BJA open最新文献

Acknowledgment of BJA Open Peer Reviewers 感谢BJA开放同行评审

BJA open

Pub Date : 2026-01-28 DOI: 10.1016/j.bjao.2026.100527

引用次数: 0

Moral injury in clinical and academic medicine—it is time to act 临床和学术医学中的道德伤害——是时候采取行动了

BJA open

Pub Date : 2026-01-20 DOI: 10.1016/j.bjao.2025.100525

Britta S. von Ungern-Sternberg , Aine Sommerfield , Karin Becke-Jakob

When doctors working within healthcare systems under pressure perpetrate, witness, or fail to prevent acts that contradict their own moral or ethical values and expectations, it can lead to moral distress or moral injury. This can result from active behaviour and from purposeful inactive behaviour. It is a growing and critical concern, representing significant distress that extends far beyond traditional concepts such as burnout. This article discusses moral injury in clinical and academic medicine and actively gives suggestions to prevent and address moral injury.

当在卫生保健系统内工作的医生在压力下实施、目睹或未能阻止违背其自身道德或伦理价值观和期望的行为时，就可能导致道德困境或道德伤害。这可能是由积极的行为和有目的的不活跃行为造成的。这是一个日益严重的问题，它代表了远远超出倦怠等传统概念的巨大痛苦。本文对临床和学术医学中的道德伤害进行了探讨，并积极提出了预防和解决道德伤害的建议。

引用次数: 0

Development of a machine learning model to predict intensive care unit bed demand for adult elective surgical patients at a large United Kingdom National Health Service Trust 开发机器学习模型，预测大型英国国家卫生服务信托基金成人选择性手术患者重症监护病房床位需求

BJA open

Pub Date : 2026-01-16 DOI: 10.1016/j.bjao.2025.100513

Jennifer Hunter , Hrisheekesh Vaidya , Sonya Crowe , Martin Utley , Zella King , Kezhi Li , Steve Harris

Background

Elective surgical admissions form a growing share of demand for ICU beds, a constrained resource. Capacity planning for these admissions is feasible, but hospitals often lack reliable systems estimating daily elective surgical ICU bed demand before the day of surgery. Comprehensive clinical review of all elective cases is impractical, so planning relies on subjective preassessment processes of variable reliability. This study aimed to develop a machine learning model predicting elective surgical ICU bed demand using electronic health record data to improve on current electronic bed demand estimation at a large UK National Health Service (NHS) Trust.

Methods

Using a retrospective dataset comprising 38 656 elective inpatient surgeries occurring at three sites in a large UK NHS trust between 1 May 2019 and 31 December 2023, we developed two tree-based machine learning models predicting ICU admission after elective surgery: one using only basic, objective clinical data (CoreML) and one using additional preassessment data (FullML). Individual predictions were aggregated to forecast ICU bed demand. Performance was validated retrospectively and prospectively.

Results

At our large UK NHS Trust, in a prospective evaluation, only 71.6% of elective surgical cases admitted to ICU after surgery had an ICU bed electronically requested. In this evaluation, the CoreML model predicting ICU admission at an individual level 1 day before surgery achieved an area under the receiver operator curve of 0.88. It outperformed the current electronic indicator of aggregate elective surgical ICU bed demand 1 day before surgery at two sites handling 72% of inpatient elective surgery (root mean square error, 1.28 vs 1.64 at site A; 0.76 vs 1.16 at site C). CoreML outperformed FullML in aggregate prediction at all sites in prospective evaluation; however, importantly in retrospective evaluation, the converse was true.

Conclusions

We demonstrate that aggregating individual-level ICU admission predictions for elective surgeries provides a bed demand estimate that improves on the current electronic bed demand indicator 1 day before surgery at two out of three sites conducting the majority of inpatient elective surgery at our large UK NHS Trust. We demonstrate the importance of prospective validation, in which the more parsimonious model was the best performing.

选择性手术入院对ICU床位的需求越来越大，这是一种有限的资源。这些入院的容量规划是可行的，但医院往往缺乏可靠的系统，在手术前估计每天的选择性外科ICU床位需求。对所有选择性病例进行全面的临床回顾是不切实际的，因此计划依赖于可变可靠性的主观预评估过程。本研究旨在开发一种机器学习模型，利用电子健康记录数据预测选择性外科ICU床位需求，以改进英国国家卫生服务（NHS）信托基金目前的电子床位需求估计。方法：使用回顾性数据集，包括2019年5月1日至2023年12月31日期间在英国一家大型NHS信托机构的三个地点进行的38656例选择性住院手术，我们开发了两个基于树的机器学习模型，预测选择性手术后ICU住院情况：一个只使用基本的客观临床数据（CoreML），另一个使用额外的预评估数据（FullML）。汇总个人预测以预测ICU床位需求。回顾性和前瞻性地验证了性能。结果在我们的大型英国NHS信托基金中，在一项前瞻性评估中，只有71.6%的择期手术患者在手术后入住ICU时电子申请了ICU床位。在本次评估中，预测术前1天个体水平ICU入院的CoreML模型在接受者操作者曲线下的面积为0.88。在处理72%的住院选择性手术的两个地点，它优于目前的择期手术ICU床位总需求电子指标（根均方误差，A点1.28 vs 1.64； C点0.76 vs 1.16）。在前瞻性评价中，CoreML在所有位点的总体预测均优于FullML；然而，重要的是，在回顾性评估中，相反的情况是正确的。我们证明，在我们的大型英国NHS信托机构中，在进行大多数住院选择性手术的三个站点中，有两个站点在手术前1天汇总个人层面的ICU住院预测提供了床位需求估计，改善了当前的电子床位需求指标。我们证明了前瞻性验证的重要性，其中更简洁的模型表现最好。

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引用次数: 0

Noninvasive cardiac index estimation under general anaesthesia: comparison between the VenArt® device and transthoracic echocardiography☆ 全身麻醉下无创心脏指数评估：VenArt®装置与经胸超声心动图的比较

BJA open

Pub Date : 2025-12-17 DOI: 10.1016/j.bjao.2025.100516

Catherine Paschoud , Nicolas Silvestrini , John Daniels , Jérémie Koegel , Stéphanie Mulin , Florence Gonzalez Ennahdi-Elidrissi , Laszlo Vutskits , Nadia Elia , Georges L. Savoldelli

Background

VenArt® is a novel noninvasive cardiac output monitoring device which provides beat-by-beat Fick principle-based measurements of stroke volume and cardiac output. The study aim was to determine the accuracy of this device by comparing it with cardiac output measurements using transthoracic echocardiography in patients undergoing anaesthesia.

Methods

This prospective observational study included 55 women (ASA physical status classification I–III) undergoing laparoscopic gynaecological procedures. Cardiac output was assessed at five timepoints using the VenArt® device and transthoracic echocardiography. Primary endpoint was the agreement between the two methods regarding cardiac index, evaluated using Bland–Altman analysis to determine bias, precision, mean percentage error, and limits of agreement. Secondary endpoint was the ability of the device to track changes in cardiac index over time compared with echocardiography.

Results

We analysed 273 pairs of cardiac index values from 55 patients. Bland–Altman analysis showed a bias of 0.02 (95% confidence interval [CI] 0–0.05) L min⁻¹ m⁻², with a precision of 0.20 and a mean percentage error of 14.7% (95% CI 13.2–16.2%). Limits of agreement ranged from −0.37 (95% CI −0.41 to −0.33) to 0.41 (95% CI 0.37–0.45) L min⁻¹ m⁻². Trending ability demonstrated good agreement: the four-quadrant plot revealed a concordance rate of 95.88%, and the polar plot showed a mean polar angle of 0.75°, with a standard deviation of 13.4° and radial limits of agreement within plus or minus 30°.

Conclusions

The VenArt® device showed negligible bias and acceptable differences. Trending ability was favourable, with clinically acceptable agreement and high concordance in tracking haemodynamic changes.

