Thanapon Ekkunagul,Caitlin Sara MacLeod,Anna Celnik,John Chalmers,Ross Thomson,Alan J R Macfarlane,David Bosanquet,John Nagy,Patrice Forget,
INTRODUCTIONMajor lower extremity amputations occurring secondary to vascular disease remain prevalent worldwide. Pain surrounding these procedures is complex, multifactorial and associated with poor functional and psychosocial outcomes. The evidence base informing pain management approaches in major lower extremity amputations remain largely heterogeneous and limited. This study aimed to establish procedure-specific, multispeciality consensus on the ideal principles and practices required to optimise pain management for vascular surgical patients undergoing major lower extremity amputations.METHODSA three-round online modified Delphi consensus process was undertaken, with consultant anaesthetists and consultant vascular surgeons across the UK forming the expert panel. Structured statements were assessed on a 5-point Likert scale against a strong consensus threshold of ≥ 75% ratings in agreement or disagreement, and a rating stability criterion of < 10% change between rounds. Free-text responses were thematically analysed at each round to iteratively modify or generate new statements.RESULTSSeventy-two panellists participated in the study. Of the 44 consensus statements assessed, 32 reached strong consensus agreement. These included: shared cross-speciality responsibility for pain management; the mainstay role of locoregional analgesia; use of perineural catheters; opioid-sparing approaches; and protocolised decision aids with individualisation of analgesia. Barriers to practices identified included resource constraints and the paucity of direct evidence. There was non-consensus in 12 statements, notably on pre-amputation initiation of locoregional analgesia; ultrasound-guided nerve catheter placement; and surgeon-delivered regional analgesia. No statement reached strong consensus disagreement.DISCUSSIONThis study provides the first procedure-specific consensus, delineating agreed principles and preferred pharmacological and locoregional analgesic approaches to peri-operative pain management in patients undergoing major lower extremity amputations. The areas of non-consensus expose key uncertainties that may inform future research, service organisation and guideline development agendas.
{"title":"Peri-operative pain management in major lower extremity amputation in vascular Surgery: a UK anaesthetic and vascular surgery Delphi consensus study.","authors":"Thanapon Ekkunagul,Caitlin Sara MacLeod,Anna Celnik,John Chalmers,Ross Thomson,Alan J R Macfarlane,David Bosanquet,John Nagy,Patrice Forget, ","doi":"10.1111/anae.70107","DOIUrl":"https://doi.org/10.1111/anae.70107","url":null,"abstract":"INTRODUCTIONMajor lower extremity amputations occurring secondary to vascular disease remain prevalent worldwide. Pain surrounding these procedures is complex, multifactorial and associated with poor functional and psychosocial outcomes. The evidence base informing pain management approaches in major lower extremity amputations remain largely heterogeneous and limited. This study aimed to establish procedure-specific, multispeciality consensus on the ideal principles and practices required to optimise pain management for vascular surgical patients undergoing major lower extremity amputations.METHODSA three-round online modified Delphi consensus process was undertaken, with consultant anaesthetists and consultant vascular surgeons across the UK forming the expert panel. Structured statements were assessed on a 5-point Likert scale against a strong consensus threshold of ≥ 75% ratings in agreement or disagreement, and a rating stability criterion of < 10% change between rounds. Free-text responses were thematically analysed at each