Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology

Preoperative Spirometry in Patients With Known or Suspected Chronic Obstructive Pulmonary Disease Undergoing Major Surgery: The Prospective Observational PREDICT Study

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative pulmonary risk assessment, but the scientific literature is conflicting. The Preoperative Diagnostic Tests for Pulmonary Risk Assessment in Chronic Obstructive Pulmonary Disease (PREDICT) study aimed to determine whether preoperative PFTs improve the prediction of postoperative pulmonary complications (PPCs) in patients with known or suspected chronic obstructive pulmonary disease (COPD) undergoing major surgery. A secondary aim was to determine whether the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) classification of airflow limitation severity (grades I-IV) is associated with PPC.

METHODS

In this prospective, single-center study, patients with GOLD key indicators for COPD scheduled for major surgery received PFTs. Patients with confirmed COPD (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ≤0.7) were included in the COPD cohort and compared with a reference cohort without COPD. We developed 3 multivariable risk prediction models and compared their ability to predict PPC: the "standard model" (medical preconditions, and sociodemographic and surgical data), the "COPD assessment model" (additional GOLD key indicators, pack-years, and poor exercise capacity), and the "PFT model" (additional PFT parameters selected by adaptive least absolute shrinkage and selection operator [LASSO] regression). Multiple LASSO regressions were used for cross-validation.

RESULTS

A total of 31,714 patients were assessed for eligibility; 1271 individuals received PFTs. Three hundred twenty patients (240 with confirmed COPD: 78 GOLD I, 125 GOLD II, 28 GOLD III, 9 GOLD IV, and 80 without COPD) completed follow-up. The diagnostic performance was similar among the standard model (cross-validated area under the curve [cvAUC], 0.723; bias-corrected bootstrapped [bc-b] 95% confidence interval [CI], 0.663-0.775), COPD assessment model (cvAUC, 0.724; bc-b 95% CI, 0.662-0.777), and PFT model (cvAUC, 0.729; bc-b 95% CI, 0.668-0.782). Previously known COPD was an independent predictor in the standard and COPD assessment model. %FEV1 PRED was the only PFT parameter selected by LASSO regression and was an independent predictor in the PFT model (adjusted odds ratios [OR], 0.98; 95% CI, 0.967-.0.998; P = .030). The risk for PPC significantly increased with GOLD grades ( P < .001). COPD was newly diagnosed in 53.8% of the patients with confirmed COPD; however, these individuals were not at increased risk for PPC ( P = .338).

CONCLUSIONS

COPD is underdiagnosed in surgical patients. Patients with newly diagnosed COPD commonly presented with low GOLD severity grades and were not at higher risk for PPC. Neither a structured COPD-specific assessment nor preoperative PFTs added incremental diagnostic value to the standard clinical preassessment in patients with known or suspected COPD. Unnecessary postponement of surgery and undue health care costs can be avoided.

[Teleconsultation for preoperative evaluation and informed consent-Are we ready for a paradigm shift?]

In Germany, approximately 17 million anaesthesiological procedures and, consequently, roughly the same number of preoperative consultations are conducted each year. So far, these have predominantly taken place in person. However, recent developments in technology, medical-legal aspects, and politics, combined with the catalyzing effect of the pandemic situation, have led to a significant boost in telemedicine. In the field of anaesthesia, there are new approaches to implementing telemedicine in the pre- and postoperative setting. This article focuses on the preoperative setting and presents general requirements for a teleconsultation as preoperative evaluation, the current state of technology, and medical-legal aspects.

[Special features of the perioperative course in patients with frailty syndrome]

The demographic change with an increase in the number of geriatric patients presents major challenges for perioperative medicine. Frailty is a multimorbidity complex that incorporates a combination of various factors, such as physical weakness, slower walking speed and unwanted weight loss. It is of great importance that these patients receive an individually adapted perioperative care. This includes, among others, a preoperative examination for frailty, a structured prehabilitation according to the concept of better in, better out, the compliance with the guidelines on prevention and timely treatment of postoperative delirium as well as the continuous maintenance of the body's homeostasis. By means of these measures the risk of complications in this patient group can be reduced and the best possible postoperative results can be achieved.

Association of Preoperative Glycated Hemoglobin and Early Postoperative Infections After Elective Craniotomy: A Retrospective Cohort Study

BACKGROUND

The prognostic value of preoperative glycated hemoglobin (HbA1c) testing is controversial. The available evidence on the role of preoperative HbA1c in predicting postoperative complications after different surgical procedures has been conflicting. The primary aim of our retrospective observational cohort study was to assess the association between preoperative HbA1c and postoperative infections after elective craniotomy.

METHODS

We extracted and analyzed data from an internal hospital database on 4564 patients who underwent neurosurgical intervention from January 2017 to May 2022. The primary outcome measure of the present study was infections established in the first week after surgery using the Centers for Disease Control and Prevention criteria. The records were stratified by the HbA1c values and intervention types.

RESULTS

For patients who had undergone brain tumor removal with a preoperative HbA1c ≥6.5%, the odds of early postoperative infections were increased (odds ratio, 2.08; 95% confidence interval, 1.16-3.72; P = 0.01). We found no association between HbA1c and early postoperative infections for patients who had undergone elective cerebrovascular intervention, cranioplasty, or a minimally invasive procedure. After adjusting for age and gender, the threshold for significant infection risk for neuro-oncological patients increased with an HbA1c ≥7.5% (adjusted odds ratio, 2.97; 95% confidence interval, 1.37-6.45; P = 0.0058).

CONCLUSIONS

For patients undergoing elective intracranial surgery for brain tumor removal, a preoperative HbA1c ≥7.5% is associated with a higher infection rate within the first postoperative week. Future prospective studies are required to assess the prognostic value of this association for clinical decision-making.

Association of Postoperative Drift in Hemoglobin With Mortality After Brain Tumor Craniotomy

BACKGROUND

Postoperative downward drift in hemoglobin (Hb) concentration may be associated with complications and death, even if nadir Hb remains more than the red blood cell transfusion threshold of 7 g/dL.

OBJECTIVE

To assess whether postoperative Hb drift in patients undergoing brain tumor craniotomy influences mortality in the immediate perioperative period.

METHODS

This retrospective cohort study included patients undergoing craniotomy for brain tumors. We defined no postoperative Hb decrease, mild decrease, moderate decrease, and severe decrease as postoperative Hb drift of ≤25%, 26% to 50%, 51% to 75%, and >75%, respectively. The primary outcome was 30-day mortality after craniotomy.

RESULTS

This study included 8159 patients who underwent a craniotomy for brain tumors. Compared with patients with no postoperative Hb drift, the odds of postoperative mortality at 30 days increased in patients with mild postoperative Hb drift (adjusted odds ratio [OR] 2.47, 95% CI 1.72-3.56), moderate drift (adjusted OR 6.56, 95% CI 3.42-12.59), and severe drift (adjusted OR 12.33, 95% CI 3.48-43.62). When postoperative Hb drift was analyzed as a continuous variable, for each 10% increase in Hb drift, the adjusted OR of postoperative mortality at 30 days was 1.46 (95% CI 1.31-1.63).

