Wearable wireless continuous vital signs monitoring on the general ward

PURPOSE OF REVIEW

Wearable wireless sensors for continuous vital signs monitoring (CVSM) offer the potential for early identification of patient deterioration, especially in low-intensity care settings like general wards. This study aims to review advances in wearable CVSM - with a focus on the general ward - highlighting the technological characteristics of CVSM systems, user perspectives and impact on patient outcomes by exploring recent evidence.

RECENT FINDINGS

The accuracy of wearable sensors measuring vital signs exhibits variability, especially notable in ambulatory patients within hospital settings, and standard validation protocols are lacking. Usability of CMVS systems is critical for nurses and patients, highlighting the need for easy-to-use wearable sensors, and expansion of the number of measured vital signs. Current software systems lack integration with hospital IT infrastructures and workflow automation. Imperative enhancements involve nurse-friendly, less intrusive alarm strategies, and advanced decision support systems. Despite observed reductions in ICU admissions and Rapid Response Team calls, the impact on patient outcomes lacks robust statistical significance.

SUMMARY

Widespread implementation of CVSM systems on the general ward and potentially outside the hospital seems inevitable. Despite the theoretical benefits of CVSM systems in improving clinical outcomes, and supporting nursing care by optimizing clinical workflow efficiency, the demonstrated effects in clinical practice are mixed. This review highlights the existing challenges related to data quality, usability, implementation, integration, interpretation, and user perspectives, as well as the need for robust evidence to support their impact on patient outcomes, workflow and cost-effectiveness.

Opioid-Free Anesthesia in Bariatric Surgery: Is It the One and Only? A Comprehensive Review of the Current Literature

Opioid-free anesthesia (OFA) is a heterogeneous group of general anesthesia techniques in which the intraoperative use of opioids is eliminated. This strategy aims to decrease the risk of complications and improve the patient's safety and comfort. Such potential advantages are particularly beneficial for selected groups of patients, among them obese patients undergoing laparoscopic bariatric surgery. Opioids have been traditionally used as an element of balanced anesthesia, and replacing them requires using a combination of coanalgesics and various types of local and regional anesthesia, which also have their side effects, limitations, and potential disadvantages. Moreover, despite the growing amount of evidence, the empirical data on the superiority of OFA compared to standard anesthesia with multimodal analgesia are contradictory, and potential benefits in many studies are being questioned. Additionally, little is known about the long-term sequelae of such a strategy. Considering the above-mentioned issues, this study aims to present the potential benefits, risks, and difficulties of implementing OFA in bariatric surgery, considering the current state of knowledge and literature.

OUP accepted manuscript

Background

Wearable devices have been proposed as a novel method for monitoring patients after surgery to track recovery, identify complications early, and improve surgical safety. Previous studies have used a heterogeneous range of devices, methods, and analyses. This review aimed to examine current methods and wearable devices used for monitoring after abdominal surgery and identify knowledge gaps requiring further investigation.

Methods

A scoping review was conducted given the heterogeneous nature of the evidence. MEDLINE, EMBASE, and Scopus databases were systematically searched. Studies of wearable devices for monitoring of adult patients within 30 days after abdominal surgery were eligible for inclusion.

Results

A total of 78 articles from 65 study cohorts, with 5153 patients were included. Thirty-one different wearable devices were used to measure vital signs, physiological measurements, or physical activity. The duration of postoperative wearable device use ranged from 15 h to 3 months after surgery. Studies mostly focused on physical activity metrics (71.8 per cent). Continuous vital sign measurement and physical activity tracking both showed promise for detecting postoperative complications earlier than usual care, but conclusions were limited by poor device precision, adherence, occurrence of false alarms, data transmission problems, and retrospective data analysis. Devices were generally well accepted by patients, with high levels of acceptance, comfort, and safety.

Conclusion

Wearable technology has not yet realized its potential to improve postoperative monitoring. Further work is needed to overcome technical limitations, improve precision, and reduce false alarms. Prospective assessment of efficacy, using an intention-to-treat approach should be the focus of further studies.

