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{"title":"A GAP analysis of the current state of Pain Management Services in the UK, 2024","authors":"Sue Copley ,&nbsp;Beatrice Bretherton ,&nbsp;Suzanne Carty ,&nbsp;Matthew Brown ,&nbsp;Sailesh Mishra ,&nbsp;Emmy Kato Clarke ,&nbsp;Ganesan Baranidharan ,&nbsp;Devjit Srivastava ,&nbsp;GAP Analysis Working Group","doi":"10.1016/j.bjao.2025.100414","DOIUrl":"10.1016/j.bjao.2025.100414","url":null,"abstract":"<div><h3>Background</h3><div>In the UK, multidisciplinary services for patients experiencing chronic pain are currently commissioned by the NHS as specialised services. Pain services across the UK were placed under significant strain during the COVID pandemic. The ‘GAP Analysis working group’ (GAP group) was commissioned by the Board of the Faculty of Pain Medicine (FPM) in November 2021 to evaluate the post-COVID state of pain services across the country.</div></div><div><h3>Methods</h3><div>The GAP group's remit was to establish any deficit in pain services when measured against the service ‘gold standard’ outlined in the published FPM document ‘Core Standards for Pain Management Services volume 2.0’ (CSPMS). A survey was developed using an iterative consensus process among the group and was distributed to all FPM members.</div></div><div><h3>Results</h3><div>The survey included questions pertaining to 21 standards. There were 164 respondents to this GAP analysis from 97 individual clinical sites delivering pain services in the UK. The majority of respondents worked in secondary care (74%), followed by tertiary care (23%) and finally primary care (3%). No single standard was met by all reporting sites. The degree of compliance with individual standards varied, ranging from only 30% of sites reporting full compliance (standard 9: research and development) to 79% of sites reporting full compliance (standard 21: interventional pain procedure).</div></div><div><h3>Conclusions</h3><div>The following aspects of chronic pain services need urgent redress: provision of paediatric pain services, provision of cancer pain services, outcome data management support, research and development, and increased support of psychological services and pain management programme access.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100414"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144178038","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intraoperative methadone for postoperative pain in adult patients undergoing tonsillectomy—a randomised controlled trial","authors":"Michael Bøndergaard ,&nbsp;Peter Gaarsdal Uhrbrand ,&nbsp;Tutku Karaca ,&nbsp;Marianne Rhode ,&nbsp;Thomas Kjærgaard ,&nbsp;Rene Thunberg Svendsen ,&nbsp;Tejs Ehlers Klug ,&nbsp;Lone Nikolajsen ,&nbsp;Kristian Dahl Friesgaard","doi":"10.1016/j.bjao.2025.100418","DOIUrl":"10.1016/j.bjao.2025.100418","url":null,"abstract":"<div><h3>Background</h3><div>Tonsillectomy is a common procedure often associated with severe postoperative pain. This study hypothesised that methadone would provide superior postoperative pain relief and reduced opioid consumption compared with fentanyl.</div></div><div><h3>Methods</h3><div>A total of 120 adult patients undergoing elective bilateral tonsillectomy were randomly allocated to receive either methadone (0.2 mg kg⁻¹; <em>n</em>=62) or fentanyl (3 μg kg⁻¹; <em>n</em>=58) after anaesthesia induction. Joint primary outcomes were pain intensity (numeric rating scale, 0–10) at swallowing upon postanaesthesia care unit (PACU) arrival and cumulative opioid consumption (oral morphine equivalents) over 5 postoperative days. Secondary outcomes included pain at swallowing, PACU and hospital stay duration, sedation at 4 h, patient satisfaction at days 1 and 7, postoperative nausea/vomiting (PONV) on days 1–3, and PACU adverse events.