ABSTRACT Background Perioperative hypotension is associated with postoperative organ injury. However, trials of hypotension avoidance have not found meaningful improvements in postoperative cardiovascular, renal, neurological or functional outcomes. One possible explanation is that organ perfusion depends on patients’ individual autoregulatory ranges. Hence, technology enabling monitoring of the autoregulatory status of vital organs, e.g. the brain, could provide a physiologic basis for personalising of blood pressure targets. However, current established methodologies for monitoring cerebral autoregulation in noncardiac surgery, e.g. the cerebral oximetry index (COx), are limited by performance and usability. The Medtronic Cotrending algorithm has been developed to provide automated, near real-time assessment of cerebral autoregulation. While feasibility was demonstrated in cardiac surgery, its applicability in major noncardiac surgery remains unknown. This study aims to evaluate the technical feasibility and clinical implications of Cotrending-based cerebral autoregulation monitoring in major noncardiac surgery. Objectives Primary objective: To evaluate the technical feasibility of using the Medtronic Cotrending algorithm to monitor intraoperative cerebral autoregulation in real-time during major noncardiac surgery, drawing comparisons to the COx algorithm. Secondary objectives: to investigate the potential clinical implications of Cotrending-based cerebral autoregulation monitoring. Design Single-centre, prospective cohort study. Setting Swiss tertiary care centre Patients Patients enrolled in AUTOREGULATE-NONCARDIAC who were monitored intraoperatively with the Medtronic INVOS™ 5100 near-infrared spectroscopy (NIRS) system. Outcomes Technical feasibility outcomes include success rate of determination of the lower limit of cerebral autoregulation, intraoperative uptime, time to first estimate of the lower limit of cerebral autoregulation, sensitivity to external factors and to data artefacts; agreement of Cotrending-derived lower limit of cerebral autoregulation with COx-derived lower limit of cerebral autoregulation.

INTRODUCTION:Adverse neurological complications, including postoperative delirium (POD) and stroke, remain one of the major risks after cardiac surgery. A lack of comprehensive knowledge about their causes and neuroprotective strategies has hindered the development of effective interventions to reduce these events. Personalised cerebral autoregulation (CA)-oriented blood pressure monitoring aims to identify blood pressure targets tailored to each individual patient, thereby reducing brain injury. The PRECISION study aims to assess whether perioperative duration and magnitude of mean arterial pressure (MAP) deviation from an individual's CA limits are associated with adverse neurological complications. METHODS AND ANALYSIS:This international, multicentre, prospective cohort study is conducted at two Swiss and one British hospital. Patients aged 65 years or older undergoing elective primary or re-operative coronary artery bypass graft and/or valvular and/or ascending aorta surgery requiring cardiopulmonary bypass are included. Preoperatively, the patient's baseline of physical, cognitive and mental status is established. Intraoperatively, near-infrared spectroscopy (NIRS) and transcranial Doppler (TCD) are recorded in real-time to generate NIRS-derived and TCD-derived CA indices. The primary endpoint is POD, assessed daily on postoperative days 0 to 7 or up to discharge, whichever occurs earlier with the 3D-Confusion Assessment Method (3D-CAM) or CAM-Intensive Care Unit. Secondary endpoints include a composite neurological outcome of POD and overt stroke, postoperative neurocognitive disorders, major morbidity and mortality. Associations between neurologic outcomes, neurobiomarkers and genetic variation will be explored.A total of 500 participants is required to achieve 90% power to find a statistically significant effect of the area under the curve MAP<lower limit of CA (LLA) on the risk of POD at the 5% level. This includes adjustment for potential confounders and for the inability to determine the LLA. ETHICS AND DISSEMINATION:Ethical approval has been obtained from all responsible ethics committees (Swiss lead ethics committee EKNZ 2022-01457 and Health Research Authority and Health and Care Research Wales, UK, REC 23/SW/0076). Results will be disseminated at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER:NCT05595954.

