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Wang L, Wu Y, Deng L, Tian X, Ma J. Construction and validation of a risk prediction model for postoperative ICU admission in patients with colorectal cancer: clinical prediction model study. BMC Anesthesiol 2024; 24:222. [PMID: 38965472 PMCID: PMC11223334 DOI: 10.1186/s12871-024-02598-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 06/20/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Transfer to the ICU is common following non-cardiac surgeries, including radical colorectal cancer (CRC) resection. Understanding the judicious utilization of costly ICU medical resources and supportive postoperative care is crucial. This study aimed to construct and validate a nomogram for predicting the need for mandatory ICU admission immediately following radical CRC resection. METHODS Retrospective analysis was conducted on data from 1003 patients who underwent radical or palliative surgery for CRC at Ningxia Medical University General Hospital from August 2020 to April 2022. Patients were randomly assigned to training and validation cohorts in a 7:3 ratio. Independent predictors were identified using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression in the training cohort to construct the nomogram. An online prediction tool was developed for clinical use. The nomogram's calibration and discriminative performance were assessed in both cohorts, and its clinical utility was evaluated through decision curve analysis (DCA). RESULTS The final predictive model comprised age (P = 0.003, odds ratio [OR] 3.623, 95% confidence interval [CI] 1.535-8.551); nutritional risk screening 2002 (NRS2002) (P = 0.000, OR 6.129, 95% CI 2.920-12.863); serum albumin (ALB) (P = 0.013, OR 0.921, 95% CI 0.863-0.982); atrial fibrillation (P = 0.000, OR 20.017, 95% CI 4.191-95.609); chronic obstructive pulmonary disease (COPD) (P = 0.009, OR 8.151, 95% CI 1.674-39.676); forced expiratory volume in 1 s / Forced vital capacity (FEV1/FVC) (P = 0.040, OR 0.966, 95% CI 0.935-0.998); and surgical method (P = 0.024, OR 0.425, 95% CI 0.202-0.891). The area under the curve was 0.865, and the consistency index was 0.367. The Hosmer-Lemeshow test indicated excellent model fit (P = 0.367). The calibration curve closely approximated the ideal diagonal line. DCA showed a significant net benefit of the predictive model for postoperative ICU admission. CONCLUSION Predictors of ICU admission following radical CRC resection include age, preoperative serum albumin level, nutritional risk screening, atrial fibrillation, COPD, FEV1/FVC, and surgical route. The predictive nomogram and online tool support clinical decision-making for postoperative ICU admission in patients undergoing radical CRC surgery. TRIAL REGISTRATION Despite the retrospective nature of this study, we have proactively registered it with the Chinese Clinical Trial Registry. The registration number is ChiCTR2200062210, and the date of registration is 29/07/2022.
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Affiliation(s)
- Lu Wang
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, 804 Shengli South Street, Xingqing District, Yinchuan City, Ningxia, China
| | - Yanan Wu
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, 804 Shengli South Street, Xingqing District, Yinchuan City, Ningxia, China
| | - Liqin Deng
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, 804 Shengli South Street, Xingqing District, Yinchuan City, Ningxia, China.
| | - Xiaoxia Tian
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, 804 Shengli South Street, Xingqing District, Yinchuan City, Ningxia, China
| | - Junyang Ma
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, 804 Shengli South Street, Xingqing District, Yinchuan City, Ningxia, China
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Zinno C, Agnesi F, D'Alesio G, Dushpanova A, Brogi L, Camboni D, Bernini F, Terlizzi D, Casieri V, Gabisonia K, Alibrandi L, Grigoratos C, Magomajew J, Aquaro GD, Schmitt S, Detemple P, Oddo CM, Lionetti V, Micera S. Implementation of an epicardial implantable MEMS sensor for continuous and real-time postoperative assessment of left ventricular activity in adult minipigs over a short- and long-term period. APL Bioeng 2024; 8:026102. [PMID: 38633836 PMCID: PMC11023704 DOI: 10.1063/5.0169207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 04/01/2024] [Indexed: 04/19/2024] Open
Abstract
The sensing of left ventricular (LV) activity is fundamental in the diagnosis and monitoring of cardiovascular health in high-risk patients after cardiac surgery to achieve better short- and long-term outcome. Conventional approaches rely on noninvasive measurements even if, in the latest years, invasive microelectromechanical systems (MEMS) sensors have emerged as a valuable approach for precise and continuous monitoring of cardiac activity. The main challenges in designing cardiac MEMS sensors are represented by miniaturization, biocompatibility, and long-term stability. Here, we present a MEMS piezoresistive cardiac sensor capable of continuous monitoring of LV activity over time following epicardial implantation with a pericardial patch graft in adult minipigs. In acute and chronic scenarios, the sensor was able to compute heart rate with a root mean square error lower than 2 BPM. Early after up to 1 month of implantation, the device was able to record the heart activity during the most important phases of the cardiac cycle (systole and diastole peaks). The sensor signal waveform, in addition, closely reflected the typical waveforms of pressure signal obtained via intraventricular catheters, offering a safer alternative to heart catheterization. Furthermore, histological analysis of the LV implantation site following sensor retrieval revealed no evidence of myocardial fibrosis. Our results suggest that the epicardial LV implantation of an MEMS sensor is a suitable and reliable approach for direct continuous monitoring of cardiac activity. This work envisions the use of this sensor as a cardiac sensing device in closed-loop applications for patients undergoing heart surgery.
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Affiliation(s)
- C. Zinno
- The BioRobotics Institute, Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - F. Agnesi
- The BioRobotics Institute, Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - G. D'Alesio
- The BioRobotics Institute, Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - L. Brogi
- Bio@SNS, Scuola Normale Superiore, Pisa, Italy
| | - D. Camboni
- The BioRobotics Institute, Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - F. Bernini
- BioMedLab, Interdisciplinary Research Center “Health Science,” Scuola Superiore Sant'Anna, Pisa, Italy
| | - D. Terlizzi
- Fondazione Toscana “G. Monasterio,” Pisa, Italy
| | - V. Casieri
- Unit of Translational Critical Care Medicine, Laboratory of Basic and Applied Medical Sciences, Interdisciplinary Research Center “Health Science,” Scuola Superiore Sant'Anna, Pisa, Italy
| | - K. Gabisonia
- BioMedLab, Interdisciplinary Research Center “Health Science,” Scuola Superiore Sant'Anna, Pisa, Italy
| | - L. Alibrandi
- Unit of Translational Critical Care Medicine, Laboratory of Basic and Applied Medical Sciences, Interdisciplinary Research Center “Health Science,” Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - J. Magomajew
- Department of Chemistry, Fraunhofer Institute for Microengineering and Microsystems, 55129 Mainz, Germany
| | | | - S. Schmitt
- Department of Chemistry, Fraunhofer Institute for Microengineering and Microsystems, 55129 Mainz, Germany
| | - P. Detemple
- Department of Chemistry, Fraunhofer Institute for Microengineering and Microsystems, 55129 Mainz, Germany
| | - C. M. Oddo
- The BioRobotics Institute, Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - S. Micera
- Author to whom correspondence should be addressed:
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Merola R, Vargas M. Economic Indicators, Quantity and Quality of Health Care Resources Affecting Post-surgical Mortality. J Epidemiol Glob Health 2024:10.1007/s44197-024-00249-x. [PMID: 38801492 DOI: 10.1007/s44197-024-00249-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE to identify correlations between quality and quantity of health care resources, national economic indicators, and postoperative in-hospital mortality as reported in the EUSOS study. METHODS Different variables were identified from a series of publicly available database. Postoperative in-hospital mortality was identified as reported by EUSOS study. Spearman non-parametric and Coefficients of non-linear regression were calculated. RESULTS Quality of health care resources was strongly and negatively correlated to postoperative in-hospital mortality. Quantity of health care resources were negatively and moderately correlated to postoperative in-hospital mortality. National economic indicators were moderately and negatively correlated to postoperative in-hospital mortality. General mortality, as reported by WHO, was positively but very moderately correlated with postoperative in-hospital mortality. CONCLUSIONS Postoperative in-hospital mortality is strongly determined by quality of health care instead of quantity of health resources and health expenditures. We suggest that improving the quality of health care system might reduce postoperative in-hospital mortality.
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Affiliation(s)
- Raffaele Merola
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy.
| | - Maria Vargas
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
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Fiorentini G, Bingener J, Hanson KT, Starlinger P, Smoot RL, Warner SG, Truty MJ, Kendrick ML, Thiels CA. Failed recovery after pancreatoduodenectomy: A significant problem even without surgical complications. Surgery 2024:S0039-6060(24)00225-3. [PMID: 38777657 DOI: 10.1016/j.surg.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/03/2024] [Accepted: 10/24/2023] [Indexed: 05/25/2024]
Abstract
BACKGROUND The absence of surgical complications has traditionally been used to define successful recovery after pancreas surgery. However, patient-reported outcome measures as metrics of a challenging recovery may be superior to objective morbidity. This study aims to evaluate the use of patient-reported outcomes in assessing recovery after pancreas surgery. METHODS Patients scheduled for pancreatoduodenectomy were prospectively enrolled between 2016 to 2018. Patient-reported outcomes were collected using the linear analog self-assessment questionnaire preoperatively and on postoperative days 2, 7, 14, 30, and monthly until 6 months. Patients were also asked if they felt fully recovered at 30 days and 6 months. Thirty-day surgical morbidity was prospectively assessed, and the comprehensive complication index at 30 days was used to categorize morbidity as major or multiple minor complications (comprehensive complication index ≥26.2) vs uncomplicated (comprehensive complication index <26.2). Clinically significant International Study Group Pancreas Surgery Grade B and C pancreatic fistulas and delayed gastric emptying were reported. χ2 and Kruskal-Wallis tests were used to assess associations with recovery by 6 months and quality of life throughout the postoperative period. RESULTS Of 116 patients who met inclusion criteria and were enrolled, 32 (28%) had major or multiple minor complications (comprehensive complication index ≥26.2). Overall, fewer than 1 in 10 patients (7%) reported feeling fully recovered at 30 days postoperatively, whereas 55% reported feeling fully recovered at 6 months. Of patients suffering major morbidity, 62% did not recover by 6 months, whereas 38% of those in the uncomplicated group reported not being recovered at 6 months (P = .03). Patients who experienced delayed gastric emptying reported low quality-of-life scores at 1 month (P = .04) compared to those with no delayed gastric emptying, but this did not persist at 6 months (P = .80). Postoperative pancreatic fistula was not associated with quality of life at 1 or 6 months (both P > .05). In the uncomplicated patients, age, sex, surgical approach, and cancer status were not associated with failed recovery at 6 months (all P > .05), and healthier patients (American Society of Anesthesiologists 1-2) were less likely to report complete recovery (42% vs 69% American Society of Anesthesiologists 3-4, P = .04). With the exception of higher preoperative pain scores (mean 2.3 [standard deviation 2.4] among patients not fully recovered at 6 months vs 1.6 [2.2] among those fully recovered, P = .04), preoperative patient-reported outcomes were not associated with failed recovery at 6 months (all P > .05). However, lower 30-day quality of life, social activity, pain, and fatigue scores were associated with incomplete recovery at 6 months. CONCLUSION More than 1 in 3 patients with an uncomplicated course do not feel fully recovered from pancreas surgery at 6 months; the presence of surgical complications did not universally correspond with recovery failure. In patients with complications, delayed gastric emptying appears to drive quality of life more significantly than postoperative pancreatic fistula. In patients with uncomplicated recovery, healthier patients were less likely to report full recovery at 6 months. Thirty-day patient-reported outcomes may be able to identify patients who are at risk of incomplete long-term recovery.
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Affiliation(s)
- Guido Fiorentini
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Kristine T Hanson
- Kern Center, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick Starlinger
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN. https://www.twitter.com/TELL_Starlinger
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Susanne G Warner
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN. https://www.twitter.com/drsuswarner
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
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Dessalegn M, Negesse A, Deresse T, Yigzaw Birhanu M, Agedew E, Dires G. Perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: 2023: retrospective follow-up study. BMC Surg 2024; 24:114. [PMID: 38627671 PMCID: PMC11020798 DOI: 10.1186/s12893-024-02401-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Emergency laparatomy is abdominal surgery associated with a high rate of mortality. There are few reports on rates and predictors of postoperative mortality, whereas disease related or time specific studies are limited. Understanding the rate and predictors of mortality in the first 30 days (perioperative period) is important for evidence based decision and counseling of patients. This study aimed to estimate the perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia, 2023. METHODS This was a Hospital-based retrospective follow-up study conducted at Debre Markos Comprehensive Specialized Hospital in Ethiopia among patients who had undergone emergency laparatomy between January 1, 2019 and December 31, 2022. Sample of 418 emergency laparatomy patients selected with simple random sampling technique were studied. The data were extracted from March 15, 2023 to April 1, 2023 using a data extraction tool, cleaned, and entered into Epi-Data software version 3.1 before being exported to STATA software version 14.1 for analysis. Predictor variables with P value < 0.05 in multivariable Cox regression were reported. RESULTS Data of 386 study participants (92.3% complete charts) were analyzed. The median survival time was 18 days [IQR: (14, 29)]. The overall perioperative mortality rate in the cohort during the 2978 person-days of observations was 25.5 per 1000 person-days of follow-up [95% CI: (20.4, 30.9))]. Preoperative need for vasopressor [AHR: 1.8 (95% CI: (1.11, 2.98))], admission to intensive care unit [AHR: 2.0 (95% CI: (1.23, 3.49))], longer than three days of symptoms [AHR: 2.2 (95% CI: (1.15, 4.02))] and preoperative sepsis [AHR: 1.8 (95% CI: (1.05, 3.17))] were identified statistically significant predictors of perioperative mortality after emergency laparatomy. CONCLUSIONS The perioperative mortality rate is high. Preoperative need for vasopressors, admission to intensive care unit, longer than three days of symptoms and preoperative sepsis were predictors of increased perioperative mortality rate.
