Noise Levels and Sleep in a Surgical ICU

Noise; Perioperative care; SleepRuido; Cuidado perioperatorio; SueñoSoroll; Cura perioperatòria; SonSleep is disturbed in critically ill patients and is a frequently overlooked complication. The aim of our study is to evaluate the impact of sound levels in our surgical ICU on our patients’ sleep on the first night of admission. The study was performed in a tertiary care university hospital, in a 12-bed surgical ICU. Over a 6-week period, a total of 148 adult, non-intubated and non-sedated patients completed the study. During this six-week period, sound levels were continuously measured using a type II sound level meter. Sleep quality was evaluated using the Richards–Campbell Sleep Questionnaire (RCSQ), which was completed both by patients and nurses on the first morning after admission. A non-significant correlation was found between night sound levels and sleep quality in the overall sample (r = −1.83, 95% CI; −4.54 to 0.88, p = 0.19). After multivariable analysis, a correlation was found between higher sound levels at night and lower RCSQ evaluations (r = −3.92, 95% CI; −7.57 to −0.27, p = 0.04). We found a significant correlation between lower sound levels at night and a better quality of sleep in our patients; for each 1 dBA increase in LAFeq sound levels at night, patients scored 3.92 points lower on the sleep questionnaire

Cambios hemodinámicos en el postoperatorio de la cirugía endovascular de carótida : factores pronósticos

L'angioplàstia carotídia és una alternativa terapèutica per al tractament de la malaltia arterial carotídia en pacients amb un risc quirúrgic elevat, més susceptibles de presentar inestabilitat hemodinàmica en el perioperatori i també de patir més complicacions derivades d'aquesta. L'objectiu principal d'aquest treball és valorar la incidència d'hipotensió (definida com a TAS & 90mmHg) i/o bradicàrdia (definida com a variació & 20% de la FC basal) en les primeres 12 hores postoperatòries de la cirurgia endovascular carotídia, i la seva relació amb variables clíniques o ecogràfiques preparatòries. L'objectiu secundari és valorar la incidència temporal d'aquestes complicacions, i el valor predictiu negatiu de l'absència d'hipotensió i bradicàrdia durant les primeres 6 hores de monitorització.La angioplastia carotídea es una opción terapéutica para el tratamiento de la enfermedad arterial oclusiva carótidea en una población de alto riesgo quirúrgico con más propensión a presentar inestabilidad hemodinámica en el perioperatorio y a sufrir complicaciones derivadas de dicha inestabilidad.El objetivo principal del estudio es evaluar la incidencia de hipotensión (definida como TAS & 90 mmHg) y/o bradicardia (definida como variación & 20% de la FC basal) en las primeras 12 horas del postoperatorio de la cirugía endovascular carotídea y su relación con variables clínicas o ecográficas preoperatorias. Como objetivo secundario evaluamos la incidencia temporal de estas complicaciones y el valor predictivo negativo de la ausencia de hipotensión y bradicardia en las primeras 6 horas de monitorización

Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study

Cardiac imaging; Myocardial injury; Noncardiac surgeryImatge cardíaca; Lesió del miocardi; Cirurgia no cardíacaImagen cardiaca; Lesión miocárdica; Cirugía no cardiacaBackground Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention. Methods Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48–72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality. Results We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%). Conclusion This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes.The study has been supported by research grant from the Instituto de Salud Carlos III, Spain (PI16/01162), partly funded by Fondo Europeo de Desarrollo Regional (FEDER), Unión Europea, “Una manera de hacer Europa” to Ekaterine Popova, by Generalitat de Catalunya (PERIS SLT017/20/000089) to Ekaterine Popova and by a "Marato de TV3" grant (20150110) to Pablo Alonso-Coello

Study protocol for an observational cohort evaluating incidence and clinical relevance of perioperative elevation of high-sensitivity troponin I and N-terminal pro-brain natriuretic peptide in patients undergoing lung resection

Perioperative; Lung resectionPerioperatorio; Resección pulmonarPerioperatori; Resecció pulmonarIntroduction Myocardial injury after non-cardiac surgery has been defined as myocardial injury due to ischaemia, with or without additional symptoms or ECG changes occurring during or within 30 days after non-cardiac surgery and mainly diagnosed based on elevated postoperative cardiac troponin (cTn) values. In patients undergoing thoracic surgery for lung resection, only postoperative cTn elevations are seemingly not enough as an independent predictor of cardiovascular complications. After lung resection, troponin elevations may be regulated by mechanisms other than myocardial ischaemia. The combination of perioperative natriuretic peptide measurement together with high-sensitivity cTns may help to identify changes in ventricular function during thoracic surgery. Integrating both cardiac biomarkers may improve the predictive value for cardiovascular complications after lung resection. We designed our cohort study to evaluate perioperative elevation of both high-sensitivity troponin I (hs-TnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing lung resection and to establish a risk score for major cardiovascular postoperative complications. Methods and analysis We will conduct a prospective, multicentre, observational cohort study, including 345 patients undergoing elective thoracic surgery for lung resection. Cardiac biomarkers such as hs-TnI and NT-proBNP will be measured preoperatively and at postoperatively on days 1 and 2. We will calculate a risk score for major cardiovascular postoperative complications based on both biomarkers’ perioperative changes. All patients will be followed up for 30 days after surgery. Ethics and dissemination All participating centres were approved by the Ethics Research Committee. Written informed consent is required for all patients before inclusion. Results will be disseminated through publication in peer-reviewed journals and presentations at national or international conference meetings.This work was supported by a research grant number: ‘PI20/00154’ from the Instituto de Salud Carlos III (co-funded by the European Regional Development Fund ‘Una manera de hacer Europa’)

