Heart rate recovery after orthostatic challenge and cardiopulmonary exercise testing in older individuals: prospective multicentre observational cohort study.

Background: Impaired vagal function in older individuals, quantified by the 'gold standard' delayed heart rate recovery after maximal exercise (HRR), is an independent predictor of cardiorespiratory capacity and mortality (particularly when HRR ≤12 beats min). Heart rate also often declines after orthostatic challenge (HRR), but the mechanism remains unclear. We tested whether HRR reflects similar vagal autonomic characteristics as HRR.

Virtual hospitals: The future of the healthcare system? An expert consensus.

Today, social and healthcare systems at a global level are facing constant challenges dictated by an increasing mismatch between the demand for care services and the supply of human and economic resources. Such a situation has been exacerbated in the past two years by the Covid-19 pandemic. This has led to an increase in the leverage of digitalisation, which has proved to be a crucial tool for the development and application of new organisational models at both hospital and territorial levels, thus addressing the various criticalities already present in the system.

The impact of universal cardiopulmonary exercise testing on perioperative pathways and short-term patient outcomes following elective pancreatic surgery: A retrospective cohort study.

Background: The utility of Cardiopulmonary Exercise Testing (CPET) to identify higher risk surgical patients remains controversial. There is limited research investigating the value of preoperative CPET to plan perioperative pathways for patients undergoing major pancreatic surgery.

Methods: Retrospective cohort study, comprising two groups before and after a change in referral policy for High Risk preoperative anaesthetic clinic with CPET.

Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing.

Background: The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature.

Correction: Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies.

[This corrects the article DOI: 10.1371/journal.pone.

Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies.

Background: Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery.

A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications.

Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. A modified Delphi process combined expert opinion and evidence appraisal.

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery.

Background: Guidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the supporting evidence is limited, and there is concern about impaired organ perfusion.

Methods: In a pragmatic, international trial, we randomly assigned 3000 patients who had an increased risk of complications while undergoing major abdominal surgery to receive a restrictive or liberal intravenous-fluid regimen during and up to 24 hours after surgery.

Arterial pulse pressure and postoperative morbidity in high-risk surgical patients.

Background: Systemic arterial pulse pressure (systolic minus diastolic pressure) ≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke volume and is independently associated with accelerated morbidity and mortality. Given that deconditioned surgical and heart failure patients share similar cardiopulmonary physiology, we examined whether lower pulse pressure is associated with excess morbidity after major surgery.

Methods: This was a prospective observational cohort study of patients deemed by their preoperative assessors to be at higher risk of postoperative morbidity.

Comparison of risk-scoring systems in the prediction of outcome after liver resection.

Background: Risk prediction techniques commonly used in liver surgery include the American Society of Anesthesiologists (ASA) grading, Charlson Comorbidity Index (CCI) and cardiopulmonary exercise tests (CPET). This study compares the utility of these techniques along with the number of segments resected as predictive tools in liver surgery.

Methods: A review of a unit database of patients undergoing liver resection between February 2008 and January 2015 was undertaken.

Mildly elevated lactate levels are associated with microcirculatory flow abnormalities and increased mortality: a microSOAP post hoc analysis.

Background: Mildly elevated lactate levels (i.e., 1-2 mmol/L) are increasingly recognized as a prognostic finding in critically ill patients.

Elevated preoperative heart rate is associated with cardiopulmonary and autonomic impairment in high-risk surgical patients.

Background: Elevated preoperative heart rate (HR) is associated with perioperative myocardial injury and death. In apparently healthy individuals, high resting HR is associated with development of cardiac failure. Given that patients with overt cardiac failure have poor perioperative outcomes, we hypothesized that subclinical cardiac failure, identified by cardiopulmonary exercise testing, was associated with elevated preoperative HR > 87 beats min -1 (HR > 87).

Autonomic regulation of systemic inflammation in humans: A multi-center, blinded observational cohort study.

Objective: Experimental animal models demonstrate that autonomic activity regulates systemic inflammation. By contrast, human studies are limited in number and exclusively use heart rate variability (HRV) as an index of cardiac autonomic regulation. HRV measures are primarily dependent on, and need to be corrected for, heart rate.

Molecular Mechanisms Linking Autonomic Dysfunction and Impaired Cardiac Contractility in Critical Illness.

Objectives: Molecular mechanisms linking autonomic dysfunction with poorer clinical outcomes in critical illness remain unclear. We hypothesized that baroreflex dysfunction alone is sufficient to cause cardiac impairment through neurohormonal activation of (nicotinamide adenine dinucleotide phosphate oxidase dependent) oxidative stress resulting in increased expression of G-protein-coupled receptor kinase 2, a key negative regulator of cardiac function.

Design: Laboratory/clinical investigations.

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery.

Background: In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery.

Methods: Patients underwent preoperative CPET with recording of in-hospital morbidity.

Sympathetic autonomic dysfunction and impaired cardiovascular performance in higher risk surgical patients: implications for perioperative sympatholysis.

Objective: Recent perioperative trials have highlighted the urgent need for a better understanding of why sympatholytic drugs intended to reduce myocardial injury are paradoxically associated with harm (stroke, myocardial infarction). We hypothesised that following a standardised autonomic challenge, a subset of patients may demonstrate excessive sympathetic activation which is associated with exercise-induced ischaemia and impaired cardiac output.

Methods: Heart rate rise during unloaded pedalling (zero workload) prior to the onset of cardiopulmonary exercise testing (CPET) was measured in 2 observation cohorts of elective surgical patients.

Randomized controlled trial of stroke volume optimization during elective major abdominal surgery in patients stratified by aerobic fitness.

Background: The benefits of stroke volume optimization during surgery are unclear, with recent data not replicating the positive effects of earlier studies.

Methods: This was a randomized controlled trial of standard fluid therapy with or without supplementary blinded intraoperative stroke volume optimization in 220 patients having major elective rectal resection or cystectomy with ileal conduit. All patients were treated using a contemporary enhanced recovery pathway.

Clinical assessment before hepatectomy identifies high-risk patients.

Background: Liver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution.

Monitoring needs and goal-directed fluid therapy within an enhanced recovery program.

Patients having major abdominal surgery need perioperative fluid supplementation; however, enhanced recovery principles mitigate against many of the factors that traditionally led to relative hypovolemia in the perioperative period. An estimate of fluid requirements for abdominal surgery can be made but individualization of fluid prescription requires consideration of clinical signs and hemodynamic variables. The literature supports goal-directed fluid therapy.