Major Elective Noncardiac Surgery Research Articles

Effect of small dose esketamine on perioperative neurocognitive disorder and postoperative depressive symptoms in elderly patients undergoing major elective noncardiac surgery for malignant tumors: A randomized clinical trial.

Perioperative neurocognitive disorder and postoperative depressive symptoms are significant complications after surgery. Studies have indicated that esketamine possesses neuroprotective and antidepressant qualities. This trial included 209 patients aged 60 to 86 years undergoing tumor resection who received esketamine (Group E) or not (Group C) during and after surgery. In group E, patients were given an intravenous dose of 0.5 mg/kg of esketamine 10 minutes after induction of general anaesthesia. In addition, esketamine (2 mg/kg) in combination with sufentanil was used for PCIA during 48 hours postoperatively. On the other hand, saline was used as a substitute for esketamine in group C. Cognitive function was evaluated using neuropsychological tests and telephone interview for cognitive status-modified, and symptoms of depression were assessed using Hamilton Depression Rating Scale 17. Compared to Group C, patients in Group E exhibited lower rates of depressive symptoms at 3, 7, and 90 days post-surgery (53.9% vs 67.7%, 26.3% vs 47.9%, and 13.3% vs 28.4%). Group E also showed decreased time for Trail Making Test on days 7 and 90. However, there were no significant differences in the incidence of delirium 1 to 5 days post-surgery or cognitive impairment 90 days post-surgery between the 2 groups (12.1% vs 10.9% and 8.4% vs 9.7%). Intraoperative low-dose esketamine and postoperative low-dose esketamine combined with sufentanil for patient-controlled intravenous analgesia has been shown to improve postoperative analgesia, alleviate postoperative depressive symptoms, and aid in the recovery of social executive ability. However, this approach did not reduce the incidence of postoperative delirium or postoperative cognitive dysfunction.

Effect of perioperative blood transfusion on preoperative haemoglobin levels as a risk factor for long-term outcomes in patients undergoing major noncardiac surgery: a prospective multicentre observational study

Preoperative anaemia and red blood cell (RBC) transfusions are associated with poorer clinical outcomes. It is unknown whether perioperative RBC transfusions mediate the relationship between preoperative haemoglobin levels and postoperative outcomes. This was a prospective observational study among patients aged ≥50 yr undergoing elective major noncardiac surgery from four Swedish hospitals. The co-primary outcomes were 1-yr major adverse cardiovascular and cerebrovascular events (MACCEs) and all-cause mortality. The secondary outcome was a composite of 30-day mortality, MACCEs, acute kidney injury (AKI), pulmonary embolism, anastomotic leak, and postoperative infection. Mediation analyses were conducted with preoperative haemoglobin as the exposure and RBC transfusion as a mediator. Among 1060 patients (mean age 70 [SD 9] yr; 472 [45%] women), 171 patients (16.1%) developed 1-yr MACCEs, and 105 patients (9.9%) died within 1 yr. Preoperative haemoglobin levels were significantly associated with both 1-yr MACCEs (b=-0.015, P=0.041) and all-cause mortality (b=-0.028, P<0.001). Volume of RBC transfusion was not directly associated with the outcomes and did not mediate the relationship between preoperative haemoglobin levels and 1-yr MACCEs (b=-0.001, P=0.451) or all-cause mortality (b=-0.002, P=0.293). For the secondary outcome, RBC transfusions had a significant mediating effect between preoperative haemoglobin and the composite 30-day outcome; however, no direct association was observed (b=0.006, P=0.554). Preoperative haemoglobin levels were significantly associated with 1-yr MACCEs and all-cause mortality. This effect was not mediated by perioperative RBC transfusions. Further research is needed to confirm these findings.

Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative

Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.

Transitions from Aerobic to Anaerobic Metabolism and Oxygen Debt during Elective Major and Emergency Non-Cardiac Surgery.

