Background Sepsis-induced coagulopathy (SIC) is a scoring system developed for early detection of coagulopathy in sepsis and selection of patients for interventional studies. Our aim was to define the prevalence of SIC in a critically ill population and investigate if SIC at intensive care unit (ICU) admission is associated with morbidity and mortality. Methods Patients admitted with septic shock between 2011, and March 2024 were propensity matched into 2 groups (control and SIC). Primary outcome was 28-day mortality. Other outcomes were 90-, 180-day and ICU-mortality, days alive and free of vasopressors, mechanical ventilation and renal replacement therapy (RRT) along with the use of RRT, number of critical bleeding events and red blood cell transfusion. Results 1367 patients with septic shock were identified, 422 (31%) had SIC at ICU admission. Propensity matching resulted in 340 patients in each group. SIC was not associated with higher 28-day mortality (44% versus 37%, p = 0.091). ICU-mortality was higher in the SIC group (30% versus 22%, p = 0.016) and it had fewer median days alive and free of vasopressors (20 versus 22, p = 0.046). Incidence of critical bleeding events was higher in the SIC group (17% versus 10%, p = 0.009). More patients in the SIC group required red blood cell transfusion (63% versus 53%, p = 0.009). There was no significant difference in other outcomes. Conclusion SIC was prevalent in 31% of patients at ICU admission and was associated with higher ICU-mortality, fewer days alive and free of vasopressors, more critical bleeding events and more red blood cell transfusions.

BACKGROUND:The aim of this study was to examine whether a novel semi-automated dataset based on electronic health record documentation can be used for surveillance of central venous catheter-related mechanical complications (failed catheterization, bleeding, cardiac arrhythmia, pneumothorax and nerve injury) within 24 h of catheterization. METHODS:The semi-automated dataset comprised a fully automated extraction of clinical documentation from the electronic health record supplemented with a minor manual review aimed at identifying pneumothoraces, as these are rarely diagnosed at the time of insertion but rather after a postprocedural chest X-ray. To assess surveillance performance, we compared the number of mechanical complications between the semi-automated and manually evaluated datasets for the same cohort and study period, focusing on agreement in aggregate counts. Comparisons were made at the group level only, without enforcing insertion-by-insertion matching. RESULTS:A total of 12 667 insertions were included. Minor mechanical complications occurred in 615 (4.9%) of the insertions in the semi-automated dataset and in 645 (5.1%) of the insertions in the manually validated dataset. Major mechanical complications occurred in 44 (0.35%) of the insertions in the semi-automated dataset compared to 48 (0.38%) in the manually validated dataset. CONCLUSION:A semi-automated dataset based on electronic health record documentation provides sufficiently accurate surveillance of central catheterization-related mechanical complications at the group level. Despite minor discrepancies, the semi-automated method enhances efficiency, scalability, and supports continuous real-time quality assurance. The potential underestimation of complication rates is offset by the possibility of robust real-time quality assurance in registries and a substantial analytical power in scientific studies.

INTRODUCTION:Central venous catheter (CVC) insertion is frequently required in patients with haematological diseases. Despite limited evidence, thrombocytopenia often prompts prophylactic platelet transfusion before catheterisation. METHODS:We conducted an observational before-and-after study including the first non-tunnelled CVC insertion performed in adult patients with haematological diseases between 2013 and 2026 at the Department of Haematology, Skåne University Hospital, Lund, Sweden. In March 2023, the recommended platelet transfusion threshold before CVC insertion was lowered from < 50 × 109/L to < 10 × 109/L. The primary outcome was the proportion of grade 3-4 bleeding events. Secondary outcomes included the proportion of grade 2 bleeding events and transfusion practices. RESULTS:A total of 992 patients were included (715 before and 277 after implementation). Grade 3-4 bleeding events occurred in 14/715 procedures before implementation and in none of the 277 insertions after implementation (absolute risk difference -2.0%, 95% CI: -3.3 to -0.4; p = 0.014). Grade 2 bleeding events were unchanged (8.5% vs. 6.5%, absolute risk difference -2.0%, 95% CI: -5.2 to 2.0; p = 0.289). Preprocedural platelet transfusions decreased substantially (30% vs. 6.5%; p < 0.001). CONCLUSIONS:Lowering the platelet transfusion threshold to < 10 × 109/L was not associated with increased bleeding complications and reduced platelet transfusion use. These findings support a more restrictive preprocedural transfusion strategy.