The Importance of Respiratory Rate Monitoring: From Healthcare to Sport and Exercise

Respiratory rate is a fundamental vital sign that is sensitive to different pathological conditions (e.g., adverse cardiac events, pneumonia, and clinical deterioration) and stressors, including emotional stress, cognitive load, heat, cold, physical effort, and exercise-induced fatigue. The sensitivity of respiratory rate to these conditions is superior compared to that of most of the other vital signs, and the abundance of suitable technological solutions measuring respiratory rate has important implications for healthcare, occupational settings, and sport. However, respiratory rate is still too often not routinely monitored in these fields of use. This review presents a multidisciplinary approach to respiratory monitoring, with the aim to improve the development and efficacy of respiratory monitoring services. We have identified thirteen monitoring goals where the use of the respiratory rate is invaluable, and for each of them we have described suitable sensors and techniques to monitor respiratory rate in specific measurement scenarios. We have also provided a physiological rationale corroborating the importance of respiratory rate monitoring and an original multidisciplinary framework for the development of respiratory monitoring services. This review is expected to advance the field of respiratory monitoring and favor synergies between different disciplines to accomplish this goal.

Current clinical methods of measurement of respiratory rate give imprecise values

Background

Respiratory rate is a basic clinical measurement used for illness assessment. Errors in measuring respiratory rate are attributed to observer and equipment problems. Previous studies commonly report rate differences ranging from 2 to 6 breaths·min^-1 between observers.

Methods

To study why repeated observations should vary so much, we conducted a virtual experiment, using continuous recordings of breathing from acutely ill patients. These records allowed each breathing cycle to be precisely timed. We made repeated random measures of respiratory rate using different sample durations of 30, 60 and 120 s. We express the variation in these repeated rate measurements for the different sample durations as the interquartile range of the values obtained for each subject. We predicted what values would be found if a single measure, taken from any patient, were repeated and inspected boundary values of 12, 20 or 25 breaths·min^-1, used by the UK National Early Warning Score, for possible mis-scoring.

Results

When the sample duration was nominally 30 s, the mean interquartile range of repeated estimates was 3.4 breaths·min^-1. For the 60 s samples, the mean interquartile range was 3 breaths·min^-1, and for the 120 s samples it was 2.5 breaths·min^-1. Thus, repeat clinical counts of respiratory rate often differ by >3 breaths·min^-1. For 30 s samples, up to 40% of National Early Warning Scores could be misclassified.

Conclusions

Early warning scores will be unreliable when short sample durations are used to measure respiratory rate. Precision improves with longer sample duration, but this may be impractical unless better measurement methods are used.

Opioid free anesthesia: evidence for short and long-term outcome

The introduction of synthetic opioids in clinical practice played a major role in the history of anesthesiology. For years, anesthesiologists have been thinking that opioids are needed for intraoperative anesthesia. However, we now know that opioids (especially synthetic short-acting molecules) are definitely not ideal analgesics and may even be counterproductive, increasing postoperative pain. As well, opioids have revealed important drawbacks associated to poor perioperative outcomes. As a matter of fact, efforts in postoperative pain management in the last 30 years were driven by the idea of reducing/eliminating opioids from the postoperative period. However, a modern concept of anesthesia should eliminate opioids already intra-operatively towards a balanced, opioid-free approach (opioid-free anesthesia - OFA). In OFA drugs and techniques historically proven for their efficacy are combined in rational and defined protocols. They include ketamine, alpha-2 agonists, lidocaine, magnesium, anti-inflammatory drugs and regional anesthesia. Promising results have been obtained on perioperative outcome. For sure, analgesia is not reduced with OFA, but it is effective and with less opioid-related side effects. These benefits may be of particular importance in some high-risk patients, like OSAS, obese and chronic opioid-users/abusers. OFA may also increase patient-reported outcomes; despite it is difficult to specifically rule out the effect of intraoperative opioids. Finally, few data are available on long-term outcomes (persistent pain and opioid abuse, cancer outcome). New studies and data are required to elaborate the optimal approach for each patient/surgery, but interest and publication are increasing and may open the road to the wider adoption of OFA.

Use of accelerometers for automatic regional chest movement recognition during tidal breathing in healthy subjects

Recognition of breathing patterns helps clinicians to understand acute and chronic adaptations during exercise and pathological conditions. Wearable technologies combined with a proper data analysis provide a low cost option to monitor chest and abdominal wall movements. Here we set out to determine the feasibility of using accelerometry and machine learning to detect chest-abdominal wall movement patterns during tidal breathing. Furthermore, we determined the accelerometer positions included in the clusters, considering principal component domains. Eleven healthy participants (age: 21 ± 0.2 y, BMI: 23.4 ± 0.7 kg/m², FEV₁: 4.1 ± 0.3 L, VO₂: 4.6 ± 0.2 mL/min kg) were included in this cross-sectional study. Spirometry and ergospirometry assessments were performed with participants seated with 13 accelerometers placed over the thorax. Data collection lasted 10  min. Following signal pre-processing, principal components and clustering analyses were performed. The Euclidean distances in respect to centroids were compared between the clusters (p < 0.05), identifying two clusters (p < 0.001). The first cluster included sensors located at the right and left second rib midline, body of sternum, left fourth rib midline, right and left second thoracic vertebra midline, and fifth thoracic vertebra. The second cluster included sensors at the fourth right rib midline, right and left seventh ribs, abdomen at linea alba, and right and left tenth thoracic vertebra midline. Costal-superior and costal-abdominal patterns were also recognized. We conclude that accelerometers placed on the chest and abdominal wall permit the identification of two clusters of movements regarding respiration biomechanics.

