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2. The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery ( <scp>PREVENTT</scp> ) trial

Author

Richards, T., Miles, L.F., Clevenger, B., Keegan, A., Abeysiri, S., Rao Baikady, R., Besser, M.W., Browne, J.P., Klein, Andrew, Macdougall, I.C., Murphy, G.J., Anker, S.D., Dahly, Darren, Richards, Toby, Besser, Martin, Browne, John, Clevenger, Ben, Kegan, Anastazia, Miles, Lachlan, MacDougall, Iain, Baikady, Ravishankar Rao, Bradbury, Andrew, Evans, Richard, Grocott, Mike, Gibbs, Charlotte, Hughes, Timothy, Johnson, Lucy, Edwards, Mark, Plumb, James, Dushianthan, Ahilanandan, Collins, Hannah, Wilson, Amber, Ball, Darran, Wilson, Jonathan, Davies, Simon, Yates, David, Howard, Kate, Collins, Karen, Jenkins, Stephen, Parker, Jane, Hughes, Claire, Jones, Chris, Taylor, Louise, Williams, Sarah, and Horton, Sarah

Subjects
Anesthesiology and Pain Medicine
Abstract

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 −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.

Published
2022
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3. Systematic reviews and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: mortality, morbidity, and organ failure

Author

Alexander I.R. Jackson, Oliver Boney, Rupert M. Pearse, Andrea Kurz, D. James Cooper, Wilton A. van Klei, Luca Cabrini, Timothy E. Miller, S. Ramani Moonesinghe, Paul S. Myles, Michael P.W. Grocott, Paul Myles, T.J. Gan, Phil Peyton, Dan Sessler, Martin Tramèr, Alan Cyna, Gildasio S. De Oliveira, Christopher Wu, Mark Jensen, Henrik Kehlet, Mari Botti, Guy Haller, Mike Grocott, Tim Cook, Lee Fleisher, Mark Neuman, David Story, Russell Gruen, Sam Bampoe, Lis Evered, David Scott, Brendan Silbert, Diederik van Dijk, Cor Kalkman, Matthew Chan, Hilary Grocott, Rod Eckenhoff, Lars Rasmussen, Lars Eriksson, Scott Beattie, Duminda Wijeysundera, Giovanni Landoni, Kate Leslie, Bruce Biccard, Simon Howell, Peter Nagele, Toby Richards, Andre Lamy, Manoj Lalu, Rupert Pearse, Monty Mythen, Jaume Canet, Ann Moller, Tony Gin, Marcus Schultz, Paolo Pelosi, Marcelo Gabreu, Emmanuel Futier, Ben Creagh-Brown, Tom Abbot, Andy Klein, Tomas Corcoran, D. Jamie Cooper, Stefan Dieleman, Elisabeth Diouf, David McIlroy, Rinaldo Bellomo, Andrew Shaw, John Prowle, Keyvan Karkouti, Josh Billings, David Mazer, Mohindas Jayarajah, Michael Murphy, Justyna Bartoszko, Rob Sneyd, Steve Morris, Ron George, Ramani Moonesinghe, Mark Shulman, Meghan Lane-Fall, Ulrica Nilsson, Nathalie Stevenson, Wilton van Klei, Tim Miller, Sandy Jackson, Donal Buggy, Tim Short, Bernhard Riedel, Vijay Gottumukkala, Nathan Pace, Bilal Alkhaffaf, Mark Johnson, Intensive Care Medicine, ACS - Pulmonary hypertension & thrombosis, and AII - Inflammatory diseases

Subjects
surgery, Anesthesiology and Pain Medicine, consensus, morbidity, organ failure, anaesthesia, postoperative morbidity, perioperative outcomes, mortality
Abstract

Background: Mortality, morbidity, and organ failure are important and common serious harms after surgery. However, there are many candidate measures to describe these outcome domains. Definitions of these measures are highly variable, and validity is often unclear. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid measures of mortality, morbidity, and organ failure for use in perioperative clinical trials. Methods: Three domains of endpoints (mortality, morbidity, and organ failure) were explored through systematic literature review and a three-stage Delphi consensus process using methods consistently applied across the StEP initiative. Reliability, feasibility, and patient-centredness were assessed in round 3 of the consensus process. Results: A high level of consensus was achieved for two mortality time points, 30-day and 1-yr mortality, and these two measures are recommended. No organ failure endpoints achieved threshold criteria for consensus recommendation. The Clavien–Dindo classification of complications achieved threshold criteria for consensus in round 2 of the Delphi process but did not achieve the threshold criteria in round 3 where it scored equivalently to the Post Operative Morbidity Survey. Clavien–Dindo therefore received conditional endorsement as the most widely used measure. No composite measures of organ failure achieved an acceptable level of consensus. Conclusions: Both 30-day and 1-yr mortality measures are recommended. No measure is recommended for organ failure. One measure (Clavien–Dindo) is conditionally endorsed for postoperative morbidity, but our findings suggest that no single endpoint offers a reliable and valid measure to describe perioperative morbidity that is not dependent on the quality of deli-vered care. Further refinement of current measures, or development of novel measures, of postoperative morbidity might improve consensus in this area.

Published
2023
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4. Perioperative Risk Stratification and Modification

Author

Lewis, Matthews, Denny Z H, Levett, and Michael P W, Grocott

Subjects
Anesthesiology and Pain Medicine, Humans, General Medicine, Perioperative Period, Risk Assessment
Abstract

This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.

Published
2022
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6. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Author

Charlotte C. McEwen, Takhliq Amir, Yuan Qiu, Jack Young, Kevin Kennedy, Hilary P. Grocott, Hessam Kashani, David Mazer, Scott Brudney, Morvarid Kavosh, Eric Jacobsohn, Anne Vedel, Eugene Wang, Richard P. Whitlock, Emilie P. Belley-Coté, and Jessica Spence

Subjects
Adult, Cardiopulmonary Bypass, Anesthesiology and Pain Medicine, Humans, General Medicine, Cardiac Surgical Procedures, Hypotension, Morbidity, Randomized Controlled Trials as Topic
Abstract

Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT.We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings.We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials.Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required.PROSPERO (CRD42020177376); registered: 5 July 2020.RéSUMé: OBJECTIF: Pour beaucoup, la prise en charge de la pression artérielle pendant la chirurgie cardiaque serait associée aux issues postopératoires. Nous avons réalisé une revue systématique et une méta-analyse d’études randomisées contrôlées (ERC) afin de déterminer l’impact de cibles peropératoires de pression artérielle élevées par rapport à des cibles basses sur la morbidité et la mortalité postopératoires d’adultes bénéficiant d’une chirurgie cardiaque sous circulation extracorporelle (CEC). Notre objectif principal était d’orienter la conception d’une future ERC d’envergure.Nous avons analysé les bases de données MEDLINE, EMBASE, Web of Science, CINAHL et CENTRAL afin d’en tirer les ERC comparant des cibles de pression artérielle peropératoire élevées à des cibles basses chez des patients adultes bénéficiant d’une intervention chirurgicale cardiaque sous CEC. Nous avons passé au crible les listes de références, la littérature grise et les travaux de congrès.Nous avons inclus huit ERC (N = 1116 participants); toutes les études ont examiné l’effet de la prise en charge de la pression artérielle uniquement pendant la CEC. Les définitions d’une pression artérielle élevée ou basse variaient d’une étude à l’autre et, dans certains cas, un écart a été noté entre la pression artérielle cible et la pression artérielle moyenne atteinte. Nous n’avons observé aucune différence dans les taux de delirium, de déclin cognitif, d’accident vasculaire cérébral, d’insuffisance rénale aiguë ou de mortalité entre les cibles de pression artérielle élevée et basse (données probantes de qualité très faible à faible). Des cibles de pression artérielle plus élevées pourraient avoir augmenté le risque de transfusion sanguine (trois études; n = 456 participants; risque relatif, 1,4; intervalle de confiance à 95 %, 1,1 à 1,9; P = 0,01; données probantes de qualité modérée), mais ce résultat se fondait sur un petit nombre d’études.Les définitions individuelles des cibles d’hypertension et d’hypotension artérielle variaient, ce qui a limité les inférences. L’effet de cibles de pression artérielle élevée (par rapport à une pression artérielle basse) sur d’autres mesures de la morbidité et de la mortalité après une chirurgie cardiaque demeure incertain en raison des limites de l’ensemble des données probantes existantes. Des recherches visant à déterminer la prise en charge optimale de la pression artérielle pendant la chirurgie cardiaque sont nécessaires. ENREGISTREMENT DE L’éTUDE: PROSPERO (CRD42020177376); enregistrée le 5 juillet 2020.

Published
2022
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7. Systematic review and consensus definitions for the Standardized Endpoints in Perioperative Medicine (StEP) initiative: cardiovascular outcomes

Author

W. Scott Beattie, Manoj Lalu, Matthew Bocock, Simon Feng, Duminda N. Wijeysundera, Peter Nagele, Lee A. Fleisher, Andrea Kurz, Bruce Biccard, Kate Leslie, Simon Howell, Giovanni Landoni, Hilary Grocott, Andre Lamy, Toby Richards, Paul Myles, T.J. Gan, Phil Peyton, Dan Sessler, Martin Tramèr, Alan Cyna, Gildasio S. De Oliveira, Christopher Wu, Mark Jensen, Henrik Kehlet, Mari Botti, Oliver Boney, Guy Haller, Mike Grocott, Tim Cook, Lee Fleisher, Mark Neuman, David Story, Russell Gruen, Sam Bampoe, Lis Evered, David Scott, Brendan Silbert, Diederik van Dijk, Cor Kalkman, Matthew Chan, Rod Eckenhoff, Lars Rasmussen, Lars Eriksson, Scott Beattie, Duminda Wijeysundera, Richard J. Bartlett, Robert McMonnies, Jacob Gerstl, Mohammad Jay, David Kishlyansky, Matthew Machina, Matthew Bobcock, Rupert Pearse, Monty Mythen, Jaume Canet, Ann Moller, Tony Gin, Marcus Schultz, Paolo Pelosi, Marcelo Gabreu, Emmanuel Futier, Ben Creagh-Brown, Tom Abbott, Andy Klein, Tomas Corcoran, D. Jamie Cooper, Stefan Dieleman, Elisabeth Diouf, David McIlroy, Rinaldo Bellomo, Andrew Shaw, John Prowle, Keyvan Karkouti, Josh Billings, David Mazer, Mohindas Jayarajah, Michael Murphy, Justyna Bartoszko, Rob Sneyd, Steve Morris, Ron George, Ramani Moonesinghe, Mark Shulman, Meghan Lane-Fall, Ulrica Nilsson, Nathalie Stevenson, Jamie (DJ) Cooper, Wilton van Klei, Luca Cabrini, Tim Miller, Nathan Pace, Sandy Jackson, Donal Buggy, Tim Short, Bernhard Riedel, Vijay Gottumukkala, Bilal Alkhaffaf, Mark Johnson, Beattie, W. S., Lalu, M., Bocock, M., Feng, S., Wijeysundera, D. N., Nagele, P., Fleisher, L. A., Kurz, A., Biccard, B., Leslie, K., Howell, S., Landoni, G., Grocott, H., Lamy, A., Richards, T., Myles, P., Cooper, D. J., Gan, T. J., Peyton, P., Sessler, D., Tramer, M., Cyna, A., De Oliveira, G. S., Wu, C., Jensen, M., Kehlet, H., Botti, M., Boney, O., Haller, G., Grocott, M., Cook, T., Fleisher, L., Neuman, M., Story, D., Gruen, R., Bampoe, S., Evered, L., Scott, D., Silbert, B., van Dijk, D., Kalkman, C., Chan, M., Eckenhoff, R., Rasmussen, L., Eriksson, L., Beattie, S., Wijeysundera, D., Bartlett, R. J., Mcmonnies, R., Gerstl, J., Jay, M., Kishlyansky, D., Machina, M., Bobcock, M., Pearse, R., Mythen, M., Canet, J., Moller, A., Gin, T., Schultz, M., Pelosi, P., Gabreu, M., Futier, E., Creagh-Brown, B., Abbott, T., Klein, A., Corcoran, T., Dieleman, S., Diouf, E., Mcilroy, D., Bellomo, R., Shaw, A., Prowle, J., Karkouti, K., Billings, J., Mazer, D., Jayarajah, M., Murphy, M., Bartoszko, J., Sneyd, R., Morris, S., George, R., Moonesinghe, R., Shulman, M., Lane-Fall, M., Nilsson, U., Stevenson, N., Cooper, J. D., van Klei, W., Cabrini, L., Miller, T., Pace, N., Jackson, S., Buggy, D., Short, T., Riedel, B., Gottumukkala, V., Alkhaffaf, B., Johnson, M., Tramer, Martin, and Haller, Guy Serge Antoine

Subjects
medicine.medical_specialty, Consensus, Heart disease, Delphi Technique, Endpoint Determination, perioperative medicine, MACE, Cochrane Library, Perioperative Care, 03 medical and health sciences, Patient safety, cardiovascular events, outcome measures, 0302 clinical medicine, Postoperative Complications, 030202 anesthesiology, Anesthesiology, medicine, Humans, clinical trials, myocardial infarction, standardised endpoint, Intensive care medicine, Adverse effect, Clinical Trials as Topic, Perioperative medicine, ddc:617, business.industry, Cardiovascular Diseases, Perioperative Medicine, Research Design, Perioperative, medicine.disease, Clinical trial, Anesthesiology and Pain Medicine, business
Abstract

Background: Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of standardised and valid cardiovascular outcomes for use in future perioperative clinical trials.Methods: We identified currently used perioperative cardiovascular outcomes by a systematic review of the anaesthesia and perioperative medicine literature (PubMed/Ovid, Embase, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 55 clinician researchers worldwide. Cardiovascular outcomes were first shortlisted and the most suitable definitions determined. These cardiovascular outcomes were then assessed for validity, reliability, feasibility, and clarity.Results: We identified 18 cardiovascular outcomes. Participation in the three Delphi rounds was 100% (n=19), 71% (n=55), and 89% (n=17), respectively. A final list of nine cardiovascular outcomes was elicited from the consensus: myocardial infarction, myocardial injury, cardiovascular death, non-fatal cardiac arrest, coronary revascularisation, major adverse cardiac events, pulmonary embolism, deep vein thrombosis, and atrial fibrillation. These nine cardiovascular outcomes were rated by the majority of experts as valid, reliable, feasible, and clearly defined.Conclusions: These nine consensus cardiovascular outcomes can be confidently used as endpoints in clinical trials designed to evaluate perioperative interventions with the goal of improving perioperative outcomes.