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Affiliation(s)
- Megbar Dessalegn
- Department of Surgery, School of Medicine, Debre Markos University, Debre Markos, Ethiopia.
| | - Ayenew Negesse
- Department of Human Nutrition, Health Science College, Debre Markos University, Debre markos, Ethiopia
| | - Tilahun Deresse
- Department of Surgery, School of Medicine, Debre Birhan University, Debre Markos, Ethiopia
| | - Molla Yigzaw Birhanu
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Eskeziyaw Agedew
- College of Health Sciences, Debre Markos University, Debre markos, Ethiopia
| | - Gedefaw Dires
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Ren Y, Li Y, Loftus TJ, Balch J, Abbott KL, Ruppert MM, Guan Z, Shickel B, Rashidi P, Ozrazgat-Baslanti T, Bihorac A. Identifying acute illness phenotypes via deep temporal interpolation and clustering network on physiologic signatures. Sci Rep 2024; 14:8442. [PMID: 38600110 PMCID: PMC11006654 DOI: 10.1038/s41598-024-59047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 04/05/2024] [Indexed: 04/12/2024] Open
Abstract
Using clustering analysis for early vital signs, unique patient phenotypes with distinct pathophysiological signatures and clinical outcomes may be revealed and support early clinical decision-making. Phenotyping using early vital signs has proven challenging, as vital signs are typically sampled sporadically. We proposed a novel, deep temporal interpolation and clustering network to simultaneously extract latent representations from irregularly sampled vital signs and derive phenotypes. Four distinct clusters were identified. Phenotype A (18%) had the greatest prevalence of comorbid disease with increased prevalence of prolonged respiratory insufficiency, acute kidney injury, sepsis, and long-term (3-year) mortality. Phenotypes B (33%) and C (31%) had a diffuse pattern of mild organ dysfunction. Phenotype B's favorable short-term clinical outcomes were tempered by the second highest rate of long-term mortality. Phenotype C had favorable clinical outcomes. Phenotype D (17%) exhibited early and persistent hypotension, high incidence of early surgery, and substantial biomarker incidence of inflammation. Despite early and severe illness, phenotype D had the second lowest long-term mortality. After comparing the sequential organ failure assessment scores, the clustering results did not simply provide a recapitulation of previous acuity assessments. This tool may impact triage decisions and have significant implications for clinical decision-support under time constraints and uncertainty.
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Affiliation(s)
- Yuanfang Ren
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Yanjun Li
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Natural Products, Drug Discovery and Development, University of Florida, Gainesville, FL, USA
| | - Tyler J Loftus
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Jeremy Balch
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Kenneth L Abbott
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Matthew M Ruppert
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Ziyuan Guan
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Benjamin Shickel
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Parisa Rashidi
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Tezcan Ozrazgat-Baslanti
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Azra Bihorac
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA.
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA.
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Naqeeb MR, Naser AY. Postprocedural Disorders of Eye and Adnexa Admissions Profile. CLINICAL OPTOMETRY 2023; 15:261-270. [PMID: 37937276 PMCID: PMC10627053 DOI: 10.2147/opto.s437044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
Purpose The aim of this study was to examine hospitalisation profiles related to postprocedural disorders of eye and adnexa in England and Wales. Patients and Methods This was an ecological study using publicly available data extracted from the "Hospital Episode Statistics (HES) database" in England and the "Patient Episode Database for Wales (PEDW)" for the period between April 1999 and April 2020. Diagnostic code for postprocedural disorders of eye and adnexa (H59) was used to identify hospital admission. We used the chi-squared test to assess the difference between the hospital admission rates between 1999 and 2020. Results Hospital admission rate decreased by 6.3% [from 4.98 (95% CI 4.79-5.17) in 1999 to 4.67 (95% CI 4.50-4.84) in 2020 per 100,000 persons, trend test, p<0.05]. The most common hospital admissions causes were other postprocedural disorders of eye and adnexa "Chorioretinal scars after surgery for detachment." The age group 75 years and above accounted for 44.3% of the total number of admissions. Hospital admission rate among females decreased by 30.2% [from 5.90 (95% CI 5.61-6.19) in 1999 to 4.12 (95% CI 3.89-4.35) in 2020 per 100,000 persons]. Hospital admission rate among males increased by 30.2% [from 4.02 (95% CI 3.77-4.26) in 1999 to 5.23 (95% CI 4.97-5.49) in 2020 per 100,000 persons]. Conclusion This study revealed that hospital admission rates for postprocedural disorders of the eye and adnexa decreased over the course of the study period. Eye and adnexa disorders accounted for the preponderance of hospital admissions among the elderly. Further research is required to identify risk factors that can be avoided.
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Affiliation(s)
| | - Abdallah Y Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
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Bouras M, Clément A, Schirr-Bonnans S, Mauduit N, Péré M, Roquilly A, Riche VP, Asehnoune K. Cost effectiveness and long-term outcomes of dexamethasone administration in major non-cardiac surgery. J Clin Anesth 2023; 90:111218. [PMID: 37487337 DOI: 10.1016/j.jclinane.2023.111218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 07/26/2023]
Abstract
STUDY OBJECTIVES Postoperative administration of dexamethasone has been proposed to reduce morbidity and mortality in patients undergoing major non-cardiac surgery. In this ancillary study of the PACMAN trial, we aimed to evaluate the cost effectiveness of dexamethasone in patients undergoing major non-cardiac surgery. METHODS Patients included in the multicentric randomized double-blind, placebo-controlled PACMAN trial were followed up for 12 months after their surgical procedure. Patients were randomized to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Cost effectiveness between the dexamethasone and placebo groups was assessed for the 12-month postoperative period from a health payer perspective. RESULTS Of 1222 randomized patients in PACMAN, 137 patients (11%) were followed up until 12 months after major surgery (71 in the DXM group and 66 in the placebo group). Postoperative dexamethasone administration reduced costs per patient at 1 year by €358.06 (95%CI -€1519.99 to €803.87). The probability of dexamethasone being cost effective was between 12% and 22% for a willingness to pay of €100,000 to €150,000 per life-year, which is the threshold that is usually used in France and was 52% for willingness to pay of €50,000 per life-year (threshold in USA). At 12 months, 9 patients (13.2%) in the DXM group and 10 patients (16.1%) in the placebo group had died. In conclusion, our study does not demonstrate the cost effectiveness of perioperative administration of DXM in major non-cardiac surgery.
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Affiliation(s)
- Marwan Bouras
- Nantes Université́, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes F-44093, France.
| | - Amandine Clément
- Nantes Université́, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes F-44093, France
| | - Solène Schirr-Bonnans
- Nantes Université́, CHU Nantes, Service Evaluation Economique et Développement des Produits de Santé, Direction de la Recherche et de l'Innovation, Nantes, France
| | - Nicolas Mauduit
- Department of Medical Information, Nantes University Hospital, 1 Place Alexis-Ricordeau, 44000 Nantes, France
| | - Morgane Péré
- CHU de Nantes, Direction de la Recherche et de l'Innovation, Plateforme de Méthodologie et Biostatistique, Nantes, France
| | - Antoine Roquilly
- Nantes Université́, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes F-44093, France
| | - Valery-Pierre Riche
- Nantes Université́, CHU Nantes, Service Evaluation Economique et Développement des Produits de Santé, Direction de la Recherche et de l'Innovation, Nantes, France
| | - Karim Asehnoune
- Nantes Université́, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie et Infectiologie, Nantes F-44093, France
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Xu Z, Yao S, Jiang Z, Hu L, Huang Z, Zeng Q, Liu X. Development and validation of a prediction model for postoperative intensive care unit admission in patients with non-cardiac surgery. Heart Lung 2023; 62:207-214. [PMID: 37567008 DOI: 10.1016/j.hrtlng.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Accurately forecasting patients admitted to the intensive care units (ICUs) after surgery may improve clinical outcomes and guide the allocation of expensive and limited ICU resources. However, studies on predicting postoperative ICU admission in non-cardiac surgery have been limited. OBJECTIVE To develop and validate a prediction model combining pre- and intraoperative variables to predict ICU admission after non-cardiac surgery. METHODS This study is based on data from the Vital Signs DataBase (VitalDB) database. Predictors were selected using the least absolute shrinkage and selection operator regression method and logistic regression to develop a nomogram and an online web calculator. The model was internally verified by 1000-Bootstrap resampling. Performance of model was evaluated using area under the receiver operating characteristic curve (AUC), calibration curve and Brier score. The Youden's index was used to find the optimal nomogram's probability threshold. Clinical utility was assessed by decision curve analysis. RESULTS This study included 5216 non-cardiac surgery patients; of these, 812 (15.6%) required postoperative ICU admission. Potential predictors included age, ASA classification, surgical department, emergency surgery, preoperative albumin level, preoperative urea nitrogen level, intraoperative crystalloid, intraoperative transfusion, intraoperative catheterization, and surgical time. A nomogram was constructed with an AUC of 0.917 (95% CI: 0.907-0.926) and a Brier score of 0.077. The Bootstrap-adjusted AUC was 0.914; the adjusted Brier score was 0.078. The calibration curve showed good agreement between predicted and actual probabilities; and the decision curve indicated clinical usefulness. Finally, we established an online web calculator for clinical application (https://xuzhikun.shinyapps.io/postopICUadmission1/). CONCLUSION We developed and internally validated an easy-to-use nomogram for predicting ICU admission after non-cardiac surgery.
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Affiliation(s)
- Zhikun Xu
- Department of Critical Care Medicine, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, The Second Affiliated Hospital of Jinan University, Shenzhen 518020, China
| | - Shihua Yao
- Division of Cardiovascular Surgery, Cardiac and Vascular Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Zhongji Jiang
- Department of Biology, School of Medicine, Shenzhen Center, Cancer Hospital Chinese Academy of Medical Sciences, Southern University of Science and Technology, Shenzhen, Guangdong 518055, China
| | - Linhui Hu
- Department of Critical Care Medicine, Maoming People's Hospital, The Affiliated Maoming Hospital of Southern Medical University, Maoming 525000, China
| | - Zijun Huang
- Department of Anesthesiology, Maoming People's Hospital, The Affiliated Maoming Hospital of Southern Medical University, Maoming 525000, China
| | - Quanjun Zeng
- Department of Anesthesiology, University of Chinese Academy of Sciences Shenzhen Hospital, Shenzhen 518107, China
| | - Xueyan Liu
- Department of Critical Care Medicine, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, The Second Affiliated Hospital of Jinan University, Shenzhen 518020, China.
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10
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Douglas NW, Coleman OM, Steel AC, Leslie K, Darvall JN. Triggers for medical emergency team activation after non-cardiac surgery. Anaesth Intensive Care 2023:310057X221141107. [PMID: 37314025 DOI: 10.1177/0310057x221141107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Deterioration after major surgery is common, with many patients experiencing a medical emergency team (MET) activation. Understanding the triggers for MET calls may help design interventions to prevent deterioration. We aimed to identify triggers for MET activation in non-cardiac surgical patients. A retrospective cohort study of adult patients who experienced a postoperative MET call at a single tertiary hospital was undertaken. The trigger and timing of each MET call and patient characteristics were collected.Four hundred and one MET calls occurred after 23,258 surgical procedures, a rate of 1.7% of all non-cardiac surgical procedures, accounting for 11.7% of all MET calls over the study period. Hypotension (41.4%) was the most common trigger, followed by tachycardia (18.5%), altered conscious state (11.0%), hypoxia (10.0%), tachypnoea (5.7%), 'other' (5.7%), clinical concern (4.0%), increased work of breathing (1.5%) and bradypnoea (0.7%). Cardiac and/or respiratory arrest triggered 1.2% of MET activations. Eighty-six percent of patients had a single MET call, 10.2% had two, 1.8% had three and one patient (0.3%) had four. The median interval between post-anaesthetic care unit (PACU) discharge and MET call was 14.7 h (95% confidence interval 4.2 to 28.9 h). MET calls resulted in intensive care unit (ICU) admission in 40 patients (10%), while 82% remained on the ward, 4% had a MET call shortly after ICU discharge and returned there, 2% returned to theatre, and 2% went to a high dependency unit.Hypotension was the most common trigger for MET calls after non-cardiac surgery. Deterioration frequently occurred within 24 h of PACU discharge. Future research should focus on prevention of hypotension and tachycardia after surgery.
