Background:Lower fitness is a predictor of adverse outcomes after radical cystectomy. Lockdown measures during the COVID-19 pandemic affected daily physical activity. We hypothesised that lockdown during the pandemic was associated with a reduction in preoperative aerobic fitness and an increase in postoperative complications in patients undergoing radical cystectomy. Methods:We reviewed routine preoperative cardiopulmonary exercise testing (CPET) data collected prior to the pandemic (September 2018 to March 2020) and after lockdown (March 2020 to July 2021) in patients undergoing radical cystectomy. Differences in CPET variables, Postoperative Morbidity Survey (POMS) data, and length of hospital stay were compared. Results:We identified 267 patients (85 pre-lockdown and 83 during lockdown) who underwent CPET and radical cystectomy. Patients undergoing radical cystectomy throughout lockdown had lower ventilatory anaerobic threshold (9.0 [7.9-10.9] vs 10.3 [9.1-12.3] ml kg-1 min-1; P=0.0002), peak oxygen uptake (15.5 [12.9-19.1] vs 17.5 [14.4-21.0] ml kg-1 min-1; P=0.015), and higher ventilatory equivalents for carbon dioxide (34.7 [31.4-38.5] vs 33.4 [30.5-36.5]; P=0.030) compared with pre-lockdown. Changes were more pronounced in males and those aged >65 yr. Patients undergoing radical cystectomy throughout lockdown had a higher proportion of day 5 POMS-defined morbidity (89% vs 75%, odds ratio [OR] 2.698, 95% confidence interval [CI] 1.143-6.653; P=0.019), specifically related to pulmonary complications (30% vs 13%, OR 2.900, 95% CI 1.368-6.194; P=0.007) and pain (27% vs 9%, OR 3.471, 95% CI 1.427-7.960; P=0.004), compared with pre-lockdown on univariate analysis. Conclusions:Lockdown measures in response to the COVID-19 pandemic were associated with a reduction in fitness and an increase in postoperative morbidity among patients undergoing radical cystectomy.

BACKGROUND:The use of exercise testing has expanded in recent decades and there is a wealth of information examining the prognostic significance of exercise variables, such as peak oxygen consumption or ventilatory measures whilst exercising. However, a paucity of research has investigated the use of recovery-derived parameters after exercise cessation. Heart rate recovery (HRR) has been considered a measure of the function of the autonomic nervous system and its dysfunction is associated with cardiovascular risk.OBJECTIVES:We aim to provide an overview of the literature surrounding HRR and its prognostic significance in patients with cardiovascular disease undertaking an exercise test.DATA SOURCES:In December 2020, searches of PubMed, Scopus, and ScienceDirect were performed using key search terms and Boolean operators.STUDY SELECTION:Articles were manually screened and selected as per the inclusion criteria.RESULTS:Nineteen articles met inclusion criteria and were reviewed. Disagreement exists in methodologies used for measuring and assessing HRR. However, HRR provides prognostic mortality information for use in clinical practice.CONCLUSIONS:HRR is a simple, non-invasive measure which independently predicts mortality in patients with heart failure and coronary artery disease; HRR should be routinely incorporated into clinical exercise testing.

CLINICAL CASE ABSTRACT – Return to exercise in a patient with recurrent episodes of exertional rhabdomyolysis. HISTORY: 25-year-old gentlemen presented to the sports and exercise medicine department with a history of recurrent episodes (4) of ER. All episodes required hospitalisation for Intravenous fluids – with one requiring ICU admission for organ support (renal) (CK range on admission 1000-40,000 IU). Two episodes had no clear triggers and were precipitated by low intensity exercise. The patient was able to walk for 20 minutes but suffered from forearm cramps with Activities of Daily Living, and a reduced exercise tolerance (deconditioning). Due to recurrent episodes of ER, and a high CK response the patient was deemed high risk and had a full neuromuscular investigative work up. DIFFERENT DIAGNOSIS: 1. Metabolic myopathy 2. Glycogen storage disorder3.Mitochondrial disorder 4. Neuromuscular disorder 5. Idiopathic exertional rhabdomyolysis TEST AND RESULTS: -Genome analysis (rhabdo panel), muscle biopsy, EMG, mitochondrial analysis, and muscle biopsy stains were normal.-Submaximal bike 20 W ramp protocol (CPET terminated at the AT) – early Anaerobic threshold identified (12 ml/kg/min - 27% of predicted, 62 watts) with a normal cardiorespiratory profile and lactate clearance, (mMol: pre-test = 0.9, immediately post-test = 2.1, 10 minutes post-test lactate = 1.1). -Post exertional myoglobin (6 hour) and post exertional Creatinine Kinase (CK) (24 and 48 hour) were within normal limits.-Lateral biceps femoris 6 hours post exertion MRI (low grade muscle oedema present- unilateral) FINAL WORKING DIAGNOSIS: -Idiopathic exertional rhabdomyolysis TREATMENT OUTCOMES: -The patient subsequently completed a 20-minute steady work rate CPET, set at the AT – and was asymptomatic with no evidence of a raised CK post exercise. -The submaximal CPET protocol, with lactate clearance and CK monitoring post-test was used to design a graded exercise programme for the patient to undertake a return to exercise programme and define safe workloads. -The exercise prescription was set at the work rate that corresponded with the AT and increased in intensity and duration over 3 months; a submaximal CPET challenge can be used to define safe workloads in athletes with idiopathic exertional rhabdomyolysis.

