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Background: The benefits of stroke volume optimization during surgery are unclear, with recent data not replicating the positive effects of earlier studies., Methods: This was a randomized controlled trial of standard fluid therapy with or without supplementary blinded intraoperative stroke volume optimization in 220 patients having major elective rectal resection or cystectomy with ileal conduit. All patients were treated using a contemporary enhanced recovery pathway. Interventional fluid challenges used Gelofusine (B Braun, Germany), guided by stoke volume variability measured by LiDCOrapid (LiDCO, UK). Participants were stratified by aerobic fitness (characterized by preoperative cardiopulmonary exercise test), surgical specialty, and intended surgical approach (open or laparoscopic). The primary outcome was the prevalence of moderate or severe complications on day 5 after surgery, defined using the postoperative morbidity survey (POMS) criteria., Results: Patients received ∼13 ml kg(-1) h(-1) of i.v. fluids during surgery. The intervention group received an additional mean (sd) 956 (896) ml Gelofusine. There were no statistically significant differences between groups in any primary or secondary end point. A positive POMS on postoperative day 5 was noted in 54 of 111 control subjects (48.6%) and 55 of 109 participants in the intervention group [50.5%; adjusted odds ratio 0.90 (95% confidence interval 0.52-1.57), P=0.717]. Mean (sd) hospital length of stay was 9.6 (6.8) days in the control group and 11.8 (11.5) days in the intervention group (adjusted difference -2.1 (-4.6 to 0.3) days, P=0.091). There was no statistical interaction between stroke volume optimization and aerobic fitness in terms of rate of complications or length of stay., Conclusions: Algorithm-driven stroke volume optimization is of no benefit when superimposed on a liberal baseline fluid regimen in patients having elective major abdominal surgery, when stratified to minimize differences in fitness and surgical approach between groups., Clinical Trial Registration: ISRCTN21597243., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Purpose: The current methods (work based assessments and logbooks) used to assess procedural competency and performance have well-documented deficiencies. Cumulative sum analysis (cusum), a statistical method that generates performance graphs over time, is an alternative tool that is not currently widely used. The purpose of this review is to investigate its current role in anesthetic procedural skills training and performance., Source: A literature search of MEDLINE(®), EMBASE™, BNI, CINAHL(®), the Cochrane Library, NHS Evidence, and the Trip database was performed in October 2012. All papers using cusum to investigate performance in anesthetic procedural skills were included. Their references were searched manually to identify any additional studies., Principal Findings: Thirteen papers were identified. The procedural skills they investigated could be split broadly into three groups: ultrasound skills, airway and cannulation, and regional anesthesia. All papers had small sample sizes (< 30), with most researching novice trainee performance. Wide ranges were seen in the number of procedures required to achieve cusum-defined procedural competency. These were due to differences in definitions of success/failure of a procedure, the acceptable and unacceptable failure rates used for the initial cusum calculation, and individual trainee performance., Conclusion: Cusum can be used to assess procedural competency, but several problems need to be overcome before it can become a universally accepted method. It is ideally placed to be used as a quality control tool for a trained individual and could also be used to assess the impact of new training methods or equipment on performance.

Background: The aim of this study was to determine if the post-operative serum arterial lactate concentration is associated with mortality, length of hospital stay or complications following hepatic resection., Methods: Serum lactate concentration was recorded at the end of liver resection in a consecutive series of 488 patients over a seven-year period. Liver function, coagulation and electrolyte tests were performed post-operatively. Renal dysfunction was defined as a creatinine rise of >1.5x the pre-operative value., Results: The median lactate was 2.8 mmol/L (0.6 to 16 mmol/L) and was elevated (≥2 mmol/L) in 72% of patients. The lactate concentration was associated with peak post-operative bilirubin, prothrombin time, renal dysfunction, length of hospital stay and 90-day mortality (P < 0.001). The 90-day mortality in patients with a post-operative lactate ≥6 mmol/L was 28% compared to 0.7% in those with lactate ≤2 mmol/L. Pre-operative diabetes, number of segments resected, the surgeon's assessment of liver parenchyma, blood loss and transfusion were independently associated with lactate concentration., Conclusions: Initial post-operative lactate concentration is a useful predictor of outcome following hepatic resection. Patients with normal post-operative lactate are unlikely to suffer significant hepatic or renal dysfunction and may not require intensive monitoring or critical care.