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Affiliation(s)
- Ned Wr Douglas
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Australia
| | - Olivia M Coleman
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Australia
| | - Amelia Ca Steel
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Australia
| | - Kate Leslie
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Australia
| | - Jai Nl Darvall
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Australia
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11
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Development of a predictive model for unplanned intensive care unit admission after pancreatic resection within an enhanced recovery pathway. Surg Endosc 2022; 37:2932-2942. [PMID: 36509947 DOI: 10.1007/s00464-022-09787-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is unclear whether routine postoperative admission to the intensive care unit (ICU) can improve outcomes for patients undergoing elective pancreatic surgery. Aim of the study was to determine preoperative and intraoperative predictors of unplanned ICU access in patients undergoing pancreatectomy treated within an established enhanced recovery pathway (ERP) and compare outcomes between direct and late ICU admission. METHODS A retrospective observational study was conducted on adult patients who underwent pancreatic resection (2015-2019) within an ERP. Patients with preoperatively planned ICU admission were excluded from the study. Multiple multivariate logistic regression models were constructed to verify the association of preoperative and intraoperative variables with study outcomes. RESULTS The study included 1486 consecutive patients (cancer diagnosis 60%, pancreaticoduodenectomy 60%; laparoscopic approach 20%; vascular resection 9%). Sixty-six (4.4%) patients had an unplanned ICU admission. Direct admission occurred in 22 (33%) patients and late ICU admission in 44 (67%) patients. Mortality was significantly lower in direct admission group (n = 3, 14%) compared to late admission (n = 25, 57%; p > 0.001). A comprehensive model including preoperative and intraoperative variables identified ASA score ≥ 3 (OR 5.59, p value < 0.001), history of hypertension (OR 2.29, p = 0.029), chronic obstructive pulmonary disease (OR 3.05, p = 0.026), proximal pancreatic resection (OR 2.79, p value 0.046), multivisceral resection (OR 8.86, p value < 0.001), high intraoperative blood loss (OR 1.01 per ml, p < 0.001), and increased serum lactate at the end of surgery (OR 1.25, p = 0.017) as independent factors associated with ICU admission. Area under the ROC curve was 0.891. CONCLUSION Patient comorbidities, surgical complexity, and lactic acidosis at the end of surgery were associated with unplanned postoperative ICU admission. Late ICU admission had very high mortality rates compared to direct admission. Our findings suggest that patients with a combination of preoperative and intraoperative risk factors could benefit from upfront postoperative ICU admission to potentially improve postoperative outcomes.
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12
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Extension of patient safety initiatives to perioperative care. Curr Opin Anaesthesiol 2022; 35:717-722. [PMID: 36302210 DOI: 10.1097/aco.0000000000001195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW Patient safety has significantly improved during the intraoperative period thanks to the anesthesiologists, surgeons, and nurses. Nowadays, it is within the perioperative period where most of the preventable harm happened to the surgical patient. We aim to highlight the main issues and efforts to improve perioperative patient safety focusing and the relation to intraoperative safety strategies. RECENT FINDINGS There is ongoing research on perioperative safety strategies aiming to initiate multidisciplinary interventions on early stages of the perioperative period as well as an increasing focus on preventing harm from postoperative complications. SUMMARY Any patient safety strategy to be implemented needs to be framed beyond the operating room and include in the intervention the whole perioperative period.
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13
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Mathoulin S, Minto G, Taylor G, Erasmus P. The impact of universal cardiopulmonary exercise testing on perioperative pathways and short-term patient outcomes following elective pancreatic surgery: A retrospective cohort study. J Intensive Care Soc 2022; 23:407-413. [PMID: 36751357 PMCID: PMC9679911 DOI: 10.1177/17511437211022128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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. Period 1 discretionary referral and Period 2: universal referral. The primary aim was to investigate the impact of this policy change on critical care use (planned vs unplanned) on the day of surgery and on delayed critical care admission. Secondary end points included a comparison of the total number of critical care bed days, days in hospital, complication rates and mortality data between the two cohorts. Results 177 patients were included; 114 in Period 1 and 63 in Period 2. There was a reduction in unplanned day of surgery postoperative admissions to critical care (28.1% vs. 11.1%, p = 0.008). Seven (6.1%) of patients in Period 1 and 1 (1.6%) patient in Period 2 had delayed admission, though no p value was calculated due to the small numbers involved. Complication rates were similar in each group. The median critical care bed days was 1 (range 0-21) days in Period 1 and 1 (0-13) days in Period 2. Conclusions A universal referral policy for preoperative CPET demonstrated a decrease in unplanned day of surgery critical care admissions and a trend towards reducing delayed (>24 h postop) critical care admission which could be investigated in a larger study. No measurable impact was seen on clinical outcomes.
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Affiliation(s)
- Sophie Mathoulin
- Department of Anaesthesia, Derriford Hospital, Plymouth,
UK,Sophie Mathoulin, Department of
Anaesthesia, Derriford Hospital, Plymouth, UK.
| | - Gary Minto
- Department of Anaesthesia, Derriford Hospital, Plymouth,
UK
| | - Gordon Taylor
- Department of Medical Statistics, University of Exeter, Exeter,
UK
| | - Paul Erasmus
- Department of Anaesthesia, Derriford Hospital, Plymouth,
UK
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14
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Preparing the Patient for ICU Transfer: What Is the Anesthesiologist’s Role? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Purpose of Review
This review summarizes the anesthesiologist’s role in transferring critically ill surgical patients at different phases of care.
Recent Findings
Early recognition of patients at high intraoperative and postoperative risk is one of the most important first steps, followed by preoperative and intraoperative stabilization measures depending on the individual needs. It mainly is the anesthesiologist’s responsibility to decide on postoperative ICU admission. The transfer of the critically ill should be planned; the ICU staff has to be informed as early as possible. Locally developed checklists should be used during the preparation of patient transport. Trained, dedicated staff should be made available in every institution. A detailed handover using dedicated institutional flowcharts should ensure patient safety upon arrival to the ICU.
Summary
Transfer of critically ill patients from the OR to the ICU is an interdisciplinary task with a high probability of eventual incidents. Anesthesiologists should play a key role in all phases of the procedure to improve patient outcomes.
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Clemente Vivancos Á, León Castelao E, Castellanos Ortega Á, Bodi Saera M, Gordo Vidal F, Martin Delgado MC, Jorge-Soto C, Fernandez Mendez F, Igeño Cano JC, Trenado Alvarez J, Caballero Lopez J, Parraga Ramirez MJ. National Survey: How Do We Approach the Patient at Risk of Clinical Deterioration outside the ICU in the Spanish Context? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12627. [PMID: 36231926 PMCID: PMC9565925 DOI: 10.3390/ijerph191912627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Anticipating and avoiding preventable intrahospital cardiac arrest and clinical deterioration are important priorities for international healthcare systems and institutions. One of the internationally followed strategies to improve this matter is the introduction of the Rapid Response Systems (RRS). Although there is vast evidence from the international community, the evidence reported in a Spanish context is scarce. METHODS A nationwide cross-sectional research consisting of a voluntary 31-question online survey was performed. The Spanish Society of Intensive, Critical and Coronary Care Medicine (SEMICYUC) supported the research. RESULTS We received 62 fully completed surveys distributed within 13 of the 17 regions and two autonomous cities of Spain. Thirty-two of the participants had an established Rapid Response Team (RRT). Common frequency on measuring vital signs was at least once per shift but other frequencies were contemplated (48.4%), usually based on professional criteria (69.4%), as only 12 (19.4%) centers used Early Warning Scores (EWS) or automated alarms on abnormal parameters. In the sample, doctors, nurses (55%), and other healthcare professionals (39%) could activate the RRT via telephone, but only 11.3% of the sample enacted this at early signs of deterioration. The responders on the RRT are the Intensive Care Unit (ICU), doctors, and nurses, who are available 24/7 most of the time. Concerning the education and training of general ward staff and RRT members, this varies from basic to advanced and specific-specialized level, simulating a growing educational methodology among participants. A great number of participants have emergency resuscitation equipment (drugs, airway adjuncts, and defibrillators) in their general wards. In terms of quality improvement, only half of the sample registered RRT activity indicators. In terms of the use of communication and teamwork techniques, the most used is clinical debriefing in 29 centers. CONCLUSIONS In terms of the concept of RRS, we found in our context that we are in the early stages of the establishment process, as it is not yet a generalized concept in most of our hospitals. The centers that have it are in still in the process of maturing the system and adapting themselves to our context.
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Affiliation(s)
- Álvaro Clemente Vivancos
- Health Sciences Doctoral Program, Universidad Católica de Murcia (UCAM), 30107 Murcia, Spain
- Advanced Nursing Practice, Hospital del Mar, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - Esther León Castelao
- Simulation Laboratory, School of Medicine and Health Sciences, 08036 Barcelona, Spain
- Clinical Simulation Lab, University of Barcelona, 08036 Barcelona, Spain
| | - Álvaro Castellanos Ortega
- Intensive Care Unit Medical Director, University Hospital La Fe, 46026 Valencia, Spain
- Associate Lecturer, University of Valencia, 46010 Valencia, Spain
| | - Maria Bodi Saera
- Intensive Care Unit, University Hospital Joan XIII, 43005 Tarragona, Spain
- Pere I Virgili Health Research Institute, Rovira I Virgili University, 43003 Tarragona, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIEBERES), Carlos III Health Institute, 28029 Madrid, Spain
| | - Federico Gordo Vidal
- Intensive Care Unit, University Hospital of Henares, 28822 Madrid, Spain
- Critical Pathology Research Group, Francisco de Vitoria University, 28223 Madrid, Spain
| | - Maria Cruz Martin Delgado
- Intensive Care Unit, Hospital 12th of October, 28041 Madrid, Spain
- Facultad de Medicina, Francisco de Vitoria University, 28223 Madrid, Spain
| | - Cristina Jorge-Soto
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidad de Santiago de Compostela, 15705 Galicia, Spain
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, 15705 Santiago de Compostela, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15705 Santiago de Compostela, Spain
| | - Felipe Fernandez Mendez
- School of Nursing, Universidade de Vigo, 36310 Pontevedra, Spain
- REMOSS Research Group, Universidade de Vigo, 36310 Pontevedra, Spain
| | | | - Josep Trenado Alvarez
- Intensive Care and High Dependency Unit, Mutua Terrassa Hospital, 08221 Terrasa, Spain
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Jesus Caballero Lopez
- Intensive Care Unit, University Hospital Arnau de Vilanova, 25198 Lleida, Spain
- IRBLleida, 25198 Lleida, Spain
| | - Manuel Jose Parraga Ramirez
- Intensive Care Unit, JM Morales Meseguer, 30008 Murcia, Spain
- Simulation and Clinical Skills Director, UCAM, 30107 Murcia, Spain
- Medical Degree Direction Team, UCAM, 30107 Murcia, Spain
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Hamilton DB, Jooma Z. Haemodynamic monitoring in patients undergoing high-risk surgery: a survey of current practice among anaesthesiologists at the University of the Witwatersrand. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.4.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- DB Hamilton
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand,
South Africa
| | - Z Jooma
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand,
South Africa
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Gebran A, Vapsi A, Maurer LR, El Moheb M, Naar L, Thakur SS, Sinyard R, Daye D, Velmahos GC, Bertsimas D, Kaafarani HMA. POTTER-ICU: An artificial intelligence smartphone-accessible tool to predict the need for intensive care after emergency surgery. Surgery 2022; 172:470-475. [PMID: 35489978 DOI: 10.1016/j.surg.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/15/2022] [Accepted: 03/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Delays in admitting high-risk emergency surgery patients to the intensive care unit result in worse outcomes and increased health care costs. We aimed to use interpretable artificial intelligence technology to create a preoperative predictor for postoperative intensive care unit need in emergency surgery patients. METHODS A novel, interpretable artificial intelligence technology called optimal classification trees was leveraged in an 80:20 train:test split of adult emergency surgery patients in the 2007-2017 American College of Surgeons National Surgical Quality Improvement Program database. Demographics, comorbidities, and laboratory values were used to develop, train, and then validate optimal classification tree algorithms to predict the need for postoperative intensive care unit admission. The latter was defined as postoperative death or the development of 1 or more postoperative complications warranting critical care (eg, unplanned intubation, ventilator requirement ≥48 hours, cardiac arrest requiring cardiopulmonary resuscitation, and septic shock). An interactive and user-friendly application was created. C statistics were used to measure performance. RESULTS A total of 464,861 patients were included. The mean age was 55 years, 48% were male, and 11% developed severe postoperative complications warranting critical care. The Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application was created as the user-friendly interface of the complex optimal classification tree algorithms. The number of questions (ie, tree depths) needed to predict intensive care unit admission ranged from 2 to 11. The Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application had excellent discrimination for predicting the need for intensive care unit admission (C statistics: 0.89 train, 0.88 test). CONCLUSION We recommend the Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application as an accurate, artificial intelligence-based tool for predicting severe complications warranting intensive care unit admission after emergency surgery. The Predictive OpTimal Trees in Emergency Surgery Risk Intensive Care Unit application can prove useful to triage patients to the intensive care unit and to potentially decrease failure to rescue in emergency surgery patients.
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Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Center for Outcomes and Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | - Annita Vapsi
- Massachusetts Institute of Technology, Cambridge, MA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Center for Outcomes and Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Center for Outcomes and Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | - Leon Naar
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Center for Outcomes and Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | | | - Robert Sinyard
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dania Daye
- Center for Outcomes and Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA; Division of Interventional Radiology, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Center for Outcomes and Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA.
