The Association of Socio-Environmental Inequality and Outcomes Among Patients Undergoing Major Surgery.

INTRODUCTION: Environmental hazards may influence health outcomes and be a driver of health inequalities. We sought to characterize the extent to which social-environmental inequalities were associated with surgical outcomes following a complex operation. METHODS: In this cross-sectional study, patients who underwent abdominal aortic aneurysm repair, coronary artery bypass grafting, colectomy, pneumonectomy, or pancreatectomy between 2016 and 2021 were identified from Medicare claims data. Patient data were linked with social-environmental data sourced from Centers for Disease Control and Agency for Toxic Substances and Disease Registry data based on county of residence. The Environmental Justice Index social-environmental ranking (SER) was used as a measure of environmental injustice. Multivariable regression analysis was performed to assess the relationship between SER and surgical outcomes. RESULTS: Among 1,052,040 Medicare beneficiaries, 346,410 (32.9%) individuals lived in counties with low SER, while 357,564 (33.9%) lived in counties with high SER. Patients experiencing greater social-environmental injustice were less likely to achieve textbook outcome (odds ratio 0.95, 95% confidence interval 0.94-0.96, P < 0.001) and to be discharged to an intermediate care facility or home with a health agency (odds ratio 0.97, 95% confidence interval 0.96-0.98, P < 0.001). CONCLUSIONS: Cumulative social and environmental inequalities, as captured by the Environmental Justice Index SER, were associated with postoperative outcomes among Medicare beneficiaries undergoing a range of surgical procedures. Policy makers should focus on environmental, as well as socioeconomic injustice to address preventable health disparities.

Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review.

BACKGROUND: Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS: A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS: From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS: This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022369944).

Outcomes associated with postoperative cognitive dysfunction: a systematic review and meta-analysis.

BACKGROUND: Postoperative cognitive dysfunction (POCD) manifests as a subtle decline in cognition, potentially leading to unfavourable postoperative outcomes. We explored the impact of POCD on physical function, length of hospital stay (LOS), dementia and mortality outcomes. METHODS: PubMed and Scopus were searched until May 2023. All studies of major surgical patients that assessed POCD and outcomes of interest were included. POCD effects were stratified by surgery type (cardiac and noncardiac) and time of POCD assessment (<30 and ≥30 days postsurgery). RESULTS: Of 2316 studies, 20 met the inclusion criteria. POCD was not associated with functional decline postsurgery. Patients who experienced POCD postcardiac surgery had an increased relative risk (RR) of death of 2.04 [(95% CI: 1.18, 3.50); I2 = 0.00%]. Sensitivity analyses showed associations with intermediate-term mortality among noncardiac surgical patients, with an RR of 1.84 [(95% CI: 1.26, 2.71); I2 = 0.00%]. Patients who developed POCD <30 days postcardiac and noncardiac surgeries experienced longer LOS than those who did not [mean difference (MD) = 1.37 days (95% CI: 0.35, 2.39); I2 = 92.38% and MD = 1.94 days (95% CI: 0.48, 3.40); I2 = 83.29%, respectively]. Postoperative delirium (POD) may contribute to the heterogeneity observed, but limited data were reported within the studies included. CONCLUSIONS: Patients undergoing cardiac and noncardiac surgeries who developed POCD <30 days postsurgery had poorer outcomes and an increased risk of premature death. Early recognition of perioperative neurocognitive disorders in at-risk patients may enable early intervention. However, POD may confound our findings, with further studies necessary to disentangle the effects of POD from POCD on clinical outcomes.

Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery.

BACKGROUND: We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS: A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS: Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION: Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.

Serum creatinine is an unreliable marker of renal function in patients undergoing heart transplantation.

