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Compared with anaemia before surgery, the underlying pathogenesis and implications of postoperative anaemia are largely unknown.This retrospective cohort study analysed prospective data obtained from 2983 adult patients across 47 centres enrolled in a clinical trial evaluating restrictive and liberal intravenous fluids. The primary endpoint was persistent disability or death up to 90 days after surgery. Secondary endpoints included major septic complications, hospital stay, and patient quality of recovery using a 15-item quality of recovery (QoR-15) score, hospital re-admissions, and disability-free survival up to 12 months after surgery. Anaemia and disability were defined according to the WHO definitions. Multivariable regression was used to adjust for baseline risk and surgery.A total of 2983 patients met inclusion criteria for this study, of which 78.5% (95% confidence interval [CI], 76.7-80.1%) had postoperative anaemia. Patients with postoperative anaemia had a higher adjusted risk of death or disability up to 90 days after surgery when compared with those without anaemia: 18.2% vs 9.2% (risk ratio [RR]=1.51; 95% CI, 1.10-2.07, P=0.011); lower QoR-15 scores on Day 3 and Day 30, 105 (95% CI, 87-119) vs 114 (95% CI, 99-128; P0.001), and 130 (95% CI, 112-140) vs 139 (95% CI, 121-144; P0.011), respectively; higher adjusted risk of a composite of mortality/septic complications, 2.01 (95% CI, 1.55-42.67; P0.001); unplanned admission to ICU (RR=2.65; 95% CI, 1.65-4.23; P0.001); and longer median (inter-quartile range [IQR]) hospital stays, 6.6 (4.4-12.4) vs 3.7 (2.5-6.5) days (P0.001).Postoperative anaemia is common and is independently associated with poor outcomes after surgery. Optimal prevention and treatment strategies need to be investigated.NCT04978285 (ClinicalTrials.gov).

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.Surgery can have a long-lasting impact on a person’s ‘functional status’, which is their ability to carry out routine functions of daily living (e.g. work, chores, and social activity). International societies now recommend that functional status be routinely measured in research studies of patients having surgery. A potential instrument to measure functional status in patients having surgery is the WHO Disability Assessment Schedule (WHODAS) 2.0. The WHODAS 2.0 was originally designed to measure function and disability in a general population (i.e. not patients having surgery). In this study, we show that the WHODAS 2.0 has acceptable performance when measuring functional status in patients having surgery.

Background There is a paucity of data on depression, anxiety and post-traumatic stress disorder after left ventricular assist device (LVAD) implantation. We designed an observational study to integrate these with functional capacity and health-related quality of life (HR-QOL) in surviving LVAD patients. Methods and Results Consenting patients between 1 month and 9 years after LVAD implantation (n = 121) were screened for functional capacity (World Health Organization Disability Assessment Schedule 2.0 [WHODAS 2.0)]); HR-QOL (European Quality of Life [EQ-5D] and Visual Assessment Scales [EQ-VAS]), depression (Patient Health Questionnaire [PHQ-9], anxiety (Generalized Anxiety Disorder Scale [GAD-7]) and post-traumatic stress disorder (Impact of Event Scale Revised [IES-R]). Of the 94% of patients who consented, 34.7% reported impaired functional capacity (WHODAS 2.0 score of ≥25%), 23.1%–34.7% HR-QOL problems (domain EQ-5D of ≥3), 10.7% “poor health” (EQ-VAS of ≤40), 14.9% depression (PHQ-9 of >14), 11.7% suicidal ideation and 17.5% anxiety (GAD-7 of >10). Among these patients, 23.5% had a positive screen for post-traumatic stress disorder (IES-R of ≥24). An EQ-VAS of 80 or greater predicted good functional capacity (P Conclusions One-third of discharged LVAD patients reported impaired function, HR-QOL, and psychological issues. A standardized evaluation before and after LVAD implantation could facilitate psychologic prehabilitation, inform decision-making, and identify indications for mental health intervention.

Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital. Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years; 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%); median time to Medical Emergency Team call was 146 (interquartile range 77–279) h. Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today’s surgical patients.