round to iteratively modify or generate new statements.RESULTSSeventy-two panellists participated in the study. Of the 44 consensus statements assessed, 32 reached strong consensus agreement. These included: shared cross-speciality responsibility for pain management; the mainstay role of locoregional analgesia; use of perineural catheters; opioid-sparing approaches; and protocolised decision aids with individualisation of analgesia. Barriers to practices identified included resource constraints and the paucity of direct evidence. There was non-consensus in 12 statements, notably on pre-amputation initiation of locoregional analgesia; ultrasound-guided nerve catheter placement; and surgeon-delivered regional analgesia. No statement reached strong consensus disagreement.DISCUSSIONThis study provides the first procedure-specific consensus, delineating agreed principles and preferred pharmacological and locoregional analgesic approaches to peri-operative pain management in patients undergoing major lower extremity amputations. The areas of non-consensus expose key uncertainties that may inform future research, service organisation and guideline development agendas.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"153 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145771562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Persistent postoperative anaemia and 1‐year mortality: re‐examining time origin and sample selection – a reply","authors":"Hee Won Choi, Young‐Lan Kwak, Hyun‐Soo Zhang","doi":"10.1111/anae.70095","DOIUrl":"https://doi.org/10.1111/anae.70095","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"12 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145753124","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Venkatesan Thiruvenkatarajan, Benjamin Teng Jen Khoo, Anil Roy, Wai‐Man Liu, Tharun Kathiravan, Roelof Van Wijk
Summary Introduction The STOP‐BANG questionnaire assesses the peri‐operative risk of obstructive sleep apnoea and relies on subjective components, which limit its reliability. The B‐APNEIC score was proposed as a more objective alternative, incorporating just four STOP‐BANG variables: BMI > 35 kg.m ‐2 ; arterial blood pressure; neck circumference > 40 cm; and witnessed breathing interruptions. This study aimed to evaluate the predictive performance of the B‐APNEIC score in an Australian sleep clinic population. These findings would have important implications for use in the pre‐operative screening of obstructive sleep apnoea. Methods We enrolled participants referred for overnight diagnostic polysomnography. The STOP‐BANG questionnaire was administered and the B‐APNEIC score was extracted. The primary outcome was the predictive ability of a B‐APNEIC score ≥ 3 to detect severe obstructive sleep apnoea. Performance metrics were compared with a STOP‐BANG score ≥ 5. Results Among 274 patients, the B‐APNEIC score showed a sensitivity of 84% (95%CI 75–90%), specificity of 60% (95%CI 52–67%), positive predictive value of 56% (95%CI 48–64%) and negative predictive value of 86% (95%CI 78–91%) for predicting severe obstructive sleep apnoea. Compared with the STOP‐BANG score, the B‐APNEIC score showed superior sensitivity (84% vs. 73%); positive predictive value (56% vs. 52%); negative predictive value (86% vs. 78%); Youden Index (0.43 vs. 0.32); and area under the receiver operating characteristic curve (0.72 (95%CI 0.66–0.77) vs. 0.66 (95%CI 0.60–0.72); p = 0.02). Both scores had similar specificity (59%). Discussion The B‐APNEIC score showed strong predictive accuracy for severe obstructive sleep apnoea and could serve as a simple, objective alternative to STOP‐BANG. While further validation in surgical populations is warranted, these findings support its use in pre‐operative screening for obstructive sleep apnoea.
