Evaluating gender bias in ML-based clinical risk prediction models: A study on multiple use cases at different hospitals.

BACKGROUND: An inherent difference exists between male and female bodies, the historical under-representation of females in clinical trials widened this gap in existing healthcare data. The fairness of clinical decision-support tools is at risk when developed based on biased data. This paper aims to quantitatively assess the gender bias in risk prediction models. We aim to generalize our findings by performing this investigation on multiple use cases at different hospitals. METHODS: First, we conduct a thorough analysis of the source data to find gender-based disparities. Secondly, we assess the model performance on different gender groups at different hospitals and on different use cases. Performance evaluation is quantified using the area under the receiver-operating characteristic curve (AUROC). Lastly, we investigate the clinical implications of these biases by analyzing the underdiagnosis and overdiagnosis rate, and the decision curve analysis (DCA). We also investigate the influence of model calibration on mitigating gender-related disparities in decision-making processes. RESULTS: Our data analysis reveals notable variations in incidence rates, AUROC, and over-diagnosis rates across different genders, hospitals and clinical use cases. However, it is also observed the underdiagnosis rate is consistently higher in the female population. In general, the female population exhibits lower incidence rates and the models perform worse when applied to this group. Furthermore, the decision curve analysis demonstrates there is no statistically significant difference between the model's clinical utility across gender groups within the interested range of thresholds. CONCLUSION: The presence of gender bias within risk prediction models varies across different clinical use cases and healthcare institutions. Although inherent difference is observed between male and female populations at the data source level, this variance does not affect the parity of clinical utility. In conclusion, the evaluations conducted in this study highlight the significance of continuous monitoring of gender-based disparities in various perspectives for clinical risk prediction models.

Self-reported exhaustion and a 4-item physical frailty index to predict the incidence of major complications after onco-geriatric surgery.

BACKGROUND: The aim of this study was to analyze four pre-operative physical frailty indicators from a geriatric assessment (GA) independently and combined in a physical frailty index, in their ability to predict postoperative 30 d-complications. MATERIALS AND METHODS: In this secondary analysis of data from the published PERATECS study (ClinicalTrials.gov: NCT01278537), the predictive value of four physical frailty indicators from a defined GA battery was examined with univariable and multivariate logistic regression models in a sample of 493 onco-geriatric surgical patients. The primary endpoint was incidence of major (Clavien-Dindo ≥ grade 2 [CD ≥ 2]) complications within 30 postoperative days. Predictors of the first model included self-reported exhaustion (SRE), body mass index (BMI), Timed Up-and-Go (TUG) and handgrip strength (HGS) independently, and a second model combined these four items as a Physical Frailty Index (4i-PFI). Both regression models were adjusted for age, gender, American Society of Anesthesiologists (ASA) status, tumor sites, duration of surgery time and Mini Nutritional Assessment (MNA) score. RESULTS: A total of 233 patients (47 %) developed CD ≥ 2 complications. In addition to ASA score, length of surgery, and gynecological and upper gastrointestinal tumor sites, the first model showed that SRE (OR 1.866) predicted CD ≥ 2 complications, but not TUG, BMI and HGS. In the second model, the 4i-PFI predicted CD ≥ 2 complications (OR pre-frail = 1.808, frail = 3.787). CONCLUSIONS: Physical frailty indicators as SRE revealed a better ability to predict CD ≥ 2 complications than BMI, TUG and HGS. However, prediction of CD ≥ 2 complications was enhanced when these parameters were combined in a novel 4i-PFI.

Randomized feasibility trial for evaluating the impact of primary nursing on delirium duration during intensive care unit stay.