Comparison of cerebral metabolic rate of oxygen, blood flow, and bispectral index under general anesthesia

Cerebral blood flow; Diffuse optics; Propofol-induced anesthesiaFlujo sanguíneo cerebral; Óptica difusa; Anestesia inducida por propofolFlux sanguini cerebral; Òptica difusa; Anestèsia induïda per propofolSignificance The optical measurement of cerebral oxygen metabolism was evaluated. Aim Compare optically derived cerebral signals to the electroencephalographic bispectral index (BIS) sensors to monitor propofol-induced anesthesia during surgery. Approach Relative cerebral metabolic rate of oxygen (rCMRO2) and blood flow (rCBF) were measured by time-resolved and diffuse correlation spectroscopies. Changes were tested against the relative BIS (rBIS) ones. The synchronism in the changes was also assessed by the R-Pearson correlation. Results In 23 measurements, optically derived signals showed significant changes in agreement with rBIS: during propofol induction, rBIS decreased by 67% [interquartile ranges (IQR) 62% to 71%], rCMRO2 by 33% (IQR 18% to 46%), and rCBF by 28% (IQR 10% to 37%). During recovery, a significant increase was observed for rBIS (48%, IQR 38% to 55%), rCMRO2 (29%, IQR 17% to 39%), and rCBF (30%, IQR 10% to 44%). The significance and direction of the changes subject-by-subject were tested: the coupling between the rBIS, rCMRO2, and rCBF was witnessed in the majority of the cases (14/18 and 12/18 for rCBF and 19/21 and 13/18 for rCMRO2 in the initial and final part, respectively). These changes were also correlated in time (R > 0.69 to R = 1, p-values < 0.05). Conclusions Optics can reliably monitor rCMRO2 in such conditions.This work received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 675332 (BitMap), No. 101016087 (VASCOVID) and No. 101017113 (TinyBRAINS), KidsBrainIT (ERA-NET NEURON), FEDER EC and LASERLAB-EUROPE V (EC H2020 no. 871124). It was also supported by Fundació CELLEX Barcelona, Fundació Mir-Puig the “Severo Ochoa” Programme for Centres of Excellence in R&D (SEV-2015-0522), the Obra social “la Caixa” Foundation (LlumMedBcn), Generalitat de Catalunya (CERCA, AGAUR-2017-SGR-1380, RIS3CAT-001-P-001682 CECH), la Fundació La Marató de TV3 (201724.31 and 201709.31), and by Agencia Estatal de Investigación (PHOTOMETABO, PID2019-106481RB-C31/10.13039/501100011033)

Influence of early neurological complications on clinical outcome following lung transplant

BACKGROUND. Neurological complications after lung transplantation are common. The full spectrum of neurological complications and their impact on clinical outcomes has not been extensively studied. METHODS. We investigated the neurological incidence of complications, categorized according to whether they affected the central, peripheral or autonomic nervous systems, in a series of 109 patients undergoing lung transplantation at our center between January 1 2013 and December 31 2014. RESULTS. Fifty-one patients (46.8%) presented at least one neurological complication. Critical illness polyneuropathy-myopathy (31 cases) and phrenic nerve injury (26 cases) were the two most prevalent complications. These two neuromuscular complications lengthened hospital stays by a median period of 35.5 and 32.5 days respectively. However, neurological complications did not affect patients' survival. CONCLUSIONS. The real incidence of neurological complications among lung transplant recipients is probably underestimated. They usually appear in the first two months after surgery. Despite not affecting mortality, they do affect the mean length of hospital stay, and especially the time spent in the Intensive Care Unit. We found no risk factor for neurological complications except for long operating times, ischemic time and need for transfusion. It is necessary to develop programs for the prevention and early recognition of these complications, and the prevention of their precipitant and risk factors

Study protocol for an observational cohort evaluating incidence and clinical relevance of perioperative elevation of high-sensitivity troponin I and N-terminal pro-brain natriuretic peptide in patients undergoing lung resection

