Publications by authors named "Rupert M Pearse"

114 Publications

Acute kidney injury in COVID-19: multicentre prospective analysis of registry data.

Clin Kidney J 2021 Nov 27;14(11):2356-2364. Epub 2021 Mar 27.

William Harvey Research Institute, Queen Mary University of London, London, UK.

Background: Acute kidney injury (AKI) is a common and important complication of coronavirus disease 2019 (COVID-19). Further characterization is required to reduce both short- and long-term adverse outcomes.

Methods: We examined registry data including adults with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to five London Hospitals from 1 January to 14 May 2020. Prior end-stage kidney disease was excluded. Early AKI was defined by Kidney Disease: Improving Global Outcomes creatinine criteria within 7 days of admission. Independent associations of AKI and survival were examined in multivariable analysis. Results are given as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals.

Results: Among 1855 admissions, 455 patients (24.5%) developed early AKI: 200 (44.0%) Stage 1, 90 (19.8%) Stage 2 and 165 (36.3%) Stage 3 (74 receiving renal replacement therapy). The strongest risk factor for AKI was high C-reactive protein [OR 3.35 (2.53-4.47), P < 0.001]. Death within 30 days occurred in 242 (53.2%) with AKI compared with 255 (18.2%) without. In multivariable analysis, increasing severity of AKI was incrementally associated with higher mortality: Stage 3 [HR 3.93 (3.04-5.08), P < 0.001]. In 333 patients with AKI surviving to Day 7, 134 (40.2%) recovered, 47 (14.1%) recovered then relapsed and 152 (45.6%) had persistent AKI at Day 7; an additional 105 (8.2%) patients developed AKI after Day 7. Persistent AKI was strongly associated with adjusted mortality at 90 days [OR 7.57 (4.50-12.89), P < 0.001].

Conclusions: AKI affected one in four hospital in-patients with COVID-19 and significantly increased mortality. Timing and recovery of COVID-19 AKI is a key determinant of outcome.
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http://dx.doi.org/10.1093/ckj/sfab071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083651PMC
November 2021

Contemporary use of antimicrobial prophylaxis for surgical patients: An observational cohort study.

Eur J Anaesthesiol 2021 11 3. Epub 2021 Nov 3.

From the William Harvey Research Institute, Queen Mary University of London, London (PD, AP, RMP, TEFA), University Hospitals Birmingham NHS Foundation Trust, Birmingham (WR), and Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK, Acute, Critical & Perioperative Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK (MRE).

Background: Antimicrobial prophylaxis is commonly used to prevent surgical site infection (SSI), despite concerns of overuse leading to antimicrobial resistance. However, it is unclear how often antimicrobials are used and whether guidelines are followed.

Objectives: To describe contemporary clinical practice for antimicrobial prophylaxis including guideline compliance, the rate of postoperative infection and associated side effects.

Design: A prospective, multicentre, observational cohort study.

Setting: Twelve United Kingdom National Health Service hospitals.

Participants: One thousand one hundred and sixteen patients, aged at least 18 years undergoing specific colorectal, obstetric, gynaecological, urological or orthopaedic surgical procedures.

Exposure: Compliance with guidelines for antimicrobial prophylaxis.

Outcomes: The primary outcome was SSI within 30 days after surgery. Secondary outcomes were number of doses of antimicrobials for prophylaxis and to treat infection, incidence of antimicrobial-related side effects and mortality within 30 days after surgery. Data are presented as number with percentage (%) or median with interquartile range [IQR]. Results of logistic regression analyses are presented as odds ratio/rate ratio (OR) with 95% confidence intervals (95% CIs).

Results: One thousand one hundred and two out of 1106 (99.6%) patients received antimicrobial prophylaxis, which was compliant with local guidelines in 929 out of 1102 (84.3%) cases. Two thousand one hundred and sixty-nine out of 5128 (42.3%) doses of antimicrobials were administered as prophylaxis (median 1 [1 to 2] dose) and 2959 out of 5128 (57.7%) were administered to treat an infection (median 21 [11 to 28] doses). Fifty-six patients (5.2%) developed SSI. Antimicrobial prophylaxis administered according to local guidelines was not associated with a lower incidence of SSI compared with administration outside guidelines [OR 0.90 (0.35 to 2.29); P = 0.823]. Twenty-three out of 1072 (2.2%) patients experienced a side effect of antimicrobial therapy. Seven out of 1082 (0.6%) patients died. The median hospital stay was 3 [1 to 5] days.

Conclusion: Antimicrobial prophylaxis was administered for almost all the surgical procedures under investigation. However, this was not always compliant with guidelines. Further research is required to determine whether the amount of prophylactic antimicrobials could be safely and effectively reduced without increasing the incidence of SSI.
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http://dx.doi.org/10.1097/EJA.0000000000001619DOI Listing
November 2021

Ethnicity and acute hospital admissions: Multi-center analysis of routine hospital data.

EClinicalMedicine 2021 Sep 19;39:101077. Epub 2021 Aug 19.

William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom.

