Background:Guidelines recommend structured self-reported functional capacity assessment for preoperative cardiac risk stratification, including the Duke Activity Status Index (DASI). However, evidence supporting its incremental prognostic value beyond established risk factors remains limited. We evaluated the prognostic performance of the DASI using pooled data from two prospective cohorts. Methods:We conducted a pooled cohort analysis of adults undergoing elective major non-cardiac surgery enrolled in the Measurement of Exercise Tolerance before Surgery (METS) and Functional Improvement Trajectories After Surgery (FIT After Surgery) studies, including data collected between March 2013 and April 2023. Before surgery, participants completed the Duke Activity Status Index (DASI), a structured 12-item questionnaire based on daily physical activities, and underwent routine preoperative biomarker measurement. The primary outcome was 30-day major cardiac complications (myocardial infarction or non-fatal cardiac arrest) or death. The secondary outcome was all-cause major complications. Hierarchical logistic regression assessed the incremental prognostic value of the DASI beyond age, Revised Cardiac Risk Index (RCRI), and natriuretic peptide concentration. Prognostic performance was evaluated using the likelihood ratio test (LRT), fraction of new predictive information, net reclassification improvement, c-index, calibration plots, and decision curve analysis. Findings:Among 3485 patients, 3.6% (n = 126) experienced the primary outcome and 19% (n = 647) experienced the secondary outcome. The DASI provided prognostic information beyond age, RCRI, and natriuretic peptide concentration for the primary outcome (LRT p = 0.009), and beyond age, sex, and surgery type for the secondary outcome (LRT p < 0.001). Inclusion of the DASI improved prognostic performance across multiple metrics, but overall discrimination of the final models remained modest (c-index 0.70-0.71), with limited net clinical benefit. Predicted risk associated with a given DASI score varied substantially by age, RCRI, and natriuretic peptide concentration, supporting interpretation of the DASI as a continuous prognostic marker rather than a dichotomous screening test. Interpretation:The DASI provides incremental prognostic information for preoperative cardiac risk assessment beyond guideline-recommended predictors. Its prognostic implications are modest, context-dependent, and best interpreted as a continuous prognostic marker alongside established risk factors, rather than as a stand-alone threshold-based tool. Funding:Canadian Institutes of Health Research; PSI Foundation; and the Elizabeth A. and Richard J. Currie, O.C. Chair in Translational Anesthesia Research at St. Michael's Hospital and the University of Toronto; The Ottawa Hospital Academic Medical Organization Innovation Fund; Heart and Stroke Foundation of Canada; Ontario Ministry of Health and Long-Term Care; Ontario Ministry of Research, Innovation and Science; UK National Institute of Academic Anaesthesia; UK Clinical Research Collaboration; Australian and New Zealand College of Anaesthetists; Monash University.

Background:Prophylactic antimicrobial drugs are routinely administered for most surgical procedures worldwide. However, the benefit may be modest and supported by low-certainty evidence, while little is known about safety in contemporary practice. Methods:Observational study in 26 UK hospitals between 2022 and 2024. Eligible patients were aged ≥18 years undergoing any of six common surgical procedures. The exposure was the number of antimicrobial doses administered before, during or after surgery to prevent infection. The primary outcome was surgical site infection (SSI) within 30 days after surgery. Secondary outcomes were antimicrobial side effects (diarrhoea, hearing loss, tinnitus, vertigo, acute kidney injury), all post-operative infections and all post-operative complications. Data are presented as mean (SD), median (IQR) or risk differences (RD) with 95% confidence intervals. Findings:Of 13,720 patients, 13,646 were included in the analysis. Mean age was 59 (20) years and 9059/13,646 (66%) patients were women. 13,246/13,646 (97.1%) patients received antimicrobial prophylaxis (median of 2 (1-2) doses). 1097/13,646 (8.0%) patients experienced an SSI. Increasing number of antimicrobial prophylaxis doses was not associated with a reduction in SSI (1 dose: RD -0.2% [-2.5 to 2.2]; to >10 doses: 0.6% [-2.4 to 3.6]). There was a dose-related increase in antimicrobial side effects (1 dose: RD -1.4% [-3.9 to 1.0], to >10 doses: 4.2% [0.4-7.9]) and complications (1 dose: RD -0.2% [-4.2 to 3.8], to >10 doses: 6.2% [0.5-11.8]). 875/13,646 (6.4%) patients experienced antimicrobial-related side effects compared to an expected incidence of 2.2%. Overall infection rates did not differ with increasing antimicrobial doses. Study registration: ISRCTN15775657. Interpretation:In this study, increasing doses of antimicrobial prophylaxis did not improve SSI prevention. Antimicrobial side effect rates were much higher than expected, especially among patients receiving more doses. Adherence to antimicrobial prophylaxis protocols could improve side effect rates without an increase in the incidence of SSI. Funding:British Journal of Anaesthesia (WKR0-2020-0020); National Institute for Health and Care Research (NIHR): (CL-2021-19-501), (NIHR305701), (DRF-2020-301454), (DRF-2018-11-ST2-062), (NIHR RP-PG-0218-20001).