Abstract Introduction Perioperative intravenous (IV) lidocaine can reduce postoperative pain, opioid use, bowel recovery time and the length of stay, but is rarely tested in liver surgery. This study evaluated the postoperative analgesic efficacy and safety of IV lidocaine in patients undergoing minor liver surgery. Methods Patients undergoing minor liver surgery were randomized 1:1 to receive either perioperative IV lidocaine, administered as a 1.5 mg/kg bolus followed by an infusion of 1.5 mg/kg/h until 1 h after surgery, or placebo. Patients received postoperative opioid analgesia via a patient-controlled analgesia device. The primary outcome was postoperative opioid consumption during the first 24 h after surgery. Secondary outcomes included postoperative pain scores, quality of recovery, adverse events, length of stay, and plasma lidocaine concentrations. Results In total, 124 subjects were included. Postoperative opioid consumption during the first 24 h after surgery was 97 (60–135) mg oral morphine equivalents (OME) in the placebo group, and 83 (50–129) mg OME in the lidocaine group, P = 0.429. Patients in the lidocaine group experienced lower early pain scores, but not from postoperative day 1 onward. Quality of recovery score did not differ, and adverse events were similar between groups. In two cases, plasma concentrations of lidocaine were transiently above 5 µg/ml after bolus administration, without clinical toxicity. Plasma concentrations after resection and at end of infusion were safely below. Discussion Perioperative intravenous lidocaine did not reduce postoperative opioid consumption after minor liver surgery but conferred transient early analgesic benefits and was found to be safe.

BACKGROUND/OBJECTIVES:Vitamin K dependent proteins are involved in numerous biological processes, including coagulation, cancer development and inflammation, but their profile and functions in many patient groups and conditions are still unknown. The aim of this study was to describe vitamin K dependent proteins in patients undergoing head and neck free flap surgery, with the hypothesis that these patients experience postoperative vitamin K deficiency. METHODS:A prospective observational study including 39 patients undergoing extensive head and neck resection and reconstruction using free flap(s) was conducted with analyses of the γ-carboxyglutamic acid-containing proteins desphospho-uncarboxylated Matrix Gla Protein (dp-uc-MGP), Growth arrest-specific gene 6 (Gas6) and Protein Induced by Vitamin K Absence/Antagonist for FII (PIVKA-II), as well as soluble Axl receptor (sAxl), on the day of surgery and postoperative (POD) days 1, 2 and 6. Changes from preoperative levels were explored using Kruskal-Wallis test with a Dunn's post hoc multiple comparison's test. RESULTS:Gas6 showed a significant increase from preoperative levels to all postoperative days (POD1 and 2 p < 0.001, POD6 p = 0.002). For PIVKA-II a continuous increase was seen throughout the study period (POD1 ns, POD2 and 6 p < 0.001). No significant changes were seen in dp-uc-MGP or sAxl levels. CONCLUSIONS:Patients undergoing head and neck free flap surgery show signs of vitamin K deficiency during the first postoperative week.