The effects of ethnic and social inequalities on patient outcomes in acute healthcare remain poorly understood. Prospectively-defined analysis of registry data from four acute NHS hospitals in east London including all patients ≥ 18 years with a first emergency admission between 1st January 2013 and 31st December 2018. We calculated adjusted one-year mortality risk using logistic regression. Results are presented as n (%), median (IQR), and odds ratios (OR) with 95% confidence intervals. We included 203,182 patients. 43,101 (21%) patients described themselves as Asian, 21,388 (10.5%) Black, 2,982 (1.4%) Mixed, 13,946 (6.8%) Other ethnicity, and 100,065 (49%) White. We excluded 21,700 (10.7%) patients with undisclosed ethnicity. 16,054 (7.9%) patients died within one year. Non-white patients were younger (Asian: 43 [31-62] years; Black: 48 [33-63] years; Mixed 36 [26-52] years) than White patients (55 [35-75] years), with a higher incidence of comorbid disease. In each age-group, non-white patients were more likely to be admitted to hospital. This effect was greatest in the ≥ 80 years age-group (32% non-white admitted to hospital versus 23% non-white in community population). Deprivation was associated with increased mortality in all ethnic groups (OR 1.41 [1.33-1.50];  < 0.001). However, when adjusted for age, Asian (0.69 [0.66-0.73],  < 0.0001) and Black patients (0.79 [0.74-0.85];  < 0.0001) experienced a lower mortality risk than White patients. Ethnic and social disparities are associated with important differences in acute health outcomes. However, these differences are masked by statistical adjustment because patients from ethnic minorities present at a younger age. None.
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http://dx.doi.org/10.1016/j.eclinm.2021.101077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8478677PMC
September 2021

Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study.

Br J Anaesth 2021 08 18;127(2):196-204. Epub 2021 Jun 18.

Reconstructive Surgery & Regenerative Medicine Research Centre, Institute of Life Sciences, Swansea University Medical School, Swansea, UK; Welsh Centre for Burns and Plastics, Morriston Hospital, Swansea, UK.

Background: A significant proportion of healthcare resource has been diverted to the care of those with COVID-19. This study reports the volume of surgical activity and the number of cancelled surgical procedures during the COVID-19 pandemic.

Methods: We used hospital episode statistics for all adult patients undergoing surgery between January 1, 2020 and December 31, 2020 in England and Wales. We identified surgical procedures using a previously published list of procedure codes. Procedures were stratified by urgency of surgery as defined by NHS England. We calculated the deficit of surgical activity by comparing the expected number of procedures from 2016 to 2019 with the actual number of procedures in 2020. Using a linear regression model, we calculated the expected cumulative number of cancelled procedures by December 31, 2021.

Results: The total number of surgical procedures carried out in England and Wales in 2020 was 3 102 674 compared with the predicted number of 4 671 338 (95% confidence interval [CI]: 4 218 740-5 123 932). This represents a 33.6% reduction in the national volume of surgical activity. There were 763 730 emergency surgical procedures (13.4% reduction) compared with 2 338 944 elective surgical procedures (38.6% reduction). The cumulative number of cancelled or postponed procedures was 1 568 664 (95% CI: 1 116 066-2 021 258). We estimate that this will increase to 2 358 420 (95% CI: 1 667 587-3 100 808) up to December 31, 2021.

Conclusions: The volume of surgical activity in England and Wales was reduced by 33.6% in 2020, resulting in more than 1.5 million cancelled operations. This deficit will continue to grow in 2021.
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http://dx.doi.org/10.1016/j.bja.2021.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277602PMC
August 2021

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative.

Nat Rev Nephrol 2021 09 11;17(9):605-618. Epub 2021 May 11.

Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.

Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.
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http://dx.doi.org/10.1038/s41581-021-00418-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367817PMC
September 2021

Preprints in perioperative medicine: immediacy for the greater good.

Br J Anaesth 2021 05 29;126(5):915-918. Epub 2021 Mar 29.

Departments of Anesthesiology and Pharmacology, Weill Cornell Medicine, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2021.02.024DOI Listing
May 2021

Emergency hospital admissions associated with non-communicable diseases 1998-2018 in England, Wales and Scotland: an ecological study.

Clin Med (Lond) 2021 03;21(2):e179-e185

The Royal London Hospital, London, UK and William Harvey Research Institute, London, UK.

Background: Non-communicable diseases (NCDs) are increasingly prevalent and were responsible for 40.5 million deaths (71%) globally in 2016. We examined the number of NCD-related emergency hospital admissions during the years 1998 to 2018 in the UK.

Methods: Demographic features for those admitted as an emergency with NCDs as their primary diagnosis were collated for all admissions in England, Wales and Scotland. NCDs recorded as secondary diagnoses for all admissions in England from 2012 to 2018 were additionally recorded.

Results: We identified 120,662,155 emergency episodes of care. From 1998 to 2018 there was an increase from 1,416,233 to 1,892,501 in annual emergency admissions due to NCDs. This, however, represented a fall in the proportion of NCD among all emergency admissions, from 33.4% to 26.9%. Mean age of all patients admitted increased from 46.3 to 53.8 years.

Conclusion: Despite a fall in proportion of NCD admissions, the population acutely admitted to hospital was increasingly elderly and increasingly comorbid.
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http://dx.doi.org/10.7861/clinmed.2020-0830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002810PMC
March 2021

The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients - a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study.

BMC Anesthesiol 2021 03 19;21(1):84. Epub 2021 Mar 19.

Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.