BACKGROUND:The relationship between socioeconomic status and outcomes after hip fracture surgery remains unclear. We aimed to assess the association between individual-level socioeconomic status indicators and mortality after acute hip fracture surgery in Sweden. METHODS:Cross-linked registry-based cohort study of patients undergoing acute hip fracture surgery in Sweden 2015-20. Co-primary outcomes were 30-day and 2-yr all-cause mortality. Socioeconomic status was defined using four indicators: level of education, income, residential area, and receipt of social services. Attributable fractions were calculated to illustrate the potential population-level distribution of mortality differences across SES categories. RESULTS:There were 58 641 patients included (median age 83 [interquartile range 75-89] yr, 66.1% women). Crude 30-day and 2-yr mortalities were 7.9% (95% confidence interval [CI] 7.7-8.1) and 35.3% (95% CI 34.9-35.7). Level of education showed the strongest association, with a stepwise gradient most pronounced for 2-yr mortality: adjusted odds ratio 1.16 (95% CI 1.08-1.24) for 10-12 yr, 1.20 (95% CI 1.09-1.32) for 9 yr, and 1.25 (95% CI 1.16-1.34) for <9 yr vs >12 yr (all P<0.001). The attributal fraction for 2-yr mortality was 14.0% (standard error 0.022), with an increase in absolute risk of 6.3% (95% CI 4.3-8.2) for >12 yr vs <9 yr of education. Other socioeconomic status factors, except residential area, were also associated with mortality, although less substantially. CONCLUSIONS:Individual socioeconomic status was associated with short- and long-term death after acute hip fracture surgery in Sweden, with education showing the strongest relationship. These findings support consideration of individual-level socioeconomic factors in perioperative hip fracture care at the population level.