BACKGROUND: Renal dysfunction is a common complication after heart transplantation (Htx). Glomerular filtration rate (GFR) can be assessed by various estimating equations (eGFR). We evaluated the correlation, agreement, and accuracy between eGFR and mGFR and the ability of eGFR to track changes in mGFR early after Htx. METHODS: A single-center prospective observational study on 55 patients undergoing Htx. Serum creatinine and mGFR (plasma clearance of Cr51-EDTA or iohexol) were measured preoperatively and on the fourth postoperative day. The accuracy of eGFR to predict true mGFR was calculated as the percentage of patients with an eGFR within 30% of mGFR (P30). The agreement between eGFR and mGFR was assessed according to Bland and Altman. A four-quadrant plot was made to evaluate the ability of eGFR to track changes in mGFR. RESULTS: The accuracy of eGFR to assess mGFR was 52%. The bias was 11.2 ± 17.4 mL/min/1.72 m2. The limits of agreement were -23.0 to 45.4 mL/min/1.72 m2 and the error 58%. The concordance rate between eGFR and mGFR was 72%. CONCLUSIONS: eGFR underestimated mGFR and the agreement between eGFR and mGFR was low with an unacceptably large between-group error and low accuracy. Furthermore, the ability of eGFR to assess changes in mGFR, postoperatively, was poor. Thus, the use of estimating equations from serum creatinine will not adequately assess renal function early after major heart surgery. To gain adequate information on renal function early after Htx, GFR needs to be measured, not estimated.

Prevalence of relevant early complications during the first 24 h on a normal ward in patients following PACU care after medium and major surgery: a monocentric retrospective observational study.

PURPOSE: Even today, it remains a challenge for healthcare professionals to decide whether a clinically stable patient who is recovering from uncomplicated medium or major surgery would benefit from a postoperative intensive care unit (ICU) admission, or whether they would be at least as adequately cared for by a few hours of monitoring in the post-operative care unit (PACU). METHODS: In this monocentric retrospective observational study, all adult patients who (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) in Anästh Intensivmed (50):S486-S489, 2009) underwent medium or major surgery between 1 January 1 2014 and 31 December 2018 at the Heidelberg University Surgical Center, and (Vimlati et al. in Eur J Anaesthesiol September 26(9):715-721, 2009) were monitored for 1-12 h in the PACU, and then (De Pietri et al. in World J Gastroenterol 20(9):2304-23207, 2014) transferred to a normal ward (NW) immediately thereafter were included. At the end of the PACU stay, each patient was cleared by both a surgeon and an anesthesiologist to be transferred to a NW. The first objective of this study was to determine the prevalence of relevant early complications (RECs) within the first 24 h on a normal ward. The secondary objective was to determine the prevalence of RECs in the subgroup of included patients who underwent partial pancreaticoduodenectomy. RESULTS: A total of 10,273 patients were included in this study. The prevalence of RECs was 0.50% (confidence interval [CI] 0.40-0.60%), with the median length of stay in the PACU before the patient's first transfer to a NW being 285 min (interquartile range 210-360 min). In the subgroup of patients who underwent partial pancreaticoduodenectomy (n = 740), REC prevalence was 1.1% (CI = 0.55-2.12%). CONCLUSION: Based on a medical case-by-case assessment, it is possible to select patients who after a PACU stay of only up to 12 h have a low risk of emergency readmission to an ICU within the 24 h following the transfer to the NW. Continued research will be needed to further improve transfer decisions in such low-risk subgroups.

Systematic development and validation of a predictive model for major postoperative complications in the Peri-operative Quality Improvement Project (PQIP) dataset.

Complications are common following major surgery and are associated with increased use of healthcare resources, disability and mortality. Continued reliance on mortality estimates risks harming patients and health systems, but existing tools for predicting complications are unwieldy and inaccurate. We aimed to systematically construct an accurate pre-operative model for predicting major postoperative complications; compare its performance against existing tools; and identify sources of inaccuracy in predictive models more generally. Complete patient records from the UK Peri-operative Quality Improvement Programme dataset were analysed. Major complications were defined as Clavien-Dindo grade ≥ 2 for novel models. In a 75% train:25% test split cohort, we developed a pipeline of increasingly complex models, prioritising pre-operative predictors using Least Absolute Shrinkage and Selection Operators (LASSO). We defined the best model in the training cohort by the lowest Akaike's information criterion, balancing accuracy and simplicity. Of the 24,983 included cases, 6389 (25.6%) patients developed major complications. Potentially modifiable risk factors (pain, reduced mobility and smoking) were retained. The best-performing model was highly complex, specifying individual hospital complication rates and 11 patient covariates. This novel model showed substantially superior performance over generic and specific prediction models and scores. We have developed a novel complications model with good internal accuracy, re-prioritised predictor variables and identified hospital-level variation as an important, but overlooked, source of inaccuracy in existing tools. The complexity of the best-performing model does, however, highlight the need for a step-change in clinical risk prediction to automate the delivery of informative risk estimates in clinical systems.