Background: It is uncertain whether the association of the intraoperative driving pressure (ΔP) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time-weighted average ΔP (ΔP) with PPCs. We also tested the association of ΔP with intraoperative adverse events.

Methods: Posthoc retrospective propensity score-weighted cohort analysis of patients undergoing open or closed abdominal surgery in the 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events.

Results: The analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. ΔP was lower in open abdominal surgery patients, but ΔP was not different between groups. The association of ΔP with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P <  0.001 versus 1.05 [95%CI 1.05 to 1.05], P <  0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P <  0.001). The association of ΔP with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12- to 1.14], P <  0.001 versus 1.07 [95%CI 1.05 to 1.10], P <  0.001; risk difference 0.05 [95%CI 0.030.07], P <  0.001).

Conclusions: ΔP is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery.

Trial Registration: LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223 ).
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http://dx.doi.org/10.1186/s12871-021-01268-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977277PMC
March 2021

Current use of inotropes in circulatory shock.

Ann Intensive Care 2021 Jan 29;11(1):21. Epub 2021 Jan 29.

Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.

Background: Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock.

Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions.

Results: A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81-90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement).

Conclusion: Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.
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http://dx.doi.org/10.1186/s13613-021-00806-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846624PMC
January 2021

Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study.

BMJ Open 2021 01 17;11(1):e042140. Epub 2021 Jan 17.

William Harvey Research Institute, Queen Mary University of London, London, UK, EC1M 6BQ.

Objective: To describe outcomes within different ethnic groups of a cohort of hospitalised patients with confirmed COVID-19 infection. To quantify and describe the impact of a number of prognostic factors, including frailty and inflammatory markers.

Setting: Five acute National Health Service Hospitals in east London.

Design: Prospectively defined observational study using registry data.

Participants: 1737 patients aged 16 years or over admitted to hospital with confirmed COVID-19 infection between 1 January and 13 May 2020.

Main Outcome Measures: The primary outcome was 30-day mortality from time of first hospital admission with COVID-19 diagnosis during or prior to admission. Secondary outcomes were 90-day mortality, intensive care unit (ICU) admission, ICU and hospital length of stay and type and duration of organ support. Multivariable survival analyses were adjusted for potential confounders.

Results: 1737 were included in our analysis of whom 511 had died by day 30 (29%). 538 (31%) were from Asian, 340 (20%) black and 707 (40%) white backgrounds. Compared with white patients, those from minority ethnic backgrounds were younger, with differing comorbidity profiles and less frailty. Asian and black patients were more likely to be admitted to ICU and to receive invasive ventilation (OR 1.54, (95% CI 1.06 to 2.23); p=0.023 and OR 1.80 (95% CI 1.20 to 2.71); p=0.005, respectively). After adjustment for age and sex, patients from Asian (HR 1.49 (95% CI 1.19 to 1.86); p<0.001) and black (HR 1.30 (95% CI 1.02 to 1.65); p=0.036) backgrounds were more likely to die. These findings persisted across a range of risk factor-adjusted analyses accounting for major comorbidities, obesity, smoking, frailty and ABO blood group.

Conclusions: Patients from Asian and black backgrounds had higher mortality from COVID-19 infection despite controlling for all previously identified confounders and frailty. Higher rates of invasive ventilation indicate greater acute disease severity. Our analyses suggest that patients of Asian and black backgrounds suffered disproportionate rates of premature death from COVID-19.
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http://dx.doi.org/10.1136/bmjopen-2020-042140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813387PMC
January 2021

Mode of blood pressure monitoring and morbidity after noncardiac surgery: A prospective multicentre observational cohort study.

Eur J Anaesthesiol 2021 05;38(5):468-476

From the Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, EC1 M 6BQ (Abbott, Pearse, Ackland), and Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK (Howell).

Background: Control of blood pressure remains a key goal of peri-operative care, because hypotension is associated with adverse outcomes after surgery.

Objectives: We explored whether increased vigilance afforded by intra-arterial blood pressure monitoring may be associated with less morbidity after surgery.

Design: A prospective observational cohort study.

Setting: Four UK secondary care hospitals.

Patients: A total of 4342 patients ≥45 years who underwent noncardiac surgery.

Methods: We compared outcome of patients who received peri-operative intra-arterial blood pressure monitoring with those whose blood pressure was measured noninvasively.

Outcomes: The primary outcome was peri-operative myocardial injury (high-sensitivity troponin-T ≥ 15 ng l-1 within 72 h after surgery), compared between patients who received intra-arterial versus noninvasive blood pressure monitoring. Secondary outcomes were morbidity within 72 h of surgery (postoperative morbidity survey), and vasopressor and fluid therapy. Multivariable logistic regression analysis explored associations between morbidity and age, sex, location of postoperative care, mode of blood pressure/haemodynamic monitoring and Revised Cardiac Risk Index.

Results: Intra-arterial monitoring was used in 1137/4342 (26.2%) patients. Myocardial injury occurred in 440/1137 (38.7%) patients with intra-arterial monitoring compared with 824/3205 (25.7%) with noninvasive monitoring [OR 1.82 (95% CI 1.58 to 2.11), P < 0.001]. Intra-arterial monitoring remained associated with myocardial injury when adjusted for potentially confounding variables [adjusted OR 1.56 (1.29 to 1.89), P < 0.001). The results were similar for planned ICU versus ward postoperative care.