{"title":"Validation and diagnostic performance of the novel B‐ APNEIC score for predicting severe obstructive sleep apnoea: a cross‐sectional study in an Australian population","authors":"Venkatesan Thiruvenkatarajan, Benjamin Teng Jen Khoo, Anil Roy, Wai‐Man Liu, Tharun Kathiravan, Roelof Van Wijk","doi":"10.1111/anae.70102","DOIUrl":"https://doi.org/10.1111/anae.70102","url":null,"abstract":"Summary Introduction The STOP‐BANG questionnaire assesses the peri‐operative risk of obstructive sleep apnoea and relies on subjective components, which limit its reliability. The B‐APNEIC score was proposed as a more objective alternative, incorporating just four STOP‐BANG variables: BMI > 35 kg.m <jats:sup>‐2</jats:sup> ; arterial blood pressure; neck circumference > 40 cm; and witnessed breathing interruptions. This study aimed to evaluate the predictive performance of the B‐APNEIC score in an Australian sleep clinic population. These findings would have important implications for use in the pre‐operative screening of obstructive sleep apnoea. Methods We enrolled participants referred for overnight diagnostic polysomnography. The STOP‐BANG questionnaire was administered and the B‐APNEIC score was extracted. The primary outcome was the predictive ability of a B‐APNEIC score ≥ 3 to detect severe obstructive sleep apnoea. Performance metrics were compared with a STOP‐BANG score ≥ 5. Results Among 274 patients, the B‐APNEIC score showed a sensitivity of 84% (95%CI 75–90%), specificity of 60% (95%CI 52–67%), positive predictive value of 56% (95%CI 48–64%) and negative predictive value of 86% (95%CI 78–91%) for predicting severe obstructive sleep apnoea. Compared with the STOP‐BANG score, the B‐APNEIC score showed superior sensitivity (84% vs. 73%); positive predictive value (56% vs. 52%); negative predictive value (86% vs. 78%); Youden Index (0.43 vs. 0.32); and area under the receiver operating characteristic curve (0.72 (95%CI 0.66–0.77) vs. 0.66 (95%CI 0.60–0.72); p = 0.02). Both scores had similar specificity (59%). Discussion The B‐APNEIC score showed strong predictive accuracy for severe obstructive sleep apnoea and could serve as a simple, objective alternative to STOP‐BANG. While further validation in surgical populations is warranted, these findings support its use in pre‐operative screening for obstructive sleep apnoea.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"59 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145731075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Amelia Place, Thalys Sampaio Rodrigues, Phillip S. Naimo, Melissa G. Y. Lee, Riley J. Batchelor, Laurence Weinberg, Lachlan F. Miles, Jeffrey Lefkovits, Anoop N. Koshy
Summary Introduction Aortic stenosis is a risk factor for adverse outcomes following non‐cardiac surgery; however, existing data regarding peri‐operative morbidity and mortality in this patient cohort remain conflicted. This systematic review and meta‐analysis aimed to quantify the peri‐operative risks in patients with aortic stenosis undergoing non‐cardiac surgery. Methods Following the development of our search strategy, we searched databases for relevant studies. The primary endpoint was all‐cause in‐hospital or 30‐day mortality associated with aortic stenosis in patients undergoing non‐cardiac surgery. Secondary endpoints included: myocardial infarction; heart failure; stroke; delirium; venous thromboembolism; and acute kidney injury. Results Nineteen studies involving 100,486 patients were included. The estimated all‐cause mortality was 3.8% (95%CI 3.7–3.9%) for patients with any degree of aortic stenosis and 9.6% (95%CI 7.7–12.1%) for those with severe aortic stenosis. A meta‐analysis of 14 comparative studies involving 2,885,254 patients revealed significantly increased mortality in patients with aortic stenosis compared with those without aortic stenosis (relative risk 1.58, 95%CI 1.18–2.12, p < 0.001). Aortic stenosis was also associated with an elevated risk of postoperative myocardial infarction (relative risk 1.79, 95%CI 1.2–2.67, p < 0.001) and heart failure (relative risk 2.06, 95%CI 1.19–3.59, p < 0.001). Discussion Aortic stenosis in patients undergoing non‐cardiac surgery is associated with a three‐fold relative increase in the risk of mortality. These results highlight the need for further delineation of which surgical procedures are associated with the greatest risk of poor peri‐operative outcomes to guide heightened surveillance protocols, optimised peri‐operative management and thresholds for pre‐operative intervention.