Background Elevated plasma/serum troponin, indicating perioperative myocardial injury (PMI), is common after non-cardiac surgery. However, underlying mechanisms remain unclear. Acute coronary syndrome (ACS) is associated with the early appearance of circulating microRNAs, which regulate post-translational gene expression. We hypothesised that if PMI and ACS share pathophysiological mechanisms, common microRNA signatures should be evident. Methods Nested case-control study of samples obtained before and after non-cardiac surgery from patients enrolled in two prospective observational studies of PMI (postoperative troponin I/T>99 th centile). In cohort one, serum microRNAs were compared between patients with/without PMI, matched for age, gender and comorbidity. Real-time polymerase chain reaction quantified relative microRNA expression (cycle quantification threshold <37) before and after surgery for microRNA signatures associated with ACS, blinded to PMI. In cohort two, we analysed (EdgeR) microRNA from plasma extracellular vesicles using next-generation sequencing (Illumina HiSeq500). microRNA-messenger RNA-function pathway analysis was performed (DIANA miRPath v3.0/TopGO). Results MicroRNA were detectable in all 59 patients (median age:67yrs (61-75); 42% male), who had similar clinical characteristics independent of developing PMI. In cohort one, PMI was not associated with increased serum microRNA expression levels after surgery (hsa-miR-1-3p mean fold-change (FC):3.99 (95%CI:1.95-8.19); hsa-miR-133-3p FC:5.67(95%CI:2.94-10.91); p<0.001). hsa-miR-208b-3p was more commonly detected after PMI (odd ratio (OR):10.0 (95%CI:1.9-52.6); p<0.01). Bioinformatic analysis of differentially expressed microRNAs from cohorts one and two identified pathways associated with adrenergic stress involving calcium dysregulation, rather than ischaemia. Conclusions Circulating microRNAs synonymous with cardiac ischaemia were universally elevated in patients after surgery, independent of developing myocardial injury.

AbstractBackgroundElevated heart rate (HR) is associated with accelerated mortality and independently predicts poorer outcomes in patients discharged from hospital after myocardial infarction and/or heart failure. We examined whether resting HR measured within 24 hours of hospital discharge following elective non-cardiac surgery was elevated compared to preoperative values. We also investigated the relationship between changes in HR with and/or autonomic function associated with morbidity after surgery.MethodsWe conducted a post-hoc analysis of HR data obtained in a prospective observational cohort study of patients ≥18years in whom serial Holter-based measurements of cardiac autonomic activity were made before, and for 48h after, surgery. The primary outcome was absolute discharge HR (beats minute-1), recorded at rest before hospital discharge. We examined the association between quartiles of discharge HR and autonomic measures (time/frequency domain heart rate variability) associated with morbidity (defined by Postoperative morbidity survey).ResultsIn 157 patients (66 (42%) male; age 67(9) years), HR at hospital discharge (range: 53-122) increased by 5 beats minute-1(95%CI:3–7;p<0.001) compared to preoperative values. Patients in the upper quartile of discharge HR (≥85bpm) were more likely to sustain pulmonary (odds ratio (OR):2.18 (95%CI:1.07-4.44);p=0.03) and infectious (OR:2.31 (95%CI:1.13-4.75);p=0.02) morbidity within seven days of surgery, compared to lower quartiles. Pulmonary/infectious morbidity was associated with loss of cardiac vagal activity.ConclusionsHeart rate on discharge from hospital following major elective non-cardiac surgery is frequently elevated and is promoted by morbidity associated with reductions in cardiac vagal activity.