Published
2021

8. Oxygen Management During Cardiopulmonary Bypass: A Single-Center, 8-Year Retrospective Cohort Study

Author

Hilary P. Grocott, Bronwen B. Grocott, Hendrick Maakamedi, Hessam H. Kashani, Brett Hiebert, Martin Rakar, and Vikas Dutta

Subjects
medicine.medical_specialty, chemistry.chemical_element, 030204 cardiovascular system & hematology, Single Center, Oxygen, law.invention, 03 medical and health sciences, 0302 clinical medicine, 030202 anesthesiology, law, Fraction of inspired oxygen, Cardiopulmonary bypass, medicine, Humans, Oximetry, Cardiac Surgical Procedures, Management practices, Retrospective Studies, Cardiopulmonary Bypass, business.industry, Retrospective cohort study, Cardiac surgery, Anesthesiology and Pain Medicine, chemistry, Anesthesia, Circulatory system, Cardiology and Cardiovascular Medicine, business
Abstract

Objective To characterize the institutional oxygen management practices during cardiopulmonary bypass (CPB) in patients undergoing cardiac surgery, including any potential changes during an 8-year study period. Design A retrospective cohort study. Setting A tertiary care cardiac surgical program. Participants Patients who underwent cardiac surgery involving CPB, with or without hypothermic circulatory arrest (HCA), between January 1, 2010, and December 31, 2017. Measurements and Main Results In addition to baseline patient characteristics, the authors recorded the partial pressures of arterial oxygen (Pa o 2), fraction of inspired oxygen, and mixed venous oxygen saturation during CPB of 696 randomly selected patients during an 8-year study period. The overall mean Pa o 2 was 255 ± 48 mmHg, without any significant change during the 8-year study period (p = 0.30). The mean Pa o 2 of HCA patients was significantly higher than in patients without HCA (327 ± 93 mmHg v 252 ± 45 mmHg, respectively; p Conclusions The current approach to oxygen management during CPB at the authors’ institution is within the range of hyperoxemic levels, and these practices have not changed over time. The impact of these practices on patients’ outcomes is not fully understood, and additional studies are needed to establish firm evidence to guide optimal oxygen management practice during CPB.

Published
2021
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9. Extracorporeal Membrane Oxygenation for Respiratory Failure

Author

John J. Marini, Stefano Nava, Daniel Brodie, Michael Quintel, Luciano Gattinoni, Alain Combes, Francesco Vasques, Massimo Baiocchi, Mattia Busana, Marco Ranieri, Robert H. Bartlett, Luigi Camporota, Michael P.W. Grocott, Quintel M., Bartlett R.H., Grocott M.P.W., Combes A., Ranieri M.V., Baiocchi M., Nava S., Brodie D., Camporota L., Vasques F., Busana M., Marini J.J., and Gattinoni L.

Subjects
Extracorporeal Circulation, medicine.medical_specialty, ARDS, Ventilator-Induced Lung Injury, medicine.medical_treatment, Context (language use), Lung injury, Extracorporeal, 03 medical and health sciences, Extracorporeal Membrane Oxygenation, 0302 clinical medicine, medicine, Extracorporeal membrane oxygenation, Animals, Humans, Intensive care medicine, Mechanical ventilation, Animal, Pulmonary Gas Exchange, business.industry, Extracorporeal circulation, 030208 emergency & critical care medicine, Carbon Dioxide, medicine.disease, Respiration, Artificial, Anesthesiology and Pain Medicine, 030228 respiratory system, Respiratory failure, Respiratory Insufficiency, business, Human
Abstract

This review focuses on the use of veno-venous extracorporeal membrane oxygenation for respiratory failure across all blood flow ranges. Starting with a short overview of historical development, aspects of the physiology of gas exchange (i.e., oxygenation and decarboxylation) during extracorporeal circulation are discussed. The mechanisms of phenomena such as recirculation and shunt playing an important role in daily clinical practice are explained. Treatment of refractory and symptomatic hypoxemic respiratory failure (e.g., acute respiratory distress syndrome [ARDS]) currently represents the main indication for high-flow veno-venous-extracorporeal membrane oxygenation. On the other hand, lower-flow extracorporeal carbon dioxide removal might potentially help to avoid or attenuate ventilator-induced lung injury by allowing reduction of the energy load (i.e., driving pressure, mechanical power) transmitted to the lungs during mechanical ventilation or spontaneous ventilation. In the latter context, extracorporeal carbon dioxide removal plays an emerging role in the treatment of chronic obstructive pulmonary disease patients during acute exacerbations. Both applications of extracorporeal lung support raise important ethical considerations, such as likelihood of ultimate futility and end-of-life decision-making. The review concludes with a brief overview of potential technical developments and persistent challenges.

Published
2020
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11. Perioperative hyperoxia and myocardial injury after surgery (MINS): a randomized controlled trial

Author

Marc SADURNI, Laura CASTELLTORT, Pedro RIVERA, Lluís GALLART, Marta PASCUAL, Xavier DURAN, and Mike P. GROCOTT

Subjects
Anesthesiology and Pain Medicine
Abstract

The World Health Organization recommends hyperoxia (80% fraction of inspired oxygen, FiO2) during and for 2-6 hours following surgery to reduce surgical site infection (SSI). However, some studies suggest increased cardiovascular complications with such a high perioperative FiO2. The goal of our study was to compare the appearance of cardiovascular complications in elective adult colorectal surgery comparing the use of FiO20.8 versus conventional therapy (FiO20.4).We performed a randomized controlled trial in intubated patients undergoing elective major colorectal surgery. Patients were randomly assigned to receive perioperative FiO20.8 or FiO20.4. The primary outcome, expressed as Odds Ratio (OR) ± 95% Confidence Interval (95%CI), was the incidence of MINS (myocardial injury after noncardiac surgery evaluated for the first 4 postoperative days). Secondary outcomes included MACCE (major adverse cardiovascular and cerebral events) up to 30 postoperative days, SSI, other postoperative complications (according to Clavien-Dindo classification) and length of stay.We included in the final analyses 403 patients. Comparing the FiO20.8 and FiO20.4 groups, there was no difference in the appearance of MINS (6.0 % vs. 10.4%; OR 0.55; 95% CI 0.26 - 1.14; p=0.945). There were no differences between the groups for important secondary outcomes including MACCE to 30 days, SSI, postoperative complications or length of stay.Perioperative hyperoxia therapy (FiO20.8) with the aim of decreasing SSI did not increase cardiovascular complications after elective colorectal surgery in a general population.

Published
2022

12. A capaciflector provides continuous and accurate respiratory rate monitoring for patients at rest and during exercise

Author

Nick Hayward, Mahdi Shaban, James Badger, Isobel Jones, Yang Wei, Daniel Spencer, Stefania Isichei, Martin Knight, James Otto, Gurinder Rayat, Denny Levett, Michael Grocott, Harry Akerman, and Neil White

Subjects
Respiratory monitoring, Respiration, Capaciflector, Reproducibility of Results, Health Informatics, Critical Care and Intensive Care Medicine, Perioperative medicine, Critical care, Anesthesiology and Pain Medicine, Respiratory Rate, Humans, Original Research, Sensor, Monitoring, Physiologic
Abstract

Respiratory rate (RR) is a marker of critical illness, but during hospital care, RR is often inaccurately measured. The capaciflector is a novel sensor that is small, inexpensive, and flexible, thus it has the potential to provide a single-use, real-time RR monitoring device. We evaluated the accuracy of continuous RR measurements by capaciflector hardware both at rest and during exercise. Continuous RR measurements were made with capaciflectors at four chest locations. In healthy subjects (n = 20), RR was compared with strain gauge chest belt recordings during timed breathing and two different body positions at rest. In patients undertaking routine cardiopulmonary exercise testing (CPET, n = 50), RR was compared with pneumotachometer recordings. Comparative RR measurement bias and limits of agreement were calculated and presented in Bland–Altman plots. The capaciflector was shown to provide continuous RR measurements with a bias less than 1 breath per minute (BPM) across four chest locations. Accuracy and continuity of monitoring were upheld even during vigorous CPET exercise, often with narrower limits of agreement than those reported for comparable technologies. We provide a unique clinical demonstration of the capaciflector as an accurate breathing monitor, which may have the potential to become a simple and affordable medical device.Clinical trial number: NCT03832205 https://clinicaltrials.gov/ct2/show/NCT03832205 registered February 6th, 2019.

Published
2022

15. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery

Author

Daniel I. Sessler, Joshua A. Bloomstone, Solomon Aronson, Colin Berry, Tong J. Gan, John A. Kellum, James Plumb, Monty G. Mythen, Michael P.W. Grocott, Mark R. Edwards, Timothy E. Miller, Michael PW. Grocott, Gareth L. Ackland, Charles S. Brudney, Maurizio Cecconi, Can Ince, Michael G. Irwin, Jonathan Lacey, Michael R. Pinsky, Robert Sanders, Finton Hughes, Angela Bader, Annemarie Thompson, Andreas Hoeft, David Williams, Andrew D. Shaw, Sol Aronson, John Kellum, Joshua Bloomstone, Matthew D. McEvoy, Julie K.M. Thacker, Ruchir Gupta, Elena Koepke, Aarne Feldheiser, Denny Levett, Frederic Michard, and Mark Hamilton

Subjects
Anesthesiology and Pain Medicine
Published
2019
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16. Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery

Author

Robert D. Sanders, Fintan Hughes, Andrew Shaw, Annemarie Thompson, Angela Bader, Andreas Hoeft, David A. Williams, Michael P.W. Grocott, Monty G. Mythen, Timothy E. Miller, Mark R. Edwards, Michael PW. Grocott, Gareth L. Ackland, Charles S. Brudney, Maurizio Cecconi, Can Ince, Michael G. Irwin, Jonathan Lacey, Michael R. Pinsky, Robert Sanders, Finton Hughes, David Williams, Andrew D. Shaw, Daniel I. Sessler, Sol Aronson, Colin Berry, Tong J. Gan, John Kellum, James Plumb, Joshua Bloomstone, Matthew D. McEvoy, Julie K.M. Thacker, Ruchir Gupta, Elena Koepke, Aarne Feldheiser, Denny Levett, Frederic Michard, and Mark Hamilton

Subjects
medicine.medical_specialty, business.industry, MEDLINE, Diastole, Hemodynamics, Perioperative, medicine.disease, Discontinuation, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Blood pressure, 030202 anesthesiology, Emergency medicine, Medicine, Myocardial infarction, Elective surgery, business
Abstract

Background A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk. Methods A modified Delphi technique was used, evaluating papers published in MEDLINE on associations between preoperative numerical arterial pressure values or cardiovascular medications and perioperative outcomes. The strength of the recommendations was graded by National Institute for Health and Care Excellence guidelines. Results Significant heterogeneity in study design, including arterial pressure measures and perioperative outcomes, hampered the comparison of studies. Nonetheless, consensus recommendations were that (i) preoperative arterial pressure measures may be used to define targets for perioperative management; (ii) elective surgery should not be cancelled based solely upon a preoperative arterial pressure value; (iii) there is insufficient evidence to support lowering arterial pressure in the immediate preoperative period to minimise perioperative risk; and (iv) there is insufficient evidence that any one measure of arterial pressure (systolic, diastolic, mean, or pulse) is better than any other for risk prediction of adverse perioperative events. Conclusions Future research should define which preoperative arterial pressure values best correlate with adverse outcomes, and whether modifying arterial pressure in the preoperative setting will change the perioperative morbidity or mortality. Additional research should define optimum strategies for continuation or discontinuation of preoperative cardiovascular medications.

Published
2019
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17. A changing of the Journal’s guard

Author

Hilary P. Grocott

Subjects
medicine.medical_specialty, Guard (information security), business.industry, Pain medicine, Editorials, MEDLINE, General Medicine, medicine.disease, Anesthesiology and Pain Medicine, Anesthesiology, Anesthesia, medicine, Medical emergency, business
Published
2020
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18. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Cerebral Near-Infrared Spectroscopy

Author

Robert H, Thiele, Andrew D, Shaw, Karsten, Bartels, Charles H, Brown, Hilary, Grocott, Matthias, Heringlake, Tong Joo, Gan, Timothy E, Miller, and Matthew D, McEvoy

Subjects
medicine.medical_specialty, Consensus, Context (language use), Perioperative Care, law.invention, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, 030202 anesthesiology, law, Humans, Medicine, Intensive care medicine, Stroke, Coma, Spectroscopy, Near-Infrared, business.industry, Venous blood, Perioperative, medicine.disease, Neurophysiological Monitoring, Intensive care unit, Cardiac surgery, Anesthesiology and Pain Medicine, Anesthesia Recovery Period, Nervous System Diseases, medicine.symptom, Enhanced Recovery After Surgery, business, Neurocognitive, 030217 neurology & neurosurgery
Abstract

Some neurological complications following surgery have been related to a mismatch in cerebral oxygen supply and demand that may either lead to more subtle changes of brain function or overt complications like stroke or coma. Discovery of a perioperative neurological complication may be outside the treatment window, thereby making prevention an important focus. Early commercial devices used differential spectroscopy to measure relative changes from baseline of 2 chromophores: oxy- and deoxyhemoglobin. It was the introduction of spatially resolved spectroscopy techniques that allowed near-infrared spectroscopy (NIRS)-based cerebral oximetry as we know it today. Modern cerebral oximeters measure the hemoglobin saturation of blood in a specific "optical field" containing arterial, capillary, and venous blood, not tissue oxygenation itself. Multiple cerebral oximeters are commercially available, all of which have technical differences that make them noninterchangeable. The mechanism and meaning of these measurements are likely not widely understood by many practicing physicians. Additionally, as with many clinically used monitors, there is a lack of high-quality evidence on which clinicians can base decisions in their effort to use cerebral oximetry to reduce neurocognitive complications after surgery. Therefore, the Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together an international team of multidisciplinary experts including anesthesiologists, surgeons, and critical care physicians to objectively survey the literature on cerebral oximetry and provide consensus, evidence-based recommendations for its use in accordance with the GRading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature. The group produced the following consensus recommendations: (1) interpreting perioperative cerebral oximetry measurements in the context of a preinduction baseline value; (2) interpreting perioperative cerebral oximetry measurements in the context of the physiologic variables that affect them; (3) using caution in comparing cerebral oximetry values between different manufacturers; (4) using preoperative cerebral oximetry to identify patients at increased risk of adverse outcomes after cardiac surgery; (5) using intraoperative cerebral oximetry indexed to preinduction baseline to identify patients at increased risk of adverse outcomes after cardiac surgery; (6) using cerebral oximetry to identify and guide management of acute cerebral malperfusion during cardiac surgery; (7) using an intraoperative cerebral oximetry-guided interventional algorithm to reduce intensive care unit (ICU) length of stay after cardiac surgery. Additionally, there was agreement that (8) there is insufficient evidence to recommend using intraoperative cerebral oximetry to reduce mortality or organ-specific morbidity after cardiac surgery; (9) there is insufficient evidence to recommend using intraoperative cerebral oximetry to improve outcomes after noncardiac surgery.

