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In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67–78 ] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing. [ABSTRACT FROM AUTHOR]

Intravenous lidocaine is used as an adjuvant analgesic agent in perioperative settings. It has been investigated in various patient populations and surgical interventions, but there are limited data on its efficacy, particularly for patients undergoing bariatric surgery. Obese patients are at high risk of postoperative respiratory complications and can be expected to benefit from anaesthetic techniques that minimise opioid administration. We studied administration of lidocaine hydrochloride 1% i.v. to general anaesthesia at a dose of 1.5 mg kg−1 (lean body mass×1.28) or placebo in patients undergoing bariatric surgery. Subjects randomly assigned to each group were surveyed for 48 h after surgery for experienced pain (primary outcome), and administered opioids, postoperative nausea and vomiting (PONV), resumption of bowel function, and length of hospital stay (secondary outcomes). We recruited and randomised 140 subjects to either the lidocaine or placebo group; 137 completed the study. Subjects with pain numeric rating scale (NRS) >3 within the first 4 h postoperatively were similar in both groups (proportion of any NRS >3 within first 4 h lidocaine group: 47/68 (69%) vs placebo group: 44/69 (63%), P =0.507; within first h P =0.177, within second h P =0.513, within third h P =0.145, within fourth h P =0.510). There was no difference in maximal pain score, opioid consumption, recovery of bowel function, incidence of PONV, or length of hospital stay. Lidocaine does not improve postoperative pain scores, analgesia, or any secondary outcomes in patients undergoing bariatric surgery. NCT03667001. [ABSTRACT FROM AUTHOR]

Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery. This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated. In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUC baseline 0.74 [0.71–0.77], ROC AUC baseline+4METs 0.74 [0.71–0.77], ROC AUC baseline+floors climbed 0.75 [0.71–0.78], AUC baseline+fitness vs peers 0.74 [0.71–0.77], and AUC baseline+physical activity 0.75 [0.72–0.78]). Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery. NCT03016936. [ABSTRACT FROM AUTHOR]

Comment on Br J Anaesth 2021; 126: 386-94. Model, propofol, pharmacodynamic, pharmacokinetic, target-controlled infusion Clinical validation of pharmacokinetic and pharmacodynamic models for propofol infusion. [Extracted from the article]