Pulse contour techniques for perioperative hemodynamic monitoring: A nationwide carbon footprint and cost estimation

Pulmonary Embolism in Critically Ill Patients-Prevention, Diagnosis, and Management

Critically ill patients in the intensive care unit (ICU) are often immobilized and on mechanical ventilation, placing them at increased risk for thromboembolic diseases, particularly deep vein thrombosis (DVT) and, to a lesser extent, pulmonary embolism (PE). While these conditions are frequently encountered in the emergency department, managing them in the ICU presents unique challenges. Although existing guidelines are comprehensive and effective, they are primarily designed for patients presenting with PE in the emergency department and do not fully address the complexities of managing critically ill patients in the ICU. This review aims to summarize the available data on these challenging cases, offering a practical approach to the prevention, diagnosis, and treatment of PE, particularly when it is acquired in the ICU.

Association of velocity-pressure loop-derived values recorded during neurosurgical procedures with postoperative organ failure biomarkers: a retrospective single-center study

BACKGROUND

Perioperative renal and myocardial protection primarily depends on preoperative prediction tools, along with intraoperative optimization of cardiac output (CO) and mean arterial pressure (MAP). We hypothesise that monitoring the intraoperative global afterload angle (GALA), a proxy of ventricular afterload derived from the velocity pressure (VP) loop, could better predict changes in postoperative biomarkers than the recommended traditional MAP and CO.

METHOD

This retrospective monocentric study included patients programmed for neurosurgery with continuous VP loop monitoring. Patients with hemodynamic instability were excluded. Those presenting a 1-day post-surgery increase in creatinine, B-type natriuretic peptide, or troponin Ic us were labelled Bio+, Bio- otherwise. Demographics, intra-operative data, and comorbidities were considered as covariates. The study aimed to determine if intraoperative GALA monitoring could predict early postoperative biomarker disruption.

RESULT

From November 2018 to November 2020, 86 patients were analysed (Bio+/Bio- = 47/39). Bio+ patients were significantly older (62 [54-69] vs. 42 [34-57] years, p <  0.0001), More often hypertensive (25% vs. 9%, p = 0.009), and more frequently treated with antihypertensive drugs (31.9% vs. 7.7%, p = 0.013). GALA was significantly larger in Bio+ patients (40 [31-56] vs. 23 [19-29] °, p < 0.0001), while CO, MAP, and cumulative time spent <65mmHg were similar between groups. GALA exhibited strong predictive performances for postoperative biological deterioration (AUC = 0.88 [0.80-0.95]), significantly outperforming MAP (MAP AUC = 0.55 [0.43-0.68], p < 0.0001).

CONCLUSION

GALA under general anaesthesia prove more effective in detecting patients at risk of early cardiac or renal biological deterioration, compared to classical hemodynamic parameters.

Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review

OBJECTIVES

The environmental impacts of healthcare are important factors that should be considered during health technology assessments. This study aims to summarize the evidence that exists about methods to include environmental impacts in health economic evaluations and health technology assessments.

METHODS

We identified records for screening using an existing scoping review and a systematic search of academic databases and gray literature up to September 2023. We screened the identified records for eligibility and extracted data using a narrative synthesis approach. The review was conducted following the JBI Manual for Evidence Synthesis and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews checklist.

RESULTS

We identified 2898 records and assessed the full text of 114, of which 54 were included in this review. Ten methods were identified to include environmental impacts in health economic evaluations and health technology assessments. Methods included converting environmental impacts to dollars or disability-adjusted life years and including them in a cost-effectiveness, cost-utility, or cost-benefit analysis, calculating an incremental carbon footprint effectiveness ratio or incremental carbon footprint cost ratio, incorporating impacts as one criteria of a multi-criteria decision analysis, and freely considering impacts during health technology assessment deliberation processes.

CONCLUSIONS

Methods to include environmental impacts in health economic evaluations and health technology assessments exist but have not been tested for widespread use by health technology assessment agencies. Further research and implementation work is needed to determine which method can best aid decision makers to choose low environmental impact healthcare interventions.

Haemodynamic monitoring during noncardiac surgery: past, present, and future

During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.

Risk factors for poor performance in finger cuff non-invasive monitoring of arterial pressure: A prospective multicenter study

BACKGROUND

Compared to the invasive technique, non-invasive monitoring of arterial pressure favors easier and faster implementation while potentially sacrificing some reliability. This may be particularly true for the Clearsight™ system (Edwards Lifesciences), which enables continuous monitoring. We evaluated the risk factors for its poor performance.

METHODS

Patients with an arterial catheter and stable mean arterial pressure (MAP) over a 5-min period were included. Six pairs of invasive and Clearsight measurements of MAP were collected and the bias between the two techniques was calculated. Poor performance of the Clearsight™ system was defined as either a failure to measure and display MAP or displaying an erroneous MAP (individual bias > 5 mmHg). Fingertip perfusion was assessed using the plethysmographic perfusion index (PI) and the capillary refill time (CRT).

RESULTS

Among 152 ICU patients (MAP of 81 ± 14 mmHg, norepinephrine in 78 [51%]), 78 (51%) experienced a poor performance of the Clearsight™ system: failure to display MAP in 19 (13%) patients, and erroneous value displayed in 59 (44%). In multivariate analysis, PI ≤ 0.85% (adjusted odds ratio [aOR] = 2.94 [95% confidence interval (95%CI):1.34;6.45]), CRT > 4 s (aOR = 5.28 [95%CI 1.39;20.05]), and the presence of hand edema (aOR = 2.06 [95%CI 1.01;4.21]) were associated with a higher likelihood of poor performance. Cardiac arrhythmia (aOR = 1.39 [95%CI 0.64;3.02]) and other tested variables were not associated with poor performance.

CONCLUSIONS

Half of the included patients exhibited poor Clearsight™ system performance. Our results caution against using finger cuff arterial pressure monitoring in patients with low PI (≤0.85%), protracted CRT (>4 s), or hand edema.

REGISTRATION

ClinicalTrials.gov, NCT04269382, Dr. G. Muller, February 13, 2020. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04269382.