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Katori N, Yamakawa K, Yagi K, Kimura Y, Doi M, Uezono S. Characteristics and outcomes of unplanned intensive care unit admission after general anesthesia. BMC Anesthesiol 2022; 22:191. [PMID: 35725372 PMCID: PMC9208222 DOI: 10.1186/s12871-022-01729-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Unplanned ICU admission after surgery has been validated as a measure of a quality indicator of perioperative management because it may put surgical patients at risk of increased morbidity and mortality. Postoperative unscheduled admission to the ICU is usually determined either in the post-anesthesia care unit (PACU) or in the general surgical ward; however, it could be expected patient outcomes after ICU admission would be affected by the circumstances. The purpose of this retrospective observational study was to investigate the clinical characteristics and the outcome of unplanned admission to the ICU directly from the PACU or from the ward within 7 days after PACU discharge. Methods Forty-three thousand, five hundred fifty-three patients admitted to the PACU after general anesthesia were included in the study. Unplanned ICU admission was defined as the admission which was not anticipated preoperatively but was due to adverse events in the PACU (PACU group) or the ward after discharge from the PACU (Ward group). The following parameters were compared between the groups: patient characteristics, surgical characteristics, length of ICU and hospital stay, the principal adverse event for ICU admission, treatments in the ICU, and in-hospital mortality. The primary outcome was in-hospital mortality and the second was the length of ICU and hospital stay. Results Among 43,553 patients, 109 patients underwent unplanned ICU admission directly from the PACU (n= 73, 0.17%) or subsequently from the ward (n= 36, 0.08%). The length of both ICU and hospital stay was significantly longer in the Ward group than in the PACU group (1.4 and 19 days vs. 2.5 and 39 days, respectively). There was no significant difference in in-hospital mortality between the groups (4.1% vs. 8.3%, respectively). Conclusions The incidence of unplanned ICU admission after PACU stay was low, however, delayed admission to the ICU from the ward may prolong the length of both ICU and hospital stay compared to those directly from the PACU.
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Affiliation(s)
- Nobuyuki Katori
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minatoku, Tokyo, 105-8461, Japan.
| | - Kentaro Yamakawa
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minatoku, Tokyo, 105-8461, Japan
| | - Kosuke Yagi
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minatoku, Tokyo, 105-8461, Japan
| | - Yoshihiro Kimura
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minatoku, Tokyo, 105-8461, Japan
| | - Mayuko Doi
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minatoku, Tokyo, 105-8461, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minatoku, Tokyo, 105-8461, Japan
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Ohbe H, Matsui H, Kumazawa R, Yasunaga H. Postoperative ICU admission following major elective surgery: A nationwide inpatient database study. Eur J Anaesthesiol 2022; 39:436-444. [PMID: 34636358 DOI: 10.1097/eja.0000000000001612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether the routine use of the ICU after major elective surgery improves postoperative outcomes is not well established. OBJECTIVES To describe the association between use of postoperative ICU admission and clinical outcomes for patients undergoing major elective surgery. DESIGN Observational study. SETTING Nationwide inpatient database in Japan, July 2010 to March 2018. PATIENTS Patients undergoing one of 15 major elective orthopaedic, gastrointestinal, neurological, thoracic or cardiovascular surgical procedures. INTERVENTION ICU admission on the day of surgery. ICU was defined as a separate unit providing critical care services with around-the-clock physician staffing and nursing, the equipment necessary for critical care and a nurse-to-patient ratio at least one to two. MAIN OUTCOME In-hospital mortality. Patient-level and hospital-level analyses were performed. RESULTS Overall, 2 011 265 patients from 1524 hospitals were assessed. The cohort size ranged from 38 547 patients in 467 hospitals for surgical clipping for cerebral aneurysms to 308 952 patients in 599 hospitals for spinal fixation, laminectomy or laminoplasty. In the patient-level analyses, there were no significant mortality differences among patients undergoing the 12 major noncardiovascular surgical procedures, whereas postoperative ICU admission was associated with trends towards lower in-hospital mortality among patients undergoing coronary artery bypass grafting, risk difference -1.0% (95% CI -1.8 to -0.1) open aortic aneurysm repair, risk difference -0.6% (95% CI -1.3 to 0.1), and heart valve replacement, risk difference -0.7% (95% CI - 1.6 to 0.1). In the hospital-level analyses, similar to the results of the patient-level analyses, a higher proportion of postoperative ICU admission at hospital level was associated with trends toward lower in-hospital mortality for patients undergoing the three cardiovascular surgical procedures. CONCLUSION This nationwide observational study showed that postoperative ICU admission was associated with improved survival outcomes among patients undergoing three types of cardiac surgery but not among patients undergoing low-risk elective surgery.
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Affiliation(s)
- Hiroyuki Ohbe
- From the Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan (HO, HM, RK, HY)
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Loftus TJ, Balch JA, Ruppert MM, Tighe PJ, Hogan WR, Rashidi P, Upchurch GR, Bihorac A. Aligning Patient Acuity With Resource Intensity After Major Surgery: A Scoping Review. Ann Surg 2022; 275:332-339. [PMID: 34261886 PMCID: PMC8750209 DOI: 10.1097/sla.0000000000005079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Develop unifying definitions and paradigms for data-driven methods to augment postoperative resource intensity decisions. SUMMARY BACKGROUND DATA Postoperative level-of-care assignments and frequency of vital sign and laboratory measurements (ie, resource intensity) should align with patient acuity. Effective, data-driven decision-support platforms could improve value of care for millions of patients annually, but their development is hindered by the lack of salient definitions and paradigms. METHODS Embase, PubMed, and Web of Science were searched for articles describing patient acuity and resource intensity after inpatient surgery. Study quality was assessed using validated tools. Thirty-five studies were included and assimilated according to PRISMA guidelines. RESULTS Perioperative patient acuity is accurately represented by combinations of demographic, physiologic, and hospital-system variables as input features in models that capture complex, non-linear relationships. Intraoperative physiologic data enriche these representations. Triaging high-acuity patients to low-intensity care is associated with increased risk for mortality; triaging low-acuity patients to intensive care units (ICUs) has low value and imparts harm when other, valid requests for ICU admission are denied due to resource limitations, increasing their risk for unrecognized decompensation and failure-to-rescue. Providing high-intensity care for low-acuity patients may also confer harm through unnecessary testing and subsequent treatment of incidental findings, but there is insufficient evidence to evaluate this hypothesis. Compared with data-driven models, clinicians exhibit volatile performance in predicting complications and making postoperative resource intensity decisions. CONCLUSION To optimize value, postoperative resource intensity decisions should align with precise, data-driven patient acuity assessments augmented by models that accurately represent complex, non-linear relationships among risk factors.
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Affiliation(s)
- Tyler J. Loftus
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Jeremy A. Balch
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Patrick J. Tighe
- Departments of Anesthesiology, Orthopedics, and Information
Systems/Operations Management, University of Florida Health, Gainesville, FL,
USA
| | - William R. Hogan
- Department of Health Outcomes & Biomedical Informatics,
College of Medicine, University of Florida, Gainesville, FL, USA
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and
Information Science and Engineering, and Electrical and Computer Engineering,
University of Florida, Gainesville, Florida, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | | | - Azra Bihorac
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
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21
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Ren Y, Loftus TJ, Li Y, Guan Z, Ruppert MM, Datta S, Upchurch GR, Tighe PJ, Rashidi P, Shickel B, Ozrazgat-Baslanti T, Bihorac A. Physiologic signatures within six hours of hospitalization identify acute illness phenotypes. PLOS DIGITAL HEALTH 2022; 1:e0000110. [PMID: 36590701 PMCID: PMC9802629 DOI: 10.1371/journal.pdig.0000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
During the early stages of hospital admission, clinicians use limited information to make decisions as patient acuity evolves. We hypothesized that clustering analysis of vital signs measured within six hours of hospital admission would reveal distinct patient phenotypes with unique pathophysiological signatures and clinical outcomes. We created a longitudinal electronic health record dataset for 75,762 adult patient admissions to a tertiary care center in 2014-2016 lasting six hours or longer. Physiotypes were derived via unsupervised machine learning in a training cohort of 41,502 patients applying consensus k-means clustering to six vital signs measured within six hours of admission. Reproducibility and correlation with clinical biomarkers and outcomes were assessed in validation cohort of 17,415 patients and testing cohort of 16,845 patients. Training, validation, and testing cohorts had similar age (54-55 years) and sex (55% female), distributions. There were four distinct clusters. Physiotype A had physiologic signals consistent with early vasoplegia, hypothermia, and low-grade inflammation and favorable short-and long-term clinical outcomes despite early, severe illness. Physiotype B exhibited early tachycardia, tachypnea, and hypoxemia followed by the highest incidence of prolonged respiratory insufficiency, sepsis, acute kidney injury, and short- and long-term mortality. Physiotype C had minimal early physiological derangement and favorable clinical outcomes. Physiotype D had the greatest prevalence of chronic cardiovascular and kidney disease, presented with severely elevated blood pressure, and had good short-term outcomes but suffered increased 3-year mortality. Comparing sequential organ failure assessment (SOFA) scores across physiotypes demonstrated that clustering did not simply recapitulate previously established acuity assessments. In a heterogeneous cohort of hospitalized patients, unsupervised machine learning techniques applied to routine, early vital sign data identified physiotypes with unique disease categories and distinct clinical outcomes. This approach has the potential to augment understanding of pathophysiology by distilling thousands of disease states into a few physiological signatures.
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Affiliation(s)
- Yuanfang Ren
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Tyler J. Loftus
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
| | - Yanjun Li
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Computer & Information Science & Engineering, University of Florida, Gainesville, Florida, United States of America
| | - Ziyuan Guan
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Matthew M. Ruppert
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Shounak Datta
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Gilbert R. Upchurch
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
| | - Patrick J. Tighe
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States of America
| | - Benjamin Shickel
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Tezcan Ozrazgat-Baslanti
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
- Sepsis and Critical Illness Research Center, University of Florida, Gainesville, Florida, United States of America
| | - Azra Bihorac
- Intelligent Critical Care Center (IC), University of Florida, Gainesville, Florida, United States of America
- Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, United States of America
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
- Sepsis and Critical Illness Research Center, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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22
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Knight SR, Ng N, Tsanas A, Mclean K, Pagliari C, Harrison EM. Mobile devices and wearable technology for measuring patient outcomes after surgery: a systematic review. NPJ Digit Med 2021; 4:157. [PMID: 34773071 PMCID: PMC8590052 DOI: 10.1038/s41746-021-00525-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/23/2021] [Indexed: 12/11/2022] Open
Abstract
Complications following surgery are common and frequently occur the following discharge. Mobile and wearable digital health interventions (DHI) provide an opportunity to monitor and support patients during their postoperative recovery. Lack of high-quality evidence is often cited as a barrier to DHI implementation. This review captures and appraises the current use, evidence base and reporting quality of mobile and wearable DHI following surgery. Keyword searches were performed within Embase, Cochrane Library, Web of Science and WHO Global Index Medicus databases, together with clinical trial registries and Google scholar. Studies involving patients undergoing any surgery requiring skin incision where postoperative outcomes were measured using a DHI following hospital discharge were included, with DHI defined as mobile and wireless technologies for health to improve health system efficiency and health outcomes. Methodological reporting quality was determined using the validated mobile health evidence reporting and assessment (mERA) guidelines. Bias was assessed using the Cochrane Collaboration tool for randomised studies or MINORS depending on study type. Overall, 6969 articles were screened, with 44 articles included. The majority (n = 34) described small prospective study designs, with a high risk of bias demonstrated. Reporting standards were suboptimal across all domains, particularly in relation to data security, prior patient engagement and cost analysis. Despite the potential of DHI to improve postoperative patient care, current progress is severely restricted by limitations in methodological reporting. There is an urgent need to improve reporting for DHI following surgery to identify patient benefit, promote reproducibility and encourage sustainability.