INTRODUCTION: Myocardial injury after non-cardiac surgery has been defined as myocardial injury due to ischaemia, with or without additional symptoms or ECG changes occurring during or within 30 days after non-cardiac surgery and mainly diagnosed based on elevated postoperative cardiac troponin (cTn) values. In patients undergoing thoracic surgery for lung resection, only postoperative cTn elevations are seemingly not enough as an independent predictor of cardiovascular complications. After lung resection, troponin elevations may be regulated by mechanisms other than myocardial ischaemia. The combination of perioperative natriuretic peptide measurement together with high-sensitivity cTns may help to identify changes in ventricular function during thoracic surgery. Integrating both cardiac biomarkers may improve the predictive value for cardiovascular complications after lung resection. We designed our cohort study to evaluate perioperative elevation of both high-sensitivity troponin I (hs-TnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing lung resection and to establish a risk score for major cardiovascular postoperative complications. METHODS AND ANALYSIS: We will conduct a prospective, multicentre, observational cohort study, including 345 patients undergoing elective thoracic surgery for lung resection. Cardiac biomarkers such as hs-TnI and NT-proBNP will be measured preoperatively and at postoperatively on days 1 and 2. We will calculate a risk score for major cardiovascular postoperative complications based on both biomarkers' perioperative changes. All patients will be followed up for 30 days after surgery. ETHICS AND DISSEMINATION: All participating centres were approved by the Ethics Research Committee. Written informed consent is required for all patients before inclusion. Results will be disseminated through publication in peer-reviewed journals and presentations at national or international conference meetings. TRIAL REGISTRATION NUMBER: NCT04749212

Influence of early neurological complications on clinical outcome following lung transplant

Sistema Nerviós Autònom; Risc de malalties cardiovasculars; Procediments mèdics quirúrgics i invasiusSistema nervioso autónomo; Riesgo de enfermedad cardiovascular; Procedimientos médicos quirúrgicos e invasivosAutonomic Nervous System; Cardiovascular disease risk; Surgical and invasive medical proceduresBackground Neurological complications after lung transplantation are common. The full spectrum of neurological complications and their impact on clinical outcomes has not been extensively studied. Methods We investigated the neurological incidence of complications, categorized according to whether they affected the central, peripheral or autonomic nervous systems, in a series of 109 patients undergoing lung transplantation at our center between January 1 2013 and December 31 2014. Results Fifty-one patients (46.8%) presented at least one neurological complication. Critical illness polyneuropathy-myopathy (31 cases) and phrenic nerve injury (26 cases) were the two most prevalent complications. These two neuromuscular complications lengthened hospital stays by a median period of 35.5 and 32.5 days respectively. However, neurological complications did not affect patients’ survival. Conclusions The real incidence of neurological complications among lung transplant recipients is probably underestimated. They usually appear in the first two months after surgery. Despite not affecting mortality, they do affect the mean length of hospital stay, and especially the time spent in the Intensive Care Unit. We found no risk factor for neurological complications except for long operating times, ischemic time and need for transfusion. It is necessary to develop programs for the prevention and early recognition of these complications, and the prevention of their precipitant and risk factors.JG is the recipient of a grant from the Spanish Fondo de Investigaciones Sanitarias (FIS PI13-01272-FEDER)

Aspirin and clonidine in non-cardiac surgery: acute kidney injury substudy protocol of the Perioperative Ischaemic Evaluation (POISE) 2 randomised controlled trial

IntroductionPerioperative Ischaemic Evaluation-2 (POISE-2) is an international 2×2 factorial randomised controlled trial of low-dose aspirin versus placebo and low-dose clonidine versus placebo in patients who undergo non-cardiac surgery. Perioperative aspirin (and possibly clonidine) may reduce the risk of postoperative acute kidney injury (AKI).Methods and analysisAfter receipt of grant funding, serial postoperative serum creatinine measurements began to be recorded in consecutive patients enrolled at substudy participating centres. With respect to the study schedule, the last of over 6500 substudy patients from 82 centres in 21 countries were randomised in December 2013. The authors will use logistic regression to estimate the adjusted OR of AKI following surgery (compared with the preoperative serum creatinine value, a postoperative increase ≥26.5 μmol/L in the 2 days following surgery or an increase of ≥50% in the 7 days following surgery) comparing each intervention to placebo, and will report the adjusted relative risk reduction. Alternate definitions of AKI will also be considered, as will the outcome of AKI in subgroups defined by the presence of preoperative chronic kidney disease and preoperative chronic aspirin use. At the time of randomisation, a subpopulation agreed to a single measurement of serum creatinine between 3 and 12 months after surgery, and the authors will examine intervention effects on this outcome.Ethics and disseminationThe authors were competitively awarded a grant from the Canadian Institutes of Health Research for this POISE-2 AKI substudy. Ethics approval was obtained for additional kidney data collection in consecutive patients enrolled at participating centres, which first began for patients enrolled after January 2011. In patients who provided consent, the remaining longer term serum creatinine data will be collected throughout 2014. The results of this study will be reported no later than 2015.Clinical Trial Registration NumberNCT01082874