CONCLUSION

In patients undergoing brain tumor craniotomy, a small postoperative Hb drift was associated with increased odds of postoperative mortality at 30 days, even if the nadir Hb level remained greater than the red blood cell transfusion threshold of 7 g/dL. Future randomized clinical trials of perioperative transfusion practices may examine the effect of both nadir Hb and Hb drift.

Network prediction of surgical complication clusters: a prospective multicenter cohort study

Complicated relationships exist in both occurrence and progression of surgical complications, which are difficult to account for using a separate quantitative method such as prediction or grading. Data of 51,030 surgical inpatients were collected from four academic/teaching hospitals in a prospective cohort study in China. The relationship between preoperative factors, 22 common complications, and death was analyzed. With input from 54 senior clinicians and following a Bayesian network approach, a complication grading, cluster-visualization, and prediction (GCP) system was designed to model pathways between grades of complication and preoperative risk factor clusters. In the GCP system, there were 11 nodes representing six grades of complication and five preoperative risk factor clusters, and 32 arcs representing a direct association. Several critical targets were pinpointed on the pathway. Malnourished status was a fundamental cause widely associated (7/32 arcs) with other risk factor clusters and complications. American Society of Anesthesiologists (ASA) score ⩾3 was directly dependent on all other risk factor clusters and influenced all severe complications. Grade III complications (mainly pneumonia) were directly dependent on 4/5 risk factor clusters and affected all other grades of complication. Irrespective of grade, complication occurrence was more likely to increase the risk of other grades of complication than risk factor clusters.

Assessment of the prognostic value of preoperative high-sensitive troponin T for myocardial injury and long-term mortality for groups at high risk for cardiovascular events following noncardiac surgery: a retrospective cohort study

Background

Few studies explored the association between high-sensitive cardiac troponin T (hs-cTnT) and long-term mortality for patients after surgery. This study was conducted to assess the association of hs-cTnT with long-term mortality and to investigate the extent to which this association is mediated via myocardial injury after noncardiac surgery (MINS).

Methods

This retrospective cohort study included all patients with hs-cTnT measurements who underwent non-cardiac surgery at Sichuan University West China Hospital. Data were collected from February 2018 and November 2020, with follow-up through February 2022. The primary outcome was all-cause mortality within 1 year. As secondary outcomes, MINS, length of hospital stay (LOS), and ICU admission were analyzed.

Results

The cohort included 7,156 patients (4,299 [60.1%] men; 61.0 [49.0-71.0] years). Among 7,156 patients, there were 2,151 (30.05%) with elevated hs-cTnT(>14 ng/L). After more than 1 year of follow-up, more than 91.8% of mortality information was available. During one-year follow-up after surgery, there were 308 deaths (14.8%) with a preoperative hs-cTnT >14 ng/L, compared with 192 deaths (3.9%) with a preoperative hs-cTnT <=14 ng/L(adjusted hazard ratio [aHR] 1.93, 95% CI 1.58-2.36; p < 0.001). Elevated preoperative hs-cTnT was also associated with several other adverse outcomes (MINS: adjusted odds ratio [aOR] 3.01; 95% CI, 2.46-3.69; p < 0.001; LOS: aOR 1.48, 95%CI 1.34-1.641; p < 0.001; ICU admission: aOR 1.52, 95%CI 1.31-1.76; p < 0.001). MINS explained approximately 33.6% of the variance in mortality due to preoperative hs-cTnT levels.

Conclusion

Preoperative elevated hs-cTnT concentrations have a significant association with long-term mortality after noncardiac surgery, one-third of which may by accounted for by MINS.

Intraoperative Variables Enhance the Predictive Performance of Myocardial Injury in Patients with High Cardiovascular Risk After Thoracic Surgery When Added to Baseline Prediction Model

Purpose

Myocardial injury after non-cardiac surgery is closely related to major adverse cardiac and cerebrovascular event and is difficult to identify. This study aims to investigate how to predict the myocardial injury of thoracic surgery and whether intraoperative variables contribute to the prediction of myocardial injury.

Methods

The prospective study included adult patients with high cardiovascular risk who underwent elective thoracic surgery from May 2022 to October 2022. Multivariate logistic regression was used to establish a model with baseline variables and a model with baseline and intraoperative variables. We compare the predictive performance of two models for postoperative myocardial injury.

Results

In general, 31.5% (94 of 298) occurred myocardial injury. Age ≥65 years old, obesity, smoking, preoperative hsTnT, and one-lung ventilation time were independent predictors of myocardial injury. Compared with baseline model, the intraoperative variables improved model fit, modestly improved the reclassification (continuous net reclassification improvement 0.409, 95% CI, 0.169 to 0.648, P<0.001, improved integrated discrimination 0.036, 95% CI, 0.011 to 0.062, P<0.01) of myocardial injury cases, and achieved higher net benefit in decision curve analysis.

Conclusion

The risk stratification and anesthesia management of high-risk patients are essential. The addition of intraoperative variables to the baseline predictive model improved the performance of the overall model of myocardial injury and helped anesthesiologists screen out the patients at the greatest risk for myocardial injury and adjust anesthesia strategies.

Enabling personalized perioperative risk prediction by using a machine-learning model based on preoperative data

Preoperative risk assessment is essential for shared decision-making and adequate perioperative care. Common scores provide limited predictive quality and lack personalized information. The aim of this study was to create an interpretable machine-learning-based model to assess the patient's individual risk of postoperative mortality based on preoperative data to allow analysis of personal risk factors. After ethical approval, a model for prediction of postoperative in-hospital mortality based on preoperative data of 66,846 patients undergoing elective non-cardiac surgery between June 2014 and March 2020 was created with extreme gradient boosting. Model performance and the most relevant parameters were shown using receiver operating characteristic (ROC-) and precision-recall (PR-) curves and importance plots. Individual risks of index patients were presented in waterfall diagrams. The model included 201 features and showed good predictive abilities with an area under receiver operating characteristic (AUROC) curve of 0.95 and an area under precision-recall curve (AUPRC) of 0.109. The feature with the highest information gain was the preoperative order for red packed cell concentrates followed by age and c-reactive protein. Individual risk factors could be identified on patient level. We created a highly accurate and interpretable machine learning model to preoperatively predict the risk of postoperative in-hospital mortality. The algorithm can be used to identify factors susceptible to preoperative optimization measures and to identify risk factors influencing individual patient risk.

Association of preoperative glucose concentration with mortality in patients undergoing craniotomy for brain tumor

OBJECTIVE

Hyperglycemia is associated with worse outcomes in ambulatory settings and specialized hospital settings, but there are sparse data on the importance of preoperative blood glucose measurement before brain tumor craniotomy. The authors sought to investigate the association between preoperative glucose level and 30-day mortality rate in patients undergoing brain tumor resection.