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Affiliation(s)
- Stephen R Knight
- Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Nathan Ng
- School of Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Kenneth Mclean
- Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Claudia Pagliari
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Ewen M Harrison
- Surgical Informatics, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
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23
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Loftus TJ, Ruppert MM, Ozrazgat-Baslanti T, Balch JA, Efron PA, Tighe PJ, Hogan WR, Rashidi P, Upchurch GR, Bihorac A. Association of Postoperative Undertriage to Hospital Wards With Mortality and Morbidity. JAMA Netw Open 2021; 4:e2131669. [PMID: 34757412 PMCID: PMC8581722 DOI: 10.1001/jamanetworkopen.2021.31669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Undertriaging patients who are at increased risk for postoperative complications after surgical procedures to low-acuity hospital wards (ie, floors) rather than highly vigilant intensive care units (ICUs) may be associated with risk of unrecognized decompensation and worse patient outcomes, but evidence for these associations is lacking. OBJECTIVE To test the hypothesis that postoperative undertriage is associated with increased mortality and morbidity compared with risk-matched ICU admission. DESIGN, SETTING, AND PARTICIPANTS This longitudinal cross-sectional study was conducted using data from the University of Florida Integrated Data Repository on admissions to a university hospital. Included patients were individuals aged 18 years or older who were admitted after a surgical procedure from June 1, 2014, to August 20, 2020. Data were analyzed from April through August 2021. EXPOSURES Ward admissions were considered undertriaged if their estimated risk for hospital mortality or prolonged ICU stay (ie, ≥48 hours) was in the top quartile among all inpatient surgical procedures according to a validated machine-learning model using preoperative and intraoperative electronic health record features available at surgical procedure end time. A nearest neighbors algorithm was used to identify a risk-matched control group of ICU admissions. MAIN OUTCOMES AND MEASURES The primary outcomes of hospital mortality and morbidity were compared among appropriately triaged ward admissions, undertriaged wards admissions, and a risk-matched control group of ICU admissions. RESULTS Among 12 348 postoperative ward admissions, 11 042 admissions (89.4%) were appropriately triaged (5927 [53.7%] women; median [IQR] age, 59 [44-70] years) and 1306 admissions (10.6%) were undertriaged and matched with a control group of 2452 ICU admissions. The undertriaged group, compared with the control group, had increased median [IQR] age (64 [54-74] years vs 62 [50-73] years; P = .001) and increased proportions of women (649 [49.7%] women vs 1080 [44.0%] women; P < .001) and admitted patients with do not resuscitate orders before first surgical procedure (53 admissions [4.1%] vs 27 admissions [1.1%]); P < .001); 207 admissions that were undertriaged (15.8%) had subsequent ICU admission. In the validation cohort, hospital mortality and prolonged ICU stay estimations had areas under the receiver operating characteristic curve of 0.92 (95% CI, 0.91-0.93) and 0.92 (95% CI, 0.92-0.92), respectively. The undertriaged group, compared with the control group, had similar incidence of prolonged mechanical ventilation (32 admissions [2.5%] vs 53 admissions [2.2%]; P = .60), decreased median (IQR) total costs for admission ($26 900 [$18 400-$42 300] vs $32 700 [$22 700-$48 500]; P < .001), increased median (IQR) hospital length of stay (8.1 [5.1-13.6] days vs 6.0 [3.3-9.3] days, P < .001), and increased incidence of hospital mortality (19 admissions [1.5%] vs 17 admissions [0.7%]; P = .04), discharge to hospice (23 admissions [1.8%] vs 14 admissions [0.6%]; P < .001), unplanned intubation (45 admissions [3.4%] vs 49 admissions [2.0%]; P = .01), and acute kidney injury (341 admissions [26.1%] vs 477 admissions [19.5%]; P < .001). CONCLUSIONS AND RELEVANCE This study found that admitted patients at increased risk for postoperative complications who were undertriaged to hospital wards had increased mortality and morbidity compared with a risk-matched control group of admissions to ICUs. Postoperative undertriage was identifiable using automated preoperative and intraoperative data as features in real-time machine-learning models.
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Affiliation(s)
- Tyler J. Loftus
- Department of Surgery, University of Florida Health, Gainesville
- Precision and Intelligent Systems in Medicine Research Partnership, University of Florida, Gainesville
| | - Matthew M. Ruppert
- Precision and Intelligent Systems in Medicine Research Partnership, University of Florida, Gainesville
- Department of Medicine, University of Florida Health, Gainesville
| | - Tezcan Ozrazgat-Baslanti
- Precision and Intelligent Systems in Medicine Research Partnership, University of Florida, Gainesville
- Department of Medicine, University of Florida Health, Gainesville
| | - Jeremy A. Balch
- Department of Surgery, University of Florida Health, Gainesville
| | - Philip A. Efron
- Department of Surgery, University of Florida Health, Gainesville
| | - Patrick J. Tighe
- Department of Anesthesiology, University of Florida Health, Gainesville
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida Health, Gainesville
- Department of Information Systems and Operations Management, University of Florida Health, Gainesville
| | - William R. Hogan
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville
| | - Parisa Rashidi
- Precision and Intelligent Systems in Medicine Research Partnership, University of Florida, Gainesville
- Department of Biomedical Engineering, University of Florida, Gainesville
- Department of Computer and Information Science and Engineering, University of Florida, Gainesville
- Department of Electrical and Computer Engineering, University of Florida, Gainesville
| | | | - Azra Bihorac
- Precision and Intelligent Systems in Medicine Research Partnership, University of Florida, Gainesville
- Department of Medicine, University of Florida Health, Gainesville
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24
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Jinjing W, Kang C, Xufei L, Xueqiong L, Xinye J, Miao Y, Jinping Z, Zhaohui L, Jingtao D, Yaolong C, Linong J, Yiming M. Chinese clinical practice guidelines for perioperative blood glucose management. Diabetes Metab Res Rev 2021; 37:e3439. [PMID: 33605539 DOI: 10.1002/dmrr.3439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 12/20/2022]
Abstract
With the increased incidence of diabetes, the number of diabetic patients who require surgical treatment is also increasing. Unfortunately, practices in this area lack standardisation. The purpose of this multidisciplinary, evidence-based guidelines for perioperative blood glucose management is to provide a comprehensive set of recommendations for clinicians treating diabetes with different types of surgery. The intended audience comprises Chinese endocrinologists, surgeons, anaesthetists, clinical pharmacists, nurses and professionals involved in perioperative blood glucose management. The guidelines were formulated as follows. First, a multidisciplinary expert group was established to identify and formulate key research questions on topics of priority according to the Population, Intervention, Comparator and Outcomes (PICO) process. We conducted a meta-analysis of available studies using Review Manager version 5.3, as appropriate. We pooled crude estimates as odds ratios with 95% confidence intervals using a random-effects model, and used the Grading of Recommendations Assessment, Development, and Evaluation methods to assess the quality of the retrieved evidence. Finally, 32 recommendations were gathered that covered 11 fields-management and coordination, endocrinologists' consultation, diabetes diagnosis, surgery timing and anaesthesia method, blood glucose target values and monitoring frequency, hypoglycaemia treatment, oral administration of blood glucose lowering drugs, use of insulin, enteral and parenteral nutritional, postoperative treatment and medication and education and training. Twenty-five systematic reviews and meta-analyses were conducted for these guidelines to address the PICO questions. These guidelines are intended to improve perioperative blood glucose management and help doctors in specifying medical diagnosis and treatment, and will be implemented / disseminated extensively in China.
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Affiliation(s)
- Wang Jinjing
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Chen Kang
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Luo Xufei
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Li Xueqiong
- Department of Dry Therapy, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jin Xinye
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Nephrology, Hainan Hospital of Chinese PLA General Hospital, the Hainan Academician Team Innovation Center, Hainan, China
| | - Yu Miao
- Department of EndocrinologyKey Laboratory of EndocrinologyNational Health Commission, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhang Jinping
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Lv Zhaohui
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Dou Jingtao
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chen Yaolong
- Institute of Health Data Science, Lanzhou University, Lanzhou, China
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China
| | - Ji Linong
- Department of Endocrinology and Metabolism, Peking University people's Hospital, Peking University Diabetes Center, Beijing, China
| | - Mu Yiming
- Department of Endocrinology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
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25
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Jacobsen SM, Douglas A, Smith CA, Roberts W, Ottwell R, Oglesby B, Yasler C, Torgerson T, Hartwell M, Vassar M. Methodological quality of systematic reviews comprising clinical practice guidelines for cardiovascular risk assessment and management for noncardiac surgery. Br J Anaesth 2021; 127:905-916. [PMID: 34548174 DOI: 10.1016/j.bja.2021.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/20/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Cardiac assessment in noncardiac surgery clinical practice guidelines should be supported by the highest-quality evidence such as that offered by systematic reviews. Currently, the methodological and reporting quality of these studies remains unknown. METHODS We used PubMed to search for all clinical practice guidelines related to perioperative cardiovascular patients undergoing noncardiac surgery from 2010 to 2021. The included clinical practice guidelines were analysed for all systematic reviews and meta-analyses. The primary objective of this study was to determine reporting and methodological quality using the PRISMA (Preferred Reporting Instrument for Systematic Reviews and Meta-Analyses) and AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews-2) instruments. Our secondary objective was to compare systematic reviews conducted by the Cochrane Collaboration with non-Cochrane studies. RESULTS Three clinical practice guidelines were included in our study. Within these, 78 systematic reviews were included. PRISMA completion ranged from 34.8% to 100.0% with a mean of 76.9%. AMSTAR-2 completion ranged from 15.6% to 96.9% with a mean of 58.0%. Fifty-four systematic reviews underpinned a clinical practice guidelines recommendation, of which 25 were rated 'critically low' by AMSTAR-2 appraisal. Cochrane systematic reviews typically performed better than non-Cochrane studies, but were a minority of the included studies (10/78). CONCLUSION We found deficiencies in several key areas regarding the methodological and reporting qualities of systematic reviews included in cardiac assessment in noncardiac surgery clinical practice guidelines. As these clinical practice guidelines are instrumental to clinical decision-making and patient care in cardiac assessment in noncardiac surgery, we advocate for improved reporting quality among systematic reviews cited as supportive evidence for these recommendations.
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Affiliation(s)
- Samuel M Jacobsen
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA.
| | - Alexander Douglas
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Caleb A Smith
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Will Roberts
- Department of Anesthesiology, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Ryan Ottwell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA; Department of Internal Medicine, University of Oklahoma, School of Community Medicine, Tulsa, OK, USA
| | - Benson Oglesby
- Department of Anesthesiology, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Coy Yasler
- Department of Anesthesiology, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Trevor Torgerson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Micah Hartwell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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26
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Galway U, Chahar P, Schmidt MT, Araujo-Duran JA, Shivakumar J, Turan A, Ruetzler K. Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery. World J Diabetes 2021; 12:1255-1266. [PMID: 34512891 PMCID: PMC8394235 DOI: 10.4239/wjd.v12.i8.1255] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/17/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Prediabetes and diabetes are important disease processes which have several perioperative implications. About one third of the United States population is considered to have prediabetes. The prevalence in surgical patients is even higher. This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures. A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity. This preoperative evaluation involves an optimization of preoperative comorbidities. It also includes optimization of antidiabetic medication regimens, as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial. The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes. Therefore, prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery. This can be accomplished with either analysis in blood gas samples, venous phlebotomy or point-of-care testing. Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing, they can still be used to guide insulin dosing in the operating room. Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL. When hyperglycemia is detected in the operating room, blood glucose management may be initiated with subcutaneous rapid-acting insulin, with intravenous infusion or boluses of regular insulin. Fluid and electrolyte management are other perioperative challenges. Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.
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Affiliation(s)
- Ursula Galway
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Praveen Chahar
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Marc T Schmidt
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Jorge A Araujo-Duran
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Jeevan Shivakumar
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Alparslan Turan
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Kurt Ruetzler
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
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27
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Russo A, Romanò B. Intraoperative management and hemodynamic monitoring for ma- jor abdominal surgery : a narrative review. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background : Several trials suggest that postoperative outcomes may be improved by the use of hemodynamic monitoring, but a survey by the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology (ESA) showed that cardiac output is monitored by only 34% of ASA and ESA respondents and central venous pressure is monitored by 73% of ASA respondents and 84% of ESA respondents.
Moreover, 86.5% of ASA respondents and 98.1% of ESA respondents believe that their current hemodynamic management could be improved (1). The interaction of general anesthesia and surgical stress is the main problem and the leading cause for postoperative morbidity and mortality. The choice of a suitable hemodynamic monitoring system for patients at high anesthesiological risk is of crucial importance to reduce the incidence of major postoperative complications. The aim of the present review is to summarize the benefits of a defined path beginning before surgery, and discuss the available evidence supporting the efficacy and safety of an individualized hemodynamic approach for major abdominal surgery.
Objective : To evaluate the clinical effectiveness of a perioperative hemodynamic therapy algorithm in high risk patients
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28
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Moore D, Durie ML, Bampoe S, Buizen L, Darvall JN. The risk of postoperative deterioration of non-cardiac surgery patients with ICU referral status who are admitted to the regular ward: a retrospective observational cohort study. Patient Saf Surg 2021; 15:10. [PMID: 33612120 PMCID: PMC7897383 DOI: 10.1186/s13037-021-00283-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Higher-risk surgical patients may not be admitted to the intensive care unit due to stable immediate post-operative status on review. The outcomes of this cohort are not well described. Our aim was to examine the subsequent inpatient course of intensive care unit -referred but not admitted surgical patients. Methods All patients aged ≥18 years who were referred but not admitted for post-operative management in a tertiary metropolitan intensive care unit following non-cardiac surgery between 1/7/2017 and 30/6/2018 were eligible for inclusion in this retrospective observational cohort study. Primary outcome was Medical Emergency Team activation. Secondary outcomes included unplanned intensive care unit admission; length of stay; and 30-day mortality. Risk of serious complications and predicted length of stay were calculated using the National Surgical Quality Improvement Program scoring tool. Results Fifteen of 60 patients (25%) had a MET-call following surgery, eight (13%) patients required unplanned intensive care unit admission, with median (IQR) time to Medical Emergency Team call 9 (6–13) hours. No patients died within 30-days. There was no significant difference between mean National Surgical Quality Improvement Program predicted and actual length of stay; after adjustment, National Surgical Quality Improvement Program predicted risk of serious complications was associated with unplanned intensive care unit admission (OR [95% CI] = 1.08 [1.00–1.16], p = 0.04), although not Medical Emergency Team calls. Conclusions Post-operative deterioration occurs frequently, and early, in a cohort of high-risk surgical patients initially assessed as being safe for ward care. Changes to current triage models for post-operative intensive care unit admission may reduce the impact of complications in this high-risk group. Supplementary Information The online version contains supplementary material available at 10.1186/s13037-021-00283-9.