主动脉瓣狭窄是非心脏手术后不良后果的危险因素；然而，关于该患者队列围手术期发病率和死亡率的现有数据仍然存在冲突。本系统综述和荟萃分析旨在量化主动脉瓣狭窄患者行非心脏手术的围手术期风险。方法根据检索策略的制定，检索数据库进行相关研究。主要终点是接受非心脏手术的患者与主动脉狭窄相关的院内全因死亡率或30天死亡率。次要终点包括：心肌梗死；心力衰竭;中风;精神错乱;静脉血栓栓塞;急性肾损伤。结果纳入19项研究，100,486例患者。任何程度主动脉狭窄患者的全因死亡率估计为3.8% (95%CI 3.7-3.9%)，严重主动脉狭窄患者的全因死亡率估计为9.6% （95%CI 7.7-12.1%）。一项涉及2,885,254例患者的14项比较研究的荟萃分析显示，主动脉瓣狭窄患者的死亡率明显高于无主动脉瓣狭窄患者（相对危险度1.58,95%CI 1.18-2.12, p < 0.001）。主动脉瓣狭窄也与术后心肌梗死（相对危险度1.79,95%CI 1.2-2.67, p < 0.001）和心力衰竭（相对危险度2.06,95%CI 1.19-3.59, p < 0.001）升高相关。非心脏手术患者主动脉瓣狭窄与死亡风险相对增加3倍相关。这些结果强调需要进一步描述哪些外科手术与围手术期预后不良风险最大相关，以指导加强监测方案，优化围手术期管理和术前干预阈值。
{"title":"Peri‐operative risk of non‐cardiac surgery in patients with aortic stenosis: a systematic review and meta‐analysis","authors":"Amelia Place, Thalys Sampaio Rodrigues, Phillip S. Naimo, Melissa G. Y. Lee, Riley J. Batchelor, Laurence Weinberg, Lachlan F. Miles, Jeffrey Lefkovits, Anoop N. Koshy","doi":"10.1111/anae.70084","DOIUrl":"https://doi.org/10.1111/anae.70084","url":null,"abstract":"Summary Introduction Aortic stenosis is a risk factor for adverse outcomes following non‐cardiac surgery; however, existing data regarding peri‐operative morbidity and mortality in this patient cohort remain conflicted. This systematic review and meta‐analysis aimed to quantify the peri‐operative risks in patients with aortic stenosis undergoing non‐cardiac surgery. Methods Following the development of our search strategy, we searched databases for relevant studies. The primary endpoint was all‐cause in‐hospital or 30‐day mortality associated with aortic stenosis in patients undergoing non‐cardiac surgery. Secondary endpoints included: myocardial infarction; heart failure; stroke; delirium; venous thromboembolism; and acute kidney injury. Results Nineteen studies involving 100,486 patients were included. The estimated all‐cause mortality was 3.8% (95%CI 3.7–3.9%) for patients with any degree of aortic stenosis and 9.6% (95%CI 7.7–12.1%) for those with severe aortic stenosis. A meta‐analysis of 14 comparative studies involving 2,885,254 patients revealed significantly increased mortality in patients with aortic stenosis compared with those without aortic stenosis (relative risk 1.58, 95%CI 1.18–2.12, p < 0.001). Aortic stenosis was also associated with an elevated risk of postoperative myocardial infarction (relative risk 1.79, 95%CI 1.2–2.67, p < 0.001) and heart failure (relative risk 2.06, 95%CI 1.19–3.59, p < 0.001). Discussion Aortic stenosis in patients undergoing non‐cardiac surgery is associated with a three‐fold relative increase in the risk of mortality. These results highlight the need for further delineation of which surgical procedures are associated with the greatest risk of poor peri‐operative outcomes to guide heightened surveillance protocols, optimised peri‐operative management and thresholds for pre‐operative intervention.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"10 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145731071","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Elisabeth M Groenewegen,Peter G Noordzij,Eline Vlot,Saskia Houterman,Toni Klok,Alexander J Spanjersberg,Maarten Ter Horst,Joost M A A Van Der Maaten,Susanne Eberl,Remco R Berendsen,R Arthur Bouwman,Bastiaan M Gerritse,Thierry V Scohy,Johannes S E Haenen,Jan Hofland,Marieke F Kingma,Jan Van Klarenbosch,Sander Bramer,Marcel P J De Korte,Nicobert E Wietsma,Olaf L Cremer,Lizbeth Burgos Ochoa,Thijs C D Rettig,
INTRODUCTIONPre-operative anaemia is an established risk factor for mortality after cardiac surgery. The extent to which this risk is mediated by complications related to red blood cell transfusion remains uncertain, particularly across different age groups.METHODSThis nationwide cohort study included adult cardiac surgery patients from the Netherlands Heart Registration. Pre-operative anaemia was defined according to World Health Organization criteria and red blood cell transfusion as any red blood cell transfusion during hospital stay. The main study endpoint was 120-day mortality. We used multivariable logistic regression to quantify the associations between pre-operative anaemia, red blood cell transfusion and 120-day mortality. Subsequently, a mediation analysis was conducted to quantify how much of the effect of pre-operative