Background Myocardial injury is more frequent after non-cardiac surgery in patients with preoperative cardiac vagal dysfunction as quantified by delayed heart rate recovery after cessation of cardiopulmonary exercise testing. Here, we hypothesised that serial and dynamic measures of perioperative cardiac vagal activity should also be associated with myocardial injury after non-cardiac surgery. Methods Serial measures in cardiac vagal activity were quantified preoperatively and daily using heart rate variability and a standardised orthostatic challenge in patients undergoing elective non-cardiac surgery. The primary outcome was myocardial injury (high-sensitivity troponin (hsTnT) ≥15ng.L−1) within 48h of surgery. Clinicians, patients and investigators were blinded to hsTnT. The exposure of interest was cardiac vagal activity (high-frequency power spectral analysis [HFlog]) and heart rate recovery after a standardised orthostatic challenge. Results hsTnT≥15ng.L−1 occurred in 48/189 [25%] patients, of whom 41/48 [85%] had a revised cardiac risk index score <2. Patients with a post surgery troponin HsTnT ≥15ng.L−1 were associated with an early loss (within 24h) of cardiac vagal activity (HFLog) post surgery compared to day of surgery (4.19 [95%CI:3.62-4.75] vs 5.22 [95%CI:4.64-5.81]; p<0.001). Heart rate recovery after a standardised orthostatic challenge after surgery was slower in patients with hsTnT≥15ng.L−1 (5 beats minute−1 (95% CI: 3 −7), compared to heart rate recovery in patients who remained free of myocardial injury (10 beats minute−1 (95%CI:7 to 12]; p = 0.02). Conclusions Real-time, serial heart rate measures indicating loss of cardiac vagal activity are associated with perioperative myocardial injury in lower-risk patients undergoing non-cardiac surgery.

Indirect measures of cardiac vagal activity are strongly associated with exercise capacity, yet a causal relationship has not been established. Here we show that in rats, genetic silencing of the largest population of brainstem vagal preganglionic neurons residing in the brainstem's dorsal vagal motor nucleus dramatically impairs exercise capacity, while optogenetic recruitment of the same neuronal population enhances cardiac contractility and prolongs exercise endurance. These data provide direct experimental evidence that parasympathetic vagal drive generated by a defined CNS circuit determines the ability to exercise. Decreased activity and/or gradual loss of the identified neuronal cell group provides a neurophysiological basis for the progressive decline of exercise capacity with aging and in diverse disease states.

OBJECTIVE:Experimental animal models demonstrate that autonomic activity regulates systemic inflammation. By contrast, human studies are limited in number and exclusively use heart rate variability (HRV) as an index of cardiac autonomic regulation. HRV measures are primarily dependent on, and need to be corrected for, heart rate. Thus, independent autonomic measures are required to confirm HRV-based findings. Here, the authors sought to replicate the findings of preceding HRV-based studies by using HRV-independent, exercise-evoked sympathetic and parasympathetic measures of cardiac autonomic regulation to examine the relationship between autonomic function and systemic inflammation. METHODS:Sympathetic function was assessed by measuring heart rate changes during unloaded pedaling prior to onset of exercise, divided into quartiles; an anticipatory heart rate (AHRR) rise during this period is evoked by mental stress in many individuals. Parasympathetic function was assessed by heart rate recovery (HRR) 60s after finishing cardiopulmonary exercise testing, divided into quartiles. Parasympathetic dysfunction was defined by delayed heart rate recovery (HRR) ≤12.beats.min-1, a threshold value associated with higher cardiovascular morbidity/mortality in the general population. Systemic inflammation was primarily assessed by neutrophil-lymphocyte ratio (NLR), where a ratio >4 is prognostic across several inflammatory diseases and correlates strongly with elevated plasma levels of pro-inflammatory cytokines. High-sensitivity C-reactive protein (hsCRP) was also measured. RESULTS:In 1624 subjects (65±14y; 67.9% male), lower HRR (impaired vagal activity) was associated with progressively higher NLR (p=0.004 for trend across quartiles). Delayed HRR, recorded in 646/1624 (39.6%) subjects, was associated with neutrophil-lymphocyte ratio >4 (relative risk: 1.43 (95%CI: 1.18-1.74); P=0.0003). Similar results were found for hsCRP (p=0.045). By contrast, AHRR was not associated with NLR (relative risk: 1.24 (95%CI: 0.94-1.65); P=0.14). CONCLUSIONS:Delayed HRR, a robust measure of parasympathetic dysfunction, is independently associated with leukocyte ratios indicative of systemic inflammation. These results further support a role for parasympathetic modulation of systemic inflammation in humans.

