An analysis of referrals to a level 3 intensive care unit in a resource-limited setting in South Africa.

Background: With a shortage of intensive care unit (ICU) beds and rising healthcare costs in resource-limited settings, clinicians need to appropriately triage admissions into ICU to avoid wasteful expenditure and unnecessary bed utilisation. Objectives: To assess the nature, appropriateness and outcome of referrals to a tertiary centre ICU. Methods: A retrospective review of ICU consults from September 2016 to February 2017 at King Edward VIII Hospital was performed. The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE291/17). Data pertaining to patients' demographics, referring doctor, diagnosis, comorbidities as well as biochemical and haemodynamic parameters were extracted. This information was then cross-referenced to the outcome of the ICU consultation. Data were descriptively analysed. Results: Five hundred consultations were reviewed over a 6-month period; 52.2% of patients were male and the mean age was 44 years. Junior medical officers referred 164 (32.8%) of the consultations. Although specialist supervision was available in 459 cases, it was only utilised in 339 (73.9%) of these cases. Most referrals were from tertiary (46.8%) or regional (30.4%) hospitals; however, direct referrals from district hospitals and clinics accounted for 20.4% and 1.4% of consultations, respectively. The appropriate referral pathway was not followed in 81 (16.2%) consultations. Forty-five percent of consults were accepted; however, 9.3% of these patients died before arrival in ICU. A total of 151 (30.2%) patients were refused ICU admission, with the majority (57%) of these owing to futility. Patients were unstable at the time of consult in 53.2% of referrals and 34.4% of consults had missing data. Conclusion: Critically ill patients are often referred by junior doctors without senior consultation, and directly from low-level healthcare facilities. A large proportion of ICU referrals are deemed futile and, of the patients accepted for admission, almost 1 in 10 dies prior to ICU admission. More emphasis needs to be placed on the training of doctors to appropriately triage and manage critically ill patients and ensure appropriate ICU referral and optimising of patient outcomes. Contributions of the study: There is a paucity of information related to ICU referrals in South Africa. The nature, appropriateness and outcomes of referrals to a tertiary ICU is discussed in this study.

Deep medicine Navigating the intersection of technology, cognition and ethics in the digital age of medicine.

The digital expansion in medicine and healthcare has been immense and extremely valuable. The biggest concern in the face of this inevitable growth is how we manage to keep contact with our patients and preserve the human touch so essential in healing. Digital healthcare should not be about technology replacing clinicians. Instead, it should be about augmenting and supplementing healthcare providers to improve the ways in which we deliver personalised healthcare. It is vital that we focus on how we can revitalise the patient-clinician relationship in this digital age.

The optimal management of the patient with COVID-19 pneumonia: HFNC, NIV/CPAP or mechanical ventilation?

The recent pandemic has seen unprecedented demand for respiratory support of patients with COVID-19 pneumonia, stretching services and clinicians. Yet despite the global numbers of patients treated, guidance is not clear on the correct choice of modality or the timing of escalation of therapy for an individual patient. This narrative review assesses the available literature on the best use of different modalities of respiratory support for an individual patient, and discusses benefits and risks of each, coupled with practical advice to improve outcomes. On current data, in an ideal context, it appears that as disease severity worsens, conventional oxygen therapy is not sufficient alone. In more severe disease, i.e. PaO2/FiO2 ratios below approximately 200, helmet-CPAP (continuous positive airway pressure) (although not widely available) may be superior to high-flow nasal cannula (HFNC) therapy or facemask non-invasive ventilation (NIV)/CPAP, and that facemask NIV/CPAP may be superior to HFNC, but with noted important complications, including risk of pneumothoraces. In an ideal context, invasive mechanical ventilation should not be delayed where indicated and available. Vitally, the choice of respiratory support should not be prescriptive but contextualised to each setting, as supply and demand of resources vary markedly between institutions. Over time, institutions should develop clear policies to guide clinicians before demand exceeds supply, and should frequently review best practice as evidence matures.

Establishing a South African national framework for COVID-19 surgical prioritisation.

BACKGROUND: Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. OBJECTIVES: To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculatorfor operative care. METHODS: The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. RESULTS: A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. CONCLUSIONS: This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.

Identifying ICU admission decision patterns in a '20-questions game' approach using network analysis.

