AIMS:At present, there is a growing body of knowledge regarding the benefits and risks associated with oxygen use in medical practice. In the perioperative period, high fractions of inspiratory oxygen are used during airway management. However, oxygen can have direct toxic effects, as well as systemic effects. In different fields of medicine, protocols exist to limit the use of oxygen, for example, in the intensive care unit and emergency department. However, in pediatric perioperative care, such protocols do not exist. We conducted an international survey among pediatric anesthesiologists to assess their daily practices regarding oxygen use during non-cardiac surgery. The objective of this survey was to determine self-reported perioperative oxygen use across several key areas: the default oxygen settings on anesthesia machines, the prevalence of preoxygenation, the fraction of inspiratory oxygen used intraoperatively, and considerations regarding the intraoperative administration of oxygen. METHODS:An online digital survey consisting of up to 21 questions in LimeSurvey was developed and sent to 5667 members of various international pediatric anesthesia societies (ESPA, APAGBI, SPA, SPANZA). RESULTS:A total of 828 responses were received (response rate 15%). The median reported default inspiratory oxygen (FiO2) value of anesthesia machines was 100% (IQR 30%-100%). Preoxygenation was used by 50% of the respondents, usually with 100% oxygen. 87% of respondents reported to titrate FiO2 intraoperatively, mainly based on pulse oximetry values. Median standard percentage of oxygen intraoperatively was 35% (IQR 30%-40%). CONCLUSIONS:Oxygen administration practices during pediatric anesthesia are hardly regulated. There are opportunities to further limit the use of oxygen. For instance, default settings can be lowered, and intraoperative FiO2 can be further titrated, mainly based on SpO2.

Objective: Surveillance after endovascular aneurysm repair (EVAR) is suboptimal due to limited compliance and relatively large variability in measurement methods of abdominal aortic aneurysm (AAA) sac size after treatment. Measuring volume offers a more sensitive early indicator of aneurysm sac growth or regression and stability, but is more time consuming and thus less practical than measuring maximum diameter. This study evaluated the accuracy and consistency of the artificial intelligence (AI) driven software PRAEVAorta 2 and compared it with an established semi-automated segmentation method. Methods: Post-EVAR aneurysm sac volumes measured by AI were compared with a semi-automated segmentation method (3mensio software) in patients with an infrarenal AAA, focusing on absolute aneurysm volume and volume evolution over time. The clinical impact of both methods was evaluated by categorising patients as showing either AAA sac regression, stabilisation, or growth comparing the 30 day and one year post-EVAR computed tomography angiography (CTA) images. Inter- and intra-method agreement were assessed using Bland-Altman analysis, the intraclass correlation coefficient (ICC), and Cohen's K statistic. Results: Forty nine patients (98 CTA images) were analysed, after excluding 15 patients due to segmentation errors by AI owing to low quality CT scans. Aneurysm sac volume measurements showed excellent correlation (ICC = 0.94, 95% confidence interval [CI] 0.88- 0.99) with good to excellent correlation for volume evolution over time (ICC = 0.85, 95% CI 0.75- 0.91). Categorisation of AAA sac evolution showed fair correlation (Cohen's K = 0.33), with 12 discrepancies (24%) between methods. The intra-method agreement for the AI software demonstrated perfect consistency (bias =-0.01 cc), indicating that it is more reliable compared with the semi-automated method. Conclusion: Despite some differences in AAA sac volume measurements, the highly consistent AI driven software accurately measured AAA sac volume evolution. AAA sac evolution classification appears to be more reliable than existing methods and may therefore improve risk stratification post-EVAR, and could facilitate AI driven personalised surveillance programmes. While high quality CTA images are crucial, considering radiation exposure is important, validating the software with non-contrast CT scans might reduce the radiation burden.