OBJECTIVE: We tested the feasibility of a randomized controlled trial for comparing primary nursing with standard care. RESEARCH METHODOLOGY: Elective cardiac surgical patients were eligible for inclusion. Patients with an intensive care unit stay of ≥ 3 days were followed up until intensive care unit discharge. Recruitment period was one year. SETTING: Two intensive care units at a university hospital specialized in cardiovascular and diabetic diseases. MAIN OUTCOME MEASURES: Primary outcomes were recruitment and delivery rate. Primary clinical outcome was duration of delirium, as assessed by the Confusion Assessment Method for Intensive Care Units. Secondary outcomes included the incidence of delirium, anxiety (10-point Numeric Rating Scale), and the satisfaction of patient relatives (validated questionnaire). RESULTS: Of 369 patients screened, 269 could be allocated to primary nursing (n = 134) or standard care (n = 135), of whom 46 patients and 48 patients, respectively, underwent an intensive care unit stay ≥ 3 days. Thus, recruitment and delivery rates were 73 and 26 %, respectively. During primary nursing and standard care, 18 and 24 patients developed a delirium, with a median duration of 32 (IQR: 14-96) and 24 (IQR: 8-44) hours (P = 0.10). The risk difference of delirium for primary nursing versus standard care was 11 % and the relative risk was 0.65 (95 % CI: 0.28-1.46; P = 0.29). The extent of anxiety was similar between groups (P = 0.13). Satisfaction could be assessed in 73.5 % of relatives, without substantial differences between groups. CONCLUSION: Data demonstrate that a trial for comparing primary nursing with standard care is generally feasible. However, the incidence of delirium may be a better primary outcome parameter than delirium duration, both in terms of long-term patient outcome and robustness of data quality. IMPLICATIONS FOR CLINICAL PRACTICE: A randomized clinical trial regarding nursing organization during intensive care unit stay requires detailed planning of patient recruitment, data evaluation, and power calculation.

Practical training concept for perfusionists at the heart and diabetes center Nordrhein-Westfalen.

BACKGROUND: Increasing regulations and requirements of advisory bodies, in particular the Joint Federal Committee and the Medical Service of the health insurance funds, make it necessary to employ only demonstrably well-trained perfusionists. The minimum requirement for this staff is EBCP certification. Currently there is limited availability of such specialists on the German market. Therefore, the qualification of young people in this area is of central importance. The aim of this paper is to strengthen the training of perfusionists at our centre, to standardise the process and to provide the respective student with a "roadmap" to their internship. MATERIAL & METHODS: The structure is based on a rough division of the 24 weeks of internship. This is described in detail in the following and is backed up with the learning objectives for the respective time periods. RESULTS: At our centre, practical training has been standardized and clear responsibilities have been defined. Furthermore, as a centre of maximum care in the field of cardiac surgery, we can offer students the necessary number of perfusions in just six months to meet the requirements of the ECBP for practical training. According to this concept, 20 perfusionists have been successfully trained in the last 8 years. All of them have passed the exams and have been certified according to EBCP. CONCLUSION: The aim of the practical semester is for the student to be in a position at the end of the semester to independently supervise simple cardiac surgery procedures with the aid of the Extra- Corporal Circulation (ECC) and to carry this out in accordance with the currently valid guidelines and directives (1-8) and the departmental procedural instructions based on them. Great emphasis is placed to the students becoming aware of their competence to act, knowing their limits and being able to assess when these limits have been reached and the involvement of experienced colleagues is necessary to ensure patient safety.

Intraoperative Blood Pressure Management and Its Effects on Postoperative Delirium After Cardiac Surgery: A Single-Center Retrospective Cohort Study.

OBJECTIVES: There is accumulating evidence that blood pressure management might be associated with end-organ dysfunction after cardiac surgery. This study aimed to investigate the impact of intraoperative hypotension (IOH) on adverse neurologic outcomes and mortality. DESIGN: A single-center retrospective cohort study. SETTING: The Heart and Diabetes Centre Bad Oeynhausen NRW, Ruhr-University Bochum. PARTICIPANTS: This retrospective cohort study included 31,315 adult patients who underwent elective cardiac surgery at the authors' institution between January 2009 and December 2018. INTERVENTIONS: All cardiac surgery procedures except assist device implantation, organ transplantation, and emergency surgery. MEASUREMENTS AND MAIN RESULTS: Adverse neurologic outcomes were defined as postoperative delirium and stroke. IOH was defined as mean arterial pressure below 60 mmHg for >2 minutes. The frequency of IOH episodes and the cumulative IOH duration were recorded. The association between IOH and adverse neurologic outcomes was examined with unadjusted statistical analysis and multiple logistic regression analysis. Eight hundred forty-nine (2.9%) patients developed postoperative stroke, and 2,401 (7.7%) patients developed postoperative delirium. The frequency of IOH episodes was independently associated with postoperative delirium in the multiple logistic regression analysis (odds ratio 1.02, 95% CI 1.003-1.03, p < 0.001), whereas there was no association between it and stroke. CONCLUSION: This large retrospective monocentric cohort study revealed that increased episodes of IOH were associated with the risk of developing postoperative delirium after cardiac surgery. This might have important clinical implications with respect to careful and precise hemodynamic monitoring and proactive treatment, especially in patients with increased risk for postoperative delirium.