Conclusions: Intra-arterial monitoring is associated with greater risk of morbidity after noncardiac surgery, after controlling for surgical and patient factors. These data provide useful insights into the design of a definitive monitoring trial.
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http://dx.doi.org/10.1097/EJA.0000000000001443DOI Listing
May 2021

The effects of preoperative moderate to severe anaemia on length of hospital stay: A propensity score-matched analysis in non-cardiac surgery patients.

Eur J Anaesthesiol 2021 06;38(6):571-581

From the Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands (CSE-B, CB), Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands (SNT-H, AS-N, JM-B, MJS), Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands (SNT-H, MW-H), Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paolo, Brazil (AS-N), Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden (GH), Montpellier University Hospital, Saint Eloi Intensive Care Unit and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France (SJ), Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria (MH, WS), Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK (GH-M), Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Bostan, MA, USA (MF-VM), Queen Mary University of London, London, UK (RM-P), Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany (CP), Department of Biotechnology and Sciences of Life, ASST Sette Laghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (PS), Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany (HW), Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany (MGD-A), Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy (PP), IRCCS Ospedale Policlinico San Martino, Genova, Italy (PP), Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand (MJS), Nuffield Department of Medicine, University of Oxford, Oxford, UK (MJS).

Background: Anaemia is frequently recorded during preoperative screening and has been suggested to affect outcomes after surgery negatively.

Objectives: The objectives were to assess the frequency of moderate to severe anaemia and its association with length of hospital stay.

Design: Post hoc analysis of the international observational prospective 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study.

Patients And Setting: The current analysis included adult patients requiring general anaesthesia for non-cardiac surgery. Preoperative anaemia was defined as a haemoglobin concentration of 11 g dl-1 or lower, thus including moderate and severe anaemia according to World Health Organisation criteria.

Main Outcome Measures: The primary outcome was length of hospital stay. Secondary outcomes included hospital mortality, intra-operative adverse events and postoperative pulmonary complications (PPCs).

Results: Haemoglobin concentrations were available for 8264 of 9864 patients. Preoperative moderate to severe anaemia was present in 7.7% of patients. Multivariable analysis showed that preoperative moderate to severe anaemia was associated with an increased length of hospital stay with a mean difference of 1.3 ((95% CI 0.8 to 1.8) days; P < .001). In the propensity-matched analysis, this association remained present, median 4.0 [IQR 1.0 to 5.0] vs. 2.0 [IQR 0.0 to 5.0] days, P = .001. Multivariable analysis showed an increased in-hospital mortality (OR 2.9 (95% CI 1.1 to 7.5); P  = .029), and higher incidences of intra-operative hypotension (36.3 vs. 25.3%; P < .001) and PPCs (17.1 vs. 10.5%; P = .001) in moderately to severely anaemic patients. However, this was not confirmed in the propensity score-matched analysis.

Conclusions: In this international cohort of non-cardiac surgical patients, preoperative moderate to severe anaemia was associated with a longer duration of hospital stay but not increased intra-operative complications, PPCs or in-hospital mortality.

Trial Registration: The LAS VEGAS study was registered at Clinicaltrials.gov, NCT01601223.
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http://dx.doi.org/10.1097/EJA.0000000000001412DOI Listing
June 2021

Socioeconomic deprivation and long-term outcomes after elective surgery: analysis of prospective data from two observational studies.

Br J Anaesth 2021 Mar 18;126(3):642-651. Epub 2020 Nov 18.

Centre for Perioperative Medicine, Department of Targeted Intervention, UK; Surgical Outcomes Research Centre, University College London, London, UK; Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK.

Background: Socioeconomic deprivation is associated with health inequalities. We explored relationships between socioeconomic group and outcomes after elective surgery in the UK National Health Service (NHS).

Methods: We combined data from two observational studies in 115 NHS hospitals and determined socioeconomic group using the Index of Multiple Deprivation (IMD) quintiles based on place of residence. Postoperative complications and 3-yr survival were assessed using logistic and Cox regression. Univariate analyses were adjusted for age differences between IMD quintiles. Multivariable analyses were used to account for other baseline risk factors including sex and comorbid disease. Results are reported as n (%), hazard ratios (HR) or odds ratios (OR) with 95% confidence intervals.

Results: Postoperative complications developed in 971/9051 patients (10.7%) and 1597/9043 patients (17.7%) died within 3 yr. Complication rates increased with deprivation (reference group least-deprived IMD5): IMD1 (OR=1.44 [1.17-1.78]; P<0.001), IMD2 (OR=1.38 [1.12-1.70]; P<0.01), IMD3 (OR=1.09 [0.88-1.35]: P=0.44), IMD4 (OR=0.89 [0.71-1.11]; P=0.30). More patients from the most deprived quintile died (IMD1) (n=349, 18.8%) compared with the least deprived (IMD5) (n=297, 15.9%) with a trend across the socioeconomic spectrum (P=0.01). After age adjustment, patients in the most deprived areas experienced reduced 3-yr survival: IMD1 (HR=1.43 [1.23-1.67]; P<0.0001), IMD2 (HR=1.35 [1.15-1.57]; P<0.001), IMD3 (HR=1.04 [0.89-1.23]; P=0.60), and IMD4 (HR=1.11 [0.95-1.30]; P=0.19). This finding persisted in risk-adjusted analyses. Increased complication rates only partially explained this reduced survival.