METHODS

This retrospective cohort study included patients undergoing craniotomy for brain tumors at West China Hospital, Sichuan University, from January 2011 to March 2021. Surgical mortality rates were evaluated in patients who had normal glycemia (< 5.6 mmol/L) as well as mild (5.6-6.9 mmol/L), moderate (7.0-11.0 mmol/L), and severe hyperglycemia (> 11.0 mmol/L).

RESULTS

The study included 12,281 patients who underwent tumor resection via craniotomy. The overall 30-day mortality rate was 2.0% (242/12,281), whereas the rates for normal glycemia and mild, moderate, and severe hyperglycemia were 1.5%, 2.5%, 3.8%, and 6.5%, respectively. Compared with normal glycemia, the odds of mortality at 30 days were higher in patients with mild hyperglycemia (adjusted odds ratio [OR] 1.44, 95% confidence interval [CI] 1.05-2.00), moderate hyperglycemia (OR 2.04, 95% CI 1.41-2.96), and severe hyperglycemia (OR 3.76, 95% CI 1.96-7.20; p < 0.001 for trend). When blood glucose was analyzed as a continuous variable, for each 1 mmol/L increase in blood glucose, the adjusted OR of 30-day mortality was 1.13 (95% CI 1.08-1.19). The addition of a preoperative glucose level significantly improved the area under the curve and categorical net reclassification index for prediction of mortality.

CONCLUSIONS

In patients undergoing craniotomy for brain tumors, even mild hyperglycemia was associated with an increased mortality rate, at a glucose level that was much lower than the commonly applied level.

ACR Appropriateness Criteria® Routine Chest Imaging

Routine chest imaging has been used to identify unknown or subclinical cardiothoracic abnormalities in the absence of symptoms. Various imaging modalities have been suggested for routine chest imaging. We review the evidence for or against the use of routine chest imaging in different clinical scenarios. This document aims to determine guidelines for the use of routine chest imaging as initial imaging for hospital admission, initial imaging prior to noncardiothoracic surgery, and surveillance imaging for chronic cardiopulmonary disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A standardized anesthetic/analgetic regimen compared to standard anesthetic/analgetic regimen for patients with high-risk factors undergoing open lumbar spine surgery: a prospective comparative single-center study

The objective of the study is to improve the results of patients undergoing lumbar spine surgery who are at high risk for anesthesia and/or surgical complications. Two independent groups were compared: the study group (SG, n = 40) (standardized neuroanesthetic protocol with multimodal analgesia) and the control group (CG, n = 40) (intravenous anesthesia based on propofol and fentanyl). The data were collected using prospective observation of early and long-term results of lumbar fusion. After 24 months, the level of functional state and quality of life were studied. Patients in the SG did not have statistically significant changes in intraoperative hemodynamics; the best indicators of cognitive functions were noted. The effectiveness of the SG compared with the CG was confirmed by a statistically significantly lower amount of perioperative opioid drugs required (p = 0.01) and a minimal level of incisional pain (p < 0.05). An intergroup comparison of the adverse effects of anesthesia revealed a significantly lower number in the SG (n = 4) compared to the CG (n = 16) (p = 0.004). The number of postoperative surgical complications was comparable (p = 0.72). Intergroup comparison showed improved ODI, SF-36, and the Macnab scale at 24 months after surgery in the SG compared to the CG (p < 0.05). Long-term clinical results correlated with the level of incisional pain in the first three postoperative days. Our standardized neuroanesthetic protocol ensured effective treatment of postoperative incisional pain, significantly decreased the perioperative use of opioids, reduced adverse anesthesia events, and improved long-term clinical results in patients with high risk factors for anesthetic complications who undergoing open lumbar spine surgery.

A systematic review of perioperative clinical practice guidelines for care of older adults living with frailty

BACKGROUND

Perioperative frailty is prevalent and requires complex management, which could be guided by clinical practice guidelines (CPGs). The objective of this systematic review was to identify and synthesise CPGs that provide perioperative recommendations specific to older adults living with frailty.

METHODS

After protocol registration, we performed a systematic review of CPGs. MEDLINE, Embase, CINAHL, and 14 grey literature databases were searched (January 1, 2000 until December 22, 2021). We included all CPGs that contained at least one frailty-specific recommendation related to any phase of the perioperative period. We compiled all relevant recommendations, extracted underlying strength of evidence, and categorised them by perioperative phase of care. Within each phase, recommendations were synthesised inductively into themes. Quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

From 4707 citations, 13 guidelines were included; 8/13 were focused on the perioperative care of older surgical patients in general. Among 110 recommendations extracted, 37 themes were generated, with the majority pertaining to preoperative care. Four themes were supported by strong evidence: performing preoperative frailty assessments, using multidimensional frailty instruments, reducing urinary catheter use, and following multidisciplinary care and communication throughout the perioperative period. Per AGREE II, most guidelines (8/13; 62%) were recommended for use with modifications.

CONCLUSIONS

Despite increasing numbers of patients living with frailty, few guidelines exist that address frailty-specific perioperative care. Given the lack of strong evidence-based recommendations, particularly outside the preoperative period, high-quality primary research is required to underpin future guidelines and better inform the care of older surgical patients with frailty.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022320149.

Cost-effectiveness of a high-sensitivity cardiac troponin T systematic screening strategy compared with usual care to identify patients with peri-operative myocardial injury after major noncardiac surgery

BACKGROUND

About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery.

OBJECTIVE

To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care.

DESIGN

Cost-effectiveness analysis; single centre prospective cohort study.

SETTING

Spanish University Hospital.

PATIENTS

From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays.

INTERVENTIONS

We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis.

MAIN OUTCOME MEASURES

ICER of the systematic hs-cTnT screening strategy.

RESULTS

The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780.

CONCLUSIONS

Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03438448.

Methodological transparency of preoperative clinical practice guidelines for elective surgery. Systematic review

BACKGROUND

Clinical practice guidelines (CPG) are statements that provide recommendations regarding the approach to different diseases and aim to increase quality while decreasing the risk of complications in health care. Numerous guidelines in the field of perioperative care have been published in the previous decade but their methodological quality and transparency are relatively unknown.

OBJECTIVE

To critically evaluate the transparency and methodological quality of published CPG in the preoperative assessment and management of adult patients undergoing elective surgery.

DESIGN

Systematic review and methodological appraisal study.

DATA SOURCES

We searched for eligible CPG published in English or Spanish between January 1, 2010, and June 30, 2022, in Pubmed MEDLINE, TRIP Database, Embase, the Cochrane Library, as well as in representatives' medical societies of Anaesthesiology and developers of CPG.