OBJECTIVE:Progressing abdominal aortic aneurysms (AAAs) show a patchwork of rupture-prone wall segments with fast growth and/or greater wall stress, often not located around the maximum diameter. This study aimed to characterize AAA growth profiles over time and investigate their prognostic value for AAA progression. METHODS:In this prospective, observational cohort of AAA patients (maximum diameter, ≥40 mm) under periodic surveillance, participants underwent blood sampling at baseline and were followed over 2 years with annual computed tomography imaging. Aortic diameter was measured repeatedly between the lowermost renal artery and 10 mm above the aortic bifurcation at 5% length intervals. The greatest diameter change (≥2.6 mm or <2.6 mm) and its distance from the maximum aneurysm diameter (>10% or ≤10% of aneurysm length) were used to classify patients at 1 and 2 years into slow, edge, and peak growth. A symmetry test was used to test for directionality of changes in growth profiles between the first and the second year. Secondary outcomes were time to surgical threshold, as well as differences in diameter and volume growth and circulating biomarkers, investigated using Cox, mixed-effects, and linear regression models, respectively. RESULTS:Of 101 patients, 92 adhered to 1-year imaging recommendations (mean age, 72 ± 6.9 years; 84 males; median maximum diameter, 45 mm; 25th-75th percentile, 42-48 mm). Fifty-five patients showed edge growth, 20 slow growth, and 17 peak growth. At 2 years, 75 of 76 alive, untreated patients underwent imaging; 41 showed edge growth, 12 slow growth, and 22 peak growth. Most patients did not change in growth profile over time. Those who did change went from slow to edge to peak growth (P = .027). The cumulative incidence to qualify for surgery in the subsequent year was 0% (95% confidence interval [CI], 0-0) for patients with slow growth, 23% (95% CI, 12%-36%) for edge growth, and 43% (95% CI, 16%-67%) for peak growth (slow vs edge, P = .029; edge vs peak, P = .186). When accounting for differences in maximum diameter, the hazard ratio for qualifying for surgery was 5.24 (95% CI, 1.68-16.38) for patients showing peak growth, compared with edge growth (P = .004). CONCLUSIONS:Fast AAA growth predominantly occurs at the edges of the aneurysm, which may shift toward the maximum diameter over time. These growth profiles, alongside maximum aneurysm diameter, may help to identify patients who are more or less likely to qualify for surgery in the short term.

OBJECTIVE:To describe and compare abdominal aortic aneurysm (AAA) volume to maximum diameter regarding follow-up of AAA-progression, and investigate its added value in AAA surveillance. METHODS:This prospective, observational cohort study included 126 patients enrolled in the multicenter BIOMArCS-AAA study who were under surveillance for an AAA. Participants underwent CT-scans at study inclusion and after one and two years, alongside CT-scans for clinical care. Maximum diameter and total volume were measured after center lumen line reconstruction. Mixed-effects regression was used to evaluate maximum diameter and volume changes over time. The value of volume alongside maximum diameter to distinguish patients that will/will not experience the composite endpoint (qualifying for surgery, or AAA-rupture/AAA-related death) was evaluated using Cox-models and cumulative incidence based positive/negative predictive values (PPV/NPV). RESULTS:A median of 3 scans were available per patient. The baseline median (25th-75th percentile) maximum diameter and volume were 48 (45, 52) mm and 109 (90, 130) mL, respectively. The observed median (25th-75th percentile) growth at one-year follow-up was 2.3 (1.3, 3.1) mm in maximum diameter, and 10.8 (7.0, 16.4) mL in volume. Changes in aneurysm size at the next recommended surveillance visit lay within the boundaries of the inter-observer variability for 81 (65%) patients when measuring maximum diameter, compared to 43 (34%) patients when measuring volume (p<0.001). Using a single maximum diameter measurement, 32 (26%) patients could be exempt from surveillance imaging at one year, while ensuring that the risk of qualifying for surgery remains below 10%. When combining this with a simultaneous volume measurement, 54 (44%) patients could similarly be safely exempt from surveillance imaging (p=0.002). Moreover, simultaneously measuring volume refines the identification of patients that will qualify for surgery at two years (PPV diameter vs. diameter & volume: 57.7% and 72.5%, p<0.001). CONCLUSIONS:AAA volume is more sensitive to detect small changes in aneurysm size at the currently recommended surveillance intervals, and could be used to safely prolong surveillance intervals for patients with a small AAA. The use of volume should be encouraged in research and could prove valuable in AAA surveillance.