Objective: Reduced exercise capacity is well documented in end-stage chronic kidney disease (CKD), preceded by changes in cardiac morphology in CKD stage 3. However, it is unknown whether subclinical cardiopulmonary dysfunction occurs in CKD stage 3 independently of heart failure.Methods: Prospective observational cross-sectional study of exercise capacity assessed by cardiopulmonary exercise testing in 993 preoperative patients. Primary outcome was peak oxygen consumption (VO2peak). Anaerobic threshold (AT), oxygen pulse and exercise-evoked measures of autonomic function were analysed, controlling for CKD stage 3, age, gender, diabetes mellitus and hypertension.Results: CKD stage 3 was present in 93/993 (9.97%) patients. Diabetes mellitus (RR 2.49 (95% CI 1.59 to 3.89); p<0.001), and hypertension (RR 3.20 (95% CI 2.04 to 5.03); p<0.001)) were more common in CKD stage 3. Cardiac failure (RR 0.83 (95% CI 0.30 to 2.24); p=0.70) and ischaemic heart disease (RR 1.40 (95% CI 0.97 to 2.02); p=0.09) were not more common in CKD stage 3. Patients with CKD stage 3 had lower predicted VO2peak (mean difference: 6% (95% CI 1% to 11%); p=0.02), lower peak heart rate (mean difference: 9 bpm (95% CI 3 to 14); p=0.03)), lower AT (mean difference: 1.1 mL/min/kg (95% CI 0.4 to 1.7); p<0.001) and impaired heart rate recovery (mean difference: 4 bpm (95% CI 1 to 7); p<0.001)).Conclusions: Subclinical cardiopulmonary dysfunction in CKD stage 3 is common. This study suggests that maladaptive cardiovascular/autonomic dysfunction may be established in CKD stage 3, preceding pathophysiology reported in end-stage CKD.

