Background (aims, hypotheses, or objectives) Emergency laparotomy (EL) is a high‐risk surgical procedure associated with considerable morbidity and mortality around the world. A reliable risk‐assessment tool that is specific to patients undergoing EL allows the early identification of high‐risk patients and enables appropriate healthcare resource allocation. The objective of this study was to compare the commonly used Portsmouth‐physiologic and operative severity score for the enumeration of mortality and morbidity (P‐POSSUM) with the recently developed National Emergency Laparotomy Audit (NELA) score in terms of their accuracy for identifying patients at increased risk of 30‐day mortality in a predominantly Asian population. Methods Physiological and operative data from a prospectively collected audit of adult patients undergoing EL in 2018 and 2019 across two tertiary hospitals in Singapore were used to retrospectively calculate both the P‐POSSUM and NELA scores for each patient encounter. This was then compared to actual mortality rates to determine each model's accuracy and precision. Results 830 patients were included in the study with a 30‐day mortality of 5.66%. The area under the receiver operating characteristics curve (AUROC) was similar for both the NELA (0.86, p < 0.001, 95% CI 0.81–0.91) and the P‐POSSUM models (0.84, p < 0.001, 95% CI 0.78–0.89). While the models over‐predicted mortality, overall O:E ratios showed that the NELA model performance was superior to that of P‐POSSUM (0.58 [95% CI 0.43–0.77] compared to 0.34 [95% CI 0.26–0.46]). Conclusion The NELA risk‐prediction model accurately predicts 30‐day mortality in this large cohort of patients undergoing EL and outperforms the current P‐POSSUM model. We recommend that the NELA score should replace the P‐POSSUM score as a model to distinguish between high‐ and low‐risk patients undergoing EL.

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The education package was effective in teaching participants how to write an accurate AAP and improved their confidence and ability in demonstrating proper inhalation device technique. We believe that the package has the potential to be used more widely for either small-group or self-directed learning.

Background We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS). Methods This is a retrospective case-control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI. Results A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1-11.2%, stage 2-2.0%, stage 3-0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0-17.0] days vs 6.0 [4.0-8.0] days; P \ .001), more major complications (OR, 6.55; 95% CI, 3.00-14.35, P \ .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48-4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10 lmol/l; 95% CI, 1.03-1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06-0.39; P \ 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22-1.55; P \ 0.001), and major complications (OR, 5.55; 95% CI,; P \ 0.001). Conclusions Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.

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The Ambu® AuraGain™ (Ambu A/S, Ballerup, Denmark) is a newer phthalate-free, single-use supraglottic device with the advantage of a facility for tracheal intubation if necessary intraoperatively. We compared the oropharyngeal leak pressures and other performance variables between the AMBU AuraGain and the LMA® Supreme™ (Teleflex Medical, Athlone, Co. Westmeath, Ireland) in patients undergoing laparoscopic cholecystectomy and preperitoneoscopic inguinal herniorrhaphy with carbon dioxide insufflation under controlled ventilation. We recruited 120 American Society of Anesthesiologists physical status class I–3 patients between the ages of 21 and 80 years undergoing laparoscopic cholecystectomy or preperitoneoscopic inguinal herniorrhaphy into this single-centre randomised controlled trial. The primary outcome measure was the oropharyngeal leak pressures. Secondary outcomes included insertion parameters, ventilatory characteristics and postoperative sequelae. The AuraGain had slightly but significantly higher oropharyngeal leak pressures than the LMA Supreme (mean (standard deviation) 26.1 (6.9) versus 21.4 (4.7) cmH2O, P < 0.010). The overall insertion success of the AuraGain was comparable to the LMA Supreme (AuraGain 58/60 (96.7%); LMA Supreme 56/59 (94.9%), P = 0.679). The AuraGain was deemed more difficult to insert than the LMA Supreme, with 26/60 (43.3%) of AuraGain insertions graded easy versus 48/59 (81.4%) of LMA Supreme, P < 0.001. The mean time to insertion of the AuraGain was slightly longer than the LMA Supreme, 32.2 (10.5) versus 28.3 (12.0) s, P < 0.001. Intraoperative device failure occurred following carbon dioxide insufflation in one AuraGain and three LMA Supremes, bringing the perioperative success rate of AuraGain and LMA Supreme to 95% and 89.8%, respectively, P = 0.322. No cases of regurgitation and aspiration occurred, and minor postoperative complications were similar. The AuraGain exhibited higher oropharyngeal leak pressures than the LMA Supreme, but was slightly more difficult to insert. The higher oropharyngeal leak pressures suggest that ventilation might be less affected by high peak inspiratory pressures when using the AuraGain than the LMA Supreme.