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Affiliation(s)
- David Moore
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Grattan Street, Melbourne, VIC, 3050, Australia.
| | - Matthew L Durie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Grattan Street, Melbourne, VIC, 3050, Australia
| | - Sohail Bampoe
- Centre for Perioperative Medicine, UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Luke Buizen
- Melbourne EpiCentre, University of Melbourne, Melbourne, Australia
| | - Jai N Darvall
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Grattan Street, Melbourne, VIC, 3050, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
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29
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Leenen JPL, Dijkman EM, van Dijk JD, van Westreenen HL, Kalkman C, Schoonhoven L, Patijn GA. Feasibility of continuous monitoring of vital signs in surgical patients on a general ward: an observational cohort study. BMJ Open 2021; 11:e042735. [PMID: 33597138 PMCID: PMC7893648 DOI: 10.1136/bmjopen-2020-042735] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To determine feasibility, in terms of acceptability and system fidelity, of continuous vital signs monitoring in abdominal surgery patients on a general ward. DESIGN Observational cohort study. SETTING Tertiary teaching hospital. PARTICIPANTS Postoperative abdominal surgical patients (n=30) and nurses (n=23). INTERVENTIONS Patients were continuously monitored with the SensiumVitals wearable device until discharge in addition to usual care, which is intermittent Modified Early Warning Score measurements. Heart rate, respiratory rate and axillary temperature were monitored every 2 min. Values and trends were visualised and alerts sent to the nurses. OUTCOMES System fidelity was measured by analysis of the monitoring data. Acceptability by patients and nurses was assessed using questionnaires. RESULTS Thirty patients were monitored for a median duration of 81 hours (IQR 47-143) per patient, resulting in 115 217 measurements per parameter. In total, 19% (n=21 311) of heart rate, 51% (n=59 184) of respiratory rate and 9% of temperature measurements showed artefacts (n=10 269). The system algorithm sent 972 alerts (median alert rate of 4.5 per patient per day), of which 90.3% (n=878) were system alerts and 9.7% (n=94) were vital sign alerts. 35% (n=33) of vital sign alerts were true positives. 93% (n=25) of patients rated the patch as comfortable, 67% (n=18) felt safer and 89% (n=24) would like to wear it next time in the hospital. Nurses were neutral about usefulness, with a median score of 3.5 (IQR 3.1-4) on a 7-point Likert scale, ease of use 3.7 (IQR 3.2-4.8) and satisfaction 3.7 (IQR 3.2-4.8), but agreed on ease of learning at 5.0 (IQR 4.0-5.8). Neutral scores were mostly related to the perceived limited fidelity of the system. CONCLUSIONS Continuous monitoring of vital signs with a wearable device was well accepted by patients. Nurses' ratings were highly variable, resulting in on average neutral attitude towards remote monitoring. Our results suggest it is feasible to monitor vital signs continuously on general wards, although acceptability of the device among nurses needs further improvement.
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Affiliation(s)
- Jobbe P L Leenen
- Department of Surgery, Isala, Zwolle, The Netherlands
- Connected Care Center, Isala, Zwolle, The Netherlands
| | | | | | | | - Cor Kalkman
- Anesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | - Lisette Schoonhoven
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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30
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Petring Hasselager R, Foss NB, Andersen O, Cihoric M, Bay‐Nielsen M, Nielsen HJ, Camilla Andresen L, Toft Tengberg L. Mortality and major complications after emergency laparotomy: A pilot study of risk prediction model development by preoperative blood-based immune parameters. Acta Anaesthesiol Scand 2021; 65:151-161. [PMID: 33108695 DOI: 10.1111/aas.13722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/04/2020] [Accepted: 09/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Emergency laparotomy is associated with high risk of postoperative complications and mortality. Preoperative identification of patients at high risk of adverse outcome is important. The immune response to conditions requiring emergency laparotomy is not understood in detail. The present study describes preoperative blood-based immune profiles and their potential value in surgical risk assessment. METHOD Patients (N = 100) referred for emergency laparotomy at Hvidovre Hospital were consecutively included from 3 June 2013-11 April 2014. All patients had blood samples collected before surgery and the immune parameters c-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-10 (IL-10), interferon-γ induced protein 10 kDa (IP-10), tumor necrosis factor α (TNF-α) and soluble urokinase plasminogen receptor activator (suPAR) were determined. Patients were stratified according to major postoperative complications (including death), 30- and 180-day mortality. Using logistic regression models and receiver operating characteristics curves the predictive ability of the immune parameters were estimated. RESULTS Major complications were recorded in 45 (45.0%) of the patients, whereas 30-day and 180-day mortalities were 17 (17.0%) and 25 (25.0%), respectively. Concentrations of suPAR and TNF-α were associated with major complications while CRP, IL-6, suPAR and TNF-α were associated with mortality. Adding the combined immune parameters to a regression model including age, sex, American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status significantly improved the predictive ability for major complications, 30-day mortality and 180-day mortality. CONCLUSION In emergency laparotomy, preoperative blood-based immune parameters added predictive power to regression models and could be considered in risk prediction model development.
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Affiliation(s)
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Ove Andersen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
| | - Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Morten Bay‐Nielsen
- Department of Surgery Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology 360 Hvidovre Hospital Hvidovre Denmark
| | - Linda Camilla Andresen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
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31
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Messina A, Robba C, Calabrò L, Zambelli D, Iannuzzi F, Molinari E, Scarano S, Battaglini D, Baggiani M, De Mattei G, Saderi L, Sotgiu G, Pelosi P, Cecconi M. Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:43. [PMID: 33522953 PMCID: PMC7849093 DOI: 10.1186/s13054-021-03464-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/07/2021] [Indexed: 01/07/2023]
Abstract
Background Appropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients’ hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear.
Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid). Results The metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup [43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively]. Overall, GDT reduced the overall rate of postoperative complications, as compared to controls [pooled risk difference (95% CI) = − 0.10 (− 0.14, − 0.07); Chi2 = 30.97; p value < 0.0001], but not to a reduction of perioperative mortality [pooled risk difference (95%CI) = − 0.016 (− 0.0334; 0.0014); p value = 0.07]. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications. Conclusions Irrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality. Trial Registration CRD42020168866; Registration: February 2020 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866
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Affiliation(s)
- Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Lorenzo Calabrò
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy
| | - Daniel Zambelli
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Edoardo Molinari
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Silvia Scarano
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Marta Baggiani
- Anesthesia and Intensive Care Medicine, Maggiore Della Carità University Hospital, Novara, Italy
| | - Giacomo De Mattei
- Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Integrata Udine, Udine, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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32
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Braghiroli KS, Einav S, Heesen MA, Villas Boas PJF, Braz JRC, Corrente JE, Porto DDSM, Morais AC, Neves GC, Braz MG, Braz LG. Perioperative mortality in older patients: a systematic review with a meta-regression analysis and meta-analysis of observational studies. J Clin Anesth 2020; 69:110160. [PMID: 33338975 DOI: 10.1016/j.jclinane.2020.110160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE Older patients have a higher probability of developing major complications during the perioperative period than other adult patients. Perioperative mortality depends on not only on a patient condition but also on the quality of perioperative care provided. We tested the hypothesis that the perioperative mortality rate among older patients has decreased over time and is related to a country's Human Development Index (HDI) status. DESIGN A systematic review with a meta-regression and meta-analysis of observational studies that reported perioperative mortality rates in patients aged ≥60 years was performed. We searched the PubMed, EMBASE, LILACS and SciELO databases from inception to December 30, 2019. SETTING Mortality rates up to the seventh postoperative day were evaluated. MEASUREMENTS We evaluated the quality of the included studies. Perioperative mortality rates were analysed by time, country HDI status and baseline American Society of Anesthesiologists (ASA) physical status using meta-regression. Perioperative mortality and ASA status were analysed in low- and high-HDI countries during two time periods using proportion meta-analysis. MAIN RESULTS We included 25 studies, which reported 4,412,100 anaesthesia procedures and 3568 perioperative deaths from 12 countries. Perioperative mortality rates in high-HDI countries decreased over time (P = 0.042). When comparing pre-1990 to 1990-2019, in high-HDI countries, the perioperative mortality rates per 10,000 anaesthesia procedures decreased 7.8-fold from 100.85 (95% CI 43.36 to 181.72) in pre-1990 to 12.98 (95% CI 6.47 to 21.70) in 1990-2019 (P < 0.0001). There were no studies from low-HDI countries pre-1990. In the period from 1990 to 2019, perioperative mortality rates did not differ between low- and high-HDI countries (P = 0.395) but the limited number of patients in low-HDI countries impaired the result. Perioperative mortality rates increased with increasing ASA status (P < 0.0001). There were more ASA III-V patients in high-HDI countries than in low-HDI countries (P < 0.0001), and the perioperative mortality rate increased 24-fold in ASA III-V patients compared with ASA I-II patients (P < 0.0001). CONCLUSION The perioperative mortality rates in older patients have declined over the past 60 years in high-DHI countries, highlighting that perioperative safety in this population is increasing in these countries. Since data prior to 1990 were lacking in low-HDI countries, the evolution of their mortality rates could not be analysed. The perioperative mortality rate was similar in low- and high-HDI countries in the post-1990 period, but the low number of patients in the low-HDI countries does not allow a definitive conclusion.
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Affiliation(s)
- Karen S Braghiroli
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Sharon Einav
- Shaare Zedek Medical Centre, Jerusalem, Israel; Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Michael A Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - Paulo J F Villas Boas
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Jose R C Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Jose E Corrente
- Department of Biostatistics, Institute of Biosciences, Sao Paulo State University - UNESP, Brazil
| | - Daniela de S M Porto
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Arthur C Morais
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Gabriel C Neves
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Mariana G Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Leandro G Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil.
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33
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Song I, Cha JK, Oh TK, Lee YJ, Jo YH, Lee D, Min H, Choi YY, Lee EY, Yun M, Lee D. Post-operative alarm signs in the rapid response system and hospital mortality after non-cardiac surgery. Acta Anaesthesiol Scand 2020; 64:1431-1437. [PMID: 32659862 DOI: 10.1111/aas.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 06/10/2020] [Accepted: 07/02/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND A variety of rapid response systems (RRSs) based on the systematic assessment of vital signs and laboratory tests have been developed to reduce hospital mortality through the early detection of alarm signs, while deterioration may still be reversible. This study aimed to determine the association between alarm signs and post-operative hospital mortality during post-operative days (POD) 0-3 in patients undergoing non-cardiac surgery. METHODS This retrospective observational study used data from the registry of a single tertiary academic hospital. The study population included patients who were ≥18 years old, admitted between 1 January 2013 and 30 June 2018 for non-cardiac surgery, and subsequently transferred to the general ward. RESULTS A total of 116 329 patients were included in the analysis. Among them, 10 099 patients (8.7%) showed positive alarm criteria and triggered the RRS in the post-operative ward during POD 0-3. In the multivariate logistic regression model, PaO2 <55 mm Hg, SpO2 <90%, and total CO2 <15 mmol/L were associated with a 3.57-, 3.46-, and 12.53-fold increase in post-operative hospital mortality, respectively. Moreover, when compared to the no alarm signs group, patients with 1, 2, 3, and ≥4 alarm signs showed a 2.79-, 2.76-, 6.54-, and 20.02-fold increase in hospital mortality, respectively. CONCLUSION Increased post-operative hospital mortality was found to be associated with alarm signs detected by the RRS during POD 0-3. The post-operative alarm signs detected by the RRS may therefore be useful in determining high-risk patients who require medical interventions in the surgical ward.