Intraoperative hemodynamic and metabolic optimization of both the high-risk surgical patients and critically ill patients remains challenging. Reductions in oxygen delivery or increases in oxygen consumption can initiate complex cellular processes precipitating oxygen debt (OXD). This study tested the hypothesis that intraoperative changes in sublingual microcirculatory flow reflect clinically relevant transitions from aerobic to anaerobic metabolism (TRANAM). We included patients undergoing elective major and emergency non-cardiac surgery. Macro- and microcirculatory variables, oxygen extraction, and transitions of metabolism were assessed in both cohorts. In the elective group, OXD was progressively increased over time, with an estimated 2.24 unit increase every 30 min (adjusted p < 0.001). Also, OXD was negatively correlated with central venous pressure (ρ = -0.247, adjusted p = 0.006) and positively correlated with stroke volume variation (ρ = 0.185, adjusted p = 0.041). However, it was not significantly correlated with sublingual microcirculation variables. In the emergency surgery group, OXD increased during the first two intraoperative hours and then gradually decreased until the end of surgery. In that cohort, OXD was positively correlated with diastolic arterial pressure (ρ = 0.338, adjpatients and the critically ill patients remains challengingsted p = 0.015). Also, OXD was negatively correlated with cardiac index (ρ = -0.352, adjusted p = 0.003), Consensus Proportion of Perfused Vessels (PPV) (ρ = -0.438, adjusted p < 0.001), and Consensus PPV (small) (ρ = -0.434, adjusted p < 0.001). TRANAM were evident in both the elective major and emergency non-cardiac surgery cohorts independent of underlying alterations in the sublingual microcirculation.

Correction to: Effect of home-based prehabilitation on objectively measured physical activity in patients undergoing elective major cardiac and non-cardiac surgery. Data from a randomized controlled trial.

Correction to: Effect of home-based prehabilitation on objectively measured physical activity in patients undergoing elective major cardiac and non-cardiac surgery. Data from a randomized controlled trial.

Volatile vs Total intravenous Anaesthesia for major non-cardiac surgery: a pragmatic randomised triaL (VITAL)

BackgroundImproving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety.MethodsA multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia.DiscussionGiven the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments.Trial registrationISRCTN62903453. September 09, 2021.

Effect of home-based prehabilitation on objectively measured physical activity in patients undergoing elective major cardiac and non-cardiac surgery. Data from a randomized controlled trial

Abstract Background Low functional capacity in patients undergoing major elective surgery is associated with postoperative complications. Prehabilitation aims to increase functional capacity by increasing preoperative physical activity. Low functional capacity in patients eligible for major surgery is associated with high age and comorbid burden. In this population, center-based prehabilitation is a barrier for participation. Therefore, we developed a multimodal home-based prehabilitation intervention. Data regarding the effectiveness of a home-based prehabilitation intervention to increase physical activity before surgery is limited. We hypothesize that home-based prehabilitation leads to an increase in physical activity in patients undergoing major cardiac and non-cardiac surgery. Methods We included patients aged over 65 with a proven low functional capacity and/or ventilatory efficiency measured by preoperative cardiopulmonary exercise testing. Patients were randomized to either standard of care or intervention. The intervention group received a home-based prehabilitation intervention 2-4 weeks before surgery. As part of the multimodal intervention, patients were prescribed a walking regimen according to the physical activity guidelines published by the World Health Organization (WHO). Patients were followed-up with weekly telephone calls by a physiotherapist to increase adherence and motivation. All patients were provided a wrist-worn tri-axial accelerometer at the baseline visit. The accelerometer was collected at the ward once the patient entered the hospital for surgery. Physical activity was estimated by calculating the average Euclidean norm minus one (ENMO, milligravity [mg]) per day. Baseline characteristics were tested by Wilcoxon rank-sum test and a linear model for the primary outcome was performed to adjust for confounders. Data analysis was performed using R Studio. Results 37 patients scheduled for cardiac and 62 for non-cardiac surgery were included (Table 1). Mean group difference of daily physical activity levels in non-cardiac surgery patients was 3.01 mg (p = 0.03, 95% CI [0.3, 5.6]). Mean group difference of daily physical activity levels in cardiac surgery patients was 0.27 mg (p = 0.95, 95% CI [-4.1, 5.0]) (Figure 1). Patients undergoing cardiac surgery had higher overall activity levels compared to non-cardiac also when adjusted for age. Conclusion Home-based prehabilitation increases preoperative physical activity levels in patients undergoing major non-cardiac surgery, but not in patients undergoing major cardiac surgery. Higher activity levels in cardiac surgery patients was unexpected, but may be explained by previous inclusion of patients with cardiac diseases in exercise-based rehabilitation and physical activity recommendations at routine cardiac follow-up visits. Table 1 Figure 1

Preoperative N-terminal Pro-B-type Natriuretic Peptide and High-sensitivity Cardiac Troponin T and Outcomes after Major Noncardiac Surgery: A Prospective Cohort Study.