BACKGROUNDProcessed electroencephalography is widely used to assess depth of anaesthesia and to titrate anaesthetics, thereby increasing the quality of recovery. However, the processed electroencephalogram is influenced by technical, patient, and anaesthetic factors. Adding information from the frontal real-time raw electroencephalogram may help to overcome these limitations.OBJECTIVETo assess the effect of a raw electroencephalogram tutorial and its intra-operative implementation versus standard care on postoperative quality of recovery and propofol consumption.DESIGNMulticentre double-blind randomised controlled trial.SETTINGThe trial was conducted at four tertiary centres in Switzerland.PATIENTS AND ANAESTHESIA PRACTITIONERSWe screened 534 adult patients undergoing in-hospital laparoscopies and 346 anaesthesia practitioners with at least 2 years of anaesthesia experience. We matched and randomised 232 pairs and analysed 209. The patients were 78% female.INTERVENTIONThe anaesthesia practitioners assigned to the patients were randomised to a validated tutorial for assessing depth of anaesthesia with the raw electroencephalogram or to a no tutorial group. Monitoring included raw and processed electroencephalogram for patients allocated to the tutorial and only processed electroencephalogram for the no tutorial group.MAIN OUTCOME MEASURESThe primary outcome was quality of recovery on the first postoperative day measured with the QoR-15 score. The first secondary outcome was propofol consumption. Groups were compared with a two-sample t-test.RESULTSWe found no statistically significant difference between the tutorial and the no tutorial group with mean differences of -3.2 [95% confidence interval (CI), -8.8 to 2.5, P = 0.273] for QoR-15 score and 0.36 mg kg-1 h-1 (95% CI, -0.01 to 0.73, P = 0.055) for propofol consumption.CONCLUSIONA short tutorial on the raw electroencephalogram and its addition intra-operatively was not able to improve quality of recovery or reduce propofol consumption in middle-aged, largely female patients. A more in-depth tutorial applied to more vulnerable patients might have shown different results.

Objective:. To evaluate current practices and attitudes of general surgeons in Switzerland regarding perioperative code status discussions (CSD) and the management of surgical patients. Background:. CSDs are a critical component of perioperative care. Although guidelines recommend addressing code status with all surgical patients, implementation remains inconsistent and influenced by institutional and clinical barriers. Methods:. A national web-based survey was conducted among surgeons in Switzerland. The primary outcome was the proportion of participants routinely conducting CSD in patients classified as American Society of Anesthesiologists 3 to 4 (ASA 3–4) according to the ASA classification system. Secondary outcomes included the proportion of preoperative CSD in patients classified as ASA 1 to 2 and ASA 5, as well as preoperative discussions of therapy limitations and management of patients with do-not-resuscitate (DNR) orders. Results:. Of 266 participants, 243 were included in the analysis (mean age 45.7 years ±12.5; 40.3% female). 71.2% reported routinely conduct CSDs with patients classified as ASA 3 to 4. Factors independently associated with routine discussions included prior exposure to more than 10 perioperative resuscitations [27.2% (47/173) vs 12.9% (9/70), adjusted odds ratio (AOR) 2.9 (95% confidence interval CI: 1.28–6.56), P = 0.011, assessment of advance directives before surgery [81.2% (125/154) vs 47.5% (29/61), AOR 4.91 (95% CI: 2.56–9.43), P < 0.001] and presence of institutional training [25.3% (39/154) vs 11.5% (7/61), AOR 2.94 (95% CI: 1.2–7.23), P = 0.019]. Half of surgeons (50.0%, 107/214) reported discussing code status with patients with preexisting DNR order, which was associated with fewer conflicts concerning postoperative therapy limitations and stronger endorsement of interdisciplinary collaboration between surgical and anesthesiology teams. While 63.8% (n = 132) of surgeons supported statements upholding DNR orders perioperatively, 32.5% (n = 67) believed they should not apply. Conclusion:. Most surgeons reported conducting CSDs in patients classified as ASA 3 to 4 and generally supported respecting DNR orders perioperatively. However, institutional training remains limited. Expanding structured education, improving guideline implementation, and fostering interdisciplinary collaboration may improve the consistency and quality of perioperative communication.