anaemia on postoperative mortality is because of red blood cell transfusion.RESULTSOf 71,053 patients, 14,452 (20.3%) had pre-operative anaemia. Of these, 7621 (52.7%) received red blood cell transfusion during hospital stay, compared with 9930 (17.5%) of patients without anaemia (p < 0.001). Observed 120-day mortality was 612 (4.2%) and 901 (1.6%), respectively. In multivariable regression analysis, pre-operative anaemia remained independently associated with postoperative mortality (adjusted odds ratio 1.66, 95%CI 1.47-1.87), with consistent effects across age groups. Mediation analysis showed that red blood cell transfusion accounted for 58.9% (95%CI 41.3-76.5%) of the association between pre-operative anaemia and 120-day mortality. The proportion mediated was larger in patients aged ≥ 70 years (77.3%, 95%CI 43.1-100%) compared with younger patients (39.3%, 95%CI 21.4-57.2%).DISCUSSIONA substantial part of the association between pre-operative anaemia and mortality after cardiac surgery is mediated by red blood cell transfusion during hospital stay. The mediating role of red blood cell transfusion was more pronounced in older patients.
{"title":"Pre-operative anaemia, red blood cell transfusion and mortality after cardiac surgery: a Netherlands Heart Registration mediation analysis.","authors":"Elisabeth M Groenewegen,Peter G Noordzij,Eline Vlot,Saskia Houterman,Toni Klok,Alexander J Spanjersberg,Maarten Ter Horst,Joost M A A Van Der Maaten,Susanne Eberl,Remco R Berendsen,R Arthur Bouwman,Bastiaan M Gerritse,Thierry V Scohy,Johannes S E Haenen,Jan Hofland,Marieke F Kingma,Jan Van Klarenbosch,Sander Bramer,Marcel P J De Korte,Nicobert E Wietsma,Olaf L Cremer,Lizbeth Burgos Ochoa,Thijs C D Rettig, ","doi":"10.1111/anae.70100","DOIUrl":"https://doi.org/10.1111/anae.70100","url":null,"abstract":"INTRODUCTIONPre-operative anaemia is an established risk factor for mortality after cardiac surgery. The extent to which this risk is mediated by complications related to red blood cell transfusion remains uncertain, particularly across different age groups.METHODSThis nationwide cohort study included adult cardiac surgery patients from the Netherlands Heart Registration. Pre-operative anaemia was defined according to World Health Organization criteria and red blood cell transfusion as any red blood cell transfusion during hospital stay. The main study endpoint was 120-day mortality. We used multivariable logistic regression to quantify the associations between pre-operative anaemia, red blood cell transfusion and 120-day mortality. Subsequently, a mediation analysis was conducted to quantify how much of the effect of pre-operative anaemia on postoperative mortality is because of red blood cell transfusion.RESULTSOf 71,053 patients, 14,452 (20.3%) had pre-operative anaemia. Of these, 7621 (52.7%) received red blood cell transfusion during hospital stay, compared with 9930 (17.5%) of patients without anaemia (p < 0.001). Observed 120-day mortality was 612 (4.2%) and 901 (1.6%), respectively. In multivariable regression analysis, pre-operative anaemia remained independently associated with postoperative mortality (adjusted odds ratio 1.66, 95%CI 1.47-1.87), with consistent effects across age groups. Mediation analysis showed that red blood cell transfusion accounted for 58.9% (95%CI 41.3-76.5%) of the association between pre-operative anaemia and 120-day mortality. The proportion mediated was larger in patients aged ≥ 70 years (77.3%, 95%CI 43.1-100%) compared with younger patients (39.3%, 95%CI 21.4-57.2%).DISCUSSIONA substantial part of the association between pre-operative anaemia and mortality after cardiac surgery is mediated by red blood cell transfusion during hospital stay. The mediating role of red blood cell transfusion was more pronounced in older patients.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"1 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145732592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Peter Van de Putte, Paul S. Myles, André Theron, Nabil Elkassabany, Kariem El‐Boghdadly