Purpose: This study aimed to determine the prevalence and predictors of death or new disability following critical illness. Methods: Prospective, multicentre cohort study conducted in six metropolitan intensive care units (ICU). Participants were adults admitted to the ICU who received more than 24 h of mechanical ventilation. The primary outcome was death or new disability at 6 months, with new disability defined by a 10% increase in the WHODAS 2.0. Results: Of 628 patients with the primary outcome available (median age of 62 [49–71] years, 379 [61.0%] had a medical admission and 370 (58.9%) died or developed new disability by 6 months. Independent predictors of death or new disability included age [OR 1.02 (1.01–1.03), P = 0.001], higher severity of illness (APACHE III) [OR 1.02 (1.01–1.03), P < 0.001] and admission diagnosis. Compared to patients with a surgical admission diagnosis, patients with a cardiac arrest [OR (95% CI) 4.06 (1.89–8.68), P < 0.001], sepsis [OR (95% CI) 2.43 (1.32–4.47), P = 0.004], or trauma [OR (95% CI) 6.24 (3.07–12.71), P < 0.001] diagnosis had higher odds of death or new disability, while patients with a lung transplant [OR (95% CI) 0.21 (0.07–0.58), P = 0.003] diagnosis had lower odds. A model including these three variables had good calibration (Brier score 0.20) and acceptable discriminative power with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.72–0.80). Conclusion: Less than half of all patients mechanically ventilated for more than 24 h were alive and free of new disability at 6 months after admission to ICU. A model including age, illness severity and admission diagnosis has acceptable discriminative ability to predict death or new disability at 6 months.

Accurately measuring the incidence of major postoperative complications is essential for funding and reimbursement of healthcare providers, for internal and external benchmarking of hospital performance and for valid and reliable public reporting of outcomes. Actual or surrogate outcomes data are typically obtained by one of three methods: clinical quality registries, clinical audit, or administrative data. In 2017 a perioperative registry was developed at the Alfred Hospital and mapped to administrative and clinical data. This study investigated the statistical agreement between administrative data (International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes) and clinical audit by anaesthetists in identifying major postoperative complications. The study population included 482 high-risk surgical patients referred to the Alfred Hospital anaesthesia postoperative service over two years. Clinical audit was conducted to determine the presence of major complications and these data were compared to administrative data. The main outcome was statistical agreement between the two methods, as defined by Cohen’s kappa statistic. Substantial agreement was observed for five major complications, moderate agreement for three, fair agreement for six and poor agreement for two. Sensitivity and positive predictive value ranged from 0 to 100%. Specificity was above 90% for all complications. There was important variation in inter-rater agreement. For four of the five complications with substantial agreement between administrative data and clinical audit, sensitivity was only moderate (61.5%–75%). Using International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes to identify postoperative complications at our hospital has high specificity but is likely to underestimate the incidence compared to clinical audit. Further, retrospective clinical audit itself is not a highly reliable method of identifying complications. We believe a perioperative clinical quality registry is necessary to validly and reliably measure major postoperative complications in Australia for benchmarking of hospital performance and before public reporting of outcomes should be considered.

The most appropriate method to predict postoperative outcomes in patients with severe obesity undergoing elective non-bariatric surgery is not known. We conducted a single-centre prospective cohort study in patients with a body mass index of at least 35 kg/m2 undergoing non-bariatric, non-cardiac surgery. Patients completed the six-minute walk test prior to surgery. Disability was measured before and six months after surgery using the World Health Organization disability assessment schedule. Primary outcome measures included quality of recovery at one month and significantly increased disability at six months after surgery. A total of 293 patients participated. The median body mass index was 41 kg/m2. Patients generally recovered well. Following surgery, 9% of patients experienced a poor quality of recovery and 7% developed a significant increase in disability. The proportion of patients free from clinically significant disability increased from 66% prior to surgery to 90% at six months after surgery. The distance walked in six minutes was weakly predictive of poor recovery at one month and significantly increased disability at six months; weight and body mass index were not. The area under the receiver operating characteristic curve was 0.65 (95% confidence intervals 0.51 to 0.78) for poor recovery and 0.64 (95% confidence intervals 0.51 to 0.77) for increased disability. A preoperative six-minute walk test distance of 308 m was the best cut-off value for predicting increased postoperative disability (sensitivity 0.68, specificity 0.63). The six-minute walk test was most discriminatory at shorter distances. This population of patients with severe obesity appeared to recover well and had few adverse outcomes. The degree of functional capacity was more important than the degree of obesity in predicting postoperative outcomes.