Conclusions: Socioeconomic deprivation is associated with worse long-term outcomes after elective surgery. This risk factor should be considered when planning perioperative care for patients from deprived areas.
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http://dx.doi.org/10.1016/j.bja.2020.10.019DOI Listing
March 2021

Can we safely continue to offer surgical treatments during the COVID-19 pandemic?

BMJ Qual Saf 2021 04 20;30(4):268-270. Epub 2020 Nov 20.

Critical Care & Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK

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http://dx.doi.org/10.1136/bmjqs-2020-012544DOI Listing
April 2021

MicroRNA signatures of perioperative myocardial injury after elective noncardiac surgery: a prospective observational mechanistic cohort study.

Br J Anaesth 2020 11 24;125(5):661-671. Epub 2020 Jul 24.

Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK. Electronic address:

Background: Elevated plasma or serum troponin, indicating perioperative myocardial injury (PMI), is common after noncardiac surgery. However, underlying mechanisms remain unclear. Acute coronary syndrome (ACS) is associated with the early appearance of circulating microRNAs, which regulate post-translational gene expression. We hypothesised that if PMI and ACS share pathophysiological mechanisms, common microRNA signatures should be evident.

Methods: We performed a nested case control study of samples obtained before and after noncardiac surgery from patients enrolled in two prospective observational studies of PMI (postoperative troponin I/T>99th centile). In cohort one, serum microRNAs were compared between patients with or without PMI, matched for age, gender, and comorbidity. Real-time polymerase chain reaction quantified (qRT-PCR) relative microRNA expression (cycle quantification [Cq] threshold <37) before and after surgery for microRNA signatures associated with ACS, blinded to PMI. In cohort two, we analysed (EdgeR) microRNA from plasma extracellular vesicles using next-generation sequencing (Illumina HiSeq 500). microRNA-messenger RNA-function pathway analysis was performed (DIANA miRPath v3.0/TopGO).

Results: MicroRNAs were detectable in all 59 patients (median age 67 yr [61-75]; 42% male), who had similar clinical characteristics independent of developing PMI. In cohort one, serum microRNA expression increased after surgery (mean fold-change) hsa-miR-1-3p: 3.99 (95% confidence interval [CI: 1.95-8.19]; hsa-miR-133-3p: 5.67 [95% CI: 2.94-10.91]; P<0.001). These changes were not associated with PMI. Bioinformatic analysis of differentially expressed microRNAs from cohorts one (n=48) and two (n=11) identified pathways associated with adrenergic stress and calcium dysregulation, rather than ischaemia.

Conclusions: Circulating microRNAs associated with cardiac ischaemia were universally elevated in patients after surgery, independent of development of myocardial injury.
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http://dx.doi.org/10.1016/j.bja.2020.05.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678162PMC
November 2020

A restrictive versus liberal transfusion strategy to prevent myocardial injury in patients undergoing surgery for fractured neck of femur: a feasibility randomised trial (RESULT-NOF).

Br J Anaesth 2021 01 21;126(1):77-86. Epub 2020 Jul 21.

Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK.

Background: The optimum transfusion strategy in patients with fractured neck of femur is uncertain, particularly if there is coexisting cardiovascular disease.

Methods: We conducted a prospective, single-centre, randomised feasibility trial of two transfusion strategies. We randomly assigned patients undergoing surgery for fractured neck of femur to a restrictive (haemoglobin, 70-90 g L) or liberal (haemoglobin, 90-110 g L) transfusion strategy throughout their hospitalisation. Feasibility outcomes included: enrolment rate, protocol compliance, difference in haemoglobin, and blood exposure. The primary clinical outcome was myocardial injury using troponin estimations. Secondary outcomes included major adverse cardiac events, postoperative complications, duration of hospitalisation, mortality, and quality of life.

Results: We enrolled 200 (22%) of 907 eligible patients, and 62 (31%) showed decreased haemoglobin (to 90 g L or less) and were thus exposed to the intervention. The overall protocol compliance was 81% in the liberal group and 64% in the restrictive group. Haemoglobin concentrations were similar preoperatively and at postoperative day 1 but lower in the restrictive group on day 2 (mean difference [MD], 7.0 g L; 95% confidence interval [CI], 1.6-12.4). Lowest haemoglobin within 30 days/before discharge was lower in the restrictive group (MD, 5.3 g L; 95% CI, 1.7-9.0). Overall, 58% of patients in the restrictive group received no transfusion compared with 4% in the liberal group (difference in proportion, 54.5%; 95% CI, 36.8-72.2). The proportion with the primary clinical outcome was 14/26 (54%, liberal) vs 24/34 (71%, restrictive), and the difference in proportion was -16.7% (95% CI, -41.3 to 7.8; P=0.18).

Conclusion: A clinical trial of two transfusion strategies in hip fracture with a clinically relevant cardiac outcome is feasible.

Clinical Trial Registration: NCT03407573.
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http://dx.doi.org/10.1016/j.bja.2020.06.048DOI Listing
January 2021

Prospective observational study of postoperative infection and outcomes after noncardiac surgery: analysis of prospective data from the VISION cohort.

Br J Anaesth 2020 07 30;125(1):87-97. Epub 2020 May 30.