Background: The complex intensive care unit (ICU) admission decision process has numerous non-linear relationships involving multiple factors. To better describe and analyse this process, exploration of novel techniques to clearly delineate the importance and interrelationships of factors is warranted. Network analysis (NA), based on graph theory, attempts to identify patterns of connections within a network and may be useful in this regard. Objectives: To identify patterns of ICU decision-making pertaining to patients referred for admission to ICU and to identify key factors, their distribution, connection and relative importance. The secondary aim was to compare subgroups as per decision outcomes and case labels. Methods: NA was performed using Gephi software package as a secondary analysis on a dataset generated from a previous study on ICU admission decision-making process using a 20-questions game approach. The data were standardised and coded up to a quaternary level for this analysis. Results: The coding process generated 31 nodes and 964 edges. Regardless of the measure used (centrality, prestige, authority and hubs), properties of the acute illness, progress of the acute illness and properties of comorbidities emerged consistently as among the most important factors and their relative rankings differed. Using different measures allowed important factors to emerge differentially. The six subgroups that emerged from the modularity measure bore little resemblance to traditional factor subgroups. Differences were noted in the subgroup comparisons of decision outcomes and case prognoses. Conclusion: The use of NA with its various measures has facilitated a more comprehensive exploration of the ICU admission decision, allowing us to reflect on the process. Further studies with larger datasets are needed to elucidate the exact role of NA in decision-making processes. Contributions of the study: We performed a novel analysis of a complex decision-making process that allowed for comparison with traditional analytic methods. It allowed for identification of key factors, their distribution, connection and relative importance. This may subsequently allow for reflection on difficult decision-making processes, thereby leading to more appropriate outcomes. Moreover, this may lead to new considerations in developing decision support systems such as the formulation of pro-forma data-capture tools (e.g. referral forms). Further, the way factors have been traditionally subgrouped may need to be reconsidered, with different subgroups being partitioned to better reflect their connection. This study offers a good basis for more advanced future studies in this area to use a new variety of analytical tools.

Is there a role for melatonin in the ICU?

Summary: In the last decade, there have been significant developments in the understanding of the hormone melatonin in terms of its physiology, regulatory role and potential utility in various domains of clinical medicine. Melatonin's purported properties include, among others, regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As such, its role has been explored specifically in the critical care setting in terms of many of these properties. This review addresses the physiological basis for considering melatonin in the critical care setting as well as the current evidence pertaining to its potential utility. Contributions of the study: This review examines and discusses the role of melatonin in the intensive care unit in terms of sleep, delirium and sepsis, both the physiology and as a therapy.

The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa.

Letter by Gopalan et al. on article by Singh and Moodley (Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778); and response by Singh and Moodley.

Critical care triage during the COVID-19 pandemic in South Africa: A constitutional imperative!

Triage and rationing of scarce intensive care unit (ICU) resources are an unavoidable necessity. In routine circumstances, ICU triage is premised on the best interests of an individual patient; however, when increased demand exceeds capacity, as during an infectious disease outbreak, healthcare providers need to make difficult decisions to benefit the broader community while still respecting individual interests. We are currently living through an unprecedented period, with South Africa (SA) facing the challenges of the global COVID-19 pandemic. The Critical Care Society of Southern Africa (CCSSA) expedited the development of a triage guidance document to inform the appropriate and fair use of scarce ICU resources during this pandemic. Triage decision-making is based on the clinical odds of a positive ICU outcome, balanced against the risk of mortality and longer-term morbidity affecting quality of life. Factors such as age and comorbid conditions are considered for their potential impact on clinical outcome, but are never the sole criteria for denying ICU-level care. Arbitrary, unfair discrimination is never condoned. The CCSSA COVID-19 triage guideline is aligned with SA law and international ethical standards, and upholds respect for all persons. The Bill of Rights, however, does not mandate the level of care enshrined in the constitutional right to healthcare. ICU admission is not always appropriate, available or feasible for every person suffering critical illness or injury; however, everyone has the right to receive appropriate healthcare at another level. If ICU resources are used for people who do not stand to benefit, this effectively denies others access to potentially life-saving healthcare. Appropriate triaging can therefore be considered a constitutional imperative.