Clinical trial registration

ISRCTN92565809.

venart®是一种新型的无创心输出量监测设备，提供基于逐拍菲克原理的脑卒中量和心输出量测量。本研究的目的是通过比较麻醉患者经胸超声心动图的心输出量来确定该装置的准确性。方法本前瞻性观察研究纳入55名接受腹腔镜妇科手术的女性（ASA身体状况分类I-III）。使用VenArt®装置和经胸超声心动图在五个时间点评估心输出量。主要终点是两种方法关于心脏指数的一致性，使用Bland-Altman分析来评估偏倚、精度、平均百分比误差和一致性限度。次要终点是与超声心动图相比，该装置追踪心脏指数随时间变化的能力。结果我们分析了55例患者的273对心脏指数。Bland-Altman分析显示，偏差为0.02(95%置信区间[CI] 0-0.05) L min - 1 m - 2，精度为0.20，平均百分比误差为14.7% （95% CI 13.2-16.2%）。一致性范围为- 0.37 （95% CI - 0.41至- 0.33）至0.41 (95% CI 0.37 - 0.45) L min - 1 m - 2。趋势能力表现出良好的一致性：四象限图显示的一致性率为95.88%，极坐标图显示的平均极坐标角为0.75°，标准差为13.4°，一致性的径向极限在正负30°以内。结论VenArt®装置偏差可忽略，差异可接受。趋势能力良好，临床可接受的一致性和追踪血流动力学变化的高度一致性。临床试验注册号：isrctn92565809。

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引用次数: 0

Postoperative anaemia: the unseen challenge in cardiac surgery 术后贫血：心脏手术中看不见的挑战

BJA open

Pub Date : 2025-12-17 DOI: 10.1016/j.bjao.2025.100514

Matthew A. Warner , Jacob Raphael

Postoperative anaemia is an overlooked complication of cardiac surgery that is associated with adverse clinical outcomes. Although small clinical trials suggest that postoperative treatment with i.v. iron improves haemoglobin recovery and reduces transfusion utilisation, appropriately powered randomised controlled trials are necessary to definitively evaluate the efficacy of treatment on clinical outcomes of importance to patients, clinicians, and healthcare systems. A comprehensive approach to perioperative anaemia management demands a renewed focus on both prevention and treatment to improve patient outcomes.

术后贫血是一种被忽视的心脏手术并发症，与不良临床结果相关。尽管小型临床试验表明，术后静脉注射铁可以改善血红蛋白恢复，减少输血使用，但需要适当的随机对照试验来明确评估治疗对患者、临床医生和医疗保健系统的临床结果的疗效。围手术期贫血管理的综合方法需要重新关注预防和治疗，以改善患者的预后。

引用次数: 0

Association of postoperative haemoglobin with adverse outcomes in patients undergoing cardiac surgery: a retrospective single centre cohort study 心脏手术患者术后血红蛋白与不良结局的关系：一项回顾性单中心队列研究

BJA open

Pub Date : 2025-12-17 DOI: 10.1016/j.bjao.2025.100508

Jamal Alkadri , Maggie Chen , Keyvan Karkouti , Samantha Morais , Refik Saskin , Alexa Grudzinski , Maral Ouzounian , Jeannie Callum , Yulia Lin , Stuart A. McCluskey , Daniel I. McIsaac , Justyna Bartoszko

Background

Preoperative anaemia is an important risk factor for adverse outcomes in cardiac surgery, however data on postoperative anaemia is sparse. The aim of this study is to characterise the association of postoperative haemoglobin with 30-day mortality and morbidity after cardiac surgery.

Methods

We performed a retrospective cohort study of adults (age ≥18 yr) undergoing coronary revascularisation, valve surgery, or a combination at Toronto General Hospital from 2016 to 2020. We analysed the association between nadir postoperative day 1 (POD1) haemoglobin as a continuous and binary variable (haemoglobin ≤80 g L⁻¹), with a primary composite outcome of 30-day mortality, stroke, myocardial infarction, acute kidney injury, sternal wound infection, or a combination. The secondary outcome was the incidence of adverse events. The primary outcome was analysed using logistic regression, secondary using Poisson regression; adjusted models accounted for clustering and confounders.

Results

We included 5960 patients. On POD1, mean haemoglobin was 90.1g L⁻¹ (standard deviation 15.2) and 1794 patients (30%) had haemoglobin ≤80 g L⁻¹. Red blood cells were transfused to 49% of the cohort, and to 90% of patients with POD1 haemoglobin ≤80 g L⁻¹. Each 10 g L⁻¹ decrease in POD1 haemoglobin increased the odds of the primary outcome (adjusted odds ratio [OR] 1.15 [1.05–1.25], P<0.001), as did haemoglobin ≤80 g L⁻¹ (adjusted OR 1.44 [1.19–1.75], P<0.001). For adverse events, each 10 g L⁻¹ decrease in haemoglobin was associated with an increased incidence rate ratio (IRR) (adjusted IRR 1.14 [1.07–1.20], P<0.001), as was haemoglobin <80 g L⁻¹ (adjusted IRR 1.33 [1.16–1.54], P<0.001).

