BACKGROUND:Although the Hypotension Prediction Index (HPI) reduces intraoperative hypotension, improvements in patient-centered outcomes remain inconsistent. We performed a high-resolution signal analysis to describe the coexistence of arterial pressure, preload-related hemodynamic signals, and algorithm-derived hypotension risk during surgery. METHODS:We conducted a retrospective high-resolution signal analysis (20-second intervals) of 181 patients from the multicenter HYT trial. We quantified hypotension (mean arterial pressure [MAP] <65 mmHg), preload-dependent physiology (stroke volume variation [SVV] >13%), and their temporal relationship with HPI-derived risk signals. Patients were classified into four descriptive groups based on combinations of MAP and SVV burden. RESULTS:Overall hypotension exposure was low (median 1.3% of monitored time), whereas preload-dependent physiology was more frequent (approximately 10%) and often persisted during periods classified as low hypotension risk (HPI <80). SVV >13% preceded hypotensive events significantly earlier than HPI alerts (median 8.7 vs. 1.8 minutes; P=0.0119). Higher vasopressor burden was observed in patients with preserved MAP despite sustained SVV elevation. CONCLUSIONS:During HPI-guided care, preserved arterial pressure frequently coexists with sustained preload-dependent hemodynamic signals. These findings describe patterns of pressure and preload-related signal behavior during algorithm-guided hemodynamic management and should be interpreted as hypothesis-generating.

Postoperative delirium (POD) is the most frequent acute neurological complication in the older surgical patient and is independently associated with increased mortality, accelerated cognitive decline and loss of functional independence. Models centred on isolated organs do not explain why systemic frailty predicts perioperative cognitive failure irrespective of the type of surgery or the anaesthetic technique. We have conducted a hypothesis-generating narrative review that synthesises the evidence positioning the autonomic nervous system (ANS) as the link between frailty, the surgical stress response and POD, and that articulates a perioperative conceptual framework—the brain–heart–immune axis—in which the vagus nerve integrates an autonomic-cardiovascular arm, a neuroimmune arm mediated by the cholinergic anti-inflammatory pathway and a neurocognitive arm. The most recent studies suggest that indices of autonomic adaptability —rather than markers of tone or state—may independently predict POD and may modulate the postoperative neuroinflammatory trajectory; that preoperative baroreflex sensitivity may anticipate post-induction hypotension; that certain electroencephalographic recordings may be associated with greater POD risk; and that non-invasive vagal neuromodulation might reduce its incidence. On this basis, a four-phase perioperative strategy is proposed—autonomic assessment, multimodal prehabilitation, multimodal intraoperative monitoring and postoperative protection. Its status should be specified: the brain–heart–immune axis is proposed as an integrative, hypothesis-generating conceptual framework, not as a validated clinical model, since the evidence linking heart rate variability (HRV) and baroreflex sensitivity (BRS) with POD is predominantly observational, heterogeneous and of limited certainty; for this reason, neither HRV nor BRS should yet be employed in isolation as diagnostic or predictive tools, and the framework requires prospective validation and methodological standardisation of the autonomic indices before its incorporation into risk stratification and delirium prevention.

INTRODUCTION:Lactate is widely used as a marker of metabolic and circulatory stress, but its prognostic value in emergency surgical populations remains incompletely defined. METHODS:We performed a retrospective cohort study using the INSPIRE dataset, including emergency surgical procedures with a preoperative lactate measurement obtained within 6 h of incision. The primary outcome was in-hospital mortality. Multivariable logistic regression adjusted for age, sex, ASA physical status, surgical department, anaesthesia type, preoperative haemoglobin and creatinine. Lactate was analysed using restricted cubic splines and in prespecified categories (<2, 2-<4 and ≥4 mmol l-¹). Incremental prognostic value was assessed by comparing a baseline clinical model with and without lactate. RESULTS:The analytic cohort included 3729 emergency surgical procedures, of which 360 resulted in in-hospital death (9.7%). Mortality increased across lactate categories: 6.9% for lactate <2 mmol l-¹, 13.9% for lactate 2-<4 mmol l-¹ and 42.2% for lactate ≥4 mmol l-¹. After adjustment, lactate was still associated with mortality (odds ratio 1.79 [95% CI 1.23-2.59] for 2-<4 mmol l-¹ and 7.34 [4.65-11.57] for ≥4 mmol l-¹ vs <2 mmol l-¹). Adding lactate to the standard clinical model improved discrimination (AUC 0.755 vs 0.801) and reduced the Brier score (0.094 vs 0.088). Results were consistent across alternative measurement windows and after multiple imputation. CONCLUSION:Preoperative lactate concentration was strongly associated with in-hospital mortality and provided incremental prognostic information beyond routinely available variables. In emergency surgical pathways, lactate may support early risk stratification.