The study of perioperative medicine outcomes using large databases, so-called big data, has emerged as a valuable approach that increasingly challenges long-held clinical beliefs and forces us to rethink mechanistic paradigms underlying postoperative morbidity. In this issue of Anesthesia & Analgesia, the Department of Outcomes Research at the Cleveland Clinic continues to build on their major contribution to the perioperative medicine big data portfolio by reporting the results of the largest study yet that focuses on the relationship between rheumatoid arthritis and perioperative outcomes.1 The authors tested the primary hypothesis that rheumatoid arthritis is independently associated with increased postoperative cardiovascular complications. This hypothesis is highly plausible given the well-established literature in rheumatoid arthritis demonstrating an increased risk of atherosclerosis, coronary artery disease, and all-cause cardiovascular morbidity in the nonoperative setting.2 Patients with rheumatoid arthritis have an increased risk of myocardial infarction that is equivalent to patients who have diabetes mellitus or those patients without rheumatoid arthritis who are 10 years older.3 The underlying mechanisms are incompletely understood, particularly because the increased risk of cardiovascular disease in patients with rheumatoid arthritis precedes their diagnosis based on the American College of Rheumatology criteria.4 This excess risk cannot be explained by conventional risk factors.5 Mirroring the myocardial injury phenotype of perioperative patients more generally,6 patients with rheumatoid arthritis rarely present with angina and have higher rates of unrecognized cardiovascular disease.4 In the Cleveland Clinic’s Department of Outcomes Research analysis, inpatient hospital data across 7 American states for 1 year were assessed; each patient with rheumatoid arthritis was propensity matched with a suitable control. Multivariable logistic regression was used to compare matched rheumatoid arthritis and control patients on risk of in-hospital cardiovascular complications. Approximately 1.2% of patients undergoing noncardiac surgery had a coded diagnosis of rheumatoid arthritis; of these, 1095 rheumatoid patients were propensity matched with 1006 control patients. Unexpectedly, patients with rheumatoid arthritis were not found to be at more risk of cardiovascular complications (odds ratio, 1.08; 95% confidence interval [CI], 0.96–1.21; P = 0.08), with a similar incidence of thromboembolic complications and mortality. These findings mirror those from the Veterans Affairs Surgical Quality Improvement Program (VASQIP), where patients with rheumatoid arthritis were more likely to require a return to the operating room yet had similar rates of VASQIP-defined postoperative infection, cardiovascular events, and mortality.7 These findings were broadly similar to those of a systematic review and meta-analysis of 40 studies comparing complications after total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis.8 Although this systematic review is rather hampered by a lack of studies explicitly defining rheumatoid arthritis, and/or adjusting for covariates, patients with rheumatoid arthritis appeared to be at a higher risk of infection after total knee arthroplasty. This finding is consistent with the link between infectious complications and cardiovascular morbidity, as shown by the perioperative association between achieving adequate oxygen delivery and fewer postoperative hospital-acquired infections in the higher-risk surgical population.9,10 This observation was strengthened by an earlier need for revision of total knee arthroplasties in patients with rheumatoid arthritis. Avoiding revision procedures in patients with rheumatoid arthritis may be particularly important because they appear to be at an increased risk of prosthetic joint infection.11,12 Taken together these findings would appear to suggest that perioperative physicians may have unduly judged patients with rheumatoid arthritis to be at higher risk of postoperative cardiovascular morbidity and other morbidities linked to perioperative cardiovascular complications including infections.13 However, closer inspection of the VASQIP database, which followed patients postprocedure for 3.7 ± 2.7 years, reveals that rheumatoid arthritis was associated with a significantly higher long-term mortality (hazard ratio, 1.22 [95% CI, 1.00–1.49]). These data again reinforce the importance of considering the consequences of noncardiac surgery beyond the time period over which administrative databases typically capture hospital morbidity.14,15 In addition, we cannot be sure that surgical and/or anesthesiology bias in preoperative patient screening apparently minimizes adverse perioperative outcomes by selecting out the patients with rheumatoid arthritis who have the most severe disease characterized by chronic multiorgan dysfunction. Only the presence, rather than severity, of rheumatoid arthritis was captured by the Cleveland Clinic study. In particular, multisystem organ dysfunction commonly found in rheumatoid disease including chronic kidney disease16 is clearly associated with worse perioperative outcomes even in patients without rheumatoid arthritis.17 Furthermore, the Cleveland Clinic study did not report on the risk of perioperative infectious complications. A retrospective longitudinal cohort study found substantial risk for objectively confirmed infections (adjusted hazard ratio, 1.70 [95% CI, 1.42–2.03]) and infections requiring hospitalization in patients with rheumatoid arthritis (adjusted hazard ratio, 1.83 [95% CI, 1.52–2.21]). Complications of musculoskeletal, skin, and respiratory infections were most prevalent.18 The relative lack of data on the impact of medication for rheumatoid arthritis and perioperative outcomes is notable. The American College of Rheumatology guidelines recommend that rheumatoid arthritis patients stop taking biologic therapies 1 week before surgery and not restart them until a week after surgery.19 However, the role of other disease-modifying drugs remains unclear with generally retrospective or unblinded, low-quality studies providing limited information.20 The systemic anti-inflammatory effect of disease modifying drugs may reduce cardiovascular morbidity over the longer term.21 Two studies have associated preoperative cessation of biologic therapies with postoperative flare-ups of psoriasis22 and rheumatoid arthritis.23 Counterintuitively, continuing methotrexate may reduce the risk of postoperative infection and reduce flare-ups within 6 weeks of surgery.23 Several of these drugs are now being considered for repurposing,24 which may be of underappreciated benefit in noncardiac surgery. Translational experimental models also show that the immunosuppressive properties of chloroquine may decrease susceptibility to sepsis after hemorrhage.25 The suggestion that longer-term, postdischarge outcomes are worse in patients with rheumatoid arthritis is of particular importance and concern, suggesting that the database approach can easily miss critical time windows. Furthermore, clinical comparisons need to be underpinned by a clear biologic rationale. Although rheumatoid arthritis is often compared with osteoarthritis, the biologic basis for this may be flawed. Laboratory models have established that osteoarthritis is a chronic inflammatory disease, sharing immunologic overlap with other diseases of autoimmunity.26 Most strikingly, further subgroup analysis in the Cleveland Clinic study suggests that patients with rheumatoid arthritis and coexisting cardiovascular disease sustain more postoperative cardiovascular complications than control patients who do not have rheumatoid arthritis and coexisting cardiovascular disease. Our preoperative assessment of higher risk surgical patients by cardiopulmonary exercise testing shows that cardiopulmonary reserve is lower in 199 of 759 patients with arthritis (Fig. 1). Controlling for age-related decline in cardiopulmonary reserve, plus established cardiovascular pathology and diabetes mellitus, the anerobic threshold is 1.3 mL kg−1 min−1 lower (95% CI, 0.8–1.75; P = 0.015) in patients with arthritis (most frequently osteoarthritis). Given the association between low aerobic capacity (≤11 mL kg−1 min−1) and postoperative complications,27 it is striking that patients with arthritis are more likely (relative risk, 1.68; 95% CI, 1.28–2.20; P < 0.0001) to demonstrate poorer cardiopulmonary reserve. These data suggest that the chronic proinflammatory process common to all arthritides may lead to a deconditioning phenotype and hence poorer cardiovascular performance under stress. Deconditioning may result from lower physical activity or accelerated cardiovascular disease leading to subclinical chronic cardiac failure.Figure 1.: Association between arthritis and anerobic capacity. Unadjusted values shown for 199 of 759 patients with arthritis (osteoarthritis or rheumatoid) who underwent cardiopulmonary exercise testing at University College London Hospitals NHS Trust preoperative assessment for noncardiac surgery. Mean ± SD values are shown.These studies highlight the potential strengths and significant limitations of the large database approach. The apparent disconnect between the rheumatoid arthritis big data literature and established perioperative risk factors highlights 2 key contributions that perioperative medicine can make in a broader context. First, there is a clear need for a better understanding of how the progression of complex, multisystem diseases is altered by the perioperative phase and its management. Second, the unique translational potential of the perioperative arena not only offers an unrivalled opportunity to understand pathologic mechanisms and reduce postoperative complications but also provide other specialties’ invaluable biological insights as to whether apparently paradoxical big data findings should shape their clinical practice. Mechanistic interrogation catalyzed by unexpected findings from observational and trial data sets have transformed many other areas of medicine, statin therapy for hypercholesteremia perhaps being the most notable.28 Perioperative medicine requires a similar nonsiloed, complementary approach as bioinformatic analyses of large electronic databases generate plausible, although not necessarily conventional and/or predictable, hypotheses. Bed-to-benchside translational investigators should be an integral part of this process, through which big data can reinvigorate the role of experimental perioperative medicine. Therefore, we suggest that perioperative big data studies would greatly benefit from the contribution of experimental perioperative medicine investigators in crosscutting, multidisciplinary study designs from inception. DISCLOSURES Name: Gareth L. Ackland, PhD, FRCA, FFICM. Contribution: This author helped design the study and prepare the manuscript. Attestation: Gareth L. Ackland approved the final manuscript, attests to the integrity of the original data and the analysis reported in this manuscript, and is the archival author who is responsible for maintaining the study records. Name: Robert C. M. Stephens, MD, FRCA, FFICM. Contribution: This author helped design the study and prepare the manuscript. Attestation: Robert C. M. Stephens approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript. This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

