Hypophosphatemia (HypoP) is associated with organ dysfunction and mortality. Despite its potential severe consequences, HypoP remains poorly characterized in terms of real prevalence and timing of onset. The primary objective was to determine the prevalence of HypoP defined as blood phosphate <0.8 and < 0.65 mmol/l on one particular day at international level. One-day point prevalence survey conducted by the Section of Metabolism, Endocrinology and Nutrition (MEN) of the European Society of Intensive Care Medicine (ESICM) during week 11-2020. In total, 56 adult and 4 paediatric ICUs, from 22 countries participated: 41 ICUs were mixed medico surgical, the 19 others being cardiac, medical or surgical. Phosphate measurements were performed daily in 21 ICUs, and 1-3 times per week in 39 ICUs. On D-Day 909 patients (883 adults) were present and 668/883 (75.7%) had serum/plasma phosphate determined, revealing a HypoP in 103 (15.4%) patients aged 62 [18 to 85] years. Of those, 49 patients presented phosphate <0.65 mmol/l: cases of hypophosphatemia were detected at any time of patient's ICU stay. No HypoP was observed in children. A treatment protocol existed only in 41.1% of adult ICUs, independently of ICU type, or size. Only 41/98 of the HypoP patients (29/41 of patients with phosphate <0.65 mmol/l) were receiving phosphate. HypoP is present at least in 15.4% of ICU patients, and may occur at any time during the ICU stay. The absence of phosphate repletion protocols in 60% of participating ICUs is an unexpected finding, and confirms the necessity for the development of ICU phosphate protocols and guidelines. NCT04201899.

Background: The optimal amount and method for monitoring intravenous fluid in surgical patients is unresolved. Central venous oxygen saturation (Scvo2) has been used to guide therapy and predict outcome in high-risk and intensive-care patients. The aim of this prospective, randomized trial was to compare the rate of postoperative complications in patients receiving fluid therapy guided by Scvo2 and those treated with a traditional effluent fluid scheme. Methods: Patients undergoing open colorectal and lower intestinal surgery (n = 241) were randomized to the Scvo2 group or the control group. The Scvo2 group received perioperatively crystalloid infusion 100 ml/h. When Scvo2 was less than 75%, a bolus of 3 ml/kg hydroxyethyl starch was given. The bolus was repeated if Scvo2 increased by 1 percentage point or more. The control group was maintained with crystalloid 800 ml/h and given extra fluid if there were clinical signs of hypovolemia. The participating surgeon, unaware of the group allocation, registered complications within day 30. Results: Until 8:00 am on the first postoperative day, the Scvo2 group had received 3,869 ± 992 ml (mean ± SD) intravenous fluid compared with 6,491 ± 1,649 ml in the control group. Increase in weight was 0.8 ± 1.8 kg and 2.5 ± 1.6 kg in the two groups, respectively. The postoperative complication rate was 42% in both groups. Conclusion: Clinical outcomes among patients receiving Scvo2-guided perioperative fluid therapy were similar to those for patients treated with a traditional fluid regimen. Limitations in study design prevent full interpretation of these findings, and further large trials of this treatment algorithm are still required.

Background: Frailty is a complex syndrome shown to be an independent predictor of morbidity and mortality after surgery in older patients. Frailty scoring may, therefore, be important, for example, for pre‐operative risk assessment and prognosis estimation. The Clinical Frailty Scale (CFS) has been developed to help operationalize frailty in the individual patient. However, the inter‐rater reliability of retrospective CFS scoring through patient records by health care personnel is currently unknown in patients over 80 years of age undergoing emergency abdominal surgery.Methods: Retrospective review of electronic patient journal of 112 patients over 80 years of age undergoing emergency abdominal surgery between 2015 and 2016. Three researchers individually assigned each patient a CFS score. The inter‐rater reliability was assessed using Cohen's weighted kappa for the comparison of pairs of assessors, as well as Kendall's coefficient of concordance for the comparison of all three raters simultaneously.Results: The agreement across raters was strong, with Cohen's kappa values ranging between 0.74 and 0.85 and a Kendall's coefficient of concordance of 0.86.Conclusions: The inter‐rater reliability of assigned CFS from patient journals seems acceptable. This could permit retrospective research utilizing CFS measures from several raters and across centers.