Association between preoperative proton pump inhibitor use and postoperative acute kidney injury in patients undergoing major surgery.

BACKGROUND: Acute kidney injury (AKI) is a severe postoperative complication in patients undergoing major surgery. Proton pump inhibitors (PPIs) are used preoperatively as prophylaxis for postoperative gastrointestinal bleeding. Whether preoperative PPI use is associated with an increased risk of postoperative AKI remains uncertain. METHODS: This retrospective cohort study used electronic medical records from the clinical data warehouse of Peking University First Hospital to screen all adult hospitalizations undergoing major surgery between 1 January 2018 and 31 December 2020. Exposure was preoperative PPI use, defined as PPI use within 7 days before major surgery. The primary outcome was postoperative AKI, defined as AKI occurring within 7 days after major surgery; secondary outcomes included in-hospital AKI and in-hospital mortality. RESULTS: A total of 21,533 patients were included in the study (mean [SD] age, 57.8 [15.0] years; 51.2% male), of which 944 (4.4%) were prescribed PPI within 7 days before major surgery (PPI users). Overall, 72 PPI users (7.6%) and 356 non-users (1.7%) developed postoperative AKI. After adjustment, preoperative PPI use was associated with an increased risk of postoperative AKI (adjusted OR, 1.47; 95% CI, 1.04-2.07) and in-hospital AKI (adjusted OR, 1.41; 95% CI, 1.03-1.94). Moreover, subgroup analyses showed that the risk of PPI on postoperative AKI was amplified by the concomitant use of non-steroidal anti-inflammatory drugs or diuretics. No significant difference was observed between preoperative PPI use and in-hospital mortality in the fully adjusted model (adjusted OR 1.63; 95% CI, 0.55-4.85). CONCLUSIONS: Preoperative PPI use was associated with an increased risk of AKI in patients undergoing major surgery. This risk may be enhanced by the concomitant use of other nephrotoxic drugs. Clinicians should weigh the pros and cons before initiating PPI prophylaxis.

Agreement of zero-heat-flux thermometry with the oesophageal and tympanic core temperature measurement in patient receiving major surgery.

To identify and prevent perioperative hypothermia, most surgical patients require a non-invasive, accurate, convenient, and continuous core temperature method, especially for patients undergoing major surgery. This study validated the precision and accuracy of a cutaneous zero-heat-flux thermometer and its performance in detecting intraoperative hypothermia. Adults undergoing major non-cardiac surgeries with general anaesthesia were enrolled in the study. Core temperatures were measured with a zero-heat-flux thermometer, infrared tympanic membrane thermometer, and oesophagal monitoring at 15-minute intervals. Taking the average value of temperature measured in the tympanic membrane and oesophagus as a reference, we assessed the agreement using the Bland-Altman analysis and linear regression methods. Sensitivity, specificity, and predictive values of detecting hypothermia were estimated. 103 patients and one thousand sixty-eight sets of paired temperatures were analyzed. The mean difference between zero-heat-flux and the referenced measurements was -0.03 ± 0.25 °C, with 95% limits of agreement (-0.52 °C, 0.47 °C) was narrow, with 94.5% of the differences within 0.5 °C. Lin's concordance correlation coefficient was 0.90 (95%CI 0.89-0.92). The zero-heat-flux thermometry detected hypothermia with a sensitivity of 82% and a specificity of 90%. The zero-heat-flux thermometer is in good agreement with the reference core temperature based on tympanic and oesophagal temperature monitoring in patients undergoing major surgeries, and appears high performance in detecting hypothermia.

Prognostic value of heart rate variability for risk of serious adverse events in continuously monitored hospital patients.

