Christopher Oddy,Dominic Lowcock,Thomas W Davies,Sarah Towey,Mark Burnett,Amanda Davis,Gareth Davey,Adam Green,Olivia Bools,Michael Coulton,Henry Lewith,Paolo Perella,Danny J N Wong, ,
INTRODUCTIONThe enhanced care model of peri-operative care has evolved to meet increasing surgical demand, aiming to relieve pressure on critical care and prevent unnecessary cancellation of surgery. Despite widespread adoption of these facilities in the UK, no resources currently describe the national landscape of enhanced care or the organisational impacts of their introduction.METHODSWe conducted a UK-wide, retrospective, observational study. At each site, the local structure of enhanced (level 1) and critical care (levels 2-3) services was recorded alongside time-series data describing patient flow and individual details for all referrals to levels 1-3. Multilevel regression was used to explore the relationships between referral to an enhanced care facility and various organisational outcomes. A cluster analysis was performed to group enhanced care units with similar characteristics.RESULTSData were collected between September and November 2023. Of 110 participating centres, 70 (63.6%) had a surgical level 1 unit. In total, 5990 patient referrals to levels 1-3 were followed up, of which 3146 (52.5%) were referred to level 1 and 2844 (47.5%) to levels 2-3. Enhanced care patients were younger, with fewer comorbidities, and were undergoing less complex surgery than those referred to critical care. Referral to level 1 rather than levels 2-3 was associated with a reduced likelihood of cancellation (OR 0.50, 95%CI 0.40-0.64, p < 0.001); cancellation due to a lack of bed (OR 0.27, 95%CI 0.19-0.40, p < 0.001); and a shorter duration of hospital stay (incidence risk ratio 0.58, 95%CI 0.55-0.61, p < 0.001).DISCUSSIONEnhanced care services provide a suitable alternative to critical care for high-risk surgical patients in the UK whilst building surgical capacity and system resilience. These facilities are associated with improved organisational outcomes, associations which may reflect both operational efficiency and the lower clinical acuity of the population they serve.
围手术期强化护理模式的发展是为了满足日益增长的手术需求，旨在减轻重症监护的压力，防止不必要的手术取消。尽管这些设施在英国被广泛采用，但目前没有资源描述加强护理的国家景观或它们的引入对组织的影响。方法我们进行了一项全英国范围的回顾性观察性研究。在每个站点，记录了当地强化（1级）和重症监护（2-3级）服务的结构，以及描述患者流程和所有转介至1-3级的个人详细信息的时间序列数据。使用多水平回归来探索转诊到强化护理机构和各种组织结果之间的关系。对具有相似特征的强化护理单位进行聚类分析。结果数据采集时间为2023年9 - 11月。在110个参与的中心中，70个（63.6%）有一级外科科室。总共随访了5990例转诊至1-3级的患者，其中3146例（52.5%）转诊至1级，2844例（47.5%）转诊至2-3级。强化护理的患者更年轻，合并症更少，接受的手术比重症监护的患者更简单。转介到1级而不是2-3级与降低取消的可能性相关（OR 0.50, 95%CI 0.40-0.64, p < 0.001）；因床位不足而取消（OR 0.27, 95%CI 0.19-0.40, p < 0.001）；住院时间较短（发病率风险比0.58,95%CI 0.55 ~ 0.61, p < 0.001）。讨论增强的护理服务提供了一个合适的替代重症监护高危手术患者在英国，同时建立手术能力和系统弹性。这些设施与改善的组织成果有关，这些联系可能反映了运营效率和他们所服务的人群的临床敏锐度较低。
{"title":"Structural and organisational impacts of peri-operative enhanced care services in the UK: a Retrospective Evaluation of Postoperative Alternatives to Critical Care (REPACC).","authors":"Christopher Oddy,Dominic Lowcock,Thomas W Davies,Sarah Towey,Mark Burnett,Amanda Davis,Gareth Davey,Adam Green,Olivia Bools,Michael Coulton,Henry Lewith,Paolo Perella,Danny J N Wong, , ","doi":"10.1111/anae.70057","DOIUrl":"https://doi.org/10.1111/anae.70057","url":null,"abstract":"INTRODUCTIONThe enhanced care model of peri-operative care has evolved to meet increasing surgical demand, aiming to relieve pressure on critical care and prevent unnecessary cancellation of surgery. Despite widespread adoption of these facilities in the UK, no resources currently describe the national landscape of enhanced care or the organisational impacts of their introduction.METHODSWe conducted a UK-wide, retrospective, observational study. At each site, the local structure of enhanced (level 1) and critical care (levels 2-3) services was recorded alongside time-series data describing patient flow and individual details for all referrals to levels 1-3. Multilevel regression was used to explore the relationships between referral to an enhanced care facility and various organisational outcomes. A cluster analysis was performed to group enhanced care units with similar characteristics.RESULTSData were collected between September and November 2023. Of 110 participating centres, 70 (63.6%) had a surgical level 1 unit. In total, 5990 patient referrals to levels 1-3 were followed up, of which 3146 (52.5%) were referred to level 1 and 2844 (47.5%) to levels 2-3. Enhanced care patients were younger, with fewer comorbidities, and were undergoing less complex surgery than those referred to critical care. Referral to level 1 rather than levels 2-3 was associated with a reduced likelihood of cancellation (OR 0.50, 95%CI 0.40-0.64, p < 0.001); cancellation due to a lack of bed (OR 0.27, 95%CI 0.19-0.40, p < 0.001); and a shorter duration of hospital stay (incidence risk ratio 0.58, 95%CI 0.55-0.61, p < 0.001).DISCUSSIONEnhanced care services provide a suitable alternative to critical care for high-risk surgical patients in the UK whilst building surgical capacity and system resilience. These facilities are associated with improved organisational outcomes, associations which may reflect both operational efficiency and the lower clinical acuity of the population they serve.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"162 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145477653","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}
Alemayehu H. Jufar, Clive N. May, Taku Furukawa, Roger G. Evans, Andrew D. Cochrane, Bruno Marino, Jaishankar Raman, Peter R. McCall, Abraham Hulst, Sally G. Hood, Anton Trask-Marino, Rinaldo Bellomo, Lachlan F. Miles, Yugeesh R. Lankadeva
Introduction
Intra-operative hypotension is common during cardiopulmonary bypass and may contribute to tissue hypoxia. Tissue hypoxia has been linked to the development of postoperative kidney and brain injury. Vasopressors are used to treat hypotension during and after cardiopulmonary bypass. However, the effects of these drugs on renal and cerebral tissue oxygenation and perfusion are unknown. We tested the effects of four vasopressors on renal and cerebral tissue perfusion and oxygenation in a clinically-relevant ovine model of cardiopulmonary bypass.
Methods
We studied 16 sheep before and after induction of anaesthesia and during 2.5 h of cardiopulmonary bypass. After commencing cardiopulmonary bypass at a target non-pulsatile flow of 2.4 l.min-1.m-2, we observed a baseline period with a target mean arterial pressure of 50–60 mmHg, after which we targeted a mean arterial pressure of 75–85 mmHg using a continuous infusion of metaraminol (n = 8); noradrenaline (n = 8); phenylephrine (n = 8); or vasopressin (n = 7). Sheep were allocated randomly to receive two of the four vasopressors.
Results
Compared with the pre-induction state, cardiopulmonary bypass significantly decreased renal medullary tissue perfusion (median (IQR [range]) decrease 55 (4–82 [1–99])%; p = 0.01) and medullary oxygen tension (mean (SD) difference 3.1 (2.5) kPa; p < 0.001). Cardiopulmonary bypass did not significantly alter cerebral tissue perfusion or oxygenation compared with the pre-induction state. Infusing noradrenaline significantly decreased medullary oxygen tension (mean (SD) difference 2.7 (1.6) kPa; p = 0.003). This decrease in medullary oxygen tension was significant compared with vasopressin (mean difference -3.4 kPa, 95%CI -5.7 to -1.0; p = 0.008). No vasopressor infusion significantly altered renal medullary perfusion, cerebral tissue perfusion or oxygenation.
Discussion
Intra-operative noradrenaline during ovine cardiopulmonary bypass worsens renal medullary tissue oxygenation relative to vasopressin. These findings suggest that the choice of vasopressors may affect renal oxygenation.