Published
2020
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19. From theory to practice: an international approach to establishing prehabilitation programmes

Author

Davis, June F., van Rooijen, Stefan J., Grimmett, Chloe, West, Malcom A., Campbell, Anna M., Awasthi, Rashami, Slooter, Gerrit D., Grocott, Michael P., Carli, Franco, and Jack, Sandy

Subjects
Anesthesiology and Pain Medicine, Prehabilitation, Cancer, Surgery, Business case, Multidisciplinary, Multimodal, Team, Implementation
Abstract

Purpose This article focuses on the following: The importance of prehabilitation in people with cancer and the known and hypothesised benefits. Exploration of the principles that can be used when developing services in the absence of a single accepted model of how these services could be established or configured. Description of approaches and learning in the development and implementation of prehabilitation across three different countries: Canada, the Netherlands and the United Kingdom, based on the authors’ experiences and perspectives. Recent Findings Practical tips and suggestions are shared by the authors to assist others when implementing prehabilitation programmes. These include experience from three different approaches with similar lessons. Important elements include the following: (i) starting with a small identified clinical group of patients to refine and test the delivery model and demonstrate proof of concept; (ii) systematic data collection with clearly identified target outcomes from the outset; (iii) collaboration with a wide range of stakeholders including those who will be designing, developing, delivering, funding and using the prehabilitation services; (iv) adapting the model to fit local situations; (v) project leaders who can bring together and motivate a team; (vi) recognition and acknowledgement of the value that each member of a diverse multidisciplinary team brings; (vii) involvement of the whole team in prehabilitation prescription including identification of patients’ levels of risk through appropriate assessment and need-based interventions; (viii) persistence and determination in the development of the business case for sustainable funding; (ix) working with patients ambassadors to develop and advocate for the case for support; and (x) working closely with commissioners of healthcare. Summary Principles for the implementation of prehabilitation have been set out by sharing the experiences across three countries. These principles should be considered a framework for those wishing to design and develop prehabilitation services in their own areas to maximise success, effectiveness and sustainability.

Published
2022

20. Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC): a modified Delphi process to develop a core outcome set for trials in perioperative care and anaesthesia

Author

Rinaldo Bellomo, W.S. Beattie, Toby Richards, D. I. Sessler, Donal J. Buggy, D.P.J. van Dijk, David Mazer, Brendan S. Silbert, Kate Leslie, Andrew D. Shaw, Simon J. Howell, Mark D. Neuman, P. Peyton, Mohandas Jayarajah, Mark A Shulman, Hilary P. Grocott, Luca Cabrini, Oliver Boney, Cornelis J. Kalkman, Andrew A. Klein, Tim Cook, Mervyn Singer, Lis Evered, Monty G. Mythen, John R. Prowle, P. J. Devereaux, David R. McIlroy, Timothy G. Short, David James Cooper, R.M. Pearse, Tony Gin, Michael P.W. Grocott, R. Eckenhoff, Jaume Canet, Paul S. Myles, David Scott, Keyvan Karkouti, Ann Merete Møller, Guy Haller, T. J. Gan, S Ramani Moonesinghe, David A Story, J.R. Sneyd, Brian P. Kavanagh, Tomas Corcoran, Justyna Bartoszko, W. A. van Klei, and Giovanni Landoni

Subjects
Adult, Male, Consensus, Adolescent, Delphi Technique, perioperative medicine, Outcome (game theory), core outcome, Perioperative Care, surgery, Patient safety, Young Adult, Quality of life (healthcare), Postoperative Complications, Outcome Assessment, Health Care, Medicine, Humans, Anesthesia, Adverse effect, Aged, Anesthetics, Randomized Controlled Trials as Topic, Perioperative medicine, standardised endpoints, business.industry, anaesthesia, Perioperative, Middle Aged, Clinical trial, Anesthesiology and Pain Medicine, Clinical research, patient-centred outcome, Quality of Life, Female, business
Abstract

Background Outcome selection underpins clinical trial interpretation. Inconsistency in outcome selection and reporting hinders comparison of different trials' results, reducing the utility of research findings. Methods We conducted an iterative consensus process to develop a set of Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC), following the established Core Outcome Measures for Effectiveness Trials (COMET) methodology. First, we undertook a systematic review of RCTs in high-impact journals to describe current outcome reporting trends. We then surveyed patients, carers, researchers, and perioperative clinicians about important outcomes after surgery. Finally, a purposive stakeholder sample participated in a modified Delphi process to develop a core outcome set for perioperative and anaesthesia trials. Results Our systematic review revealed widespread inconsistency in outcome reporting, with variable or absent definitions, levels of detail, and temporal criteria. In the survey, almost all patients, carers, and clinicians rated clinical outcome measures critically important, but clinicians rated patient-centred outcomes less highly than patients and carers. The final core outcome set was: (i) mortality/survival (postoperative mortality, long-term survival); (ii) perioperative complications (major postoperative complications/adverse events; complications/adverse events causing permanent harm); (iii) resource use (length of hospital stay, unplanned readmission within 30 days); (iv) short-term recovery (discharge destination, level of dependence, or both); and (v) longer-term recovery (overall health-related quality of life). Conclusions This core set, incorporating important outcomes for both clinicians and patients, should guide outcome selection in future perioperative medicine or anaesthesia trials. Mapping these alongside standardised endpoint definitions will yield a comprehensive perioperative outcome framework.

Published
2021

21. Impact of cardiopulmonary bypass duration on efficacy of fibrinogen replacement with cryoprecipitate compared with fibrinogen concentrate: a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) randomised controlled trial

Author

Justyna Bartoszko, Selene Martinez-Perez, Jeannie Callum, Keyvan Karkouti, Michael E. Farouh, Damon C. Scales, Nancy M. Heddle, Mark Crowther, Vivek Rao, Hans-Peter Hucke, Jo Carroll, Deep Grewal, Sukhpal Brar, Jean Brussières, Hilary Grocott, Christopher Harle, Katerina Pavenski, Antoine Rochon, Tarit Saha, Lois Shepherd, Summer Syed, Diem Tran, Daniel Wong, and Michelle Zeller

Subjects
Adult, Anesthesiology and Pain Medicine, Cardiopulmonary Bypass, Fibrinogen, Humans, Blood Transfusion, Hemorrhage, Blood Coagulation Disorders, Afibrinogenemia, Hemostatics
Abstract

Coagulopathy in cardiac surgery is frequently associated with acquired hypofibrinogenaemia, which can be treated with either purified fibrinogen concentrate (FC) or cryoprecipitate. Because the latter is not purified and therefore contains additional coagulation factors, it is thought to be more effective for treatment of coagulopathy that occurs after prolonged cardiopulmonary bypass (CPB). We examined the impact of CPB duration on the efficacy of the two therapies in cardiac surgery.This was a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) RCT comparing FC (4 g) to cryoprecipitate (10 U) in adult patients undergoing cardiac surgery and experiencing bleeding with acquired hypofibrinogenaemia (n=735). The primary outcome was allogeneic blood products transfused within 24 h after CPB. Subjects were stratified by CPB duration (≤120, 121-180, and180 min). The interaction of treatment assignment with CPB duration was tested.Subjects with longer CPB duration experienced more bleeding and transfusion. With CPB time ≤120 min (FC, n=134; cryoprecipitate, n=146), the ratio of least-squares means between the FC and cryoprecipitate groups for total allogeneic blood products at 24 h was 0.90 (one-sided 97.5% confidence interval [CI]: 0.00-1.12); P=0.004. For subjects with CPB time 121-180 min, it was 1.00 ([one-sided 97.5% CI: 0.00-1.22]; P=0.03], and for CPB time180 min it was 0.91 ([one-sided 97.5% CI: 0.00-1.12]; P=0.005). Results were similar for all secondary outcomes, with no interaction between treatment and CPB duration for all outcomes.The haemostatic efficacy of FC was non-inferior to cryoprecipitate irrespective of CPB duration in cardiac surgery.NCT03037424.

Published
2022

22. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: clinical indicators

Author

Guy Haller, Sohail Bampoe, Tim Cook, Lee A. Fleisher, Michael P.W. Grocott, Mark Neuman, David Story, Paul S. Myles, P. Myles, M. Grocott, B. Biccard, J. Blazeby, O. Boney, M. Chan, E. Diouf, L. Fleisher, C. Kalkman, A. Kurz, R. Moonesinghe, D. Wijeysundera, T.J. Gan, P. Peyton, D. Sessler, M. Tramèr, A. Cyna, G.S. De Oliveira, C. Wu, M. Jensen, H. Kehlet, M. Botti, G. Haller, T. Cook, M. Neuman, D. Story, R. Gruen, S. Bampoe, L. Evered, D. Scott, B. Silbert, D. van Dijk, H. Grocott, R. Eckenhoff, L. Rasmussen, L. Eriksson, S. Beattie, G. Landoni, K. Leslie, S. Howell, P. Nagele, T. Richards, A. Lamy, M. Lalu, R. Pearse, M. Mythen, J. Canet, A. Moller, T. Gin, M. Schultz, P. Pelosi, M. Gabreu, E. Futier, B. Creagh-Brown, T. Abbott, A. Klein, T. Corcoran, D. Jamie Cooper, S. Dieleman, D. McIlroy, R. Bellomo, A. Shaw, J. Prowle, K. Karkouti, J. Billings, D. Mazer, M. Jayarajah, M. Murphy, J. Bartoszko, R. Sneyd, S. Morris, R. George, M. Shulman, M. Lane-Fall, U. Nilsson, N. Stevenson, J.D.J. Cooper, W. van Klei, L. Cabrini, T. Miller, N. Pace, S. Jackson, D. Buggy, T. Short, B. Riedel, V. Gottumukkala, B. Alkhaffaf, M. Johnson, Intensive Care Medicine, ACS - Diabetes & metabolism, ACS - Pulmonary hypertension & thrombosis, ACS - Microcirculation, Haller, G, Bampoe, S, Cook, T, Fleisher, La, Grocott, Mpw, Neuman, M, Story, D, Myles, P, on behalf of the StEP-COMPAC, Group, Landoni, G, and Tramer, Martin

Subjects
Outcome Assessment, Cochrane Library, law.invention, quality improvement, 0302 clinical medicine, 030202 anesthesiology, law, Outcome Assessment, Health Care, Health care, patient safety, clinical indicators, clinical trials, outcome measures, perioperative medicine, standardised endpoint, Clinical Trials as Topic, Humans, Patient Safety, Perioperative Care, Quality of Health Care, Reference Standards, Reproducibility of Results, Consensus, Perioperative medicine, ddc:617, Manchester Cancer Research Centre, Patient Safety/standards, Outcome Assessment, Health Care/standards, clinical trial, Intensive care unit, Quality of Health Care / standards, medicine.medical_specialty, Health Care/standards, Perioperative Care/standards, Quality of Health Care/standards, 03 medical and health sciences, Patient safety, Anesthesiology, medicine, Journal Article, clinical indicator, outcome measure, business.industry, ResearchInstitutes_Networks_Beacons/mcrc, Perioperative Care / standards, Perioperative, Patient Safety / standards, Clinical trial, Health Care, Anesthesiology and Pain Medicine, Emergency medicine, Quality and Patient Safety, Outcome Assessment, Health Care / standards, Systematic Review, business
Abstract

Background Clinical indicators are powerful tools to quantify the safety and quality of patient care. Their validity is often unclear and definitions extremely heterogeneous. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid clinical outcome indicators for use in perioperative clinical trials. Methods We identified clinical indicators via a systematic review of the anaesthesia and perioperative medicine literature (PubMed/OVID, EMBASE, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 54 clinician–researchers worldwide. Indicators were first shortlisted and the most suitable definitions for evaluation of quality and safety interventions determined. Indicators were then assessed for validity, reliability, feasibility, and clarity. Results We identified 167 clinical outcome indicators. Participation in the three Delphi rounds was 100% (n=13), 68% (n=54), and 85% (n= 6), respectively. A final list of eight outcome indicators was generated: surgical site infection at 30 days, stroke within 30 days of surgery, death within 30 days of coronary artery bypass grafting, death within 30 days of surgery, admission to the intensive care unit within 14 days of surgery, readmission to hospital within 30 days of surgery, and length of hospital stay (with or without in-hospital mortality). They were rated by the majority of experts as valid, reliable, easy to use, and clearly defined. Conclusions These clinical indicators can be confidently used as endpoints in clinical trials measuring quality, safety, and improvement in perioperative care. Registration PROSPERO 2016 CRD42016042102 (http://www.crd.york.ac.uk/PROSPERO/display_record.php? ID=CRD42016042102).

Published
2019
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23. Noninvasive ventilation for COVID-19 associated acute hypoxaemic respiratory failure: experience from a single centre

Author

Hannah Burke, Mpw Grocott, Michael Celinski, Rebecca Cusack, Mark Jones, Myra Nasim-Mohi, David Land, David Sparkes, Mai Wakatsuki, S Jackson, Michael Stewart, Meyer Brown, A.A. Sivaloganathan, Denny Z. H. Levett, S.V. Fletcher, Shashank R Gupta, Jonathan Fennell, Kathleen Nolan, Anna Freeman, Paul T. Elkington, Robert Chambers, Suzie Tanser, Saul N. Faust, Paddy Dennison, Ahilanandan Dushianthan, Sophie V. Fletcher, Ben Thomas, Julian Nixon, Sanjay Gupta, Arjjana Sivaloganathan, Francois Wessels, Anastasios Lekkas, Mark I. Allenby, Ahilanadan Dushianthan, Christopher Kipps, Michael P.W. Grocott, Timothy Nicholson-Robert, Tom Wilkinson, Gareth J. Thomas, Dominic Richardson, Thomas Daniels, N. Abdul, and Benjamin Skinner

Subjects
Adult, Male, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Adolescent, Critical Care, medicine.medical_treatment, Pneumonia, Viral, mechanical ventilation, Article, Cohort Studies, Young Adult, Intensive care, Pandemic, Medicine, Humans, Young adult, Hypoxia, Pandemics, Aged, intensive care, Mechanical ventilation, business.industry, COVID-19, noninvasive ventilation, Middle Aged, Respiration, Artificial, Anesthesiology and Pain Medicine, Respiratory failure, Emergency medicine, Acute Disease, Noninvasive ventilation, Female, business, Coronavirus Infections, Respiratory Insufficiency, Cohort study
Published
2020

24. Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery

Author

Matthew D. McEvoy, Ruchir Gupta, Elena J. Koepke, Aarne Feldheiser, Frederic Michard, Denny Levett, Julie K.M. Thacker, Mark Hamilton, Michael P.W. Grocott, Monty G. Mythen, Timothy E. Miller, Mark R. Edwards, Michael PW. Grocott, Gareth L. Ackland, Charles S. Brudney, Maurizio Cecconi, Can Ince, Michael G. Irwin, Jonathan Lacey, Michael R. Pinsky, Robert Sanders, Finton Hughes, Angela Bader, Annemarie Thompson, Andreas Hoeft, David Williams, Andrew D. Shaw, Daniel I. Sessler, Sol Aronson, Colin Berry, Tong J. Gan, John Kellum, James Plumb, Joshua Bloomstone, Elena Koepke, and Intensive Care

Subjects
Anesthesiology and Pain Medicine
Published
2019

25. Development and evaluation of a novel pre‐operative surgery school and behavioural change intervention for patients undergoing elective major surgery: Fit‐4‐Surgery School

Author

Chloe Grimmett, Denny Z. H. Levett, H Leach, J Smith, Imogen Fecher-Jones, Mark R Edwards, Sandy Jack, Helen Moyses, J S Knight, and Michael P.W. Grocott

Subjects
Adult, Male, medicine.medical_specialty, Behaviour change, Adolescent, Prehabilitation, Health Promotion, Multiple deprivation, Young Adult, 03 medical and health sciences, 0302 clinical medicine, 030202 anesthesiology, Surveys and Questionnaires, Intervention (counseling), Preoperative Care, Humans, Medicine, 030212 general & internal medicine, Health Education, Life Style, Aged, Aged, 80 and over, business.industry, Middle Aged, Pre operative, Surgery, Anesthesiology and Pain Medicine, Lifestyle factors, Elective Surgical Procedures, Female, business, Program Evaluation
Abstract

Group pre-operative education has usually been limited to conditioning expectations and providing education. Prehabilitation has highlighted modifiable lifestyle factors that are amenable to change and may improve clinical outcomes. We instituted a pre-operative ‘Fit-4-Surgery School’ for patients scheduled for major surgery, to educate and promote healthy behaviour. We evaluated patients’ views having attended the school, and after surgery we asked how it had changed their behaviour with a lifestyle questionnaire. The school was launched in May 2016 and was attended by 586/1017 (58%) of invited patients. Patients who did not attend: lived further away, median (IQR [range]) 8 (4–19 [0–123]) miles vs. 5 (3–14 [0–172]) miles, p < 0.001; and were more deprived, Index of Multiple Deprivation Rank decile median (IQR [range]), 6 (4–8 [1–10]) vs. 7 (4–9 [1–10]), p = 0.04. Of the 492/586 (84%) participants who completed an evaluation questionnaire, 462 (94%) would recommend the school to a friend having surgery and 296 (60%) planned lifestyle changes. After surgery, 232/586 (40%) completed a behavioural change questionnaire, 106 (46%) of whom reported changing at least one lifestyle factor, most commonly by increasing exercise. The pre-operative school was acceptable to patients.