William Harvey Research Institute, Queen Mary University of London, London, UK. Electronic address:

Background: Infection is a frequent cause of postoperative morbidity and mortality. The incidence, risk factors, and outcomes for postoperative infections remain poorly characterised.

Methods: This is a secondary analysis of a prospective international cohort study of patients aged ≥45 yr who had noncardiac surgery (VISION), including data describing infection within 30 days after surgery. The primary outcome was postoperative infection. The secondary outcome was 30 day mortality. We used univariable and multivariable logistic regression to identify baseline risk factors for infection. Results are presented as n (%) or odds ratio (OR) with 95% confidence intervals. Some denominators vary according to rates of missing data.

Results: Among 39 996 surgical patients, 3905 (9.8%) experienced 5152 postoperative infections and 715 (1.8%) died. The most frequent infection was surgical site infection (1555/3905 [39.8%]). Infection was most strongly associated with general surgery (OR: 3.74 [3.11-4.49]; P<0.01) and open surgical technique (OR: 2.03 [1.82-2.27]; P<0.01); 30 day mortality was greater amongst patients who experienced infection (262/3905 [6.7%] vs 453/36 091 patients who did not [1.3%]; OR: 3.47 [2.84-4.22]; P<0.01). Mortality was highest amongst patients with CNS infections (OR: 14.72 [4.41-49.12]; P<0.01).

Conclusions: Infection is a common and important complication of noncardiac surgery, which is associated with high mortality. Further research is needed to identify more effective measures to prevent infections after surgery.
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http://dx.doi.org/10.1016/j.bja.2020.03.027DOI Listing
July 2020

Early elevation in plasma high-sensitivity troponin T and morbidity after elective noncardiac surgery: prospective multicentre observational cohort study.

Br J Anaesth 2020 05 5;124(5):535-543. Epub 2020 Mar 5.

William Harvey Research Institute, Queen Mary University of London, London, UK.

Background: Elevated high-sensitivity troponin (hsTnT) after noncardiac surgery is associated with higher mortality, but the temporal relationship between early elevated troponin and the later development of noncardiac morbidity remains unclear.

Methods: Prospective observational study of patients aged ≥45 yr undergoing major noncardiac surgery at four UK hospitals (two masked to hsTnT). The exposure of interest was early elevated troponin, as defined by hsTnT >99th centile (≥15 ng L) within 24 h after surgery. The primary outcome was morbidity 72 h after surgery, defined by the Postoperative Morbidity Survey (POMS). Secondary outcomes were time to become morbidity-free and Clavien-Dindo ≥grade 3 complications.

Results: Early elevated troponin (median 21 ng L [16-32]) occurred in 992 of 4335 (22.9%) patients undergoing elective noncardiac surgery (mean [standard deviation, sd] age, 65 [11] yr; 2385 [54.9%] male). Noncardiac morbidity was more frequent in 494/992 (49.8%) patients with early elevated troponin compared with 1127/3343 (33.7%) patients with hsTnT <99th centile (odds ratio [OR]=1.95; 95% confidence interval [CI], 1.69-2.25). Patients with early elevated troponin had a higher risk of proven/suspected infectious morbidity (OR=1.54; 95% CI, 1.24-1.91) and critical care utilisation (OR=2.05; 95% CI, 1.73-2.43). Clavien-Dindo ≥grade 3 complications occurred in 167/992 (16.8%) patients with early elevated troponin, compared with 319/3343 (9.5%) patients with hsTnT <99th centile (OR=1.78; 95% CI, 1.48-2.14). Absence of early elevated troponin was associated with morbidity-free recovery (OR=0.44; 95% CI, 0.39-0.51).

Conclusions: Early elevated troponin within 24 h of elective noncardiac surgery precedes the subsequent development of noncardiac organ dysfunction and may help stratify levels of postoperative care in real time.
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http://dx.doi.org/10.1016/j.bja.2020.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222220PMC
May 2020

Prevention of postoperative pulmonary complications in the hypoxaemic patient - gathering the evidence for noninvasive respiratory support.

Eur J Anaesthesiol 2020 04;37(4):263-264

From the Queen Mary University of London, London, UK (TEFA, RMP) and Department of Anaesthesia and Intensive Care, Medical and Health Sciences, Linköping University, Linköping, Sweden (MSC).

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http://dx.doi.org/10.1097/EJA.0000000000001188DOI Listing
April 2020

Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study.

Br J Anaesth 2020 03 19;124(3):261-270. Epub 2019 Dec 19.

Peter McCallum Cancer Centre, Australia.

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.
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http://dx.doi.org/10.1016/j.bja.2019.11.025DOI Listing
March 2020

The association between ICU admission and emergency hospital readmission following emergency general surgery.

J Intensive Care Soc 2019 Nov 25;20(4):316-326. Epub 2019 Apr 25.

Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.

Background: The relationship between postoperative intensive care (ICU) admission following emergency general surgery (EGS) and emergency hospital readmission has not been widely investigated.

Methods: Retrospective analysis of registry data for patients undergoing EGS in Scotland, 2005-2007. Exposure of interest was ICU admission status (direct from theatre; indirect after initial care on ward; no ICU admission). The primary outcome was emergency hospital readmission within 30 days of discharge.