INTRODUCTION:Hypotension is a frequent complication after induction of general anaesthesia leading to end-organ injury, for which elderly and multimorbid patients are particularly susceptible. The extent of hypotension depends, among other factors, on the dose and rate of propofol administration. Target-controlled infusion systems are widely used to administer short-acting anaesthetics such as propofol and remifentanil. Commonly, induction is started with a fixed effect-site concentration. Titration, an alternative method of induction using an incremental augmentation of propofol, leads to a reduced induction dose and rate of propofol. We hypothesise that the titration method improves haemodynamic stability compared with conventional induction. METHODS AND ANALYSIS:This multicentre, expertise-based randomised controlled trial takes place at four Swiss hospitals. Patients ≥55 years of age undergoing non-cardiac surgery under general anaesthesia using propofol target-controlled infusion are randomised to either a conventional or a titrated anaesthesia induction method. Patients, statisticians and, if resources allow, outcome assessors will be blinded. The primary endpoint is the mean arterial pressure under the individual baseline mean arterial pressure (area under threshold) during the first 30 min after start of induction. Secondary endpoints include the maximum deviation from baseline mean arterial pressure, haemodynamic rescue methods, propofol consumption and neurocognitive recovery after regaining consciousness.A total of 320 patients are required to have an 80% chance of observing superiority of titration for the area under the threshold as significant at the 5% level, assuming a true difference of 100 mm Hg*min. The area under threshold and the maximum deviation will be compared between arms using mixed linear regression models. ETHICS AND DISSEMINATION:Ethical approval has been obtained from all responsible ethics committees (BASEC2025-01007). The results will be presented at international meetings and published in peer-reviewed journals and may contribute to a change in clinical practice for anaesthesia induction using target-controlled infusion systems with propofol. TRIAL REGISTRATION NUMBER:clinicaltrials.gov (NCT06980688) and www.humanforschung-schweiz.ch (HumRes67022).

BACKGROUND:International clinical practice guidelines recommend discontinuing sodium-glucose cotransporter-2 inhibitors (SGLT2i) 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis, chiefly on the basis of case reports/series. Whether SGLT2i discontinuation may increase the risk of postoperative cardiovascular complications is unclear. METHODS:In a secondary analysis of the Basel-PMI (NCT02573532) and PMI-Vital (NCT05866874) prospective cohort studies in major noncardiac surgery, the exposure of interest was continuing, or stopping, SGLT2i in participants receiving chronic SGLT2i therapy. The primary outcome was an ordinal composite of acute heart failure hospitalisation and cardiovascular death within 90 days of surgery, adjusting for prespecified covariates. Secondary outcomes included the incidence of euglycemic diabetic ketoacidosis within 7 days. RESULTS:Among 451 study participants receiving SGLT2i (mean age 72 (range: 47-86) yr; 22% women), 404/451 (89.6%) had diabetes mellitus, and 166/451 (36.9%) had chronic heart failure. SGLT2i were discontinued before surgery in 393/451 (87.1%) participants (39.2% for 1 day, 34.4% for 2 days, 13.5% for ≥3 days). Cardiovascular complications occurred in 1/58 (1.7%) participants who continued SGLT2i, compared with 10/177 (5.7%) stopping for 1 day, 13/155 (8.4%) stopping for 2 days and 7/61 (11.5%) stopping for ≥3 days (P=0.011; adjusted odds ratio: 1.58 [95% confidence interval: 1.08-2.30] per discontinued day). Euglycemic diabetic ketoacidosis occurred in 1/451 participants after SGLT2i discontinuation. CONCLUSIONS:Perioperative SGLT2i discontinuation was associated with a substantially increased risk of 90-day cardiac complications. This suggests potential harm in current guideline recommendations; randomised controlled trials are needed to confirm these findings. STUDY REGISTRATION:NCT02573532, NCT05866874.

BACKGROUND AND AIMS:Peri-operative myocardial infarction/injury (PMI) is a common cardiac complication following non-cardiac surgery. It remains unclear whether involvement of cardiologists in the management of patients developing PMI improves outcomes. METHODS:This multicentre, prospective study included high-risk patients undergoing non-cardiac surgery, eligible for the institutional PMI active surveillance and response programme. Due to staffing constraints, cardiologist evaluation of patients with PMI was inconsistently available on weekends, on public holidays, or when care for more urgent patients had to be prioritized, allowing a comparison between patients receiving cardiologist evaluation and those who did not. The primary endpoint was major adverse cardiac events, defined as a composite of cardiovascular death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 365 days. The secondary endpoint was all-cause death at 365 days. Cox proportional hazards models were used to evaluate the association between cardiologist evaluation and outcomes. RESULTS:Among 14 294 patients, 1048 developed PMI and were eligible for this analysis, of whom 614 patients (58.6%) received post-operative cardiologist evaluation. Baseline characteristics were similar between groups. After adjustment, cardiologist evaluation was independently associated with lower risk of major adverse cardiac events (adjusted hazard ratio .54, P = .001) and all-cause death (adjusted hazard ratio .65, P = .037) at 365 days. Sensitivity analyses confirmed these findings. Patients receiving cardiology evaluation were more likely to undergo non-invasive cardiac imaging and to receive dual antiplatelet and statin therapy. CONCLUSIONS:Cardiologist evaluation of patients with PMI following major non-cardiac surgery was associated with a reduced risk of major adverse cardiac events and all-cause mortality at 365 days after surgery, suggesting that interdisciplinary management may improve post-operative outcomes.