Patients undergoing noncardiac surgery have varying risk of cardiovascular complications. This study evaluated preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T to enhance cardiovascular events prediction for major noncardiac surgery. This prospective cohort study included adult patients with cardiovascular disease or risk factors undergoing elective major noncardiac surgery at four hospitals in China. Blood samples were collected within 30 days before surgery for NT-proBNP and high-sensitivity troponin T (hs-TnT) measurements. The primary outcome was a composite of any cardiovascular events within 30 days after surgery. Logistic regression models were used to assess associations, and the predictive performance was evaluated primarily using area under the receiver operating characteristics curve (AUC) and fraction of new predictive information. Between June 2019 and September 2021, a total of 2,833 patients were included, with 435 (15.4%) experiencing the primary outcome. In the logistic regression model that included clinical variables and both biomarkers, the odds ratio for the primary outcome was 1.68 (95% CI, 1.37 to 2.07) when comparing the 75th percentile to the 25th percentile of NT-proBNP distribution, and 1.91 (95% CI, 1.50 to 2.43) for hs-TnT. Each biomarker enhanced model discrimination beyond clinical predictors, with a change in AUC of 0.028 for NT-proBNP and 0.029 for high-sensitivity cardiac troponin T, and a fraction of new information of 0.164 and 0.149, respectively. The model combining both biomarkers demonstrated the best discrimination, with a change in AUC of 0.042 and a fraction of new information of 0.219. Preoperative NT-proBNP and hs-TnT both improved the prediction for cardiovascular events after noncardiac surgery in addition to clinical evaluation, with their combination providing maximal predictive information.

Metabolic change in monocytes and postoperative morbidity after major abdominal surgery in elderly patients: A prospective cohort study

Metabolic change in monocytes and postoperative morbidity after major abdominal surgery in elderly patients: A prospective cohort study

Postoperative haemoglobin and anaemia-associated ischaemic events after major noncardiac surgery: A sex-stratified cohort study

To determine the sex-specific associations between postoperative haemoglobin and mortality or complications reflecting ischaemia or inadequate oxygen supply after major noncardiac surgery. A retrospective cohort study with prospective validation. A large university hospital health system in China. Men and women undergoing elective major noncardiac surgery. The primary exposure was nadir haemoglobin within 48h after surgery. The outcome of interest was a composite of postoperative mortality or ischaemic events including myocardial injury, acute kidney injury and stroke within hospitalisation. The study included 26,049 patients (15,757 men and 10,292 women). Low postoperative haemoglobin was a strong predictor of the composite outcome in both sexes, with the risk progressively increasing as the nadir haemoglobin concentration dropped below 130gl-1 in men and 120gl-1 in women (adjusted odds ratio [OR] 1.43, 95% CI 1.37-1.50 in men, and OR 1.45, 95% CI 1.35-1.55 in women, per 10gl-1 decrease in postoperative nadir haemoglobin). Above these sex-specific thresholds, the change of nadir haemoglobin was no longer associated with odds of the composite outcome in either men or women. There was no significant interaction between patient sex and the association between postoperative haemoglobin and the composite outcome (Pinteraction=0.673). Validation in an external prospective cohort (n=2120) with systematic postoperative troponin and creatinine measurement confirmed our findings. Postoperative haemoglobin levels following major noncardiac surgery were nonlinearly associated with ischaemic complications or mortality, without any clinically important interaction with patient sex.

Plasma SOMAmer proteomics of postoperative delirium.

Postoperative delirium is prevalent in older adults and has been shown to increase the risk of long-term cognitive decline. Plasma biomarkers to identify the risk for postoperative delirium and the risk of Alzheimer's disease and related dementias are needed. This biomarker discovery case-control study aimed to identify plasma biomarkers associated with postoperative delirium. Patients aged ≥65 years undergoing major elective noncardiac surgery were recruited. The preoperative plasma proteome was interrogated with SOMAmer-based technology targeting 1433 biomarkers. In 40 patients (20 with vs. 20 without postoperative delirium), a preoperative panel of 12 biomarkers discriminated patients with postoperative delirium with an accuracy of 97.5%. The final model of five biomarkers delivered a leave-one-out cross-validation accuracy of 80%. Represented biological pathways included lysosomal and immune response functions. In older patients who have undergone major surgery, plasma SOMAmer proteomics may provide a relatively non-invasive benchmark to identify biomarkers associated with postoperative delirium.

