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Quantitative neuromuscular monitoring in children remains challenging, particularly in weight and age categories without equipment certification. The study compared the precision of kinemyography and electromyography in children <5 yr of age. Sixty-four children were stratified into neonates (&#x2264;44 weeks postmenstrual age), infants (44-58 weeks postmenstrual age), toddlers (>58 weeks postmenstrual age to &#x2264;2 yr), and children (2-5 yr). Kinemyography and electromyography were applied to contralateral arms. Primary endpoints were precision of train-of-four ratios before rocuronium administration and after assumed complete recovery (i.e. after sugammadex administration). Precision was quantified using the repeatability coefficient, indicating the range within which a repeated train-of-four ratio is with 95% probability. A low repeatability coefficient indicates high precision. Median repeatability coefficients were 0.06 [IQR 0.03-0.10] for kinemyography and 0.06 [0.05-0.09] for electromyography (median difference 0.00 [95% confidence interval, CI -0.01 to 0.01]) at baseline and 0.04 [0.02-0.07] and 0.04 [0.03-0.06] after recovery (median difference 0.00 [-0.01 to 0.01]). Kinemyography precision was worse in non-certified use (<5 kg: 0.08 [0.05-0.11], &#x2265;5 kg: 0.04 [0.02-0.06]; median difference 0.04 [0.02-0.05]), whereas electromyography performed similarly regardless of its certification (neonates 0.05 [0.03-0.11], others 0.06 [0.03-0.09]; median difference -0.01 [-0.04 to 0.05]). Train-of-four ratios <0.9 were more frequent in kinemyography than in electromyography (33% vs 16%, P<0.05). Neither kinemyography nor electromyography was inferior to the other in terms of precision. Unlike kinemyography, electromyography remained precise even when applied below recommended age or weight limits. The importance of baseline values before rocuronium is underlined by the frequently measured train-of-four ratios of <0.9. ClinicalTrials.gov; NCT06062290 (registered August 15th, 2023).

Virtual care is increasingly used for preoperative assessment. We aimed to estimate the noninferiority of virtual vs in-person anaesthesiology consultations with respect to 90-day morbidity and mortality in at-risk adults having noncardiac surgery. We conducted a retrospective observational comparative effectiveness study using a target trial emulation framework. Eligible participants were aged &#x2265;40 yr, with an ASA physical status &#x2265;3, having elective, noncardiac, non-orthopaedic, moderate- to high-risk surgery, and attended a preoperative anaesthesiology consultation in Ontario, Canada, between October 2020 and March 2022. Exposures were receipt of virtual vs in-person preoperative anaesthesiology consultation in the 60 days preceding surgery. The primary outcome was 90-day major morbidity or mortality (noninferiority margin of upper 95% confidence interval [CI] <1.10 on relative scale). Secondary outcomes included 90-day mortality, length of hospital stay, costs of care, and days alive and at home within 90 days (DAH90). Travel-attributable carbon emissions were also estimated. Analyses used instrumental variable and propensity score methods. Among 17&#x2009;027 patients, 8399 (49.3%) received a virtual consultation. The primary outcome occurred in 2212 (26.3%) virtual consult patients and 2147 (24.9%) of 8628 in-person consult patients. Primary outcome noninferiority was inconclusive based on both instrumental variable (adjusted odds ratio [adj-OR] 1.02, 95% CI 0.92-1.13) and propensity-score adjusted (adj-OR 0.99, 95% CI 0.89-1.101) analyses. Noninferiority was observed for length of hospital stay, costs of care, and DAH90. In-person care was associated with an estimated increase of 8618 (SD 17 200) g CO2 per visit. Before moderate-to-high-risk noncardiac, non-orthopaedic elective surgery, the noninferiority of virtual vs in-person anaesthesiology consultation for major morbidity or mortality was inconclusive. Virtual care was noninferior for several secondary outcomes and associated with reduced carbon emissions. Further research is required to refine triage models and increase certainty regarding morbidity.