BACKGROUND:More than 5 million surgical procedures are performed every year in the UK, but little is known about individuals at high surgical risk who account for most deaths after surgery. We aimed to describe the size, demographics, and long-term outcomes of high-risk surgical patients in the UK. METHODS:In this retrospective, observational cohort study, we analysed routine National Health Service (NHS) data from England (hospital episode statistics, and admitted patient care), Scotland (Scottish Morbidity Records), and Wales (Patient Episode Database for Wales). We derived death data from linkage to Office for National Statistics (England & Wales), National Records of Scotland (Scotland), and the Welsh Death Service (Wales). We included adults (aged ≥18 years) undergoing elective or emergency, in-patient or day-case, non-obstetric surgery between Jan 1, 2015, and Dec 31, 2019 (Dec 31, 2018, in Wales) using an existing code-based definition. We included patients in sequential surgical spells (from day of surgery to 365 days follow-up) and patients who underwent more than one surgical procedure over the study period could contribute more than one surgical spell. The primary (explanatory) outcome was death within 90 days after the index surgery. Secondary outcomes were duration of hospital stay, 90-day emergency hospital readmission, 1-year mortality, and 5-year survival. Patients were ranked from highest to lowest risk of 90-day death using a logistic regression model. The high-risk group included patients accounting for the first 80% of deaths, moderate-risk group included those accounting for the next 15% of deaths, and the low-risk group included those accounting for the final 5% of deaths. We compared high-risk and low-risk groups with risk ratios (RR; 95% CI). FINDINGS:We included 12 905 737 patients (mean age 57·5 [SD 19·2] years; 8 584 593 [53·2%] women, 7 552 101 [46·8%] men; 12 086 325 [74·9%] White patients) who experienced 16 136 694 surgical spells. There were 262 500 (1·6%) deaths within 90 days, and 644 596 (4·0%) deaths within 1 year. The median length of stay was 0 days (IQR 0-1), and there were 1 506 299 (9·4%) emergency readmissions within 90 days after surgery. We identified 1 481 357 (9·2%) patient spells in the high-risk group, who had experienced 206 257 (13·9%) deaths within 90 days (RR vs low 117·15 [115·18-119·14]), a median length of stay of 10 days (IQR 3-21), 426 496 (30·9%) emergency readmissions (RR vs low 5·67 [5·65-5·69]), and 402 033 (27·1%) deaths within 1 year (RR vs low 38·89 [38·61-39·17]). As a proportion of all outcomes in the cohort, high-risk patients accounted for 53·8% of all hospital bed-days used after surgery (21 206 482 of 39 441 408), 28·3% of emergency readmissions (426 496 of 1 506 299), and 62·4% of 1-year deaths (402 033 of 644 596). In England, 94·9% (95% CI 94·8-94·9) of patients in the low-risk group survived by 5 years, compared with 75·1% (75·0-75·2) of patients in the moderate-risk group, and 40·3% (40·1-40·4) of patients in the high-risk group. INTERPRETATION:Data from 2015-19 suggest that around 300 000 high-risk patients undergo surgery each year in the NHS. This group have poor outcomes and very high health-care resource needs, which presents important health policy and delivery challenges in the UK. FUNDING:National Institute for Health and Care Research (NIHR).

Hospitals are under substantial demand with an ageing population, expanding waiting lists, and seasonal pressures. In the UK National Health Service (NHS), more hospital beds are needed to maintain healthcare provision, without which, there is a major concern ‘corridor care’ will be normalised, reducing the dignity, safety, and quality of care for patients. In addition to acute care, a portion of hospital beds are used for elective surgery, which often requires an inpatient stay. However, some patients are admitted the night before elective surgery, which can reduce the number of beds available and has a knock-on financial cost. Understanding preventable reasons for hospital admission the day before surgery might improve efficiency of inpatient care and reduce costs. Here we discuss the recent study of Hou and colleagues6, who describe factors leading to admission the day before elective surgery. We explore the financial impact associated with admission the day before surgery and future policy changes that could improve hospital bed space and reduce cost.

Abstract Background One in four surgical patients carries a drug allergy label, of which an estimated 90% are incorrect. Avoidance of first-choice drug therapies may lead to worse postoperative outcomes. We sought to determine the nature and extent of any association between drug allergy labels and postoperative complications. Methods A multicentre observational study in 21 NHS hospitals. Eligible patients were ≥18 years, undergoing common surgical procedures: primary hip or knee replacement; internal fixation of closed long bone fracture; colorectal resection; trans-urethral resection of prostate or bladder tumour; caesarean section; hysterectomy. Exclusion criteria: use of antibiotics in the two weeks prior to surgery, previous participation in the study. Primary outcome was postoperative complications within 30 days following surgery, a composite outcome comprising: all postoperative infections, anastomotic leak, acute respiratory distress syndrome, myocardial infarction, postoperative bleed, pulmonary embolism, stroke, antimicrobial side effects, death. Results Among 13,646 patients, 3924 (29%) carried ≥1 drug allergy labels. Labelled patients were more likely to develop postoperative complications (989/3924 (25%) vs 1926/9722 (20%); OR 1·21 [1·10-1·34]; p<0·001). They were more likely to develop surgical site infections (337/3924 (9%) vs 760/9722 (8%); OR 1·19 [1·03 -1·38]; p<0·018), and any postoperative infection (750/3924 (19%) vs 1472/9722 (15%); OR 1·24 [1·11-1·38] p<0·001). Labelled patients experienced increased risk of allergic drug reactions (31/3924 (0·01%) vs 29/9722 (<0·01%); OR 3·00 [1·77-5·09]; p<0·001), but no increase in mortality. Conclusions Drug allergy labels are common, but often incorrect. Labelled patients experience worse postoperative outcomes, including infective and non-infective complications and increased risk of allergic drug reactions. Trial registration Registered with ISRCTN registry, ISRCTN15775657 .