BACKGROUND Acute kidney injury (AKI) is a common complication after surgery. Greater fluid administration has been related to an increased incidence in patients undergoing major surgery but there are no large series of patients in specific perioperative settings showing relationship between fluid balance and the occurrence of AKI. OBJECTIVE This study tested the hypothesis that higher perioperative fluid balance was associated with an increased risk of postoperative AKI. DESIGN Prospective observational study. Predefined secondary sub-study of the Postoperative Outcomes Within Enhanced Recovery After Surgery (POWER) study SETTING A pre-planned secondary analysis of a multicentre study in 80 hospitals in Spain during a single period of 2 months of recruitment between September and December 2017. PATIENTS Patients undergoing elective primary colorectal surgery with a planned overnight stay were included if they had complete data regarding postoperative fluid balance. Patients who underwent urgent or emergency surgery or with estimated glomerular filtration rate less than 30 ml min −1 were excluded. MAIN OUTCOMES MEASURES The primary outcome was the occurrence of AKI (mild, moderate, or severe) at 30 days following surgery. AKI was defined according to KDIGO and EPCO guidelines, incorporating serum creatinine and urine output criteria. RESULTS A total of 1139 patients were included in the study. Of these, 73 patients (6.4%) developed acute kidney injury in the postoperative period. The adjusted relative risks (RR) that compared the quartile with the lowest perioperative fluid balance (Q1) with other quartiles were 4.10 [95% confidence interval (CI), 1.60 to 10.51] for Q3 and 4.81 (95% CI, 1.91 to 12.11) for Q4. In the Poisson loglinear model after adjusting by sex, ASA grade, Enhanced Recovery After Surgery (ERAS) adherence and intraoperative bleeding, RR for AKI were higher with a higher positive perioperative fluid balance (quadratic nonlinear P < 0.01) CONCLUSIONS In this secondary analysis, we found that higher positive perioperative fluid balance during the first 24 h was associated with an increased risk of postoperative acute kidney injury in patients undergoing elective colorectal surgery. TRIAL REGISTRATION Clinicaltrials.com identifier: NCT03012802.

Study objective To determine whether routinely recorded intraoperative hemodynamic data can identify clinically meaningful patterns associated with postoperative complications after major abdominal surgery. Design Retrospective observational cohort study. Setting Single tertiary academic center; analysis of the INSPIRE perioperative research database. Patients 13,143 adult patients undergoing elective major abdominal surgery with continuous invasive arterial pressure monitoring. Interventions None. Measurements Intraoperative hemodynamics were summarized using median mean arterial pressure (MAP), percentage of measurements with MAP <65 mmHg, vasopressor use, and fluid administration. Unsupervised k-means clustering was used to derive intraoperative hemodynamic phenotypes. Associations with postoperative acute kidney injury (AKI), intensive care unit (ICU) admission, in-hospital mortality, and hospital length of stay were assessed using adjusted regression models controlling for age, sex, body mass index, ASA physical status, and surgical department. Main results Four distinct intraoperative hemodynamic patterns were identified. Most procedures were hemodynamically stable (phenotype 1, 63.9%). Two intermediate (phenotype 2 and 3; 35.0% combined) were characterized by greater hypotension burden with increased vasopressor or fluid requirements. A small group (phenotype 4, 1.0%) showed sustained hypotension and high vasopressor use. Postoperative outcomes followed a graded pattern: AKI increased from 4.9% in phenotype 1 to 41.4% in phenotype 4, ICU admission from 8.3% to 93.2%, and in-hospital mortality from 0.7% to 6.0%. After adjustment, phenotypes 2 and 3 were associated with approximately two- to threefold higher odds of AKI and ICU admission compared with phenotype 1. Conclusions Distinct intraoperative hemodynamic phenotypes are associated with graded increases in postoperative complications after major abdominal surgery.