Objective: Recent perioperative trials have highlighted the urgent need for a better understanding of why sympatholytic drugs intended to reduce myocardial injury are paradoxically associated with harm (stroke, myocardial infarction). We hypothesised that following a standardised autonomic challenge, a subset of patients may demonstrate excessive sympathetic activation which is associated with exercise-induced ischaemia and impaired cardiac output.Methods: Heart rate rise during unloaded pedalling (zero workload) prior to the onset of cardiopulmonary exercise testing (CPET) was measured in 2 observation cohorts of elective surgical patients. The primary outcome was exercise-evoked, ECG-defined ischaemia (>1 mm depression; lead II) associated with an exaggerated increase in heart rate (EHRR >= 12 bpm based on prognostic data for all-cause cardiac death in preceding epidemiological studies). Secondary outcomes included cardiopulmonary performance (oxygen pulse (surrogate for left ventricular stroke volume), peak oxygen consumption (VO2peak), anaerobic threshold (AT)) and perioperative heart rate.Results: EHRR was present in 40.4-42.7% in both centres (n= 232, n= 586 patients). Patients with EHRR had higher heart rates perioperatively (p < 0.05). Significant ST segment depression during CPET was more common in EHRR patients (relative risk 1.7 (95% CI 1.3 to 2.1); p < 0.001). EHRR was associated with 11% (95% CI 7% to 15%) lower predicted oxygen pulse (p < 0.0001), consistent with impaired left ventricular function.Conclusions: EHRR is common and associated with ECG-defined ischaemia and impaired cardiac performance. Perioperative sympatholysis may further detrimentally affect cardiac output in patients with this phenotype.