Introduction Central venous catheters (CVCs) are essential in modern healthcare. Insertion of a CVC promotes a hypercoagulable environment, in part through activation of the intrinsic coagulation pathway. We have previously shown that blood obtained from newly inserted CVCs demonstrates immediate coagulation activation, with differences between samples collected directly after insertion and after flushing of the catheter. The aim of this randomised trial is to compare early coagulation activation between four commonly used CVCs and to assess whether the different CVCs demonstrate different degrees of coagulation activation.Methods and analysis This is a single-centre, randomised, parallel-group trial where adult patients (≥18 years) with a clinical indication for a two-lumen CVC will be eligible for inclusion. Participants will be randomised in a 1:1:1:1 ratio to receive one of four commercially available CVCs. The calculated sample size is 88 participants. Two blood samples will be obtained from each newly inserted CVC, the first obtained from the initial backflow of blood within seconds after insertion and the second after flush and discard. Samples will be analysed using rotational thromboelastometry with the non-activated thromboelastometry (ROTEM NATEM) and plasma-based coagulation assays. The primary outcome is the between-group comparison of the change in ROTEM NATEM clotting time between the two samples. Secondary outcomes include within-group and overall cohort comparisons of changes in clotting time. Additional secondary outcomes are between-group, within-group and overall cohort comparisons of changes in other ROTEM NATEM parameters, including clot formation time, alpha angle and maximum clot firmness, and changes in plasma-based coagulation markers, including prothrombin time–international normalised ratio, activated partial thromboplastin time, Factor VII, Factor XII and thrombin–antithrombin complex concentration. The results may help identify catheter materials that are less prone to activate coagulation and support in the selection and development of CVCs.Ethics and dissemination This study has been approved by the Swedish Ethical Review Authority (#2022-00265-0). Written informed consent will be obtained from all participants before inclusion. The results will be published in a peer-reviewed journal and presented at scientific meetings.Trial registration number NCT07014722.

Background:Central venous catheters (CVCs) are commonly used in patients with haematological diseases but are associated with infectious complications. The CVC Anti-infection Double Lumen Bundle was introduced in December 2020 to reduce this risk. The bundle included a double-lumen noble metal alloy-coated CVC and chlorhexidine-impregnated dressings. This study evaluated whether the bundle was associated with a reduction in catheter-related infections. Methods:Non-tunnelled CVC insertions with a dwell time ≥24 h in adults treated for haematological diseases between May 2013 and June 2024 were included. Data were extracted from the electronic health records. The main objectives of the study were to investigate the proportions of suspected catheter-related infection (sCRI) and catheter-related bloodstream infection (CRBSI). Secondary objectives were catheter tip colonization and incidence of sCRI and CRBSI per 1000 catheter-days. Results:A total of 907 CVC insertions in 690 patients were analysed (471 before and 436 after the bundle implementation date). No differences were observed in the proportions of sCRI (6.4% vs 7.6%), CRBSI (0.4% vs 0.7%) or catheter tip colonization (4.7% vs 4.4%). The incidence per 1000 catheter-days also did not differ (sCRI: 1.67 vs 2.34 and CRBSI: 0.11 vs 0.21). In multi-variable analysis, no variables were associated with a higher risk of sCRI, whereas antibiotic administration at insertion was associated with a lower risk. Conclusion:The introduction of the Anti-infection Double Lumen Bundle did not reduce CVC-related infectious complications in patients with haematological diseases.

Abstract Introduction Central venous catheters (CVCs) are vital during the perioperative and postoperative period for patients undergoing abdominal surgery, but they carry risks such as catheter-related infections. Early signs of infection, including tenderness and induration at the insertion site, are important to detect as they may precede infection; however, these symptoms are often overlooked. The aim of this study was to compare surgical patients’ experiences of having a CVC with corresponding nursing documentation. Methods Data were collected through brief patient interviews and a review of electronic health record (EHR) documentation. Results A total of 106 patients were included, of whom 103 had a CVC inserted in the internal jugular vein. The median number of catheter days was 10 (IQR 8–16). No catheter-related infections occurred, but potential risks were identified. In 56% of cases, the CVC was removed within the last 2 days before discharge, and the most common reason for catheter retention was blood sampling. Interview results showed that 37 patients experienced significant discomfort, including persistent sensations of constriction, restricted mobility, and pain. Despite this, these symptoms were documented in the EHR for only three patients. Discussion The findings highlight the need to systematically address patients’ symptoms and individual needs in postoperative CVC care. Integrating such assessments into mandatory fields within standardized EHR documentation templates may help promote patient-centred care. Additionally, clearly defined guidelines for when to retain or remove CVCs are needed to reduce unnecessary catheter-days in postoperative care.