Background: Increasing awareness of the potential environmental impact of volatile anaesthetic agents has stimulated increased use of total i.v. anaesthesia. However, consolidated comparative evidence of the environmental impact of anaesthetic agents across the whole life cycle is lacking. Methods: We performed a systematic review and narrative evidence synthesis of the environmental impact of anaesthetic agents stratified by drug life cycle. We searched MEDLINE (PubMed), Excerpta Medica dataBASE (EMBASE), Cumulative index to nursing and allied health literature (CINAHL), and DrugBank, from inception until 05 March 2023, for studies describing the environmental impact of anaesthetic drugs on the WHO essential medicine list. Independent review and data extraction were performed by pairs of reviewers. Data on any aspect of cradle-to-grave life cycle analysis were reported, with narrative synthesis grouped according to life cycle domains. Results: From 15 229 records, 42 unique reports met our inclusion criteria. The predominant environmental impact of inhalation anaesthetic agents is atmospheric release, contributing to global warming. This may be improved with the emergence of more efficacious scavenging and capture systems. Packaging and waste contributed most to the environmental impact of i.v. anaesthetic agents. There is increasing concern over the ecological impact of i.v. agents entering water sources, either by disposal of unused medication or through the excretion of drug post-administration. Conclusions: There is increasing concern about the global warming impact of inhalation anaesthetic agents. However, there are insufficient ‘cradle-to-grave’ comparative analyses of the environmental impact of i.v. and inhalation anaesthesia to form evidence-based conclusions. Further research is urgently needed to guide clinical practice.

Autonomic dysfunction leads to hemodynamic instability and immunosuppression after ischaemic stroke, and is independently associated with worse outcomes. We hypothesized that non-invasive peripheral neuromodulation, using transcutaneous auricular vagal nerve stimulation (tVNS), may reduce blood pressure variability and/or reverse immunosuppression early after ischaemic stroke requiring mechanical thrombectomy (MT). In this pre-registered phase 2 study (NCT05417009), we randomized 36 patients >18 years referred for emergent MT following an acute ischaemic stroke. Patients were randomized to receive bilateral auricular active-tVNS or sham-tVNS, for the entire MT and the morning after admission. Participants, clinicians and investigators were masked to treatment allocations. The primary outcome was systolic blood pressure variability (coefficient of variation) over the entire first 24h after mechanical thrombectomy, analysed by intention-to-treat. Secondary outcomes were whole blood RNA sequencing. Explanatory measures were time/frequency-domain measures of heart rate variability. Active-tVNS was safe in this hyperacute stroke setting, with no serious adverse events recorded. The systolic blood pressure coefficient of variability over the first 24h was 0.106±0.029 after active-tVNS, compared to 0.107±0.027 after sham-tVNS (p=0.93). Active-tVNS increased the relative expression of genes coordinating tumor-necrosis factor and toll-like receptor signaling, in parallel with alterations in heart rate variability over the first 24h after MT. This phase 2 study established thatearly tVNS is safe and feasible in the hyperacute phase of acute ischaemic stroke requiring MT, but did not alter systolic blood pressure variability. Trial registration number: NCT05417009, registered 8TH June 2022.