PreOpNet is a novel deep-learning algorithm using 12-lead digital electrocardiogram (ECG) for preoperative risk assessment of all-cause death and major adverse cardiac events (MACE) within 30 days. Its performance in European high-risk patients undergoing major non-cardiac surgery—the target population for guideline-recommended risk assessment—and comparison to high-sensitivity cardiac troponin T (hs-cTnT), is unknown. In a prospective European study (2014–2019), 6098 high-risk patients with available ECGs were enrolled. PreOpNet showed moderate discrimination for death (AUC 0.707) and MACE (0.675), but overestimated risk. It outperformed the revised cardiac risk index (RCRI) for death (AUC 0.644), but not for MACE (0.662). Hs-cTnT remained superior for both outcomes (AUC 0.762 and 0.743). Importantly, PreOpNet provided incremental prognostic value when combined with RCRI and/or hs-cTnT. PreOpNet has limited benefit for preoperative risk stratification in high-risk surgical patients as a stand-alone test. However, it holds promise when used in conjunction with RCRI and hs-cTnT. Clinical Trial Registration: ClinicalTrials.gov number: NCT02573532; https://www.clinicaltrials.gov/study/NCT02573532 .

BACKGROUND:Peri-operative hypotension is strongly associated with organ injury following noncardiac surgery, however hypotension avoidance trials have not shown meaningful improvements in cardiovascular outcomes and only inconsistent improvements in renal and neurological outcomes. The true haemodynamic drivers of peri-operative organ injury are probably falls in BP below individual autoregulatory boundaries and not below population-based harm thresholds. Novel methods of personalising peri-operative blood pressure (BP) management are needed. Cerebral autoregulation (cAR)-guided precision BP monitoring is an established paradigm that uses near-infrared spectroscopy (NIRS) to noninvasively estimate the safe BP range for the brain and potentially other vital organs. We aim to assess the feasibility and clinical implications of cAR-based precision BP monitoring in major noncardiac surgery. OBJECTIVES:To investigate the association of intra-operative BP excursions below the lower level of cerebral autoregulation, and other measures of disturbed cerebral autoregulatory function, with the primary and secondary outcomes, to determine the feasibility of cAR-based precision BP monitoring in noncardiac surgery. DESIGN:Multicentre, prospective cohort study. SETTING:3 Swiss tertiary care centres. PATIENTS:Inclusion criteria: Adults ≥45 years of age, at cardiovascular risk, undergoing elective major noncardiac surgery with invasive BP monitoring, surgical time ≥90 min, postoperative hospital stay ≥1 night. Exclusion criteria include pregnancy, emergency or urological surgery, glomerular filtration rate <30 ml min-1, dialysis. PRIMARY OUTCOME MEASURES:Composite of peri-operative myocardial injury and/or peri-operative acute kidney injury on postoperative days 1 to 3. SECONDARY OUTCOMES:Composite of major cardiovascular, renal and neurological complications up to 1 year following surgery: acute coronary syndrome, acute congestive heart failure, coronary revascularisation, stroke, new or progressive chronic kidney disease, new need for renal replacement therapy, all-cause mortality, cardiovascular mortality. RESULTS:N/A. CONCLUSIONS:N/A. TRIAL REGISTRATION:Association of Intraoperative Blood Pressure Excursions Below Cerebral Autoregulatory Boundaries With Organ Injury Following Major Noncardiac Surgery (AUTOREGULATE-NONCARDIAC), Clinicaltrials.gov NCT05336864. registered 13/04/2022.