Background/Objectives: Vitamin K-dependent proteins (VKDPs) all commonly possess specially modified γ-carboxyglutamic acid residues created in a vitamin K-dependent manner. Several liver-derived coagulation factors are well characterised VKDPs. However, much less is known about extrahepatic VKDPs, which are more diverse in their molecular structures and functions, and some of which have been implicated in inflammatory disorders. Vitamin K metabolism was shown to be impaired in critically ill patients, in whom systemic inflammation and sepsis are common features. Therefore, the aim of this study was to investigate the effect of vitamin K administration to these patients on their circulating levels of selected VKDPs. A particular novelty of this study was the measurement of specifically carboxylated forms of these proteins in addition to their overall levels. Methods: Blood samples were taken from 47 patients in the intensive care unit before and approximately 24 h after intravenous vitamin K1 (10 mg) administration, and proteins were analysed by specific immunoassay. Results: Vitamin K1 induced increases in plasma levels of carboxylated osteocalcin and total Gas6 (p = 0.0002 and p = 0.0032, respectively). No changes were detected in levels of carboxylated Gas6 or PIVKA-II (undercarboxylated prothrombin), although the latter positively correlated with undercarboxylated osteocalcin (r = 0.38). Conclusion: Injected vitamin K1 increases the blood levels of two distinct VKDPs in critically ill patients, both of which have been implicated in inflammation regulation, including the increased carboxylation of one of them.

Medical students navigate a complex landscape of digital tools with potential to enhance learning. The main objectives of the current study were to investigate which digital resources are being used, which background factors are associated with utilization, perceived advantages and disadvantages of different digital resources, and explore future directions. Cross-sectional, nationwide, online 25-item multiple-choice question survey and one free-text question enabling qualitative data analysis. Medical students at all seven universities with medical school programs in Sweden were invited to participate. Data were collected October – December 2024. One thousand seven hundred sixty-six students responded to the survey, with an average response rate of 20.2

Background and Aim:Central venous catheters are vital in the peri- and postoperative period for patients undergoing abdominal surgery but are associated with risks such as catheter related infections. Signs of infection, like tenderness and induration at the insertion site, are important to recognize, as they may precede catheter-related infections, but are often neglected. The aim was to compare surgical patients' experience of central venous catheter with the nursing documentation. Methods:Data was collected from short patient interviews and by reviewing electronic health record documentation. Results:In total, 106 patients were included, 103 of whom had a central venous catheter located in the internal jugular vein. The median (interquartile range) number of days with a catheter was 10 (8-16). There were no catheter related infections, but potential risks were identified. In 56% of the patients, central venous catheters were removed within the last 2 days before discharge. The most common reason for keeping the catheter was blood sampling. The results from the interviews indicate that 37 of the patients experienced considerable discomfort, such as persistent sensations of constriction, restricted mobility and pain, however, these symptoms were documented in the electronic health record for only three patients. Conclusion:The findings emphasize the necessity of systematically addressing patients' symptoms and individual needs in the postoperative care of the central venous catheter. Incorporating these aspects as a mandatory element in the standardized documentation template within the electronic health record will constitute an important first step toward enhancing patient-centred care. There is a need for clearly defined guidelines outlining the indications for retention or removal of central venous catheters to minimize catheter-days during postoperative care in surgical wards. Trial Registration:As this was a descriptive, qualitative observational study that did not involve testing a new intervention, compare interventions, or randomize participants, we did not find trial registration necessary under commonly accepted guidelines for clinical trial registration.

BACKGROUND:Platelet transfusions are frequent in the Intensive Care Unit (ICU), either as prophylaxis against bleeding complications or as treatment for bleeding. The European Society of Intensive Care Medicine guidelines for ICU patients generally recommend not using prophylactic platelet transfusions unless the platelet count falls below 10 × 109 cells/L in non-bleeding patients and make no recommendation for platelet transfusion threshold in non-massively bleeding patients with thrombocytopenia. Therefore, the decision to transfuse platelets is often left to clinical assessment by the treating physician. This study aims to describe current platelet transfusion preferences among ICU physicians. METHODS:An online, anonymous survey consisting of 43 items was produced in two languages (French and English) and distributed by investigators in the Nine-I research network to ICU physicians in Europe and the United States of America. The survey evaluated platelet transfusion practices in ICU patients with and without bleeding, the presence of local guidelines, and factors influencing the decisions to transfuse platelets. Only completed surveys were analysed. RESULTS:We received 997 surveys completed by ICU physicians. Overall, there was large heterogeneity in platelet transfusion practices between and within countries. In non-bleeding, thrombocytopenic medical ICU patients, most would transfuse prophylactic platelets at a platelet count threshold of 10 × 109 cells/L. Thirty percent would change their strategy in patients with bone marrow failure and either be more liberal (60%; 95% Confidence Limits 0.54, 0.66), more restrictive (31%; 0.26,0.36) or seek assistance. Higher thresholds were preferred in surgical patients, prior to procedures and in patients with bleeding. Only 173 (17%; 0.15,0.19) responded that they were confident about the clinical indications every time they prescribed a platelet transfusion. As for existing guidelines, only 123 (12%; 0.10,0.15) responded that they always read them. Colleagues' attitudes and departmental culture were important influencers on transfusion practice. CONCLUSION:Platelet transfusion practice in the ICU is heterogeneous, both between and within countries; guidelines are often not used, and there is often uncertainty about the clinical indication.