BACKGROUND:Acute kidney injury (AKI) is a common complication after surgery. Greater fluid administration has been related to an increased incidence in patients undergoing major surgery but there are no large series of patients in specific perioperative settings showing relationship between fluid balance and the occurrence of AKI. OBJECTIVE:This study tested the hypothesis that higher perioperative fluid balance was associated with an increased risk of postoperative AKI. DESIGN:Prospective observational study. Predefined secondary sub-study of the Postoperative Outcomes Within Enhanced Recovery After Surgery (POWER) study. SETTING:A pre-planned secondary analysis of a multicentre study in 80 hospitals in Spain during a single period of 2 months of recruitment between September and December 2017. PATIENTS:Patients undergoing elective primary colorectal surgery with a planned overnight stay were included if they had complete data regarding postoperative fluid balance. Patients who underwent urgent or emergency surgery or with estimated glomerular filtration rate less than 30 ml min -1 were excluded. MAIN OUTCOMES MEASURES:The primary outcome was the occurrence of AKI (mild, moderate, or severe) at 30 days following surgery. AKI was defined according to KDIGO and EPCO guidelines, incorporating serum creatinine and urine output criteria. RESULTS:A total of 1139 patients were included in the study. Of these, 73 patients (6.4%) developed acute kidney injury in the postoperative period. The adjusted relative risks (RR) that compared the quartile with the lowest perioperative fluid balance (Q1) with other quartiles were 4.10 [95% confidence interval (CI), 1.60 to 10.51] for Q3 and 4.81 (95% CI, 1.91 to 12.11) for Q4. In the Poisson loglinear model after adjusting by sex, ASA grade, Enhanced Recovery After Surgery (ERAS) adherence and intraoperative bleeding, RR for AKI were higher with a higher positive perioperative fluid balance (quadratic nonlinear P  < 0.01). CONCLUSIONS:In this secondary analysis, we found that higher positive perioperative fluid balance during the first 24 h was associated with an increased risk of postoperative acute kidney injury in patients undergoing elective colorectal surgery. TRIAL REGISTRATION:Clinicaltrials.com identifier: NCT03012802.

Preoperative anemia and transfusion are common in gastric cancer surgery and have been associated with adverse short-term outcomes. Their impact on long-term oncologic prognosis remains unclear. We aimed to assess the association between preoperative anemia, perioperative red blood cell transfusion, and disease-free survival (DFS) after gastrectomy. This was a prespecified long-term analysis of the prospective POWER4 multicenter cohort conducted across 72 Spanish hospitals. Patients undergoing elective gastrectomy for gastric cancer between 2019 and 2020 were followed for ≥ 36 months. DFS was defined as time from surgery to recurrence or death. Primary exposures were preoperative anemia (World Health Organization criteria) and perioperative transfusion (within 72 h). Analyses included Kaplan–Meier estimates, multivariable Cox regression, logistic regression for delayed or omitted adjuvant chemotherapy (RIOT), and causal mediation analysis. Generalized additive models (GAMs) explored nonlinear associations between hemoglobin and DFS. Among 386 patients, 47

BACKGROUND:Postoperative acute kidney injury (AKI) after major abdominal surgery leads to poor outcomes. The Hypotension Prediction Index (HPI; Edwards Lifesciences, USA) may aid in managing intraoperative hemodynamic instability. This study assessed whether HPI-guided therapy reduces moderate-to-severe AKI incidence in moderate- to high-risk elective abdominal surgery patients. METHODS:This multicenter randomized trial was conducted from October 2022 to February 2024 across 28 hospitals evaluating HPI-guided management compared to a wide range of real-world hemodynamic approaches. A total of 917 patients (65 yr or older or older than 18 yr with American Society of Anesthesiologists Physical Status greater than II) undergoing moderate- to high-risk elective abdominal surgery were included in the intention-to-treat analysis. HPI-guided management triggered interventions when the HPI exceeded 80, using fluids and/or vasopressors/inotropes based on hemodynamic data. The primary outcome was the incidence of moderate-to-severe AKI within the first 7 days after surgery. Secondary outcomes included overall complications, the need for renal replacement therapy, duration of hospital stay, and 30-day mortality. RESULTS:Median age was 71 yr (interquartile range, 65 to 77) in the HPI group and 70 yr (interquartile range, 63 to 76) in standard care group. American Society of Anesthesiologists Physical Status III/IV was 58.3% (268 of 459) in the HPI group and 57.9% (263 of 458) in standard care group. The incidence of moderate-to-severe AKI was 6.1% (28 of 459) in the HPI group and 7.0% (32 of 458) in the standard care group (risk ratio, 0.89; 95% CI, 0.54 to 1.49; P = 0.66). Overall complications occurred in 31.9% (146 of 459) of the HPI group and 29.7% (136 of 458) of the standard care group (risk ratio, 1.08; 95% CI, 0.85 to 1.37; P = 0.52). The incidence of renal replacement therapy did not differ between groups. Median length of hospital stay was 6 days (interquartile range, 4 to 10) in both groups. The 30-day mortality was 1.1% (5 of 459) in the HPI group versus 0.9% (4 of 458) in standard care group (risk ratio, 1.35; 95% CI, 0.36 to 5.10; P = 0.66). CONCLUSIONS:HPI-guided hemodynamic therapy did not reduce the incidence of postoperative AKI or overall complications compared to standard care.