Craniotomy involves procedures with high incidences of postoperative pain. Dexmedetomidine, a highly selective a₂-adrenoreceptor agonist, has been shown to be beneficial in neuroanaesthesia. The purpose of this narrative review was to assess the effect and safety of dexmedetomidine given intraoperatively during anaesthesia compared to placebo and demonstrate the effect on acute postoperative pain in adult patients undergoing craniotomy. Literature published from 1996 until 2021 were analysed through a search of PubMed, Medline and Embase. Randomised controlled trials investigating intraoperative administration of Dexmedetomidine with evaluation of postoperative pain were included. Medical Subject Headings terms and free-text words were used to identify articles related to the intraoperative use of Dexmedetomidine and postcraniotomy pain. Thirteen distinct randomized controlled trials with 882 recruited patients undergoing craniotomy were identified as eligible for final inclusion. Intraoperative administration of dexmedetomidine is associated with decreased postoperative pain and opioid consumption, and it assures haemodynamic stability. Dexmedetomidine is an efficacious adjunct in craniotomy in adults, showing benefits in reduction of postoperative pain and analgesic consumption. Dexmedetomidine also offers haemodynamic stability. However, widespread methodological heterogeneity of the papers prohibits a valid meta-analysis.

Summary: Introduction: Evidence suggests that existing pre‐operative fasting guidelines are associated with prolonged fasting times. Prolonged fasting, particularly from clear liquids, has the potential to harm patients through reduced peri‐operative wellbeing; impaired glucose metabolism and peri‐operative inflammatory response; delayed return of bowel function; and reduced muscle strength. Liberalisation of fasting practices has, therefore, become increasingly common. Such a change in practice dictates the need for updated practice guidance. We aimed to develop recommendations on peri‐operative fasting that reflect increasing global awareness of the adverse effects of prolonged fasting. Methods: Following a systematic literature review, 13 draft recommendations related to peri‐operative fasting were developed iteratively. These were modified during a three‐round Delphi process by an international, multidisciplinary stakeholder panel, which included: patients; anaesthetists; surgeons; physicians; nurses; and members of relevant international organisations from five continents. Results: Sixty‐eight stakeholders participated in the Delphi consensus process. The panel subsequently agreed on eight recommendations. We recommend continuing current practices on pre‐operative fasting for solid food and non‐clear liquids. We recommend encouraging clear liquids until 2 h before the start of anaesthesia or sedation, unless institutional protocols allow for more liberal liquid intake. We further recommend implementation of institutional protocols that allow more liberal clear liquid intake < 2 h before the start of anaesthesia or sedation. Salivation stimulants can be used until transfer for the procedure. Oral intake should be resumed as soon as clinically feasible. Preprocedural gastric ultrasound performed by a trained provider may be used to guide clinical decisions when additional information is required. Discussion: This international, multidisciplinary consensus statement aims to improve the quality of patient care by minimising periprocedural fasting times, within safe margins. To achieve this, liberalised pre‐operative clear liquid intake regimens may be implemented with institutional protocols.

Hypotension after major noncardiac surgery is associated with increased morbidity, mortality, and costs, and is often treated with postoperative vasopressor infusions. The frequency of administration in the postoperative period is unknown. This international prospective cohort study was conducted between October 2020 and October 2023. At each hospital, adults undergoing noncardiac surgery were enrolled into two cohorts: all consecutive patients for 1 week (Cohort A) and an additional sample of up to 30 consecutive patients administered postoperative vasopressor infusions within 1 yr (Cohort B). The primary outcome (Cohort A) was the incidence of postoperative vasopressor infusions, defined as any continuous infusion of vasopressors. Secondary outcomes included in-hospital mortality, organ dysfunction, length of hospital stay, and complications associated with postoperative vasopressor infusions (both cohorts). In total, 25 675 participants were enrolled from 228 hospitals across 42 countries. In Cohort A, 770/19 768 (3.9%) participants received postoperative vasopressor infusions, with vasopressor use ranging between 0% and 18% across hospitals (median odds ratio: 2.30 [credible interval 1.96-2.73]). This variability did not alter after adjustment for case-mix and procedural characteristics. For both cohorts, postoperative vasopressor infusions were associated with higher (15.5%) in-hospital mortality, higher rates of organ failure, and longer hospital stay. Administration of postoperative vasopressors after noncardiac surgery varied across hospitals and was associated with worse outcomes. Variable practice across hospitals could not be explained by differences in case-mix. https://clinicaltrials.gov/study/NCT03805230, ESAIC tracking ID: ESAIC_CTN_SQUEEZE.