Patient satisfaction is an important measure of the quality of health care and is used as an outcome measure in interventional and quality improvement studies. Previous studies have found that there are few appropriately developed and validated questionnaires available. The authors conducted a systematic review to identify all tools used to measure patient satisfaction with anesthesia, which have undergone a psychometric development and validation process, appraised the quality of these processes, and made recommendations of tools that may be suitable for use in different clinical and academic settings. There are a number of robustly developed and subsequently validated instruments, however, there are still many studies using nonvalidated instruments or poorly developed tools, claiming to accurately assess satisfaction with anesthesia. This can lead to biased and inaccurate results. Researchers in this field should be encouraged to use available validated tools, to ensure that patient satisfaction is measured and reported fairly and accurately.

Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.

Extravascular fluid but not extravascular lung water is increased in patients after surgery with cardiopulmonary bypass. Pretreatment of adult patients with 1 mg/kg-1 dexamethasone before coronary bypass grafting decreases extravascular fluid gain and seems to improve postoperative cardiovascular performance. This effect is not caused by a better intravascular volume status.

Induction of general anaesthesia with positive-pressure ventilation is regularly associated with a blood volume shift from intra- to extrathoracic compartments. Even in low-dose opioid monoanaesthesia with sufentanil--often regarded as relatively inert in haemodynamic terms--the phenomenon could be demonstrated as the primary cause of the often-observed decrease of arterial pressure. It seems, therefore, rationally justified to restore cardiac filling by generous administration of intravenous fluids, at least in patients with unaffected cardiac pump function. During induction of anaesthesia, central venous pressure and pulmonary capillary wedge pressure do not reliably indicate cardiac filling.

Introduction Remote ischaemic preconditioning (RIPC) has emerged as a non-invasive, low-cost therapeutic intervention for reducing peri-operative myocardial injury (PMI) in patients undergoing coronary artery bypass graft (CABG) and/or valve surgery. However, some studies have been neutral, suggesting that the standard single limb RIPC stimulus may be ineffective under certain conditions. We investigated the effect of increasing the strength of the RIPC stimulus in patients undergoing elective cardiac bypass surgery. Methods and results 180 consecutive patients undergoing elective CABG and/or valve surgery were randomised to receive either RIPC (2-5 min cycles of simultaneous upper arm and thigh cuff inflation and deflation, N=90) or control (uninflated cuffs placed on the upper arm and thigh for 20 min, N=90). Patients randomised to RIPC had less PMI (26% reduction in 72 h area-under-the-curve high-sensitivity Troponin T; p=0.003), reduced incidence of postoperative atrial fibrillation (AF, 11% RIPC vs 24% control; p=0.031), decreased the incidence of acute kidney injury (AKI, 7% RIPC vs 17% control; p=0.036), and shortened the stay on the intensive care unit (ICU, 2 days RIPC vs 3 days control; p=0.043). Interestingly, we found that in those patients who received IV GTN during surgery sustained less PMI, and RIPC was ineffective. Conclusions Multi-limb RIPC induced by simultaneous upper arm and leg cuff inflation reduced PMI, decreased the incidence of postoperative AF, reduced the incidence of AKI and shortened the ITU stay, in patients undergoing CABG and/or valve surgery.

BackgroundPre-operative antibody levels have been shown to be inversely related to development of post-operative complications. Staphylococcal infection is a major source of morbidity following surgery.MethodsWe examined the variability of anti-staphylococcal antibody levels across a group of healthy volunteers and compared this with patients scheduled to undergo cardiac surgery.ResultsPre-operative cardiac surgical patients exhibited significantly higher levels of staphylococcal antibodies compared with healthy volunteers.ConclusionsThe relationship between pre-surgery staphylococcal antibody levels and outcome warrants further investigation.

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