{"title":"Effects of noradrenaline, vasopressin, phenylephrine or metaraminol on kidney and brain microcirculation in ovine cardiopulmonary bypass: a randomised trial","authors":"Alemayehu H. Jufar, Clive N. May, Taku Furukawa, Roger G. Evans, Andrew D. Cochrane, Bruno Marino, Jaishankar Raman, Peter R. McCall, Abraham Hulst, Sally G. Hood, Anton Trask-Marino, Rinaldo Bellomo, Lachlan F. Miles, Yugeesh R. Lankadeva","doi":"10.1111/anae.70049","DOIUrl":"10.1111/anae.70049","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Intra-operative hypotension is common during cardiopulmonary bypass and may contribute to tissue hypoxia. Tissue hypoxia has been linked to the development of postoperative kidney and brain injury. Vasopressors are used to treat hypotension during and after cardiopulmonary bypass. However, the effects of these drugs on renal and cerebral tissue oxygenation and perfusion are unknown. We tested the effects of four vasopressors on renal and cerebral tissue perfusion and oxygenation in a clinically-relevant ovine model of cardiopulmonary bypass.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We studied 16 sheep before and after induction of anaesthesia and during 2.5 h of cardiopulmonary bypass. After commencing cardiopulmonary bypass at a target non-pulsatile flow of 2.4 l.min<sup>-1</sup>.m<sup>-2</sup>, we observed a baseline period with a target mean arterial pressure of 50–60 mmHg, after which we targeted a mean arterial pressure of 75–85 mmHg using a continuous infusion of metaraminol (n = 8); noradrenaline (n = 8); phenylephrine (n = 8); or vasopressin (n = 7). Sheep were allocated randomly to receive two of the four vasopressors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Compared with the pre-induction state, cardiopulmonary bypass significantly decreased renal medullary tissue perfusion (median (IQR [range]) decrease 55 (4–82 [1–99])%; p = 0.01) and medullary oxygen tension (mean (SD) difference 3.1 (2.5) kPa; p < 0.001). Cardiopulmonary bypass did not significantly alter cerebral tissue perfusion or oxygenation compared with the pre-induction state. Infusing noradrenaline significantly decreased medullary oxygen tension (mean (SD) difference 2.7 (1.6) kPa; p = 0.003). This decrease in medullary oxygen tension was significant compared with vasopressin (mean difference -3.4 kPa, 95%CI -5.7 to -1.0; p = 0.008). No vasopressor infusion significantly altered renal medullary perfusion, cerebral tissue perfusion or oxygenation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>Intra-operative noradrenaline during ovine cardiopulmonary bypass worsens renal medullary tissue oxygenation relative to vasopressin. These findings suggest that the choice of vasopressors may affect renal oxygenation.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"81 3","pages":"383-394"},"PeriodicalIF":6.9,"publicationDate":"2025-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145477657","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":"Effects of anaesthesia and surgery on sleep–wake timing and subjective sleep quality in children: a reply","authors":"Jorinde A. W. Polderman, Mark L. van Zuylen","doi":"10.1111/anae.70071","DOIUrl":"https://doi.org/10.1111/anae.70071","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"61 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145461322","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":"Routine pre‐operative modified telephone interview for cognitive status screening: feasible, but is it justified?","authors":"Mark L. van Zuylen","doi":"10.1111/anae.70064","DOIUrl":"https://doi.org/10.1111/anae.70064","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"39 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145462293","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}
Renata K. Carvalho, Gustavo A. Moreira, Sergio Tufik, Monica L. Andersen
{"title":"Time, sleep and children: integrating chronobiology into anaesthesia","authors":"Renata K. Carvalho, Gustavo A. Moreira, Sergio Tufik, Monica L. Andersen","doi":"10.1111/anae.70065","DOIUrl":"https://doi.org/10.1111/anae.70065","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"13 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145461319","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":"The ‘afternoon effect’ as a proxy for systemic vulnerabilities in surgical care","authors":"Yu‐Chi Su, Pei‐Yi Hung, Ming‐Hui Hung","doi":"10.1111/anae.70066","DOIUrl":"https://doi.org/10.1111/anae.70066","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"14 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145461323","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":"Dexmedetomidine and postoperative cardiac surgical delirium: methodological concerns and small effect sizes","authors":"Liwen Liu, Gaosheng Su, Zhong Lin","doi":"10.1111/anae.70073","DOIUrl":"https://doi.org/10.1111/anae.70073","url":null,"abstract":"","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"100 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145461321","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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