Background Patient-centred outcomes are increasingly used in perioperative clinical trials. The Standardised Endpoints in Perioperative Medicine (StEP) initiative aims to define which measures should be used in future research to facilitate comparison between studies and to enable robust evidence synthesis. Methods A systematic review was conducted to create a longlist of patient satisfaction, health-related quality of life, functional status, patient well-being, and life-impact measures for consideration. A three-stage Delphi consensus process involving 89 international experts was then conducted in order to refine this list into a set of recommendations. Results The literature review yielded six patient-satisfaction measures, seven generic health-related quality-of-life measures, eight patient well-being measures, five functional-status measures, and five life-impact measures for consideration. The Delphi response rates were 92%, 87%, and 100% for Rounds 1, 2, and 3, respectively. Three additional measures were added during the Delphi process as a result of contributions from the StEP group members. Firm recommendations have been made about one health-related quality-of-life measure (EuroQol 5 Dimension, five-level version with visual analogue scale), one functional-status measure (WHO Disability Assessment Schedule version 2.0, 12-question version), and one life-impact measure (days alive and out of hospital at 30 days after surgery). Recommendations with caveats have been made about the Bauer patient-satisfaction measure and two life-impact measures (days alive and out of hospital at 1 yr after surgery, and discharge destination). Conclusions Several patient-centred outcome measures have been recommended for use in future perioperative studies. We suggest that every clinical study should consider using at least one patient-centred outcome within a suite of endpoints.

Background Outcome selection underpins clinical trial interpretation. Inconsistency in outcome selection and reporting hinders comparison of different trials' results, reducing the utility of research findings. Methods We conducted an iterative consensus process to develop a set of Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC), following the established Core Outcome Measures for Effectiveness Trials (COMET) methodology. First, we undertook a systematic review of RCTs in high-impact journals to describe current outcome reporting trends. We then surveyed patients, carers, researchers, and perioperative clinicians about important outcomes after surgery. Finally, a purposive stakeholder sample participated in a modified Delphi process to develop a core outcome set for perioperative and anaesthesia trials. Results Our systematic review revealed widespread inconsistency in outcome reporting, with variable or absent definitions, levels of detail, and temporal criteria. In the survey, almost all patients, carers, and clinicians rated clinical outcome measures critically important, but clinicians rated patient-centred outcomes less highly than patients and carers. The final core outcome set was: (i) mortality/survival (postoperative mortality, long-term survival); (ii) perioperative complications (major postoperative complications/adverse events; complications/adverse events causing permanent harm); (iii) resource use (length of hospital stay, unplanned readmission within 30 days); (iv) short-term recovery (discharge destination, level of dependence, or both); and (v) longer-term recovery (overall health-related quality of life). Conclusions This core set, incorporating important outcomes for both clinicians and patients, should guide outcome selection in future perioperative medicine or anaesthesia trials. Mapping these alongside standardised endpoint definitions will yield a comprehensive perioperative outcome framework.

The six-minute walk test (6MWT) is a simple and valid test for assessing cardiopulmonary fitness. Nevertheless, the relationship between preoperative 6MWT distance and postoperative complications is uncertain. We conducted a secondary analysis of the 6MWT nested cohort substudy of the Measurement of Exercise Tolerance before Surgery study to determine if 6MWT distance predicts postoperative complications or death.This analysis included 545 adults (≥ 40 yr) who were at elevated cardiac risk and had elective inpatient non-cardiac surgery at 15 hospitals in Canada, Australia, and New Zealand. Each participant performed a preoperative 6MWT and was followed for 30 days after surgery. The primary outcome was moderate or severe in-hospital complications. The secondary outcome was 30-day death or myocardial injury. Multivariable logistic regression modelling was used to characterize the adjusted association of 6MWT distance with these outcomes.Seven participants (1%) terminated their 6MWT sessions early because of lower limb pain, dyspnea, or dizziness. Eighty-one (15%) participants experienced moderate or severe complications and 69 (13%) experienced 30-day myocardial injury or death. Decreased 6MWT distance was associated with increased odds of moderate or severe complications (adjusted odds ratio, 1.32 per 100 m decrease; 95% confidence interval, 1.01 to 1.73; P = 0.045). There was no association of 6MWT distance with myocardial injury or 30-day death (non-linear association; P = 0.49).Preoperative 6MWT distance had a modest association with moderate or severe complications after inpatient non-cardiac surgery. Further studies are needed to determine the optimal role of the 6MWT as an objective exercise test for informing preoperative risk stratification.RéSUMé: OBJECTIF: Le test de marche de six minutes (6MWT) est un test simple et validé pour évaluer la santé cardiopulmonaire. Néanmoins, la relation entre la distance parcourue lors d’un 6MWT préopératoire et les complications postopératoires est inconnue. Nous avons effectué une analyse secondaire de la sous-étude de cohorte imbriquée du 6MWT dans l’étude de la Mesure de la tolérance à l’exercice avant chirurgie (Measurement of Exercise Tolerance before Surgery) afin de déterminer si la distance parcourue lors du 6MWT était prédictive de complications postopératoires ou de décès. MéTHODE: Cette analyse comprenait 545 adultes (≥ 40 ans) courant un risque cardiaque élevé et hospitalisés pour une chirurgie non cardiaque élective dans 15 hôpitaux au Canada, en Australie et en Nouvelle-Zélande. Chaque participant a exécuté un 6MWT préopératoire et a été suivi pendant 30 jours post chirurgie. Le critère d’évaluation principal touchait aux complications modérées ou graves à l’hôpital. Le critère secondaire était le décès à 30 jours ou une lésion myocardique. Un modèle de régression logistique multivariée a été employé pour caractériser l’association ajustée entre la distance parcourue lors du 6MWT et ces critères d’évaluation. RéSULTATS: Sept participants (1 %) n’ont pas terminé leurs séances de 6MWT en raison de douleurs aux membres inférieurs, de dyspnée ou de vertiges. Quatre-vingt-un (15 %) participants ont souffert de complications modérées ou graves et 69 (13 %) ont subi une lésion myocardique ou sont décédés à 30 jours. La diminution de la distance parcourue au 6MWT a été associée à une augmentation du risque de complications modérées ou graves (rapport de cotes ajusté, 1,32 par diminution de 100 m; intervalle de confiance 95 %, 1,01 à 1,73; P = 0,045). Aucune association n’a été observée entre la distance parcourue au 6MWT et la lésion myocardique ou le décès à 30 jours (association non linéaire; P = 0,49). CONCLUSION: La distance parcourue lors d’un 6MWT préopératoire a été modestement associée à des complications modérées ou graves après une chirurgie non cardiaque avec hospitalisation. D’autres études sont nécessaires pour déterminer le rôle optimal du 6MWT en tant que test d’exercice objectif pour informer la stratification préopératoire des risques.

The clinical and functional characteristics of patients with severe obesity who present for non-bariatric surgery have rarely been described. For this study, 293 such patients (mean body mass index 42 kg/m2) were investigated using their medical records, a 6-minute walk test, N-terminal pro B-type natriuretic peptide measurement, and the World Health Organization Disability Assessment Schedule 2.0 measure of disability. Cardiorespiratory disease and diabetes were common, with blood tests revealing a high probability of additional unexpected and undiagnosed renal and cardiac disease in a significant proportion of patients. One-third of patients had natriuretic peptide values that identify early left ventricular dysfunction in the community, with 16% above a value described as useful in predicting adverse outcomes for elective surgical patients. Only 10% of patients walked a distance within 10% of that predicted in six minutes, and 22% did not complete the test. Over one-third of patients (34%) had a clinically significant level of disability, with those unable to walk for six minutes describing higher levels of disability. Functional capacity as measured by the 6-minute walk test was significantly lower than would be expected from age, gender, and weight alone, and was related to age and degree of disability but not body mass index. We describe a severely obese population presenting for non-bariatric surgery who had significant levels of comorbid disease, functional impairment, and disability that were not apparent on routine preoperative assessment.