European Pediatric Cardiac Anesthesia Fellowship Program: A First Proof of Concept.

The Pediatric Cardiac Anesthesia (PCA) fellowship is a demanding training program in Europe and the United States. Successful completion of the program requires years of training in anesthesiology, a thorough understanding of cardiovascular anatomy and physiology, and extensive experience in the perioperative management of neonates and children with heart disease. In the context of the first candidate to successfully complete the PCA program in Europe, this article presents excerpts from the design and structure of the European PCA program. The PCA program is evaluated critically by both external and internal reviewers, and points are highlighted that could be included in the next version of the program.

Midazolam for Post-Arrest Sedation in Pre-Hospital Emergency Care.

BACKGROUND: An out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) may need to be treated with airway management, emergency ventilation, invasive interventions, and post-arrest sedation. We investigated the influence of the use of midazolam for post-arrest sedation on achieving postresuscitation care targets and the associated risk of hemodynamic complications. METHODS: All emergency rescue missions of the Dresden, Gütersloh, and Lippe medical rescue services in the years 2019-2021 were reviewed to identify adult patients who had OHCA, unconsciousness, and sustained ROSC with spontaneous circulation until arrival at the hospital; the findings were supplemented with data from the German Resuscitation Registry. Patients who received midazolam (alone or in combination with other anesthetic agents) for post-arrest sedation were compared with those who did not. The endpoints were the regaining of a systolic blood pressure ≥ 100 mmHg, end-tidal pCO2 35-45 mmHg, and oxygen saturation (SpO2) 94-98%. A propensity score analysis was used to adjust for age, sex, and variables potentially affecting hemodynamic status or the targets for oxygenation and ventilation. RESULTS: There were 2335 cases of OHCA among 391 305 emer - gency rescue missions. 571 patients had ROSC before arrival in the hospital (24.5%; female, 33.6%; age, 68 ± 14 years). Of the 395 among them (69.2%) who were treated with postarrest sedation, 249 (63.0%) received midazolam. Patients who received midazolam reached the guideline- recommended targets for oxygenation, ventilation, and blood pressure more frequently than those who were not sedated: the respective odds ratios and 95% confidence intervals were 2.00 [1.20; 3.34], 1.57 [0.99; 2.48], and 1.41 [0.89; 2.21]. CONCLUSION: The pre-hospital administration of midazolam leads to more frequent pre-hospital attainment of the oxygenation and ventilation targets in post-resuscitation care, without any evidence of an elevated risk of hemodynamic complications.

Peripheral cholinesterase activity is not correlated with postoperative delirium in urological surgery.

The value of biomarkers, such as acetylcholinesterase and butyrylcholinesterase, for guiding perioperative patients suffering from postoperative delirium and/or (possibly related) postoperative cognitive dysfunction is unclear. Only recently have different biomarkers are being explored to assess postoperative delirium's occurrence and/or course. The aim of this work is to investigate whether acetylcholinesterase and butyrylcholinesterase can help detect increased risks of the development and course of postoperative delirium in urological patients undergoing surgery. In total, 45 urology patients were screened. During five perioperative time points (meaning preoperative and postoperative), acetylcholinesterase or butyrylcholinesterase concentrations from serum were correlated with three perioperative postoperative delirium and two perioperative postoperative cognitive dysfunction investigations. Results showed neither a significant decline of either acetylcholinesterase or butyrylcholinesterase concentration before and after surgery, nor a significant correlation with postoperative delirium. Furthermore, significant postoperative cognitive dysfunction could not be detected in this perioperative urological collective.

The Efficacy and Safety of a Low-Dose Tranexamic Acid Bolus-Only Protocol Compared with the Moderate-Dose Protocol in Valvular Heart Surgery.