</div></div><div><h3>Results</h3><div>Cumulative 5-day opioid consumption was lower in the methadone group (30 mg, inter-quartile range [IQR] 10–50 mg) <em>vs</em> the fentanyl group (49 mg, IQR 29–80 mg, <em>P</em>=0.002), driven by reduced use on day 1. Pain intensity was lower in the methadone group compared with the fentanyl group in the PACU (4, IQR 3–5 <em>vs</em> 5, IQR 4–7, <em>P</em>=0.0004), at 24 h (<em>P</em>=0.005) and 48 h (<em>P</em>=0.03). More patients in the methadone group experienced moderate to severe PONV at 24 h (45.0%, <em>vs</em> 14.1%, <em>P</em>=0.001), 48 h (43.3% <em>vs</em> 17.6%, <em>P</em>=0.005), and 72 h (33.9% <em>vs</em> 18.2%, <em>P</em>=0.03). Secondary outcomes, including patient satisfaction, sedation, and discharge times, did not differ significantly.</div></div><div><h3>Conclusion</h3><div>Methadone reduced opioid consumption and pain intensity but increased PONV. Identifying risk factors for both severe postoperative pain and PONV may help guide patient selection for methadone use.</div></div><div><h3>Clinical trial registration</h3><div>NCT05445856, EudraCT ID 2022-002496-11.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100418"},"PeriodicalIF":0.0,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144134374","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Glucose variability and mode of anaesthesia in major noncardiac surgery (GlucoVITAL): study protocol for a randomised controlled trial","authors":"Henrike Janssen ,&nbsp;Priyanthi Dias ,&nbsp;Louise Hiller ,&nbsp;Russell Hewson ,&nbsp;Rupert M. Pearse ,&nbsp;Nick S. Oliver ,&nbsp;Shaman Jhanji ,&nbsp;Gareth L. Ackland","doi":"10.1016/j.bjao.2025.100419","DOIUrl":"10.1016/j.bjao.2025.100419","url":null,"abstract":"<div><h3>Background</h3><div>Hyperglycaemia after noncardiac surgery occurs commonly and is associated with complications. The choice of maintenance anaesthesia may promote hyperglycaemia and increase glucose variability, both of which exacerbate inflammation and organ dysfunction. We hypothesise that total intravenous anaesthesia reduces glucose variability, particularly in individuals with insulin resistance or diabetes mellitus, and hence may reduce postoperative complications.</div></div><div><h3>Methods</h3><div>This multicentre, randomised controlled parallel group trial will recruit 450 participants ≥50 yr undergoing elective noncardiac surgery. Participants will be randomly allocated in a 1:1 ratio (with minimisation) to receive either total intravenous anaesthesia or inhalation agents (typically sevoflurane) for maintenance of anaesthesia. The primary outcome is blood glucose, measured at prespecified timepoints (before, immediately after, and the morning after surgery). Continuous glucose monitoring (CGM; Dexcom G7) will commence at induction of anaesthesia for up to 10 days after surgery (or hospital discharge) to establish the reliability and accuracy of CGM compared with blood glucose measurements. Secondary outcomes include days alive and out of hospital within 30 days of surgery and postoperative complications (Clavien–Dindo grade ≥2). Absolute glucose and CGM-derived measures of glucose variability will be compared between participants who sustain, or remain free of, myocardial injury within 24 h of surgery, infectious complications within 30 days of surgery, and vasopressor use persisting &gt;4 h after surgery.</div></div><div><h3>Conclusions</h3><div>GlucoVITAL will establish whether the mode of anaesthesia may alter glucose control in susceptible individuals and also explore the role of glucose variability in organ injury after noncardiac surgery using CGM.</div></div><div><h3>Clinical trial registration</h3><div>ISRCTN46862025.