BACKGROUND: An association between increasing anaesthetic depth and decreased postoperative survival has been shown in observational studies; however, evidence from randomised controlled trials is lacking. Our aim was to compare all-cause 1-year mortality in older patients having major surgery and randomly assigned to light or deep general anaesthesia.METHODS: In an international trial, we recruited patients from 73 centres in seven countries who were aged 60 years and older, with significant comorbidity, having surgery with expected duration of more than 2 h, and an anticipated hospital stay of at least 2 days. We randomly assigned patients who had increased risk of complications after major surgery to receive light general anaesthesia (bispectral index [BIS] target 50) or deep general anaesthesia (BIS target 35). Anaesthetists also nominated an appropriate range for mean arterial pressure for each patient during surgery. Patients were randomly assigned in permuted blocks by region immediately before surgery, with the patient and assessors masked to group allocation. The primary outcome was 1-year all-cause mortality. The trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12612000632897, and is closed to accrual.FINDINGS: Patients were enrolled between Dec 19, 2012, and Dec 12, 2017. Of the 18 026 patients screened as eligible, 6644 were enrolled, randomly assigned to treatment or control, and formed the intention-to-treat population (3316 in the BIS 50 group and 3328 in the BIS 35 group). The median BIS was 47·2 (IQR 43·7 to 50·5) in the BIS 50 group and 38·8 (36·3 to 42·4) in the BIS 35 group. Mean arterial pressure was 3·5 mm Hg (4%) higher (median 84·5 [IQR 78·0 to 91·3] and 81·0 [75·4 to 87·6], respectively) and volatile anaesthetic use was 0·26 minimum alveolar concentration (30%) lower (0·62 [0·52 to 0·73] and 0·88 [0·74 to 1·04], respectively) in the BIS 50 than the BIS 35 group. 1-year mortality was 6·5% (212 patients) in the BIS 50 group and 7·2% (238 patients) in the BIS 35 group (hazard ratio 0·88, 95% CI 0·73 to 1·07, absolute risk reduction 0·8%, 95% CI -0·5 to 2·0). Grade 3 adverse events occurred in 954 (29%) patients in the BIS 50 group and 909 (27%) patients in the BIS 35 group; and grade 4 adverse events in 265 (8%) and 259 (8%) patients, respectively. The most commonly reported adverse events were infections, vascular disorders, cardiac disorders, and neoplasms.INTERPRETATION: Among patients at increased risk of complications after major surgery, light general anaesthesia was not associated with lower 1-year mortality than deep general anaesthesia. Our trial defines a broad range of anaesthetic depth over which anaesthesia may be safely delivered when titrating volatile anaesthetic concentrations using a processed electroencephalographic monitor.FUNDING: Health Research Council of New Zealand; National Health and Medical Research Council, Australia; Research Grant Council of Hong Kong; National Institute for Health and Research, UK; and National Institutes of Health, USA.

Background The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to characterise the association of preoperative DASI scores with postoperative death or complications. Methods The analysis included 1546 participants (≥40 yr of age) at an elevated cardiac risk who had inpatient noncardiac surgery. The primary outcome was 30-day death or myocardial injury. The secondary outcomes were 30-day death or myocardial infarction, in-hospital moderate-to-severe complications, and 1 yr death or new disability. Multivariable logistic regression modelling was used to characterise the adjusted association of preoperative DASI scores with outcomes. Results The DASI score had non-linear associations with outcomes. Self-reported functional capacity better than a DASI score of 34 was associated with reduced odds of 30-day death or myocardial injury (odds ratio: 0.97 per 1 point increase above 34; 95% confidence interval [CI]: 0.96–0.99) and 1 yr death or new disability (odds ratio: 0.96 per 1 point increase above 34; 95% CI: 0.92–0.99). Self-reported functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00–1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01–1.05). Conclusions A DASI score of 34 represents a threshold for identifying patients at risk for myocardial injury, myocardial infarction, moderate-to-severe complications, and new disability.

Measuring clinically relevant and patient-centered perioperative outcomes provides the knowledge that enables clinicians to optimize their practice and guide shared decision-making, researchers to set a future agenda and policymakers to prioritize healthcare spending.A large international collaboration is currently working to define a set of core outcomes for use in perioperative medicine research. Standardizing which outcomes are measured and how they are defined will help ensure that perioperative research output is meaningful and practice changing. The ability to pool nonheterogeneous data from multiple clinical trials will also improve ability of research to provide definitive answers and improve the cost-effectiveness of research spending.Future clinical trials in perioperative medicine should utilize clearly defined, validated and standardized patient-centered outcome measures.

Purpose Reported outcomes after left ventricular assist device (LVAD) implantation include mortality, hospital readmission and severe adverse events. We have less information about patients’ perceptions of their quality of life (QOL) after hospital discharge. We conducted a prospective two-center international pilot study to assess at-home functional capacity and QOL following LVAD implantation as a bridge to transplant (BTT) or destination therapy (DT). Methods 124 patients ≥ 30 days after discharge post-implantation were assessed telephonically or during on-site clinic visits. WHODAS 2.0 assesses disability in cognition, mobility, self-care, interpersonal relationships, work/household roles and societal participation. EQ-5D assesses impact of health status on 5 life dimensions. EQ-VAS reflects health self-assessment from 0-100 (worst to best imaginable). Results Mean patient age was 57.5±15.2 yrs; 15% female; 47% >1 yr post-implantation; 56% DT; 67% had HeartMate 3. Disability was minimal in 67% but moderate to severe in 33% (Figure). In the EQ-5D, moderate to extreme problems were reported with usual activities (33%), pain (32%), mobility (31%), self-care (24%) and anxiety (22%). At assessment, 42% reported an EQ-VAS ≥70, but 25% reported Conclusion The majority of LVAD out-patients reported good functional capacity, little impact of their health on major life domains, and high subjective health self-assessment. Yet a substantial minority did not enjoy a high QOL. A good EQ-VAS correlates with high functional ability, but some patients have a poor EQ-VAS even without disability. Routine assessment of functional ability and health status is feasible in post-discharge LVAD patients. Standardized, regular assessments could help us identify factors associated with a high versus low QOL.