In 873 propensity score-matched pairs of patients undergoing valvular heart surgery, we compared a "moderate dose" of tranexamic acid (TXA) protocol (group 1; median TXA dose: 24 mg/kg body weight) with a 1.5-g "bolus-only" protocol (group 2; median TXA dose: 19 mg/kg body weight). The number of transfused patients was higher in group 2 than in group 1 (74.5 vs 66.0%, p < 0.001), as was the number of transfused red blood cell concentrates (p = 0.001). The risks of re-exploration and convulsive seizures were similar between groups (p > 0.50). Data indicate an impaired efficacy following the "bolus-only" protocol, without a significant safety improvement.

How Would We Treat Our Own Cystic Fibrosis With Lung Transplantation?

Lung transplantation is the only therapy for patients with end-stage lung disease. In advanced lung diseases such as cystic fibrosis (CF), life expectancy increases, and it is important to recognize extrapulmonary comorbidities. Cardiovascular involvement, including pulmonary hypertension, right-heart failure, and myocardial dysfunction, are manifest in the late stages of CF disease. Besides right-heart failure, left-heart dysfunction seems to be underestimated. Therefore, an optimal anesthesia and surgical management risk evaluation in this high-risk patient population is mandatory, especially concerning the perioperative use of mechanical circulatory support. The use of an index case of an older patient with the diagnosis of cystic fibrosis demonstrates the importance of early risk stratification and strategy planning in a multidisciplinary team approach to guarantee successful lung transplantation.

PERSUADE Survey-PERioperative AnestheSia and Intensive Care Management of Left VentricUlar Assist DevicE Implantation in Europe and the United States.

OBJECTIVE: To comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DESIGN: The authors used a prospective data analysis. SETTING: This was an online survey. PARTICIPANTS: Participants were from LVAD centers in Europe and the US. INTERVENTIONS: After investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and postoperative intensive care aspects. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years of experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was used more often for maintenance in Europe (p < 0.001). The choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and the US). The use of quantitative methods for defining right ventricular (RV) function was reported more often from European centers than from US centers (p < 0.05). Temporary mechanical circulatory support for the treatment of RV failure was more often used in Europe. Nitric oxide appeared to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European versus US centers. CONCLUSIONS: Although the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.

Implementation of the Kidney Disease Improving Global Outcomes guidelines for the prevention of acute kidney injury after cardiac surgery: An international cohort survey.

BACKGROUND: Increasing evidence from randomised controlled trials supports the implementation of a six-measure care bundle proposed by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines in patients at high risk for acute kidney injury (AKI) to reduce its incidence after cardiac surgery. OBJECTIVE: To assess compliance with the KDIGO bundle in clinical practice. DESIGN: Prospective observational multinational study. SETTING: Six international tertiary care centres, from February 2021 to November 2021. PATIENTS: Five hundred and thirty-seven consecutive patients undergoing cardiac surgery during a 1-month observational period. INTERVENTIONS: All patients were assessed for the postoperative implementation of the following measures: avoidance of nephrotoxic medication and radiocontrast agents whenever possible, strict glycaemic control, close monitoring of renal function, optimisation of haemodynamic and volume status and functional monitoring of haemodynamic status. MAIN OUTCOME MEASURES: The primary endpoint was the proportion of patients receiving fully compliant care. Secondary outcomes were occurrence of AKI and major adverse kidney event rate at day 30. RESULTS: The full care bundle was applied to 0.4% of patients. There was avoidance of nephrotoxic drugs in 15.6%, radiocontrast agents in 95.3% and hyperglycaemia in 39.6%. Close monitoring of urine output and serum creatinine was achieved in 6.3%, 57.4% underwent optimisation of volume and haemodynamic status, and 43.9% received functional haemodynamic monitoring. 27.2% developed AKI within 72 h after surgery. The average number of implemented measures was 2.6 ±â€Š1.0 and did not differ between AKI or non-AKI patients ( P  = 0.854). CONCLUSION: Adherence with the KDIGO bundle was very low in cardiac surgery patients. Initiatives to improve guideline compliance might provide a strategy to mitigate the burden of AKI. TRIAL REGISTRATION: www.drks.de DRKS00024204.

Current practices in nutrition therapy in cardiac surgery patients: An international multicenter observational study.