Published
2021

26. The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis

Author

Hilary P. Grocott, Rasheda Rabbani, Christine J. Neilson, George N. Okoli, Ahmed M Abou-Setta, Carly Lodewyks, Maya M. Jeyaraman, Hessam H. Kashani, Morvarid S. Kavosh, and Ryan Zarychanski

Subjects
medicine.medical_specialty, Blood transfusion, business.industry, Mortality rate, medicine.medical_treatment, General Medicine, Perioperative, 030204 cardiovascular system & hematology, Cardiac surgery, Clinical trial, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Meta-analysis, Relative risk, Anesthesia, Anesthesiology, Emergency medicine, Medicine, 030212 general & internal medicine, business
Abstract

Blood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a “restrictive” strategy with a “liberal” strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery. We searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1 December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery. From 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I2 = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I2 = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy. In adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery. PROSPERO (CRD42017071440); registered 20 April, 2018.

Published
2020
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27. Cardiopulmonary Exercise Testing for Preoperative Evaluation: What Does the Future Hold?

Author

James M. Otto, Michael P.W. Grocott, and Denny Z. H. Levett

Subjects
medicine.medical_specialty, business.industry, Prehabilitation, Cardiopulmonary exercise testing, Perioperative, 030204 cardiovascular system & hematology, medicine.disease, Comorbidity, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, 030220 oncology & carcinogenesis, Anesthesiology, Medicine, Constant work rate, business, Intensive care medicine, Prospective cohort study, Exercise prescription
Abstract

Purpose of Review Cardiopulmonary exercise testing (CPET) informs the preoperative evaluation process by providing individualised risk profiles; guiding shared decision-making, comorbidity optimisation and preoperative exercise training; and informing perioperative patient management. This review summarises evidence on the role of CPET in preoperative evaluation and explores the role of novel and emerging CPET variables and alternative testing protocols that may improve the precision of preoperative evaluation in the future. Recent Findings CPET provides a wealth of physiological data, and to date, much of this is underutilised clinically. For example, impaired chronotropic responses during and after CPET are simple to measure and in recent studies are predictive of both cardiac and noncardiac morbidity following surgery but are rarely reported. Exercise interventions are increasingly being used preoperatively, and endurance time derived from a high intensity constant work rate test should be considered as the most sensitive method of evaluating the response to training. Further research is required to identify the clinically meaningful difference in endurance time. Measuring efficiency may have utility, but this requires exploration in prospective studies. Summary Further work is needed to define contemporaneous risk thresholds, to explore the role of other CPET variables in risk prediction, to better characterise CPET’s role in combination with other tools in multifactorial risk stratification and increasingly to evaluate CPET’s utility for preoperative exercise prescription in prehabilitation.

Published
2020
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30. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients

Author

David A. Edwards, Padma Gulur, Michael G. Mythen, Robert W. Hurley, Adam B. King, Debra B. Gordon, Andrew D. Shaw, Jennifer M. Hah, Tong J. Gan, Traci L. Hedrick, Michael L. Kent, Stefan D. Holubar, Jennifer Jayaram, Erin Sun, Julie K. M. Thacker, Michael C. Grant, Timothy M. Geiger, Charles Argoff, Gary M. Oderda, Ruchir Gupta, Matthew D. McEvoy, Timothy E. Miller, Christopher L. Wu, and Michael P.W. Grocott

Subjects
medicine.medical_specialty, Consensus, Time Factors, Delphi Technique, media_common.quotation_subject, MEDLINE, Delphi method, Psychological intervention, Risk Assessment, Drug Administration Schedule, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, 030202 anesthesiology, Terminology as Topic, Anesthesiology, medicine, Humans, Pain Management, Quality (business), Intensive care medicine, media_common, Postoperative Care, Pain, Postoperative, business.industry, Incidence, Perioperative, Opioid-Related Disorders, Analgesics, Opioid, Treatment Outcome, Anesthesiology and Pain Medicine, Opioid, business, Risk assessment, 030217 neurology & neurosurgery, medicine.drug
Abstract

Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.

Published
2019
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31. Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study

Author

Helen J. Manning, Jonathan G. Hardman, Puja R. Myles, Mark Coburn, Monty G. Mythen, Sudhir Venkatesan, Mads E. Jørgensen, Pierre Foëx, Abdul Mozid, Robert D. Sanders, S Ramani Moonesinghe, Charlotte Andersson, and Michael P.W. Grocott

Subjects
Male, medicine.medical_specialty, medicine.drug_class, Systolic hypertension, Adrenergic beta-Antagonists, Blood Pressure, Cardiovascular, Poisons, Cohort Studies, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, Risk Factors, 030202 anesthesiology, Internal medicine, Preoperative Care, medicine, Humans, Myocardial infarction, Risk factor, Beta blocker, Aged, Aged, 80 and over, business.industry, Odds ratio, Perioperative, medicine.disease, United Kingdom, Editorial, Anesthesiology and Pain Medicine, Blood pressure, Heart failure, Hypertension, Cardiology, Female, business
Abstract

Background : Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. Methods We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin–angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. Results Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05–3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09–3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17–0.75) and thiazides (aOR: 0.28; 95% CI: 0.10–0.78) were associated with lower mortality in patients with systolic hypertension. Conclusions These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.

Published
2019
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32. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use

Author

David A. Edwards, Tong J. Gan, Padma Gulur, Ruchir Gupta, Matthew D. McEvoy, Michael G. Mythen, Christopher L. Wu, Timothy E. Miller, Timothy M. Geiger, Jennifer M. Hah, Traci L. Hedrick, Monty G. Mythen, Jennifer Jayaram, Erin Sun, Julie K. M. Thacker, Michael C. Grant, Michael L. Kent, Robert W. Hurley, Stefan D. Holubar, Eric C. Sun, Debra B. Gordon, Andrew D. Shaw, Adam B. King, Michael P.W. Grocott, Charles Argoff, and Gary M. Oderda

Subjects
medicine.medical_specialty, business.industry, Incidence (epidemiology), Perioperative, medicine.disease, Article, Substance abuse, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, 030202 anesthesiology, Anesthesiology, Health care, medicine, Medical prescription, Intensive care medicine, business, Risk assessment, 030217 neurology & neurosurgery, Medical literature
Abstract

Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naive patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.

Published
2019
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33. Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine

Author

Gareth L. Ackland, Charles S. Brudney, Maurizio Cecconi, Can Ince, Michael G. Irwin, Jonathan Lacey, Michael R. Pinsky, Michael PW. Grocott, Monty G. Mythen, Mark R. Edwards, Timothy E. Miller, Robert Sanders, Finton Hughes, Angela Bader, Annemarie Thompson, Andreas Hoeft, David Williams, Andrew D. Shaw, Daniel I. Sessler, Sol Aronson, Colin Berry, Tong J. Gan, John Kellum, James Plumb, Joshua Bloomstone, Matthew D. McEvoy, Julie K.M. Thacker, Ruchir Gupta, Elena Koepke, Aarne Feldheiser, Denny Levett, Frederic Michard, Mark Hamilton, Intensive Care, Translational Physiology, and ACS - Microcirculation

Subjects
Delphi Technique, Physiology, Hemodynamics, Perioperative Care, law.invention, 03 medical and health sciences, 0302 clinical medicine, 030202 anesthesiology, law, medicine, Homeostasis, Humans, Arterial Pressure, Perioperative medicine, business.industry, Microcirculation, Blood Pressure Determination, Perioperative, Blood flow, Blood Pressure Monitoring, Ambulatory, Anesthesiology and Pain Medicine, Pressure measurement, medicine.anatomical_structure, Blood pressure, Vascular resistance, business, Perfusion
Abstract

Background Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors. Methods A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perioperative medicine. We addressed predefined questions by undertaking a modified Delphi analysis, in which primary clinical research and review articles were identified using MEDLINE. Strength of recommendations, where applicable, were graded by National Institute for Health and Care Excellence (NICE) guidelines. Results Multiple physiological factors contribute to the perioperative physiological importance of arterial pressure: (i) arterial pressure is the input pressure to organ blood flow, but is not the sole determinant of perfusion pressure; (ii) blood flow is often independent of changes in perfusion pressure because of autoregulatory changes in vascular resistance; (iii) microvascular dysfunction uncouples microvascular blood flow from arterial pressure (haemodynamic incoherence). From a practical clinical perspective, we identified that: (i) ambulatory measurement is the optimal method to establish baseline arterial pressure; (ii) automated and invasive arterial pressure measurements have inherent physiological and technical limitations; (iii) individualised arterial pressure targets may change over time, especially in the perioperative period. There remains a need for research in non-invasive, continuous arterial pressure measurements, macro- and micro-circulatory control, regional perfusion pressure measurement, and the development of sensitive, specific, and continuous measures of cellular function to evaluate blood pressure management in a physiologically coherent manner. Conclusion The multivariable, complex physiology contributing to dynamic changes in perioperative arterial pressure may be underappreciated clinically. The frequently unrecognised dissociation between arterial pressure, organ blood flow, and microvascular and cellular function requires further research to develop a more refined, contextualised clinical approach to this routine perioperative measurement.

Published
2019
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34. The MacGyver bias and attraction of homemade devices in healthcare

Author

Hilary P. Grocott, Stuart Marshall, Peter G. Brindley, Laura V. Duggan, and Jeanette Scott

Subjects
medicine.medical_specialty, business.industry, Pain medicine, MEDLINE, General Medicine, medicine.disease, Attraction, Anesthesiology and Pain Medicine, Anesthesiology, Anesthesia, Health care, medicine, Medical emergency, business
Published
2019
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35. Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand

Author

Swarna Baskar Sharma, Mansoor Sange, Michael Girgis, Joanne Humphreys, Vishal Patil, Nick Greenwood, Sai Tim Yam, Santhana Kannan, Marc Slorach, Julian Giles, Suman Shrestha, Philippa Marshall, Vinanti Cherian Mcivor, Moore Joanna, Elizabeth Thomas, Stuart M. White, James Hanison, Suhail Zaidi, Andrew Burtenshaw, Douglas Campbell, Jaya Nariani, Ross Freebairn, Omar Alex Pemberton, Davina Ross-Anderson, Lisa M. Barneto, Shabir Qadri, Giles Bond-Smith, Pallavi Kumar, Khaled Razouk, M. Amir Rafi, Dermot Moloney, Ashok Raj, Kirtida Mukherjee, Vasheya Naidoo, Sonia Sathe, Jason Cupitt, Priya Shanmuganathan, Andrew Brammar, David Saunders, Anna Batchelor, James R. Anderson, Hew D.T. Torrance, Catriona Barr, Helen Melsom, Adrian Taylor, Jon Bramall, Sumant Shanbhag, Jenny Ritzema, Winston Cheung, Alexandra Frankpitt, David Shan, Killian McCourt, Chiraag Talati, Richard Kennedy, Ravishankar Jakkala Saibaba, Abigail Hine, Cathryn Matthews, Christian Frey, Laurin Allen, Gary Minto, Thomas Fitzgerald, James Bain, Dominik Teisseyre, Stephen Hill, M. Dickinson, Subhamay Ghosh, J.A. Ezihe-Ejiofor, Vincent Hamlyn, Karuna Kotur, Joyce Yeung, Helen Roberts, Johann Harten, Stefan Schraag, Jonathan Aldridge, Alexander Garden, Carol McArthur, Louis Guy, John Orr, Tom Pettigrew, Atideb Mitra, Cindy Persad, Abhinav Kant, Robin Alston, Nicolas Price, Sarang Puranik, Jacqueline Howes, Ritoo Kapoor, Peter Knowlden, Mai Wakatsuki, Charles Allen, Deepa Jumani, Mark MacGregor, Prashant Kakodkar, Dhir Bhattacharya, Valerie J. Page, Narendra Siddaiah, Dick Ongley, Vandana Goel, Sibtain Anwar, Bronwyn Posselt, Rebecca Sutton, David Scott, Danny J.N. Wong, Austin Rattray, Paul S. Myles, Mrutyunjaya Rao Rambhatla, Richard Dobson, Kathryn Jenkins, Tim J. Smith, Helen Bromhead, Zhana Ignatova, Katheryn Fogg, Lynne Williams, Sanjeev Garg, Nikhil Patel, Gary Lau, Sock Huang Koh, Stephen Merron, David Robinson, Nagendra Natarajan, Seema Charters, Mark Welch, Laura Farmer, Simon Young, Susan Kirby, Madhushankar Balasubramaniam, Robert Wonders, Paul Glyn Jones, Satyanarayana Jakkampudi, Mizan Khondoker, Paul Rowe, Andrew Jones, Monica Diczbalis, Manju Agarwal, Andrew Robinson, Emert White, Catherine Hunter, Stephen T. Webb, Srikanth Chukkambotla, Jenny Henry, Catriona Ferguson, Manish Kakkar, Waisun Kok, Colin Williams, Vijayakumar Gopal, Vidhya Nagaratnam, Shafi Ahmed, Melinda Same, Doug Campbell, Stuart P. D. Gill, Scott Popham, Gabor Debreceni, Dancho Ignatov, D. L. Williams, I.J. Wrench, Andrew Claxton, Eleanor Ford, Shondipon Laha, Laurie Dwyer, Christopher Littler, Stephan Clements, David Gillespie, Ceri Lynch, Lillian Coventry, Paul Clements, Paul Foley, Claire Ireland, Vikramjit Singh, M. H. Nathanson, R. Jonathan T. Wilson, Shilpa Rawat, Pieter Bothma, David Pritchard, Victor Birioukov, Robert Campbell, Brien Hennessy, Stephanie Bell, Robert Smith, Muhammad Usman Latif, Nicolas Hooker, Anand Kulkarni, Chelsea Hicks, Steve Harris, Caroline Reavley, Claire Botfield, Christopher Nutt, Andrew Gorman, Peter J O'Brien, Murray Geddes, Carlos Kidel, Samar Al-Rawi, atyas Andorka, John John, Stephen Washington, Peter Csabi, Anil Hormis, Emily Dana, Sharon Hilton-Christie, Brian Spain, Suganthi Joachim, Richard Partridge, Tony Miller-Greenman, Andrew Marshall Wilson, Samuel Perrin, Carol Bradbury, Christopher Goddard, Paul Cooper, Simon Williams, Iain K. Moppett, Han Truong, Stephen J. Brett, Robert Orme, Alexandra Matson, Michael P.W. Grocott, Sunita Agarwal, Jonathan Chambers, Georgina Prassas, Rachel Markham, Kevin Hamilton, Jane Wright, Julian Sonksen, Robert Spencer, James Limb, Tehal Kooner, James Tozer, Sujesh Bansal, Fiona Graham, Suresh Singaravelu, Adrienne Stewart, Sophie Gormack, Buzz Shephard, Julian Berry, Nick Spittle, Philip Blackie, Richard Stewart, R. Sneyd, Laura Kwan, Ben Chandler, Helen Lindsay, Wendy Lum Hee, Vivien Edwards, David Highton, Helen A. Lindsay, Tendai Ramhewa, Daphne Varveris, Liam McLoughlin, Duncan Brown, Justin Woods, Annabelle Whapples, Jonathan Panckhurst, Garry Henry, Kate Campbell, Jeremy Henning, Stephanie Sim, Baigel Gary, Nam Le, Joellene Mitchell, Laura Tasker, Geoff Wright, Con Papageorgiou, Simon Whiteley, Richard Pugh, Joel Matthews, Suneetha Ramani Moonesinghe, Andrew M. Wilson, Sandeep Varma, Chris Hargreaves, Malcolm Gunning, Agnieszka Kubisz-Pudelko, Richard Shawyer, N. M. Wharton, Janette Moss, Gurunath Hosdurga, Catherine Plowright, Jane Montgomery, Stuart McLellan, Emma Gent, Patrick Dill-Russell, James Craig, Nirav Shah, Julius Dale-Gandar, Geoff Thorning, Lawrence Wilson, Roddy Chapman, Andrew Gratrix, Kate Bailey, Sunil kumar Chaurasia, Sophie Wallace, Rob Dawson, Richard Siviter, Christine Range, Helen McNamara, Tim Cook, Khong Tan, Michael Brett, Alan Kakos, Samuel Armanious, Liana Zucco, Sam Clark, Laura Troth, Rajeev Jha, Michael Weisz, James Pennington, Chris Bowden, Jeremy Drake, David Rogerson, Ritesh Maharaj, Alison Jackson, Sophie van Oudenaaren, Rohit Juneja, and Naomi Goodwin