Background: The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance.Methods: We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician–researchers was then used to refine a recommended list of endpoints.Results: We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival).Conclusion: Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia–analgesia technique on oncological outcomes.

Summary Background Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. Methods We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor ( 10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. Findings Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2–25) and 94·7% specificity (93·2–95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83–0·99; p=0·03). Interpretation Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. Funding Canadian Institutes of Health Research, 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, and Monash University.

Occasionally accidents and complications occur during anaesthesia and perioperative care that result in injury to the patient. Unfortunately, this is sometimes due to a breach in the anaesthetist's duty of care to the patient. Sometimes, rather than being the cause of immediate damage, the act or omission results in an alteration in the prognosis of the complaint or increased risk of complications related to the complaint. This avenue for a negligence action is known as 'loss of chance of a better outcome' and has been the subject of much legal argument in Australia in recent years. A recent High Court of Australia decision is widely seen as having 'closed the door' to, or at least made it difficult for the patient to succeed in, loss of chance cases. Many anaesthetists may not be familiar with the concept of 'loss of chance'. This review will explore the concept of loss of chance and the manner in which Australian courts have dealt with it before and after Tabet v Gett from the perspective of the anaesthetist.

Amniotic fluid embolism is a rare syndrome with potentially lethal outcomes. Complications include cardiorespiratory failure, disseminated intra-vascular coagulation, seizures, neurological deficits, and death. A 34-year-old woman had amniotic fluid embolism complicated by paradoxical embolism and disseminated intravascular coagulation. Emergency cesarean section followed by cardiopulmonary bypass with removal of the clot from the atria and closure of the patent foramen ovale was performed, resulting in a good outcome for both the mother and the baby. Subsequent treatment with anticoagulants for 6 months was recommended. A literature review revealed that this clinical scenario is rare but can be successfully managed by cardiopulmonary bypass and thromboembolectomy. Data on guidelines for the use of anticoagulation in this situation are limited.

Background: There is a need for robust, clearly defined, patient-relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research.Methods: A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three-stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials.Results: From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions); (ii) pneumonia (12 definitions); and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition.Conclusions: A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.

Anesthesiologists managing patients with drug-eluting stents (DES) face the challenge of balancing the risks of bleeding vs perioperative stent thrombosis (ST). This article reviews DES and the influence of antiplatelet medications related to their use. A perioperative management algorithm is suggested. Novel P2Y12 antagonists currently under investigation, including cangrelor and prasugrel are considered, as well as their potential role in modification of perioperative cardiovascular risks and management of patients with DES.A PubMed search of the relevant literature over the period 1985-2005 was undertaken using the terms "drug-eluting stent", "coronary artery stent", "bare metal stent", "antiplatelet medication", "aspirin", "clopidogrel."Delayed re-endothelialization may render both sirolimus-eluting and paclitaxel-eluting stents susceptible to thrombosis for a longer duration than bare metal stents. Stent thrombosis may be associated with resistance to antiplatelet medication. In patients with a DES, a preoperative cardiology consultation is essential. Elective surgery should be postponed if the duration between DES placement and noncardiac surgery is less than six months. For semi-emergent procedures, both aspirin and clopidogrel should be continued during surgery unless clearly contraindicated by the nature of the surgery. If the risk of bleeding is high, then modification of antiplatelet medications should be considered on a case-by-case basis.A profound increase in the number of patients with DES requires anesthesiologists to be familiar with their associated antiplatelet medications, and strategies for risk modification of ST and possible hemorrhagic complications in the perioperative setting.