Background and Aims Vagal parasympathetic dysfunction is strongly associated with impaired exercise tolerance, indicating that coordinated autonomic control is essential for optimizing exercise performance. This study tested the hypothesis that autonomic neuromodulation by non-invasive transcutaneous vagus nerve stimulation (tVNS) can improve exercise capacity in humans. Methods This single-centre, randomized, double-blind, sham-controlled, crossover trial in 28 healthy volunteers evaluated the effect of bilateral transcutaneous stimulation of vagal auricular innervation, applied for 30 min daily for 7 days, on measures of cardiorespiratory fitness (peak oxygen consumption (VO2peak)) during progressive exercise to exhaustion. Secondary endpoints included peak work rate, cardiorespiratory measures, and the whole blood inflammatory response to lipopolysaccharide ex vivo. Results tVNS applied for 30 min daily over 7 consecutive days increased VO2peak by 1.04 mL/kg/min (95% CI: .34-1.73; P = .005), compared with no change after sham stimulation (-0.54 mL/kg/min; 95% CI: -1.52 to .45). No carry-over effect was observed following the 2-week washout period. tVNS increased work rate (by 6 W; 95% CI: 2-10; P = .006), heart rate (by 4 bpm; 95% CI: 1-7; P = .011), and respiratory rate (by 4 breaths/min; 95% CI: 2-6; P < .001) at peak exercise. Analysis of the whole blood transcriptomic response to lipopolysaccharide in serial samples obtained from five participants showed that tVNS reduced the inflammatory response. Conclusions Non-invasive vagal stimulation improves measures of cardiorespiratory fitness and attenuates inflammation, offering an inexpensive, safe, and scalable approach to improve exercise capacity.

Background: Hypertension therapy in older adults is often suboptimal, in part because of inadequate suppression of the renin-angiotensin-aldosterone system (RAAS). We hypothesised that distinct endotypes of RAAS activation before noncardiac surgery are associated with increased risk of myocardial injury. Methods: This was a prespecified exploratory analysis of a multicentre randomised controlled trial (ISRCTN17251494) which randomised patients >= 60 yr old undergoing elective noncardiac surgery to either continue or stop RAAS inhibitors (determined by pharmacokinetic profiles). Unsupervised hierarchical cluster analysis identified distinct groups of patients with similar RAAS activation from samples obtained before induction of anaesthesia, quantified by enzyme-linked immunoassays for plasma renin, aldosterone, angiotensin-converting enzyme 2, and dipeptidyl peptidase-3. The primary outcome, masked to investigators and participants, was myocardial injury (plasma high-sensitivity troponin-T). Results: We identified three clusters, with similar proportions of RAAS inhibitors randomised to stop or continue. Cluster 1 (n=52; mean age [standard deviation], 75 yr [8 yr]; 54% female) and cluster 3 (n=25; 75 yr [6 yr]; 44% female) had higher rates of myocardial injury (23/52 [44%] and 13/25 [52%], respectively), compared with cluster 2 with 51/164 (31.1%; n=153; 70 yr [6] yr; 46% female; odds ratio: 1.95, 95% confidence interval (CI) 1.12-3.39, P=0.018). Cluster 2 was characterised by lower N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration (mean difference 698 pg ml-1, 95% CI 576-820 pg ml-1) and higher renin concentration (mean difference 350 pg ml-1, 95% CI 123-577 pg ml-1), compared with clusters 1 and 3 which had higher rates of myocardial injury. Conclusions: This mechanistic exploratory analysis suggests that effective preoperative RAAS inhibition is associated with lower risk of myocardial injury after noncardiac surgery, independent of stopping or continuing RAAS inhibitors before surgery. Clinical trial registration: ISRCTN17251494.

The traditional model for testing new treatments, before widespread usage in clinical practice, is the parallel group randomised trial. However, these are often inefficient, time-consuming and expensive, which can be barriers to the timely improvement of clinical care. This is a particular issue for anaesthesia and perioperative medicine where funding for large clinical trials is often scarce. Platform trials are an emerging methodology for testing new interventions, which offer benefits over the traditional parallel group paradigm. Platform trials have the ability to test multiple interventions at the same time, and to add or remove interventions during the course of the programme without undermining the validity or integrity of the trial findings. They are most often structured around a master protocol, which describes the core methods and research governance processes, with each intervention described in either a sub-section or appendix to the master protocol. The principal benefit to researchers and to research funders is that, unlike the sequential parallel group trial model, platform trials can use the same research infrastructure (e.g. database, standard operating procedures etc.) to answer multiple research questions, which is much more time and cost effective. The benefits of platform trials can be further enhanced with the use of adaptive designs or by sharing control patients, for example, by using a multi-arm multi-stage design. Perioperative medicine, anaesthesia and surgery are ideally placed to benefit from platform trials.