Background: Delirium is a frequent yet pathophysiologically still poorly understood complication in the intensive care unit (ICU) and is associated with adverse outcomes for the patients. Currently, guidelines give several recommendations for treating delirium in the ICU, but to date no sufficient drug treatment exists. Dexmedetomidine, primarily used for anesthesia and sedation in ICUs has shown a preventive effect of delirium compared to other sedatives, such as propofol. We hypothesize that overnight administration of dexmedetomidine may prevent and/or shorten the duration of delirium in ICU patients. Methods: The Basel propofol dexmedetomidine (BaProDex) Study was a single-center, prospective, randomized controlled trial. We included adult ICU patients with hyperactive or mixed delirium. Patients with delirium prior to ICU admission, advanced heart block, uncontrolled hypotension, or status epilepticus were excluded. The participants were randomly assigned 1:1 to either receive dexmedetomidine (study group) or propofol (control group) as a continuous infusion overnight. The Intensive Care Delirium Screening Checklist (ICDSC) was applied at least three times per day. Delirium was defined as an ICDSC ≥ 4. The study drug was administered until the end of delirium or ICU discharge. The primary endpoint was the time to delirium episode end, which was analyzed using cumulative incidence curves and a cause specific Cox proportional hazards regression with death as a competing risk. Secondary endpoints included recurrence of delirium until 28 days after ICU discharge, death until day 28, severity of ICU delirium, number of ventilation days, ICU length of stay (LOS) in hours, hospital length of stay in days and survival after three and twelve months after ICU discharge. Due to insufficient recruitment the trial needed to be stopped prematurely. Results: In total, 38 patients were enrolled and randomized in the two groups. The median duration of delirium was shorter in the dexmedetomidine group as compared to the propofol group (ITT: 34 vs. 66 h; PP: 31 vs. 66 h), resulting in a hazard ratio of 1.92 (95% CI 0.89–4.15, p = 0.097) in the ITT and 2.95 (95% CI 1.27–6.86, p = 0.012) in the PP analysis. In the PP analysis, the 28-day mortality was lower in the dexmedetomidine group (1 vs. 5 deaths) and fewer patients needed ventilation (7 vs. 15 patients). Both ICU and hospital LOS were shorter in the dexmedetomidine group (ICU LOS: median 43 vs. 128 h; hospital LOS: median 12 vs. 22 days). Further, mortality up to three and twelve months was lower in the dexmedetomidine group compared to the propofol group (PP: 2 vs. 8 patients died within twelve months, 2 vs. 7 patients died within three months). The recurrence of delirium until 28 days after ICU discharge and severity of delirium were similar in both groups. Conclusions: Despite premature termination, BaProDex provides preliminary evidence for a reduction in the duration of delirium by nocturnal infusion of dexmedetomidine compared to propofol. Therefore, dexmedetomidine may be considered an option to treat hyperactive or mixed delirium in ICU patients. However, due to the small sample size, the study is rather of exploratory nature due to the premature termination, and we cannot rule out that the observed treatment effect is overly optimistic or by chance.

Introduction & aim Intraoperative adverse events (iAEs) increase postoperative complications, which are devastating to patients and costly to healthcare systems. To optimise patient outcomes, the WHO Surgical Safety Checklist (WHO SSC) was introduced in 2008, but adherence, especially to its third part (sign-out), is low, and iAEs are currently not routinely assessed. This gap between evidence supporting the use of the WHO SSC, current inconsistent sign-out practice and the lack of standardised reporting of iAEs warrants applying an implementation science approach. Hence, this project aims to simultaneously evaluate the effectiveness and implementation of the sign-out, including systematic recording and discussion of iAEs during the sign-out.Methods & analysis Using a hybrid effectiveness-implementation approach, this prospective before-and-after-cohort project includes five surgical disciplines within nine Swiss hospitals. Following an extensive context analysis, this project is set up in three phases: (1) recruitment of 40 patients per surgical discipline and site (approx. 900 in total) for baseline assessment; (2) implementation based on a multifaceted, tailored implementation strategy (including formation of implementation teams, comprehensive education of healthcare professionals, top-down leadership, regular feedback rounds and tailoring implementation to local needs); and (3) recruitment of 40 patients per discipline to assess the changes after implementation (approx. 900). Implementation (eg, checklist fidelity composed of completion and quality) and effectiveness outcomes (ie, clinical patient outcomes) will be analysed using a mixed regression model.Discussion & conclusion By enhancing adherence to the WHO SSC sign-out, including standardised reporting of iAEs, we expect to further improve perioperative patient outcomes. Based on the context analysis, we will provide a widely applicable implementation plan to support and sustain the required behavioural change, which will support roll-out in further hospitals. Meanwhile, clinical and implementation science expertise is meeting the challenges of the complex environment of perioperative care.

