Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Barriers to ultrasound guidance for central venous access:a survey among Dutch intensivists and anaesthesiologists

\u3cp\u3eAccumulating evidence shows that ultrasound (US) guidance improves effectiveness and safety of central venous catheter (CVC) placement. Several international guidelines therefore recommend the use of US for placement of CVCs. However, surveys show that the landmark-based technique is still widely used, while the percentage of physicians using US is increasing less than expected. The goal of this study was to investigate current practice for central venous catheterization in anaesthesiology and intensive care in the Netherlands, identify barriers for further implementation of US guidance and to evaluate whether personality traits are associated with the choice of technique. We conducted a web-based national survey, distributed among members of the Dutch societies of anaesthesiology (NVA) and intensive care (NVIC). The survey contained questions regarding physician and hospital characteristics, frequency of US use and reasons for use or non-use, as well as the NEO-FFI-3, a validated, translated questionnaire to characterize personality traits according to the ‘Big Five’ concept. Response rate was 22% (506/2291), of which 400 had also the personality questionnaire complete. Ultrasound guidance was used always or almost always in 68%; barriers for US use were working in a non-academic non-teaching hospital, providing cardiac anaesthesia and more years of physician experience. Reasons for not using US were perceived lack of benefit, increased procedure time, lack of US equipment and fear of loss of landmark technique skills. 13% of respondents had never experienced a complication during CVC placement, and 67% knew of a complication occurring the past year at their department. Ultrasound was thought not to be able to prevent the complication in half of these cases. Of the personality traits, only neuroticism and extraversion showed a minor positive association with US guidance. A majority of anaesthesiologists and intensivists uses US guidance for CVC placement, but a significant proportion of physicians still prefers the landmark technique. Most arguments from respondents against US guidance can be challenged. Personality traits most likely do not play a major role in the acceptance of US guidance for central venous catheterization. A potential intervention to increase US use could be formalizing local hospital policies mandating compliance with US guidance. Future research can perhaps focus on cognitive biases that currently limit more widespread use of US guidance.\u3c/p\u3

Improving needle tip identification during ultrasound-guided procedures in anaesthetic practice

Ultrasound guidance is becoming standard practice for needle-based interventions in anaesthetic practice, such as vascular access and peripheral nerve blocks. However, difficulties in aligning the needle and the transducer can lead to incorrect identification of the needle tip, possibly damaging structures not visible on the ultrasound screen. Additional techniques specifically developed to aid alignment of needle and probe or identification of the needle tip are now available. In this scoping review, advantages and limitations of the following categories of those solutions are presented: needle guides; alterations to needle or needle tip; three- and four-dimensional ultrasound; magnetism, electromagnetic or GPS systems; optical tracking; augmented (virtual) reality; robotic assistance; and automated (computerised) needle detection. Most evidence originates from phantom studies, case reports and series, with few randomised clinical trials. Improved first-pass success and reduced performance time are the most frequently cited benefits, whereas the need for additional and often expensive hardware is the greatest limitation to widespread adoption. Novice ultrasound users seem to benefit most and great potential lies in education. Future research should focus on reporting relevant clinical parameters to learn which technique will benefit patients most in terms of success and safety

Cardiac structure and function before and after bariatric surgery:a clinical overview

\u3cp\u3eObesity, defined as a body mass index of ≥30 kg/m2 , is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.\u3c/p\u3

Towards flow estimation in the common carotid artery using free-hand cross-sectional doppler

\u3cp\u3eQuantifying blood flow is of major clinical importance for the assessment of the cardiovascular status. Longitudinal flow measurements in the common carotid suffer from operator-dependency and are very sensitive to motion. In this work, a method is proposed to perform flow estimation from cross-sectional acquisitions, which reduces operator-dependency and is more robust to motion. By modeling the vessel as a cylinder, the intersection between the ultrasound plane and the vessel is an ellipse. The properties of this ellipse (semi-major and semi- minor axis, rotation and center position) are used to estimate the Doppler angle (beam-to-flow angle). This method was tested in vitro on a constant flow phantom using a wide variety of Doppler angles, where the errors in the flow estimates were below 10%. Further research should aim at quantifying the sensitivity of this method and validating this method in vivo.\u3c/p\u3

A mathematical model to investigate the effects of intravenous fluid administration and fluid loss

\u3cp\u3eThe optimal fluid administration protocol for critically ill perioperative patients is hard to estimate due to the lack of tools to directly measure the patient fluid status. This results in the suboptimal clinical outcome of interventions. Previously developed predictive mathematical models focus on describing the fluid exchange over time but they lack clinical applicability, since they do not allow prediction of clinically measurable indices. The aim of this study is to make a first step towards a model predictive clinical decision support system for fluid administration, by extending the current fluid exchange models with a regulated cardiovascular circulation, to allow prediction of these indices. The parameters of the model were tuned to correctly reproduce experimentally measured changes in arterial pressure and heart rate, observed during infusion of normal saline in healthy volunteers. With the resulting tuned model, a different experiment including blood loss and infusion could be reproduced as well. These results show the potential of using this model as a basis for a decision support tool in a clinical setting.\u3c/p\u3