ELIGIBILITY CRITERIA

CPG dedicated on preoperative fasting, cardiac assessment for non-cardiac surgery, and the use of routine preoperative tests were included. Methodological quality and transparency of CPG were assessed by 3 evaluators using the 6 domains of the AGREE-II tool.

RESULTS

We included 20 CPG of which 14 were classified as recommended guidelines. The domain of "applicability" scored the lowest (44%), while the domains "scope and objective" and "editorial interdependence" received the highest median scores of 93% and 97% respectively. The remaining domains received scores ranging from 44% to 84%. The top mean scored CPG in preoperative fasting was ASA 2017 (93%); among cardiac evaluation, CPG for non-cardiac surgery were CCS 2017 (91%), ESC-ESA 2014 (90%), and AHA-ACC 2014 (89%); in preoperative testing ICSI 2020 (97%).

CONCLUSIONS

In the last ten years, most published CPG in the preoperative assessment or management of adult patients undergoing elective surgery focused on preoperative fasting, cardiac assessment for non-cardiac surgery, and use of routine preoperative tests, present moderate to high methodological quality and can be recommended for their use or adaptation. Applicability and stakeholder involvement domains must be improved in the development of future guidelines.

Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review

Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.

Prediction model for myocardial injury after non-cardiac surgery using machine learning

Myocardial injury after non-cardiac surgery (MINS) is strongly associated with postoperative outcomes. We developed a prediction model for MINS and have provided it online. Between January 2010 and June 2019, a total of 6811 patients underwent non-cardiac surgery with normal preoperative level of cardiac troponin (cTn). We used machine learning techniques with an extreme gradient boosting algorithm to evaluate the effects of variables on MINS development. We generated two prediction models based on the top 12 and 6 variables. MINS was observed in 1499 (22.0%) patients. The top 12 variables in descending order according to the effects on MINS are preoperative cTn level, intraoperative inotropic drug infusion, operation duration, emergency operation, operation type, age, high-risk surgery, body mass index, chronic kidney disease, coronary artery disease, intraoperative red blood cell transfusion, and current alcoholic use. The prediction models are available at https://sjshin.shinyapps.io/mins_occur_prediction/ . The estimated thresholds were 0.47 in 12-variable models and 0.53 in 6-variable models. The areas under the receiver operating characteristic curves are 0.78 (95% confidence interval [CI] 0.77-0.78) and 0.77 (95% CI 0.77-0.78), respectively, with an accuracy of 0.97 for both models. Using machine learning techniques, we demonstrated prediction models for MINS. These models require further verification in other populations.

Effectiveness of Nurse-led Preoperative Assessment for Anesthesia: A Prospective Cohort Study

PURPOSE

This study aimed to evaluate, in low-complexity surgical patients, the effectiveness of preoperative assessment carried out by nurses with formal postgraduate anaesthetic training compared to that carried out by anesthesiologists in terms of cancellations and inadequate surgical preparation.

DESIGN

This experimental research was conducted using a prospective cohort study.

METHODS

One hundred and eighty-three patients were recruited who had undergone low-complexity surgery between May and September 2020. Sixty-nine patients were preoperatively assessed by a nurse with specific 1-year postgraduate university training in anesthesia and 114 by an anesthesiologist. Data collection included a questionnaire to assess patient satisfaction and knowledge acquired from the preoperative assessment.

FINDINGS

Cancellations of surgery were the same in both cohorts (3.8%, 2.6%). The incidence of poor preparation attributable to the patient was also similar in both cohorts (17.0% vs 18.4%). Patients seen by nurses valued the satisfaction with the preoperative assessment more highly than patients seen by anesthesiologists (median 91.67 vs 84.62). In terms of Knowledge obtained from the preoperative assessment, both professionals did not show statistically significant differences in knowledge levels.

CONCLUSIONS

Preoperative patient assessment performed by a nurse, with formal anesthesia training, in low-complexity surgical patients can be as effective as that performed by an anesthesiologist, without having an impact on surgical cancellations or patient preparation. On the day of surgery, patients who had been assessed by a nurse were more satisfied with their care during the visit and acquired similar knowledge about preoperative preparation as patients assessed by anesthesiologists.

Update on preoperative evaluation and optimisation

The patients presenting for surgery today often belong to the extremes of age, have multiple co-morbidities, and undergo complex surgeries. This makes them more prone to morbidity and mortality. A detailed preoperative evaluation of the patient can contribute to reducing this mortality and morbidity. There are various risk indices and validated scoring systems and many of them need to be calculated using preoperative parameters. Their key objective is to identify patients vulnerable to complications and to return them to desirable functional activity as soon as possible. Any individual undergoing surgery should be optimised preoperatively, but special considerations should be given to patients with comorbidity, on multiple drugs, and undergoing high-risk surgery. The objective of this review is to put forth the latest trends in the preoperative evaluation and optimisation of patients undergoing noncardiac surgery and emphasise the importance of risk stratification in these patients.

Perioperative troponin surveillance in major noncardiac surgery: a narrative review

Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.

[Position statement: surgery and diabetes mellitus (Update 2023)]

This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.

Accuracy and Comprehensiveness in Recording Information of a Web-Based Application for Preoperative Assessment: A Prospective Observational Study

PURPOSE

Preanestes@s is a web-based application that includes a smart computer-based self-assessment preoperative questionnaire (PreQuest). Preanestes@s enables remote non-telephonic preoperative assessment via a virtual visit. We aimed to determine if the American Society of Anesthesiologists (ASA) physical status classification assigned by PreQuest and virtual visit is comparable with that assigned by face-to-face assessment, and to determine the accuracy of Preanestes@s in recording complementary preoperative information.

DESIGN

Prospective, observational, paired study.

METHODS

This study was conducted in a tertiary teaching hospital. A total of 510 adult patients scheduled for surgery were consecutively recruited. Of these, 220 patients were included in the analysis of ASA grade agreement.

FINDINGS

PreQuest and virtual visit showed higher predictive value than face-to-face assessment in detecting patients with ASA grades 1 to 2. Face-to-face assessment showed the highest rate of false negatives (ASA 3-4 misclassified as ASA 1-2), with a sensitivity of 44.2% versus 69.8% and 50% for PreQuest and virtual visit, respectively. Virtual visit showed the highest agreement with the ASA grade assigned by a panel of experts (kappa index 0.52, 95% confidence interval 0.15-0.89). PreQuest and virtual visit offered a more comprehensive registry of anthropometric data, more detailed record of chronic diseases condition, and more accurate registry of patients' treatments (virtual visit > PreQuest > face-to-face assessment).

CONCLUSIONS

The combined use of PreQuest and virtual visit offers a better performance in assigning the ASA grade for non-complex patients and a more accurate and detailed record of complementary information. This finding suggests the feasibility of Preanestes@ as a tool for preoperative assessment.

