INTRAOPERATIVE hypotension (IOH) is a common and frequent side effect of anesthesia.1,2 Previously, IOH was reported to be independently associated with adverse perioperative outcomes in several clinical settings, and even an association between IOH and long-term (1-year) mortality was reported.3–7 These findings have important clinical and medicolegal consequences. Perioperative stroke, for example, has often been attributed to IOH,8–11 although Limburg et al. 12 were unable to find an association between IOH and postoperative stroke. Furthermore, IOH was recently reported to be one of the most important concerns associated with the occurrence of postoperative myocardial ischemia and infarction.13

Objective: To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance. Background: Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues. Methods: This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity. Results: After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73–0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28–0.70), compared to 1.09 (95% CI, 0.78–1.52) and 1.16 (95% CI, 0.86–1.56) for partial or noncompliance, respectively. Conclusions: Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

Background: Many studies have analyzed risk factors for the development of severe postoperative pain with contradictory results. To date, the association of risk factors with postoperative pain intensity among different surgical procedures has not been studied and compared. Methods: The authors selected precisely defined surgical groups (at least 150 patients each) from prospectively collected perioperative data from 105 German hospitals (2004–2010). The association of age, sex, and preoperative chronic pain intensity with worst postoperative pain intensity was studied with multiple linear and logistic regression analyses. Pooled data of the selected surgeries were studied with random-effect analysis. Results: Thirty surgical procedures with a total number of 22,963 patients were compared. In each surgical procedure, preoperative chronic pain intensity and younger age were associated with higher postoperative pain intensity. A linear decline of postoperative pain with age was found. Females reported more severe pain in 21 of 23 surgeries. Analysis of pooled surgical groups indicated that postoperative pain decreased by 0.28 points (95% CI, 0.26 to 0.31) on the numeric rating scale (0 to 10) per decade age increase and postoperative pain increased by 0.14 points (95% CI, 0.13 to 0.15) for each higher score on the preoperative chronic pain scale. Females reported 0.29 points (95% CI, 0.22 to 0.37) higher pain intensity. Conclusions: Independent of the type and extent of surgery, preoperative chronic pain and younger age were associated with higher postoperative pain. Females consistently reported slightly higher pain scores regardless of the type of surgery. The clinical significance of this small sex difference has to be analyzed in future studies.

An important aim of clinical prediction models is to positively impact clinical decision making and subsequent patient outcomes. The impact on clinical decision making and patient outcome can be quantified in prospective comparative—ideally cluster-randomized—studies, known as ‘impact studies’. However, such impact studies often require a lot of time and resources, especially when they are (cluster-)randomized studies. Before envisioning such large-scale randomized impact study, it is important to ensure a reasonable chance that the use of the prediction model by the targeted healthcare professionals and patients will indeed have a positive effect on both decision making and subsequent outcomes. We recently performed two differently designed, prospective impact studies on a clinical prediction model to be used in surgical patients. Both studies taught us new valuable lessons on several aspects of prediction model impact studies, and which considerations may guide researchers in their decision to conduct a prospective comparative impact study. We provide considerations on how to prepare a prediction model for implementation in practice, how to present the model predictions, and how to choose the proper design for a prediction model impact study.

On self-report. METHODS: We studied the incidence of intraoperative hypoxemia as well as that of pulse oximeter artifacts prospectively in 575 pediatric noncardiac surgery patients aged between 0 and 16 years operated in a tertiary pediatric university hospital. Subsequently, the incidence of intraoperative hypoxemia was determined retrospectively in 8277 patients registered in an anesthesia information management system (AIMS) of the same hospital. RESULTS: In the prospective cohort, at least 1 episode of oxygen saturation (SpO2) ≤ 90% for at least 1 minute occurred in 69 of 575 cases (12%; 95% confidence interval [CI], 9%–15%). Furthermore, in 35 of 575 (6%; 95% CI, 4%–8%) cases at least 1 true hypoxemic event was observed. In total, 117 episodes of SpO2 ≤ 90% were observed in the prospective study, of which 3 of 117 could not be specified and 67 of 114 (54%; 95% CI, 42%–65%) episodes were classified as true hypoxemia. False-positive low SpO2 values were mainly caused by dislodgment of the pulse oximeter. In the retrospective analysis, SpO2 ≤ 90% and SpO2 ≤ 80% for at least 1 minute were documented in the AIMS in 18% (95% CI, 17%–19%) and 7.5% (95% CI, 7%–8%) of the cases, respectively; 31 and 10 episodes per 100 cases, respectively. The incidence of hypoxemia increased in younger age groups: SpO2 ≤ 90% for at least 1 minute occurred in 56% (95% CI, 49%–63%) of neonates (170 episodes per 100 cases). CONCLUSIONS: The incidence of intraoperative hypoxemia increased with younger age, with the highest incidence in neonates. Because of the high artifact rate, unvalidated pulse oximeter data in AIMS should be interpreted with caution because only up to 65% of all hypoxemic episodes recorded during pediatric anesthesia were caused by true hypoxia....