Conclusions

In postoperative cardiac surgical patients, progressive decreases in postoperative haemoglobin are associated with increased risk of mortality and major morbidity at 30 days.

背景术前贫血是心脏手术不良结果的重要危险因素，然而关于术后贫血的数据很少。本研究的目的是描述心脏手术后血红蛋白与30天死亡率和发病率的关系。方法：我们对2016年至2020年在多伦多总医院接受冠状动脉血管重建术、瓣膜手术或联合手术的成人（年龄≥18岁）进行了回顾性队列研究。我们分析了术后第1天最低点（POD1）血红蛋白作为一个连续和二元变量（血红蛋白≤80 g L−1）与30天死亡率、中风、心肌梗死、急性肾损伤、胸骨伤口感染或两者组合的主要复合结局之间的关系。次要结果是不良事件的发生率。主要结局采用logistic回归分析，次要结局采用泊松回归分析；调整后的模型考虑了聚类和混杂因素。结果纳入5960例患者。在POD1中，平均血红蛋白为90.1g L−1（标准差为15.2），1794例（30%）患者血红蛋白≤80 g L−1。向49%的队列和90%的POD1血红蛋白≤80 g L−1的患者输注红细胞。POD1血红蛋白每降低10 g L−1，主要结局的几率就会增加（校正比值比[OR] 1.15[1.05-1.25], 0.001），血红蛋白≤80 g L−1也是如此（校正比值比[OR] 1.44[1.19-1.75], 0.001）。对于不良事件，血红蛋白每降低10 g L−1与发病率比（IRR）增加相关（调整后的IRR为1.14 [1.07-1.20],P<0.001），血红蛋白80 g L−1也是如此（调整后的IRR为1.33 [1.16-1.54],P<0.001）。结论心脏手术患者术后血红蛋白进行性下降与术后30天死亡率和主要发病率增高相关。

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引用次数: 0

Interventions for iron deficiency with or without anaemia in visceral surgery: recommendations for future research 内脏手术伴或不伴贫血缺铁的干预措施：对未来研究的建议

BJA open

Pub Date : 2025-12-17 DOI: 10.1016/j.bjao.2025.100503

Caroline R. Evans , Henrik Kehlet , Sigismond Lasocki , Patrick Meybohm , Manuel Muñoz , Aryeh Shander , Donat R. Spahn , Suma Choorapoikayil , Kai Zacharowski

引用次数: 0

Access to haemodynamic evaluation tools in middle-income countries: a survey of 1593 anaesthetists and intensivists from 39 nations 中等收入国家血液动力学评估工具的获取：对来自39个国家的1593名麻醉师和重症监护员的调查

BJA open

Pub Date : 2025-12-15 DOI: 10.1016/j.bjao.2025.100515

Frederic Michard , Jigeeshu Divatia , Flavio E. Nacul , Syarifah N.N.S. Masri , Suraphong Lorsomradee , Vanina Kanoore-Edul , Eduardo Kattan , Asli Z. Demir , Francisco Chacon-Lozsan , Ever L. Rojas-Diaz , Manu L.N.G. Malbrain , Michelle S. Chew

Background

Approximately 75% of the world’s population lives in middle-income countries (MICs), where access to haemodynamic evaluation tools may be limited, exacerbating global healthcare disparities.

Methods

We conducted an online survey of anaesthetists and intensivists working in MICs, inviting them to complete 15 questions on bedside haemodynamic evaluations and access to haemodynamic monitoring tools.

Results

We analysed 1593 valid questionnaires from 20 Upper and 19 Lower MICs. Most respondents (66%) worked in academic hospitals, 43% in private hospitals, and 20% in non-academic public hospitals. Respondents worked in ICUs (39%), operating rooms (38%), or both (23%). Nearly all had access to central venous catheters (99%) and invasive radial arterial pressure monitoring (91%). Fewer than two-thirds (63%) reported access to echocardiography, and only 37% had access to cardiac output monitoring systems when needed. The main barriers were the cost of monitors (54%) and the cost of disposable sensors (52%). Notably, 72% indicated they would use cardiac output monitoring equipment more frequently if costs were reduced. Most respondents (89%) reported a routine practice of predicting fluid responsiveness before giving a fluid bolus, most commonly with pulse pressure variation (64%) or ultrasound indices (55%). Tissue perfusion was mainly assessed by clinical evaluation (86%), blood lactate (81%), and capillary refill time (63%).