Technological advances allow continuous vital sign monitoring at the general ward, but traditional vital signs alone may not predict serious adverse events (SAE). This study investigated continuous heart rate variability (HRV) monitoring's predictive value for SAEs in acute medical and major surgical patients. Data was collected from four prospective observational studies and two randomized controlled trials using a single-lead ECG. The primary outcome was any SAE, secondary outcomes included all-cause mortality and specific non-fatal SAE groups, all within 30 days. Subgroup analyses of medical and surgical patients were performed. The primary analysis compared the last 24 h preceding an SAE with the last 24 h of measurements in patients without an SAE. The area under a receiver operating characteristics curve (AUROC) quantified predictive performance, interpretated as low prognostic ability (0.5-0.7), moderate prognostic ability (0.7-0.9), or high prognostic ability (> 0.9). Of 1402 assessed patients, 923 were analysed, with 297 (32%) experiencing at least one SAE. The best performing threshold had an AUROC of 0.67 (95% confidence interval (CI) 0.63-0.71) for predicting cardiovascular SAEs. In the surgical subgroup, the best performing threshold had an AUROC of 0.70 (95% CI 0.60-0.81) for neurologic SAE prediction. In the medical subgroup, thresholds for all-cause mortality, cardiovascular, infectious, and neurologic SAEs had moderate prognostic ability, and the best performing threshold had an AUROC of 0.85 (95% CI 0.76-0.95) for predicting neurologic SAEs. Predicting SAEs based on the accumulated time below thresholds for individual continuously measured HRV parameters demonstrated overall low prognostic ability in high-risk hospitalized patients. Certain HRV thresholds had moderate prognostic ability for prediction of specific SAEs in the medical subgroup.

Management of edoxaban therapy and clinical outcomes in patients undergoing major or nonmajor surgery: a subanalysis of the EMIT-AF/VTE study.

BACKGROUND: Optimising periprocedural management of direct oral anticoagulation in patients with atrial fibrillation on chronic treatment undergoing major surgeries is an important aspect of balancing the risk of surgery-related bleeding with the risk of thromboembolic events, which may vary by surgery type. METHODS: This subanalysis of the prospective EMIT-AF/VTE programme assessed periprocedural-edoxaban management, according to physicians' decisions, and bleeding and thromboembolic event rates in patients who underwent major vs. nonmajor surgeries. Edoxaban interruption and clinical outcomes were compared between major vs. nonmajor surgeries and between renal function subgroups (creatinine clearance [CrCL] ≤ 50 mL/min vs. > 50 mL/min). RESULTS: We included 276 major and 512 nonmajor surgeries. The median pre- and postprocedural duration of edoxaban interruption in major vs. nonmajor surgeries was 4 vs. 1 days, whereas median duration of interruption for those with preprocedural-only and postprocedural-only interruption was 2 vs. 1 days and 2 vs. 0 days, respectively (P < 0.0001). Rates of all bleeding and clinically relevant nonmajor bleeding were numerically higher in major vs. nonmajor surgeries. Event rates (number of events per 100 surgeries) were low overall (< 6 events per 100 surgeries), independent of renal function subgroups. CONCLUSION: In this subanalysis of the EMIT-AF/VTE programme, periprocedural-edoxaban interruption was significantly longer in patients undergoing major vs. nonmajor surgery. This clinician-driven approach was associated with low rates of bleeding and thromboembolic events following both major and nonmajor surgeries. TRIAL REGISTRATION: NCT02950168, registered October 31, 2016; NCT02951039, registered November 1, 2016.

Therapeutic efficacy of intravenous lidocaine infusion compared with thoracic epidural analgesia in major abdominal surgery: a noninferiority randomised clinical trial.

BACKGROUND: Open major abdominal surgery is one of the most risky surgical procedures for acute postoperative pain. Thoracic epidural analgesia (TEA) has been considered the standard analgesic approach. In different reports, lidocaine i.v. has been shown to have an analgesic efficacy comparable with TEA. We compared the analgesic efficacy of i.v. lidocaine with thoracic epidural analgesia using bupivacaine in patients undergoing major abdominal surgery. METHODS: In this noninferiority clinical trial, 210 patients were randomised to thoracic epidural bupivacaine with morphine or i.v. lidocaine. Dynamic pain at 24 h after surgery was measured using a numerical pain rating scale (NPR), and morphine consumption was also measured. A difference in i.v. the lidocaine-epidural bupivacaine NPR of ≤1 for dynamic pain was considered a noninferiority margin. RESULTS: The NPR for dynamic pain in the lidocaine group at 24 h was between 5.7 (1.8) and 5.2 (1.9) in the epidural group, with a difference of 0.53 (95% confidence interval 0.0-1.0). In the first 24 h, the average difference in morphine consumption was 1.8 mg between the i.v. lidocaine and epidural groups (95% confidence interval 1-3 mg). No differences were found in adverse events or complications associated with the procedures. CONCLUSIONS: Intravenous lidocaine is noninferior to thoracic epidural analgesia for acute postoperative pain control in major abdomial surgery at 24 h postoperatively. CLINICAL TRIALS REGISTRATION: NCT04017013.

