British journal of anaesthesia
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Observational Study
Heart failure diagnostic accuracy, intraoperative fluid management, and postoperative acute kidney injury: a single-centre prospective observational study.
The accurate diagnosis of heart failure (HF) before major noncardiac surgery is frequently challenging. The impact of diagnostic accuracy for HF on intraoperative practice patterns and clinical outcomes remains unknown. ⋯ An accurate preoperative diagnosis of heart failure before noncardiac surgery is associated with reduced intraoperative fluid administration and less acute kidney injury. Targeted efforts to improve preoperative diagnostic accuracy for heart failure may improve perioperative outcomes.
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Intraoperative hypotension is associated with acute kidney injury (AKI). Clinicians thus frequently use vasopressors, such as norepinephrine, to maintain blood pressure. However, vasopressors themselves might promote AKI. We sought to determine whether both intraoperative hypotension and cumulative intraoperative norepinephrine dose are independently associated with postoperative AKI in patients undergoing noncardiac surgery. ⋯ Both intraoperative hypotension and cumulative intraoperative norepinephrine dose were independently associated with postoperative AKI in patients undergoing noncardiac surgery. Pending results of trials testing whether these relationships are causal, it seems prudent to avoid both profound hypotension and high norepinephrine doses in adults undergoing noncardiac surgery.
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Total hip replacement surgery is performed to improve quality of life (QoL). We explored the association between multimorbidity and change in QoL after total hip replacement. ⋯ Hip replacement surgery improves QoL. However, patients with multimorbidity are less likely to experience these benefits. Poor QoL outcomes became more frequent as the number of comorbid diseases increased. These data should inform shared decision-making conversations around joint replacement surgery.
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With an ageing world population and increasing prevalence, heart failure is increasingly frequent as a comorbidity in operative patients, and its accurate preoperative diagnosis is essential to improve postoperative prognosis in patients undergoing noncardiac surgery. Use of electronic health records to assist in the accuracy of diagnosis and definition of an adjudicated heart failure reference standard could help guide intraoperative practice and improve outcomes in patients with heart failure.
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Operating theatres are steeply hierarchical, and yet the hierarchy between surgeons and anaesthetists is unclear, even blurry. Both the steep hierarchy and the blurriness at the top can present a risk to patient safety through inhibiting speaking up with concerns and negotiating safe patient care. ⋯ The study prompts us to confront hierarchy in operating theatres and to address its negative effects. This might include explicit whole-team reflections on the hierarchies that divide us, working to overcome divisions through identifying our common values and goals in patient care, and building shared decision-making into our organisational structures and patient care processes so that they no longer reinforce historical hierarchies but rather reflect the needs and realities of modern healthcare.