BACKGROUND:False cardiac troponin (cTn) elevations from non-cardiac causes are a major concern. We aimed to assess terminal renal failure as a possible non-cardiac cause of elevated high-sensitivity cTnT (hs-cTnT) concentrations using renal transplantation as an in vivo model of rapid restoration of renal function. METHODS:We analysed consecutive patients with end-stage renal disease (ESRD) undergoing renal transplantation at a single centre. Patients with perioperative myocardial infarction or injury were excluded. Changes in hs-cTnT and creatinine were measured pretransplant and at four post-transplant intervals (day 1, days 2-5 and days 14-180). A decrease of ≥25% in hs-cTnT within 24 hours post-transplant was deemed evidence of renal clearance recovery. RESULTS:Among 45 patients (median age 67 years, 31% women), the median pretransplant plasma creatinine concentration was 608 μmol/L (IQR 482-830), and fell to 425 μmol/L (IQR 337-619) on day 1, 289 μmol/L (IQR 201-492) on days 2-5 and 126 μmol/L (IQR 103-191) on days 14-180 (p<0.001, p<0.001 and p=0.003, respectively). The median pretransplant hs-cTnT concentration was 48 ng/L (IQR 34-70). It fell to 26 ng/L (IQR 15-38; geometric mean of relative change 36%) on day 1 (p<0.001) and then remained constant on days 2-5 (26 ng/L (IQR 18-35)) and days 14-180 (25 ng/L (IQR 20-30), p=ns). CONCLUSION:Terminal renal failure is a non-cardiac cause of elevated circulating hs-cTnT concentrations, contributing more than one-third in this cohort, while the remaining two-thirds seem related to chronic cardiomyocyte injury.

Aim:To evaluate current practices and beliefs among anaesthetists regarding perioperative code status discussions and management in surgical patients. Methods:A nationwide web-based survey was conducted in Switzerland among anaesthetists providers. Primary endpoint: proportion of participants routinely discussing code status with medium-risk patients based on the American Society of Anesthesiologists (ASA) physical status classification system (ASA 3-4). Secondary endpoints: proportion of code status discussions in low-risk (ASA 1-2) and high-risk (ASA 5) patients; perioperative intensive care unit (ICU) admissions, severe complications, therapy limitations and management of patients with Do Not Resuscitate (DNR) orders. Results:Of 496 respondents, 474 were included. 56.8 % (n = 269) of anaesthetists reported routinely discussing code status with medium-risk patients (ASA 3-4). Factors associated with routine code status discussion included greater experience (mean [±SD] 20.7 [±10.6] vs. 17.4 [10.8] years, adjusted OR 1.03 [95 % CI 1.02-1.05], p < 0.001), more exposure to cardiopulmonary resuscitation (CPR) (≥50 CPRs: 169/269 [62.8 %] vs. 93/205 [45.4 %]; adjusted OR 2.99 [95 % CI 1.39-6.42], p = 0.005), and awareness of institutional teaching (48/243 [19.8 %] vs. 13/180 [7.2 %], adjusted OR 2.93 [95 % CI 1.51-5.68], p = 0.001), though only 14.4 % reported such training. 76.3 % (n = 318) of anaesthetists reported discussing code status preoperatively with patients who have DNR orders. While 70.4 % (n = 285) supported respecting DNR orders perioperatively, 21.3 % (n = 86) felt they should not apply. Conclusion:Code status discussions are commonly reported for medium-risk patients, but formal education is limited. Experience and clinical exposure increase the likelihood of such discussions. Enhanced training and clearer guidelines are needed to support consistent ethical management of code status in the perioperative setting.