Functional brain network and trail making test changes following major surgery and postoperative delirium: a prospective, multicentre, observational cohort study.

BACKGROUND: Delirium is a frequent complication after surgery in older adults and is associated with an increased risk of long-term cognitive impairment and dementia. Disturbances in functional brain networks were previously reported during delirium. We hypothesised that alterations in functional brain networks persist after remission of postoperative delirium and that functional brain network alterations are associated with long-term cognitive impairment. METHODS: In this prospective, multicentre, observational cohort study, we included older patients who underwent clinical assessments (including the Trail Making Test B [TMT-B]) and resting-state functional MRI (rs-fMRI) before and 3 months after elective surgery. Delirium was assessed on the first seven postoperative days. RESULTS: Of the 554 enrolled patients, 246 remained after strict motion correction, of whom 38 (16%) developed postoperative delirium. The rs-fMRI functional connectivity strength increased 3 months after surgery in the total study population (ß=0.006; 95% confidence interval [CI]: 0.001-0.011; P=0.013), but it decreased after postoperative delirium (ß=-0.015; 95% CI: -0.028 to 0.002; P=0.023). No difference in TMT-B scores was found at follow-up between patients with and without postoperative delirium. Patients with decreased functional connectivity strength declined in TMT-B scores compared with those who did not (ß=11.04; 95% CI: 0.85-21.2; P=0.034). CONCLUSIONS: Postoperative delirium was associated with decreased brain functional connectivity strength after 3 months, suggesting that delirium has a long-lasting impact on brain networks. The decreased connectivity strength was associated with significant cognitive deterioration after major surgery. CLINICAL TRIAL REGISTRATION: NCT02265263.

Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study.

BACKGROUND: Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. METHODS: This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery. RESULTS: Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory. CONCLUSIONS: Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.

Identifying risk factors for poor multidimensional recovery after major surgery: A systematic review.

Traditional risk factors used for predicting poor postoperative recovery have focused on postoperative complications, adverse symptoms (nausea, pain), length of hospital stay, and patient quality of life. Despite these being traditional performance indicators of patient postoperative "status," they may not fully define the multidimensional nature of patient recovery. The definition of postoperative recovery is thus evolving to include patient-reported outcomes that are important to the patient. Previous reviews have focused on risk factors for the above traditional outcomes after major surgery. Yet, there remains a need for further study of risk factors predicting multidimensional patient-focused recovery, and investigation beyond the immediate postoperative period after patients are discharged from the hospital. This review aimed to appraise the current literature identifying risk factors for multidimensional patient recovery. METHODS: A systematic review without meta-analysis was performed to qualitatively summarize preoperative risk factors for multidimensional recovery 4-6 weeks after major surgery (PROSPERO, CRD42022321626). We reviewed three electronic databases between January 2012 and April 2022. The primary outcome was risk factors for multidimensional recovery at 4-6 weeks. A GRADE quality appraisal and a risk of bias assessment were completed. RESULTS: In total, 5150 studies were identified, after which 1506 duplicates were removed. After the primary and secondary screening, nine articles were included in the final review. Interrater agreements between the two assessors for the primary and secondary screening process were 86% (k = 0.47) and 94% (k = 0.70), respectively. Factors associated with poor recovery were found to include ASA grade, recovery tool baseline score, physical function, number of co-morbidities, previous surgery, and psychological well-being. Mixed results were reported for age, BMI, and preoperative pain. Due to the observational nature, heterogeneity, multiple definitions of recovery, and moderate risk of bias of the primary studies, the quality of evidence was rated from very low to low. CONCLUSION: Our review found that there were few studies assessing preoperative risk factors as predictors for poor postoperative multidimensional recovery. This confirms the need for higher quality studies assessing risk for poor recovery, ideally with a consistent and multi-dimensional definition of recovery.