Effect of intraoperative personalized goal-directed hemodynamic management on acute myocardial injury in high-risk patients having major abdominal surgery: a post-hoc secondary analysis of a randomized clinical trial

Acute myocardial injury is common after noncardiac surgery and associated with mortality. Impaired intraoperative cardiovascular dynamics are a risk factor for acute myocardial injury. Optimizing intraoperative cardiovascular dynamics may thus reduce acute myocardial injury. We aimed to investigate the effect of intraoperative personalized goal-directed hemodynamic management on the incidence of acute myocardial injury. We hypothesized that personalized goal-directed hemodynamic management reduces the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. We performed a post-hoc secondary analysis of a randomized clinical trial including 180 high-risk major abdominal surgery patients that were randomized to personalized goal-directed hemodynamic management or routine hemodynamic management. We compared the incidences of acute myocardial injury-defined according to the Fourth Universal Definition of Myocardial Infarction (2018)-between patients randomized to personalized goal-directed hemodynamic management or routine hemodynamic management by calculating the relative and absolute risk reduction together with 95% Wald confidence intervals and P values. Acute myocardial injury occurred in 4 of 90 patients (4%) in the personalized goal-directed hemodynamic management group and in 12 of 90 patients (13%) in the routine hemodynamic management group (relative risk: 0.33, 95% confidence interval: 0.11 to 0.99, P = 0.036; absolute risk reduction: - 9%, 95% confidence interval: - 17% to - 0.68%, P = 0.034). In this post-hoc secondary analysis, intraoperative personalized goal-directed hemodynamic management reduced the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. This needs to be confirmed in larger prospective trials.

Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture

Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.

Severe Intraoperative Hyperglycemia and Infectious Complications After Elective Brain Neurosurgical Procedures: Prospective Observational Study

BACKGROUND

Postoperative infections after brain surgery are a serious complication potentially worsening the outcome of surgical treatment. Severe intraoperative hyperglycemia (SIH) contributes to both infectious and noninfectious postoperative complications. However, there are a lack of data on the incidence of SIH in patients undergoing elective neurosurgical brain procedures and its association with the risk of postoperative infections.

METHODS

A total of 514 patients were prospectively enrolled in this single-center observational cohort clinical study to assess the incidence of SIH (blood glucose concentration [BGC] ≥180 mg/dL) in adult patients undergoing elective brain neurosurgical procedures and its association with postoperative infections. Both nondiabetic and diabetic patients were included in the study. BGC was determined by whole-blood analyses taken at the beginning and at the end of the surgery. Diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection, or central nervous system infection) was established according to US Centers for Disease Control and Prevention (CDC) criteria within the first postoperative week.

RESULTS

SIH was recorded in at least 1 blood sample in 23 patients (4.5%). Infectious complications within the first postoperative week were diagnosed in 40 patients (7.8%). Five of 23 patients (22%) with SIH had postoperative infections, compared with 35 of 491 patients (7%) without SIH (odds ratio [OR] = 3.71; 95% confidence interval [CI], 1.24-11.09; P = .018 after fitting a multiple logistic regression model to adjust for age, body mass index [BMI], and surgery duration). Intraoperative BGC >140 mg/dL was also associated with an increased risk of postoperative infections (OR = 3.10; 95% CI, 1.43-6.75; P = .004). Elevated preoperative glycated hemoglobin (HbA1c) concentration was also associated with postoperative infections in the study population (OR = 2.4; 95% CI, 1.02-6.00; P = .045). Age, BMI, American Society of Anesthesiologists (ASA) physical status, type of surgery, and duration of intervention had no significant association with the postoperative infection rate.

CONCLUSIONS

SIH is associated with a higher risk of infections within the first postoperative week in patients undergoing elective brain neurosurgical procedures. Preoperative HbA1c is a reliable marker of the potential risk both of SIH and postoperative infections in the selected cohort. Future studies need to assess possible improvements in outcome under more precise monitoring and tighter control of perioperative hyperglycemia.

N-terminal Pro-B-Type Natriuretic Peptide is a Myocardial Biomarker in Pulmonary Sepsis and Septic Shock

The objective: to study changes and prognostic significance of the blood NT-proBNP in the patients with pulmonary sepsis.

Subjects and Methods. The study included 34 patients aged 54.5 ± 2.9 years with pulmonary sepsis or septic shock. Lethality in the intensive care unit (ICU) was 47.1%. NT-proBNP, procalcitonin (PCT) levels, blood lactate and hemodynamic parameters were registered on the 1st day (stage 1) and on the 4th-5th day of the ICU stay (stage 2). Hemodynamics was assessed through transpulmonary thermodilution. The differences were considered statistically significant at p < 0.05.

Results: At stage 1, NT-proBNP level was 5,220 [1,380‒17,850] pg/ml, did not decrease (p = 0.726) at stage 2 and amounted to 1,760 [631‒847] pg/ml. At stage 1, NT-proBNP correlated with extravascular lung water index (rho = 0.445; p = 0.038) and systolic pulmonary artery pressure (rho = 0.414; p = 0.023). At stage 2, NT-proBNP correlated with PCT (rho = 0.569; p = 0.003), blood lactate (rho = 0.525; p = 0.001), and mean arterial pressure to norepinephrine dosage ratio (rho = -0.422; p = 0.035). At stage 1, NT-proBNP was no predictor of lethality in the ICU: OR 1.0000; 95% CI 1.0000-1.0001. At stage 2, NT-proBNP > 4,260 pg/ml (sensitivity 87.5%, specificity 94.4%) was a predictor of lethality: OR 1.0004, 95% CI 1.0000-1.0008, p = 0.046 (AUC 0.893, 95% CI 0.732-0.974). Any increase of NT-proBNP level (> 0 pg/ml) between stages 2 and 1 was a predictor of lethality (sensitivity 87.5%, specificity 94.4%): OR 119.0, 95% CI 9.7432‒1,453.4241, p = 0.0002 (AUC 0.903, 95% CI 0.751-0.977).

Conclusion: Patients with pulmonary sepsis are characterized by a significant increase of blood NT-proBNP. At stage 1, the biomarker correlated with pulmonary hypertension and moderate pulmonary edema and was no predictor of lethality. At stage 2, NT-proBNP correlated with the indices of infection and sepsis severity (procalcitonin, blood lactate, and mean arterial blood pressure/norepinephrine dosage ratio). At this stage, NT-proBNP levels greater than 4,000 pg/mL and/or any degree of increase in blood levels of the biomarker were both sensitive and specific predictors of a lethal outcome. Specific features of etiopathogenesis of BNP hyperproduction in pulmonary sepsis make it difficult to interpret the elevation of NT-proBNP as an indicator of septic cardiomyopathy but does not reduce its value as a sensitive and specific predictor of lethality.

The value of multiparameter combinations for predicting difficult airways by ultrasound

Background

Based on the upper airway anatomy and joint function parameters examined by ultrasound, a multiparameter ultrasound model for difficult airway assessment (ultrasound model) was established, and we evaluated its ability to predict difficult airways.