BACKGROUND:Processed electroencephalography is widely used to assess depth of anaesthesia and to titrate anaesthetics, thereby increasing the quality of recovery. However, the processed electroencephalogram is influenced by technical, patient, and anaesthetic factors. Adding information from the frontal real-time raw electroencephalogram may help to overcome these limitations. OBJECTIVE:To assess the effect of a raw electroencephalogram tutorial and its intra-operative implementation versus standard care on postoperative quality of recovery and propofol consumption. DESIGN:Multicentre double-blind randomised controlled trial. SETTING:The trial was conducted at four tertiary centres in Switzerland. PATIENTS AND ANAESTHESIA PRACTITIONERS:We screened 534 adult patients undergoing in-hospital laparoscopies and 346 anaesthesia practitioners with at least 2 years of anaesthesia experience. We matched and randomised 232 pairs and analysed 209. The patients were 78% female. INTERVENTION:The anaesthesia practitioners assigned to the patients were randomised to a validated tutorial for assessing depth of anaesthesia with the raw electroencephalogram or to a no tutorial group. Monitoring included raw and processed electroencephalogram for patients allocated to the tutorial and only processed electroencephalogram for the no tutorial group. MAIN OUTCOME MEASURES:The primary outcome was quality of recovery on the first postoperative day measured with the QoR-15 score. The first secondary outcome was propofol consumption. Groups were compared with a two-sample t -test. RESULTS:We found no statistically significant difference between the tutorial and the no tutorial group with mean differences of -3.2 [95% confidence interval (CI), -8.8 to 2.5, P  = 0.273] for QoR-15 score and 0.36 mg kg -1  h -1 (95% CI, -0.01 to 0.73, P  = 0.055) for propofol consumption. CONCLUSION:A short tutorial on the raw electroencephalogram and its addition intra-operatively was not able to improve quality of recovery or reduce propofol consumption in middle-aged, largely female patients. A more in-depth tutorial applied to more vulnerable patients might have shown different results.

BACKGROUND:Although current guidelines recommend active surveillance for perioperative myocardial infarction, injury, or both in high-risk patients, implementation remains limited in most institutions worldwide because of a lack of resources. METHODS:We hypothesised that robotic process automation (RPA), a software technology that enables virtual bots to replicate human tasks within digital systems, could accurately replace experienced clinical staff. Manual screening by experienced clinical staff and RPA screening were carried out simultaneously and blinded to identify high-risk patients eligible for active surveillance for myocardial infarction/injury, according to predefined screening criteria. Discrepant identification was reviewed by an independent clinician blinded to the origin of the identification, generating a reference standard classification of paired reader-controlled patients to investigate the primary diagnostic endpoint: relative true positive fraction. RESULTS:In 660 participants (median age 60 yr, interquartile range 42-73 yr, 54.8% female), 77/660 (12%) were eligible for active surveillance for perioperative myocardial infarction or injury according to the reference standard classification. RPA screening achieved 75 (97%) true positive identifications, compared with 63 (82%) identified from manual screening (relative true positive fraction: 1.19, 95% confidence interval 1.08-1.32, P=0.004). The number needed to screen to identify one additional true positive using RPA screening was 6. RPA screening had a sensitivity of 0.97 (0.91-0.99), compared with 0.82 (0.72-0.89) for. Both approaches had high specificity (RPA screening: 0.98 [0.97-0.99], compared with manual screening: 1.0 [0.99-1.00]). The estimated annual cost of RPA screening was 81% lower compared with manual screening. CONCLUSIONS:RPA screening was superior to standard-of-care manual screening by experienced clinical staff in identifying patients at high risk for perioperative myocardial infarction or injury. CLINICAL TRIAL REGISTRATION:NCT02573532.