Results: Thirty-seven thousand one hundred seventy-three patients were included in the analysis. Overall emergency readmission rate was 8% ( = 2983): 2756 (7.8%) in patients without postoperative ICU admission; 155 (12.1%) with direct ICU admission and 65 (14.7%) with indirect ICU admission. Indirect ICU admission was associated with increased hospital readmission rates (HR 1.24 [1.03, 1.49];  = 0.024) compared with direct ICU admission. ICU admission was associated with increased three-year readmission rates ( = 0.006) and costs ( < 0.001) compared with initial ward care.

Conclusion: Indirect ICU admission is associated with increased emergency hospital readmission and healthcare costs for patients undergoing EGS.
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http://dx.doi.org/10.1177/1751143719843416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820227PMC
November 2019

The role of goal-directed therapy in the prevention of acute kidney injury after major gastrointestinal surgery: Substudy of the OPTIMISE trial.

Eur J Anaesthesiol 2019 12;36(12):924-932

From the Department of Peri-operative Medicine and Pain, Royal London Hospital, London, UK (NM), UCD School of Medicine (PTM, PD), Clinical Research Centre, UCD School of Medicine, University College Dublin, Dublin, Ireland (RI) and William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK (RMP, JRP).

Background: Acute kidney injury (AKI) is an important adverse outcome after major surgery. Peri-operative goal-directed haemodynamic therapy (GDT) may improve outcomes by reducing complications such as AKI.

Objective: To determine if GDT was associated with a reduced incidence of postoperative AKI according to specific renal biomarkers.

Design: Prospective substudy of the OPTIMISE trial, a multicentre randomised controlled trial comparing peri-operative GDT to usual patient care.

Setting: Four UK National Health Service hospitals.

Patients: A total of 287 high-risk patients aged at least 50 years undergoing major gastrointestinal surgery.

Outcome Measures: The primary outcome measure was AKI defined as urinary neutrophil gelatinase-associated lipase (NGAL) at least 150 ng ml 24 and 72 h after surgery. Secondary outcomes were between-group differences in NGAL measurements and NGAL : creatinine ratios 24 and 72 h after surgery and AKI stage 2 or greater according to Kidney Disease Improving Global Outcomes (KDIGO) criteria within 30 days of surgery.

Results: In total, 20 of 287 patients (7%) experienced postoperative AKI of KDIGO grade 2 or 3 within 30 days. The proportion of patients with urinary NGAL at least 150 ng ml 24 or 72 h after surgery was similar in the two groups [GDT 31/144 (21.5%) patients vs. usual patient care 28/143 (19.6%) patients; P = 0.88]. Absolute values of urinary NGAL were also similar at 24 h (GDT 53.5 vs. usual patient care 44.1 ng ml; P = 0.38) and 72 h (GDT 45.1 vs. usual patient care 41.1 ng ml; P = 0.50) as were urinary NGAL : creatinine ratios at 24 h (GDT 45 vs. usual patient care 43 ng mg; P = 0.63) and 72 h (GDT 66 vs. usual patient care 63 ng mg; P = 0.62). The incidence of KDIGO-defined AKI was also similar between the groups [GDT 9/144 (6%) patients vs. usual patient care 11/143 (8%) patients; P = 0.80].

Conclusion: In this trial, GDT did not reduce the incidence of AKI amongst high-risk patients undergoing major gastrointestinal surgery. This may reflect improving standards in usual patient care.

Trial Registration: OPTIMISE Trial Registration ISRCTN04386758.
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http://dx.doi.org/10.1097/EJA.0000000000001104DOI Listing
December 2019

Cost-effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery: Learning from 15,856 patients.

Int J Surg 2019 Dec 8;72:25-31. Epub 2019 Oct 8.

Barts & The London School of Medicine and Dentistry, Queen Mary University of London, UK.

Background: Patients undergoing emergency abdominal surgery are exposed to a high risk of death. A quality improvement (QI) programme to improve the survival for these patients was evaluated in the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. This study aims to assess its cost-effectiveness versus usual care from a UK health service perspective.

Methods: Data collected in a subsample of trial participants were employed to estimate costs and quality-adjusted life years (QALYs) for the QI programme and usual care within the 180-day trial period, with results also extrapolated to estimate lifetime costs and QALYs. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). The probability of being cost-effective was determined for different cost-effectiveness thresholds (£13,000 to £30,000 per QALY). Analyses were performed for lower-risk and higher-risk subgroups based on the number of surgical indications (single vs multiple).

Results: Within the trial period, QI was more costly (£467) but less effective (-0.002 QALYs). Over a lifetime, it was more costly (£1395) and more effective (0.018 QALYs), but did not appear to be cost-effective (ICER: £77,792 per QALY, higher than all cost-effectiveness thresholds; probability of being cost-effective: 28.7%-43.8% across the thresholds). For lower-risk patients, QI was more costly and less effective both within trial period and over a lifetime and it did not appear to be cost-effective. For higher-risk patients, it was more costly and more effective, and did not appear cost-effective within the trial period (ICER: £158,253 per QALY) but may be cost-effective over a lifetime (ICER: £14,293 per QALY).

Conclusion: The QI programme does not appear cost-effective at standard cost-effectiveness thresholds. For patients with multiple surgical indications, this programme is potentially cost-effective over a lifetime, but this is highly uncertain.
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http://dx.doi.org/10.1016/j.ijsu.2019.10.001DOI Listing
December 2019

Anaesthesia providers and maternal mortality in Africa - Authors' reply.