Postoperative myocardial injury phenotypes and self-reported disability in patients undergoing noncardiac surgery: a multicentre observational study

Postoperative myocardial injury (PMI) comprises a spectrum of mechanisms resulting in troponin release. The impact of different PMI phenotypes on postoperative disability remains unknown. This was a multicentre prospective cohort study including patients aged ≥50 yr undergoing elective major noncardiac surgery. Patients were stratified in five groups based on the occurrence of PMI and clinical information on postoperative adverse events: PMI classified as myocardial infarction (MI; according to fourth definition), PMI plus adverse event other than MI, clinically silent PMI (PMI without adverse events), adverse events without PMI, and neither PMI nor an adverse event (reference). The primary endpoint was 6-month self-reported disability (assessed by WHO Disability Assessment Schedule 2.0 [WHODAS]). Disability-free survival was defined as WHODAS ≤16%. We included 888 patients of mean age 69 (range 53-91) yr, of which 356 (40%) were women; 151 (17%) patients experienced PMI, and 625 (71%) experienced 6-month disability-free survival. Patients with PMI, regardless of its phenotype, had higher preoperative disability scores than patients without PMI (difference in WHODAS; β: 3.3, 95% confidence interval [CI]: 0.5-6.2), but scores remained stable after surgery (β: 1.2, 95% CI: -3.2-5.6). Before surgery, patients with MI (n=36, 4%) were more disabled compared with patients without PMI and no adverse events (β: 5.5, 95% CI: 0.3-10.8). At 6 months, patients with MI and patients without PMI but with adverse events worsened in disability score (β: 11.2, 95% CI: 2.3-20.2; β: 8.1, 95% CI: 3.0-13.2, respectively). Patients with clinically silent PMI did not change in disability score at 6 months (β: 1.39, 95% CI: -4.50-7.29, P=0.642). Although patients with postoperative myocardial injury had higher preoperative self-reported disability, disability scores did not change at 6 months after surgery. However, patients experiencing myocardial infarction worsened in disability score after surgery.

The impact of cognitive reserve on delayed neurocognitive recovery after major non-cardiac surgery: an exploratory substudy

IntroductionDelayed neurocognitive recovery is a common and severe complication after surgery and anesthesia with an adverse impact on daily living, morbidity, and mortality. High cognitive reserve may mitigate the development of delayed neurocognitive recovery, however, supporting data is lacking. We aimed to assess the association between cognitive reserve and delayed neurocognitive recovery in the early postoperative period.MethodsThis is a substudy of two prospective observational studies. Adult patients undergoing elective major non-cardiac surgery, who were fluent in German, were eligible for study participation. Patients with any pre-existing central nervous system disorders were excluded. Cognitive reserve was assessed using the Cognitive Reserve Index questionnaire. Delayed neurocognitive recovery was defined as a decline in cognitive function compared with baseline assessments and was evaluated with a battery of neuropsychological tests on the day of hospital admission and between day three post procedure and before hospital discharge.ResultsA total of 67 patients with a median age of 67 [IQR: (63–73)] years were included in our analysis. We found delayed neurocognitive recovery in 22.4% of patients. There was a significant association between Cognitive Reserve Index questionnaire total score and the occurrence of delayed neurocognitive recovery in the early postoperative period [OR = 0.938, (95% CI, 0.891; 0.988), p = 0.015].ConclusionHigher cognitive reserve in elderly patients undergoing major non-cardiac surgery decreases the risk for subsequent delayed neurocognitive recovery in the early postoperative period.

Sex-Specific Associations Between Preoperative Hemoglobin and Outcomes After Major Noncardiac Surgery: A Retrospective Cohort Study.