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100419"},"PeriodicalIF":0.0,"publicationDate":"2025-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144131256","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Derivation and internal–external validation of clinical prediction model for postoperative clinically important hypotension in patients undergoing noncardiac surgery: an international prospective cohort study","authors":"Stephen Su Yang ,&nbsp;German Malaga ,&nbsp;Maria Lazo-Porras ,&nbsp;Patricia Busta-Flores ,&nbsp;Aida del Carmen Rotta-Rotta ,&nbsp;Pavel S. Roshanov ,&nbsp;Daniel I. Sessler ,&nbsp;Amal Bessissow ,&nbsp;Thomas Schricker ,&nbsp;Vicky Tagalakis ,&nbsp;Diane Heels-Ansdell ,&nbsp;Shirley Pettit ,&nbsp;P.J. Devereaux","doi":"10.1016/j.bjao.2025.100410","DOIUrl":"10.1016/j.bjao.2025.100410","url":null,"abstract":"<div><h3>Background</h3><div>Intraoperative and postoperative hypotension are associated with myocardial injury/infarction, stroke, acute kidney injury, and death. Because of its prolonged duration, postoperative hypotension contributes more to the risk of organ injury compared with intraoperative hypotension. A prediction model for clinically important postoperative hypotension after noncardiac surgery is needed to guide clinicians.</div></div><div><h3>Methods</h3><div>We performed a secondary analysis of the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study. Patients aged ≥45 yr who had inpatient noncardiac surgery across 28 centres in 14 countries were included. In 14 of the centres selected at random (derivation cohort), we evaluated 49 variables using logistic regression to develop a model to predict postoperative clinically important hypotension, defined as a systolic blood pressure ≤90 mm Hg, that resulted in clinical intervention. The postoperative period was defined from the Post-Anesthesia Care Unit to hospital discharge. We then evaluated its calibration and discrimination in the other 14 centres (validation cohort).</div></div><div><h3>Results</h3><div>Among 40 004 patients in VISION, 20 442 (51.1%) were included in the derivation cohort, and 19 562 (48.9%) patients were included in the validation cohort. The incidence of clinically important postoperative hypotension in the entire cohort was 12.4% (4959 patients). A 41-variable model predicted the risk of clinically important postoperative hypotension (bias-corrected C-statistic: 0.73, C-statistic in validation cohort: 0.72). A simplified prediction model also predicted clinically important hypotension (bias-corrected C-statistic: 0.68) based on four information items.</div></div><div><h3>Conclusions</h3><div>Postoperative clinically important hypotension may be estimated before surgery using our primary model and a simple four-element model.</div></div><div><h3>Clinical trial registration</h3><div>NCT00512109.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100410"},"PeriodicalIF":0.0,"publicationDate":"2025-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144107814","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perioperative and persistent opioid use after surgery: a scoping review","authors":"Bader Almodibeg ,&nbsp;Jungwoo Kang ,&nbsp;Patrice Forget","doi":"10.1016/j.bjao.2025.100412","DOIUrl":"10.1016/j.bjao.2025.100412","url":null,"abstract":"<div><div>Persistent opioid use after surgery is a growing concern, with existing reviews lacking strong predictors beyond prior opioid use. This scoping review aimed to identify knowledge gaps for future research, particularly regarding the impact of the perioperative period (including preoperative, intraoperative, and postoperative) opioid use on persistent opioid use after surgery. A comprehensive database search of prospective studies explored the association between perioperative opioid use and persistent use in adults after surgery. From the 21 identified studies, we found a complex relationship between perioperative opioid use and persistent use. Preoperative opioid use correlated with persistent use, but the impact of intraoperative and short-term postoperative use remained unclear. Interestingly, postoperative prescriptions at 3 months predicted a higher risk of persistent use at 6 and 12 months. These findings highlight the need for further research to explore the mediating factors that increase the risk of persistent use among preoperative opioid users, along with the specific roles of intraoperative and postsurgical inpatient opioid consumption, and short-term postoperative opioid prescriptions (≤30 days).