Conclusions

In MICs, less than two-thirds of anaesthetists and intensivists reported having access to echocardiography for haemodynamic assessment. Fewer than 40% have access to cardiac output monitoring systems, mainly attributable to economic constraints. As this report represents a potential concerning equity gap in global healthcare, efforts should be made to prioritise and facilitate access to haemodynamic evaluation tools in MICs.

世界上大约75%的人口生活在中等收入国家（MICs），在这些国家获得血液动力学评估工具的机会可能有限，从而加剧了全球医疗保健差距。方法对在MICs工作的麻醉师和重症监护医师进行在线调查，邀请他们完成床边血流动力学评估和使用血流动力学监测工具的15个问题。结果共分析了20个上、下MICs的1593份有效问卷。大多数受访者（66%）在学术医院工作，43%在私立医院工作，20%在非学术公立医院工作。受访者在icu（39%）、手术室（38%）或两者都工作（23%）。几乎所有患者都有中心静脉导管（99%）和有创桡动脉压监测（91%）。不到三分之二（63%）的人报告获得了超声心动图，只有37%的人在需要时获得了心输出量监测系统。主要障碍是监测器的成本（54%）和一次性传感器的成本（52%）。值得注意的是，72%的人表示，如果成本降低，他们会更频繁地使用心输出量监测设备。大多数应答者（89%）报告了在给予液体丸之前预测液体反应的常规做法，最常见的是脉搏压力变化（64%）或超声指数（55%）。组织灌注主要通过临床评价（86%）、血乳酸（81%）和毛细血管再充盈时间（63%）来评估。结论：在中等收入国家中，不到三分之二的麻醉师和重症监护师报告使用超声心动图进行血流动力学评估。只有不到40%的人能够获得心输出量监测系统，这主要是由于经济限制。由于该报告可能涉及全球医疗保健方面的公平差距，因此应努力优先考虑并促进中等收入国家获得血流动力学评估工具。

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引用次数: 0

Determining reduced functional capacity in older adults using research-grade wearable accelerometers: a secondary analysis of the study of muscle, mobility, and aging 使用研究级可穿戴加速度计确定老年人功能能力下降：肌肉、活动能力和衰老研究的二次分析

BJA open

Pub Date : 2025-12-01 DOI: 10.1016/j.bjao.2025.100510

Anthony Hung , Nancy W. Glynn , Reagan E. Garcia , Megan Hetherington-Rauth , Peggy M. Cawthon , Daniel E. Forman , Eileen Johnson , Daniel S. Rubin

Background

Reduced functional capacity (FC) is associated with adverse surgical outcomes in older adults. Current FC assessments rely on questionnaires; however, it remains unclear whether accelerometer-measured daily activity provides a more accurate evaluation. Our primary aim was to identify accelerometer-based variables associated with reduced FC.

Methods

We conducted a secondary analysis of the Study of Muscle, Mobility and Aging (SOMMA) cohort. Participants were community-dwelling adults (non-surgical) aged ≥70 yr and recruited between the years 2019 to 2021 at the University of Pittsburgh (Pittsburgh, PA, USA) and Wake Forest University School of Medicine (Winston-Salem, NC, USA). Participants were included if they completed cardiopulmonary exercise testing and had valid wear time (≥3 days) for two accelerometers used in the SOMMA study (ActiGraph GT9X and activPAL4). We applied classification and regression tree and random forest models to accelerometry-derived metrics. For comparison, we constructed a logistic regression model using modified Duke Activity Status Index 4-Question (M-DASI-4Q) scores extrapolated from the Community Healthy Activities Model Program for Seniors questionnaire.

