Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Nearly all geriatric surgical complications are studied in the context of a single organ system, e.g., cardiac complications and the heart; delirium and the brain; infections and the immune system. Yet, we know that advanced age, physiological stress, and infection all increase sympathetic and decrease parasympathetic nervous system function. Parasympathetic function is mediated through the vagus nerve, which connects the heart, brain, and immune system to form, what we have termed, the brain-heart-immune axis. We hypothesize that this brain-heart-immune axis plays a critical role in surgical recovery among older adults. In particular, we hypothesize that the brain-heart-immune axis plays a critical role in the most common surgical complication among older adults: postoperative delirium. Further, we present heart rate variability as a measure that may eventually become a multi-system vital sign evaluating brain-heart-immune axis function. Finally, we suggest the brain-heart-immune axis as a potential interventional target for bio-electronic neuro-immune modulation to enhance resilient surgical recovery among older adults.

OBJECTIVE: Postoperative complications such as postoperative pulmonary complications (PPCs) and other organ complications are associated with increased morbidity and mortality after successful lung transplantation and have a detrimental effect on patient recovery. The aim of this study was to investigate perioperative risk factors for in-hospital mortality and postoperative complications with a focus on PPC and graft injury in patients undergoing lung transplantation DESIGN: Single-center retrospective cohort study of 173 patients undergoing lung transplantation SETTING: University Hospital, Medical Center Freiburg.
RESULTS: In the stepwise multivariate regression analysis, donor age >60 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.27-2.81), intraoperative extracorporeal membrane oxygenation (OR, 2.4; 95% CI, 1.7-3.3), transfusion of >4 red blood cell concentrates (OR, 3.1; 95% CI, 1.82-5.1), mean pulmonary artery pressure of >30 mmHg at the end of surgery (OR, 3.5; 95% CI, 2-6.3), the occurrence of postoperative graft injury (OR, 4.1; 95% CI, 2.8-5.9), PPCs (OR, 2.1; 95% CI, 1.7-2.6), sepsis (OR, 4.5; 95% CI, 2.8-7.3), and Kidney disease Improving Outcome grading system stage 3 acute renal failure (OR, 4.3; 95% CI, 2.4-7.7) were associated with increased in hospital mortality, whereas patients with chronic obstructive pulmonary disease had a lower in-hospital mortality (OR, 1.6; 95% CI, 1.4-1.9). The frequency and number of PPCs correlated with postoperative mortality.
CONCLUSIONS: Clinical management and risk stratification focusing on the underlying identified factors that could help to improve patient outcomes.

The rapidly developing field of artificial intelligence (AI) may soon equip clinicians with algorithms that model and predict perioperative problems with extreme accuracy. Here, we outline emerging AI applications in preoperative risk stratification and intraoperative event prediction, where algorithm performance has been shown to outstrip commonly used conventional risk prediction tools. While offering an enticing view of a novel perioperative practice with superhuman foresight, AI\'s limited scope and lack of transparency remain key challenges for widespread adoption. As yet it is unclear whether machine learning alone can influence human clinical practice to exert real-world effects on patient outcomes.

Adoption of electronic health record systems offers an opportunity to collate massive volumes of complex information about patient care. Healthcare data can inform performance management, enable predictive analytics and enhance strategic decision making. A data-driven approach to improving patient care is vital to address the growing burden of morbidity and mortality associated with major surgery. We describe our methodology for transforming and utilising process of care data in an electronic health record system to develop a registry for quality improvement purposes in patients undergoing major surgery at a single UK hospital. We highlight development of our data-driven vision, technical aspects of processing raw data into metrics relevant to clinical decision making, alongside challenges encountered. Finally, we outline how our data infrastructure supports clinical governance, quality improvement and research. In sharing our experiences, we hope to enable others to embed and access the transformative clinical insights that healthcare data can yield.

Background/Objectives: New-onset atrial fibrillation (AF) after cardiac surgery is associated with patient-important outcomes. Uncertainty persists regarding its prevention, detection, and management. This review seeks to identify, compile, and describe ongoing registered research studies involving patients with or at risk for post-operative AF (POAF) after cardiac surgery. Methods: We searched clinical trial registries in January 2023 for studies focusing on POAF prediction, prevention, detection, or management. We extracted data from each record and performed descriptive analyses. Results: In total, 121 studies met the eligibility criteria, including 82 randomized trials. Prevention studies are the most common (n = 77, 63.6%), followed by prediction (n = 21, 17.4%), management (n = 16, 13.2%), and detection studies (n = 7, 5.8%). POAF after cardiac surgery is an area of active research. Conclusions: There are many ongoing randomized prevention studies. However, two major clinical gaps persist; future randomized trials should compare rate and rhythm control in patients who develop POAF, and long-term follow-up studies should investigate strategies to monitor for AF recurrence in patients with POAF.