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Affiliation(s)
- In‐Ae Song
- Department of Anesthesiology and Pain Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Jun Kwon Cha
- Department of Emergency Medicine Hallym University Sacred Heart Hospital Anyang Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine Department of Internal Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - You Hwan Jo
- Department of Emergency Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Dong‐Seon Lee
- Interdepartment of Critical Care Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Hyunju Min
- Interdepartment of Critical Care Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Yun Young Choi
- Interdepartment of Critical Care Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Eun Young Lee
- Interdepartment of Critical Care Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Mi‐Ae Yun
- Interdepartment of Critical Care Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Da‐Yun Lee
- Interdepartment of Critical Care Medicine Seoul National University Bundang Hospital Seongnam Korea
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Mazzarello S, McIsaac DI, Beattie WS, Fergusson DA, Lalu MM. Risk Factors for Failure to Rescue in Myocardial Infarction after Noncardiac Surgery: A Cohort Study. Anesthesiology 2020; 133:96-108. [PMID: 32349069 DOI: 10.1097/aln.0000000000003330] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Compared to other perioperative complications, failure to rescue (i.e., death after suffering a complication) is highest after perioperative myocardial infarction (a myocardial infarction that occurs intraoperatively or within 30 days after surgery). The purpose of this study was to identify patient and surgical risk factors for failure to rescue in patients who have had a perioperative myocardial infarction. METHODS Individuals who experienced a perioperative myocardial infarction after noncardiac surgery between 2012 and 2016 were identified from the American College of Surgeons (Chicago, Illinois) National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue. Subgroup and sensitivity analyses evaluated the robustness of primary findings. RESULTS The authors identified 1,307,884 individuals who had intermediate to high-risk noncardiac surgery. A total of 8,923 (0.68%) individuals had a perioperative myocardial infarction, of which 1,726 (19.3%) experienced failure to rescue. Strongest associations (adjusted odds ratio greater than 1.5) were age 85 yr or older (2.52 [95% CI, 2.05 to 3.09] vs. age younger than 65 yr), underweight body mass index (1.53 [95% CI, 1.17 to 2.01] vs. normal body mass index), American Society of Anesthesiologists class IV (1.76 [95% CI, 1.33 to 2.31] vs. class I or II) and class V (3.48 [95% CI, 2.20 to 5.48] vs. class I or II), and presence of: ascites (1.81 [95% CI, 1.15 to 2.87]), disseminated cancer (1.54 [95% CI, 1.18 to 2.00]), systemic inflammatory response syndrome (1.55 [95% CI, 1.26 to 1.90]), sepsis (1.75 [95% CI, 1.39 to 2.20]), septic shock (1.79 [95% CI, 1.34 to 2.37]), and dyspnea at rest (1.94 [95% CI, 1.32 to 2.86]). Patients who had emergency surgery, high-risk procedures, and postoperative complications were at higher risk of failure to rescue. CONCLUSIONS Routinely identified patient and surgical factors predict risk of failure to rescue after perioperative myocardial infarction.
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Affiliation(s)
- Sasha Mazzarello
- From the School of Epidemiology and Public Health (S.M., D.I.M., D.A.F.) Faculty of Medicine (S.M., D.I.M., D.A.F., M.M.L.) Department of Cellular and Molecular Medicine (M.M.L.), University of Ottawa, Ottawa, Canada the Clinical Epidemiology Program (S.M., D.I.M., D.A.F., M.M.L.) Blueprint Translational Research Group (S.M., D.A.F., M.M.L.) the Regenerative Medicine Program (M.M.L.), Ottawa Hospital Research Institute, Ottawa, Canada the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital (D.I.M., M.M.L.), University of Ottawa, Ottawa, Canada the R. Fraser Elliot Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management University Health Network, Peter Munk Cardiac Centre, University of Toronto, Toronto, Canada (W.S.B.)
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35
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Jawad M, Baigi A, Chew M. Exposure to surgery is associated with better long-term outcomes in patients admitted to Swedish intensive care units. Acta Anaesthesiol Scand 2020; 64:1154-1161. [PMID: 32297658 DOI: 10.1111/aas.13604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/24/2020] [Accepted: 04/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term outcomes of patients admitted to intensive care units (ICUs) after surgery are unknown. We investigated the long-term effects of surgical exposure prior to ICU admission. METHODS Registry-based cohort study. The adjusted effect of surgical exposure for mortality was examined using Cox regression. Secondary analysis with conditional logistic regression in a case-control subpopulation matched for age, gender, and Simplified Acute Physiology Score III (SAPS3) was also conducted. RESULTS 72 242 adult patients (56.9% males, median age 66 years [IQR 50-76]), admitted to Swedish ICUs in 3-year (2012-2014) were followed for a median of 2026 days (IQR 1745-2293). Cardiovascular diseases (17.5%), respiratory diseases (15.8%), trauma (11.2%), and infections (11.4%) were the leading causes for ICU admission. Mortality at longest follow-up was 49.4%. Age; SAPS3; admissions due to malignancies, respiratory, cardiovascular and renal diseases; and transfer to another ICU were associated with increased mortality. Surgical exposure prior to ICU admission (adjusted hazard ratio [aHR] 0.90; 95% CI 0.87-0.94; P < .001), admissions from the operation theatre (aHR 0.94; CI 0.90-0.99; P = .022) or post-anaesthesia care unit (aHR 0.92; CI 0.87-0.97; P = .003) were associated with decreased mortality. Conditional logistic regression confirmed the association between surgical exposure and decreased mortality (adjusted odds ratio 0.82; CI 0.75-0.91; P < .001). CONCLUSIONS Long-term ICU mortality was associated with known risk factors such as age and SAPS3. Transfer to other ICUs also appeared to be a risk factor and requires further investigation. Prior surgical exposure was associated with better outcomes, a noteworthy observation given limited ICU admissions after surgery in Sweden.
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Affiliation(s)
- Monir Jawad
- Central Hospital in Kristianstad Kristianstad Sweden
- Lund University Lund Sweden
| | | | - Michelle Chew
- Department of Anaesthesia and Intensive Care Medical and Health Sciences, Linköping University Linköping Sweden
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36
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Fernandes A, Rodrigues J, Antunes L, Lages P, Santos CS, Moreira-Gonçalves D, Costa RS, Sousa JA, Dinis-Ribeiro M, Santos LL. Development of a preoperative risk score on admission in surgical intermediate care unit in gastrointestinal cancer surgery. Perioper Med (Lond) 2020; 9:23. [PMID: 32774846 PMCID: PMC7409477 DOI: 10.1186/s13741-020-00151-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
Background Gastrointestinal cancer surgery continues to be a significant cause of postoperative complications and mortality in high-risk patients. It is crucial to identify these patients. Our study aimed to evaluate the accuracy of specific perioperative risk assessment tools to predict postoperative complications, identifying the most informative variables and combining them to test their prediction ability as a new score. Methods A prospective cohort study of digestive cancer surgical patients admitted to the surgical intermediate care unit of the Portuguese Oncology Institute of Porto, Portugal was conducted during the period January 2016 to April 2018. Demographic and medical information including sex, age, date from hospital admission, diagnosis, emergency or elective admission, and type of surgery, were collected. We analyzed and compared a set of measurements of surgical risk using the risk assessment instruments P-POSSUM Scoring, ACS NSQIP Surgical Risk Calculator, and ARISCAT Risk Score according to the outcomes classified by the Clavien-Dindo score. According to each risk score system, we studied the expected and observed post-operative complications. We performed a multivariable regression model retaining only the significant variables of these tools (age, gender, physiological P-Possum, and ACS NSQIP serious complication rate) and created a new score (MyIPOrisk-score). The predictive ability of each continuous score and the final panel obtained was evaluated using ROC curves and estimating the area under the curve (AUC). Results We studied 341 patients. Our results showed that the predictive accuracy and agreement of P-POSSUM Scoring, ACS NSQIP Surgical Risk Calculator, and ARISCAT Risk Score were limited. The MyIPOrisk-score, shows to have greater discrimination ability than the one obtained with the other risk tools when evaluated individually (AUC = 0.808; 95% CI: 0.755–0.862). The expected and observed complication rates were similar to the new risk tool as opposed to the other risk calculators. Conclusions The feasibility and usefulness of the MyIPOrisk-score have been demonstrated for the evaluation of patients undergoing digestive oncologic surgery. However, it requires further testing through a multicenter prospective study to validate the predictive accuracy of the proposed risk score.
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Affiliation(s)
- Antero Fernandes
- Experimental Pathology and Therapeutics Group, Portuguese Oncology Institute of Porto FG, EPE (IPO-Porto), Porto, Portugal.,Polyvalent Intensive Care Unit, Hospital Garcia de Orta, E.P.E, Almada, Portugal
| | - Jéssica Rodrigues
- Epidemiology Service, Portuguese Institute of Oncology of Porto FG, EPE (IPO-Porto), Porto, Portugal
| | - Luís Antunes
- Epidemiology Service, Portuguese Institute of Oncology of Porto FG, EPE (IPO-Porto), Porto, Portugal.,Cancer Epidemiology Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Patrícia Lages
- Experimental Pathology and Therapeutics Group, Portuguese Oncology Institute of Porto FG, EPE (IPO-Porto), Porto, Portugal
| | - Carla Salomé Santos
- Surgical Intermediate Care Unit, Portuguese Institute of Oncology, Porto, Portugal
| | - Daniel Moreira-Gonçalves
- Experimental Pathology and Therapeutics Group, Portuguese Oncology Institute of Porto FG, EPE (IPO-Porto), Porto, Portugal.,Research Center in Physical Activity, Health and Leisure (CIAFEL), Faculty of Sport, University of Porto, Porto, Portugal
| | - Rafael S Costa
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.,REQUIMTE/LAQV, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa, Caparica, Portugal
| | - Joaquim Abreu Sousa
- Surgical Oncology Department, Portuguese Institute of Oncology of Porto FG, EPE (IPO-Porto), Porto, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Portuguese Institute of Oncology of Porto FG, EPE (IPO-Porto), Porto, Portugal
| | - Lúcio Lara Santos
- Experimental Pathology and Therapeutics Group, Portuguese Oncology Institute of Porto FG, EPE (IPO-Porto), Porto, Portugal.,Surgical Intermediate Care Unit, Portuguese Institute of Oncology, Porto, Portugal.,Surgical Oncology Department, Portuguese Institute of Oncology of Porto FG, EPE (IPO-Porto), Porto, Portugal
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Shen Y, Cai G, Gong S, Yan J. Perioperative Fluid Restriction in Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2020; 43:2747-2755. [PMID: 31332489 DOI: 10.1007/s00268-019-05091-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Perioperative fluid management is a critical component in patients undergoing abdominal surgery. However, the benefit of restricted fluid regimen remains inconclusive. This systematic review aimed to explore potential factors causing these inconsistent findings. METHODS The literature searches were performed in three databases including PubMed, Embase, and the Cochrane library until August 30, 2018. Only randomized, controlled trials comparing the effect of restricted versus liberal regimen in abdominal surgery were included. The primary outcome was total postoperative complications. Subgroup analysis was performed according to between-group weight increase difference (≥ 2 kg and < 2 kg) and fluid intake ratio (≥ 1.8 and < 1.8). RESULTS Sixteen studies were finally included in this meta-analysis. The benefit of the restricted regimen in reducing postoperative complication was only significant in the subgroup with high weight increase difference (≥ 2 kg) (RR 0.67, 95% CI 0.57-0.79) and the subgroup with high fluid intake ratio (≥ 1.8) (RR 0.72, 95% CI 0.62-0.82). In the subgroup with low weight increase difference (< 2 kg) or low fluid intake ratio (< 1.8), the effect of the restricted regimen was not significant (RR 0.88, 95% CI 0.51-1.50, and RR 1.18, 95% CI 0.91-1.53, respectively). CONCLUSIONS The benefit of the restricted regimen was only significant in the subgroup with high weight increase difference (≥ 2 kg) or high fluid intake ratio (≥ 1.8).
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Affiliation(s)
- Yanfei Shen
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Guolong Cai
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China.
| | - Shijin Gong
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Jing Yan
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China
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Silva Júnior JM, Chaves RCDF, Corrêa TD, Assunção MSCD, Katayama HT, Bosso FE, Amendola CP, Serpa Neto A, Malbouisson LMS, Oliveira NED, Veiga VC, Rojas SSO, Postalli NF, Alvarisa TK, Lucena BMND, Oliveira RAGD, Sanches LC, Silva UVDAE, Nassar Junior AP. Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil. Rev Bras Ter Intensiva 2020; 32:17-27. [PMID: 32401988 PMCID: PMC7206944 DOI: 10.5935/0103-507x.20200005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
Objective To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated. Results Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.
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Affiliation(s)
| | | | | | | | | | | | | | - Ary Serpa Neto
- Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | | | - Neymar Elias de Oliveira
- Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil
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Abstract
Patients admitted to a medical-surgical unit infrequently require early transfer to higher level care, although how their inpatient length of stay compares to untransferred patients, or those directly admitted to intermediate care, is unknown. We sought to compare the inpatient length of stay of these groups.
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40
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Mann J, Williams M, Wilson J, Yates D, Harrison A, Doherty P, Davies S. Exercise-induced myocardial dysfunction detected by cardiopulmonary exercise testing is associated with increased risk of mortality in major oncological colorectal surgery. Br J Anaesth 2020; 124:473-479. [PMID: 32085879 DOI: 10.1016/j.bja.2019.12.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) identifies high-risk patients before major surgery. In addition to using oxygen uptake and ventilatory efficiency to assess functional capacity, CPET can be used to identify underlying myocardial dysfunction through the assessment of the oxygen uptake to heart rate response (oxygen pulse response). We examined the relationship of oxygen pulse response, in combination with other CPET variables and known cardiac risk factors, with mortality after colorectal cancer surgery. METHODS This work focused on a retrospective cohort study of patients who had CPET and underwent colorectal cancer surgery. The primary outcome was a composite of in-hospital and 30-day mortality. Ventilatory inefficiency (Ve/Vco2>34) and exercise-induced myocardial dysfunction (abnormal oxygen pulse response) were investigated for an association with mortality using bivariable analysis and multivariable Cox regression. RESULTS A total of 1214 patients who underwent colorectal cancer surgery were included, and the primary outcome occurred in 26 patients (2.1%). Multivariable Cox regression showed abnormal oxygen pulse response was independently associated with the primary outcome (odds ratio [OR]=2.75; 95% confidence interval [CI], 1.17-6.47). Bivariable analysis showed that Ve/Vco2 >34 was associated with the primary outcome (OR=3.43; 95% CI, 1.47-8.01). Combining Ve/Vco2 >34 and abnormal oxygen pulse response conferred an increased risk for the primary outcome (OR=4.47; 95% CI, 1.62-12.34), compared with Ve/Vco2 >34 and normal oxygen pulse response. CONCLUSION Ventilatory inefficiency and an abnormal oxygen pulse response were independently associated with short- (30-day) and long-term (2-yr) mortality. Oxygen pulse response may provide additional information when considering perioperative risk stratification.
