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Cardiac surgery has two distinct treatment pathways; approximately half of the 32,000 adult cardiac surgery episodes in the UK per year are planned (mean waiting time of 104 days) and half are urgent inpatients (mean waiting time of 11 days), plus a small number of emergency cases [[3]]. Prehabilitation is the practice of enhancing a patient's functional capacity before surgery, with the aim of improving postoperative outcomes [[1]]. 1 Table Pre-operative assessment (POA) service and prehabilitation components in urgent and elective cardiac surgery pathways from 34 cardiac surgery centres. [Extracted from the article]

Summary: In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre‐operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l−1; functional iron deficiency as ferritin 30–100 μg.l−1 or transferrin saturation < 20%; and the remainder as non‐iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co‐primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri‐operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one‐third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre‐operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l−1, 95%CI 5.3–12.5; moderate in functional iron deficiency, mean difference 2.8 g.l−1, 95%CI −0.1 to 5.7; and with little change seen in those patients who were non‐iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay. [ABSTRACT FROM AUTHOR]

Background: The aim of this systematic review was to summarize the results of trials evaluating interventions for the reduction of sarcopenia in patients undergoing surgery. Methods: Searches were conducted using the Cochrane Central Register of Controlled Trials, MEDLINE and Embase. RCTs evaluating exercise, dietary or pharmacological interventions to address sarcopenia in the perioperative period were included. Treatment effect estimates were expressed as standardized mean differences (MDs) with confidence intervals, and heterogeneity was expressed as I2 values. Results: Seventy trials including 3402 participants were selected for the data synthesis. Exercise interventions significantly increased muscle mass (MD 0.62, 95 per cent c.i. 0.34 to 0.90; P < 0.001), muscle strength (MD 0.55, 0.39 to 0.71; P < 0.001), measures of gait speed (MD 0.42, 0.05 to 0.79; P = 0.03), and reduced time for completion of set exercises (MD −0.76, −1.12 to −0.40; P < 0.001) compared with controls. Subgroup analysis showed that interventions in the early postoperative period were more likely to have a positive effect on muscle mass (MD 0.71, 0.35 to 1.07; P < 0.001) and timed tests (MD −0.70, −1.10 to −0.30; P = 0.005) than preoperative interventions. Treatment effects on muscle mass (MD 0.09, −0.31 to 0.49; P = 0.66) and strength (MD 0.46, −0.01 to 0.92; P = 0.05) were attenuated by the presence of cancer. Results of analyses restricted to nine trials at low risk of allocation concealment bias and fourteen trials at low risk of attrition bias were comparable to those of the primary analysis. Risk-of-bias assessment showed that most trials were at high risk of incomplete outcome and attrition bias, thus reducing the estimate of certainty of the evidence according to the GRADE assessment tool. Conclusion: Exercise interventions appear beneficial in reducing the impact of sarcopenia. Because of the high risk of bias and low certainty of the current evidence, large RCTs using standardized measures of muscle mass should be undertaken. [ABSTRACT FROM AUTHOR]

Objectives: To inform the design of a clinical trial of a targeted screening programme for relatives of individuals affected by thoracic aortic disease, we performed a consensus exercise as to the acceptability of screening, the optimal sequence and choice of tests, long-term patient management, and choice of trial design.Methods: Working with the Aortic Dissection Awareness UK & Ireland patient association, we performed a Delphi exercise with clinical experts, patients, and carers, consisting of three rounds of consultation followed by a final multi-stakeholder face-to-face workshop.Results: Thirty-five experts and 84 members of the public took part in the surveys, with 164 patients and clinicians attending the final workshop. There was substantial agreement on the need for a targeted screening pathway that would employ a combined approach (imaging + genetic testing). The target population would include the first- and second-degree adult (> 15 years) relatives, with no upper age limit of affected patients. Disagreement persisted about the screening process, sequence, personnel, the imaging method to adopt, computed tomography (CT) scan vs magnetic resonance imaging (MRI), and the specifics of a potential trial, including willingness to undergo randomisation, and measures of effectiveness and acceptability.Conclusion: A Delphi process, initiated by patients, identified areas of uncertainty with respect to behaviour, process, and the design of a targeted screening programme for thoracic aortic disease that requires further research prior to any future trial. [ABSTRACT FROM AUTHOR]

Background: The aim was to investigate whether preoperative weight loss results in improved clinical outcomes in surgical patients with clinically significant obesity. Methods: This was a systematic review and aggregate data meta‐analysis of RCTs and cohort studies. PubMed, MEDLINE, Embase and CINAHL Plus databases were searched from inception to February 2018. Eligibility criteria were: studies assessing the effect of weight loss interventions (low‐energy diets with or without an exercise component) on clinical outcomes in patients undergoing any surgical procedure. Data on 30‐day or all‐cause in‐hospital mortality were extracted and synthesized in meta‐analyses. Postoperative thromboembolic complications, duration of surgery, infection and duration of hospital stay were also assessed. Results: A total of 6060 patients in four RCTs and 12 cohort studies, all from European and North American centres, were identified. Most were in the field of bariatric surgery and all had some methodological limitations. The pooled effect estimate suggested that preoperative weight loss programmes were effective, leading to significant weight reduction compared with controls: mean difference –7·42 (95 per cent c.i. –10·09 to –4·74) kg (P < 0·001). Preoperative weight loss interventions were not associated with a reduction in perioperative mortality (odds ratio 1·41, 95 per cent c.i. 0·24 to 8·40; I2 = 0 per cent, P = 0·66) but the event rate was low. The weight loss groups had shorter hospital stay (by 27 per cent). No differences were found for morbidity. Conclusion: This limited preoperative weight loss has advantages but may not alter the postoperative morbidity or mortality risk. Possible, but how much is enough? [ABSTRACT FROM AUTHOR]