{"title":"Towards a dedicated quality of recovery scale for regional anaesthesia","authors":"Peter Van de Putte, Paul S. Myles, André Theron, Nabil Elkassabany, Kariem El‐Boghdadly","doi":"10.1111/anae.70090","DOIUrl":"https://doi.org/10.1111/anae.70090","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"1 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145673965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We read with interest the randomised controlled trial by Liu et al. [<span>1</span>], which showed the efficacy of a comprehensive peri-operative rehabilitation bundle in reducing postoperative pulmonary complications in patients undergoing elective cardiac valve surgery. Although maximal inspiratory pressure guided intensity progression in the rehabilitation group, the absence of paired pre- and postintervention spirometry and diaphragm ultrasound assessment limits mechanistic clarity [<span>2</span>]. Recent work emphasising diaphragm dysfunction as a key driver of postoperative morbidity suggests that quantifying diaphragmatic excursion, thickness changes and diaphragm thickening fraction could elucidate how inspiratory muscle training translates to clinical benefit [<span>3</span>]. Future studies incorporating these functional biomarkers would strengthen the pathophysiological framework linking respiratory muscle conditioning to a reduced incidence of pneumonia and atelectasis.</p> <p>The authors acknowledge that adherence to and feedback on self-directed training in the usual care group were unrecorded, potentially underestimating group differences. Implementation of objective monitoring tools such as electronic activity logs, wearable accelerometers or visual compliance checklists would clarify the distinction between usual care as delivered vs. intended. This is particularly important given that basic respiratory exercises are now standard in many Chinese hospitals, and documented adherence rates may reveal whether the advantage in patients allocated to the rehabilitation stems from supervised intensity escalation or simple engagement.</p> <p>Given emerging evidence that postoperative pulmonary complications are mediated by cardiopulmonary bypass-triggered systemic inflammation, concurrent measurement of high-sensitivity C-reactive protein, interleukin-6 and tumour necrosis factor-α at baseline, immediately postoperatively and at 48-h intervals could reveal whether peri-operative rehabilitation modulates inflammatory trajectory. Establishing correlations between respiratory muscle training intensity and inflammatory suppression would clarify whether benefits are driven mechanistically by immune modulation or purely functional, a distinction with implications for translating the intervention to higher-risk populations and informing future pharmacotherapeutic combinations.</p> <p>Despite these suggestions for methodological advancement, the pragmatic design and safety profile shown make this intervention particularly relevant for implementation in resource-constrained settings [<span>4</span>]. The study underscores that structured, supervised rehabilitation, even with modest training frequency, delivers clinically significant pneumonia reduction, supporting its integration into standard peri-operative pathways for patients with valvular heart disease [<span>5</span>]. We congratulate the authors on their rigorous work and look forward t
{"title":"Peri-operative rehabilitation bundles and postoperative pulmonary complications in elective cardiac valve surgery","authors":"Tian Ruan","doi":"10.1111/anae.70093","DOIUrl":"https://doi.org/10.1111/anae.70093","url":null,"abstract":"<p>We read with interest the randomised controlled trial by Liu et al. [<span>1</span>], which showed the efficacy of a comprehensive peri-operative rehabilitation bundle in reducing postoperative pulmonary complications in patients undergoing elective cardiac valve surgery. Although maximal inspiratory pressure guided intensity progression in the rehabilitation group, the absence of paired pre- and postintervention spirometry and diaphragm ultrasound assessment limits mechanistic clarity [<span>2</span>]. Recent work emphasising diaphragm dysfunction as a key driver of postoperative morbidity suggests that quantifying diaphragmatic excursion, thickness changes and diaphragm thickening fraction could elucidate how inspiratory muscle training translates to clinical benefit [<span>3</span>]. Future studies incorporating these functional biomarkers would strengthen the pathophysiological framework linking respiratory muscle conditioning to a reduced incidence of pneumonia and atelectasis.