Results

The final cohort included 640 participants (57.2% [366/640] women; mean age 76.3 [5.0] yr), of whom 18% (114/640) had reduced FC (peak oxygen uptake [VO₂peak] <16 ml kg⁻¹ min⁻¹). Participants with adequate FC had higher daily step counts (5843.9 [2950.4] vs 2988.3 [1757.2] steps per day; P<0.001) and more time in moderate-to-vigorous physical activity (118.0 [62.2] vs 59.9 [42.4] min day⁻¹; P<0.001) compared with those with reduced FC. The accelerometer-based random forest model (AUC 0.79) did not significantly outperform the M-DASI-4Q model (AUC 0.72; P=0.16).

Conclusion

Among community-dwelling older adults, daily step count and time in moderate-to-vigorous activity were most associated with FC, but the accelerometer-based model showed only fair discrimination to identify participants with reduced FC. Validation in surgical populations is needed.

背景：功能能力下降（FC）与老年人不良手术结果相关。目前的FC评估依赖于问卷；然而，目前尚不清楚加速度计测量的日常活动是否能提供更准确的评估。我们的主要目的是确定与减少FC相关的加速度计变量。方法对肌肉运动与衰老研究（SOMMA）队列进行二次分析。参与者是年龄≥70岁的社区居住成年人（非手术），于2019年至2021年在匹兹堡大学（美国宾夕法尼亚州匹兹堡）和维克森林大学医学院（美国北卡罗来纳州温斯顿-塞勒姆）招募。如果参与者完成了心肺运动测试，并且在SOMMA研究中使用的两种加速度计（ActiGraph GT9X和activPAL4）有有效磨损时间（≥3天），则纳入受试者。我们将分类、回归树和随机森林模型应用于加速度测量衍生的度量。为了进行比较，我们使用从老年人社区健康活动模型计划问卷中推断出的修正杜克活动状态指数4-问题（M-DASI-4Q）得分构建了一个逻辑回归模型。结果最终队列包括640名参与者（57.2%[366/640]名女性，平均年龄76.3[5.0]岁），其中18%（114/640）的FC降低（峰值摄氧量[vo2峰值]& 16 ml kg - 1 min - 1）。与FC减少的参与者相比，FC充足的参与者有更高的每日步数（5843.9 [2950.4]vs 2988.3[1757.2]步/天；P<0.001）和更多的中高强度体力活动时间（118.0 [62.2]vs 59.9[42.4]分钟/天；P<0.001）。基于加速度计的随机森林模型（AUC 0.79）没有显著优于M-DASI-4Q模型（AUC 0.72； P=0.16）。结论：在社区居住的老年人中，每日步数和中高强度活动时间与FC最相关，但基于加速度计的模型对识别FC减少的参与者仅显示公平歧视。需要在手术人群中进行验证。

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引用次数: 0

Kidney disease and cardiac surgery: marker, mediator, or both? 肾脏疾病和心脏手术：标志、中介，还是两者都有？

BJA open

Pub Date : 2025-12-01 DOI: 10.1016/j.bjao.2025.100507

Abraham H. Hulst , Fabrizio Monaco

Cardiac surgery places an enormous burden on the kidneys, and therefore, acute kidney injury (AKI) is a common postoperative complication. Pre-existing chronic kidney disease (CKD) is a strong predictor of cardiac surgery-associated AKI, in addition to the evidence of a bidirectional interaction where AKI also accelerates the progression of CKD and increases the risk of renal failure. While observational research links kidney dysfunction to prolonged hospital stays, morbidity, and mortality, the question remains whether AKI is a modifiable mediator or merely a perioperative risk predictor. Larger analyses, including that of Bille and colleagues, indicate that AKI drives the acceleration of CKD. These findings provide further evidence for systematic follow-up and early implementation of kidney-protective measures to optimise long-term renal function after cardiac surgery.

心脏手术给肾脏带来了巨大的负担，因此，急性肾损伤（AKI）是常见的术后并发症。已有慢性肾脏疾病（CKD）是心脏手术相关AKI的一个强有力的预测因素，此外还有双向相互作用的证据，其中AKI也加速CKD的进展并增加肾衰竭的风险。虽然观察性研究将肾功能障碍与延长住院时间、发病率和死亡率联系起来，但AKI是一种可改变的调节因子还是仅仅是围手术期风险预测因子，这个问题仍然存在。包括Bille及其同事在内的大型分析表明，AKI会加速CKD的发展。这些发现为系统随访和早期实施肾脏保护措施以优化心脏手术后的长期肾功能提供了进一步的证据。

引用次数: 0