Topical studies have reinforced the view that there is little evidence in choosing starches as the fluid of choice in resuscitation, especially in critical care. They may increase mortality when used in the resuscitation of patients with severe sepsis. This has led to the partial withdrawal of starch-based colloids in the U. K. What is more unclear is whether colloids as a whole are beneficial compared to crystalloids with conflicting evidence in the literature.Administration of large amounts of physiologically 'dun-balanced' fluids can result in the development of hyperchloraemic acidosis but the question remains as to whether there is a resultant effect on morbidity or mortality. Goal-directed therapy has been demonstrated as being beneficial although the best method of assessing the response to fluid remains to be elucidated.With the publication of recent trials, the basis for deciding which intravenous fluids to give, when to give it and how much to give, more than ever before, can be based on sound scientific evidence. (C) 2014 Elsevier Ltd. All rights reserved.

British Journal of Hospital MedicineVol. 74, No. Sup5 What You Need to Know AboutAn introduction to anaesthesiaCiara Donohue, Ben Hobson, Robert CM StephensCiara Donohue, Ben Hobson, Robert CM StephensCiara Donohue; Ben Hobson; Robert CM StephensPublished Online:14 Nov 2014https://doi.org/10.12968/hmed.2013.74.Sup5.C71AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Al-Shaikh B, Stacey S (2007) Non invasive monitoring. In: Al-Shaikh B, Stacey S, eds. Essentials of Anaesthetic Equipment. 3rd edn. Churchill Livingstone, London: 151–3 Google ScholarAppiah-Ankam J, Hunter J (2004) Pharmacology of neuromuscular blocking drugs. Contin Educ Anaesth Crit Care Pain 4(1): 2–7 Crossref, Google ScholarCranshaw J, Cook T (2011) Airway assessment and management. In: Allman K, Wilson I, eds. Oxford Handbook of Anaesthesia. 3rd edn. Oxford University Press, Oxford: 970–6 Google ScholarDavis P, Kenny G (2007) Biological Electrical Potentials: Their display and recording. In: Davis P, Kenny G, eds. Basic Physics and Measurement in Anaesthesia. 5th edn. Butterworth-Heinemann, London: 171 Google ScholarDoherty M, Buggy D (2012) Intraoperative fluids: how much is too much? Br J Anaesth 109(1): 69–79 Crossref, Medline, Google ScholarHarper CM, Andrzejowski JC, Alexander R (2008) NICE and warm. Br J Anaesth 101(3): 293–5 Crossref, Medline, Google ScholarKing JM, Hunter J (2002) Physiology of the neuromuscular junction. Br J Anaesth CEPD Reviews 2(Sup5): 129–33 Google ScholarKnight DJW, Mahajan RP (2004) Patient positioning in anaesthesia. Contin Educ Anaesth Crit Care Pain 4(Sup5): 160–3 Crossref, Google ScholarPeck TE, Hill S, Williams M (2008) Core drugs in anaesthetic practice. In: Peck TE, Hill S, Williams M, eds. Pharmacology for Anaesthesia and Intensive Care. 3rd edn. Cambridge University Press, Cambridge: 99–102 Crossref, Google ScholarSasada M, Smith S (2008) Drugs in Anaesthesia and Intensive Care. 3rd edn. Oxford University Press, Oxford Google ScholarSinclair RCF, Luxton MC (2005) Rapid sequence induction. Contin Educ Anaesth Crit Care Pain 5(2): 45–8 Crossref, Google ScholarWalker A, Reshamwalla S, Wilson I (2012) Surgical safety checklists: do they improve outcomes? Br J Anaesth 109(1): 47–54 Crossref, Medline, Google ScholarYentis S, Hirsch N, Smith G (2009) Anaesthesia and Intensive Care A-Z. 4th edn. Churchill Livingstone, London: 354 Google ScholarYuill G, Simpson M (2002) An introduction to total intravenous anaesthesia. Br J Anaesth CEPD Reviews 2(1): 24–6 Google Scholar FiguresReferencesRelatedDetailsCited ByA comparative analysis of the anaesthetic effect of sodium bicarbonate (NaHCO 3 ) on male and female three spotted tilapia ( Oreochromis andersonii )20 April 2022 | Journal of Applied Animal Research, Vol. 50, No. 1CFD investigation of CO2 separation from anesthesia gaseous stream applying novel cholinium lysinate amino acid-based ionic liquid inside the gas–liquid membrane contactor14 September 2022 | The European Physical Journal Plus, Vol. 137, No. 9A Co-Induction Technique Utilizing 4% Sevoflurane Followed by 0.75 mg/kg Propofol in Elderly Patients Undergoing Minimally Invasive Procedures: A Prospective Randomized Control Study10 December 2020 | Medicina, Vol. 56, No. 12Preoperative Evaluation Before Noncardiac SurgeryMayo Clinic Proceedings, Vol. 95, No. 4Sense and Insensibility – An Appraisal of the Effects of Clinical Anesthetics on Gastropod and Cephalopod Molluscs as a Step to Improved Welfare of Cephalopods24 August 2018 | Frontiers in Physiology, Vol. 9The principles of surgical care: intraoperative care2 December 2015 | British Journal of Healthcare Assistants, Vol. 9, No. 11 1 May 2013Volume 74Issue Sup5ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 14 November 2014 Published in print 1 May 2013 Information© MA Healthcare LimitedPDF download