Automatic Calculation of Hydrostatic Pressure Gradient in Patients with Head Injury: A Pilot Study

The non-surgical management of patients with traumatic brain injury is the treatment and prevention of secondary insults, such as low cerebral perfusion pressure (CPP). Most clinical pressure monitoring systems measure pressure relative to atmospheric pressure. If a patient is managed with their head tilted up, relative to their arterial pressure transducer, then a hydrostatic pressure gradient (HPG) can act against arterial pressure and cause significant errors in calculated CPP.To correct for HPG, the arterial pressure transducer should be placed level with the intracranial pressure transducer. However, this is not always achieved. In this chapter, we describe a pilot study investigating the application of speckled computing (or "specks") for the automatic monitoring of the patient's head tilt and subsequent automatic calculation of HPG. In future applications this will allow us to automatically correct CPP to take into account any HPG.

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review

BACKGROUND

The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery.

METHODS

Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale.

RESULTS

Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited.

CONCLUSIONS

An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery

BACKGROUND

Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016.

OBJECTIVES

To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery.

SEARCH METHODS

We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update.

SELECTION CRITERIA

We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids.

DATA COLLECTION AND ANALYSIS

We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale.

MAIN RESULTS

We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) and industry (in part or in total) (n = 15). The source of funding was not specified for the other studies.Results of 22 trials including 1138 participants show that an epidural containing a local anaesthetic will decrease the time required for return of gastrointestinal transit as measured by time to first flatus after an abdominal surgery (standardized mean difference (SMD) -1.28, 95% confidence interval (CI) -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportionate to the concentration of local anaesthetic used. A total of 28 trials including 1559 participants reported a decrease in time to first faeces (stool) (SMD -0.67, 95% CI -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Thirty-five trials including 2731 participants found that pain on movement at 24 hours after surgery was also reduced (SMD -0.89, 95% CI -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on scale from 0 to 10). From findings of 22 trials including 1154 participants we did not find a difference in the incidence of vomiting within 24 hours (risk ratio (RR) 0.84, 95% CI 0.57 to 1.23; low quality of evidence). From investigators in 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak (RR 0.74, 95% CI 0.41 to 1.32; low quality of evidence). Researchers in 30 trials including 2598 participants noted that epidural analgesia reduced length of hospital stay for an open surgery (SMD -0.20, 95% CI -0.35 to -0.04; very low quality of evidence; equivalent to one day). Data on costs were very limited.

AUTHORS' CONCLUSIONS

An epidural containing a local anaesthetic, with or without the addition of an opioid, accelerates the return of gastrointestinal transit (high quality of evidence). An epidural containing a local anaesthetic with an opioid decreases pain after abdominal surgery (moderate quality of evidence). We did not find a difference in the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anaesthetic would reduce the length of hospital stay (very low quality of evidence).

Options for assessing and measuring chest wall motion

Assessing chest wall motion is a basic and vital component in managing the child with respiratory problems, whether these are due to pathology in the lungs, airways, chest wall or muscles. Since the 1960s, clinical assessment has been supplemented with an ever-growing range of technological options for measuring chest wall motion, each with unique advantages and disadvantages. Measurements of chest wall motion can be used to: (1) Assess respiratory airflow and volume change, as a non-invasive alternative to measurement at the airway opening, (2) Monitor breathing over long periods of time, to identify apnoea and other types of sleep-disordered breathing, (3)Identify and quantify patterns of abnormal chest wall movement, whether between ribcage and abdominal components (thoracoabdominal asynchrony) or between different regions of the ribcage (eg in scoliosis and pectus excavatum). Measuring chest wall motion allows us to do things which simply cannot be done by more mainstream respiratory function techniques measuring flow at the airway opening: it allows respiratory airflow to be measured when it would otherwise be impossible, and it tells us how the different parts of the chest wall (eg ribcage vs abdomen, right vs left) are moving in order to generate that airflow. The basis of the different techniques available to assess and measure chest wall motion will be reviewed and compared, and their relevance to paediatric respiratory practice assessed.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.