Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Critical pathway for patients undergoing aortic-surgery : impact on postoperativecare at an intensive care unit in Sweden

The aim of the present study was to identify and describe intensive care nurses’different conceptions of a critical pathway in caring for patients that have undergone aorticsurgery.Individual semi-structured interviews with eight specialist registered nurses at aSwedish intensive care unit were conducted and phenomenographically analysed. Three descriptivecategories, with a total of five sub-categories, constituted the outcome-space of how thepathway was conceived of in caring: as a guide open to individual patients needs (clinical judgementgoverns caring and patient autonomy governs caring), as an instrument to promote patientsafety (a source of knowledge, a planning tool and a reference standard) and as a source ofsupport for professional confidence.In accordance with current literature, the nurses in the present study identified a number ofadvantages in applying the pathway in caring even if they were also conscious that the use of apathway can give rise to unreflective standardisation. The nurses’ conceptions indicate that thepathway prescribed for managing patients who have undergone aortic surgery is supportive andfacilitates patient safety without jeopardising respect for the patient’s individual care needs.This insight may be used to influence a thoughtful dialogue about the practice of pathways inintensive care

Intensive care nurses' conceptions of a critical pathway in caring for aortic-surgery patients : a phenomenographic study

The aim of the present study was to identify and describe intensive care nurses' different conceptions of a critical pathway in caring for patients that have undergone aortic-surgery. Individual semi-structured interviews with eight specialist registered nurses at a Swedish intensive care unit were conducted and phenomenographically analysed. Three descriptive categories, with a total of five sub-categories, constituted the outcome-space of how the pathway was conceived of in caring: as a guide open to individual patients needs (clinical judgement governs caring and patient autonomy governs caring), as an instrument to promote patient safety (a source of knowledge, a planning tool and a reference standard) and as a source of support for professional confidence. In accordance with current literature, the nurses in the present study identified a number of advantages in applying the pathway in caring even if they were also conscious that the use of a pathway can give rise to unreflective standardisation. The nurses' conceptions indicate that the pathway prescribed for managing patients who have undergone aortic surgery is supportive and facilitates patient safety without jeopardising respect for the patient's individual care needs. This insight may be used to influence a thoughtful dialogue about the practice of pathways in intensive care

Object-relation mapping tool comparison within the ASP.NET platform

ORM rīki ir populāra izvēle ASP.NET lietotnes loģiskā slāņa savienošanai ar datubāzi. Tomēr jauniem izstrādātājiem ne vienmēr var būt skaidrs un zināms, kādu ORM rīku izmantot lietotnes realizācijā. “Bakalaura” darba galvenais mērķis ir izpētīt ASP.NET ORM rīku piedāvājumu un veikt savstarpēju salīdzināšanu autora izvēlētā ORM rīku izlasē. Darbā tiek izprasts, kas ir objektorientēta kartēšana, kādus ORM rīkus piedāvā ASP.NET ietvars, un tiek veikts izvēlētu ORM rīku praktisks salīdzinājums. Lai veiktu praktisku salīdzinājumu, tika izveidota ASP.NET lietotne, datubāze un vaicājumi, kas katram ORM rīkam ir jāizpilda. Praktiskā pētījuma rezultātā ir formulēti secinājumi par katru ORM rīku, analizējot iegūtos datus.ORM tools are a popular choice for connecting the logical layer with the database in an ASP.NET application. But for new developers it may not always be clear, which ORM tool to use for developing an application. The main goal of this bachelor’s paper is to research the provided ORM tool selection by ASP.NET and to conduct a comparison of an ORM tool set chosen by the author. Within the paper answers are found to what is object relation mapping, what ORM tools the ASP.NET platform provides, and a practical comparison of chosen ORM tools is performed. To perform the practical comparison, the following were made: an ASP.NET application, a database and queries that the ORM tools have to implement. The results of practical research are analysed and conclusions are drawn about each ORM tool

The effect of COVID-19 pandemic on perioperative factors: data from the Swedish Perioperative Register

Abstract Background The COVID-19 pandemic has affected healthcare organizations in many areas. The aim of this study was to describe surgical interventions, anesthesia, and postoperative outcomes in adult patients during the first wave and 1 year into the COVID-19 pandemic in Sweden, and to compare these outcomes with outcomes during the same period the year before the pandemic. Methods Data were collected from the Swedish PeriOperative Register, and included 417, 233 perioperative registration of patients ≥ 18 years old between period 1 (March–June 2019), period 2 (March–June 2020), and period 3 (March–June 2021). Results Compared with pre-pandemic (period 1), the number of surgical interventions decreased by 28% in the first wave (period 2); 1 year into the pandemic (period 3), the number of interventions was still 7.5% lower than pre-pandemic. The largest drops between periods 1 and 2 were noted in the specialties of ear, nose, and larynx surgery, – 55.6%; teeth, jaws, mouth, and pharynx surgery, – 45.0%; endocrine system surgery, – 38.8%. The number of acute surgeries remained stable during all three periods. Volatiles were more frequently used for the maintenance of general anesthesia in period 2 than in either period 1 or 3 (p < 0.001). Minor differences were noted throughout the periods in postoperative nausea and vomiting as well as postoperative pain. Conclusions The COVID-19 pandemic has had an impact on perioperative care in Sweden. During the first wave of the pandemic, the number of surgical interventions decreased, but the number of acute surgeries remained stable compared with pre-pandemic numbers. Perioperative organizations have had and will continue to have challenges handling the increased number of patients needing perioperative care

Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index

Background: Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality. Methods: Prospective, observational, cohort study in patients &amp;gt;= 50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE. Results: We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT &amp;gt;= 14 ng L-1 above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds. Conclusions: Perioperative increases in hsTnT &amp;gt;= 14 ng L-1 above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE.Funding Agencies|Swedish Research CouncilSwedish Research CouncilEuropean Commission [2019-02833]; South Eastern Sweden Research Council [746981, 712291]; Linkoping University-Region Ostergotland ALF [687681, 792291]; Swiss National Science FoundationSwiss National Science Foundation (SNSF)European Commission [320030-179362]; Swiss Heart Foundation; University Hospital of Basel; Roche Diagnostics; University of Basel; AstraZenecaAstraZeneca</p

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally