Demographics of the study population
Among a total of 1013 screened patients, 63 were excluded for not meeting the criteria or refusing to participate. Finally, 950 subjects from 59 hospitals in the region of Chongqing, Sichuan, Hubei and Ningxia Province were enrolled (All the participating hospital were shown in the file of supplementary information). The median of age was 52 years old with BMI being 23.5 kg/m2. 363 male and 587 female were included. And most of them were complained with cardiovascular diseases (215 cases, 22.6%) and endocrine diseases (106 cases, 11.1%) for past illness. In addition, 190 patients had the history of drinking or/and smoking. A total of 731 subjects were assessed with lower-risk for surgery (ASA classification I and II). For the report of blood examination, the median of red blood cells, hemoglobin, albumin, creatinine, bilirubin was 4.24*1012/L, 127 g/L, 42.04 g/L, 60.6 μmol/L, 10.9 μmol/L, relatively. All the data of the characteristic of the patients were shown in table 1.
Characteristic of surgery/anesthesia and intraoperative vital sign of the patients
Orthopedic surgeries (287 cases, 30.2%), hepatobiliary surgeries (198 cases, 20.8%) and gynecology and obstetrics (192 cases, 20.2%) surgeries were the three most frequent operation categories. According to the severity of surgery injure, most surgeries were major, including joint replacement surgery, hepatic, gynecological, gastrointestinal and lung tumor surgery, etc. Most surgery was elective, the proportion of emergency surgery was only 5.6%. 76.2% of patients received minimally invasive surgery, and 59.6% of surgeries were conducted with general anesthesia. A great amount of surgeries were completed within 125 min. Correspondingly, most patients were under anesthesia condition within 180 min. Results suggested that the vital signs (heart rate, breathe, blood pressure, temperature) of patient were relative stable during the operation although a certain fluctuation in heart rate and blood pressure was shown. The volume of fluid therapy was also reported and the input were 1100 (800-1600) ml, crystalloid was the main component. The volume of output were 350 (85-600) ml (Table 2).
Compliance and clinical outcomes with ERAS program
ERAS program was consisted of 16 items in our study. The highest compliance was counseling and education, the lowest compliance was belonged to the item of carbohydrate intake. And there were 3 items which the compliance was over 90%. However, the compliance of 4 items, including carbohydrate intake, prevention of DVT, prevention of PONV and multimodal analgesia, were less than 70% (Figure 1).
The time of anal exhaust and defecation were 12 (6-26)h and 30 (18-50)h postoperatively. Moreover, about 50% patients could drink water within 6h postoperatively, and a quarter of patients even could drink water within 4h postoperatively. A half of patients could returned to liquid diet within 11h postoperatively and gradually converted to normal diet within 30h postoperatively. Otherwise, 25% of patients could not fully recovered to normal diet at postoperative 48h. The time of active exercises in bed for patients postoperatively was 6(2-10)h. About 75% patients had the ability to stand without assist within 48h postoperatively. The time of walking with assist was 24 (13-55)h postoperatively while the time of walking without assist was 33 (20-72)h postoperatively (Table 3).
In generally, postoperative pain was controlled well although a significant minority of patients experienced moderate-severe pain in hospital. The NRS scores were 2 (1-3) at POD1, 1 (0-2) at POD2 and 1 (0-1) at POD3 at rest. While for pain in motion, the NRS scores were 3 (2-4) at POD1, 2 (1-3) at POD2 and 2 (1-3) at POD3, respectively. And no patients were reported more than 3 points at 1 month postoperatively (Figure 2).
106 cases of postoperative complication were reported within 1 month postoperatively in this study, and the incidence of complication was 11.1%. The complications included death (1 case, 0.1%), stroke (1 case, 0.1%), organ failure (1 case, 0.1%), ileus (3 cases, 0.4%), postoperative hemorrhage (2 cases, 0.2%), surgical site infection (8 cases, 0.8%), urinary infection (2 cases, 0.2%), pulmonary infection (8 cases, 0.8%), deep venous thrombosis (1 case, 0.1%), perioperative neurocognitive disorders (1 case, 0.1%), mechanical ventilation last for 48h (2 cases, 0.2%), re-admission within 30 days (6 cases, 0.6%), postoperative nausea and vomiting (23 cases, 2.4%), severe sedation with analgesia (2 cases, 0.2%), respiratory depression with analgesia (2 cases, 0.2%), uncontrolled postoperative pain (40 cases, 4.6%), others (3 cases, 0.3%). The median of hospital stay postoperatively was 6 days, about 75% patients could discharge within postoperative 10 days. And the median of hospitalization expenses were 13000 CNY, and the satisfaction scores was 9 (Table 3).
Clinical risk factors of complications within 1 months postoperatively
The risk factors were summarized with univariate and multivariate logistical regression analysis in table 4. Univariate analysis revealed that 20 potential perioperative factors (age, preoperative hemoglobin, hematocrit, red blood cell, creatinine, total protein, albumin, bilirubin, and fibrinogen, mode of anesthesia, duration of anesthesia, intraoperative maximum of heart rate, pulse and systolic blood pressure, NRS at rest and in motion at 3 days postoperatively, time of activity in bed, minimally invasive surgery, no drainage placed as usual and early exercise) were associated with postoperative complications. And the final multivariate logistical regression showed 5 significant independent predictors: preoperative creatinine (OR 1.012, 95%CI 1.002-1.021) and bilirubin (OR 1.017, 95%CI 1.001-1.033), intraoperative maximum systolic blood pressure (OR 1.015, 95%CI 1.001-1.029), NRS scores at rest at postoperative 3 days (OR 1.43, 95%CI 1.111-1.84), minimally invasive surgery (OR 0.539, 95%CI 0.292-0.995). Results of the Hosmer-Lemeshow test suggested a good fit of the model (χ2=11.869, df=8, P=0.157).
Prediction model for complications within 1 months postoperatively
To identify the high-risk patients of complications after surgery, a predictive nomogram model based on the results of multivariate logistical regression analysis was conducted to present the probability of complications within 1 months postoperatively. “Points” were calculated with the corresponding independent predictors. “Total points” were summed with each single points, and we draw a vertical line and projected it from the “Total points” scale to the “Probability” scale to predict the probability of complications within 1 months postoperatively. Results of ROC curve suggested a good discrimination with AUC 0.702 (95%CI 0.624-0.779). At the optimal cutoff value of 0.241, the sensitivity and specificity were 57.7% and 73.2%, respectively. The model showed a relatively good calibration because the actual line was not significantly deviated from the ideal line (Figure 3).