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Affiliation(s)
- Jason Mann
- York Teaching Hospitals NHS Foundation Trust, Department of Anaesthetics, York, North Yorkshire, UK.
| | - Murray Williams
- York Teaching Hospitals NHS Foundation Trust, Department of Anaesthetics, York, North Yorkshire, UK
| | - Jonathan Wilson
- York Teaching Hospitals NHS Foundation Trust, Department of Anaesthetics, York, North Yorkshire, UK
| | - David Yates
- York Teaching Hospitals NHS Foundation Trust, Department of Anaesthetics, York, North Yorkshire, UK
| | | | - Patrick Doherty
- Department of Health Sciences, University of York, Heslington, York, UK
| | - Simon Davies
- York Teaching Hospitals NHS Foundation Trust, Department of Anaesthetics, York, North Yorkshire, UK
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Lian C, Wang P, Fu Q, Du X, Wu J, Lian Q, ShangGuan W. Modified paediatric preoperative risk prediction score to predict postoperative ICU admission in children: a retrospective cohort study. BMJ Open 2020; 10:e036008. [PMID: 32193276 PMCID: PMC7150599 DOI: 10.1136/bmjopen-2019-036008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To integrate intrinsic surgical risk into the paediatric preoperative risk prediction score (PRPS) model to construct a more comprehensive risk scoring system (modified PRPS) and improve the prediction accuracy of postoperative intensive care unit (ICU) admission in paediatric patients. DESIGN This was a retrospective study conducted between 1 January and 30 December 2016. Data on age, American Society of Anaesthesiology physical status (ASA-PS), oxygen saturation, prematurity, non-fasted status, severity of surgery and immediate transfer to the ICU after surgery were collected. The modified PRPS was developed by logistic regression in the derivation cohort; it was tested and compared with the paediatric PRPS and ASA-PS by the Hosmer-Lemeshow test, the receiver operating characteristic (ROC) curve and Kappa analysis in the validation cohort. SETTING Hospital-based study in China. PARTICIPANTS Paediatric patients (≤14 years) who underwent surgery under general anaesthesia were included, and those who needed reoperation due to surgical complications or stayed in the ICU preoperatively were excluded. MAIN OUTCOME MEASURE ICU admission rate, defined as any patients' direct disposition from the operating room to the ICU immediately after the surgery. RESULTS A total of 9261 paediatric patients were included in this study, with 418 patients admitted to the ICU. In the validation cohort, the modified PRPS model fit the test data well (deciles of risk goodness-of-fit χ2=6.84, p=0.077). The area under the ROC curve of the modified PRPS, paediatric PRPS and ASA-PS were 0.963, 0.941 and 0.870, respectively (p<0.05), and the Kappa values were 0.620, 0.286 and 0.267. Analyses in the cohort indicated that the modified PRPS was superior to the paediatric PRPS and ASA-PS. CONCLUSIONS The modified PRPS integrating intrinsic surgical risk shows better prediction accuracy than the previous PRPS.
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Affiliation(s)
- Chunwei Lian
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital & Yuying Children's hospital of Wenzhou Medical University, Wenzhou, China
| | - Pei Wang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital & Yuying Children's hospital of Wenzhou Medical University, Wenzhou, China
- Department of Anesthesiology, Maternal and Child Care Hospital of Anhui Province, Hefei, China
| | - Qingxia Fu
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital & Yuying Children's hospital of Wenzhou Medical University, Wenzhou, China
| | - Xudong Du
- Department of Medical Quality Management and Statistics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junzheng Wu
- Department of Anesthesia and Paediatrics, Cincinnati Children Hospital Medical Center, Cincinnati, OH, USA
| | - Qingquan Lian
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital & Yuying Children's hospital of Wenzhou Medical University, Wenzhou, China
| | - Wangning ShangGuan
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital & Yuying Children's hospital of Wenzhou Medical University, Wenzhou, China
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Abstract
As the population ages, there is a higher prevalence of both dementia and conditions that require major surgery. However, patients with dementia undergoing surgery have poorer outcomes than surgical patients without dementia. This article explores new guidance about delivering perioperative care for patients with dementia presenting for surgery. Management of patients with cognitive changes begins with developing an understanding of the classifications and pathophysiology of these disease processes, and addressing any modifiable risk factors for developing dementia, postoperative cognitive decline and postoperative delirium. Thorough preoperative assessment provides the opportunity to identify patients with and at risk of these cognitive impairments and to involve the appropriate multidisciplinary team in care planning. Once patients are identified, an individualised perioperative management plan addressing any issues surrounding capacity and consent, conduct of anaesthesia, possible polypharmacy and potential drug interactions, and postoperative pain management can improve quality of care and outcomes for these patients.
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Affiliation(s)
| | - Helen Jordan
- South East Scotland School of Anaesthesia, Edinburgh, Scotland
| | - Annemarie B Docherty
- Department of Anaesthesia and Critical Care, University of Edinburgh, Edinburgh, Scotland Conflicts of interest
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43
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Nunnally ME, Nurok M. What Does it Take to Run an ICU and Perioperative Medicine Service? Int Anesthesiol Clin 2020; 57:144-162. [PMID: 30864997 DOI: 10.1097/aia.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mark E Nunnally
- Departments of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Health, New York, New York.,Departments of Neurology, Surgery and Medicine, NYU Langone Health, New York, New York
| | - Michael Nurok
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Onwochei DN, Fabes J, Walker D, Kumar G, Moonesinghe SR. Critical care after major surgery: a systematic review of risk factors for unplanned admission. Anaesthesia 2020; 75 Suppl 1:e62-e74. [DOI: 10.1111/anae.14793] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 12/17/2022]
Affiliation(s)
- D. N. Onwochei
- Department of Anaesthesia Guy's & St. Thomas’ NHS Foundation Trust London UK
| | - J. Fabes
- Department of AnaesthesiaRoyal Free NHS Foundation Trust LondonUK
| | - D. Walker
- Centre for Anaesthesia and Peri‐operative Medicine UCL Division of Surgery and Interventional Science University College London London UK
| | - G. Kumar
- Centre for Anaesthesia and Peri‐operative Medicine UCL Division of Surgery and Interventional Science University College London London UK
| | - S. R. Moonesinghe
- Centre for Anaesthesia and Peri‐operative Medicine UCL Division of Surgery and Interventional Science University College London London UK
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Perioperative mortality at Tibebe Ghion Specialized Teaching Hospital, Ethiopia: A longitudinal study design. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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46
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Wrzosek A, Jakowicka‐Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Swierz MJ, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Cochrane Database Syst Rev 2019; 12:CD012767. [PMID: 31829446 PMCID: PMC6953415 DOI: 10.1002/14651858.cd012767.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization. OBJECTIVES To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery. SEARCH METHODS We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person. MAIN RESULTS From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.
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Affiliation(s)
- Anna Wrzosek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
- University HospitalDepartment of Anaethesiology and Intensive CareKrakowPoland
| | | | - Renata Zajaczkowska
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Wojciech T Serednicki
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Milosz Jankowski
- University HospitalDepartment of Anaesthesiology and Intensive CareKrakowPoland
- Jagiellonian University Medical CollegeDepartment of Internal Medicine; Systematic Reviews UnitKrakowPoland
| | - Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics; Systematic Reviews UnitKopernika 7KrakowPoland31‐034
| | - Mateusz J Swierz
- Jagiellonian University Medical CollegeDepartment of Hygiene and Dietetics; Systematic Reviews UnitKrakowPoland
| | - Maciej Polak
- Jagiellonian University Medical CollegeDepartment of Epidemiology and Population Studies in the Institute of Public HealthKrakowPoland
| | - Jerzy Wordliczek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
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La unidad de cuidados intensivos en el postoperatorio de cirugía mayor abdominal. Med Intensiva 2019; 43:569-577. [DOI: 10.1016/j.medin.2019.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/09/2019] [Accepted: 05/09/2019] [Indexed: 01/04/2023]
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Aseni P, Orsenigo S, Storti E, Pulici M, Arlati S. Current concepts of perioperative monitoring in high-risk surgical patients: a review. Patient Saf Surg 2019; 13:32. [PMID: 31660064 PMCID: PMC6806509 DOI: 10.1186/s13037-019-0213-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022] Open
Abstract
A substantial number of patients are at high-risk of intra- or post-operative complications or both. Most perioperative deaths are represented by patients who present insufficient physiological reserve to meet the demands of major surgery. Recognition and management of critical high-risk surgical patients require dedicated and effective teams, capable of preventing, recognize, start treatment with adequate support in time to refer patients to the satisfactory ICU level provision. The main task for health-care planners and managers is to identify and reduce this severe risk and to encourage patient’s safety practices. Inadequate tissue perfusion and decreased cellular oxygenation due to hypovolemia, heart dysfunction, reduced cardiovascular reserve, and concomitant diseases are the most common causes of perioperative complications. Hemodynamic, respiratory and careful sequential monitoring have become essential aspects of the clinical practice both for surgeons and intensivists. New monitoring techniques have changed significantly over the past few years and are now able to rapidly identify shock states earlier, define the etiology, and monitor the response to different therapies. Many of these techniques are now minimally invasive or non-invasive. Advanced hemodynamic and respiratory monitoring combines invasive, non-invasive monitoring skills. Non-invasive ultrasound has emerged during the last years as an essential operative and perioperative evaluation tool, and its use is now rapidly growing. Perioperative management guided by appropriate sequential clinical evaluation combined with respiratory and hemodynamic monitoring is an established tool to help clinicians to identify those patients at higher risk in the attempt to reduce the complications rate and potentially improve patient outcomes. This review aims to provide an update of currently available standard concepts and evolving technologies of the various respiratory and hemodynamic monitoring systems for the high-risk surgical patients, highlighting their potential usefulness when integrated with careful clinical evaluation.
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Affiliation(s)
- Paolo Aseni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Stefano Orsenigo
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enrico Storti
- Dipartimento Emergenza Urgenza, UOC Anestesia e Rianimazione, ASST, Lodi, Italy
| | - Marco Pulici
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Sergio Arlati
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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The Extended Postoperative Care-Score (EXPO-Score)-An Objective Tool for Early Identification of Indication for Extended Postoperative Care. J Clin Med 2019; 8:jcm8101666. [PMID: 31614741 PMCID: PMC6832365 DOI: 10.3390/jcm8101666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 11/16/2022] Open
Abstract
Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early prediction of admission to extended care in surgical patients. This prospective observational study was divided into two periods (Period 1: Extended Postoperative Care-Score (EXPO)-Score generation; Period 2: EXPO-Score validation) and it was performed at a tertiary university center in Germany. A total of 4042 (Period 1) and 2198 (Period 2) adult patients ≥ 18 years old receiving elective or emergency surgery were included in this study. After identifying patient- and surgery-related risk factors by an expert panel, the EXPO-Score was developed through logistic regression from data of Period 1 and validated in Period 2. Three risk factors are sufficient for generating a reliable predictive EXPO-Score: (1) the American Society of Anesthesiologists’ (ASA) physical status, (2) cardiopulmonary physical exercise status expressed in metabolic equivalents (MET), and (3) the type of surgery. The score threshold (0.23) has a sensitivity of 0.87, a specificity of 0.91, and an accuracy of 0.90 for predicting indication for extended postoperative care. The EXPO-Score provides a validated, early collectable, and easy-to-use tool for predicting indication of extended postoperative care in adult surgical patients.
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How to optimize critical care resources in surgical patients: intensive care without physical borders. Curr Opin Crit Care 2019; 24:581-587. [PMID: 30299312 DOI: 10.1097/mcc.0000000000000557] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Timely identification of surgery patients at risk of postoperative complications is important to improve the care process, including critical care. This review discusses epidemiology and impact of postoperative complications; prediction scores used to identify surgical patients at risk of complications, and the role of critical care in the postoperative management. It also discusses how critical care may change, with respect to admission to the ICU. RECENT FINDING Optimization of postoperative outcome, next to preoperative and intraoperative optimization, consists of using risk scores to early identify patients at risk of developing complications. Critical care consultancy should be performed in the ward after surgery, if necessary. ICUs could work at different levels of intensity, but remain preferably multidisciplinary, combining care for surgical and medical patients. ICU admission should still be considered for those patients at very high risk of postoperative complications, and for those receiving complex or emergency interventions. SUMMARY To optimize critical care resources for surgery patients at high risk of postoperative complications, the care process should not only include critical care and monitoring in ICUs, but also strict monitoring in the ward. Prediction scores could help to timely identify patients at risk. More intense care (monitoring) outside the ICU could improve outcome. This concept of critical care without borders could be implemented in the near future to optimize the local resources and improve patient safety. Predict more, do less in ICUs, and more in the ward.
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