The UK NHS faces increasing pressure to diminish its carbon footprint, with fluorinated anaesthetic agents representing a significant source of direct greenhouse gas emissions. Several NHS trusts retain substantial quantities of unused stock and waste volatile anaesthetics (VAs), particularly desflurane, requiring appropriate disposal. However, a crucial unquantified aspect is the endpoint destruction routes and associated emissions for accumulated desflurane stock and waste anaesthetics. We developed a mathematical model accompanied by an open-source Python-based application programming interface (API) to estimate equivalent carbon emissions and their climate impacts across disposal pathways. Stochastic modelling also estimates uncertainties of input parameters and their effects on model predictions. User-defined input parameters in the API allow practitioners to model specific destruction pathways. We identified high-temperature incineration in clinical waste streams as the most likely route, which, compared with release, shows reductions of more than 70% in equivalent emissions. Model predictions suggest that plasma destruction has the highest potential for reducing equivalent carbon emissions, to less than 5% from all waste fluorinated VAs by reducing the formation of products of incomplete combustion, with an associated reduction in climate impact. Crucial work still needs to be done to validate theoretical estimates, accurately assess the formation of products of incomplete combustion from fluorinated VAs under varying destruction conditions, and evaluate the feasibility of implementing the assessed waste streams.

Malignant hyperthermia (MH) is a life-threatening pharmacogenetic disorder triggered by volatile anaesthetics or depolarising neuromuscular blockers, characterised by dysregulated calcium homeostasis in skeletal muscle. Dysfunction of ryanodine receptor type 1 (RYR1) because of genetic variants plays a central role in MH. Functional evaluation of newly identified RYR1 variants is essential for accurate presymptomatic diagnosis of MH susceptibility. This study aimed to assess the function of novel RYR1 variants detected in Japanese patients. Six previously uncharacterised RYR1 variants were introduced into full-length rabbit RYR1 cDNA and expressed in human embryonic kidney (HEK-293) cells. Calcium release in response to caffeine and 4-chloro-m-cresol (4-CmC) was measured using Fura-2 AM. Expression of variants and wild-type (WT) RYR1 was confirmed by immunoblotting. Concentration-response curves (EC50 values) were analysed using Prism 9.5. Statistical significance was determined by an extra sum-of-squares F test (global fit) (P < 0.01 indicates statistical significance). Data are presented as 95% confidence intervals for EC50 values (n &#x2265; 14). All six variants (p.Ile2358Thr, p.Asp2431His, p.Asp2431Glu, p.Pro2366Arg, p.Arg2454Gly, p.Glu2545Asp) showed hypersensitivity to caffeine and 4-CmC. Best-fit EC50 values for caffeine (1.82-2.50 mM) and 4-CmC (74.6-103.6 &#x3bc;M) were significantly lower than WT (4.28 mM and 178 &#x3bc;M, respectively; P<0.01). The RYR1 variant p.Pro2366Arg was classified as pathogenic or likely pathogenic, whereas p.Ile2358Thr, p.Asp2431His and p.Arg2454Gly remained as variants of uncertain significance but as likely pathogenic, and p.Asp2431Glu and p.Glu2545Asp remained variants of uncertain significance.

Respiratory failure after surgery and other major invasive procedures, defined as the unanticipated need for invasive or noninvasive ventilation, is a life-threatening complication affecting &#x223c;10 million patients annually. At present, there are no guidelines for risk assessment and prevention of postprocedural respiratory failure. We developed expert-informed practice recommendations for the prediction and prevention of postoperative and postprocedural respiratory failure. These recommendations focused on modifiable pre- and post-procedural risk factors and implementation feasibility, using a structured multidisciplinary expert panel process. An international expert panel reviewed current literature, supplemented evidence gaps with expert opinion, and drafted preliminary action statements. Iterative voting rounds were used to refine expert panel statements, which were classified as recommendations with broad applicability and low likelihood of delaying care, or suggestions that can be applied selectively. The study panel included 25 experts from four continents and multiple medical disciplines. An initial set of 54 preliminary statements was refined into 13 recommendations and 15 suggestions. Recommendations included using screening tools systematically, promoting tobacco cessation, reconsidering procedure timing in patients with symptomatic respiratory tract infections, mobilising patients early and maximising upright positioning, maintaining good oral hygiene, using noninvasive respiratory support to minimise need for invasive ventilation, and minimising deep sedation while promoting early tracheal extubation. These recommendations reflect expert interpretation of a broad and heterogeneous body of evidence and provide practical strategies to predict and prevent postprocedural respiratory failure, offering a framework for future study of a risk-targeted care bundle.

Perioperative abnormalities presenting in patients with inherited primary disorders of skeletal muscle can share similar characteristics to those in a malignant hyperthermia crisis. These patients are often referred to malignant hyperthermia units for perioperative advice as clinicians are accessing conflicting and non-current literature. To address this, the European Malignant Hyperthermia Group (EMHG) has conducted a review of the current literature and used a formal consensus process, with review at annual EMHG meetings and workshops, to provide guidelines for the perioperative management of patients with these myopathies. The guidelines include general recommendations and suggestions applicable to all patients with myopathy requiring anaesthesia or procedural sedation and additional specific recommendations, suggestions and main concerns for patients with specific primary myopathies (ICD-11-CM) with inheritable pathology distal to the neuromuscular junction, including congenital, mitochondrial and metabolic myopathies; muscular dystrophies; myotonias; and familial periodic paralyses.

The underlying pathophysiological mechanisms of complex regional pain syndrome (CRPS) have been under debate in recent years. Previous studies identified mechanistic CRPS subtypes, which were characterised as 'cold' and 'warm' or peripheral and central phenotypes. Our aim was to examine CRPS patients through comprehensive somatosensory testing and identify potential subgroups using unbiased statistics. Thus, our approach differs fundamentally from previous top-down approaches which stratified along predefined pathophysiological mechanisms. In total, 604 patients (age: 51.9 [SD 13.4] yr, female: 436, disease duration: 1.6 [SD 2.9] yr) with CRPS (type I: n=520; type II: n=84) underwent Quantitative Sensory Testing according to the DFNS protocol (German Research Network on Neuropathic Pain). We assessed 13 parameters, including thermal and mechanical detection and pain thresholds, indicating one distinct sensory profile for each participant. We conducted a hypothesis-free cluster analysis in a training set (A, n=380), which was re-evaluated in a validation set (B, n=224) to account for possible overfitting of the data and a comparison towards human pain surrogate models. We identified three sensory phenotypes in the training set, which were confirmed in the validation set. The largest group showed pronounced hypersensitivity towards cold and heat pain (n=382), a second group showed loss of thermal and mechanical sensation (n=200), and a third, small, but consistent, group exhibited strong allodynia and mechanical hyperalgesia (n=22). A novel bottom-up approach can stratify CRPS based on sensory phenotypes, adding to a mechanistic understanding through a comparative analysis of human pain surrogate models.

The predictive value of preoperative resting ECGs for cardiovascular events after noncardiac surgery is unclear. This study evaluated whether incorporating conventional ECG features or the output of a deep-learning algorithm for ECG waveform analysis (PreOpNet) improves risk prediction beyond established clinical risk scores. We conducted a secondary analysis of two prospective cohorts of patients undergoing major noncardiac surgery in China between 2019 and 2023. Eight prespecified conventional ECG features were extracted from ECG reports, and raw ECG waveforms were analysed using PreOpNet. The primary outcome was a composite of any cardiovascular events within 30 days after surgery; the secondary outcome was major adverse cardiac events (MACEs). We built nested logistic regression models based on clinical risk scores, with or without ECG findings. Predictive performance was evaluated using area under the receiver-operating-characteristic curve (AUC), risk reclassification metrics, and decision curve analyses. Among 6080 patients, 733 (12.1%) experienced postoperative cardiovascular events and 174 (2.9%) had MACEs. Adding conventional ECG features (&#x394;AUC 0.035) or PreOpNet (&#x394;AUC 0.032) to the Revised Cardiac Risk Index improved model discrimination modestly. When added to the Gupta Perioperative Myocardial Infarction or Cardiac Arrest risk score, both approaches yielded minimal gains (&#x394;AUC 0.010 for conventional ECG features; 0.006 for PreOpNet). Risk reclassification and decision curve analyses had limited incremental predictive value. Preoperative ECG findings, assessed by including conventional waveform features and the PreOpNet algorithm, provide limited incremental predictive value for cardiovascular risk assessment before noncardiac surgery.

Unplanned postoperative reintubation is associated with increased morbidity, mortality, and healthcare use. Unplanned postoperative reintubation represents a heterogeneous clinical endpoint arising from distinct and often overlapping etiopathogenetic mechanisms, including airway compromise, respiratory insufficiency, cardiac dysfunction, neurological impairment and acute organ failure. Early reintubation need is more commonly associated with residual anaesthetic/neuromuscular blocker effects and airway-related factors, whereas intermediate and late restoration of invasive ventilation frequently reflects evolving respiratory, cardiac or multiorgan complications. Risk prediction models and advanced monitoring tools may support early identification of vulnerable patients but are limited by heterogeneous and variable predictive performance. Consequently, preventive strategies are most effective when tailored to specific phenotypes. A phenotype-based approach enables targeted surveillance and interventions, highlighting unplanned postoperative reintubation as a marker of perioperative vulnerability rather than a uniform pathology.

Licensed, ready-to-administer injectable medicines can reduce medication errors, minimise waste, and streamline perioperative workflows, but higher acquisition costs have limited uptake in England. This study evaluated the economic impact of switching selected anaesthetic and critical care medicines from conventional ampoules and vials to licensed prefilled syringes within NHS practice. An economic model compared current mixed-use practice with a hypothetical switch to 100% licensed ready-to-administer products for eight medicines: epinephrine 1 mg in 10 ml, ephedrine 30 mg, atropine 3 mg, rocuronium 100 mg in 10 ml, lidocaine (1% and 2%), and midazolam (5 mg in 5 ml and 50 mg in 50 ml). Modelled cost components included medicine acquisition, wastage, nursing preparation time, consumables and preventable adverse drug events. Preparation time reductions were interpreted as capacity release rather than workflow substitution. Deterministic sensitivity analyses explored variation in key assumptions and procurement thresholds. Under the modelling assumptions, epinephrine, ephedrine, atropine and lidocaine 2% were associated with reduced overall system costs of more than &#xa3;5.3 million annually, largely driven by reduced wastage, preparation workload and modelled adverse drug events. Rocuronium and midazolam were associated with increased costs because of higher acquisition prices despite operational advantages. Sensitivity analyses did not alter the direction of findings. Substantial price reductions would be required for certain medicines to achieve cost neutrality. Licensed ready-to-administer injectable medicines can provide safety and workflow advantages and be associated with economic benefit. Acquisition cost remains a barrier, but broader adoption and market development could improve affordability.

Two percent to 50% of patients undergoing elective cardiac surgery experience acute kidney injury (AKI) postoperatively. Medications to prevent AKI after elective cardiac surgery have not been identified. In patients undergoing elective cardiac surgery, to evaluate whether initiating dapagliflozin 1 day prior to surgery reduces the incidence of AKI at 7 days after cardiac surgery, compared with placebo. Multicenter, double-blind, placebo-controlled randomized clinical trial conducted at 2 academic medical centers and 5 nonacademic hospitals in the Netherlands. Eligible participants were adults undergoing elective cardiac surgery. Enrollment occurred between June 8, 2023, and January 27, 2025. Final follow-up occurred May 16, 2025. Patients were randomized 1:1 to receive either dapagliflozin (10 mg orally; n&#x2009;=&#x2009;392) or placebo once daily (n&#x2009;=&#x2009;392), beginning on the day before surgery and continuing through the second postoperative day (total of 4 doses). The primary outcome was the between-group difference in AKI (defined as an increase in serum creatinine level by at least 0.3 mg/dL [26.5 &#xb5;mol/L] within 48 hours after surgery, a 1.5-fold creatinine increase within 7 days of surgery, or urine output less than 0.5 mL/kg/h for 6 to 12 hours according to Kidney Disease: Improving Global Outcomes criteria) during the first 7 postoperative days. Of 784 participants enrolled, 778 (99%) completed follow-up testing (median age, 68 [61-74] years; 76% male; 97% White; median body mass index, 27 [IQR, 25-30]; and median estimated glomerular filtration rate, 80 [IQR, 67-89] mL/min/1.73 m2). Compared with placebo, dapagliflozin reduced the incidence of AKI (28% vs 52%; relative risk, 0.54 [95% CI, 0.45-0.65]; P&#x2009;<&#x2009;.001) over 7-day follow-up after surgery. Atrial fibrillation and reoperation were the most frequent adverse events. The incidence of atrial fibrillation was 45% (176/392) in the dapagliflozin group vs 45% (176/392) in the placebo group, and the incidence of reoperation was 11% (43/392) vs 10% (39/392), respectively. In patients undergoing elective cardiac surgery, 4 doses of dapagliflozin, beginning the day before surgery, reduced the incidence of AKI during the 7-day postoperative period. ClinicalTrials.gov Identifier: NCT05590143.

Guidelines recommend routine preoperative frailty assessment; however, existing data suggest that adherence is low. The ability with which patients can evaluate their frailty before surgery is unknown. Our objective was to evaluate the agreement of patient self-reporting of frailty compared with trained assessors using the Clinical Frailty Scale (CFS). This was a sub study of a multicentre prospective cohort study of people &#x2265;65 yr of age having elective noncardiac surgery. Preoperatively, patients and trained assessors independently rated patient frailty using the CFS. Agreement between raters on the ordinal scale was estimated using weighted kappa. We evaluated agreement after dichotomising scores (CFS&#x2265;4) using Cohen's kappa. We also described the discriminative ability of self-reported and assessor-reported CFS scores in predicting the occurrence of death or new disability 90 days after surgery. There were 531 participants with both self-reported and assessor-reported CFS. Agreement was moderate (weighted kappa=0.58 [95% confidence interval, CI 0.53-0.63], Cohen's kappa=0.61 [95% CI 0.54-0.68]). Assessor-rated scores were systematically higher than self-rated scores by a mean of 0.45 points (95% CI 0.39-0.52; P<0.001). When predicting death or new disability, paired receiver operating characteristic curve analysis revealed no difference in discriminative capability of self-rated or assessor-rated CFS assessment (c-statistic difference 0.010 [95% CI -0.072 to 0.092; P=0.81]). Patients self-report their frailty status using the CFS with moderate agreement to a trained frailty assessor. Self-reported and assessor-rated scores had similar predictive capability for postoperative death or new disability.

Opioid receptor-ligand signalling has been implicated in tumour biology and perioperative outcomes; however, its pan-cancer molecular landscape and clinical relevance remain incompletely defined. We performed a pan-cancer multi-omics analysis of eight predefined opioid receptor-ligand genes across 33 tumour types from The Cancer Genome Atlas. Analyses included gene expression analysis using the linear models for microarray data (limma) package, genomic alterations, DNA methylation, regulatory network inference, pathway activity estimation using gene set variation analysis, and survival modelling. Multivariable Cox regression models were adjusted for age, sex, and tumour stage. Opioid receptor-ligand genes exhibited heterogeneous and generally low-to-moderate expression across tumour types. Genomic and epigenetic alterations were tumour-specific and variably associated with gene expression. Selected genes showed associations with overall survival in a tumour-dependent manner; however, these associations were attenuated after adjustment for clinical covariates and were accompanied by wide confidence intervals in some cohorts. Pathway analyses suggested associations with broader biological programmes, including epithelial-mesenchymal transition and immune-related pathways. Regulatory analyses identified candidate transcription factors and miRNAs, although these findings are exploratory. This pan-cancer analysis provides a systematic overview of opioid receptor-ligand gene features across human cancers. The observed associations are context-dependent and should be interpreted as hypothesis-generating. Further mechanistic and prospective studies are required to determine the clinical relevance of opioid signalling in cancer and perioperative settings.

Body mass index does not distinguish adiposity from muscle. We examined associations of BMI and CT-derived body composition phenotypes with postoperative cardiovascular events. This secondary analysis included patients aged &#x2265;45 yr undergoing major noncardiac surgery. In the overall cohort, BMI associations with postoperative cardiovascular events were examined using multivariable logistic regression with restricted cubic splines. In patients with preoperative CT, body composition phenotypes were derived using k-means clustering. Associations between CT-derived body composition phenotypes and postoperative cardiovascular events were examined after adjustment for BMI category and prespecified covariates; model performance was compared before and after adding phenotype to the BMI category model. The overall cohort included 6320 patients. Lower BMI was associated with higher postoperative cardiovascular risk, with evidence of non-linearity (P<0.001; P for non-linearity=0.001) and heterogeneity by surgical type (P for interaction=0.005). The CT sub-cohort included 2399 patients. Three CT-derived phenotypes were identified: low muscle/low adiposity (Cluster 1), adiposity predominance (Cluster 2), and muscle predominance (Cluster 3). After adjustment for BMI category and prespecified covariates, Cluster 3 was associated with lower odds than Cluster 1 (adjusted odds ratio=0.59, 95% confidence interval=0.40-0.88; P=0.010). Adding body composition phenotype to the BMI category model improved overall model fit, but gains in discrimination and reclassification were modest. Lower BMI was associated with higher postoperative cardiovascular risk, with heterogeneity by surgical type. When preoperative CT is available, CT-derived body composition phenotyping may provide complementary information beyond BMI, although added predictive value appears modest.

Acute respiratory distress syndrome (ARDS) is defined by severe hypoxaemia and bilateral pulmonary infiltrates, yet clinical outcomes are not determined by gas exchange alone. Increasing evidence suggests that right ventricular (RV) dysfunction is a frequent and clinically relevant complication, reflecting the combined effects of pulmonary vascular injury and mechanical ventilation. In this narrative review, we examine the mechanisms through which inflammatory lung injury, pulmonary vascular dysfunction, and mechanical ventilation contribute to RV-pulmonary arterial uncoupling. We discuss how hypoxic vasoconstriction, microvascular thrombosis, endothelial dysfunction, hypercapnia, driving pressure, intra-abdominal pressure, transpulmonary and transdiaphragmatic pressures, and inappropriate PEEP together increase pulmonary vascular load beyond the adaptive capacity of the RV. Extracardiac factors, including fluid accumulation, venous congestion, and abdominal-thoracic interactions, further influence RV loading conditions but are often under-recognised in ARDS. We also review the clinical features of acute cor pulmonale and its association with increased mortality. We emphasise the importance of systematic bedside assessment integrating echocardiography, invasive haemodynamics, ventilatory variables, while acknowledging the limitations of current biomarkers and diagnostic tools. Finally, we discuss the therapeutic implications of RV dysfunction, outlining how ventilatory management, fluid strategy, vasoactive support, prone positioning, and extracorporeal life support can be informed by RV physiology. Recognition of RV dysfunction can improve physiological assessment and individualised cardiopulmonary management in ARDS.

Enhanced Recovery After Surgery (ERAS) Society guidelines provide procedure-specific, evidence-based recommendations for perioperative care. Many interventions fall within anaesthesiology, yet the extent to which they reflect cross-speciality principles remains unclear. The objective of this systematic review was to identify a universal anaesthesiological core across ERAS guidelines. All ERAS Society guidelines were screened for eligibility. Guidelines were excluded if they had no practical anaesthesiological recommendations, had been superseded, or were not intended for standard hospital settings. A classification of 45 anaesthesiological umbrella terms was developed through pilot extraction and Delphi consensus. Two reviewers independently extracted recommendations and their strength. Methodological quality was assessed using Appraisal of Guidelines for Research and Evaluation II (AGREE II). Umbrella terms were classified as consistent (>80%), mostly consistent (60-80%), mixed (20-60%), or sparse (&#x2264;20%). Of 39 publications, 24 guidelines (2013-2025) were included. Anaesthesiological involvement was identifiable in 23 out of 24 guidelines. Of the 45 umbrella terms, eight were consistent, 10 mostly consistent, 16 mixed, and 11 sparse. The consistent domains were: multimodal analgesia, fasting, thromboprophylaxis, antimicrobial prophylaxis, nutrition, temperature and fluid management, and surgery-specific recommendations. The mean AGREE II score was 76%, highest for scope and purpose and clarity of presentation and lowest for stakeholder involvement. Despite procedural heterogeneity, a consistent anaesthesiological core is identifiable within the ERAS guidelines. Cross-guideline consistency identifies the priority domains for cross-speciality implementation, whereas recommendation strength independently indicates the confidence with which guidance transposes onto local practice; high-frequency, mixed-strength domains, notably fluid management, preoperative carbohydrate administration and preanaesthetic medication, warrant structured local appraisal. The study protocol: Open Science Framework (DOI: 10.17605/OSF.IO/CBWDT).

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The number of older adults living with frailty who undergo surgery is rapidly increasing worldwide. Life-space mobility (LSM) can capture physical and social dimensions of recovery and has been linked to functional decline and reduced quality of life. To examine postoperative recovery using LSM among older adults living with frailty and to identify factors associated with restricted mobility and readmission. This cohort study within the larger Functional Improvement Trajectories After Surgery study used a convergent mixed-methods exploratory design. Seventeen hospitals across Canada included older adults aged 65 years or older with a clinical frailty score (CFS) of 3 or more who underwent major elective noncardiac surgery from March 2021 to June 2023. Data were analyzed from September to October 2025. Elective noncardiac surgery among older adults. LSM (range 0-120, with higher scores indicating more mobility) was measured at 1 to 2 months and 6 months postoperatively, with retrospective presurgery LSM captured at 1 to 2 months. Multivariable linear mixed-effects models and multivariable mixed-effects logistic regression were used to identify factors associated with LSM trajectories, restricted mobility (ie, LSM&#x2009;<&#x2009;60), and hospital readmission. This study included 204 participants (mean [SD] age, 72.8 [5.6] years; 108 males [53%]). The mean (SD) LSM was 65.1 (26.7) presurgery, 56.6 (26.7) at 2 months postsurgery, and 64.9 (25.9) at 6 months postsurgery. Eighty participants (39.2%) had restricted mobility presurgery, 114 (56.4%) at 2 months postsurgery, and 84 (41.2%) at 6 months postsurgery. Restricted mobility was associated with being a woman (odds ratio [OR], 4.72; 95% CI, 2.27-9.84), greater frailty (OR, 10.42; 95% CI, 3.56-30.49), and concurrent need for support from formal or informal caregivers (OR, 5.43; 95% CI, 2.72-10.86). Elevated-risk surgery was associated with hospital readmission at 6 months (OR, 3.18; 95% CI, 1.48-7.25). In this nested cohort study, mean LSM recovered by 6 months postsurgery, but 41% of older adults still had restricted mobility. Being a woman, having greater frailty, and needing support from caregivers were associated with poor recovery. Integrating life-space assessments into individualized perioperative care planning may enhance evaluation of functional recovery, inform shared decision-making, and guide support strategies.