BACKGROUND Fully digital preoperative information could save valuable time and resources. However, compared with face to face consultations, equivalent levels of safety, patient satisfaction and participation need to be maintained when using other methods to inform patients. This trial compared knowledge retention between preoperative stand-alone video education and face-to-face education by an anaesthesiologist. OBJECTIVES To assess if video education, alone or combined with face-to-face education, leads to better knowledge retention more than conventional face-to-face education. DESIGN A randomised controlled trial with four arms: Video, Anaesthesiologist, Video & Anaesthesiologist, and Reference for baseline measurements and exploration of a test-enhanced learning effect. SETTING A Dutch tertiary care centre from February 2022 to February 2023. PATIENTS A total of 767 adult patients undergoing preoperative consultation for elective non-cardiothoracic surgery, with 677 included in the complete case analysis. INTERVENTION(S) Stand-alone preoperative video education and video education in combination with face-to-face education in the preoperative outpatient clinic. MAIN OUTCOME MEASURES Primary outcome, measured by the Rotterdam Anaesthesia Knowledge Questionnaire, was knowledge retention on day 0. Secondary outcomes included knowledge retention at 14 and 42 days, preoperative anxiety, and the need for additional information using the Amsterdam Preoperative Anxiety and Information Scale. Other outcomes were satisfaction, self-assessed knowledge, and test-enhanced learning effect. RESULTS Stand-alone video education led to higher Rotterdam Anaesthesia Knowledge Questionnaire scores than face-to-face education on day 0: median [IQR], 87.5 [81.3 to 93.8] vs. 81.3 [68.8 to 87.5], P < 0.001. Combined education in the "Video & Anaesthesiologist" group led to better knowledge retention compared with both the "Anaesthesiologist" group and the Video group: 93.8 [87.5 to 93.8] vs. 81.3 [68.8 to 87.5], P < 0.001; 93.8 [87.5 to 93.8] vs. 87.5 [81.3 to 93.8], P = 0.01, respectively. No differences in the patients' preoperative anxiety and satisfaction levels were found. CONCLUSION Compared with face-to-face education by an anaesthesiologist, stand-alone video and combined video education improve short-term knowledge retention, without increasing patient anxiety. TRIAL REGISTRATIONClinicalTrials.gov Identifier: NCT05188547.

OBJECTIVE:Peri-operative myocardial injury (PMI) is characterised by an acute but clinically asymptomatic increase in troponin levels. Its incidence in vascular surgery is under-reported. Moreover, the impact of PMI on survival in patients undergoing endovascular aneurysm repair (EVAR), who are particularly at risk owing to their cardiovascular burden, remains unclear. This study aimed to assess the incidence of PMI following infrarenal EVAR and its association with long term mortality. METHODS:Pre- and consecutive post-operative high sensitivity troponin T (hsTnT) levels were retrospectively analysed from patients who underwent standard infrarenal EVAR in a tertiary Dutch hospital between 2012 and 2022. PMI was defined as a difference of ≥ 14 ng/L (ΔhsTnT) between pre- and post-operative troponin concentrations without clinical features of myocardial ischaemia. Patients with clinically evident myocardial infarction were excluded. The primary outcomes were the incidence of PMI and the long term mortality rate. A secondary outcome was the association between the magnitude of ΔhsTnT and long term mortality rate, irrespective of PMI criteria. RESULTS:Three hundred and eighteen patients were included, with a median follow up of 43 months. PMI occurred in 38 patients (11.9%). The six year risk of death was statistically significantly higher in patients with PMI (42.1% vs. 23.6%, adjusted hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.13 - 3.92; p = .019). Age (adjusted HR 1.06, 95% CI 1.02 - 1.09; p ≤ .001) and American Society of Anesthesiologists score (adjusted HR 1.82, 95% CI 1.16 - 2.87; p = .009) were independent predictors of death. Statin therapy demonstrated protective advantages against death (adjusted HR 0.40, 95% CI 0.25 - 0.65; p < .001). Lastly, there was a statistically significant association between the magnitude of ΔhsTnT and long term death (adjusted HR = 1.016/Δ1 ng/L, 95% CI 1.004 - 1.029; p = .012). CONCLUSION:Asymptomatic PMI is relatively common following EVAR and is associated with impaired long term survival. HsTnT is a sensitive marker for identifying cardiac damage in patients undergoing EVAR. Prospective studies may strengthen the evidence of the potential association between PMI and post-EVAR death and clarify any benefit from intensified post-operative cardiac care.

Background: Hypotension is common during and after surgery and is known to be associated with myocardial injury. This study investigated whether hypotension in the recovery room after non-cardiac surgery is associated with myocardial injury. Methods: In this retrospective cohort study, data were used from a clinical registry of patients aged 60 years or older undergoing intermediate-to-high-risk non-cardiac surgery. Patients admitted to the Intensive Care Unit or the high-dependency ward were excluded. Hypotension was characterized by the time-weighted average (TWA) below 75 mmHg mean arterial pressure (MAP) measured in the recovery room after surgery. Patients were divided into quartiles of increasing hypotension exposure, i.e., increasing TWA. The primary outcome was myocardial injury, defined as peak high-sensitivity troponin T over 50 ng/L within the first 3 postoperative days. Results: In total, 2660 patients were analyzed. Hypotension in the recovery room was observed in 1119 (43.7%) of the patients while myocardial injury occurred in 198 (7.7%) patients. There was no association between increasing exposures of hypotension and myocardial injury (lowest TWA vs. highest TWA quartile: 7.9% vs. 9.0%, p = 0.65). Furthermore, there was no association between hypotension and 30-day mortality (highest vs. lowest quartile: 1.5% vs. 1.5%, p = 0.82). However, an association was noted at 1 year (9.8% vs. 14.7%, p = 0.02). Conclusions: Hypotension in the recovery room after moderate-to-high-risk non-cardiac surgery is not associated with the development of myocardial injury.