Lancet Glob Health 2019 10;7(10):e1322

Intensive Care Medicine, Queen Mary University of London, UK.

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http://dx.doi.org/10.1016/S2214-109X(19)30282-7DOI Listing
October 2019

Elevated urea-to-creatinine ratio provides a biochemical signature of muscle catabolism and persistent critical illness after major trauma.

Intensive Care Med 2019 12 17;45(12):1718-1731. Epub 2019 Sep 17.

Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK.

Purpose: Muscle wasting is common amongst patients with persistent critical illness and associated with increased urea production, but reduced creatinine production. We hypothesised that elevated urea:creatinine ratio would provide a biochemical signature of muscle catabolism and characterise prolonged intensive care (ICU) admissions after major trauma.

Methods: Using pre-specified hypotheses, we analysed two existing data sets of adults surviving ≥ 10 days following admission to ICU after major trauma. We analysed trauma-ICU admissions to the major trauma centre serving the North East London and Essex Trauma Network, with a verification cohort of trauma-ICU cases from the MIMIC-III database. We compared serum urea, creatinine, and urea:creatinine ratio (ratio of concentrations in mmol/L) between patients with persistent critical illness (defined as ICU stay of ≥ 10 days) and those discharged from ICU before day 10. In a sub-group undergoing sequential abdominal computerised tomography (CT), we measured change in cross-sectional muscle area (psoas muscle at L4 vertebral level and total muscle at L3 level) and assessed for relationships with urea:creatinine ratio and ICU stay. Results are provided as median [interquartile range].

Results: We included 1173 patients between February 1st, 2012 and May 1st, 2016. In patients with ICU stay ≥ 10 days, day 10 urea:creatinine ratio had increased by 133% [72-215], from 62 [46-78] to 141 [114-178], p < 0.001; this rise was larger (p < 0.001) than in patients discharged from ICU before day 10, 59% [11-122%], 61 [45-75] to 97 [67-128], p < 0.001. A similar separation in trajectory of urea:creatinine ratio was observed in 2876 trauma-ICU admissions from MIMIC-III. In 107 patients undergoing serial CTs, decrease in L4 psoas and L3 muscle cross-sectional areas between CTs significantly correlated with time elapsed (R = 0.64 and R = 0.59, respectively). Rate of muscle decrease was significantly greater (p < 0.001 for interaction terms) in 53/107 patients with the second CT during evolving, current or recent persistent critical illness. In this group, at the second CT urea:creatinine ratio negatively correlated with L4 psoas and L3 muscle cross-sectional areas (R 0.39, p < 0.001 and 0.44, p < 0.001).

Conclusion: Elevated urea:creatinine ratio accompanies skeletal muscle wasting representing a biochemical signature of persistent critical illness after major trauma. If prospectively confirmed, urea:creatinine ratio is a potential surrogate of catabolism to examine in epidemiological and interventional studies.
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http://dx.doi.org/10.1007/s00134-019-05760-5DOI Listing
December 2019

Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data.

BMJ Qual Saf 2020 08 12;29(8):623-635. Epub 2019 Sep 12.

William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.

Background And Objectives: A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies.

Methods: We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal.

Results: Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2-5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies.

Conclusion: Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.
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http://dx.doi.org/10.1136/bmjqs-2019-009537DOI Listing
August 2020

Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies.

PLoS One 2019 21;14(8):e0221277. Epub 2019 Aug 21.

William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.

Background: Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery.

Methods: In two prospective, blinded, observational cohort studies, we established the definition of impaired vagal function in terms of the HRR threshold that is associated with perioperative myocardial injury (HRR ≤ 12 beats min-1 (bpm), 60 seconds after cessation of cardiopulmonary exercise testing. The primary outcome of this secondary analysis was all-cause morbidity three and five days after surgery, defined using the Post-Operative Morbidity Survey. Secondary outcomes of this analysis were type of morbidity and time to become morbidity-free. Logistic regression and Cox regression tested for the association between HRR and morbidity. Results are presented as odds/hazard ratios [OR or HR; (95% confidence intervals).

Results: 882/1941 (45.4%) patients had HRR≤12bpm. All-cause morbidity within 5 days of surgery was more common in 585/822 (71.2%) patients with HRR≤12bpm, compared to 718/1119 (64.2%) patients with HRR>12bpm (OR:1.38 (1.14-1.67); p = 0.001). HRR≤12bpm was associated with more frequent episodes of pulmonary (OR:1.31 (1.05-1.62);p = 0.02)), infective (OR:1.38 (1.10-1.72); p = 0.006), renal (OR:1.91 (1.30-2.79); p = 0.02)), cardiovascular (OR:1.39 (1.15-1.69); p<0.001)), neurological (OR:1.73 (1.11-2.70); p = 0.02)) and pain morbidity (OR:1.38 (1.14-1.68); p = 0.001) within 5 days of surgery.

Conclusions: Multi-organ dysfunction is more common in surgical patients with cardiac vagal dysfunction, defined as HRR ≤ 12 bpm after preoperative cardiopulmonary exercise testing.

Clinical Trial Registry: ISRCTN88456378.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221277PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703687PMC
March 2020
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