Background:Reports on delays to National Health Service (NHS) surgical care have been widespread during and after the pandemic, however the impact on paediatric surgery is poorly described. Methods:This retrospective observational cohort study used NHS hospital data in England for children aged <18 yr undergoing surgery over an 8-yr period from 1 April 2015 to 31 December 2020, with supplementary data until March 2023. The primary outcome was in-hospital mortality within 90 days after surgery. The secondary outcome was hospital stay. We report trends in annual surgical procedure volume and mortality. Frequencies presented as n (%). Results:We identified 36 605 870 surgical procedures, between 1 April 2015 and 31 December 2020, of which 1 846 965 (5.0%) were for children. A total of 759 083/1 846 965 (41.1%) patients were female and 313 981 (17.0%) were from minority ethnic groups. There were 41 018/1 846 965 (2.2%) procedures among neonates, 93 872 (5.1%) for children aged 28 days to 1 yr, 532 828 (28.8%) for years 1-5, 502 971 (27.2%) for years 5-12, 361 176 (19.6%) for years 12-15, and 315 100 (17.1%) for years 15-17. Median hospital stay was 1 (0-1) day. There were 6 573/1 846 965 (0.36%) in-hospital deaths within 90 days after surgery, and a trend for increasing mortality risk between 2015 and 2020 (P<0.05). The average annual number of procedures before the pandemic (2015-19) was 340 596, decreasing to 266 049 in 2023 (22% reduction in volume). Conclusions:We report the trends in paediatric surgical volume and assocaited mortality for an entire healthcare system over eight years inlcuding during the COVID-19 pandemic. One in 14 surgical procedures were performed on children, with substantially lower mortality risk than adults.

Background Myocardial injury is strongly associated with excess morbidity and mortality after noncardiac surgery. Higher heart rate may result in perioperative myocardial injury through demand–supply mismatch. Alternatively, higher heart rates may reflect autonomic dysfunction that promotes myocardial injury independently of heart rate. The specific hyperpolarisation-activated, cyclic nucleotide-gated (HCN)-4 (funny) channel inhibitor ivabradine slows the heart rate without altering autonomic control, blood pressure, or myocardial contractility. We hypothesise that individuals with autonomic dysfunction may benefit most from ivabradine reducing heart rate control to minimise myocardial injury-associated morbidity. Methods This triple-blind, international, multicentre, randomised, placebo-controlled, parallel group randomised trial will recruit 350 patients, aged ≥55 yr, with cardiovascular risk factors for myocardial injury during elective noncardiac surgery. To achieve the target heart rate <70 beats min−1 (sinus rhythm), patients will be randomly allocated in a 1:1 ratio using minimisation and will receive either ivabradine (2.5–7.5 mg) or placebo tablet twice daily, from the morning of surgery for 72 h. High-sensitivity troponin T concentrations will be measured before and up to 72 h after surgery, blinded to participants, clinicians, and investigators. The primary outcome is myocardial injury associated with morbidity within 7 days of randomisation (defined by Postoperative Morbidity Survey). Secondary outcomes include peak troponin concentrations, complications within 30 days, and mortality within 6 months of surgery. Pre-specified analyses will include resting and orthostatic heart rate plus N-terminal prohormone of brain natriuretic peptide concentrations before surgery. Conclusions This phase 2b study will explore whether targeted heart rate control reduces morbidity after surgery, using ivabradine to selectively slow the heart rate without altering perioperative autonomic control. Clinical trial registration ISRCTN12903789.