BACKGROUND AND OBJECTIVE:Thoracic epidural analgesia has traditionally been used for pain management after open abdominal surgery, but its use has declined. The quest for efficient alternatives has resulted in the increasing use of regional techniques. These can be applied as single-shot or continuous blocks using catheters. Long-acting liposomal bupivacaine could preclude the use of catheters. This review aimed to evaluate the effectiveness of ultrasound-guided abdominal wall blocks with liposomal bupivacaine for open abdominal surgery. DATABASES AND DATA TREATMENT:Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were systematically searched. Screening, data extraction, and quality assessment were done by two independent researchers. Inclusion criteria were (1) liposomal bupivacaine in ultrasound-guided abdominal wall blocks for open abdominal surgery, (2) outcome of pain and/or opioid consumption, (3) patients >18 years, and (4) reports published in English. RESULTS:Of the 1277 studies found, 22 met the inclusion criteria. The Cochrane Risk of Bias (Version 2) tool was used to assess randomized controlled trials. Studies were grouped for clarity. Transversus abdominis plane (TAP) blocks were mostly investigated. Data were heterogenic regarding types of surgery, approach to block placement, anesthetic solution injected, and use of intrathecal morphine (ITM). CONCLUSIONS:Patients undergoing cesarean section with neuraxial anesthesia and intrathecal morphine benefit from TAP blocks with liposomal bupivacaine, demonstrating reduced opioid consumption and comparable pain. Evidence for other open abdominal surgeries was inconclusive. Abdominal wall blocks with liposomal bupivacaine could be a viable alternative when epidural analgesia is contraindicated.

INTRODUCTION:Thoracic endovascular aortic repair (TEVAR) is the predominant treatment for thoracic aortic aneurysms (TAA) due to its superior perioperative outcomes. International guidelines recommend assessing TAA characteristics via computed tomography angiography (CTA). However, the lack of a standardized measurements protocol introduces variability in preoperative planning, and imaging surveillance, and therefore hinders artificial intelligence (AI) integration for fully automated measurements. This study aims to develop and validate a standardized measurement protocol for TAA to improve consistency in measurement and enhance imaging surveillance. METHODS:A retrospective cohort study was performed at a Dutch tertiary center on patients who underwent TEVAR for a descending TAA from 2010 to 2019. We included degenerative and mycotic TAAs, and exclusions were the lack of a preoperative CTA and/or incomplete postoperative imaging. A standardized measurement protocol was developed based on expert opinion and validated endovascular aortic repair (EVAR) protocols. Imaging analysis utilized dedicated 3D imaging software. The protocol included semi-automated 3D segmentation, center lumen line (CLL) reconstruction, and several measurements, including aortic diameter/volume and sealing lengths. Intraobserver and interobserver agreements were assessed using Bland-Altman analysis and intraclass correlation coefficients (ICCs). RESULTS:We analyzed 133 CTA scans from 31 patients, showing high levels of agreement across measurements, particularly for those repeated by the same observer. Maximum diameter measurements demonstrated excellent consistency, with minimal mean differences for intraobserver and interobserver agreements and excellent correlation (ICC>0.900). Volume measurements were similar consistent, with mean differences of 3.45 (intraobserver) and 2.75 (interobserver) cc. Proximal and distal seal measurements showed good agreement, although interobserver correlation was slightly less consistent. Length of coverage by the endograft exhibited strong consistency. CONCLUSION:Our standardized measurement protocol for descending TAA offers a consistent approach for preoperative planning, imaging surveillance, and research applications, with high agreement in most measurements. This consistency could reduce variability, enhance imaging surveillance. Future research should focus on external validation, integrating AI to further improve measurement consistency, and simplify TEVAR surveillance.Clinical ImpactThis retrospective study of 133 CTA scans from 31 thoracic endovascular aortic repair (TEVAR) for TAA patients demonstrated excellent measurements consistency, including maximum diameter showing strong agreement and minimal differences in volume measurements. In the absence of an existing measurements protocol, our proposed standardized protocol supports improved preoperative planning, imaging surveillance to further enhance TEVAR surveillance.