The aim of this this cross-sectional observational study was to investigate coagulation and platelet activation in blood collected from newly inserted catheters. Blood samples were collected from newly inserted central venous, peripheral venous and arterial catheters in adult patients. Sample 1 was collected within seconds after insertion. Sample 2 was collected directly after Sample 1 but after proper flush and discard. A selected set of haemostatic assays were performed and the results for Sample 1 and 2 compared per catheter type. In total 10 patients per catheter type were included between December 2021 and June 2022. For central venous catheters, there was a difference in ROTEM NATEM clotting time, clot formation time, α-angle, prothrombin time international normalised ratio, factor VII and thrombin-antithrombin complex, supporting strongly enhanced activation in Sample 1 compared to Sample 2. Peripheral venous catheters and arterial catheters were less prone to activate coagulation. In conclusion, our results support flush and discard ahead of haemostatic assay blood sampling in newly inserted catheters. Furthermore, the results enhance the understanding of central venous catheter-related thrombosis formation.

In septic shock, administration of large fluid volumes is associated with poor outcomes. Recent evidence shows that non-resuscitation fluids are the major modifiable source of fluids for patients with septic shock in intensive care units (ICUs). This clinical trial is designed to test the hypothesis that restrictive administration of non-resuscitation fluids improves outcomes compared to usual care. Adult patients admitted to ICUs with septic shock will be randomly assigned within 12 h of admission to receive protocolized restrictive administration of non-resuscitation fluids or usual care. The primary outcome is all-cause mortality at 90 days. Secondary outcomes are complications during ICU stay up to 90 days (defined as any acute kidney injury or cerebral, coronary, intestinal, or limb ischemia), mechanical ventilation free days within 90 days, and for survivors cognitive function (by the Montreal Cognitive Assessment [MOCA-BLIND]) and Health-Related Quality of Life (by the EQ Visual Analogue Scale [EQ-VAS]), both at 6 months. In addition, the climate impact of the interventions will be assessed. To detect an absolute reduction in mortality of 7.5%, with an alpha of 5% and a power of 90%, we aim to include 1850 patients. The trial is approved by the Swedish Ethical Review Authority. Results of primary and secondary clinical outcomes and the environmental outcome will be submitted for publication in a peer-reviewed journal. Trial Registration: NCT06140147.

BACKGROUND:Extensive head and neck reconstructive surgery is a complex procedure often performed in patients with multiple comorbidities, and the risk of complications is high. Evidence-based preoperative assessment and reliable risk prediction are therefore essential, and the anesthesiologist plays an important role in this process. The aim of this study was to evaluate the predictive properties of readily available clinical parameters for postoperative complications. METHODS:We performed a retrospective registry study including 388 patients undergoing head and neck free flap surgery between 2009 and 2022. Logistic regression analyses were used to establish associations between perioperative variables and postoperative flap compromise and systemic complications during primary in-hospital stay. Perioperative variables included risk prediction instrument scores, biochemical laboratory values, type of flap, surgery time, and fluids and drugs administered. RESULTS:Factors associated with flap compromise in multivariable analysis were surgery time (p = 0.005) and perioperative red blood cell transfusion (p = 0.001). American Society of Anesthesiologists Physical Status (ASA-PS) (p = 0.012), Charlson Comorbidity Index (CCI) (p = 0.021) and Head Neck Charlson Comorbidity Index (HN-CCI) (p = 0.024) were factors most significantly associated with systemic complications. DISCUSSION:Strong association was seen between surgery time and perioperative red blood cell transfusion and flap compromise. ASA-PS, CCI, and its simplified version HN-CCI were shown to be independently associated with systemic complications. To the best of our knowledge, this is the first study demonstrating the value of Head Neck Charlson Comorbidity Index in this setting. EDITORIAL COMMENT:This single center cohort analysis describes factors associated with head and neck free flap surgery postoperative flap compromise and other major complications. Established comorbidity indices were included in the analysis.