La candidiasis intraabdominal (CIA) es un síndrome infeccioso muy prevalente y una importante causa de mortalidad en las unidades de cuidados intensivos. El Grupo de Trabajo en Infecciones Perioperatorias de la Sociedad Española de Anestesiología, Reanimación y Tratamiento del Dolor ha promovido la elaboración de recomendaciones fundamentadas en la experiencia de un panel multidisciplinar de expertos procedentes de diversas especialidades médicas, con el objetivo de optimizar el diagnóstico y tratamiento de procesos infecciosos graves como la CIA. Estas recomendaciones se han desarrollado a partir de un riguroso análisis crítico de la evidencia científica actualmente disponible. El presente documento ofrece unas recomendaciones para la optimización del abordaje terapéutico de la CIA a partir de los últimos hallazgos en microbiología, las novedades terapéuticas, las particularidades farmacocinéticas y farmacodinámicas en el paciente crítico con CIA, las consideraciones terapéuticas especiales en la oxigenación por membrana extracorpórea y las técnicas continuas de reemplazo renal, la idoneidad del tratamiento empírico vs. dirigido, y la mejora y disminución de la duración del proceso terapéutico.

BACKGROUND:Enhanced Recovery After Surgery (ERAS) protocols have been widely adopted in gastric cancer surgery, with consistent benefits in perioperative recovery. However, whether adherence to ERAS influences long-term oncologic outcomes remains unclear. This study aimed to evaluate the association between ERAS adherence and disease-free survival (DFS) following curative-intent gastrectomy. METHODS:This was a prespecified substudy of the POWER4 cohort, a prospective, multicentre investigation of perioperative care and outcomes in patients undergoing elective gastrectomy for gastric cancer. ERAS adherence was assessed using 22 predefined components and analysed as a binary (high vs. low), continuous (per 10-point increment), and quartile-based variable. The primary endpoint was DFS, defined as the time from surgery to recurrence or death. Kaplan-Meier estimates and multivariable Cox models were used to evaluate the association between ERAS adherence and DFS, adjusting for age, sex, ASA, BMI, nutritional risk, anaemia, chronic kidney disease, surgical approach, procedure type, operative time, and tumour stage. RESULTS:Among 368 patients with complete oncologic follow-up, the median follow-up was 1616 days. Kaplan-Meier curves suggested a trend toward improved DFS with higher ERAS adherence (log-rank p =  0.10 for binary comparison; p =  0.05 across quartiles). In multivariable Cox models, ERAS adherence was not significantly associated with DFS. Prognosis was independently predicted by tumour stage, chronic kidney disease, ASA ≥ III, and total gastrectomy. CONCLUSION:In this multicentre cohort, ERAS adherence was not independently associated with long-term DFS after gastrectomy for gastric cancer. Long-term prognosis appeared primarily driven by tumour and patient-related factors rather than perioperative protocol adherence. The study was registered on Clinicaltrials.gov: NCT06790238.