Decision-making in the ICU: An analysis of the ICU admission decision-making process using a '20 Questions' approach.

Background: Deciding to admit a patient into the intensive care unit (ICU) is a high-stakes, high-stress, time-sensitive process. Elucidating the complexities of these decisions can contribute to a more efficient, effective process. Objectives: To explore physicians' strategic thought processes in ICU triage decisions and identify important factors. Methods: Practitioners (N=29) were asked to decide on ICU referrals of two hypothetic cases using a modified '20 Questions' approach. Demographic data, decisions when full information was available, feedback on questions, rating of factors previously identified as important and influence of faith and personality traits were explored. Results: Of the 735 questions asked, 95.92% were patient related. There were no significant differences in interview variables between the two cases or with regard to presentation order. The overall acceptance rate was 68.96%. Refusals were associated with longer interview times (p=0.014), as were lower ICU bed capacity (p=0.036), advancing age of the practitioner (p=0.040) and a higher faith score (p=0.004). Faith score correlated positively with the number of questions asked (p=0.028). There were no significant correlations with personality trait stanines. When full information was available, acceptances for Case A decreased (p=0.003) but increased for Case B (p=0.026). The net reclassification improvement index was -0.138 (p=0.248). Non-subspecialists were more likely to change their decisions (p=0.036). Conclusion: Limiting information to what is considered vital by using a '20 Questions' approach and allowing the receiving practitioner to create the decision frame may assist with ICU admission decisions. Practitioners should consider the metacognitive elements of their decision-making. Contributions of the study: The study used a novel approach to explore physicians' decision-making process for admitting a patient to the intensive care unit (ICU). Understanding the main factors that influence the decision-making process will allow for streamlining the referral process, more effective selection of patients most likely to benefit from ICU treatment, and prevent inappropriate admissions into the ICU. The findings can also help to improve data capture tools and encourage practitioners to critically reflect on their decision-making processes.

The role of laboratory testing in hospitalised and critically ill COVID-19-positive patients.

The COVID-19 pandemic has placed healthcare resources around the world under immense pressure. South Africa, given the condition of its healthcare system, is particularly vulnerable. There has been much discussion around rational healthcare utilisation, ranging from diagnostic testing and personal protective equipment to triage and appropriate use of ventilation strategies. There has, however, been little guidance around use of laboratory tests once COVID-19 positive patients have been admitted to hospital. We present a working guide to rational laboratory test use, specifically for COVID-19, among hospitalised patients, including the critically ill. The specific tests, the reasons for testing, their clinical usefulness, timing and frequency are addressed. We also provide a discussion around evidence for the use of these tests from a clinical perspective.

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit.

BACKGROUND: When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context. OBJECTIVES: To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care. METHODS: A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors. RESULTS: A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease. CONCLUSIONS: A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors.

The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri).

Background: In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector. Purpose: The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care. Recommendations: In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years. Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.

The Critical Care Society of Southern Africa Consensus Guideline on ICU Triage and Rationing (ConICTri).

Background: In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector. Purpose: The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources. Recommendations: An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years. Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit

Background. When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context.Objectives. To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care.Methods. A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors.Results. A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease.Conclusions. A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors

Preoperative serum sodium measurements and postoperative inpatient mortality: A case-control analysis of data from the South African Surgical Outcomes Study.

BACKGROUND: Abnormal preoperative serum sodium measurements have been shown to be associated with increased postoperative mortality in US and European surgical populations. It is possible that such measurements are also associated with increased postoperative mortality in a South African (SA) setting, but this is yet to be confirmed. Establishing whether preoperative serum sodium measurements are associated with postoperative mortality could have implications for perioperative risk stratification in SA settings. OBJECTIVES: To determine whether preoperative serum sodium measurements are associated with postoperative mortality in SA surgical patients. METHODS: This was an unmatched case-control study of patient data (demographics, comorbidities, procedure-related variables, and preoperative serum sodium measurements) collected during the South African Surgical Outcomes Study. Data were analysed using recommended statistical methods for unmatched case-control studies. RESULTS: The study population comprised 103 patients and 410 controls. Cases were defined as patients who suffered postoperative inpatient mortality, while controls were defined as patients who did not suffer postoperative inpatient mortality. Preoperative hypernatraemia (i.e. a preoperative serum sodium measurement >144 mEq/L) was independently associated with a four-fold higher risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement of 135 - 144 mEq/L (odds ratio (OR) 4.21, 95% confidence interval (CI) 1.19 - 14.83, p=0.025). Preoperative hyponatraemia (i.e. a preoperative serum sodium measurement <135 mEq/L) was not independently associated with a higher or lower risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement (OR 1.39, 95% CI 0.70 - 2.76, p=0.346). CONCLUSIONS: Preoperative hypernatraemia, but not preoperative hyponatraemia, is a risk factor for postoperative inpatient mortality in SA surgical patients.