Predicting severe pain after major surgery: a secondary analysis of the Peri-operative Quality Improvement Programme (PQIP) dataset.

Acute postoperative pain is common, distressing and associated with increased morbidity. Targeted interventions can prevent its development. We aimed to develop and internally validate a predictive tool to pre-emptively identify patients at risk of severe pain following major surgery. We analysed data from the UK Peri-operative Quality Improvement Programme to develop and validate a logistic regression model to predict severe pain on the first postoperative day using pre-operative variables. Secondary analyses included the use of peri-operative variables. Data from 17,079 patients undergoing major surgery were included. Severe pain was reported by 3140 (18.4%) patients; this was more prevalent in females, patients with cancer or insulin-dependent diabetes, current smokers and in those taking baseline opioids. Our final model included 25 pre-operative predictors with an optimism-corrected c-statistic of 0.66 and good calibration (mean absolute error 0.005, p = 0.35). Decision-curve analysis suggested an optimal cut-off value of 20-30% predicted risk to identify high-risk individuals. Potentially modifiable risk factors included smoking status and patient-reported measures of psychological well-being. Non-modifiable factors included demographic and surgical factors. Discrimination was improved by the addition of intra-operative variables (likelihood ratio χ2 496.5, p < 0.001) but not by the addition of baseline opioid data. On internal validation, our pre-operative prediction model was well calibrated but discrimination was moderate. Performance was improved with the inclusion of peri-operative covariates suggesting pre-operative variables alone are not sufficient to adequately predict postoperative pain.

Postoperative systemic inflammation after major abdominal surgery: patient-centred outcomes.

Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient-centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient-centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high-risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. The co-primary endpoints were persistent disability or death up to 90 days after surgery, and quality of recovery using a 15-item quality of recovery score at days 3 and 30. Secondary endpoints included: 90-day and 1-year all-cause mortality; septic complications; acute kidney injury; unplanned admission to intensive care/high dependency unit; and total intensive care unit and hospital stays. Patients were assigned into quartiles of maximum postoperative C-reactive protein concentration up to day 3, after multiple imputations of missing values. The lowest (reference) group, quartile 1, C-reactive protein ≤ 85 mg.l-1 , was compared with three inflammation groups: quartile 2 > 85 mg.l-1 to 140 mg.l-1 ; quartile 3 > 140 mg.l-1 to 200 mg.l-1 ; and quartile 4 > 200 mg.l-1 to 587 mg.l-1 . Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31-2.36), p < 0.001. Increased inflammation was associated with increasing decline in risk-adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being -14.4 (-17.38 to -10.71), p < 0.001 on day 3, and -5.94 (-8.92 to -2.95), p < 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery.

Association and prediction of subjective sleep quality and postoperative delirium during major non-cardiac surgery: a prospective observational study.

BACKGROUND: Postoperative delirium (POD) is an acute form of brain dysfunction that can result in serious adverse consequences. There has been a link between cognitive dysfunction and poor sleep. The present study aimed to determine the association and prediction of subjective sleep quality and postoperative delirium during major non-cardiac surgery. METHODS: One hundred and thirty-four patients, aged 60 years or older, were scheduled for elective laparotomy or orthopaedic procedures. The Pittsburgh Sleep Quality Index (PSQI) and sleep log were used to assess perioperative subjective sleep quality in participants. Nursing Delirium Screening Checklist (NU-DESC) was used for screening, and the Confusion Assessment Method (CAM) was used to diagnose POD during the first seven days following surgery. The association between subjective sleep quality and POD was assessed using a multivariate logistic regression model. Thereafter, the prediction performance of subjective sleep quality was evaluated using a receiver operating characteristic (ROC) curve. RESULTS: All assessments were completed on 119 patients who had an average PSQI score of 7.0 ± 2.4 before surgery. 23 patients (19.3%) suffered from POD. The multivariate logistic regression analysis showed that the occurrence of POD was closely related to age, BMI, PSQI and operation time. After adjusting for related factors, there was a statistically significant association between PSQI and POD occurrence (OR = 1.422, 95%CI 1.079-1.873, per 1-point increase in PSQI). The ROC curve analysis showed that the optimal PSQI cutoff value was 8.0 for predicting POD, and the area under the ROC (AUROC) value of PSQI was 0.741 (95%CI 0.635 to 0.817). The AUROC of the model developed by the multivariate logistic regression analysis was 0.870 (95%CI 0.797 to 0.925). CONCLUSIONS: The study found that preoperative subjective sleep quality was strongly associated with POD during major non-cardiac surgery. Additionally, PSQI combined with age, BMI, and operation time improved POD prediction.