Introduction: In cases of arterial hypotension and/or hypoperfusion that do not respond to fluid therapy, the administration of intravenous catecholamines, especially norepinephrine, is usually the treatment of choice. However, prolonged exposure to high doses of norepinephrine increases mortality, as well as the possibility of arrhythmias, organ damage, and tissue ischemia. An early multimodal vasopressor strategy, which involves adding vasopressin (a drug with a mechanism of action different from catecholamines) to low-dose norepinephrine, could improve the safety profile. Objectives: The main objective is to characterise the routine clinical practice of vasopressin (VASOPRES) use in the context of shock, collecting clinical, analytical and echocardiographic data. Materials and methods The VASOPRES Registry is a prospective multicentre observational study, in which critical care anaesthesia units from all over Spain will participate, collecting data on patients over 18 years of age in whom treatment with vasopressin is initiated, regardless of the type of shock they present. The duration of the study is estimated at 24 months, starting from its approval by the Clinical Research Ethics Committee (CEIm). Results: Data collection started in July 2024 and is expected to end in July 2026. Ethics and publications: The VASOPRES Registry has already been approved by the Clinical Research Ethics Committee of the Hospital Universitario de La Princesa, Madrid (registration number 5596) in May 2024. The study is registered in ClinicalTrials.gov under the number NCT06422975 and in the Spanish Clinical Trials Register (REec) through the GESTO platform (Observational studys with authorized medicines) under the identification number 0083-2024-OBS. The results will be published in specialised journals and presented at conferences and congresses. Conclusions: The Vasopres Registry may provide insight into the uncertainties that still exist about the use of AVP as well as its use in routine clinical practice in various types of shock. Furthermore, it is also hoped that the results of this study will identify potential areas for improvement where more targeted research is needed.

BACKGROUND:The Hypotension Prediction Index (HPI) is a machine-learning algorithm designed to predict hypotension. by maintaining mean arterial pressure (MAP) above 65 mmHg. This meta-analysis evaluated whether HPI-guided management improves postoperative outcomes and included post hoc analyses of intraoperative hypotension (IOH) metrics in adults undergoing major abdominal surgery. METHODS:A comprehensive search of PubMed, EMBASE, and Cochrane databases identified randomized controlled trials comparing HPI-guided management with standard care. Primary outcomes were postoperative complications, acute kidney injury (AKI), perioperative mortality, and hospital length of stay (LOS). Post hoc analyses assessed IOH metrics, including time-weighted average (TWA) of MAP < 65 mmHg, area under the threshold (AUT), total time with MAP < 65 mmHg, and intraoperative fluid use. Meta-analyses were conducted using random-effects models to calculate pooled standardized mean differences (SMDs), odds ratios (ORs), and mean differences (MDs). RESULTS:Eight trials involving 1534 patients were included. No significant differences were observed for AKI (OR: 0.85; 95% CI: 0.64-1.13), postoperative complications (OR: 1.10; 95% CI: 0.83-1.46), mortality (OR: 0.96; 95% CI: 0.32-2.83), LOS (SMD: -0.15; 95% CI: -0.73 to 0.42), or fluid use (SMD: -0.06; 95% CI: -0.35 to 0.24). HPI reduced TWA MAP < 65 mmHg (SMD: -0.25; MD: -20.5 min), AUT (SMD: -0.83), and total time with MAP < 65 mmHg (SMD: -0.74). CONCLUSIONS:HPI-guided management did not significantly improve patient-centered outcomes. Post hoc analyses indicated a reduction in IOH metrics, but the clinical relevance of these findings remains uncertain given the lack of blinding and high risk of bias. REGISTRATION:PROSPERO: CRD42023490654.

Purpose: Our aim was to examine the efficacy of concurrent exercise (i.e., aerobic and strength exercise) during prehabilitation programs on functional capacity in comparison with standard cancer care strategies in colorectal cancer (CRC) patients scheduled for surgery. Methods: A systematic review of randomized controlled trials was performed. A search of electronic databases [PubMed, Web of Science, and EBSCO Host] was conducted to identify all publications employing concurrent exercise in patients with CRC. Random-effects meta-analyses were used to calculate the standardized change in mean difference (SMD) and 95%CI between exercise intervention and control groups for the 6 min walking test (6MWT) distance covered before and after prehabilitation. Results: Six studies met the inclusion criteria (379 patients with CRC). Concurrent training during prehabilitation led to significant positive effects on the 6MWT (0.28 SMD [0.03–0.54], p = 0.037). Subgroup analyses showed a higher SMD (0.48 [0.00–0.98], p = 0.050) in younger (i.e., <70 years) CRC patients compared to their older counterparts (0.10 [0.08–0.11], p = 0.310). Meta-regression models between SMD of the 6MWT and body mass index, prehabilitation program duration, and baseline 6MWT distance covered did not show any significant relationship. Conclusions: This meta-analysis demonstrates the superiority of concurrent exercise prehabilitation in improving functional capacity related to cardiometabolic changes and lowering postoperative risk in patients with CRC.

