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IntroductionThe global volume of surgery is growing and the population ageing, and economic pressure is rising. Major surgery is associated with relevant morbidity and mortality. Postoperative reduction in physiological and functional capacity is especially marked in the elderly, multimorbid patient with low fitness level, sarcopenia and malnutrition. Interventions aiming to optimise the patient prior to surgery (prehabilitation) may reduce postoperative complications and consequently reduce health costs.Methods and analysisThis is a multicentre, multidisciplinary, prospective, 2-arm parallel-group, randomised, controlled trial with blinded outcome assessment. Primary outcome is the Comprehensive Complications Index at 30 days. Within 3 years, we aim to include 2×233 patients with a proven fitness deficit undergoing major surgery to be randomised using a computer-generated random numbers and a minimisation technique. The study intervention consists of a structured, multimodal, multidisciplinary prehabilitation programme over 2–4 weeks addressing deficits in physical fitness and nutrition, diabetes control, correction of anaemia and smoking cessation versus standard of care.Ethics and disseminationThe PREHABIL trial has been approved by the responsible ethics committee (Kantonale Ethikkomission Bern, project ID 2020-01690). All participants provide written informed consent prior to participation. Participant recruitment began in February 2022 (10 and 8 patients analysed at time of submission), with anticipated completion in 2025. Publication of the results in peer-reviewed scientific journals are expected in late 2025.Trial registration numberNCT04461301.

The use of norepinephrine and the restriction of intraoperative hydration have gained increasing acceptance over the last few decades. Recently, there have been concerns regarding the impact of this approach on renal function. The objective of this study was to examine the influence of norepinephrine, intraoperative fluid administration and their interaction on acute kidney injury (AKI) after cystectomy. In our cohort of 1488 consecutive patients scheduled for cystectomies and urinary diversions, the overall incidence of AKI was 21.6% (95%-CI: 19.6% to 23.8%) and increased by an average of 0.6% (95%-CI: 0.1% to 1.1%, p = 0.025) per year since 2000. The fluid and vasopressor regimes were characterized by an annual decrease in fluid balance (-0.24 mL·kg-1·h-1, 95%-CI: -0.26 to -0.22, p < 0.001) and an annual increase in the amount of norepinephrine of 0.002 µg·kg-1·min-1 (95%-CI: 0.0016 to 0.0024, p < 0.001). The interaction between the fluid balance and norepinephrine levels resulted in a U-shaped association with the risk of AKI; however, the magnitude and shape depended on the reference categories of confounders (age and BMI). We conclude that decreased intraoperative fluid balance combined with increased norepinephrine administration was associated with an increased risk of AKI. However, other potential drivers of the observed increase in AKI incidence need to be further investigated in the future.

OBJECTIVES To determine whether early acute kidney injury affects mid-term renal function, to identify risk factors for impaired mid-term renal function, and to highlight the evolution of plasma creatinine and estimated glomerular filtration rate in the first 12 months after cystectomy and urinary diversion. METHODS We conducted a single-center retrospective observational cohort study from 2000 to 2019. We included 900 consecutive patients undergoing cystectomy and urinary diversion. Patients with incomplete data and preoperative hemodialysis were excluded. Early acute kidney injury was defined as an increase in plasma creatinine of >50% or >26.5 μmol/L within 24 h after surgery. Multiple linear regression analysis was performed to model the association between risk factors and change in plasma creatinine and estimated glomerular filtration rate at 12 months. RESULTS Early acute kidney injury was diagnosed in 183/900 patients (20.3%) and was associated with significant mid-term plasma creatinine increase compared to preoperative value (+10.0 μmol/L [95% confidence interval -1.5, 25.0] vs +4.0 μmol/L [-7.0, 13.0]; P