BACKGROUND:The risks and benefits of stopping or continuing renin-angiotensin system (RAS) inhibitors for major noncardiac surgery remain uncertain. We conducted an updated systematic review, national service evaluation, and clinician survey to inform the design of a large clinical trial of perioperative RAS inhibitor use. METHODS:We searched MEDLINE, CINAHL, ProQuest, Cochrane database, Scopus, and Web of Science from January 2000 to October 2024 for randomised controlled trials (RCT) of perioperative RAS inhibitor use. The primary outcome was a composite of mortality and major cardiovascular events (MACE). Secondary outcomes included acute perioperative hypertension and hypotension. Meta-analysis was performed using random effects models. The I2 index was used to quantify heterogeneity. We also conducted a prospective clinical service evaluation and clinician survey to describe current clinical practice in UK. RESULTS:We identified five RCTs (n=2848 patients). Stopping RAS inhibitors was not associated with mortality or MACE (odds ratio [OR] 1.21 [0.60-2.42]; P=0.59; I2=19%). Stopping RAS inhibitors was associated with acute hypertension (OR 1.90 [1.20-3.02]; P=0.007; I2=8%) but fewer hypotension events (OR 0.62 [0.42-0.90]; P=0.01; I2=38%). In a service evaluation of 316 patients in seven hospitals, RAS inhibitors were stopped for 248/316 (79%) patients, with 230/248 (93%) restarting these drugs within 48 h after surgery. In the survey, >80% of clinicians asked patients to stop RAS inhibitors before surgery, for variable reasons concerning risks and benefits. CONCLUSIONS:The optimal approach to perioperative RAS inhibitor use remains uncertain. Although UK clinicians often withhold these drugs, this strategy could cause harm.

BACKGROUND:Five million surgical procedures are performed annually in the UK NHS. One in five patients experience postoperative complications, causing longer admissions and additional treatments. However, the economic cost of complications is poorly understood. METHODS:This was a planned analysis of the International Surgical Outcomes Study linked to NHS England Hospital Episode Statistics data, focusing on Payment by Results (PbR), the predominant funding mechanism before COVID-19. The primary outcome was cost of postoperative complications. The secondary outcome was profit-loss, comparing PbR (income) with surgical cost accounting for complications (expenditure). We calculated expenditure of admission by multiplying length of stay by average daily ward or critical care unit costs. We defined income using the tariff linked to PbR. RESULTS:We included 5167 patients undergoing surgery in the NHS in England, of whom 848 (16.4%) experienced a complication. Patients were on average 58.9 yr old, with 58.1% female and 41.9% male. Median length of stay was 7 days for patients with complications and 2 days without complications. The average cost of admission for patients with complications was £3100 (95% confidence interval [95% CI]: £2921-3279) compared with £1038 (95% CI: £1006-1070) for patients without complications. Profit-loss analysis, accounting for procedure and length of stay, showed a loss for most surgeries, regardless of complications. Average loss without complications was £930 (95% CI: £866-995) and £850 (95% CI: £629-1071) with complications. CONCLUSIONS:Postoperative complications increase expenditure by ∼200%. For most procedures, expenditure exceeds income, independent of complications.

BACKGROUND:Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. METHODS:In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors. RESULTS:Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]). CONCLUSIONS:Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.

Introduction: The number of surgical extractions performed in hospitals in England remains unclear. This study reports the volume of surgical extractions conducted in hospitals and change in activity during the COVID-19 pandemic. Methods: We conducted a nationwide observational cohort study using Hospital Episode Statistics (HES) in England for patients undergoing surgical removal of a tooth (defined using OPSC-4 code F09) between April 1, 2015, and December 31, 2020. Procedures were stratified by age, gender, and urgency (elective or nonelective), reported using descriptive statistics, number, and percentage. We conducted post hoc modeling to predict surgical activity to December 2023. In addition, we contrasted this with aggregate national data on simple dental extraction procedures and drainage of dental abscesses in hospital as well as dental activity in general practice. Results: We identified a total of 569,938 episodes for the surgical removal of a tooth (females 57%). Of these, 493,056/569,938 (87%) were for adults and 76,882/569,938 (13%) children ≤18 years. Surgical extractions were most frequent in adult females. Elective cases accounted for 96% ( n = 548,805/569,938) of procedures. The median number of procedures carried out per quarter was 27,256, dropping to 12,003 during the COVID-19 pandemic, representing a 56% reduction in activity. This amounted to around 61,058 cancelled procedures. Modeling predicts that this activity has not returned to prepandemic levels. Conclusions: The number of surgical extractions taking place in hospitals during the pandemic fell by 56%. The true impact of this reduction is unknown, but delayed treatment increases the risk of complications, including life-threatening infections. Knowledge Transfer Statement: The result of this study provides an evidence-based overview of the trends relating to surgical extractions of teeth in England taking place in hospitals. This information can be used to inform service and workforce planning to meet the needs of patients requiring surgical extractions. The data also provide an insight into the oral health needs of the population in England.