.29 (0.13-0.62), and urgent surgery 0.06 (0.01-0.29); and in T6, MAP 0.91 (0.85-0.97) and red blood cell units 1.35 (1.04-1.75).
Conclusions:
Multiple risk factors were identified using a multistate model with moderate discrimination for the postoperative period of CS, allowing for the incorporation of the temporal sequence and interdependence of organ failures.