Subjects
medicine.medical_specialty, Critical Care, Population, Staffing, Care provision, Patient safety, Postoperative Complications, medicine, Per capita, Humans, education, Postoperative Care, Response rate (survey), education.field_of_study, Tertiary Healthcare, business.industry, Australia, Health services research, Emergency department, United Kingdom, Intensive Care Units, Anesthesiology and Pain Medicine, Hospital Bed Capacity, Health Care Surveys, Emergency medicine, Health Services Research, business, New Zealand
Abstract

Background Decisions to admit high-risk postoperative patients to critical care may be affected by resource availability. We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe additional ‘high-acuity' beds capable of managing high-risk patients outside the ICU/HDU environment. Methods We used a modified Delphi consensus method to design a survey that was disseminated via investigator networks in the UK, Australia, and NZ. Hospital- and ward-level data were collected, including bed numbers, tertiary services offered, presence of an emergency department, ward staffing levels, and the availability of critical care facilities. Results We received responses from 257 UK (response rate: 97.7%), 35 Australian (response rate: 32.7%), and 17 NZ (response rate: 94.4%) hospitals (total 309). Of these hospitals, 91.6% reported on-site ICU or HDU facilities. UK hospitals reported fewer critical care beds per 100 hospital beds (median=2.7) compared with Australia (median=3.7) and NZ (median=3.5). Additionally, 31.1% of hospitals reported having high-acuity beds to which high-risk patients were admitted for postoperative management, in addition to standard ICU/HDU facilities. The estimated numbers of critical care beds per 100 000 population were 9.3, 14.1, and 9.1 in the UK, Australia, and NZ, respectively. The estimated per capita high-acuity bed capacities per 100 000 population were 1.2, 3.8, and 6.4 in the UK, Australia, and NZ, respectively. Conclusions Postoperative critical care resources differ in the UK, Australia, and NZ. High-acuity beds may have developed to augment the capacity to deliver postoperative critical care.

Published
2019
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36. Correction to: Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Author

Charlotte C. McEwen, Takhliq Amir, Yuan Qiu, Jack Young, Kevin Kennedy, Hilary P. Grocott, Hessam Kashani, David Mazer, Scott Brudney, Morvarid Kavosh, Eric Jacobsohn, Anne Vedel, Eugene Wang, Richard P. Whitlock, Emilie P. Belley-Coté, and Jessica Spence

Subjects
Anesthesiology and Pain Medicine, General Medicine
Published
2022
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37. Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries

Author

Ahmad T., Bouwman R. A., Grigoras I., Aldecoa C., Hofer C., Hoeft A., Holt P., Buhre W., Pearse R. M., Clavien P. -A., Demartines N., Grocott M., Haddow J., Moreno R., Pritchard N., Rhodes A., Wilson M., Ahmed T., Halliwell R., Shulman M., Myles P., Schmid W., Hiesmayr M., Wouters P., De Hert S., Lobo S., Beattie S., Wijeysundera D., Fang X., Rasmussen L., Futier E., Biais M., Venara A., Slim K., Sander M., Koulenti D., Arvaniti K., Chan M., Kulkarni A., Chandra S., Tantri A., Geddoa E., Abbas M., Della Rocca G., Sivasakthi D., Mansor M., Luna P., Bouwman A., Beavis V., Campbell D., Short T., Osinaike T., Matos R., Kirov M., Protsenko D., Biccard B., Chew M., Hubner M., Ditai J., Szakmany T., Fleisher L., Ferguson M., MacMahon M., Cherian R., Currow H., Kanathiban K., Gillespie D., Pathmanathan E., Phillips K., Reynolds J., Rowley J., Douglas J., Kerridge R., Garg S., Bennett M., Jain M., Alcock D., Terblanche N., Cotter R., Leslie K., Stewart M., Zingerle N., Clyde A., Hambidge O., Rehak A., Cotterell S., Huynh W. B. Q., McCulloch T., Ben-Menachem E., Egan T., Cope J., Fellinger P., Markus P., Haselberger S., Holaubek C., Lichtenegger P., Scherz F., Hoffer F., Cakova V., Eichwalder A., Fischbach N., Klug R., Schneider E., Vesely M., Wickenhauser R., Gernot K., Leitgeb M., Lang F., Toro N., Bauer M., Laengle F., Haberl C., Mayrhofer T., Trybus C., Buerkle C., Forstner K., Germann R., Rinoesl H., Schindler E., Trampitsch E., Bogner G., Dankl D., Duenser M., Fritsch G., Gradwohl I. -M., Hartmann A., Hoelzenbein T., Jaeger T., Landauer F., Lindl G., Lux M., Steindl J., Stundner O., Szabo C., Bidgoli J., Verdoodt H., Forget P., Kahn D., Lois F., Momeni M., Pregardien C., Pospiech A., Steyaert A., Veevaete L., De Kegel D., De Jongh K., Foubert L., Smitz C., Vercauteren M., Poelaert J., Van Mossevelde V., Abeloos J., Bouchez S., Coppens M., De Baerdemaeker L., Deblaere I., De Bruyne A., Fonck K., Heyse B., Jacobs T., Lapage K., Moerman A., Neckebroek M., Parashchanka A., Roels N., Van Den Eynde N., Vandenheuvel M., Van Limmen J., Vanluchene A., Vanpeteghem C., Wyffels P., Huygens C., Vandenbempt P., Van De Velde M., Dylst D., Janssen B., Schreurs E., Aleixo F. B., Candido K., Batista H. D., Guimaraes M., Guizeline J., Hoffmann J., Lobo F. R. M., Nascimento V., Nishiyama K., Pazetto L., Souza D., Rodrigues R. S., Dos Santos A. M. V., Jardim J., Sa Malbouisson L. M., Silva J., Do Nascimento P., Baio T. H., De Castro G. I. P., Oliveira H. R. W., Amendola C. P., Cardoso G., Ortega D., Brotto A. F., De Oliveira M. C., Rea-Neto A., Dias F., Travi M. E., Zerman L., Azambuja P., Knibel M. F., Martins A., Almeida W., Neto C. N., Tardelli M. A., Caser E., MacHado M., Aguzzoli C., Baldisserotto S., Tabajara F. B., Bettega F., Rodrigues L. H. C., De Gasperi J., Faina L., Nolasco M. F., Da Costa Fischer B. F., De Campos Ferreira M. F., Hartmann C., Kliemann M., Ribeiro G. L. H., Fraga J. M., Netto T. M., Pozza L. V., Wendling P. R., Azevedo C., Garcia J., Lopes M., Maia B., Maselli P., Melo R., Mendes W., Neves M., Ney J., Piras C., Applewhaite C., Carr A., Chow L., Duttchen K., Foglia J., Greene M., Hinther A., Houston K., McCormick T. J., Mikhayel J., Montasser S., Ragan A., Suen A., Woolsey A., Yu H. C., Funk D., Stephen D., Regina D., Heather D., Faisal D., Pridham J., Rowe B., Sampson S., Thiessen B., Zbitnew G., Bernard A., George R., Jones P., Moor R., Siddiqui N., Wolfer A., Tran D., Winch D., Dobson G., Montasser O., Hall R., Baghirzada L., Curley G., Dai S. Y., Hare G., Lee E., Shastri U., Tsui A., Yagnik A., Alvares D., Choi S., Dwyer H., Flores K., McCartney C., Somascanthan P., Carroll J., Pazmino-Canizares J., Ami N., Chan V., Perlas A., Argue R., Huang Y., Lavis K., Mayson K., Cao Y., Gao H., Hu T., Lv J., Yang J., Yang Y., Zhong Y., Zhou J., Zou X., He M., Li X., Luo D., Wang H., Yu T., Chen L., Wang L., Cai Y., Cao Z., Li Y., Lian J., Sun H., Wang S., Wang Z., Wang K., Zhu Y., Du X., Fan H., Fu Y., Huang L., Hwan H., Luo H., Qu P. -S., Tao F., Wang G., Zhang Y., Zhang X., Chen C., Wang W., Liu Z., Fan L., Tang J., Chen Y., Han Y., Huang C., Liang G., Shen J., Wang J., Yang Q., Zhen J., Zhou H., Chen J., Chen Z., Meng B., Ye H., Bi Y., Cao J., Guo F., Lin H., Liu Y., Lv M., Shi P., Song X., Sun C., Sun Y., Wang Y., Zhang M., Chen R., Hou J., Leng Y., Meng Q. -T., Qian L., Shen Z. -Y., Xia Z. -Y., Xue R., Zhao B., Zhou X. -J., Chen Q., Guo H., Guo Y., Qi Y., Wei J., Zhang W., Zheng L., Bao Q., Fei Y., Hu N., Hu X., Lei M., Lv X., Miao F., Ouyang L., Shen C., Wang D., Wu C., Xu L., Yuan J., Zhang L., Zhang H., Zhao J., Zhao C., Zhao L., Zheng T., Zhou D., Zhou C., Lu K., Zhao T., He C., Chen H., Chen S., Cheng B., He J., Jin L., Li C., Li H., Pan Y., Shi Y., Wen X. H., Wu S., Xie G., Zhang K., Lu X., Chen F., Liang Q., Lin X., Ling Y., Liu G., Tao J., Yang L., Cheng Z., Dai H., Feng Y., Hou B., Gong H., Hua C., Huang H., Huang J., Jiang Z., Li M., Lin J., Liu M., Liu W., Luo F., Ma L., Min J., Shi X., Song Z., Wan X., Xiong Y., Yang S., Zhang Q., Zhao W., Zhu X., Bai Y., Dai Q., Geng W., Han K., He X., Ji B., Jia D., Jin S., Li Q., Liang D., Luo S., Lwang L., Mo Y., Qi X., Qian M., Qin J., Ren Y., Xie J., Yan Y., Yao Y., Zhuang X., Ai Y., Du F., He L., Li Z., Li L., Meng S., Yuan Y., Zhang E., Zhang J., Zhao S., Ji Z., Pei L., Dong B., Li J., Miao Z., Mu H., Qin C., Su L., Wen Z., Xie K., Yu Y., Yuan F., Xiao W., Zhu Z., Fu K., Hu R., Huang S., Liang Y., Yu S., Guo Z., Jing Y., Tang N., Wu J., Yuan D., Zhang R., Zhao X., Bai H. -P., Liu C. -X., Liu F. -F., Ren W., Wang X. -L., Xu G. -J., Li B., Ou Y., Tang Y., Yao S., Zhang S., Kong C. -C., Liu B., Wang T., Lu B., Xia Y., Cai F., Chen P., Hu S., Xu Q., Hu L., Jing L., Liu Q., Dan Z., Qiu X., Ren Q., Tong Y., Wen Y., Wu Q., Xia J., Xiong X., Xu S., Yang T., Yin N., Zeng Q., Zhang B., Zheng K., Cang J., Fan Y., Fu S., Ge X., Guo B., Huang W., Jiang L., Jiang X., Shan Q., Wang F., Christiansen I. C., Granum S. N., Rasmussen B. S., Daugaard M., Gambhir R., Brandsborg B., Steingrimsdottir G. E., Jensen-Gadegaard P., Kovgaard K. O., Siegel H., Eskildsen K. Z., Gatke M. R., Wibrandt I., Heintzelmann S. B., Lange K. H. W., Lundsgaard R. S., Amstrup-Hansen L., Hovendal C., Larsen M., Lenstrup M., Kobborg T., Larsen J. R., Pedersen A. B., Smith S. H., Oestervig R. M., Afshari A., Andersen C., Ekelund K., Lilja E., Beloeil H., Lasocki S., Ouattara A., Sineus M., Molliex S., Legouge M. L., Wallet F., Tesniere A., Gaudin C., Lehur P., Forsans E., De Rudnicki S., Maudet V. S., Sojod G., Ouaissi M., Regimbeau J. -M., Desbordes J., Comptaer N., El Manser D., Ethgen S., Lebuffe G., Auer P., Hartl C., Deja M., Legashov K., Sonnemann S., Wiegand-Loehnert C., Falk E., Habicher M., Angermair S., Laetsch B., Schmidt K., Von Heymann C., Ramminger A., Jelschen F., Pabel S., Weyland A., Czeslick E., Gille J., Malcharek M., Sablotzki A., Lueke K., Wetzel P., Weimann J., Lenhart F. -P., Reichle F., Schirmer F., Huppe M., Klotz K., Nau C., Schon J., Mencke T., Wasmund C., Bankewitz C., Baumgarten G., Fleischer A., Guttenthaler V., Hack Y., Kirchgaessner K., Manner O., Schurig-Urbaniak M., Struck R., Van Rebekkazyl, Wittmann M., Goebel U., Harris S., Veit S., Andreadaki E., Souri F., Katsiadramis I., Skoufi A., Vasileiou M., Aimoniotou-Georgiou E., Katsourakis A., Veroniki F., Vlachogianni G., Petra K., Chlorou D., Oloktsidou E., Ourailoglou V., Papapostolou K., Tsaousi G., Daikou P., Dedemadi G., Kalaitzopoulos I., Loumpias C., Bristogiannis S., Dafnios N., Gkiokas G., Kontis E., Kozompoli D., Papailia A., Theodosopoulos T., Bizios C., Koutsikou A., Moustaka A., Plaitakis I., Armaganidis A., Christodoulopoulou T., Lignos M., Theodorakopoulou M., Asimakos A., Ischaki E., Tsagkaraki A., Zakynthinos S., Antoniadou E., Koutelidakis I., Lathyris D., Pozidou I., Voloudakis N., Dalamagka M., Elena G., Chronis C., Manolakaki D., Mosxogiannidis D., Slepova T., Tsakiridou I. -S., Lampiri C., Vachlioti A., Panagiotakis C., Sfyras D., Tsimpoukas F., Tsirogianni A., Axioti E., Filippopoulos A., Kalliafa E., Kassavetis G., Katralis P., Komnos I., Pilichos G., Ravani I., Totis A., Apagaki E., Efthymiadi A., Kampagiannis N., Paraforou T., Tsioka A., Georgiou G., Vakalos A., Bairaktari A., Charitos E., Markou G., Niforopoulou P., Papakonstantinou N., Tsigou E., Xifara A., Zoulamoglou M., Gkioni P., Karatzas S., Kyparissi A., Mainas E., Papapanagiotou I., Papavasilopoulou T., Fragandreas G., Georgopoulou E., Katsika E., Psarras K., Synekidou E., Verroiotou M., Vetsiou E., Zaimi D., Anagnou A., Apostolou K., Melissopoulou T., Rozenberg T., Tsigris C., Boutsikos G., Kalles V., Kotsalas N., Lavdaiou C., Paikou F., Panagou G. -L., Spring A., Botis I., Drimala M., Georgakakis G., Kiourtzieva E., Ntouma P., Prionas A., Xouplidis K., Dalampini E., Giannaki C., Iasonidou C., Ioannidis O., Lavrentieva A., Papageorgiou G., Kokkinoy M., Stafylaraki M., Gaitanakis S., Karydakis P., Paltoglou J., Ponireas P., Chaloulis P., Provatidis A., Sousana A., Gardikou V. V., Konstantivelli M., Lataniotou O., Lisari E., Margaroni M., Stamatiou K., Nikolaidis E., Pnevmatikos I., Sertaridou E., Andreou A., Arkalaki E., Athanasakis E., Chaniotaki F., Chatzimichali C. A., Christofaki M., Dermitzaki D., Fiorentza K., Frantzeskos G., Geromarkaki E., Kafkalaki K., Kalogridaki M., Karydi K., Kokkini S., Kougentakis G., Lefaki T., Lilitsis E., Makatounaki A., Malliotakis P., Michelakis D., Neonaki M., Nyktari V., Palikyra I., Papadakis E., Papaioannou A., Sfakianakis K., Sgouraki M., Souvatzis X., Spartinou A., Stefanidou N., Syrogianni P., Tsagkaraki G., Arnaoutoglou E., Arnaoutoglou C., Bali C., Bouris V., Doumos R., Gkini K. -P., Kapaktsi C., Koulouras V., Lena A., Lepida D., Michos E., Papadopoulos D., Paschopoulos M., Rompou V. A., Siouti I., Tsampalas S., Ververidou O., Zilis G., Charlalampidoy A., Christodoulidis G., Flossos A., Stamoulis K., Tsang M. S. C., Lai M. L., Yip C. P., Chan H. M. H., Law B., Li W. S., Chu H. M., Koo E. G. Y., Lam C. C. J., Cheng K. H., Lam T., Chu S., Lam W. Y., Wong K. W. K., Kwok D., Hung C. Y. J., Chan W. K. J., Wong W. L., Chung C. K. E., Ma S. K., Kaushik S., Shah B., Shah D., Shah S., Ar P., Muthuchellappan R., Agarwal V., Divatia J., Mishra S., Nimje G., Pande S., Savarkar S., Shrivastava A., Thomas M., Yegnaram S., Hidayatullah R., Puar N., Niman S., Indra I., Hamzah Z., Yuliana A., Abidin U. N., Dursin A. N., Kurnia A., Susanti A., Handayani D., Alit M. A., Arya A., Senapathi T. G. A., Utara U. H., Wid W. M., Wima S., Wir W. M., Jehosua B., Kaunang J., Lantang E. Y., Najoan R., Waworuntu N., Awad H., Fuad A., Geddoa B., Khalaf A. R., Al Hussaini S., Albaj S., Kenber M., Bettinelli A., Spadaro S., AlbertoVolta C., Giancarlo L., Sottosanti V., Copetti U. E., Spagnesi L., Toretti I., Alloj C., Cardellino S., Carmino L., Costanzo E., Fanfani L. C., Novelli M. T., Roasio A., Bellandi M. M., Beretta L., Bignami E., Bocchino S., Cabrini L., Corti D., Landoni G., Meroni R., Moizo E., Monti G., Pintaudi M., Plumari V. P., Taddeo D., Testa V., Winterton D., Zangrillo A., Cloro R. L. M., Colangelo C., Colangelo A., Rotunno G., Paludi M. A., Maria C. P., Pata A., Parrini V., Gatta A., Nastasi M., Tinti C., Baroselli A., Arrigo M., Benevento A., Bottini C., Cannavo M., Gastaldi C., Marchesi A., Pascazio A., Pata F., Pozzi E., Premoli A., Tessera G., Boschi L., D'Andrea R., Ghignone F., Poggioli G., Sibilio A., Taffurelli M., Ugolini G., Ab Majid M. A., Ab Rahman R., Joseph J., Pathan F., Shah M. H. S., Yap H. L., Cheah S., Chin I. I., Looi J. K., Tan S. C., Visvalingam S., Kwok F. Y., Lee C. K., Tan T. S., Wong S. M., Abdullah N. H., Liew C. F., Luxuman L., Mohd Zin N. H., Norddin M. F., Alias R. L. R., Wong J. Y., Yong J., Mustapha M. T. B., Chan W. K., Dzulkipli N., Kuan P. X., Lee Y. C., Alias A., Guok E. C., Jee C. C., Ramon B. R., Wong C. W., Abd Ghafar F. N. I., Aziz F. Z., Hussain N., Lee H. S., Sukawi I., Woon Y. L., Abd Hadi H. Z., Azam U. A. A., Alias A. H., Kesut S. A., Lee J. M., Ooi D. V., Sulaiman H. A., Lih T. A. T., Veerakumaran J., Rojas E., Resendiz G. E. A., Zapata D. D. M., Lopez J. C. J. A., Flores A. A. A., Amador J. C. B., Avila E. J. D., Aquino L. P. G., Rodriguez R. L., Landa M. T., Urias E., Hollmann M., Hulst A., Preckel O. K. B., Gemert A. K. -V., Buise M., Tolenaar N., Weber E., De Fretes J., Houweling P., Ormskerk P., Van Bommel J., Lance M., Smit-Fun V., Van Zundert T., Baas P., De Boer H. D., Sprakel J., Elferink-Vonk R., Noordzij P., Van Zeggeren L., Brand B., Spanjersberg R., Ten Bokkel-Andela J., Numan S., Van Klei W., Van Zaane B., Boer C., Van Duivenvoorde Y., Hering J. P., Van Rossum S., Zonneveldt H., Hoare S., Santa S., Ali M., Allen S. J., Bell R., Choi H. -M. D., Drake M., Farrell H., Hayes K., Higgie K., Holmes K., Jenkins N., Kim C. J., Kim S., Law K. 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B., Burrows T., Byrne K., English D., Johnson R., Manikkam B., Naidoo S., Rumball M., Whittle N., Franks R., Gibson-Lapsley H., Salter R., Walsh D., Richard D., Perry K., Obobolo A., Sule U. M., Ahmad A., Atiku M., Mohammed A. D., Sarki A. M., Adekola O., Akanmu O., Durodola A., Olukoju O., Raji V., Olajumoke T., Oyebamiji E., Adenekan A., Adetoye A., Faponle F., Olateju S., Owojuyigbe A., Talabi A., Adenike O., Adewale B., Collins N., Ezekiel E., Fatungase O. M., Grace A., Sola S., Stella O., Ademola A., Adeolu A. A., Adigun T., Akinwale M., Fasina O., Gbolahan O., Idowu O., Olonisakin R. P., Osinaike B. B., Asudo F., Mshelia D., Abdur-Rahman L., Agodirin O., Bello J., Bolaji B., Oyedepo O. O., Ezike H., Iloabachie I., Okonkwo I., Onuora E., Onyeka T., Ugwu I., Umeh F., Alagbe-Briggs O., Dodiyi-Manuel A., Echem R., Obasuyi B., Onajin-Obembe B., Bandeira M. E., Tome M., Costa A. C. M. M., Krystopchuk A., Branco T., Esteves S., Melo M. A., Monte J., Rua F., Martins I., Pinho-Oliveira V. M., Rodrigues C. M., Cabral R., Marques S., Rego S., Jesus J. S. T., Marques M. C., Romao C., Dias S., Santos A. M., Alves M. J., Salta C., Cruz S., Duarte C., Paiva A. A. F., Do Nascimento Cabral T., E Maia D. F., Da Silva R. F. M. C., Langner A., Resendes H. O., Da Conceicao Soares M., Abrunhosa A., Faria F., Miranda L., Pereira H., Serra S., Ionescu D., Margarit S., Mitre C., Vasian H., Manga G., Stefan A., Tomescu D., Daniela D., Paunescu M. -A., Stefan M., Stoica R., Gavril L., Patrascanu E., Ristescu I., Rusu D., Diaconescu C., Iosep G. F., Pulbere D., Ursu I., Balanescu A., Grintescu I., Mirea L., Rentea I., Vartic M., Lupu M. -N., Stanescu D., Streanga L., Antal O., Hagau N., Patras D., Petrisor C., Tosa F., Tranca S., Copotoiu S. M., Ungureanu L. L., Harsan C. R., Papurica M., Cernea D. D., Dragoescu N. A., Aflori L., Vaida C., Ciobotaru O. R., Aignatoaie M., Carp C. P., Cobzaru I., Mardare O., Purcarin B., Tutunaru V., Ionita V., Arustei M., Codita A., Busuioc M., Chilinciuc I., Ciobanu C., Belciu I., Tincu E., Blaj M., Grosu R. -M., Sandu G., Bruma D., Corneci D., Dutu M., Krepil A., Copaciu E., Dumitrascu C. O., Jemna R., Mihaescu F., Petre R., Tudor C., Ursache E., Kulikov A., Lubnin A., Grigoryev E., Pugachev S., Tolmasov A., Hussain A., Ilyina Y., Roshchina A., Iurin A., Chazova E., Dunay A., Karelov A., Khvedelidze I., Voldaeva O., Belskiy V., Dzhamullaev P., Grishkowez E., Kretov V., Levin V., Molkov A., Puzanov S., Samoilenko A., Tchekulaev A., Tulupova V., Utkin I., Allorto N. L., Bishop D. G., Builu P. M., Cairns C., Dasrath A., De Wet J., Den Hoedt M., Grey B., Hayes M. P., Kusel B. S., Shangase N., Wise R., Cacala S., Farina Z., Govindasamy V., Kruse C. -H., Lee C., Marais L., Naidoo T. D., Rajah C., Rodseth R. N., Ryan L., Von Rhaden R., Adam S., Alphonsus C., Ameer Y., Anderson F., Basanth S., Bechan S., Bhula C., Biccard B. M., Biyase T., Buccimazza I., Cardosa J., Daya B., Drummond L., Elabib A., Goad E. H. A., Goga I. E., Goga R., Harrichandparsad R., Hodgson R. E., Jordaan J., Kalafatis N., Kampik C., Landers A. T., Loots E., Madansein R., Madaree A., Madiba T. E., Manzini V. T., Mbuyisa M., Moodley R., Msomi M., Mukama I., Naidoo D., Naidoo R., Naidu T. K., Ntloko S., Padayachee E., Padayachee L., Phaff M., Pillay B., Pillay D., Pillay L., Ramnarain A., Ramphal S. R., Ryan P., Saloojee A., Sebitloane M., Sigcu N., Taylor J. L., Torborg A., Visser L., Anderson P., Conradie A., De Swardt M., De Villiers M., Eikman J., Liebenberg R., Mouton J., Paton A., Van Der Merwe L., Wilscott-Davids C., Barrett W. J., Bester M., De Beer J., Geldenhuys J., Gouws H., Potgieter J. -H., Strydom M., Turton E. W., Chetty R. R., Chirkut S., Cronje L., De Vasconcellos K., Dube N. Z., Gama N. S., Green G. M., Green-Thompson R., Kinoo S. M., Kistnasami P., Maharaj K., Moodley M. S., Mothae S. J., Noorbhai M. A. F., Rughubar V., Reddy J., Singh A., Skinner D. L., Smith M. J., Singh B., Misra R., Naidoo M., Ramdharee P., Selibea Y., Sewpersad S., Sham S., Wessels J. D., Africander C., Bejia T., Blakemore S. P., Botes M., Bunwarie B., Hernandez C. B., Jeeraz M. A., Legutko D. A., Lopez A. G., De Meyer J. N., Muzenda T., Naidoo N., Patel M., Pentela R., Junge M., Mansoor N., Rademan L., Scislowski P., Seedat I., Van Den Berg B., Van Der Merwe D., Van Wyk S., Govender K., Naicker D., Ramjee R., Saley M., Kuhn W. P., Matos-Puig R., Moolla Z., Lisi A., Perez G., Beltran A. V., Lozano A., Navarro C. D., Duca A., Ernesto E. P. M., Ferrando C., Fuentes I., Garcia-Perez M. L., Gracia E., Palomares A. I., Katime A., Minana A., Incertis R. R., Romero E., Garcia C. S. R., Rubio C., Artiles T. S., Soro M., Valls P., Laguarda G. A., Benavent P., Cuenca V. C., Cueva A., Lafuente M., Parra A. M., Rodrigo A. R., Sanchez-Morcillo S., Tormo S., Redondo F. J., De Andres Ibanez J. A., Diago L. G., Cadiz M. J. H., Manuel G. G., Peris R., Saiz C., Vivo J. T., Soto M. T. T., Brunete T., Cancho D., Garcia D. R. D., Zamudio D., Del Valle S. G., Serrano M. L., Alonso E., Anillo V., Maseda E., Salgado P., Suarez L., Suarez-De-La-Rica A., Villagran M. J., Alonso J. I., Cabezuelo E., Garcia-Saiz I., Del Moral O. L., Martin S., Gonzalez A. P., Doncel M. S. T., Vera M. A., Sanchez F. J. A., Castano B., Moreira B. C., Risco S. F., Martin D. P., Martin F. P., Poza P., Ruiz A., Martinez W. F. S., Vicente B. V., Dominguez S. V., Fernandez S., Munoz-Lopez A., Bernat M. J., Mas A., Planas K., Jawad M., Saeed Y., Hedin A., Levander H., Holmstrom S., Lonn D., Zoerner F., Akring I., Widmark C., Zettergren J., Liljequist V. A., Nystrom L., Odeberg-Wernerman S., Oldner A., Fagerlund M. J., Reje P., Lyckner S., Sperber J., Adolfsson A., Klarin B., O K., Barras J. -P., Buhrer T., Despotidis V., Helmy N., Holliger S., Raptis D. A., Schmid R., Meyer A., Jaquet Y., Kessler U., Muradbegovic M., Nahum S. 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K., Karpate S., O'Hara C., Troko J., Angus K., Bradley J., Brennan E., Brooks C., Brown J., Brown G., Finch A., Gratrix K., Hesketh S., Hill G., Jeffs C., Morgan M., Pemberton C., Slawson N., Spickett H., Swarbrick G., Van Duyvenvoorde G., Brennan A., Briscoe R., Cooper S., Lawton T., Northey M., Senaratne R., Stanworth H., Burrows L., Cain H., Craven R., Davies K., Jonas A., Pachucki M., Walkden G., Davies H., Gudaca M., Hobrok M., Arawwawala D., Fergey L., Gardiner M., Gunn J., Johnson L., Lofting A., Lyle A., Neela F. M., Smolen S., Topliffe J., Williams S., Bland M., Balaji P., Kaura V., Lanka P., Naylor C., Ahmed A., Myatt J., Shenoy R., Soon W. C., Tan J., Karadia S., Self J., Durant E., Tripathi S., Bullock C., Ghosh A., Hughes T., Zsisku L., Bengeri S., Cowton A., Khalid M. S., Limb J., McAdam C., Porritt M., Rafi M. 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W., Docherty P., Gillies M., McGregor E., Usher H., Craig J., Bodger P., Creary T., Everingham K., Fowler A., Hewson R., Ijuo E., Januszewska M., Jones T., Kantsedikas I., Lahiri S., McLean A. L., Niebrzegowska E., Phull M., Wickboldt N., Baldwin J., Doyle D., McMullan S., Oladapo M., Owen T., Williams A., Gregory P., Husain T., Kirk-Bayley J., Mathers E., Montague L., Harper M., Jack J., Ridley C., Avis J., Cook T., Dali-Kemmery L., Kerslake I., Lambourne V., Pearson A., Boyd C., Callaghan M., Lawson C., McCrossan R., Nesbitt V., O'Connor L., Sinclair R., Farid N., Morgese C., Bhatia K., Karmarkar S., Ahmed J., Branagan G., Hutton M., Swain A., Brookes J., Cornell J., Dolan R., Hulme J., Van Vuuren A. J., Jowitt T., Kalashetty G., Lloyd F., Kiran Patel, Sherwood N., Brown L., Chandler B., Deighton K., Emma T., Haunch K., Cheeseman M., Dent K., Gray C., Hood M., Jones D., Juj J., Rao R., Walker T., Al Anizi M., Cheah C., Cheing Y., Coutinho F., Gondo P., Hadebe B., Hove M. 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O., Khader, A., Krishnachetty, B., Rhodes, K., Sokhi, J., Baker, K. -A., Bertram, W., Looseley, A., Mouton, R., Hanna, G., Arnold, G., Arya, S., Balfoussia, D., Baxter, L., Harris, J., Jones, C., Knaggs, A., Markar, S., Perera, A., Scott, A., Shida, A., Sirha, R., Wright, S., Frost, V., Andrews, E., Arrandale, L., Barrett, S., Cifra, E., Cooper, M., Dragnea, D., Elna, C., Maclean, J., Meier, S., Milliken, D., Munns, C., Ratanshi, N., Ramessur, S., Salvana, A., Watson, A., Ali, H., Critchley, R., Endersby, S., Hicks, C., Liddle, A., Pass, M., Ritchie, C., Thomas, C., Too, L., Welsh, S., Gill, T., Johnson, J., Reed, J., Davis, E., Papadopoullos, S., Attwood, C., Biffen, A., Boulton, K., Gray, S., Hay, D., Mills, S., Montgomery, J., Riddell, R., Simpson, J., Bhardwaj, N., Paul, E., Uwubamwen, N., Alexander, M., Arrich, J., Arumugam, S., Blackwood, D., Boggiano, V., Lam, Y., Chatterjee, D., Chhabra, A., Christian, R., Costelloe, H., Matthewman, M. C., Dalton, E., Darko, J., Davari, M., Dave, T., Deacon, M., Deepak, S., Edmond, H., Ellis, J., El-Sayed, A., Eneje, P., English, R., Ewe, R., Foers, W., Franklin, J., Gallego, L., Garrett, E., Goldberg, O., Goss, H., Greaves, R., Harris, R., Hennings, C., Jones, E., Kamali, N., Kokkinos, N., Lewis, C., Lignos, L., Malgapo, E. V., Malik, R., Milne, A., Mulligan, J. -P., Nicklin, P., Palipane, N., Parsons, T., Piper, R., Prakash, R., Ramesh, B., Rasip, S., Reading, J., Rela, M., Reyes, A., Stephens, R., Rooms, M., Shah, K., Simons, H., Solanki, S., Spowart, E., Stevens, A., Waggett, H., Yassaee, A., Kennedy, A., Scott, S., Somanath, S., Berg, A., Hernandez, M., Nanda, R., Tank, G., Wilson, N., Wilson, D., Al-Soudaine, Y., Baldwin, M., Cornish, J., Davies, Z., Davies, L., Edwards, M., Frewer, N., Gallard, S., Glasbey, J., Harries, R., Hopkins, L., Kim, T., Koompirochana, V., Lawson, S., Lewis, M., Makzal, Z., Scourfield, S., Ahmad, Y., Bates, S., Blackwell, C., Bryant, H., Collins, H., Coulter, S., Cruickshank, R., Daniel, S., Daubeny, T., Golder, K., Hawkins, L., Helen, B., Hinxman, H., Levett, D., Salmon, K., Seaward, L., Ben, L., Tyrell, B., Wadams, B., Walsgrove, J., Dickson, J., Constantin, K., Karen, M., O'Brien, P., O'Donohoe, L., Payne, H., Sundayi, S., Walker, E., Brooke, J., Cardy, J., Humphreys, S., Kessack, L., Kubitzek, C., Kumar, S., Cotterill, D., Hodzovic, E., Hosdurga, G., Miles, E., Saunders, G., Campbell, M., Chan, P., Jemmett, K., Raj, A., Naik, A., Oshowo, A., Ramamoorthy, R., Shah, N., Sylvan, A., Blyth, K., Burtenshaw, A., Freeman, D., Johnson, E., Lo, P., Martin, T., Plunkett, E., Wollaston, J., Allison, J., Carroll, C., Craw, N., Craw, S., Pitt-Kerby, T., Rowland-Axe, R., Spurdle, K., Mcdonald, A., Simon, D., Sinha, V., Banner-Goodspeed, V., Boone, M., Campbell, K., Lu, F., Scannell, J., Sobol, J., Balajonda, N., Clemmons, K., Conde, C., Elgasim, M., Funk, B., Hopkins, T., Olaleye, O., Omer, O., Pender, M., Porto, A., Waweru, P., Yeh, E., Bodansky, D., Evans, A., Kleopoulos, S., Maril, R., Mathney, E., Sanchez, A., Tinuoye, E., Bateman, B., Eng, K., Jiang, N., Ladha, K., Needleman, J., Chen, L. -L., Lane, R., Robinowitz, D., Ghushe, N., Irshad, M., O'Connor, J., Patel, S., Takemoto, S., Wallace, A., Mazzeffi, M., Rock, P., Wallace, K., Chua, P., Mattera, M., Sharar, R., Thilen, S., Treggiari, M., Morgan, A., Sofjan, I., Subramaniam, K., Avidan, M., Maybrier, H., Muench, M., and Wildes, T.

