The use of perioperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative events and inform the perioperative management of patients undergoing surgery has increased over the last decade. CPET provides an objective assessment of exercise capacity preoperatively and identifies the causes of exercise limitation. This information may be used to assist clinicians and patients in decisions about the most appropriate surgical and non-surgical management during the perioperative period. Information gained from CPET can be used to estimate the likelihood of perioperative morbidity and mortality, to inform the processes of multidisciplinary collaborative decision making and consent, to triage patients for perioperative care (ward vs critical care), to direct preoperative interventions and optimization, to identify new comorbidities, to evaluate the effects of neoadjuvant cancer therapies, to guide prehabilitation and rehabilitation, and to guide intraoperative anaesthetic practice. With the rapid uptake of CPET, standardization is key to ensure valid, reproducible results that can inform clinical decision making. Recently, an international Perioperative Exercise Testing and Training Society has been established (POETTS www.poetts.co.uk) promoting the highest standards of care for patients undergoing exercise testing, training, or both in the perioperative setting. These clinical cardiopulmonary exercise testing guidelines have been developed by consensus by the Perioperative Exercise Testing and Training Society after systematic literature review. The guidelines have been endorsed by the Association of Respiratory Technology and Physiology (ARTP).

SummarySevoflurane, desflurane and isoflurane were compared using a circle system in 97 patients undergoing short surgical procedures. Using initial high flows, the time intervals to equilibration between inspired and end-expired agent concentrations were measured; equilibration was defined as F E = F I 0:8. The mean (SD) times obtained for sevoflurane, desflurane and isoflurane were 8.2 (2.1) min, 3.8 (0.7) min and 19.7 (6.5) min, respectively. These times were significantly different from each other (p < 0:0001). After equilibration total flows were reduced to 500 ml.min ÿ 1 ; at these flows the initial decline in end-expired agent concentration was minimal with desflurane, intermediate with sevoflurane and greatest with isoflurane. Both desflurane and sevoflurane are appropriate for efficient use of the circle system during short anaesthetics.Keywords Anaesthetics, volatile; sevoflurane, desflurane, isoflurane. Equipment; breathing systems, circle, closed. ...................................................................................... Correspondence to: Dr N. Soni Accepted: 17 November 1996 In contrast to other anaesthetic breathing systems in common use, the circle system has the unique advantage of permitting anaesthesia with low fresh gas flows, thereby conferring physiological, economic and environmental benefits [1, 2]. In clinical practice, the important considerations when using circle systems are firstly the initial period of high gas inflow required to denitrogenate the lungs and attain an adequate alveolar anaesthetic concentration and subsequently the effective maintenance of this concentration during low flows. There is no general agreement as to what constitutes an adequate alveolar concentration before flows can be reduced. Low-flow anaesthesia is commonly instituted only after about 20 min at high flows, but this precludes the efficient use of the circle system for the large proportion of anaesthetics which are of short duration. (The term 'efficient' refers to a low value for the ratio of fresh gas flow to expired minute volume. This is obtained by flows classified minimal (250-500 ml.min ÿ 1 ) or low (500-1000 ml.min ÿ 1 ), using the terminology proposed by Simionescu [3].It has been shown that, when desflurane is used in the circle system, an adequate alveolar concentration, as indicated by end-expired (F E 0 ) desflurane concentration, is rapidly achieved [4]. This allows reduction of fresh gas flow after a very short time, with the end-expired desflurane concentration effectively maintained at flows of 500 ml.min ÿ 1 . In contrast, isoflurane takes longer for endexpired and inspired (F I ) concentrations to equilibrate [4], and after flow reduction end-expired isoflurane concentrations are poorly maintained. Sevoflurane has not been studied in this context, although its physical properties [5] suggest that it should behave similarly to desflurane. This study compares sevoflurane, desflurane and isoflurane for efficient use of the circle system during short anaesthetics. Me...

Preoperative CPX testing, combined with simple co-morbidity scoring, identified patients unlikely to survive in the mid-term, even after successful AAA repair.

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BackgroundCardiopulmonary exercise testing (CPET) is an exercise stress test with concomitant expired gas analysis that provides an objective, non-invasive measure of functional capacity under stress. CPET-derived variables predict postoperative morbidity and mortality after major abdominal and thoracic surgery. Two previous surveys have reported increasing utilisation of CPET preoperatively in England. We aimed to evaluate current CPET practice in the UK, to identify who performs CPET, how it is performed, how the data generated are used and the funding models.MethodsAll anaesthetic departments in trusts with adult elective surgery in the UK were contacted by telephone to obtain contacts for their pre-assessment and CPET service leads. An online survey was sent to all leads between November 2016 and March 2017.ResultsThe response rate to the online survey was 73.1% (144/197) with 68.1% (98/144) reporting an established clinical service and 3.5% (5/144) setting up a service. Approximately 30,000 tests are performed a year with 93.0% (80/86) using cycle ergometry. Colorectal surgical patients are the most frequently tested (89.5%, 77/86). The majority of tests are performed and interpreted by anaesthetists. There is variability in the methods of interpretation and reporting of CPET and limited external validation of results.ConclusionsThis survey has identified the continued expansion of perioperative CPET services in the UK which have doubled since 2011. The vast majority of CPET tests are performed and reported by anaesthetists. It has highlighted variation in practice and a lack of standardised reporting implying a need for practice guidelines and standardised training to ensure high-quality data to inform perioperative decision making.

SummaryThe majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115). They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%). Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%, 95%CI 55.8-75.4%) had clinics for high-risk surgical patients. However, 80 (93%, 70.2-87.2%) expressed a desire for support and training in shared decision-making. We asked about management of pre-operative anaemia, and identified that 69 (80%, 71.5-88.1%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively. A need for perioperative support in managing frailty and cognitive impairment was identified, as few (24%, 6.5-34.5%) respondents indicated that they had access to specific interventions. Respondents were asked to rank their 'top five' priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction; and primary care collaboration. We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

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Brain oxygenation is currently monitored by using jugular bulb oximetry, which attracts a number of potential artifacts and may not reflect regional changes in oxygenation. We compared this method with measurement of brain tissue oxygenation using a multiparameter sensor inserted into brain tissue. The brain tissue monitor seemed to reflect regional brain oxygenation better than jugular bulb oximetry.