Risk factors for acute postoperative hypertension in non-cardiac major surgery: a case control study.

PURPOSE: Acute postoperative hypertension (APH) is a common complication during the anesthesia recovery period that can lead to adverse outcomes, including cardiovascular and cerebrovascular accidents. Identification of risk factors for APH will allow for preoperative optimization and appropriate perioperative management. This study aimed to identify risk factors for APH. PATIENTS AND METHODS: In this retrospective single-center study, 1,178 cases were included. Data was entered by two investigators, and consistency analysis was performed by another. Patients were divided into APH and non-APH groups. A predictive model was built by multivariate stepwise logistic regression. The predictive ability of the logistic regression model was tested by drawing the receiver operating characteristic (ROC) curve and calculating the area under the curve (AUC). Hosmer and Lemeshow goodness-of-fit (GOF) test was performed to reflect the goodness of fit of the model. Calibration curve was created to represent the relationship between predicted risk and observed frequency. Sensitivity analysis was performed to evaluate the robustness of the results. RESULTS: Multivariate logistic regression analysis showed that age over 65 years (OR = 3.07, 95% CI: 2.14 ~ 4.42, P < 0.001), female patients (OR = 1.37, 95% CI: 1.02 ~ 1.84, P = 0.034), presence of intraoperative hypertension (OR = 2.15, 95% CI: 1.57 ~ 2.95, P < 0.001), and use of propofol in PACU (OR = 2.14, 95% CI: 1.49 ~ 3.06, P < 0.001) were risk factors for APH. Intraoperative use of dexmedetomidine (OR = 0.66, 95% CI: 0.49 ~ 0.89, P = 0.007) was a protective factor. Higher baseline SBP (OR = 0.90, 95% CI: 0.89 ~ 0.92, P < 0.001) also showed some correlation with APH. CONCLUSIONS: The risk of acute postoperative hypertension increased with age over 65 years, female patients, intraoperative hypertension and restlessness during anesthesia recovery. Intraoperative use of dexmedetomidine was a protective factor for APH.

The use of digital technologies to support home-based prehabilitation prior to major surgery: A systematic review.

BACKGROUND: Prehabilitation is a multidimensional and multidisciplinary approach, to prepare patients for surgery, with the aim of improving postoperative outcomes. Worldwide, healthcare systems are facing challenges with a gap between demand and supply of healthcare services. Telehealth is seen as a solution for delivering sustainable and efficient treatments. The effect of providing prehabilitation using telehealth solutions is unclear. OBJECTIVE: This systematic review investigated the existing literature regarding the effects and feasibility of technologies for remotely supporting home-based prehabilitation compared to standard care on pre- and postoperative outcomes in adults undergoing elective major surgery. METHODS: A literature search identified relevant studies published between 1 January 2012 and December 2022 in PubMed, PsychInfo, Cinahl and the Cochrane Library. We included RCTs, feasibility and pilot studies. The quality of studies was evaluated using Cochrane's Risk of bias assessment and by narratively rating the certainty of evidence. RESULTS: Six randomized controlled trials and 20 pilot/feasibility studies were included. The number and content of the interventions varied, depending on context and resources. Multiple approaches in the use of digital healthcare solutions were applied and the results highlight the potential of providing health services remotely. CONCLUSION: The use of technologies to support remote home-based prehabilitation in patients undergoing elective major surgery is feasible and has high acceptability, though telehealth is a broad term and wide-ranging strategies are used. Digital technologies for supporting home-based prehabilitation are likely to play an essential role in future health care as resources are scarce and innovative solutions are needed.