An investigation of barriers to the use of the World Health Organization Surgical Safety Checklist in theatres.

BACKGROUND: The World Health Organization (WHO) has implemented the Surgical Safety Checklist (SSCL) as part of the Safe Surgery Saves Lives campaign. This is aimed at improving surgical safety worldwide. Despite many perceived benefits of the SSCL, compliance and acceptance in many areas remain poor. OBJECTIVES: To investigate perceptions of theatre staff regarding the checklist and to identify reasons and barriers for poor compliance and implementation. METHODS: Questionnaires were handed out to theatre teams across all surgical disciplines at two large hospitals in Durban, South Africa, over a 2-week period. Data collected included role in theatre, intention of the SSCL, training received, as well as questions regarding previously identified barriers and staff perceptions. RESULTS: Questionnaires were distributed to 225 practitioners, with a response rate of 81.7% from 51 nurses, 54 anaesthetists and 79 surgeons. Rank of medical staff included 52 seniors (consultants) and 81 juniors (registrars and medical officers). The majority (95%) of respondents perceived the SSCL as intended to improve safety, prevent errors or reduce morbidity and mortality. A total of 146 respondents (79.3%) received no SSCL training. No new barriers were identified, but previously identified barriers were confirmed. Our key factors were time-related issues and lack of buy-in from team members. Surgeons were perceived as being supportive by 45.1% of respondents, in contrast to nurses (62.5%), anaesthetists (70.1%) and management (68.5%). When compared with junior staff, senior staff were 5-fold more likely to feel that staff did not need to be trained and 8-fold more likely to indicate that the checklist did not improve patient safety. CONCLUSIONS: The WHO SSCL is an important tool in the operating room environment. The barriers in our setting are similar to those identified in other settings. There needs to be widespread training in the use of the SSCL, including adaptation of the checklist to make it fit for purpose in our setting. Improving use of the checklist will allow theatre staff to work together towards ensuring a safer theatre environment for both patients and staff.

Preoperative serum sodium measurements and postoperative inpatient mortality: A case-control analysis of data from the South African Surgical Outcomes Study

Background. Abnormal preoperative serum sodium measurements have been shown to be associated with increased postoperative mortality in US and European surgical populations. It is possible that such measurements are also associated with increased postoperative mortality in a South African (SA) setting, but this is yet to be confirmed. Establishing whether preoperative serum sodium measurements are associated with postoperative mortality could have implications for perioperative risk stratification in SA settings.Objectives. To determine whether preoperative serum sodium measurements are associated with postoperative mortality in SA surgical patients.Methods. This was an unmatched case-control study of patient data (demographics, comorbidities, procedure-related variables, and preoperative serum sodium measurements) collected during the South African Surgical Outcomes Study. Data were analysed using recommended statistical methods for unmatched case-control studies.Results. The study population comprised 103 patients and 410 controls. Cases were defined as patients who suffered postoperative inpatient mortality, while controls were defined as patients who did not suffer postoperative inpatient mortality. Preoperative hypernatraemia (i.e. a preoperative serum sodium measurement >144 mEq/L) was independently associated with a four-fold higher risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement of 135 - 144 mEq/L (odds ratio (OR) 4.21, 95% confidence interval (CI) 1.19 - 14.83, p=0.025). Preoperative hyponatraemia (i.e. a preoperative serum sodium measurement <135 mEq/L) was not independently associated with a higher or lower risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement (OR 1.39, 95% CI 0.70 - 2.76, p=0.346).Conclusions. Preoperative hypernatraemia, but not preoperative hyponatraemia, is a risk factor for postoperative inpatient mortality in SA surgical patients