Background and objectives: To review preclinical and clinical studies that have evaluated the effects of red cell rejuvenation in vivo and in vitro and to assess the potential risks and benefits from their clinical use. Materials and methods: A systematic review and narrative synthesis of the intervention of red cell rejuvenation using a red cell processing solution containing inosine, pyruvate, phosphate and adenine. Outcomes of interest in vitro were changes in red cell characteristics including adenosine triphosphate (ATP), 2,3‐diphosphoglycerate (2,3‐DPG), deformability and the accumulation of oxidized lipids and other reactive species in the red cell supernatant. Outcomes in vivo were 24‐h post‐transfusion survival and the effects on oxygen delivery, organ function and inflammation in transfused recipients. Results: The literature search identified 49 studies evaluating rejuvenated red cells. In vitro rejuvenation restored cellular properties including 2,3‐DPG and ATP to levels similar to freshly donated red cells. In experimental models, in vivo transfusion of rejuvenated red cells improved oxygen delivery and myocardial, renal and pulmonary function when compared to stored red cells. In humans, in vivo 24‐h survival of rejuvenated red cells exceeded 75%. In clinical studies, rejuvenated red cells were found to be safe, with no reported adverse effects. In one adult cardiac surgery trial, transfusion of rejuvenated red cells resulted in improved myocardial performance. Conclusion: Transfusion of rejuvenated red cells reduces organ injury attributable to the red cell storage lesion without adverse effects in experimental studies in vivo. The clinical benefits of this intervention remain uncertain. [ABSTRACT FROM AUTHOR]

Author(s): G. J. Walkden [sup.1], R. Goudie [sup.2], V. Verheyden [sup.3], G. J. Murphy [sup.3] Author Affiliations: (1) grid.5337.2, 0000000419367603, Bristol Heart Institute , University of Bristol, , BS8 1TH, [...]

Viscoelastic point-of-care tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients. We updated existing meta-analyses that have evaluated the clinical effectiveness of viscoelastic point-of-care tests vs the current standard of care for the management of cardiac surgery patients at risk of coagulopathic bleeding. Randomized controlled trials comparing viscoelastic point-of-care diagnostic testing with standard care in cardiac surgery patients were sought. All-cause mortality, blood loss, reoperation, blood transfusion, major morbidity, and intensive care unit and hospital length of stay were analysed using random-effects modelling. Fifteen trials that randomized a total of 8737 participants were included for the analysis. None of the trials was classified as low risk of bias. The use of thromboelastography- (TEG®) or thromboelastometry (ROTEM®)-guided algorithms did not reduce mortality [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.28-1.10] without heterogeneity (I2=1%), reoperation for bleeding, stroke, ventilation time, or hospital length of stay compared with standard care. Use of TEG® or ROTEM® resulted in reductions in the frequency of red blood cell (Risk Ratio 0.88, 95% Confidence Interval 0.79-0.97; I2=43%) and platelet transfusion (Risk Ratio 0.78, 95% Confidence Interval 0.66-0.93; I2=0%). Group Reading Assessment and Diagnostic Evaluation (GRADE) assessment demonstrated that the quality of the evidence was low or very low for all estimated outcomes. Routine use of viscoelastic point-of-care tests did not improve important clinical outcomes beyond transfusion in adults undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Objective: To assess the incremental cost and costeffectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery. Design: A within-trial cost-effectiveness analysis with a 3-month time horizon, based on a multicentre superiority randomised controlled trial from the perspective of the National Health Service (NHS) and personal social services in the UK. Setting: 17 specialist cardiac surgery centres in UK NHS hospitals. Participants:2003 patients aged >16 years undergoing non-emergency cardiac surgery with a postoperative haemoglobin of <9 g/dL. Interventions: Restrictive (transfuse if haemoglobin <7.5 g/dL) or liberal (transfuse if haemoglobin <9 g/dL) threshold during hospitalisation after surgery. Main outcome measures: Health-related quality of life measured using the EQ-5D-3L to calculate qualityadjusted life years (QALYs). Results: The total costs from surgery up to 3 months were £17 945 and £18 127 in the restrictive and liberal groups (mean difference is -£182, 95% CI -£1108 to £744). The cost difference was largely attributable to the difference in the cost of red blood cells. Mean QALYs to 3months were 0.18 in both groups (restrictive minus liberal difference is 0.0004, 95% CI -0.0037 to 0.0045). The point estimate for the base-case costeffectiveness analysis suggested that the restrictive group was slightly more effective and slightly less costly than the liberal group and, therefore, cost-effective. However, there is great uncertainty around these results partly due to the negligible differences in QALYs gained. Conclusions: We conclude that there is no clear difference in the cost-effectiveness of restrictive and liberal thresholds for red blood cell transfusion after cardiac surgery. [ABSTRACT FROM AUTHOR]