Lessons Learned from Telemonitoring in an Outpatient Bariatric Surgery Pathway-Secondary Outcomes of a Patient Preference Clinical Trial

Background: Remote monitoring is increasingly used to support postoperative care. This study aimed to describe the lessons learned from the use of telemonitoring in an outpatient bariatric surgery pathway. Materials and Methods: Patients were assigned based on their preference to an intervention cohort of same-day discharge after bariatric surgery. In total, 102 patients were monitored continuously for 7 days using a wearable monitoring device with a Continuous and Remote Early Warning Score–based notification protocol (CREWS). Outcome measures included missing data, course of postoperative heart and respiration rate, false positive notification and specificity analysis, and vital sign assessment during teleconsultation. Results: In 14.7% of the patients, data for heart rate was missing for &gt; 8 h. A day-night-rhythm of heart rate and respiration rate reappeared on average on postoperative day 2 with heart rate amplitude increasing after day 3. CREWS notification had a specificity of 98%. Of the 17 notifications, 70% was false positive. Half of them occurred between day 4 and 7 and were accompanied with surrounding reassuring values. Comparable postoperative complaints were encountered between patients with normal and deviated data. Conclusion: Telemonitoring after outpatient bariatric surgery is feasible. It supports clinical decisions, however does not replace nurse or physician care. Although infrequent, the false notification rate was high. We suggested additional contact may not be necessary when notifications occur after restoration of circadian rhythm or when surrounding reassuring vital signs are present. CREWS supports ruling out serious complications, what may reduce in-hospital re-evaluations. Following these lessons learned, increased patients’ comfort and decreased clinical workload could be expected. Trial Registration: ClinicalTrials.gov. Identifier: NCT04754893. Graphical Abstract: [Figure not available: see fulltext.]</p

Heparin-resistance in AL amyloidosis: a case report

Abstract Background Non-AT-III mediated heparin-resistance during CPB occurs by complex-forming with heparin-binding proteins. Currently, there are no specific recommendations for non-AT-III mediated heparin-resistance. Case presentation We present a fatal case of a 70-yr-old male-patient undergoing cardiac-surgery in which refractory heparin-resistance was observed. The massive AL amyloidosis found at autopsy is thought to be responsible and illustrates that awareness and knowledge of the etiology and perioperative strategies of non-AT-III mediated heparin-resistance is important. Conclusion For anticoagulation during cardiopulmonary bypass surgery in case of a non-AT-III medicated heparin resistance, we refer to the decision tree added to this manuscript and if necessary to consider direct thrombin inhibitors, such as bivalirudin or argatroban, as it bypasses the complexing pathway

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research