BACKGROUND Surgery carries inherent risks, with the postoperative phase being as critical as the intraoperative period. Enhanced perioperative care units, positioned between general wards and intensive care units, aim to provide adequate postoperative management and resource allocation. Despite their widespread implementation, evidence on outcomes remains limited. OBJECTIVES The primary outcome was 30-day or in-hospital mortality following extended postoperative recovery, with subgroup meta-analysis examining enhanced perioperative care units and intensive care units. Secondary outcomes included, among others, hospital length of stay. DESIGN Systematic review with meta-analysis. DATA SOURCES A comprehensive search was conducted in MEDLINE, Embase, Web of Science, Cochrane Central, and Google Scholar from inception up to 22 April 2024. ELIGIBILITY CRITERIA The search string encompassed extended postoperative recovery units, including enhanced perioperative care units and intensive care units, for noncardiac, nontransplant surgery, excluding speciality-specific, age-specific, indirect and nonsurgical admissions. Two reviewers independently conducted screening, eligibility assessment and quality appraisal. RESULTS Of 28 179 records screened, 24 were included of which 22 were unique studies. The overall pooled random-effects mortality, based on 15 studies, was 3 (95% confidence interval (CI) 2 to 6)%. Subgroup analysis demonstrated a mortality of 2 (95% CI 1 to 4)% for patients managed in enhanced perioperative care units and 8 (95% CI 4 to 14)% in intensive care units (chi 2 = 7.99; P < 0.01). Risk of bias (ROBINS I) was moderate to serious, and heterogeneity substantial. Pooled hospital length of stay, based on six studies, was 8.6 (95% CI 5.9 to 11.3) days. CONCLUSION Pooled mortality following extended postoperative recovery in noncardiac surgery was 3% (95% CI 2 to 6). Subgroup analysis indicated lower mortality among patients managed in enhanced perioperative care units. However, considerable heterogeneity in operational definitions, unit capabilities, and admission criteria necessitates cautious interpretation while reflecting real-world practices. Delineation through further research is warranted. PROSPERO REGISTRATIONCRD42023457051.

Decision-making whether older patients benefit from surgery can be a difficult task. This report investigates characteristics and outcomes of a large cohort of inpatients, aged 80 years and over, undergoing non-cardiac surgery. This observational study was performed at a tertiary university medical centre in the Netherlands. Patients of 80 years or older undergoing elective or urgent surgery from January 2004 to June 2017 were included. Outcomes were length of stay, discharge destination, 30-day and long-term mortality. Patients were divided into low-, intermediate and high-risk surgery subgroups. Univariable and multivariable logistic regression were used to evaluate the association of risk factors and outcomes. Secondary outcomes were time trends, assessed with Mantel–Haenszel chi-square test. Data of 8251 patients, undergoing 19,027 surgical interventions were collected from the patients’ medical record. 7032 primary procedures were suitable for analyses. Median LOS was 3 days in the low-risk group, compared to six in the intermediate- and ten in the high-risk group. Median LOS of the total cohort decreased from 5.8 days (IQR 1.9–14.5) in 2004–2007 to 4.6 days (IQR 1.9–9.0) in 2016–2017. Three quarters of patients were discharged to their home. Postoperative 30-day mortality in the low-risk group was 2.3

Purpose: Metformin, widely used for the treatment of diabetes mellitus (DM), has shown potential for inhibiting abdominal aortic aneurysm (AAA) growth by reducing extracellular matrix remodeling and inflammation. However, its influence on clinical outcomes and aneurysm sac dynamics after endovascular aneurysm repair (EVAR) remains uncertain. This retrospective study aims to explore the effects of metformin on long-term outcomes following EVAR.Materials and Methods: Patients who underwent elective standard EVAR for infrarenal AAA at a single academic Dutch hospital from 2000 to 2022 were included. We collected baseline patient demographics, comorbid conditions, anatomical and operative characteristics, and 30-day postoperative events. Metformin use was defined as using it preceding EVAR. The primary outcome, the postoperative aneurysm sac volume over time, was investigated using linear mixed-effects modeling. The secondary outcomes, 8-year all-cause mortality and freedom from graft-related events, were evaluated using Kaplan-Meier methods.Results: We analyzed 685 patients, including 634 (93%) non-metformin users and 51 (7%) metformin users. The median follow-up period was similar (4.0 years [IQR=1.5, 6.5] vs 5.0 years [IQR=2.0, 8.0]; p=0.091). Patients on metformin had a preoperative aneurysm sac volume of 153 cc (IQR=114, 195) compared with 178 cc (IQR=133, 240) for non-metformin patients (p=0.054). At 30 days post-EVAR, metformin patients had a comparable mean aneurysm sac volume compared with non-metformin patients (metformin: -19.4 cc [95% confidence interval [CI]: -47.4, 8.5]; p=0.173). The effect of metformin on aneurysm growth over time was not significant (-3.9 cc/year; [95% CI: -22.7, 14.9]; p=0.685). Following risk-adjusted analysis, metformin use was associated with similar rates of all-cause mortality (metformin vs no metformin: 50% vs 44%; hazard ratio [HR]=1.11, 95% CI: 0.66, 1.88; p=0.688) and freedom from graft-related events (metformin vs no metformin: 63% vs 66%; HR=1.82, 95% CI: 0.98, 3.38; p=0.059).Conclusion: Although metformin use may reduce preoperative AAA growth, it does not seem to influence overall/long-term post-EVAR AAA sac dynamics, all-cause mortality, or freedom from graft-related events. These findings suggest that the potential protective effect of metformin on AAA may not be sustained after EVAR. Further prospective studies are needed to investigate the mechanisms underlying the potential role of metformin in AAA management following EVAR.Clinical Impact There is currently no approved pharmacological treatment available to slow the abdominal aortic aneurysm (AAA) growth rate and reduce the related risk of rupture. In our retrospective analysis including 685 patients undergoing EVAR for infrarenal AAA, we found that metformin use was not associated with improved post-EVAR outcomes, such as a reduction of aneurysm sac volume over time, eight-year all-cause mortality, or freedom of graft-related events. These findings suggest that the potential protective effect of metformin on AAA may not be sustained after EVAR and underscore the need for ongoing research into this area.