Background: Advances in medicine and surgical techniques make it possible to operate on selected comorbid elderly patients for whom risk assessment is essential. We aimed to validate the American College specifically for thoracic surgery. Methods: This study retrospectively included 283 consecutive patients who all underwent various thoracic surgeries at our center. Considering "serious complication" as the most important outcome, we compared the predicted risk scores with the observed incidence of 30-day morbidity and mortality. We calculated the area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals for each outcome and utilized the Brier score to check the calibration and complication odds ratios above vs. below average risk in all score outcomes with the number of occurred events. Results: In our study population, most patients were <65 years old (48%), predominantly male (63%), and overweight or obese (48%). In addition, 13% had severe chronic obstructive pulmonary disease (COPD), and 75% were categorized as American Society of Anesthesiologists (ASA) class III or higher. For "serious complication", AUROC was 59%, and events were equal in patients with above or below average risk scores (P=0.96). AUROC was 67% for "any complication" and 58% for "return to OR", expressing no useful predictive value. The Brier score and odds ratios were low for all outcomes. Dyspnea, ASA class, COPD, and body mass index as single postoperative risk predictors significantly improved the basic model consisting of the logit of the risk calculator alone. Thus, the calculator alone did not perform as well as these single variables did. Conclusions: The ACS NSQIP surgical risk calculator exhibited low sensitivity, specificity, and low AUROC for postoperative 30-day morbidity and mortality in our study cohort. Therefore, we think it cannot be considered as valid risk estimation tool for general thoracic surgery.

Editor—We read with great interest the meta-analysis by D'Amico and colleagues 1 D'Amico F. Fominskiy E.V. Turi S. et al. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth. 2023; 131: 823-831 Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and the editorial by Michard and colleagues 2 Michard F. Joosten A. Futier E. Intraoperative blood pressure: could less be more?. Br J Anaesth. 2023; 131: 810-812 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar on intraoperative blood pressure management and thank the authors for their important work. Unfortunately, the meta-analysis contains multiple factual errors and methodological shortcomings. 3 Payne T. Moran B. Intraoperative hypotension is not associated with reduced atrial fibrillation or hospital length of stay. Comment on Br J Anaesth 2023; 131: 823–31. Br J Anaesth. 2024; 132: 181-183 Abstract Full Text Full Text PDF PubMed Google Scholar ,4 Wang F. Zhu Y. Intraoperative hypotension and postoperative outcomes. Comment on Br J Anaesth 2023; 131:823-831. Br J Anaesth. 2024; 132: 178-180 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Moreover, our own data suggest that intraoperative mean arterial pressure (MAP)≤60 mm Hg can be unsafe in many patients (Fig. 1). Having conducted one of the included trials, we would like to share our thoughts on the future of perioperative haemodynamic research. 5 Wanner P.M. Wulff D.U. Djurdjevic M. Korte W. Schnider T.W. Filipovic M. Targeting higher intraoperative blood pressures does not reduce adverse cardiovascular events following noncardiac surgery. J Am Coll Cardiol. 2021; 78: 1753-1764 Crossref PubMed Scopus (48) Google Scholar Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trialsBritish Journal of AnaesthesiaVol. 131Issue 5PreviewIntraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. Full-Text PDF

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management. A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88

BACKGROUND:Multimorbidity is a growing burden in our ageing society and is associated with perioperative morbidity and mortality. Despite several modifications to the ASA physical status classification, multimorbidity as such is still not considered. Thus, the aim of this study was to quantify the burden of comorbidities in perioperative patients and to assess, independent of ASA class, its potential influence on perioperative outcome. METHODS:In a subpopulation of the prospective ClassIntra® validation study from eight international centres, type and severity of anaesthesia-relevant comorbidities were additionally extracted from electronic medical records for the current study. Patients from the validation study were of all ages, undergoing any type of in-hospital surgery and were followed up until 30 days postoperatively to assess perioperative outcomes. Primary endpoint was the number of comorbidities across ASA classes. The associated postoperative length of hospital stay (pLOS) and Comprehensive Complication Index (CCI®) were secondary endpoints. On a scale from 0 (no complication) to 100 (death) the CCI® measures the severity of postoperative morbidity as a weighted sum of all postoperative complications. RESULTS:Of 1421 enrolled patients, the mean number of comorbidities significantly increased from 1.5 in ASA I (95% CI, 1.1-1.9) to 10.5 in ASA IV (95% CI, 8.3-12.7) patients. Furthermore, independent of ASA class, postoperative complications measured by the CCI® increased per each comorbidity by 0.81 (95% CI, 0.40-1.23) and so did pLOS (geometric mean ratio, 1.03; 95% CI, 1.01-1.06). CONCLUSIONS:These data quantify the high prevalence of multimorbidity in the surgical population and show that the number of comorbidities is predictive of negative postoperative outcomes, independent of ASA class.