BACKGROUND: Cardiac surgery patients with a prolonged stay in the intensive care unit (ICU) are at high risk for acquired malnutrition. Medical nutrition therapy practices for cardiac surgery patients are unknown. The objective of this study is to describe the current nutrition practices in critically ill cardiac surgery patients worldwide. METHODS: We conducted a prospective observational study in 13 international ICUs involving mechanically ventilated cardiac surgery patients with an ICU stay of at least 72 h. Collected data included the energy and protein prescription, type of and time to the initiation of nutrition, and actual quantity of energy and protein delivered (maximum: 12 days). RESULTS: Among 237 enrolled patients, enteral nutrition (EN) was started, on average, 45 h after ICU admission (range, 0-277 h; site average, 53 [range, 10-79 h]). EN was prescribed for 187 (79%) patients and combined EN and parenteral nutrition in 33 (14%). Overall, patients received 44.2% (0.0%-117.2%) of the prescribed energy and 39.7% (0.0%-122.8%) of the prescribed protein. At a site level, the average nutrition adequacy was 47.5% (30.5%-78.6%) for energy and 43.6% (21.7%-76.6%) for protein received from all nutrition sources. CONCLUSION: Critically ill cardiac surgery patients with prolonged ICU stay experience significant delays in starting EN and receive low levels of energy and protein. There exists tremendous variability in site performance, whereas achieving optimal nutrition performance is doable.

Patient-related effects of primary nursing : Protocol of a pilot randomized controlled trial.

BACKGROUND: Since January 2022, a primary nursing system called process-responsible nursing (PP) has substituted the standard room care system in an intensive care unit (ICU) at our institution. The process of the development and implementation of PP is already being evaluated in a separate study as an actual analysis prior to implementation, as well as after 6 and 12 months. AIM: This pilot randomized controlled trial (RCT) aims to test the feasibility of an RCT. For this purpose, the duration of delirium, among other things, will be compared in the project ICU with the results of standard care in another ICU at the university hospital. As secondary aims, the incidence of delirium, anxiety, the satisfaction of relatives, and the effects of PP on nurses will be assessed. METHODS: It is planned to recruit about 400-500 patients over a period of one year. They will be allocated to PP or standard care. Delirium will be assessed using the Confusion Assessment Method for Intensive Care Units by specifically trained nurses three times a day. Anxiety in patients, the satisfaction of relatives, and the effects of PP on nurses will be evaluated using the numeric rating scale, a standardized questionnaire, and a focus group interview, respectively. EXPECTED RESULTS: The primary hypothesis is that compared to usual care PP reduces the duration of delirium by at least 8 h. Additional hypotheses are that PP reduces anxiety in patients and increases the satisfaction of relatives.

Moderate Dose of Tranexamic Acid and Complications after Valvular Heart Surgery.

BACKGROUND: In valvular open-heart surgery, data regarding the effect of a moderate dose of tranexamic acid (TXA) on clinical outcomes are limited. METHODS: Out of a cohort of 13,293 patients, we performed a propensity-score-matched analysis in 6,106 patients and assessed the risk of convulsive seizures (CS, primary endpoint), stroke, renal replacement therapy, and mortality (secondary endpoints). In the entire study cohort of 13,293 patients, we also assessed the multivariable-adjusted association of CS with postoperative outcomes. RESULTS: The risk of CS was significantly higher in the TXA group (2.4%; n = 72) than in the non-TXA group (1.0%; n = 32), with a relative risk ratio (RR) of 2.28 (95% confidence interval [CI]: 1.50-3.47; p < 0.001). The risk of CS was also higher in patients receiving TXA doses ≥25 mg/kg body weight (3.7%; n = 40) than in patients receiving <25 mg/kg body weight (1.6%; n = 32; p < 0.001). Perioperative secondary clinical endpoints and 1-year mortality did not differ significantly between study groups (p-value > 0.05). Compared with non-CS patients (n = 13,000), patients with nonhemorrhagic, nonembolic CS (n = 253) revealed higher multivariable-adjusted in-hospital risks of stroke (RR: 3.82 [95% CI: 2.44-5.60; p < 0.001]) and mortality (RR: 2.07 [95% CI: 1.23-3.48; p = 0.006]), and a higher 1-year mortality risk (RR: 1.85 [95% CI: 1.42-2.41; p < 0.001]). CONCLUSION: A moderate TXA dose was associated with a significantly higher risk of seizure, but not with other clinical complications such as stroke, renal replacement therapy, and mortality. However, in the small group of patients experiencing a seizure, the risks of stroke and short- and mid-term mortality were substantially higher than in patients not experiencing a seizure, indicating that the use of a low-dose TXA protocol (<25 mg/kg body weight) should be considered.