Background: Postoperative elevation of plasma creatinine is a frequent complication to major surgery. A rise by 50% fulfills the criterion for Acute Kidney Injury. We studied the relationship between concentrated urine before surgery, which is usually a sign of chronically low intake of water, and the perioperative change in plasma creatinine. Methods: The creatinine concentration was measured in plasma and urine just before and at 6 h, 1 day, and 2 days after major abdominal surgery in a consecutive series of 181 patients. Receiver operating curve analysis was used to find the optimal cut-off to separate concentrated from diluted urine. Results: Urine creatinine of 11.3 mmol/L before the surgery started was exceeded in one third of the patients and associated with greater increase in plasma creatinine at 6 h (median 21 vs. 10%) and at 1 day postoperatively (21 vs. 7%; P < 0.0001). Elevation of plasma creatinine of >25% occurred in 41% and 19% in those with high and low urine creatinine, respectively (P < 0.001) and an increase by >50% in 16% and 10% (P = 0.27). Patients with high urine creatinine before surgery failed to further concentrate their urine during the perioperative period, which is normally associated with intensified renal fluid conservation. Conclusion: High urinary concentration of creatinine before surgery should be considered as a risk factor for postoperative elevation of plasma creatinine. The mechanism is probably that the renal threshold is then more easily reached.

Open radical cystectomy is associated with a substantial rate of perioperative blood transfusion. Early detection of potentially modifiable perioperative factors could reduce the need for perioperative blood transfusion and thus positively impact the outcome. We conducted an observational, single-center cohort study of 1168 patients undergoing cystectomy. Perioperative blood transfusion was defined as the need for packed red blood cells and/or fresh frozen plasma units within the first 24 h after the initiation of surgery. Multiple logistic regression analysis was performed to model the association between risk factors and blood transfusion, and a nomogram was developed. Blood transfusion occurred in 370/1168 patients (31.7%). Significant predictors were age (OR: 1.678, (95% CI: 1.379–2.042), p &lt, 0.001), blood loss ratio (6.572, (4.878–8.853), 0.001), preoperative hemoglobin (0.316, (0.255–0.391), 0.001), tumor stage (2.067, (1.317–3.244), p = 0.002), use of oral anticoagulants (2.70, (1.163–6.270), p = 0.021), and interaction between female sex and blood loss ratio (1.344, (1.011–1.787), p = 0.042). Of the major predictors found to affect perioperative blood transfusion, two can be influenced: blood loss ratio by meticulous surgery and hemoglobin by preoperative optimization. Others such as age or advanced disease are not modifiable. This emphasizes the importance of optimal management of patients prior to surgery.

OBJECTIVE To assess if uninterrupted anticoagulant agents' administration affects blood loss and blood transfusion during open radical cystectomy (RC) and urinary diversion. PATIENTS AND METHODS We conducted an observational single-centre cohort study of a consecutive series of 1430 RC patients, between 2000 and 2020. Blood loss was depicted according to body weight and duration of surgery (mL/kg/h), and blood transfusion. The group 'with anticoagulant agents' was considered if surgery was performed with uninterrupted low-dose aspirin (ASS), oral anticoagulants (OAC) with an international normalised ratio (INR) goal of 2-2.5 or bridging with therapeutic low-molecular-weight heparin (LMWH). Outcomes were intraoperative blood loss, blood transfusion rate (separately analysed if administered within 24���h perioperatively or >24���h after surgery) and the 90-day major adverse cardiac events (MACE) rate. We used propensity score (PS)-matching analysis to adjust for imbalances between groups with or without anticoagulant agents. RESULTS The PS-matched median (interquartile range [IQR]) blood loss was 2.10���(1.50-2.94)���mL/kg/h in patients with anticoagulant agents vs 2.11���(1.47-2.94)���mL/kg/h without anticoagulant agents (Padj ���>���0.99). The PS-matched blood transfusion rates were 26.2% vs 35.1% (Padj ���=���0.875) within 24���h perioperatively and 57.0% vs 55.0% (Padj ���=���0.680) if administered >24���h postoperatively. A sub-analysis of the three different anticoagulant agents could not detect any significance between ASS, OAC, or LMWH. The PS-matched incidence of MACE was 9.1% in the group with anticoagulant agents and 8.1% in those without anticoagulant agents (Padj ���>���0.99). Limitations include selection bias and retrospective analysis from prospectively assessed data. CONCLUSIONS Perioperative continuation of ASS, uninterrupted OAC with low INR goal or bridging with LMWH had no impact on blood loss and transfusion rate in RC patients. Therefore, there might be no compulsory need for discontinuation of anticoagulant agents.