</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100412"},"PeriodicalIF":0.0,"publicationDate":"2025-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144088689","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is chronic inflammation a risk factor for perioperative myocardial injury or heart failure in pancreatic surgery patients?","authors":"Ted Reniers ,&nbsp;Thijs Rettig ,&nbsp;Laura van Zeggeren ,&nbsp;Ineke Dijkstra ,&nbsp;Kyra Prinsze ,&nbsp;Izaak Molenaar ,&nbsp;Hjalmar van Santvoort ,&nbsp;Olaf Cremer ,&nbsp;Lisette Vernooij ,&nbsp;Peter Noordzij","doi":"10.1016/j.bjao.2025.100417","DOIUrl":"10.1016/j.bjao.2025.100417","url":null,"abstract":"<div><h3>Background</h3><div>Chronic inflammation is associated with cardiovascular disease. Whether cardiac risk is increased in surgical patients with chronic inflammation is unknown. We hypothesised that preoperative interleukin 6 (IL-6) is associated with postoperative biomarker release indicative of myocardial injury and heart failure.</div></div><div><h3>Methods</h3><div>In this prospective cohort study in pancreatic surgery patients, concentrations of IL-6, high-sensitive cardiac troponin-T (hs-cTnT), growth differentiation factor 15 (GDF-15), and N-terminal pro B-type natriuretic peptide (NT-proBNP) were assessed before surgery and 4, 12, 24, and 48 h after surgery. The primary outcome was perioperative myocardial injury (PMI), defined as an absolute hs-cTnT increase ≥14 pg ml⁻¹. Secondary outcomes were postoperative concentrations of GDF-15 and NT-proBNP. We used the χ² test and generalised linear mixed effects models for analyses.</div></div><div><h3>Results</h3><div>Of 88 patients, 24 (27%) had high preoperative IL-6 (&gt;7 pg ml⁻¹). PMI occurred in two (8.3%) and eight (12.5%) patients with high and normal concentrations, respectively (<em>P</em>=0.86). Patients with high IL-6 had higher preoperative concentrations of hs-cTnT (11.0 [inter-quartile range 7.0–15.0] <em>vs</em> 8.0 [5.0–11.0] pg ml⁻¹, <em>P</em>=0.01), GDF-15 (1924.5 [1403.8–2797.5] <em>vs</em> 1445.0 pg ml⁻¹ [1006.5–1905.3] pg ml⁻¹, <em>P</em>=0.021) and NT-proBNP (279.5 [128.8–569.0] <em>vs</em> 116.5 [65.1–226.5] pg ml⁻¹, <em>P</em>=0.012). All biomarkers increased after surgery (all <em>P</em>&lt;0.05), yet this increase was similar among patients with high or normal preoperative IL-6 concentrations.</div></div><div><h3>Conclusions</h3><div>Preoperative inflammation was not associated with PMI or postoperative biomarkers of heart failure after pancreatic surgery. However, patients with high IL-6 concentrations had higher preoperative concentrations of cardiac biomarkers, suggesting the presence of subclinical cardiovascular disease.</div></div><div><h3>Clinical trial registration</h3><div>NCT03460938.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100417"},"PeriodicalIF":0.0,"publicationDate":"2025-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144084629","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Population-based incidence of anxiety-related behaviours during induction of general anaesthesia in children and efficacy of anxiolytic interventions: an international multicentre retrospective observational study","authors":"Clyde T. Matava ,&nbsp;Julie Yu ,&nbsp;Casey Li ,&nbsp;Yuyang Wu ,&nbsp;Guy de Lisle Dear ,&nbsp;Timothy Liversedge ,&nbsp;James J. Thomas ,&nbsp;Abby V. Winterberg ,&nbsp;Allan F. Simpao ,&nbsp;Ari Y. Weintraub","doi":"10.1016/j.bjao.2025.100411","DOIUrl":"10.1016/j.bjao.2025.100411","url":null,"abstract":"<div><h3>Introduction</h3><div>Preoperative anxiety in children is a significant challenge for anaesthesiologists. Although various pharmacological and non-pharmacological interventions have been explored to reduce preoperative anxiety, comprehensive data on the incidence of anxiety and the efficacy of these interventions are lacking. This study aimed to determine the incidence of anxiety in children during anaesthesia induction and evaluate the effectiveness of different interventions using real-world data.</div></div><div><h3>Methods</h3><div>We conducted an international, multicentre, retrospective study, including patients under 18 yr undergoing general anaesthesia. Difficult inductions and anxiety were assessed using the Child Induction Behavioural Assessment tool and the Mask Acceptance Scale.</div></div><div><h3>Results</h3><div>Among 155 604 patient encounters across six centres, the incidence of difficult induction was 6.2%, the highest rate (11.5%) in children aged 1–3 yr. Significant anxiety behaviours were seen in 22.2% of children, the highest incidence (40.8%) in 1–3-yr-olds. Difficult mask acceptance occurred in 20% of cases, highest in the 1–3-yr age group (34.2%). Premedication was associated with a decreased incidence of difficult induction (adjusted odds ratio=0.78, 95% confidence interval: 0.73–0.84, <em>P</em>&lt;0.001). Conversely, parental presence at induction was associated with a higher incidence of difficult induction (adjusted odds ratio=1.77, 95% confidence interval: 1.55–2.01, <em>P</em>&lt;0.001). 77.8% (121 084) of children did not exhibit anxiety during induction of anaesthesia; half of these required no interventions.</div></div><div><h3>Conclusions</h3><div>Most children manage without interventions, showing a lower incidence of anxiety behaviours than previously reported. This underscores the need for tailored, evidence-based strategies to address preoperative anxiety, particularly among younger children at greatest risk.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100411"},"PeriodicalIF":0.0,"publicationDate":"2025-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143922922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-effectiveness analysis of anaesthesia regimens for paediatric strabismus surgery based on multicentre retrospective cohort data from Japan","authors":"Soichiro Obara ,&nbsp;Taiki Kojima ,&nbsp;Yusuke Yamauchi ,&nbsp;Takashi Fujiwara ,&nbsp;Aya Sueda ,&nbsp;Riku Takahashi","doi":"10.1016/j.bjao.2025.100404","DOIUrl":"10.1016/j.bjao.2025.100404","url":null,"abstract":"<div><h3>Background</h3><div>Postoperative vomiting (POV) after paediatric strabismus surgery poses both clinical and economic challenges. This study evaluates the cost-effectiveness of different anaesthesia regimens, focusing on the addition of ondansetron (OND), in preventing POV.</div></div><div><h3>Methods</h3><div>A cost-effectiveness analysis was conducted from the perspective of a Japanese public healthcare payer using retrospective cohort data of children (aged 3–15 years) undergoing strabismus surgery at three institutions (February 2016–November 2023). The primary outcome measure was cost per averted POV (aPOV) within 24 hours post-surgery. Incremental cost-effectiveness ratios were calculated, and sensitivity analyses accounted for uncertainties.</div></div><div><h3>Results</h3><div>A total of 2772 patients were included. Total intravenous anaesthesia (TIVA) regimens were compared, as OND was used only in TIVA regimens. The aPOV rate for TIVA with sub-Tenon block and dexamethasone (DEX) was 91.0%, whereas TIVA with sub-Tenon block, DEX, and OND had an aPOV rate of 96.3%. The incremental cost of adding OND was €21.2, resulting in an incremental cost-effectiveness ratio of €400.6 per aPOV. A sensitivity analysis showed OND cost was the most influential factor. The cost-effectiveness acceptability frontier showed the probability of cost-effectiveness for TIVA+DEX ranged from 0% to 97.4% for thresholds of €0–€200 per aPOV, whereas TIVA+DEX+OND raged from 0% to 9.3%, and TIVA only ranged from 100% to 0%.</div></div><div><h3>Conclusions</h3><div>TIVA with DEX alone is the most cost-effective regimen for preventing POV in paediatric strabismus surgery in the current Japanese public healthcare system. The addition of OND in TIVA regimens may not be justified from the viewpoint of cost-effectiveness.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100404"},"PeriodicalIF":0.0,"publicationDate":"2025-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143917497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluating the risks and benefits of continuing versus withholding renin–angiotensin system inhibitors: a systematic review and meta-analysis with trial sequential analysis","authors":"Laila Shalabi ,&nbsp;Ahmed Ibrahim ,&nbsp;Sofian Zreigh ,&nbsp;Mohamed Rifai ,&nbsp;Shrouk Ramadan ,&nbsp;Mohamed A. Arafa ,&nbsp;Osama M. Mustafa ,&nbsp;Muhammad Ansab ,&nbsp;Mohamed F. Krayem ,&nbsp;Ibrahim Elsabbagh ,&nbsp;Nour H. Mash’al ,&nbsp;Salem Waleed ,&nbsp;Matthieu Legrand","doi":"10.1016/j.bjao.2025.100405","DOIUrl":"10.1016/j.bjao.2025.100405","url":null,"abstract":"<div><h3>Background</h3><div>The best perioperative management of renin–angiotensin system inhibitors (RASi) in patients undergoing noncardiac surgery has been an ongoing debate as a result of inconclusive previous studies and insufficient data for robust guidelines. Although continuation of RASi may lead to intraoperative hypotension, withholding might also cause postoperative complications. Our meta-analysis aims to explore the postoperative outcomes of strategies of RASi management before surgery by evaluating randomised clinical trials, to provide more definitive conclusions for clinical practice.</div></div><div><h3>Methods</h3><div>We systematically searched PubMed, Scopus, Cochrane, and Web of Science until September 2024. Inclusion criteria included patients (≥18 yr) who underwent noncardiac surgery and received long-term RASi, which were either withheld or continued before surgery. Statistical analysis was conducted using R Studio version 4.4.2.</div></div><div><h3>Results</h3><div>A total of seven RCTs with 8741 patients receiving long-term RASi before noncardiac surgery revealed no significant difference between continuation and withholding groups regarding cardiovascular complications (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.80–1.09, <em>P</em>=0.41), mortality (RR 1.16, 95% CI 0.55–2.43, <em>P</em>=0.71), and acute kidney injury (RR 0.95, 95% CI 0.84–1.06, <em>P</em>=0.33). However, continuation of RASi was associated with a higher incidence of intraoperative hypotension (RR 1.33, 95% CI 1.23–1.44, <em>P</em>&lt;0.001). Additionally, the incidence of postoperative severe hypertension (systolic BP &gt;180 mm Hg) was significantly lower in the continuation group (RR 0.63, 95% CI 0.40–0.98, <em>P</em>&lt;0.002).</div></div><div><h3>Conclusions</h3><div>Continuing RASi before noncardiac surgery does not significantly impact mortality, cardiovascular complications or the risk of acute kidney injury. However, continuation is associated with an increased risk of intraoperative hypotension, and withholding with a higher risk of postoperative severe hypertension.</div></div><div><h3>Systematic review protocol</h3><div>CRD42024605208 (PROSPERO).</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100405"},"PeriodicalIF":0.0,"publicationDate":"2025-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143898483","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Common pitfalls of perioperative clinical trials in response to ‘Barriers and enablers to recruiting participants within paediatric perioperative and anaesthetic settings: lessons learned from a trial of melatonin versus midazolam in the premedication of anxious children (the MAGIC trial)’","authors":"Tori N. Sutherland ,&nbsp;Paul A. Stricker ,&nbsp;Andrew J. Davidson","doi":"10.1016/j.bjao.2025.100409","DOIUrl":"10.1016/j.bjao.2025.100409","url":null,"abstract":"<div><div>In this issue, Hyslop and colleagues discuss challenges leading to inadequate enrolment and premature termination of the MAGIC trial, a multicentre randomised controlled trial of melatonin <em>vs</em> midazolam premedication for anxiety among children. The authors should be commended for sharing their experiences, as they underscore common pitfalls of well-intended trials in the perioperative setting, including issues with study design and implementation.</div></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":"14 ","pages":"Article 100409"},"PeriodicalIF":0.0,"publicationDate":"2025-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143868620","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}