ObjectiveTo evaluate ‘days at home up to 30 days after surgery’ (DAH30) as a patient-centred outcome measure.DesignProspective cohort study.Data sourceUsing clinical trial data (seven trials, 2109 patients) we calculated DAH30from length of stay, readmission, discharge destination and death up to 30 days after surgery.Main outcomeThe association between DAH30and serious complications after surgery.ResultsOne or more complications occurred in 263 of 1846 (14.2%) patients, including 19 (1.0%) deaths within 30 days of surgery; 245 (11.6%) patients were discharged to a rehabilitation facility and 150 (7.1%) were readmitted to hospital within 30 days of surgery. The median DAH30was significantly less in older patients (pConclusionsDAH30has construct validity and is a readily obtainable generic patient-centred outcome measure. It is a pragmatic outcome measure for perioperative clinical trials.

Amniotic fluid embolism is a rare but devastating condition associated with a very high rate of morbidity and mortality. The treatment has traditionally been aggressive supportive care. We report a case of a term pregnant woman with complete cardiovascular collapse secondary to a paradoxical amniotic fluid embolism. The embolism was seen on transesophageal echocardiogram during an emergency Cesarean section as a free-floating interatrial clot through a patent foramen ovale. She was subsequently and successfully treated with immediate cardiopulmonary bypass, thromboembolectomy, and closure of the patent foramen ovale.

The internal jugular vein usually is found either lateral or anterolateral to the carotid artery when it is cannulated for central vein access using external anatomical landmarks. We report a case in which the carotid artery was inadvertently punctured, but the right internal jugular vein could not be found. We used ultrasonic guidance to determine that the right internal jugular vein was anteromedial to the carotid artery. A figure showing the ultrasound of this rare anatomical variation is provided. The advantages and utility of ultrasound when used for the placement of internal jugular central vein catheters are reviewed.

We report a case of technically difficult spinal anesthesia in a morbidly obese woman, which was successfully implemented under fluoroscopy. Although radiological imaging is well known to guide various regional anesthetic procedures, until now, the utility of fluoroscopic imaging to facilitate spinal anesthesia had not been reported.

Just over a century ago, the United States became a sea power, changing its basic strategic orientation in the course of a few years. Already a world-class agricultural and industrial producer, the United States joined the great power ranks only when it developed a military force capable of projection across the seas. That capability quickly helped to create an overseas empire and then played pivotal roles in both world wars. This fundamental shift has been explained by "realist" or "revisionist" historians as a continuation of the zeal to fulfill a manifest destiny, variously to spread democracy or capitalism. Still, it is only recently that historians have attempted to understand the lever of that shift. Put bluntly, the U.S. Navymore than any other single institution-has altered the world's destiny, and yet it has received less careful historical study than have the villages of eastern Massachusetts. Baer and Shulimson go a long way toward rectifying the relative neglect of the U.S. Navy and its adjunct Marine Corps. Jack Shulimson, head of the histories section at the Marine Corps Historical Center, has written several histories of the corps' experience in the Vietnam conflict. In The Marine Corps' Searchfor a Mission, 1880-1898, he looks back at the professionalization of the Marine Corps in the era between Appomattox and the new century. From the late 1700s, the corps had provided ships' guards for naval vessels and honor guards for legations across the globe. As the U.S. Navy professionalized in the 1880s, the status of the corps came under close scrutiny. Navy officials came to see the marines as redundant enforcers-which they were-and attempted to have the corps abolished. In terms of quality, the corps was on shaky ground. By law, the number of officers was already limited to seventy-five, and it was only in the 1880s that

(1993). The rise and fall of American naval intelligence, 1882–1917. Intelligence and National Security: Vol. 8, No. 2, pp. 214-226.

Amniotic fluid embolism is a rare but devastating condition associated with a very high rate of morbidity and mortality. The treatment has traditionally been aggressive supportive care. We report a case of a term pregnant woman with complete cardiovascular collapse secondary to a paradoxical amniotic fluid embolism. The embolism was seen on transesophageal echocardiogram during an emergency Cesarean section as a free-floating interatrial clot through a patent foramen ovale. She was subsequently and successfully treated with immediate cardiopulmonary bypass, thromboembolectomy, and closure of the patent foramen ovale.

Review of Henry J. Henrix, Theodore Roosevelt's Naval Diplomacy: The U.S. navy and the Birth of the American Century (2009).

Summary The perioperative roles of dezocine, ketorolac, and α2-agonists have not yet been completely defined, although these agents are known to have some advantages over opiate analgesics. Further investigation is needed to determine whether dezocine and ketorolac will replace or supplement opiates. α-Agonists will probably always be used as adjuncts to opiates because they are not complete analgesics. Capsaicin has not been employed systemically, but its local effects may be found to be useful in the perioperative period.

