Articles: postoperative-complications.
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Postoperative mortality in Africa is twice that of wealthier countries. The SMARTER trial underscores this critical issue and aims to address the high mortality rates by harnessing a readily available resource requiring minimal funding. Conducted in Mbale, Uganda, this innovative trial trained family members to monitor basic vital signs following surgery. ⋯ Although the results demonstrate a potential for increasing the capacity to rescue in the postoperative period, there is a need for further research to assess real-world effectiveness. Any improvement in patient monitoring would be limited by the system's capacity to respond effectively to escalations made by family members and the possible inaccuracy of their monitoring. Intervening earlier in the preoperative pathway can reduce the need to rescue postoperatively, but the SMARTER intervention has the potential to contribute to the larger effort needed to reduce surgical deaths globally in resource-limited settings.
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Editorial Review
Postoperative respiratory complications in children: from prediction to clinical action.
The score for prediction of postoperative respiratory complications in infants and children (SPORC-C) was recently reported. The score was developed using a large cohort of patients by applying a multivariate model, then internally and externally validated on a different cohort of patients. In order to encourage use of this score, an online calculator (https://sites.google.com/view/sporc-for-children/home) was also developed, allowing identification of patients at low and high risk for postoperative respiratory complications. We review current evidence on algorithms developed to predict postoperative respiratory complications, including how and when such scoring systems should be used in daily practice to improve the overall safety of paediatric patients.
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Deciding the optimal time for surgery in patients with pre-existing comorbid disease is complex. A careful balance of risks is required to weigh up the therapeutic benefits of surgery against an increased risk of perioperative adverse outcomes, whereas the subsequent risk of adverse events and mortality is more dependent on pre-existing conditions. A study in a recent issue of BJA shows that people with a previous cardiovascular or cerebrovascular event within 10 yr of elective surgery were at a higher risk of major adverse cardiovascular events within 1 yr from surgery and that an at-risk period existed if surgery occurred within 37 months of the preoperative event. Before this observation can be used to inform clinical decision-making, caution is needed to interpret these findings because of biases introduced by the analytical approach and potential confounding.
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Editorial Review
Challenges in Enhanced Recovery After Surgery (ERAS) research.
Despite the general agreement that implementation of Enhanced Recovery After Surgery (ERAS) pathways decrease hospital length of stay, a continuous challenge that has often been neglected is a procedure- and patient-specific approach. For example, asking 'Why is the patient still in hospital?' is the original premise for ERAS. ⋯ As there are few high-quality randomised clinical trials (RCTs) that evaluate the specific role of individual preoperative, intraoperative, and postoperative elements, challenges lie ahead to identify essential ERAS elements to facilitate more widespread implementation. To achieve this goal, the balance between large RCTs and smaller detailed hypothesis-generating observational studies needs to be addressed in order to enhance knowledge and limit waste of research resources.