</p>\u0000<p>The authors acknowledge that adherence to and feedback on self-directed training in the usual care group were unrecorded, potentially underestimating group differences. Implementation of objective monitoring tools such as electronic activity logs, wearable accelerometers or visual compliance checklists would clarify the distinction between usual care as delivered vs. intended. This is particularly important given that basic respiratory exercises are now standard in many Chinese hospitals, and documented adherence rates may reveal whether the advantage in patients allocated to the rehabilitation stems from supervised intensity escalation or simple engagement.</p>\u0000<p>Given emerging evidence that postoperative pulmonary complications are mediated by cardiopulmonary bypass-triggered systemic inflammation, concurrent measurement of high-sensitivity C-reactive protein, interleukin-6 and tumour necrosis factor-α at baseline, immediately postoperatively and at 48-h intervals could reveal whether peri-operative rehabilitation modulates inflammatory trajectory. Establishing correlations between respiratory muscle training intensity and inflammatory suppression would clarify whether benefits are driven mechanistically by immune modulation or purely functional, a distinction with implications for translating the intervention to higher-risk populations and informing future pharmacotherapeutic combinations.</p>\u0000<p>Despite these suggestions for methodological advancement, the pragmatic design and safety profile shown make this intervention particularly relevant for implementation in resource-constrained settings [<span>4</span>]. The study underscores that structured, supervised rehabilitation, even with modest training frequency, delivers clinically significant pneumonia reduction, supporting its integration into standard peri-operative pathways for patients with valvular heart disease [<span>5</span>]. We congratulate the authors on their rigorous work and look forward t","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"10 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145657351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We read with interest the study by Liu et al. [1], which reported a large, single-centre randomised controlled trial evaluating a four-component peri-operative rehabilitation programme in patients undergoing elective cardiac valve surgery. We commend the authors for conducting this comprehensive trial and for showing a significant reduction in postoperative pulmonary complications, particularly pneumonia, within 7 days of surgery.
Despite the reduction in postoperative pulmonary complications, the composite outcome of mortality, prolonged hospitalisation and postoperative pulmonary complications did not differ between groups. This suggests that the weight assigned to each component obscured clinically meaningful benefits in respiratory recovery. A stratified or hierarchical approach to composite outcomes might provide clearer insight into which domains of recovery are sensitive to rehabilitation interventions [2].
The study population was relatively low risk, comprising predominantly younger patients with preserved left ventricular function and normal pulmonary reserve. In this context, the absolute event rate for mortality and prolonged hospitalisation was low. Given previous evidence that inspiratory muscle training and early mobilisation confer the greatest benefit in patients who are frail or high risk [3], replication of this multimodal programme in cohorts with advanced age, sarcopenia or impaired spirometry could help define the true therapeutic window of peri-operative rehabilitation.
While the safety and feasibility of the intervention were shown, implementation success was modest, with a median of only six inspiratory training sessions pre-operatively. Adherence tracking and continuation following discharge were not reported. Incorporating remote models might sustain engagement and extend functional recovery beyond hospital discharge [4].
Finally, the authors highlight that standard respiratory exercises were included in usual care, which potentially dilutes between-group effects. We suggest that multicentre designs where baseline physiotherapy practices are stratified could help delineate the incremental benefit attributable to structured rehabilitation bundles. To further broaden the applicability and long-term impact of peri-operative rehabilitation in cardiac valve surgery, we encourage research focused on developing tiered, risk-stratified rehabilitation strategies. Future studies should also explore the integration of multimodal prehabilitation for high-risk patients, which may improve physiological reserve before surgery and amplify the benefits of postoperative rehabilitation. Such strategies could yield better pulmonary outcomes, longer term functional capacity, quality of life and overall survival for a broader spectrum of patients undergoing cardiac valve surgery.
{"title":"Peri-operative rehabilitation in elective cardiac valve surgery","authors":"Jing-Xuan Zhou, Yuan Meng","doi":"10.1111/anae.70087","DOIUrl":"https://doi.org/10.1111/anae.70087","url":null,"abstract":"<p>We read with interest the study by Liu et al. [<span>1</span>], which reported a large, single-centre randomised controlled trial evaluating a four-component peri-operative rehabilitation programme in patients undergoing elective cardiac valve surgery. We commend the authors for conducting this comprehensive trial and for showing a significant reduction in postoperative pulmonary complications, particularly pneumonia, within 7 days of surgery.</p>\u0000<p>Despite the reduction in postoperative pulmonary complications, the composite outcome of mortality, prolonged hospitalisation and postoperative pulmonary complications did not differ between groups. This suggests that the weight assigned to each component obscured clinically meaningful benefits in respiratory recovery. A stratified or hierarchical approach to composite outcomes might provide clearer insight into which domains of recovery are sensitive to rehabilitation interventions [<span>2</span>].</p>\u0000<p>The study population was relatively low risk, comprising predominantly younger patients with preserved left ventricular function and normal pulmonary reserve. In this context, the absolute event rate for mortality and prolonged hospitalisation was low. Given previous evidence that inspiratory muscle training and early mobilisation confer the greatest benefit in patients who are frail or high risk [<span>3</span>], replication of this multimodal programme in cohorts with advanced age, sarcopenia or impaired spirometry could help define the true therapeutic window of peri-operative rehabilitation.</p>\u0000<p>While the safety and feasibility of the intervention were shown, implementation success was modest, with a median of only six inspiratory training sessions pre-operatively. Adherence tracking and continuation following discharge were not reported. Incorporating remote models might sustain engagement and extend functional recovery beyond hospital discharge [<span>4</span>].</p>\u0000<p>Finally, the authors highlight that standard respiratory exercises were included in usual care, which potentially dilutes between-group effects. We suggest that multicentre designs where baseline physiotherapy practices are stratified could help delineate the incremental benefit attributable to structured rehabilitation bundles. To further broaden the applicability and long-term impact of peri-operative rehabilitation in cardiac valve surgery, we encourage research focused on developing tiered, risk-stratified rehabilitation strategies. Future studies should also explore the integration of multimodal prehabilitation for high-risk patients, which may improve physiological reserve before surgery and amplify the benefits of postoperative rehabilitation. Such strategies could yield better pulmonary outcomes, longer term functional capacity, quality of life and overall survival for a broader spectrum of patients undergoing cardiac valve surgery.</p>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"1 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145657354","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Arterial lines: is the pulse still strong?","authors":"Andrew J. Johnston, Andrew Conway Morris","doi":"10.1111/anae.70099","DOIUrl":"https://doi.org/10.1111/anae.70099","url":null,"abstract":"Click on the article title to read more.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"3 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658077","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Ethical and inclusive challenges of machine learning in anaesthesia","authors":"Gianni R. Lorello, Mayur Murali","doi":"10.1111/anae.70089","DOIUrl":"10.1111/anae.70089","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"81 2","pages":"182-187"},"PeriodicalIF":6.9,"publicationDate":"2025-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145657352","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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