Subjects
operative, Male, Pediatrics, GLOBAL HEALTH, Cohort Studies, 0302 clinical medicine, Postoperative Complications, 030202 anesthesiology, surgical procedures, operative, mortality, Health care, statistics and numerical data, 030212 general & internal medicine, Hospital Mortality, Prospective Studies, Prospective cohort study, Aged, 80 and over, HIGH-RISK SURGERY, COMPLICATIONS, OUTCOMES, Incidence (epidemiology), Middle Aged, PATIENT MORTALITY, Female, SURGICAL MORTALITY, Cohort study, Adult, medicine.medical_specialty, methods, 03 medical and health sciences, Anesthesiology, medicine, QUALITY, Humans, Elective surgery, postoperative care, statistics and numerical data, Aged, Quality of Health Care, Postoperative Care, business.industry, Postoperative complication, mortality, CANCER-SURGERY, surgical procedures, Anesthesiology and Pain Medicine, Logistic Models, VOLUME, postoperative care, methods, Human medicine, Complication, business
Abstract

Background.The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems.Methods.We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest).Results.A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications.Conclusions.Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.

Published
2017
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38. Postcardiac Surgery Acute Stroke Therapies: A Systematic Review

Author

Bronwen B. Grocott, Bryan A. Glezerson, Hilary P. Grocott, Hessam H. Kashani, and Lucas Mosienko

Subjects
medicine.medical_specialty, medicine.medical_treatment, Psychological intervention, MEDLINE, 030204 cardiovascular system & hematology, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, 030202 anesthesiology, medicine, Humans, Thrombolytic Therapy, Stroke, Acute ischemic stroke, Retrospective Studies, Thrombectomy, business.industry, Endovascular Procedures, Retrospective cohort study, Thrombolysis, medicine.disease, Surgery, Cardiac surgery, Mechanical thrombectomy, Anesthesiology and Pain Medicine, Treatment Outcome, Cardiology and Cardiovascular Medicine, business
Abstract

Objective To identify interventions for the treatment of acute ischemic stroke after cardiac surgery and to report the efficacy of these treatments. Design Systematic review and narrative synthesis Participants Patients with ischemic stroke after cardiac surgery. Interventions Treatment efficacy of intra-arterial thrombolysis (IAT) and/or endovascular mechanical thrombectomy (EMT). Methods and Main Results The MEDLINE (Ovid), Embase (Ovid), Scopus (Elsevier), and Cochrane Central Register of Controlled Trials (Wiley) databases were searched from January 1, 1990, until September 20, 2018. After reviewing 5,231 records, 8 case reports/series and 2 retrospective studies were included (n = 33). Three of these reports (n = 19) published between 2001 and 2003 described IAT, and 6 studies (n = 14) published between 2015 and 2019 reported the use of EMT. In the 19 patients who received IAT, 3 (16%) had good, 8 (42%) had moderate, and 8 (42%) had poor neurologic outcomes. In the 14 patients who received EMT, 7 (50%) had good, 5 (36%) had moderate, and 2 (14%) had poor neurologic outcomes. Conclusions Endovascular thrombectomy, with or without IAT, is being used increasingly with success in patients presenting with postcardiac surgery stroke. However, the number of patients reported is too small to confidently understand its overall effect on neurologic outcomes in this setting.

Published
2019

39. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative : infection and sepsis

Author

Jonathan Barnes, Jennifer Hunter, Steve Harris, Manu Shankar-Hari, Elisabeth Diouf, Ib Jammer, Cor Kalkman, Andrew A. Klein, Tomas Corcoran, Stefan Dieleman, Michael P.W. Grocott, Michael G. Mythen, Paul Myles, Tang Joon Gan, Andrea Kurz, Phil Peyton, Dan Sessler, Martin Tramèr, Alan Cyna, Gildasio S. De Oliveira, Christopher Wu, Mark Jensen, Henrik Kehlet, Mari Botti, Oliver Boney, Guy Haller, Mike Grocott, Tim Cook, Lee Fleisher, Mark Neuman, David Story, Russell Gruen, Sam Bampoe, Lis Evered, David Scott, Brendan Silbert, Diederik van Dijk, Matthew Chan, Hilary Grocott, Rod Eckenhoff, Lars Rasmussen, Lars Eriksson, Scott Beattie, Duminda Wijeysundera, Giovanni Landoni, Kate Leslie, Bruce Biccard, Simon Howell, Peter Nagele, Toby Richards, Andre Lamy, Manoj Lalu, Rupert Pearse, Monty Mythen, Jaume Canet, Ann Moller, Tony Gin, Marcus Schultz, Paolo Pelosi, Marcelo Gabreu, Emmanuel Futier, Ben Creagh-Brown, Alexander Fowler, Tom Abbott, Andy Klein, David James Cooper, David McIlroy, Rinaldo Bellomo, Andrew Shaw, John Prowle, Keyvan Karkouti, Josh Billings, David Mazer, Mohindas Jayarajah, Michael Murphy, Justyna Bartoszko, Rob Sneyd, Steve Morris, Ron George, Ramani Moonesinghe, Mark Shulman, Meghan Lane-Fall, Ulrica Nilsson, Nathalie Stevenson, Jamie (DJ) Cooper, Wilton van Klei, Luca Cabrini, Tim Miller, Nathan Pace, Sandy Jackson, Donal Buggy, Tim Short, Bernhard Riedel, Vijay Gottumukkala, Bilal Alkhaffaf, Mark Johnson, Intensive Care Medicine, AII - Infectious diseases, ACS - Diabetes & metabolism, ACS - Pulmonary hypertension & thrombosis, ACS - Microcirculation, Tramer, Martin, and Haller, Guy Serge Antoine

Subjects
medicine.medical_specialty, Consensus, Delphi Technique, Endpoint Determination, Delphi method, perioperative medicine, Perioperative Care/standards, postoperative outcome, Surgical Wound Infection/therapy, Postoperative outcome, Perioperative Care, Sepsis, Perioperative medicine, sepsis, Core outcome measures, Respiratory Tract Infections/therapy, core outcome measures, infection, standardised endpoints, surgical site infection, Humans, Infection, Respiratory Tract Infections, Surgical Wound Infection, Anesthesiology and Pain Medicine, Anesthesiology, Outcome Assessment, Health Care, Endpoint Determination/standards, medicine, Attention, Standardised endpoints, Intensive care medicine, Infections/therapy, ddc:617, business.industry, Sepsis/therapy, Perioperative, anaesthesia, medicine.disease, Clinical trial, Clinical research, Quality and Patient Safety, business, Surgical site infection
Abstract

Background: Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials.Methods: We undertook a systematic review to identify measures of infection and sepsis used in the perioperative literature. A multi-round Delphi consensus process that included more than 60 clinician researchers was then used to refine a recommended list of outcome measures.Results: A literature search yielded 1857 titles of which 255 met inclusion criteria for endpoint extraction. A long list of endpoints, with definitions and timescales, was generated and those potentially relevant to infection and sepsis circulated to the theme subgroup and then the wider StEP-COMPAC working group, undergoing a three-stage Delphi process. The response rates for Delphi rounds 1, 3, and 3 were 89% (n=8), 67% (n=62), and 80% (n=8), respectively. A set of 13 endpoints including fever, surgical site, and organ-specific infections as defined by the US Centres for Disease Control and Sepsis-3 are proposed for future use.Conclusions: We defined a consensus list of standardised endpoints related to infection and sepsis for perioperative trials using an established and rigorous approach. Each endpoint was evaluated with respect to validity, reliability, feasibility, and patient centredness. One or more of these should be considered for inclusion in future perioperative clinical trials assessing infection, sepsis, or both, thereby permitting synthesis and comparison of future results.