Use of the CytoSorb® filter for elimination of residual therapeutic argatroban concentrations during heparinized cardiopulmonary bypass for heart transplantation.

INTRODUCTION: No antidote or established extracorporeal elimination strategy is available for argatroban. Hemadsorption facilitates elimination of smaller drugs. CASE REPORT: A 34-year-old patient underwent urgent heart transplantation. Because of a history of heparin-induced thrombocytopenia, preoperative anticoagulation was performed with argatroban. Despite ceasing of the continuous infusion of argatroban 2 h before surgery, concentration only declined from 0.60 µg/ml to 0.58 µg/ml before surgery, and the activated clotting time (ACT) value shortly was 223 s. Microvascular bleeding had been observed when starting surgery. A CytoSorb® absorption column was integrated into the system of the heparin-anticoagulated cardiopulmonary bypass (CPB) circuit and a flow of 400 mL/min provided during the 2 h of extracorporeal circulation. The argatroban concentration after weaning from CPB was 0.04 µg/ml and satisfying hemostasis had been achieved after protamine administration. CONCLUSION: Data indicate that the CytoSorb® absorption column might be an effective tool for quick extracorporeal removal of therapeutic concentrations of argatroban.

Transfusions and early outcomes in anaemic patients undergoing off- or on-pump coronary artery bypass grafting.

We retrospectively compared transfusion rates and early outcomes in 1621 consecutive patients with preoperative anaemia undergoing off-pump coronary artery bypass grafting (OPCAB) or on-pump coronary artery bypass grafting (ONCAB) surgery using a propensity score analysis with inverse probability of treatment weighting. Endpoints were transfusions, early morbidity, and mortality. Surgeries were performed by 45 dedicated OPCAB and/or ONCAB surgeons during the 10-year study period. Operative data did not differ significantly between study groups with the exception of a more frequent use of bilateral internal mammary artery revascularization approach in OPCAB patients than ONCAB patients. OPCAB was associated with fewer transfusions and lower risk for the need of postoperative renal replacement therapy, but higher risk of wound infections than ONCAB. Perioperative stroke risk and 30-day and 1-year mortality did not differ significantly between the groups. Our data in a 'real-world setting' indicate that in patients with preoperative anaemia both ONCAB and OPCAB are feasible surgical approaches regarding early morbidity and mortality.

Association between post-operative delirium and use of volatile anesthetics in the elderly: A real-world big data approach.

STUDY OBJECTIVE: Early post-operative delirium is a common perioperative complication in the post anesthesia care unit. To date it is unknown if a specific anesthetic regime can affect the incidence of delirium after surgery. Our objective was to examine the effect of volatile anesthetics on post-operative delirium. DESIGN: Single Center Observational Study. SETTING: Post Anesthesia Care Units at a German tertiary medical center. PATIENTS: 30,075 patients receiving general anesthesia for surgery. MEASUREMENTS: Delirium was assessed with the Nursing Delirium Screening Scale at the end of the recovery period. Subgroup-specific effects of volatile anesthetics on post-operative delirium were estimated using generalized-linear-model trees with inverse probability of treatment weighting. We further assessed the age-specific effect of volatiles using logistic regression models. MAIN RESULTS: Out of 30,075 records, 956 patients (3.2%) developed delirium in the post anesthesia care unit. On average, patients who developed delirium were older than patients without delirium. We found volatile anesthetics to increase the risk (Odds exp. (B) for delirium in the elderly 1.8-fold compared to total intravenous anesthesia. Odds increases with unplanned surgery 3.0-fold. In the very old (87 years or older), the increase in delirium is 6.2-fold. This result was confirmed with internal validation and in a logistic regression model. CONCLUSIONS: Our exploratory study indicates that early postoperative delirium is associated with the use of volatile anesthetics especially in the sub-cohort of patients aged 75 years and above. Further studies should include both volatile and intravenous anesthetics to find the ideal anesthetic in elderly patients.

Intraoperative Circulatory Support in Lung Transplantation: Current Trend and Its Evidence.

Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.