A classification scheme is proposed as an improvement to the widely used U.S. Department of Agriculture and Arnold Arboretum plant hardiness maps using maximum and minimum air temperature, precipitation, wind speed, sunshine, relative humidity, growing season length, temperature extremes, growth units and elevation. For this analysis, the U.S.A. and Canada were divided into 1234 grid boxes for which monthly averages of each of the climatological variables were calculated. To reduce the size of the original 136 variable data set and eliminate the intercorrelation which existed among these variables, principal component analysis was used and resulted in the formation of a three-component data set. These components were subjected to the flexible clustering technique to isolate regions which, based on the components, were similar, with respect to winter plant hardiness and survival. Twenty-three distinct hardiness clusters with sound climatological and horticultural bases were produced by the clustering procedure. The clusters defined regions with similar vegetative distributions and ecological significance. In the east, clusters were oriented latitudinally and resembled the USDA zones. A distinct cluster encompassing the southern Appalachian Mountains was also formed. In the central U.S.A., the orientation of the clusters was influenced by both temperature and precipitation. The clusters were irregular in mountainous regions and became longitudinally oriented along the Pacific coast. Several of the western clusters encompassed such climatically unique regions as the desert southwest, Great Basin and Rocky Mountains.

Background:Survival and freedom from disability are arguably the most important patient-centered outcomes after surgery, but it is unclear how postoperative disability should be measured. The authors thus evaluated the World Health Organization Disability Assessment Schedule 2.0 in a surgical population.Methods:The authors examined the psychometric properties of World Health Organization Disability Assessment Schedule 2.0 in a diverse cohort of 510 surgical patients. The authors assessed clinical acceptability, validity, reliability, and responsiveness up to 12 months after surgery.Results:Criterion and convergent validity of World Health Organization Disability Assessment Schedule 2.0 were supported by good correlation with the 40-item quality of recovery scale at 30 days after surgery (r = −0.70) and at 3, 6, and 12 months after surgery with physical functioning (The Katz index of independence in Activities of Daily Living; r = −0.70, r = −0.60, and rho = −0.47); quality of life (EQ-5D; r = −0.57, −0.60, and −0.52); and pain interference scores (modified Brief Pain Inventory Short Form; r = 0.72, 0.74, and 0.81) (all P < 0.0005). Construct validity was supported by increased hospital stay (6.9 vs. 5.3 days, P = 0.008) and increased day 30 complications (20% vs. 11%, P = 0.042) in patients with new disability. There was excellent internal consistency with Cronbach’s α and split-half coefficients greater than 0.90 at all time points (all P < 0.0005). Responsiveness was excellent with effect sizes of 3.4, 3.0, and 1.0 at 3, 6, and 12 months after surgery, respectively.Conclusions:World Health Organization Disability Assessment Schedule 2.0 is a clinically acceptable, valid, reliable, and responsive instrument for measuring postoperative disability in a diverse surgical population. Its use as an endpoint in future perioperative studies can provide outcome data that are meaningful to clinicians and patients alike.

Report on symposium co-sponsored by Pace Law School, the New York State Judicial Institute, and the Westchester County Department of Health, and held at Pace Law School on Nov. 30, 2005.

Cranberry (Vaccinium macrocarpon Ericaceae Ait.) stomatal conductivity (SC) was investigated in the field to examine plant response as a function of weather conditions. Measurements were made during fruit maturation on 14 days between 0540 and 1710 HR, as weather conditions permitted. SC ranged from 0.02 to 0.08 cm·s -1 and was much lower than for most other crops. Scatter plots of SC vs. leaf temperature by day indicated only a weak linear relationship. When the data were stratified by time of day and by clear and overcast skies, several significant Pearson correlation coefficients suggested a stomatal response. The findings, when combined with current knowledge of the physical structure of cranberry stomata, suggest that cranberries behave as xeromorphic plants. amine plant response as a function of weather conditions. For this purpose, a field experi- ment was carried out from July to Oct. 1990 at a cranberry research bog at the Rutgers Univ. Blueberry and Cranberry Research Center (RUBCRC), Chatsworth, N.J. 'Early Black' cranberry SC, leaf temperature, and photosyn- thetically active radiation were measured with a steady-state porometer (model LI-1600; LI- COR, Lincoln, Neb.). The bog is 110 × 17 m and is oriented from southeast to northwest. The bog is separated from other research bogs by a dike and ditch bank. The dike and ditch bank is ≈7 m across, and each ditch is ≈1 m across.