Background: Risk prediction scores are used to guide clinical decision-making. Our primary objective was to externally validate two patient-specific risk scores for 30-day in-hospital mortality using the Multicenter Perioperative Outcomes Group (MPOG) registry: the Pediatric Risk Assessment (PRAm) score and the intrinsic surgical risk score. The secondary objective was to recalibrate these scores. Methods: Data from 56 US and Dutch hospitals with paediatric caseloads were included. The primary outcome was day mortality. To assess model discrimination, the area under the receiver operating characteristic curve (AUROC) area under the precision-recall curve (AUC-PR) were calculated. Model calibration was assessed by plotting the observed and predicted probabilities. Decision analytic curves were fit. Results: The 30-day mortality was 0.14% (822/606 488). The AUROC for the PRAm upon external validation was 0.856 (95% confidence interval 0.844-0.869), and the AUC-PR was 0.008. Upon recalibration, the AUROC was 0.873 (0.861-0.886), the AUC-PR was 0.031. The AUROC for the external validation of the intrinsic surgical risk score was 0.925 (0.914-0.936) and AUC-PR was 0.085. Upon recalibration, the AUROC was 0.925 (0.915-0.936), and the AUC-PR was 0.094. Calibration metrics for both scores were favourable because of the large cluster of cases with low probabilities of mortality. Decision curve analyses showed limited benefit to using either score. Conclusions: The intrinsic surgical risk score performed better than the PRAm, but both resulted in large numbers false positives. Both scores exhibited decreased performance compared with the original studies. ASA physical status scores in sicker patients drove the superior performance of the intrinsic surgical risk score, suggesting the use of a score does not improve prediction.

Background: Small studies have shown that patients with advanced coronary artery disease might benefit from a more liberal blood transfusion strategy. The goal of this pilot study was to test the feasibility of a blood transfusion intervention in a group of vascular surgery patients who have elevated cardiac troponins in rest. Methods: We conducted a single-centre, randomised controlled pilot study. Patients with a preoperative elevated high-sensitive troponin T undergoing non-cardiac vascular surgery were randomised between a liberal transfusion regime (haemoglobin >10.4 g/dL) and a restrictive transfusion regime (haemoglobin 8.0-9.6 g/dL) during the first 3 days after surgery. The primary outcome was defined as a composite endpoint of all-cause mortality, myocardial infarction or unscheduled coronary revascularization. Results: In total 499 patients were screened; 92 were included and 50 patients were randomised. Postoperative haemoglobin was different between the intervention and control group; 10.6 versus 9.8, 10.4 versus 9.4, 10.9 versus 9.4 g/dL on day one, two and three respectively (p < 0.05). The primary outcome occurred in four patients (16%) in the liberal transfusion group and in two patients (8%) in control group. Conclusion: This pilot study shows that the studied transfusion protocol was able to create a clinically significant difference in perioperative haemoglobin levels. Randomisation was possible in 10% of the screened patients. A large definitive trial should be possible to provide evidence whether a liberal transfusion strategy could decrease the incidence of postoperative myocardial infarction in high risk surgical patients.