El diagnóstico de infección, para el diagnóstico de shock séptico, se ha venido basando en el recuento leucocitario y los biomarcadores proteicos. Su mortalidad es persistentemente alta (20-50%), subiendo a largo plazo. La definición de sepsis no incluye el recuento de leucocitos. La linfopenia se ha relacionado con su mortalidad a corto plazo. No está demostrada la inmunosupresión y el aumento de mortalidad por sepsis a largo plazo. El objetivo es relacionar la aparición de linfopenia y la ausencia de su recuperación durante el shock séptico con la mortalidad a los 2 años. Cohorte de 332 pacientes ancianos con diagnóstico de shock séptico. Se analiza la mortalidad a 28 días y a 2 años en función del recuento de leucocitos, neutrófilos, linfocitos y la capacidad de recuperación de la linfopenia (LRec). El 74,1% de los pacientes mostraron linfopenia, que no mejoró durante la estancia en la UCI en el 66,3%. La mortalidad fue del 31,0% y del 50,3% a los 28 días y a los 2 años, respectivamente. El recuento de leucocitos < 12.000/μl fue predictor de mortalidad precoz (OR: 2,96) y la LRec, de la tardía (OR: 3,98). La mortalidad a largo plazo se asoció con LRec (HR: 1,69). En pacientes ancianos con shock séptico, la ausencia de leucocitosis y neutrofiia se asocia con la mortalidad a los 28 días, y la LRec, con la mortalidad a los 2 años, pudiendo representar dos fenotipos distintos de comportamiento tras el shock séptico. The diagnosis of infection, to diagnose septic shock, has been qualified by leukocyte counts and protein biomarkers. Septic shock mortality is persistently high (20%-50%), and rising in the long term. The definition of sepsis does not include leukocyte count, and lymphopenia has been associated with its mortality in the short term. Immunosuppression and increased mortality in the long term due to sepsis have not been demonstrated. The aim is to relate the occurrence of lymphopenia and its lack of recovery during septic shock with mortality at 2 years. Cohort of 332 elderly patients diagnosed with septic shock. Mortality at 28 days and 2 years was analysed according to leukocyte, neutrophil, and lymphocyte counts, and the ability to recover from lymphopenia (LRec). A total of 74.1% of patients showed lymphopenia, and 66.3% did not improve during ICU stay. Mortality was 31.0% and 50.3% at 28 days and 2 years, respectively. A leukocyte count < 12,000 /μL was a predictor of early mortality (OR: 2.96) and LRec of late mortality (OR: 3.98). Long-term mortality was associated with LRec (HR: 1.69). In elderly patients with septic shock, the absence of leukocytosis and neutrophilia is associated with 28-day mortality, and LRec with 2-year mortality; this may represent two distinct phenotypes of behaviour after septic shock.

OBJECTIVES:Identifying host response biomarkers implicated in the emergence of organ failure during infection is key to improving the early detection of this complication. METHODS:Twenty biomarkers of innate immunity, T-cell response, endothelial dysfunction, coagulation, and immunosuppression were profiled in 180 surgical patients with infections of diverse severity (IDS) and 53 with no infection (nIDS). Those better differentiating IDS/nIDS in the area under the curve were combined to test their association with the sequential organ failure assessment score by linear regression analysis in IDS. Results were validated in another IDS cohort of 174 patients. RESULTS:C-reactive protein, procalcitonin, pentraxin-3, lipocalin-2 (LCN2), tumoral necrosis factor-α, angiopoietin-2, triggering receptor expressed on myeloid cells-1 (TREM-1) and interleukin (IL)-15 yielded an area under the curve ≥0.75 to differentiate IDS from nIDS. The combination of LCN2, IL-15, TREM-1, angiopoietin-2 (Dys-4) showed the strongest association with sequential organ failure assessment score in IDS (adjusted regression coefficient; standard error; P): Dys-4 (3.55;0.44; <0.001), LCN2 (2.24; 0.28; <0.001), angiopoietin-2 (1.92; 0.33; <0.001), IL-15 (1.78; 0.40; <0.001), TREM-1(1.74; 0.46; <0.001), tumoral necrosis factor-α (1.60; 0.31; <0.001), pentraxin-3 (1.12; 0.18; <0.001), procalcitonin (0.85; 0.12; <0.001). Dys-4 provided similar results in the validation cohort. CONCLUSIONS:There is a synergistic impact of innate immunity hyper-activation (LCN2, IL-15, TREM-1) and endothelial dysfunction (angiopoietin-2) on the magnitude of organ failure during infection.