Preoperative anemia is an established risk factor for morbidity and mortality after surgery. Men and women have different hemoglobin concentrations and are at different risks of postoperative complications. However, sex-stratified analysis on the association between preoperative hemoglobin and outcomes after noncardiac surgery has been limited in previous studies. This was a retrospective cohort study of adult patients undergoing elective major noncardiac surgery in a large academic hospital. The primary outcome was a collapsed composite of postoperative mortality or cardiovascular, renal, pulmonary, and infectious complications during hospitalization. Sex-specific univariable associations between preoperative hemoglobin and the composite outcome were visualized using moving-average and cubic-spline smoothing plots. Multivariable regression models adjusting for patient demographics, comorbidities, medication uses, laboratory tests, and anesthesia/surgery features were used to estimate confounder-adjusted associations. Restricted cubic spline and piecewise linear functions were used to assess the possible nonlinear relationships between preoperative hemoglobin and the outcomes. The interaction between patient sex and hemoglobin on outcomes was assessed using a likelihood-ratio test. We included 22,550 patients, with 6.7% (622 of 9268) of women and 9.7% (1293 of 13,282) of men developing the primary outcome. Lower preoperative hemoglobin was associated with a higher incidence of the primary composite outcome in both men and women. Nonlinearity for the association was not statistically significant in either women (P = .539) or men (P = .165). The multivariable-adjusted odds ratios per 1 g/dL increase in hemoglobin were 0.93 (95% confidence interval [CI], 0.87-0.98; P = .013) for women and 0.94 (95% CI, 0.90-0.97; P < .001) for men, with no interaction by sex (Pinteraction = .923). No hemoglobin thresholds were confirmed at which the associations with the primary outcome changed significantly. Low preoperative hemoglobin was associated with a higher risk of complications or mortality after elective noncardiac surgery in both men and women. No differences in the strength of associations between sexes were found. Further studies are needed to assess whether these associations are linear or there are sex-specific thresholds of preoperative hemoglobin concentrations below which postoperative risks begin to increase.

Peri-Operative Wearables in Elder Recover after Surgery (POWERS) study: a protocol for a multicentre, prospective cohort study to evaluate perioperative activity with postoperative disability in older adults after non-cardiac surgery

IntroductionThe ageing population has led to an increasing proportion of surgical patients with greater frailty and comorbidity. Complications and mortality within 30 days of a surgical procedure are often used...

Impact of Postoperative Dexmedetomidine Infusion on Incidence of Delirium in Elderly Patients Undergoing Major Elective Noncardiac Surgery: a Randomized Clinical Trial [Retraction

[This retracts the article DOI: 10.2147/DDDT.S208703.].

Psychological Distress After Inpatient Noncardiac Surgery: A Secondary Analysis of the Measurement of Exercise Tolerance Before Surgery Prospective Cohort Study.

To describe the incidence and natural progression of psychological distress after major surgery. The recovery process after surgery imposes physical and mental burdens that put patients at risk of psychological distress. Understanding the natural course of psychological distress after surgery is critical to supporting the timely and tailored management of high-risk individuals. We conducted a secondary analysis of the "Measurement of Exercise Tolerance before Surgery" multicentre cohort study (Canada, Australia, New Zealand, and the UK). Measurement of Exercise Tolerance before Surgery recruited adult participants (≥40 years) undergoing elective inpatient noncardiac surgery and followed them for 1 year. The primary outcome was the severity of psychological distress measured using the anxiety-depression item of EQ-5D-3L. We used cumulative link mixed models to characterize the time trajectory of psychological distress among relevant patient subgroups. We also explored potential predictors of severe and/or worsened psychological distress at 1 year using multivariable logistic regression models. Of 1546 participants, moderate-to-severe psychological distress was reported by 32.6% of participants before surgery, 27.3% at 30 days after surgery, and 26.2% at 1 year after surgery. Psychological distress appeared to improve over time among females [odds ratio (OR): 0.80, 95% CI: 0.65-0.95] and patients undergoing orthopedic procedures (OR: 0.73, 95% CI: 0.55-0.91), but not among males (OR: 0.87, 95% CI: 0.87-1.07) or patients undergoing nonorthopedic procedures (OR: 0.95, 95% CI: 0.87-1.04). Among the average middle-aged adult, there were no time-related changes (OR: 0.94, 97% CI: 0.75-1.13), whereas the young-old (OR: 0.89, 95% CI: 0.79-0.99) and middle-old (OR: 0.87, 95% CI: 0.73-1.01) had small improvements. Predictors of severe and/or worsened psychological distress at 1 year were younger age, poor self-reported functional capacity, smoking history, and undergoing open surgery. One-third of adults experience moderate to severe psychological distress before major elective noncardiac surgery. This distress tends to persist or worsen over time among select patient subgroups.

Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: a European multicentre prospective observational registry (EU HYPROTECT)

Intraoperative hypotension is associated with organ injury. Current intraoperative arterial pressure management is mainly reactive. Predictive haemodynamic monitoring may help clinicians reduce intraoperative hypotension. The Acumen™ Hypotension Prediction Index software (HPI-software) (Edwards Lifesciences, Irvine, CA, USA) was developed to predict hypotension. We built up the European multicentre, prospective, observational EU HYPROTECT Registry to describe the incidence, duration, and severity of intraoperative hypotension when using HPI-software monitoring in patients having noncardiac surgery. We enrolled 749 patients having elective major noncardiac surgery in 12 medical centres in five European countries. Patients were monitored using the HPI-software. We quantified hypotension using the time-weighted average MAP <65 mm Hg (primary endpoint), the proportion of patients with at least one ≥1 min episode of a MAP <65 mm Hg, the number of ≥1 min episodes of a MAP <65 mm Hg, and duration patients spent below a MAP of 65 mm Hg. We included 702 patients in the final analysis. The median time-weighted average MAP <65 mm Hg was 0.03 (0.00-0.20) mm Hg. In addition, 285 patients (41%) had no ≥1 min episode of a MAP <65 mm Hg; 417 patients (59%) had at least one. The median number of ≥1 min episodes of a MAP <65 mm Hg was 1 (0-3). Patients spent a median of 2 (0-9) min below a MAP of 65 mm Hg. The median time-weighted average MAP <65 mm Hg was very low in patients in this registry. This suggests that using HPI-software monitoring may help reduce the duration and severity of intraoperative hypotension in patients having noncardiac surgery.

Association between mean arterial pressure and sublingual microcirculation during major non-cardiac surgery: Post hoc analysis of a prospective cohort.

To test the hypothesis that there is an association between mean arterial pressure (MAP) and sublingual perfusion during major surgery, and perhaps an identifiable harm threshold. This post hoc analysis of a prospective cohort included patients who had elective major non-cardiac surgery with a duration of ≥2 h under general anesthesia. We assessed sublingual microcirculation every 30min using SDF+ imaging and determined the De Backer score, Consensus Proportion of Perfused Vessels (Consensus PPV), and the Consensus PPV (small). Our primary outcome was the relationship between MAP and sublingual perfusion which was evaluated with linear mixed effects modeling. A total of 100 patients were included, with MAP ranging between 65 mmHg and 120 mmHg during anesthesia and surgery. Over a range of intraoperative MAPs between 65 and 120 mmHg, there were no meaningful associations between blood pressure and various measures of sublingual perfusion. There were also no meaningful changes in microcirculatory flow over 4.5 h of surgery. In patients having elective major non-cardiac surgery with general anesthesia, sublingual microcirculation is well maintained when MAP ranges between 65 and 120 mmHg. It remains possible that sublingual perfusion will be a useful marker of tissue perfusion when MAP is lower than 65 mmHg.

Complications Following Elective Major Noncardiac Surgery Among Patients With Prior SARS-CoV-2 Infection

There is an urgent need for evidence to inform preoperative risk assessment for the millions of people who have had SARS-CoV-2 infection and are awaiting elective surgery, which is critical to surgical care planning and informed consent. To assess the association of prior SARS-CoV-2 infection with death, major adverse cardiovascular events, and rehospitalization after elective major noncardiac surgery. This population-based cohort study included adults who had received a polymerase chain reaction test for SARS-CoV-2 infection within 6 months prior to elective major noncardiac surgery in Ontario, Canada, between April 2020 and October 2021, with 30 days follow-up. Positive SARS-CoV-2 polymerase chain reaction test result. The main outcome was the composite of death, major adverse cardiovascular events, and all-cause rehospitalization within 30 days after surgery. Of 71 144 patients who underwent elective major noncardiac surgery (median age, 66 years [IQR, 57-73 years]; 59.8% female), 960 had prior SARS-CoV-2 infection (1.3%) and 70 184 had negative test results (98.7%). Prior infection was not associated with the composite risk of death, major adverse cardiovascular events, and rehospitalization within 30 days of elective major noncardiac surgery (5.3% absolute event rate [n = 3770]; 960 patients with a positive test result; adjusted relative risk [aRR], 0.91; 95% CI, 0.68-1.21). There was also no association between prior infection with SARS-CoV-2 and postoperative outcomes when the time between infection and surgery was less than 4 weeks (aRR, 1.15; 95% CI, 0.64-2.09) or less than 7 weeks (aRR, 0.95; 95% CI, 0.56-1.61) and among those who were previously vaccinated (aRR, 0.81; 95% CI, 0.52-1.26). In this study, prior infection with SARS-CoV-2 was not associated with death, major adverse cardiovascular events, or rehospitalization following elective major noncardiac surgery, although low event rates and wide 95% CIs do not preclude a potentially meaningful increase in overall risk.