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Intra-operative hypotension frequently complicates anaesthesia in older patients and is implicated in perioperative organ hypoperfusion and injury. The prevalence and corresponding treatment thresholds of hypotension are incompletely described in the UK. This study aimed to identify prevalence of intra-operative hypotension and its treatment thresholds in UK practice. Patients aged ≥ 65 years were studied prospectively from 196 UK hospitals within a 48-hour timeframe. The primary outcome was the incidence of hypotension (mean arterial pressure <65 mmHg; systolic blood pressure reduction >20%; systolic blood pressure <100 mmHg). Secondary outcomes included the treatment blood pressure threshold for vasopressors; incidence of acute kidney injury; myocardial injury; stroke; and in-hospital mortality. Additionally, anaesthetists providing care for included patients were asked to complete a survey assessing their intended treatment thresholds for hypotension. Data were collected from 4750 patients. Hypotension affected 61.0% of patients when defined as mean arterial pressure <65 mmHg, 91.3% of patients had >20% reduction in systolic blood pressure from baseline and 77.5% systolic blood pressure <100 mmHg. The mean (SD) blood pressure triggering vasopressor therapy was mean arterial pressure 64.2 (11.6) mmHg and the mean (SD) stated intended treatment threshold from the survey was mean arterial pressure 60.6 (9.7) mmHg. A composite adverse outcome of myocardial injury, kidney injury, stroke or death affected 345 patients (7.3%). In this representative sample of UK peri-operative practice, the majority of older patients experienced intra-operative hypotension and treatment was delivered below suggested thresholds. This highlights both potential for intraoperative organ injury and substantial opportunity for improving treatment of intra-operative hypotension.

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Background Direct drug provocation testing (DPT) in patients with low-risk penicillin allergy labels would allow population-level de-labelling. We sought to determine the incidence and nature of penicillin allergy labels in a large UK surgical cohort and to define patient and anaesthetist attitudes towards penicillin allergy testing. Methods A prospective cross-sectional study was performed in 213 UK hospitals. Penicillin allergic patients were interviewed and risk-stratified. Knowledge and attitudes around penicillin allergy were defined in patients and anaesthetists, determining potential barriers to widespread testing. Findings Of 21,281 patients 12% self-reported penicillin allergy and 67% of these were potentially suitable for direct DPT (stratified low or intermediate risk). Irrespective of risk category 62% wanted allergy testing. Of 4,978 anaesthetists 40% claimed to routinely administer penicillin when they judge the label to be low-risk; 64% would then tell the patient they had received penicillin. Only 47% of all anaesthetists would be happy to administer penicillin to a patient previously de-labelled by an allergy specialist using direct DPT; the commonest reason not to administer penicillin was perceived lack of support from their hospital. On the study days, 13% of low-risk patients requiring penicillin received it, and 6 patients with high-risk labels received it. There were no adverse events in any of this group. However, 1 patient who received an alternative antibiotic suffered suspected anaphylaxis to this. Interpretation The majority of patients with a penicillin allergy label may be suitable for direct DPT and demand for testing is high among patients. Anaesthetists demonstrate inconsistent, potentially unsafe prescribing in patients labelled as penicillin allergic. More than half of anaesthetists are not reassured by a negative DPT undertaken by a specialist. Significant knowledge gaps may prevent widespread de-labelling being effectively implemented in surgical patients.

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