The transition from in-person to digital preoperative patient education requires effective methods for evaluating patients' understanding of the perioperative process, risks, and instructions to ensure informed consent. A knowledge questionnaire covering different anaesthesia techniques and instructions could fulfil this need. We constructed a set of items covering common anaesthesia techniques requiring informed consent and developed the Rotterdam Anaesthesia Knowledge Questionnaire (RAKQ) using a structured approach and Item Response Theory. A team of anaesthetists and educational experts developed the initial set of 60 multiple-choice items, ensuring content and face validity. Next, based on exploratory factor analysis, we identified seven domains: General Anaesthesia-I (regarding what to expect), General Anaesthesia-II (regarding the risks), Spinal Anaesthesia, Epidural Anaesthesia, Regional Anaesthesia, Procedural sedation and analgesia, and Generic Items. This itemset was filled out by 577 patients in the Erasmus MC, Rotterdam, and Albert Schweitzer Hospital, Dordrecht, the Netherlands. Based on factor loadings (≥0.25) and considering clinical relevance this initial item set was reduced to 50 items, distributed over the seven domains. Each domain was processed to produce a separate questionnaire. Through an iterative process of item selection to ensure that the questionnaires met the criteria for Item Response Theory modelling, 40 items remained in the definitive set of seven questionnaires. Finally, we developed an Item Response Theory model for each questionnaire and evaluated its reliability. 1-PL and 2-PL models were chosen based on best model fit. No item misfit (S-χ2, p<0.001 = misfit) was detected in the final models. The newly developed RAKQ allows practitioners to assess their patients' knowledge before consultation to better address knowledge gaps during consultation. Moreover, they can decide whether the level of knowledge is sufficient to obtain digital informed consent without face-to-face education. Researchers can use the RAKQ to compare new methods of patient education with traditional methods.

Introduction: The prevalence of abdominal aortic aneurysms(AAA) is at least twice as high in patients with coronary artery disease(CAD), and about half of the AAA-patients have clinically relevant CAD. Detecting concomitant disease and intervening on pathophysiological mechanisms could potentially improve survival in these patients. Research Questions: Which circulating biomarkers and biological mechanisms can distinguish AAA and CAD? Aims: To differentiate the circulating proteomic profiles and biological pathways associated with AAA and CAD. Methods: Patients with AAA and/or stable CAD from two prospective cohort studies were age, sex, and comorbidity matched 1:1:1 (AAA only, AAA and CAD, CAD only). 369 plasma proteins were simultaneously measured in both cohorts using the Olink Explore Cardiometabolic I panel. We investigated differences in proteomic profiles using univariable linear regression and multivariable logistic elastic net regression. Differences in biomarker interactions(pathways) were studied through differential network analysis. Results: Each matched group consisted of 53 patients. Overall, the mean age was 70 years and 92% were men. In AAA-patients, the baseline median(25 th -75 th percentile) maximum diameter was 46(43,50) mm. The proteins IRAG2 and CORO1A were significantly downregulated in AAA-patients with CAD, compared to AAA only. After multivariable selection, only IRAG2 was independently associated with the presence of CAD in AAA-patients. Protein interactions in six pathways differed in AAA-patients with CAD, compared to AAA only(Figure 1A). Moreover, the IGFBP7, CD59, REG1A and CST3 proteins were univariably, significantly upregulated in CAD-patients with AAA, compared to CAD only. Multivariable selection in the proteomic profile proposed PLA2G2A, CD59 and REG1A as independently informative biomarkers for the presence of AAA in CAD-patients. In 14 biological pathways, proteins interacted differently in CAD-patients with AAA, compared to CAD only(Figure 1B). Conclusion(s): A small set of proteins differed between phenotypes. While the average level of most biomarkers was the same, many protein interactions, in pathways implied in AAA by basic research, differed between AAA- and CAD-patients.

•ROTEM-guided transfusion reduces plasma transfusion in patients undergoing lung transplantation (LTx).•Cardiopulmonary bypass use is associated with increased blood product transfusion in these patients.•A history of cystic fibrosis is associated with increased blood product transfusion.

STUDY OBJECTIVE:Protocols are used in intensive care and emergency settings to limit the use of oxygen. However, in pediatric anesthesiology, such protocols do not exist. This study aimed to investigate the administration of oxygen during pediatric general anesthesia and related these values to PaO2, SpO2 and SaO2. DESIGN:Retrospective observational study. SETTING:Tertiary pediatric academic hospital, from June 2017 to August 2020. PATIENTS:Patients aged 0-18 years who underwent general anesthesia for a diagnostic or surgical procedure with tracheal intubation and an arterial catheter for regular blood withdrawal were included. Patients on cardiopulmonary bypass or those with missing data were excluded. Electronic charts were reviewed for patient characteristics, type of surgery, arterial blood gas analyses, and oxygenation management. INTERVENTIONS:No interventions were done. MEASUREMENTS:Primary outcome defined as FiO2, PaO2 and SpO2 values were interpreted using descriptive analyses, and the correlation between PaO2 and FiO2 was determined using the weighted Spearman correlation coefficient. MAIN RESULTS:Data of 493 cases were obtained. Of these, 267 were excluded for various reasons. Finally, 226 cases with a total of 645 samples were analyzed. The median FiO2 was 36% (IQR 31 to 43), with a range from 20% to 97%, and the median PaO2 was 23.6 kPa (IQR 18.6 to 28.1); 177 mmHg (IQR 140 to 211). The median SpO2 level was 99% (IQR 98 to 100%). The study showed a moderately positive association between PaO2 and FiO2 (r = 0.52, p < 0.001). 574 of 645 samples (89%) contained a PaO2 higher than 13.3 kPa; 100 mmHg. CONCLUSIONS:Oxygen administration during general pediatric anesthesia is barely regulated. Hyperoxemia is observed intraoperatively in approximately 90% of cases. Future research should focus on outcomes related to hyperoxemia.

