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Background The Surgical Outcome Risk Tool (SORT) was derived and validated in the UK to improve preoperative prediction of postoperative risk. The aim of this study was to validate the SORT in a European mixed-case surgical population outside of the UK. Methods The study included patients aged at least 18 years with ASA Physical Status (ASA-PS) grades I–V who underwent non-cardiac surgery at four tertiary hospitals in Sweden between November 2015 and February 2016. Exclusion criteria were surgery under local anaesthesia and missing data on the SORT predictors (ASA-PS, surgical urgency, high-risk surgery, surgical severity, malignancy, age over 65 years). The outcome was 30-day mortality. Discrimination and calibration of the SORT were assessed using area under the receiver operating curve (AUROC) statistics and calibration plots. A sensitivity analysis was done in a high-risk subgroup (ASA-PS III or higher; surgical complexity major to Xmajor according to the SORT; gastrointestinal, orthopaedic, urogenital/obstetric surgery; and age at least 18 years). Results The validation cohort included 17 965 patients; median age was 58 (i.q.r. 40–70) years, 43.2 per cent were men, and the mortality rate at 30 days was 1.6 per cent. The SORT had excellent discrimination, with an AUROC of 0.91 (95 per cent c.i. 0.89 to 0.92), and good calibration. The high-risk subgroup (1807 patients) had a 30-day mortality rate of 5.6 per cent; in the sensitivity analysis, the SORT had good discrimination, with an AUROC of 0.79 (0.74 to 0.83), and calibration remained good. Conclusion The estimates of the original the SORT for prediction of 30-day mortality were valid and reliable in a mixed-case surgical population in a non-UK European setting.

Feasible estimations of perioperative changes in oxygen consumption could enable larger studies of its role in postoperative outcomes. Current methods, by pulmonary artery catheterisation or breathing gas analysis, are often regarded as either invasive or technically requiring. In this pilot study, we investigated the relationship between estimations of oxygen consumption, based on minimal-invasive cardiac output and arterial-central venous blood gas sampling, and indirect calorimetry in the perioperative period using the data collected during a clinical trial on perioperative oxygen transport.In 20 patients >65 years during epidural and general anaesthesia for open abdominal surgery, Fick-based estimations of oxygen consumption(EVO2), the product of cardiac output from LiDCO™plus(LiDCO Ltd, Cambridge, UK) and arterial-central venous oxygen content difference, were compared with indirect calorimetry(GVO2) using QuarkRMR(COSMED, srl. Italy). Eighty-five simultaneous intra- and postoperative measurements at different time-points were analysed for prediction, parallelity and by traditional agreement assessment. There was an overall association between GVO2 and EVO2, 73(95% CI 62 to 83) + 0.45(95% CI 0.29 to 0.61) EVO2 ml min-1m-2, P2 and EVO2 changed in parallel intra- and postoperatively when normalised to their respective overall means. Unadjusted mean difference between GVO2 and EVO2 indexed for body surface area was 26(95% CI 20 to 32) with limits of agreement (1.96SD) of -32 to 85 ml min-1m-2 and did not change over time. There was low correlation for absolute agreement, ICC(A,1) 0.37(95% CI 0.34 to 0.65) [F(84,10.2)=3.07, P=0.0266].Despite lack of absolute agreement, the estimated oxygen consumption changed in parallel to the metabolic measurements in the perioperative period. Prediction or trending of oxygen consumption by this or similar methods could be further evaluated in larger samples.

BACKGROUND We have previously reported inconclusive results from a randomized controlled trial in elderly with hip-fracture comparing intra-operative goal-directed therapy with routine fluid treatment. Now we aimed to describe and compare secondary outcomes at 4 months and 1 year follow-up and to analyze the cost-effectiveness. METHODS Patients with hip fracture (age ≥70) were randomized for GDT or routine fluid treatment (RFT). The secondary outcomes were long-term survival, complications, number of hospital readmissions, and quality of life (EQ-5D) changes. Additionally, cost effectiveness was analyzed by an analytic tool which combines the clinical effectiveness, quality of life changes and costs. RESULTS Patient data (GDT n = 74; RFT n = 75) were analyzed on an intention to treat basis. Statistically significant differences (GDT vs RFT) were not found considering survival (RR 0.76, 95%CI 0.45-1.28) and complications (RR 0.68, 95% CI 0.4-1.10) at 12 months. No statistically significant difference was found between hospital readmissions and quality of life changes. CONCLUSION The statistical uncertainty of risk reduction of negative outcomes and the large variability of the collected data indicate the need of further research in large sample sizes. To enable future health economic evaluation for decision support surrounding implementation of GDT, we suggest adding patient-oriented outcomes in future trials.