Methods

A prospective case-cohort study of difficult airway prediction in adult patients undergoing elective surgery with endotracheal intubation under general anesthesia, and ultrasound phantom examination for difficult airway assessment before anesthesia, including hyomental distance, tongue thickness, mandibular condylar mobility, mouth opening, thyromental distance, and modified Mallampati tests, was performed. Receiver operating characteristic (ROC) curve analysis was used to evaluate the effectiveness of the ultrasound model and conventional airway assessment methods in predicting difficult airways.

Results

We successfully enrolled 1000 patients, including 51 with difficult laryngoscopy (DL) and 26 with difficult tracheal intubation (DTI). The area under the ROC curve (AUC) for the ultrasound model to predict DL was 0.84 (95% confidence interval [CI]: 0.82–0.87), and the sensitivity and specificity were 0.75 (95% CI: 0.60–0.86) and 0.82 (95% CI: 0.79–0.84), respectively. The AUC for predicting DTI was 0.89 (95% CI: 0.87–0.91), and the sensitivity and specificity were 0.85 (95% CI: 0.65–0.96) and 0.81 (95% CI: 0.78–0.83), respectively. Compared with mouth opening, thyromental distance, and modified Mallampati tests, the ultrasound model predicted a greater AUC for DL (P < 0.05). Compared with mouth opening and modified Mallampati tests, the ultrasound model predicted a greater AUC for DTI (P < 0.05).

Conclusions

The ultrasound model has good predictive performance for difficult airways.

Trial registration

This study is registered on chictr.org.cn (ChiCTR-ROC-17013258); principal investigator: Jianling Xu; registration date: 06/11/2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01840-0.

The influence of preoperative anxiety on postoperative pain in patients undergoing cardiac surgery

Patients undergoing cardiac surgery represent a challenge in terms of pain management due to multiple factors relating to the patients and to the procedure itself. Our aim was to identify the influence of levels of preoperative anxiety on postoperative pain in patients undergoing cardiac surgery and explore associations between preoperative anxiety, postoperative pain, analgesic requirements, and sex. We present a prospective cohort study of 116 patients undergoing cardiac surgery between January and April 2020. Preoperative anxiety was evaluated using the State-Trait Anxiety Inventory and the amount of morphine needed to keep pain intensity below 4 on the verbal numerical rating scale was recorded for 48 h post-surgery. Given the extracorporeal circulation time, type of surgery and body surface, it was observed that every percentile increase in preoperative state anxiety led to an extra 0.068 mg of morphine being administered. For each extra year of age, the amount of morphine needed decreased by 0.26 mg, no difference was observed between men and women in terms of preoperative anxiety or postoperative analgesics requirements. It may be concluded that in cardiac surgery, postoperative analgesic requirements increased with higher levels of preoperative state anxiety and decreased for every extra year of age.

Autonomous patient consent for anaesthesia without preoperative consultation: a qualitative feasibility study including low-risk procedures

Background

Informed consent for anaesthesia is mandatory and requires provision of information and subsequent consent during consultation between anaesthesiologist and patient. Although information can be provided in an electronic format, it is unknown whether this a valid substitute for a consultation. We explored whether provision of digital information is equivalent to oral consultation and whether it enables patients to give electronic informed consent (e-consent) for anaesthesia.

Methods

Qualitative feasibility study using semi-structured interviews in 20 low-risk adults scheduled for minor surgery under general anaesthesia or procedural sedation at a university hospital. Data were analysed using a thematic content analysis approach. During the interviews, patients followed an application that provides information and subsequent e-consenting.

Results

The mean age was 50 yr and patients had good digital skills. Fifteen patients (75%) had previous experience of anaesthesia. The digital application provided enough information for all patients, but eight (40%) preferred consultation with an anaesthesiologist, mainly for personal contact. Patients had different information needs, with previous experiences leading to lower information needs. Nineteen patients had sufficient information to consent autonomously. Most patients considered separate anaesthesia consent superfluous to the surgical consent.

Conclusion

The digital application provided sufficient information and patients valued the information offered and the advantage of processing information at their own pace. This information made patients feel empowered to autonomously consent to anaesthesia without consultation. Remarkably, consent for anaesthesia was considered unimportant, because patients felt they had 'no choice' if they wanted to undergo surgery.

Time to Surgery for Patients with Esophageal Cancer Undergoing Trimodal Therapy in Ontario: A Population-Based Cross-Sectional Study

Patients with resectable esophageal cancer are recommended to undergo chemoradiotherapy before esophagectomy. A longer time to surgery (TTS) and/or time to consultation (TTC) may be associated with inferior cancer-related outcomes and heightened anxiety. Thoracic cancer surgery centers (TCSCs) oversee esophageal cancer management, but differences in TTC/TTS between centers have not yet been examined. This Ontario population-level study used linked administrative healthcare databases to investigate patients with esophageal cancer between 2013–2018, who underwent neoadjuvant chemoradiotherapy and then surgery. TTC and TTS were time from diagnosis to the first surgical consultation and then to surgery, respectively. Patients were assigned a TCSC based on the location of the surgery. Patient, disease, and diagnosing physician characteristics were investigated. Quantile regression was used to model TTS/TTC at the 50th and 90th percentiles and identify associated factors. The median TTS and TTC were 130 and 29 days, respectively. The adjusted differences between the TCSCs with the longest and shortest median TTS and TTC were 32 and 18 days, respectively. Increasing age was associated with a 16-day longer median TTS. Increasing material deprivation was associated with a 6-day longer median TTC. Significant geographic variability exists in TTS and TTC. Therefore, the investigation of TCSC characteristics is warranted. Shortening wait times may reduce patient anxiety and improve the control of esophageal cancer.

Association of PeriOPerative Aspirin-ResisTance and CardioVascular Outcome (POPART- CVO) - a prospective non-interventional cohort study

OBJECTIVES

New onset of aspirin-resistance during surgery, known as perioperative aspirin-resistance, is observed in up to 30% of vascular surgery patients and is associated with post-OP myocardial damage; questioning aspirin effectiveness towards perioperative cardiovascular events. The objective of this study was to prospectively evaluate whether perioperative aspirin-resistance in vascular surgery is associated with adverse cardiovascular outcome.

DESIGN AND METHODS

Based on a sample size calculation, 194 adult elective vascular or endovascular surgery patients receiving aspirin were analyzed in this prospective, single-centered, non-interventional cohort study. Platelet function was measured before surgery, one hour after incision, four hours postoperatively, and on the morning of the first and second postoperative days using the Multiplate® analyzer. The primary outcome was Myocardial Injury after Non-Cardiac Surgery (MINS). Secondary outcomes included major bleeding, admission to intensive care unit, length of hospital stay, and Major Adverse Cardiac and Cerebrovascular Events. Subgroup analyses were performed for patients with different cardiovascular risk and for patients who underwent endovascular surgery.