Pulmonary blood volume measured by contrast enhanced ultrasound : a comparison with transpulmonary thermodilution

Background Blood volume quantification is essential for haemodynamic evaluation guiding fluid management in anaesthesia and intensive care practice. Ultrasound contrast agent (UCA)-dilution measured by contrast enhanced ultrasound (CEUS) can provide the UCA mean transit time (MTT) between the right and left heart, enabling the assessment of the intrathoracic blood volume (ITBVUCA). The purpose of the present study was to investigate the agreement between UCA-dilution using CEUS and transpulmonary thermodilution (TPTD) in vitro and in vivo. Methods In an in vitro setup, with variable flows and volumes, we injected a double indicator, ice-cold saline with SonoVue®, and performed volume measurements using transesophageal echo and thermodilution by PiCCO®. In a pilot study, we assigned 17 patients undergoing elective cardiac surgery for pulmonary blood volume (PBV) measurement using TPTD by PiCCO® and ITBV by UCA-dilution. Correlation coefficients and Bland-Altman analysis were performed for all volume measurements. Results In vitro, 73 experimental MTT's were obtained using PiCCO® and UCA-dilution. The volumes by PiCCO® and UCA-dilution correlated with true volumes; rs=0.96 (95% CI, 0.93–0.97; P<0.0001) and rs=0.97 (95% CI, 0.95–0.98; P<0.0001), respectively. The bias of PBV by PiCCO® and ITBVUCA were −380 ml and −42 ml, respectively. In 16 patients, 86 measurements were performed. The correlation between PBV by PiCCO® and ITBVUCA was rs=0.69 (95% CI 0.55–0.79; P<0.0001). Bland-Altman analysis revealed a bias of −323 ml. Conclusions ITBV assessment with CEUS seems a promising technique for blood volume measurement, which is minimally-invasive and bedside applicable

Intelligent dynamic clinical checklists improved checklist compliance in the intensive care unit

Background: Checklists can reduce medical errors. However, the use of checklists is hampered by lack of acceptance and compliance. Recently, a new kind of checklist with dynamic properties has been created to provide more specific checklist items of a patient to the specific caregiver. Our purpose of this simulation based study was to investigate the first developed intelligent dynamic clinical checklist (DCC) for the Intensive Care Unit (ICU) ward round. METHODS: Eligible clinicians were invited to participate as volunteers. Highest achievable scores were established for six typical ICU scenarios to determine which items must be checked. The participants compared the DCC with the local standard of care. The primary outcomes were the caregiver satisfaction score and, the percentages of checked items overall and of critical items requiring a direct intervention. RESULTS: In total twenty participants were included, who performed 116 scenarios. The median percentage of checked items was 100.0% with the DCC, compared to 73.6% for the scenarios completed with local standard of care (p<0.001). In the scenarios performed with local standard of care remained 23.1% of the critical items unchecked, in contrast to 0.0% if the DCC was available (p<0.001). The mean satisfaction score of the DCC was 4.13 out of 5. CONCLUSION: This simulation study indicates that an intelligent DCC significantly increases compliance to best practice by reducing the percentage of unchecked items during ICU ward rounds, while the user satisfaction rate remains high. More, real life, clinical research is required to further evaluate this new kind of checklist

Noninvasive pulmonary transit time:a new parameter for general cardiac performance

\u3cp\u3eIntroduction: Pulmonary transit time (PTT) assessed with contrast-enhanced ultrasound (CEUS) is a novel tool to evaluate cardiac function. PTT represents the time for a bolus of contrast to pass from the right to the left ventricle, measured according to the indicator dilution principles using CEUS. We investigated the hypothesis that PTT is a measure of general cardiac performance in patient populations eligible for cardiac resynchronization therapy (CRT). Methods: The study population consisted of heart failure patients referred for CRT with NYHA class II–IV, left ventricular ejection fraction (LVEF)≤35% and QRS≥120 ms. CEUS, ECG, and blood were analyzed, and participants completed a quality of life questionnaire at baseline and 3 months after CRT implantation. Normalized PTT (nPTT) was calculated to compensate for the heart rate. Correlations were assessed with Pearson's or Spearman's coefficients and stratified for rhythm and NYHA class. Results: The study population consisted of 94 patients (67 men) with a mean age of 70±8.9 years. (n)PTT was significantly correlated with left ventricular parameters (r\u3csub\u3es\u3c/sub\u3e=−.487, P<.001), right ventricular parameters (r=−.282, P=.004), N-terminal pro-B-type natriuretic peptide (NT-proBNP) (r\u3csub\u3es\u3c/sub\u3e=.475, P<.001), and quality of life (r\u3csub\u3es\u3c/sub\u3e=.364, P<.001). Stronger significant correlations were found in patients in sinus rhythm. Conclusion: CEUS-derived PTT and nPTT correlate to a fair degree with measures of systolic and diastolic function, NT-pro-BNP, and quality of life. As CEUS-derived PTT can be obtained easily, noninvasively and at the bedside, it is a promising future measure of general cardiac performance.\u3c/p\u3