IntroducciónLa disfunción cognitiva perioperatoria es un síndrome clínico muy prevalente debido al progresivo envejecimiento de la población quirúrgica. El objetivo de nuestro estudio es evaluar la práctica clínica de los anestesiólogos españoles encuestados respecto a esta entidad.Material y métodosEncuesta online prospectiva realizada por la Sección de Neurociencias y distribuida por la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor.ResultadosSe obtuvieron 544 respuestas, con una participación del 17%. Del total de los encuestados, el 54,4% no hace nunca una valoración preoperatoria del deterioro cognitivo, solo el 7,5% la realiza siempre. El 79,6% carece de protocolo de manejo intraoperatorio del paciente en riesgo de DCP. En la planificación anestésica, solo un 23,3% tenía en cuenta el DCP. El 89% considera la anestesia regional con o sin sedación preferible a la anestesia general para prevenir el DCP. Un 88,8% opina que las benzodiacepinas presentan un alto riesgo de DCP. Por otro lado, un 71,7% cree que la monitorización de la profundidad anestésica podría prevenir el déficit cognitivo posoperatorio. La evaluación rutinaria del delirium posoperatorio (DPO) es baja, solo un 14% la efectúa. Más del 80% reconoce que el DCP está infradiagnosticado.ConclusionesEntre los anestesiólogos españoles encuestados, la DCP es aún una entidad poco conocida y valorada. Es necesario concientizar sobre la necesidad de detectar los factores de riesgo de DCP y la evaluación posoperatoria. Por ello, se sugiere el desarrollo de guías y protocolos, así como la implementación de programas de formación continuada en los que los anestesiólogos deberían ser miembros clave de equipos multidisciplinares encargados de la atención perioperatoria.

BACKGROUND AND OBJECTIVE:The diagnosis of infection, to diagnose septic shock, has been qualified by leukocyte counts and protein biomarkers. Septic shock mortality is persistently high (20%-50%), and rising in the long term. The definition of sepsis does not include leukocyte count, and lymphopenia has been associated with its mortality in the short term. Immunosuppression and increased mortality in the long term due to sepsis have not been demonstrated. The aim is to relate the occurrence of lymphopenia and its lack of recovery during septic shock with mortality at 2 years. PATIENTS AND METHODS:Cohort of 332 elderly patients diagnosed with septic shock. Mortality at 28 days and 2 years was analysed according to leukocyte, neutrophil, and lymphocyte counts, and the ability to recover from lymphopenia (LRec). RESULTS:A total of 74.1% of patients showed lymphopenia, and 73.5% did not improve during ICU stay. Mortality was 31.0% and 50.3% at 28 days and 2 years, respectively. Lymphopenia was a predictor of early mortality (OR 2.96) and LRec of late mortality (OR 3.98). Long-term mortality was associated with LRec (HR 1.69). CONCLUSIONS:In elderly patients with septic shock, 28-day mortality is associated with lymphopenia and neutrophilia, and LRec with 2-year mortality; this may represent 2 distinct phenotypes of behaviour after septic shock.

Abstract Background Acute kidney injury (AKI) is a significant postoperative complication associated with increased mortality and hospital costs. Hemodynamic strategies, such as goal-directed therapy, might reduce AKI risk. Predicting and proactively managing intraoperative hypotension may be helpful. This trial aims to investigate if a preemptive hemodynamic strategy guided by the hypotension prediction index (HPI) can decrease the incidence of moderate-to-severe AKI within 30 days following major elective abdominal surgery. Methods This is an open-label, controlled, multicenter, randomized clinical trial that involves daily patient follow-up until hospital discharge. Inclusion criteria are patients aged over 65 and/or categorized as ASA III or IV physical status, undergoing major elective abdominal surgery (general, urological, or gynecological procedures) via laparoscopic or open approach under general or combined anesthesia. Intervention In the intervention group, hemodynamic management will be based on the HPI and the advanced functional hemodynamic variables provided by the Hemosphere platform and the AcumenIQ® sensor (Edwards Lifesciences). The primary outcome is the incidence of moderate-to-severe AKI within 7 days post-surgery. Secondary outcomes include postoperative complications and 30-day mortality. Discussion This study explores the potential of HPI-guided hemodynamic management in reducing AKI after major elective abdominal surgery, with implications for postoperative outcomes and patient care. Trial registration ClinicalTrials.gov NCT05569265. Registered on October 6, 2022.