RESULTS

Perioperative aspirin-resistance was observed in 27.8% of patients but was not associated with MINS (27.8% vs. 32.1%, aspirin-resistance vs. no aspirin-resistance, OR 0.812, 95% CI [0.406;1.624], p=.555) or with any of the secondary endpoints (all p>.05). In nine of the ten subgroup analyses, aspirin-resistance was not associated with a difference in MINS rate. However, in patients with a low cardiovascular risk profile (RCRI 0-2), MINS occurred more frequently in patients without aspirin-resistance (p=.049).

CONCLUSIONS

We confirmed previous reports demonstrating that perioperative aspirin-resistance is frequent in patients undergoing vascular or endovascular surgery. However, in patients who continue aspirin throughout the perioperative period, aspirin-resistance is a phenomenon, that does not appear to be related to MINS. Measuring perioperative platelet function using the Multiplate® analyzer with the intention to identify and potentially prevent or treat perioperative aspirin-resistance seems to be dispensable.

Development and patient acceptance of Preanestes@s, a web-based application and electronic questionnaire for preoperative assessment. A prospective cohort study

BACKGROUND AND OBJECTIVES

We describe the development of Preanestes@s, a web-based application for preoperative assessment, which incorporates PreQuest, a smart computer-based self-assessment questionnaire for the automated management of information. Preanestes@s potentially enables remote non-telephonic preoperative assessment. The main objective of this work was the identification of factors that independently predict adequate completion of PreQuest. As a secondary objective, we assessed patient experience using the application.

MATERIAL AND METHODS

To assess the influence of patient conditions on PreQuest completion, our sample included 880 adult patients scheduled to undergo surgery at our institution between February 2020 and February 2021. We evaluated patient satisfaction and acceptability with the use of the application and PreQuest.

RESULTS

A total of 573 participants (65.1%) successfully completed the PreQuest. Age below 65 years and higher educational attainment were identified as independent predictors for PreQuest completion (p = 0.04 and p = 0.001, respectively). Most (89.4%) participants agreed that Preanestes@s was intuitive and easy to use, with over 85% showing high levels of acceptance of PreQuest prototype's communication improvement and ease of use. The final version of Preanestes@s and PreQuest was evaluated by 218 participants, many of whom (>74%) affirmed its ease of use.

CONCLUSIONS

The use of Preanestes@s for preoperative assessment is supported by high levels of satisfaction with the prototype and by an eQuest completion rate greater than 65% in a non-selective population. In our sample, younger age and higher education attainment predicted higher rates PreQuest completion. Trial registration number NCT04259268.

Cross-cultural adaptation and validation of the STOP-bang Questionnaire from English to Spanish as a tool for the early detection of sleep apnea syndrome in the surgical patient and in the general population

INTRODUCTION

Obstructive Sleep Apnea Syndrome (OSAS) or Apnea-Hypoapnea Syndrome (SAHS) is one of the most prevalent sleep disorders in the general population. It is associated with an increase in the prevalence of difficult orotracheal intubation and postoperative complications. The application of validated early detection tests, such the STOPbang test in English (STBC), is recommended; a test of high methodological quality, sensitivity and specificity in the early detection of SAHS in both surgical and general populations.

OBJECTIVE

The validation, translation, cross-cultural adaptation of the STBC to the Spanish population.

MATERIAL AND METHODS

The transcultural adaptation of the STBC to Spanish was carried out and a subsequent validation study with 77 consecutive patients was carried out. The statistical analysis evaluated the reliability, validity and feasibility of the translated and culturally adapted version.

RESULTS

44% of women and 56% of men were included, with a mean age of 53.58 ± 12.88 years. The reliability results were: a Cronbach's Alpha Coefficient of 0.767, a Pearson correlation r = 0.777 (P < .001) and a Sperman correlation rho = 0.455 (P = .044). The feasibility of the study was 100%. Criterion validity was evaluated using the Kappa coefficient, which was 0.444. For a score >3 of the questionnaire adapted to Spanish, the results of sensitivity, specificity according to the different cut-off levels of the apnea hypopnea index (AHI) >5, >15, >30) were: Sensitivity 87%, 91% and 100% respectively and Specificity of 50%, 31% and 22%.

CONCLUSIONS

The STBC questionnaire translated, adapted and validated into Spanish, evaluated in the present study, is reliable and valid with respect to the original design of the questionnaire. It is a useful tool that is easy to understand and implement, which can be used rigorously to stratify surgical risk and carry out adequate perioperative planning of those patients at risk of SAHS.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

Effectiveness of pre-anaesthetic assessment clinic: a systematic review of randomised and non-randomised prospective controlled studies

OBJECTIVES

The aim of this systematic review was to examine the effectiveness of pre-anaesthesia assessment clinics (PACs) in improving the quality and safety of perioperative patient care.

DESIGN

Systematic review.

DATA SOURCES

The electronic databases CINAHL Plus with Full Text (EBSCOhost), Medline and Embase (OvidSP) were systematically searched on 11 September 2018 and updated on 3 February 2020 and 4 February 2021.

ELIGIBILITY CRITERIA

The inclusion criteria for this study were studies published in English or Scandinavian language and scientific original research that included randomised or non-randomised prospective controlled studies. Additionally, studies that reported the outcomes from a PAC consultation with the patient present were included.

DATA EXTRACTION AND SYNTHESIS

Titles, abstracts and full texts were screened by a team of three authors. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies. Data extraction was performed by one author and checked by four other authors. Results were synthesised narratively owing to the heterogeneity of the included studies.

RESULTS

Seven prospective controlled studies on the effectiveness of PACs were included. Three studies reported a significant reduction in the length of hospital stay and two studies reported a significant reduction in cancellation of surgery for medical reasons when patients were seen in the PAC. In addition, the included studies presented mixed results regarding anxiety in patients. Most studies had a high risk of bias.

CONCLUSION

This systematic review demonstrated a reduction in the length of hospital stay and cancellation of surgery when the patients had been assessed in the PAC. There is a need for high-quality prospective studies to gain a deeper understanding of the effectiveness of PACs.

PROSPERO REGISTRATION NUMBER

CRD42019137724.

Bedeutung von Glukosewerten im Krankenhaus

Hintergrund

Eine Hyperglykämie bei Menschen mit und ohne Diabetes, die ins Krankenhaus eingeliefert werden, ist mit einem erheblichen Anstieg von Morbidität, Mortalität und Gesundheitskosten verbunden. Während eines Krankenhausaufenthaltes treten Stoffwechseldekompensationen häufig als Folge unterschiedlicher Ereignisse oder Zusatztherapien auf. Aufgrund des erhöhten Risikos für eine Zunahme der Morbidität, verbunden mit längerem Krankenhausaufenthalt sowie höheren Kosten und Mortalität, erscheint eine genaue Betrachtung der Bedeutung von Glukosewerten und der Therapieformen im Krankenhaus sinnvoll und angebracht.