Background Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5–30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs. Methods The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined. Results In total, seven female and five male patients with a median age of 70 (interquartile range 63–76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8–20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%). Conclusions This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

We read with great interest the recent study by Naddi et al. in BMC Anesthesiology, which explores operator gender differences in major mechanical complications following central venous catheterization. The study identifies male operator gender as an independent risk factor for complications. However, our attempt to replicate these findings using Colombian data did not support this association. We caution against oversimplifying the influence of sex and gender on health outcomes, as numerous factors, including cultural norms, healthcare practices, and resource availability, significantly impact procedural outcomes. Differences in complication rates may reflect risk-taking behaviors and systemic healthcare disparities rather than inherent biological differences. We emphasize the need for a comprehensive approach to understand the multifaceted nature of central venous related complications. Replication studies across diverse populations are crucial for validating these findings and informing effective strategies for complication prevention and management.

Non-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypothesis that a restrictive protocol targeting non-resuscitation fluids reduces the overall volume administered compared with usual care. Adults with septic shock in six Swedish ICUs were randomized within 12 h of ICU admission to receive either protocolized reduction of non-resuscitation fluids or usual care. The primary outcome was the total volume of fluid administered within three days of inclusion. Median (IQR) total volume of fluid in the first three days, was 6008 ml (interquartile range [IQR] 3960–8123) in the restrictive fluid group (n = 44), and 9765 ml (IQR 6804–12,401) in the control group (n = 48); corresponding to a Hodges–Lehmann median difference of 3560 ml [95 https://clinicaltrials.gov/ct2/show/NCT05249088

BACKGROUND:Patients undergoing hepato-pancreato-biliary surgery are typically preoperatively assessed using the American Society of Anesthesiologists (ASA) classification, which is also used for case-mix adjustment when comparing centre outcomes. Studies determining the inter-rater variability of the ASA classification within hepato-pancreato-biliary surgery are currently lacking. METHODS:An international survey was collected and a case-vignette study was performed (November 2022-April 2023) regarding the ASA classification in patients undergoing hepato-pancreato-biliary surgery among anaesthesiologists and surgeons from (inter)national societies. The survey consisted of 23 questions and eight case-vignettes. Primary analysis included descriptive statistics and the inter-rater variability was calculated using Light's Kappa. RESULTS:Overall, 1283 participants from 55 countries responded: 1073 (84%) anaesthesiologists and 210 (16%) surgeons. The ASA classification was commonly used, both clinically 1003/1283 (78%) and for research 728/762 (96%). The majority of respondents (n = 1019, 79%) declared that ASA score impacted their perioperative strategy. There inter-rater variability was fair-moderate (Kappa 0.26-0.42) in all case-vignettes. Inter-rater variability differed within and among geographic regions for each case. Over 80% (n = 1138) of respondents stated that they would take the underlying disease (for example cancer) into account, but this changed the preferred ASA score within the case-vignettes by only 1%. Type of surgery changed the preferred score in the case-vignettes (13% difference). The most common suggestions to improve the ASA classification were to clarify whether type of operation should be considered, create a more extensive definition, and provide more examples. CONCLUSIONS:Inter-rater variability was present within the ASA classification of patients undergoing hepato-pancreato-biliary surgery, which may impact perioperative strategy and hamper research results. Additional guidance to classify patients according to ASA is urgently needed. Until then, more objective measurements should be considered for case-mix adjustment within research.