STUDY OBJECTIVE:During rigid bronchoscopies and microlaryngeal surgery (MLS) in children, there is currently no reliable method for managing ventilation strategies based on carbon dioxide (CO2) levels. This study aimed to investigate the effects of the clinical implementation of transcutaneous CO2 (tcPCO2) monitoring during rigid bronchoscopies or MLS. DESIGN:Prospective observational study. SETTING:Operating theatre of a tertiary pediatric hospital, from January 2019 to March 2021. PATIENTS:Children with an age < 18 years, undergoing rigid bronchoscopy or MLS, were eligible for inclusion. Children with tracheostomy and/or skin conditions limiting tcPCO2 monitoring were excluded. INTERVENTIONS:TcPCO2 monitoring was performed in two groups; blinded before clinical implementation (control group) and visible for ventilation management after clinical implementation (tcPCO2 group). MEASUREMENTS:The total tcPCO2 load outside of the normal range (35-48 mm Hg) was calculated as the area under the curve (AUC) and compared between the groups. Anesthesiologists in the tcPCO2 group received a questionnaire after each procedure. MAIN RESULTS:A total of 120 patients were included. No significant differences were found between the two groups in the AUC during the procedure (19,202 (7,863-44,944) vs 17,737 (9,800-47,566) mm Hg · s, P = 0.84) or between different ventilation strategies. The maximal tcPCO2 level was 69.2 (62.1-81.2) mm Hg in the control group and 71.1 (62.8-80.8) mm Hg, (P = 0.85) in the tcPCO2 group. Spontaneous breathing was associated with lower tcPCO2 levels. The general satisfaction score of tcPCO2 monitoring rated by the anesthesiologist was 8.19 (0.96). CONCLUSIONS:TcPCO2 levels reached approximately twice the upper limit of the normal range during rigid bronchoscopy and MLS. Availability of tcPCO2 monitoring did not affect these high levels, despite adjustments in strategy. However, tcPCO2 monitoring provides valuable insight in CO2 load and applied ventilation strategies.

Background and aims Abdominal aortic aneurysm (AAA) patients undergo uniform imaging surveillance until reaching the surgical threshold. In spite of the ongoing exploration of AAA pathophysiology, biomarkers for personalized surveillance are lacking. This study aims to identify potential circulating biomarkers for AAA growth on serial CT scans. Methods Patients with an AAA (maximal diameter ≥40 mm) were included in this multicentre, prospective cohort study. Participants underwent baseline blood sampling and yearly CT-imaging to determine AAA diameter and volume. Proteins and metabolites were measured using proximity extension assay (Olink Cardiovascular III) or separate ELISA panels, and mass-spectrometry (LC-TQMS), respectively. Linear mixed-effects, orthogonal partial least squares, and Cox regression were used to explore biomarker associations with AAA volume growth rate and the risk of surpassing the surgical threshold, as formulated by current guidelines. Results 271 biomarkers (95 proteins, 176 metabolites) were measured in 109 (90.8 % male) patients with mean age 72. Median baseline maximal AAA diameter was 47.8 mm, volume 109 mL. Mean annual AAA volume growth rate was 11.5 %, 95 % confidence interval (CI) (10.4, 12.7). Median follow-up time was 23.2 months, 49 patients reached the surgical threshold. Patients with one standard deviation (SD) higher glutathione and glycine levels at baseline had an AAA volume growth rate that respectively was 1.97 %, 95%CI (0.97, 2.97) and 1.74 %, 95%CI (0.78, 2.71) larger, relative to the actual aneurysm size. Serine was associated with the risk of reaching the surgical threshold, independent of age and baseline AAA size (cause-specific hazard ratio per SD difference 1.78, 95%CI (1.30, 2.44)). Conclusions Among multiple intertwined biomarkers related to AAA pathophysiology and progression, glutathione, glycine and serine were most promising.