Published
2019

40. Prehabilitation before surgery: Is it for all patients?

Author

Malcolm A. West, Sandy Jack, and Michael P.W. Grocott

Subjects
Adult, medicine.medical_specialty, Exercise intervention, Adult patients, Clinical effectiveness, business.industry, Prehabilitation, Psychological intervention, Preoperative Exercise, Surgery, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Postoperative Complications, Treatment Outcome, Early results, 030202 anesthesiology, Elective Surgical Procedures, Preoperative Care, medicine, Quality of Life, Postoperative outcome, Humans, business, 030217 neurology & neurosurgery
Abstract

Purpose To evaluate the role of prehabilitation interventions in adult patients before elective major surgery. Recent findings Exercise training before elective adult major surgery is feasible and safe. Efficacy has been determined but the clinical effectiveness remains uncertain. Early data suggest a reduction in morbidity, length of stay, and an improvement in the quality of life. Nutritional and psychological interventions are less well evaluated, and when they are, it is often in combination with exercise interventions as part of multimodal prehabilitation. Summary Studies evaluating multimodal prehabilitation interventions before elective major surgery in adults are producing encouraging early results, but definitive clinical effectiveness is currently very limited. Future research should focus on refining interventions, exploring mechanisms, establishing minimum dosage, interrogating interactions between therapies, and urgent implementation of large-scale clinical effectiveness studies.

Published
2021

41. In reply: Personal protective equipment during the COVID-19 pandemic (Letters #1 and #2)

Author

Hilary P. Grocott, Laura V. Duggan, and Shannon L. Lockhart

Subjects
2019-20 coronavirus outbreak, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), biology, business.industry, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Pain medicine, General Medicine, biology.organism_classification, Anesthesiology and Pain Medicine, Anesthesia, Anesthesiology, Pandemic, Emergency medicine, medicine, business, Personal protective equipment, Betacoronavirus
Published
2020
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42. Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team

Author

Stacie Deiner, Adrian W. Gelb, Lee A. Fleisher, Jacqueline M. Leung, I.V. Brown, Christopher G. Hughes, Robert A. Whittington, Carol J. Peden, Claudia Spies, Deborah J. Culley, Michael P.W. Grocott, Thomas R. Miller, H. Charles, Lisbeth Evered, Roderic G. Eckenhoff, Hugh C. Hemmings, Thomas N. Robinson, Lars Eriksson, Joseph P. Mathew, David Scott, and Roderic A. Eckenhoff

Subjects
medicine.medical_specialty, Consensus, Best practice, Psychological intervention, Risk Assessment, Perioperative Care, 03 medical and health sciences, 0302 clinical medicine, Cognition, Postoperative Cognitive Complications, 030202 anesthesiology, Multidisciplinary approach, Anesthesiology, Risk Factors, medicine, Humans, Intensive care medicine, Aged, Patient Care Team, Evidence-Based Medicine, business.industry, Incidence (epidemiology), Age Factors, Brain, Delirium, Perioperative, Middle Aged, Leadership, Anesthesiology and Pain Medicine, Anesthetists, medicine.symptom, business, Neurocognitive, Antipsychotic Agents
Abstract

Summary Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.

Published
2020

43. Effects of perioperative oxygen concentration on oxidative stress in adult surgical patients: a systematic review

Author

Martin Feelisch, Alexander H. Oldman, Daniel Martin, Michael P.W. Grocott, and Andrew F. Cumpstey

Subjects
medicine.medical_specialty, perioperative care, medicine.medical_treatment, Review Article, Anesthesia, General, medicine.disease_cause, surgery, chemistry.chemical_compound, Colon surgery, Fraction of inspired oxygen, Internal medicine, Oxygen therapy, Medicine, Humans, Surgical Wound Infection, Caesarean section, Perioperative Period, Dose-Response Relationship, Drug, business.industry, Cesarean Section, Oxygen Inhalation Therapy, Perioperative, anaesthesia, Malondialdehyde, Oxygen, Oxidative Stress, Anesthesiology and Pain Medicine, Systematic review, chemistry, inflammation, hyperoxia, business, Oxidative stress
Abstract

Background The fraction of inspired oxygen (FiO2) administered during general anaesthesia varies widely despite international recommendations to administer FiO2 0.8 to all anaesthetised patients to reduce surgical site infections (SSIs). Anaesthetists remain concerned that high FiO2 administration intraoperatively may increase harm, possibly through increased oxidative damage and inflammation, resulting in more complications and worse outcomes. In previous systematic reviews associations between FiO2 and SSIs have been inconsistent, but none have examined how FiO2 affects perioperative oxidative stress. We aimed to address this uncertainty by reviewing the available literature. Methods EMBASE, MEDLINE, and Cochrane databases were searched from inception to March 9, 2020 for RCTs comparing higher with lower perioperative FiO2 and quantifying oxidative stress in adults undergoing noncardiac surgery. Candidate studies were independently screened by two reviewers and references hand-searched. Methodological quality was assessed using the Cochrane Collaboration Risk of Bias tool. Results From 19 438 initial results, seven trials (n=422) were included. Four studies reported markers of oxidative stress during Caesarean section (n=328) and three reported oxidative stress during elective colon surgery (n=94). Risk of bias was low (four studies) to moderate (three studies). Pooled results suggested high FiO2 was associated with greater malondialdehyde, protein-carbonyl concentrations and reduced xanthine oxidase concentrations, together with reduced antioxidant markers such as superoxide dismutase and total sulfhydryl levels although total antioxidant status was unchanged. Conclusions Higher FiO2 may be associated with elevated oxidative stress during surgery. However, limited studies have specifically reported biomarkers of oxidation. Given the current clinical controversy concerning perioperative oxygen therapy, further research is urgently needed in this area.

Published
2020

44. COVID-19: a complex multi-system disorder

Author

Richard J. Schilling, Martin McKee, Marcel Levi, Wei Shen Lim, C Michael Roberts, and Michael P.W. Grocott

Subjects
Lung Diseases, 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Pneumonia, Viral, Article, Renal Circulation, coagulopathy, Betacoronavirus, delirium, Pandemic, Coagulopathy, Humans, Medicine, Pandemics, pathophysiology, Brain Diseases, biology, business.industry, SARS-CoV-2, COVID-19, adult respiratory distress syndrome, thromboembolism, medicine.disease, biology.organism_classification, Virology, Myocarditis, Anesthesiology and Pain Medicine, Delirium, medicine.symptom, Coronavirus Infections, business
Published
2020

45. Multidisciplinary guidance for safe tracheostomy care during the COVID‐19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

Author

T. Jacob, P. Twose, P. Magennis, J. Gimblett, Sarah Wallace, C. Kerawala, N. Ashby, R. Moonesinghe, K. Ferguson, M. Birchall, A. Higgs, Brendan McGrath, Catherine Doherty, P. Macnaughton, P. Dean, and Michael P.W. Grocott

Subjects
Consensus, Infectious Disease Transmission, Patient-to-Professional, medicine.medical_treatment, Pneumonia, Viral, coronavirus, MEDLINE, Guidelines as Topic, State Medicine, 03 medical and health sciences, Patient safety, Tracheostomy, 0302 clinical medicine, COVID‐19, 030202 anesthesiology, Multidisciplinary approach, Intensive care, Health care, medicine, Humans, 030212 general & internal medicine, Pandemics, Personal protective equipment, Mechanical ventilation, Rehabilitation, business.industry, COVID-19, Original Articles, medicine.disease, Respiration, Artificial, Anesthesiology and Pain Medicine, personal protective equipment, Original Article, Patient Safety, Medical emergency, Safety, Coronavirus Infections, business
Abstract

Summary The COVID‐19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation, and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and subsequent management. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units, cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme’s ‘Safe Tracheostomy Care’ workstream as part of the NHS COVID‐19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on the available literature and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. The consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol‐generating procedures and risks to staff; insertion procedures; and management following tracheostomy. These consensus recommendations are based on expert opinion and informed by the best available evidence and published guidance where possible.

Published
2020
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46. Peri-operative care pathways: re-engineering care to achieve the ‘triple aim’

Author

Mark R Edwards, Michael P.W. Grocott, Solomon Aronson, and Michael G. Mythen

Subjects
education.field_of_study, medicine.medical_specialty, Quality management, business.industry, Public health, Population, Psychological intervention, Population health, Sleep medicine, Perioperative Care, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Nursing, 030202 anesthesiology, Health care, Patient experience, Humans, Pain Management, Medicine, Sleep Hygiene, 030212 general & internal medicine, business, education, Life Style
Abstract

Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. Re-engineered pre-operative pathways open up opportunities for intervention before surgery including shared decision-making, comorbidity management and collaborative behavioural change. Individualised, risk-adapted, intra-operative interventions will drive more reliable and consistent care. Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.

Published
2019
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47. Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic

Author

Randy S. Wax, Laura V. Duggan, Shannon L. Lockhart, Hilary P. Grocott, and Stephan Saad

Subjects
2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), business.industry, General Medicine, medicine.disease, 03 medical and health sciences, Health personnel, 0302 clinical medicine, Contact precautions, Anesthesiology and Pain Medicine, 030202 anesthesiology, Anesthesia, Pandemic, Medicine, 030212 general & internal medicine, Medical emergency, business, Personal protective equipment, Healthcare providers, Healthcare system
Abstract

Healthcare providers are facing a coronavirus disease pandemic. This pandemic may last for many months, stressing the Canadian healthcare system in a way that has not previously been seen. Keeping healthcare providers safe, healthy, and available to work throughout this pandemic is critical. The consistent use of appropriate personal protective equipment (PPE) will help assure its availability and healthcare provider safety. The purpose of this communique is to give both anesthesiologists and other front-line healthcare providers a framework from which to understand the principles and practices surrounding PPE decision-making. We propose three types of PPE including: 1) PPE for droplet and contact precautions, 2) PPE for general airborne, droplet, and contact precautions, and 3) PPE for those performing or assisting with high-risk aerosol-generating medical procedures.

Published
2020
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48. Transversus Abdominis Plane Block: Comment

Author

Hilary P. Grocott

Subjects
Orthodontics, Anesthesiology and Pain Medicine, business.industry, Transversus Abdominis Plane Block, Medicine, Nerve Block, business, Bupivacaine, Abdominal Muscles
Published
2020

49. Preincision transversus thoracis plane block: advantages and pitfalls

Author

Hilary P. Grocott, Camila Machado de Souza, and Duncan Maguire

Subjects
medicine.medical_specialty, business.industry, General Medicine, Surgery, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Enhanced recovery, 030202 anesthesiology, Regional anesthesia, Block (telecommunications), medicine, Transversus thoracis muscle, Transversus thoracis, business, 030217 neurology & neurosurgery
Abstract

To the Editor We read, with keen interest, the pilot study by Fujii et al examining the transversus thoracis muscle plane block in cardiac surgery.[1][1] In the era of ‘fast track’ and other enhanced recovery after cardiac surgery efforts, novel regional anesthesia techniques are increasingly

Published
2020

50. Comparison of Two Major Perioperative Bleeding Scores for Cardiac Surgery Trials

Author

Mark Crowther, Damon C. Scales, Jean S. Bussières, Blaine Achen, Ruxandra Pinto, Hilary P. Grocott, Sukhpal Brar, Duminda N. Wijeysundera, Vivek Rao, Terry Waters, Diem Tran, Christopher Harle, Charles McAdams, David Wong, Doug Morrison, Justyna Bartoszko, Étienne de Médicis, Jeannie Callum, Tonya de Waal, Summer Syed, and Keyvan Karkouti

Subjects
medicine.medical_specialty, business.industry, Construct validity, Perioperative, 030204 cardiovascular system & hematology, Intraoperative Hemorrhage, Cardiac surgery, 03 medical and health sciences, Coronary artery bypass surgery, 0302 clinical medicine, Anesthesiology and Pain Medicine, Internal medicine, Predictive value of tests, Criterion validity, medicine, 030212 general & internal medicine, Prospective cohort study, business
Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Research into major bleeding during cardiac surgery is challenging due to variability in how it is scored. Two consensus-based clinical scores for major bleeding: the Universal definition of perioperative bleeding and the European Coronary Artery Bypass Graft (E-CABG) bleeding severity grade, were compared in this substudy of the Transfusion Avoidance in Cardiac Surgery (TACS) trial. Methods As part of TACS, 7,402 patients underwent cardiac surgery at 12 hospitals from 2014 to 2015. We examined content validity by comparing scored items, construct validity by examining associations with redo and complex procedures, and criterion validity by examining 28-day in-hospital mortality risk across bleeding severity categories. Hierarchical logistic regression models were constructed that incorporated important predictors and categories of bleeding. Results E-CABG and Universal scores were correlated (Spearman ρ = 0.78, P < 0.0001), but E-CABG classified 910 (12.4%) patients as having more severe bleeding, whereas the Universal score classified 1,729 (23.8%) as more severe. Higher E-CABG and Universal scores were observed in redo and complex procedures. Increasing E-CABG and Universal scores were associated with increased mortality in unadjusted and adjusted analyses. Regression model discrimination based on predictors of perioperative mortality increased with additional inclusion of the Universal score (c-statistic increase from 0.83 to 0.91) or E-CABG (c-statistic increase from 0.83 to 0.92). When other major postoperative complications were added to these models, the association between Universal or E-CABG bleeding with mortality remained. Conclusions Although each offers different advantages, both the Universal score and E-CABG performed well in the validity assessments, supporting their use as outcome measures in clinical trials.

Published
2018
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