British Journal of Hospital MedicineVol. 73, No. Sup5 Core TrainingCardiovascular failure, inotropes and vasopressorsJulia Benham-Hermetz, Mark Lambert, Robert CM StephensJulia Benham-HermetzSearch for more papers by this author, Mark LambertSearch for more papers by this author, Robert CM StephensSearch for more papers by this authorJulia Benham-Hermetz; Mark Lambert; Robert CM StephensPublished Online:27 Sep 2013https://doi.org/10.12968/hmed.2012.73.Sup5.C74AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleFurther readingFeneck R (2007) Phosphodiesterase inhibitors and the cardiovascular system. Contin Educ Anaesth Crit Care Pain 7(6): 203–7 Crossref, Google ScholarOvergaard CB, Dzavik V (2008) Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 118(10): 1047–56 Crossref, Medline, Google ScholarSharman A, Low J (2008) Vasopressin and its role in critical care. Contin Educ Anaesth Crit Care Pain 8(4): 134–7 Crossref, Google ScholarSinger M, Webb AR (2009) Oxford Handbook of Critical Care. 3rd edn. Oxford University Press, Oxford: 161–93 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byMidodrine improves clinical and economic outcomes in patients with septic shock: a randomized controlled clinical trial3 January 2022 | Irish Journal of Medical Science (1971 -), Vol. 191, No. 6Surgical Critical Care5 February 2021 | , Vol. 7Intensive Care Unit (ICU)Arrhythmias and Cardiac Bedside Monitoring in the Neonatal Intensive Care UnitCritical Care Nursing Clinics of North America, Vol. 28, No. 3Intensive care unit (ICU) 1 May 2012Volume 73Issue Sup5ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 27 September 2013 Published in print 1 May 2012 Information© MA Healthcare LimitedPDF download

A trauma team should consist of two to four doctors, three to five nurses, a radiologist or radiographer and porters. Before the patient arrives the team leader should assign each member a specific role (including someone to document findings and organize investigations), gowns and gloves should be put on and equipment checked.

An epidural is a small catheter that is placed blindly into the epidural space. Local anaesthetics and other analgesics injected through the catheter act locally on the nerve roots and also directly on the spinal cord. In acute hospitals, epidurals are often the domain of the anaesthetist but it is important that all specialties know how to appropriately advise patients and recognize complications. This article gives a general overview of epidurals and their care on a surgical ward for the non-anaesthetist.

The ability to insert a ‘central line’ (a catheter into a large central vein) is an essential skill for many physicians. This is a riskprone procedure and is now subject to National Institute for Health and Clinical Excellence guidance (National Institute for Clinical Excellence, 2002).

The 'can't intubate, can't ventilate' scenario is a nightmare for all clinicians who manage airways. Cricothyroidotomy is one of several emergency airway management techniques. Cricothyroidotomy is a short-term solution which provides oxygenation, not ventilation, and is not a definitive airway. Although there are tests which can help predict whether an intubation will be difficult, they are not always good predictors. As the can't intubate, can't ventilate scenario is rare, cricothyroidotomy is an unfamiliar procedure to many. In this situation, expert help must be called for early on. In the meantime, it is vital that all other simple airway manoeuvres have been attempted, such as good positioning of the patient with head tilt and chin lift, and use of airway adjuncts like the oral (Guedel) airway or nasopharyngeal airway, and the laryngeal mask airway. However, if attempts to secure the airway are unsuccessful, there may be no other option than to perform a cricothyroidotomy. It is a difficult decision to make, but with increasing hypoxia, it is essential that one oxygenates the patient. Cricothyroidotomy provides an opening in the pace between the anterior inferior border of the thyroid cartilage and the anterior superior border of the cricoid cartilage, allowing access to the airway below the glottis. The anatomical considerations are important when performing this procedure (Ellis, 2009), and there are other scenarios when it is used. It is not without consequence, as with any procedure.