Material und Methode

Aktuelle Befunde, Übersichtsarbeiten und Grundlagendaten wurden analysiert und in einer kurzen Übersicht zusammengefasst und diskutiert.

Fazit

Eine persistierende Hyperglykämie im Krankenhaus ist häufig und oft mit unzureichenden Ergebnissen des Krankenhausaufenthaltes verbunden. Die kontinuierliche Insulininfusion bleibt die Therapie der Wahl während hyperglykämischer Krisen und kritischen Erkrankungen. Auch bei nicht kritisch kranken Menschen mit ausgeprägter Hyperglykämie, schon ambulant bekannten hohen Insulindosen, mit Typ-1-Diabetes oder mit steroidinduzierter Hyperglykämie bleibt Insulin das Mittel der Wahl.

Association between benzodiazepine premedication and 30-day mortality rate: A propensity-score weighted analysis of the Peri-interventional Outcome Study in the Elderly (POSE)

BACKGROUND

Recent guidelines suggest that benzodiazepine premedication should be avoided in elderly patients, though with limited supporting evidence.

OBJECTIVE

We conducted a secondary analysis of the POSE data to explore the association of premedication in patients aged 80 years or older with 30-day mortality.

DESIGN

We used propensity score methods to perform a confounder-adjusted time-to-event analysis of the association between benzodiazepine premedication and 30-day mortality of the POSE study.

SETTING

POSE was conducted as a European multicentre prospective cohort study.

PATIENTS

Adults aged 80 years or older scheduled for surgical or nonsurgical intervention under anaesthesia.

RESULTS

A total of 9497 patients were analysed. One thousand five hundred and twenty-one patients received benzodiazepine premedication, 7936 patients received no benzodiazepine premedication, 30 received clonidine and 10 had missing premedication data. Inverse propensity-score-weighted log-rank analysis did not provide unambiguous evidence for an association between benzodiazepine premedication and 30-day mortality; median [range] P = 0.048 [0.044 to 0.078], estimated 30-day mortality rates 3.21% and 4.45% in benzodiazepine-premedicated and nonbenzodiazepine-premedicated patients, respectively. Inverse propensity-score-weighted Cox regression resulted in a hazard ratio of 0.71 (95% CI 0.49 to 1.04), pointing at a possible reduction of 30-day mortality in the benzodiazepine premedication group. Sensitivity analyses, which constituted subgroup, matched-pairs, and subclassification analyses, resulted in similar findings.

CONCLUSION

This secondary analysis of the POSE data did not find evidence for an unambiguous association between benzodiazepine premedication and 30-day mortality. Point estimates indicated a reduction of 30-day mortality in benzodiazepine-premedicated patients. The results presented here might be affected by unmeasured confounding factors, which could be addressed in a randomised trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03152734.

Tranexamic acid in total shoulder arthroplasty under regional anesthesia: a randomized, single blinded, controlled trial

PURPOSE

The purpose of this study was to determine whether Tranexamic Acid (TXA) can significantly reduce perioperative blood loss in Total Shoulder Arthroplasty (TSA) performed under regional anesthesia.

METHODS

We performed a randomized, single blinded, controlled study. Forty-five patients were submitted to TSA under regional anesthesia to treat cuff tear arthropathy, proximal humeral fractures, chronic instability, primary osteoarthrosis, and failures of previous prosthesis. Patients were randomized to either group TXA therapy (TXA), with 1 g intravenous (IV), or no Intervention (NTXA). Postoperative total drain output, hemoglobin variation, total blood loss, hemoglobin loss, and need for transfusion were measured. Pain-related variables were also assessed: postoperative pain assessment by visual analog scale, inpatient pain breakthrough, quality of recovery, length of stay, and coagulation function testing.

RESULTS

Participants presented a mean age of 76 years, 15.6% were male, 82.2% were American Society of Anesthesiologists (ASA) physical status I or II. There were no differences between groups concerning transfusions, operative time, Post-Anesthesia Care Unit (PACU) length of stay and in-hospital stay, and QoR-15 or postoperative pain. Bleeding measured by drain output at 2, 24 and 48 hours was significantly less in the TXA group at each timepoint. There was a difference in Hb variation - TXA: median (IQR) -1.4 (1.3) g.dL^-1 vs. NTXA: -2.2 (1.3) g.dL^-1; median difference: 0.80 (0.00-1.20); p = 0.047. aPTT was lower in TXA administered patients - TXA: median (IQR) 29.6 (14.0)s vs. NTXA: 33 (5.8)s; difference in medians: -4.00 (-6.50--1.00); p = 0.012.

CONCLUSION

TXA use significantly decreased blood loss measured by drain output and Hb drop in TSA under regional anesthesia.

Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

Peri-interventional outcome study in the elderly in Europe: A 30-day prospective cohort study

OBJECTIVES

The aim of this study was to describe the 30-day mortality rate of patients aged 80 years and older undergoing surgical and nonsurgical procedures under anaesthesia in Europe and to identify risk factors associated with mortality.

DESIGN

A prospective cohort study.

SETTING

European multicentre study, performed from October 2017 to December 2018. Centres committed to a 30-day recruitment period within the study period.

PATIENTS

Nine thousand four hundred and ninety-seven consecutively recruited patients aged 80 years and older undergoing any kind of surgical or nonsurgical procedures under anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was all-cause mortality within 30 days after procedure described by Kaplan-Meier curves with 95% CI. Risk factors for 30-day mortality were analysed using a Cox regression model with 14 fixed effects and a random centre effect.

RESULTS

Data for 9497 patients (median age, 83.0 years; 52.8% women) from 177 academic and nonacademic hospitals in 20 countries were analysed. Patients presented with multimorbidity (77%), frailty (14%) and at least partial functional dependence (38%). The estimated 30-day mortality rate was 4.2% (95% CI 3.8 to 4.7). Among others, independent risk factors for 30-day mortality were multimorbidity, hazard ratio 1.87 (95% CI 1.26 to 2.78), frailty, hazard ratio 2.63 (95% CI 2.10 to 3.30), and limited mobility, hazard ratio 2.19 (95% CI 1.24 to 3.86). The majority of deaths (76%) occurred in hospital. Mortality risk for unplanned ICU admission was higher, hazard ratio 3.57 (95% CI 2.38 to 5.26) than for planned ICU admission, hazard ratio 1.92 (95% CI 1.47 to 2.50). Compared with other studies, the in-hospital complication rates of 17.4 and 3.9% after discharge were low. Admission to a unit with geriatric care within 30 days after the intervention was associated with a better survival within the first 10 days.

CONCLUSIONS

The estimated 30-day mortality rate of 4.2% was lower than expected in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03152734, https://clinicaltrials.gov.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in non-thoracic surgery.

METHODS

We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy).

RESULTS

46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry).

CONCLUSION

As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before non-thoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.