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OBJECTIVE: Perioperative in-hospital cardiac arrests (Perioperative IHCAs) may have better outcomes than IHCAs in the ward (Ward IHCAs), due to enhanced monitoring and faster response. However, quantitative comparisons of their long-term outcomes are lacking, posing challenges for prognostication.
METHODS: This retrospective multicentre study included adult intensive care unit (ICU) admissions from theatre/recovery or wards with a diagnosis of cardiac arrest between January 2018 and March 2022. We used data from 175 ICUs in the ANZICS adult patient database. The primary outcome was a survival time of up to 4 years. We used the Cox proportional hazards model adjusted for Sequential Organ Failure Assessment (SOFA) score, age, sex, comorbidities, hospital type, treatment limitation on admission to the ICU, and ICU treatments. Subgroup analyses examined age (≥ 65 years), intubation within the first 24 h, elective vs. emergency admission, and survival on discharge.
RESULTS: Of 702,675 ICU admissions, 5,659 IHCAs were included (Perioperative IHCA 38%; Ward IHCA 62%). Perioperative IHCA group were younger, less frail, and less comorbid. Perioperative IHCA were most frequent in patients admitted to ICU after cardiovascular, gastrointestinal, or trauma surgeries. Perioperative IHCA group had longer 4-year survival (59.9% vs. 33.0%, p < 0.001) than the Ward IHCA group, even after adjustments (adjusted hazard ratio [HR]: 0.63, 95% confidence interval [CI] 0.57-0.69). This was concordant across all subgroups. Of note, older patients with Perioperative IHCA survived longer than both younger and older patients with Ward IHCA.
CONCLUSIONS: Patients admitted to the ICU following Perioperative IHCA had longer survival than Ward IHCA. Future studies on IHCA should distinguish these patients.

BACKGROUND: Patients undergoing surgery deserve the best possible peri-operative outcomes. Each stage of the peri-operative patient journey offers opportunities to improve care delivery, with shorter lengths of stay, less complications, reduced costs and better value.
METHODS: These opportunities were identified through narrative review of the literature, with consultation and consensus at the hidden pandemic (of postoperative complications) summit 2, July 2023 in Adelaide, Australia RESULTS: Before surgery: Some patients who receive timely alternative treatments may not need surgery at all. The period of waiting after listing should be a time of preparation. Risk assessment at the time of surgical listing facilitates recognition of need for comorbidity optimisation and identifies those who will most benefit from prehabilitation, particularly frail and deconditioned patients.
UNASSIGNED: During the surgical admission, ERAS programs result in less postoperative complications, shorter length of stay and better patient experience but require agreement between clinicians, and coordinated monitoring of delivery of the elements in the ERAS bundle of care.
UNASSIGNED: At-risk patients need to have the appropriate levels of monitoring for cardiovascular instability, renal impairment or respiratory dysfunction, to facilitate timely, proactive management if they develop. Access to allied health in the early postoperative period is also critical for promoting mobility, and earlier discharge, particularly after joint surgery. Where appropriate, provision of rehabilitation services at home improves patient experience and adds value. The peri-operative patient journey begins and ends with primary care so there is a need for clear communication, documentation, around sharing of responsibility between practitioners at each stage.
CONCLUSIONS: Identifying and mitigating risk to reduce complications and length of stay in hospital will improve outcomes for patients and deliver the best value for the health system.

UNASSIGNED: This article describes the statistical analysis plan for the Biomarker-guided intervention to prevent AKI after major surgery (BigpAK-2) trial.
UNASSIGNED: Adaptive trial design with an interim analysis after enrolment of 618 evaluable patients.
UNASSIGNED: The BigpAK.-2 trial is an international, prospective, randomised controlled multicentre study.
UNASSIGNED: The BigpAK-2 study enrols patients after major surgery who are admitted to the intensive care or high dependency unit and are at high-risk for postoperative AKI as identified by urinary biomarkers (tissue inhibitor of metalloproteinases-2 and insulin-like growth factor binding protein 7 ([TIMP-2]∗[IGFBP7]) will be enrolled.
UNASSIGNED: Patients are randomly and evenly allocated to standard of care (control) group or the implementation of a nephroprotective care bundle (intervention group), as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The KDIGO care bundle recommends discontinuation of nephrotoxic agents if possible, ensuring adequate volume status and perfusion pressure, considering functional haemodynamic monitoring, regular monitoring of serum creatinine and urine output, avoiding hyperglycemia, and considering alternatives to radiocontrast procedures when possible.
UNASSIGNED: The BigpAK-2 study investigates whether the biomarker-gudied implementation of the KDIGO care bundle reduces the incidence of moderate or severe AKI (stage 2 or 3), according to the KDIGO 2012 criteria, within 72 h after surgery.
UNASSIGNED: AKI is a common and often severe complication after major surgery. As no specific treatments exist, prevention of AKI is of high importance. The BigpAK-2 study investigates a promising approach to prevent AKI after major surgery.
UNASSIGNED: The trial was registered prior to start at clinicaltrials.gov; NCT04647396.