Can remifentanil use in obstetrics be improved by optimal patient-controlled analgesia bolus timing?

Background The safety of patient-controlled i.v. analgesia (PCA) with remifentanil for obstetrical analgesia remains a matter of concern. The efficacy of remifentanil bolus application, that is, the coincidence between pain and remifentanil effect-site concentration, may be improved by forecasting contractions, but it is not known whether such a technique would also improve safety. Methods We recorded pain intensity during labour continuously using a handheld dynamometer in 43 parturients. Using these data, we compared different models in their ability to predict future contractions. In addition, we modelled remifentanil effect-site concentration using three simulated modes of bolus administration, with and without prediction of future contractions. Results The average duration of pain during contractions recorded by the dynamometer was 45 [14 standard deviation (sd)] s. The time interval between painful contractions was highly variable, with a mean of 151 (31 sd) s during the first and 154 (52 sd) s during the second recording. Using a simple algorithm (three-point moving average), the sd of the difference between predicted and observed inter-contraction intervals can be reduced from 0.95 to 0.79 min. However, the coincidence between remifentanil concentration and pain during contraction is not substantially improved when using these models to guide remifentanil bolus application. Conclusions Because of the large variability of inter-contraction intervals, the use of prediction models will not influence the mean remifentanil concentration in-between contractions. Using models predicting future contractions to improve the timing of remifentanil PCA bolus administration will not diminish the need of continuous clinical surveillance and other safety measure

Enhancing Network Slicing Architectures with Machine Learning, Security, Sustainability and Experimental Networks Integration

Network Slicing (NS) is an essential technique extensively used in 5G networks computing strategies, mobile edge computing, mobile cloud computing, and verticals like the Internet of Vehicles and industrial IoT, among others. NS is foreseen as one of the leading enablers for 6G futuristic and highly demanding applications since it allows the optimization and customization of scarce and disputed resources among dynamic, demanding clients with highly distinct application requirements. Various standardization organizations, like 3GPP's proposal for new generation networks and state-of-the-art 5G/6G research projects, are proposing new NS architectures. However, new NS architectures have to deal with an extensive range of requirements that inherently result in having NS architecture proposals typically fulfilling the needs of specific sets of domains with commonalities. The Slicing Future Internet Infrastructures (SFI2) architecture proposal explores the gap resulting from the diversity of NS architectures target domains by proposing a new NS reference architecture with a defined focus on integrating experimental networks and enhancing the NS architecture with Machine Learning (ML) native optimizations, energy-efficient slicing, and slicing-tailored security functionalities. The SFI2 architectural main contribution includes the utilization of the slice-as-a-service paradigm for end-to-end orchestration of resources across multi-domains and multi-technology experimental networks. In addition, the SFI2 reference architecture instantiations will enhance the multi-domain and multi-technology integrated experimental network deployment with native ML optimization, energy-efficient aware slicing, and slicing-tailored security functionalities for the practical domain.Comment: 10 pages, 11 figure

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

Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions. A statement from the ESA-ESICM joint taskforce on perioperative outcome measures.

There is a need for large trials that test the clinical effectiveness of interventions in the field of perioperative medicine. Clinical outcome measures used in such trials must be robust, clearly defined and patient-relevant. Our objective was to develop standards for the use of clinical outcome measures to strengthen the methodological quality of perioperative medicine research. A literature search was conducted using PubMed and opinion leaders worldwide were invited to nominate papers that they believed the group should consider. The full texts of relevant articles were reviewed by the taskforce members and then discussed to reach a consensus on the required standards. The report was then circulated to opinion leaders for comment and review. This report describes definitions for 22 individual adverse events with a system of severity grading for each. In addition, four composite outcome measures were identified, which were designed to evaluate postoperative outcomes. The group also agreed on standards for four outcome measures for the evaluation of healthcare resource use and quality of life. Guidance for use of these outcome measures is provided, with particular emphasis on appropriate duration of follow-up. This report provides clearly defined and patient-relevant outcome measures for large clinical trials in perioperative medicine. These outcome measures may also be of use in clinical audit. This report is intended to complement and not replace other related work to improve assessment of clinical outcomes following specific surgical procedures

Relationship between norepinephrine dose, tachycardia and outcome in septic shock: A multicentre evaluation

Purpose: Septic shock is associated with massive release of endogenous catecholamines. Adrenergic agents may exacerbate catecholamine toxicity and contribute to poor outcomes. We sought to determine whether an association existed between tachycardia and mortality in septic shock patients requiring norepinephrine for more than 6 h despite adequate volume resuscitation. Materials and methods: Multicentre retrospective observational study on 730 adult patients in septic shock consecutively admitted to eight European ICUs between 2011 and 2013. Three timepoints were selected: T1 (first hour of infusion of norepinephrine), Tpeak (time of highest dose during the first 24 h of treatment), and T24 (24-h post-T1). Binary logistic regression models were constructed for the three time-points. Results: Overall ICU mortality was 38.4%. Mortality was higher in those requiring high-dose (≥0.3 mcg/kg/min) versus low-dose (<0.3 mcg/kg/min) norepinephrine at T1 (53.4% vs 30.6%; p < 0.001) and T24 (61.4% vs 20.4%; p < 0.0001). Patients requiring high-dose with concurrent tachycardia had higher mortality at T1; in the low-dose group tachycardia was not associated with mortality. Resolving tachycardia (from T1 to T24) was associated with lower mortality compared to patients where tachycardia persisted (27.8% vs 46.4%; p = 0.001). Conclusions: Use of high-dose norepinephrine and concurrent tachycardia are associated with poor outcomes in septic shock