Background and purpose — Waiting time to surgery for patients with hip fractures and its potential association with mortality has been frequently studied with the hypothesis that longer waiting time is associated with adverse outcomes. However, despite numerous studies, there is no consensus regarding which time frames are appropriate, and whether some patients are more vulnerable to waiting than others. We explored the association between waiting time to surgery and short-term mortality and whether sex, age, surgical method, and comorbidity (ASA) modified this association. Patients and methods — This is a nationwide cohort study of 59,675 patients undergoing hip fracture surgery between January 1, 2013 and December 31, 2017 with a 4-month follow-up of mortality. Data were extracted from the Swedish Registry for Hip Fracture Patients and Treatment (RIKSHÖFT) and mortality was obtained from Statistics Sweden. Results — Unadjusted analyses revealed an association between waiting more than 24 hours for surgery and increased mortality, primarily for women. However, when stratifying for ASA grade, an association persisted only among patients with ASA 3 and 4. Furthermore, the absolute differences in mortality risk between those waiting less or longer than 24 hours were small. Age, fracture type, and surgical method did not modify the association between waiting time and mortality. Interpretation — This study suggests that there may be a need for new guidelines, which take into account the heterogeneity of the patient population.

Background We have previously reported that stroke volume is reduced in a majority of elderly patients undergoing surgical repair of hip fracture before and after intrathecal injection of anaesthetic. We aimed to investigate these observations further in a prospective study of elderly patients undergoing elective hip or knee arthroplasty under spinal anaesthesia. Methods Patients ≥65 yr undergoing elective arthroplasty were monitored with LiDCOplus™ preoperatively (baseline), before and continuously for 45 min after spinal anaesthesia. Postspinal hypotension was defined as systolic blood pressure (bp) 30% decrease from baseline. Associations between post-spinal hypotension and haemodynamic changes before (i.e. between baseline and before injection) spinal anaesthesia were analysed by logistic regression analysis. Results Twenty patients with a mean age of 74 (range 66–89) yr were included. Stroke volume index decreased by 14% (95% CI 9.3%–19%) before spinal anaesthesia. When patients were categorised according to post-spinal hypotension (Y/N) the patterns of haemodynamic changes differed. In the hypotensive patients, cardiac index progressively decreased whereas it increased initially in the non-hypotensive patients. Reduction of cardiac index from baseline before spinal anaesthesia was associated with increased risk of hypotension: OR 0.79 (95% CI 0.60, 0.91). The predictive value of reduced cardiac index was good (AUC under ROC curve 0.91). Conclusions A decrease in cardiac output from baseline before spinal anaesthesia and an inability to increase it after induction may be important features of postspinal hypotension in elderly patients.

Background Increased oxygen extraction, the ratio of consumption to delivery, has been associated with poor outcome after surgery. Oxygen consumption (VO2) can change in several ways in the perioperative period, but is seldom monitored directly in routine care. This study investigates the effects of general anaesthesia on VO2. Methods We searched PubMed, EMBASE, and Cochrane Library 1946-2018 for studies including VO2 measurements before and after anaesthesia induction. Quality was assessed by Cochrane risk of bias tool and NIH Quality Assessment tool for before-and-after studies. Changes in VO2 after anaesthesia induction were pooled in a random effects model meta-analysis with standardized mean differences transformed to absolute changes of VO2. Changes in VO2 after surgical incision and after recovery from anaesthesia were analysed as secondary outcomes in the included studies. Results Twenty-four studies including 453 patients were analysed for VO2 changes induced by anaesthesia. Studies were published during 1969-2000 and mean age of patients ranged 28-70 years. VO2 decreased after anaesthesia induction by -65 (-75; -55, 95% CI) mL min-1 and indexed VO2 (VO2I) by -33 (-38; -28, 95% CI) mL min-1 m-2 . After surgical incision and in the post-operative period VO2 increased again. Heterogeneity was considerable among the studies and the overall quality of evidence was very low. Conclusions General anaesthesia probably reduces oxygen consumption but the effect estimate is uncertain. Given the limited generalizability and low quality of the available evidence, new studies in modern perioperative settings and in today's older high-risk surgical patient populations are needed.