Surveillance of high-risk early postsurgical patients for real-time detection of complications using wireless monitoring (SHEPHERD study): results of a randomized multicenter stepped wedge cluster trial

Background

Vital signs measurements on the ward are performed intermittently. This could lead to failure to rapidly detect patients with deteriorating vital signs and worsens long-term outcome. The aim of this study was to test the hypothesis that continuous wireless monitoring of vital signs on the postsurgical ward improves patient outcome.

Methods

In this prospective, multicenter, stepped-wedge cluster randomized study, patients in the control group received standard monitoring. The intervention group received continuous wireless monitoring of heart rate, respiratory rate and temperature on top of standard care. Automated alerts indicating vital signs deviation from baseline were sent to ward nurses, triggering the calculation of a full early warning score followed. The primary outcome was the occurrence of new disability three months after surgery.

Results

The study was terminated early (at 57% inclusion) due to COVID-19 restrictions. Therefore, only descriptive statistics are presented. A total of 747 patients were enrolled in this study and eligible for statistical analyses, 517 patients in the control group and 230 patients in the intervention group, the latter only from one hospital. New disability at three months after surgery occurred in 43.7% in the control group and in 39.1% in the intervention group (absolute difference 4.6%).

Conclusion

This is the largest randomized controlled trial investigating continuous wireless monitoring in postoperative patients. While patients in the intervention group seemed to experience less (new) disability than patients in the control group, results remain inconclusive with regard to postoperative patient outcome due to premature study termination.

Clinical trial registration

ClinicalTrials.gov, ID: NCT02957825.

What Really Matters to Survivors of Acute Type A Aortic Dissection-A Survey of Patient-Reported Outcomes in the Dutch National Aortic Dissection Advocacy Group

(1) Background: Type A acute aortic dissection (TAAAD) almost always requires emergency surgery, and postoperative complications are common. Quality assurance systems tend to measure only the hard outcomes, e.g., complications and mortality. Our aim was to assess the health-related quality of life of TAAAD survivors. (2) Methods: An anonymized, Dutch language, web-based survey was sent out to all of the participants of the 2022 Annual Meeting of the Dutch National Aortic Dissection (DNAD) advocacy group via their own representatives. The survey was divided into five sections: patient information, global satisfaction, surgery, including complications, and the recovery period. (3) Results: Ninety members of the DNAD group attended the meeting. Seventy-five (83%) participated in the survey, and the responses from 61 (81%) were available for analysis. Despite hindrances in their daily life (complications, changes in physical, cognitive, and social functioning), patients were satisfied with their treatment, and all would undergo the procedure again. In addition they requested better post-discharge guidance and communication (4) Conclusion: The emphasis lies in equipping patients with knowledge about potential outcomes and effective coping strategies. This underscores the importance of communication and expectation management, in line with established literature.

International Survey on Perioperative Management of Patients With Infective Endocarditis

OBJECTIVES

To estimate the current practice in the perioperative management of patients undergoing cardiac surgery due to infective endocarditis.

DESIGN

A prospective, open, 24-item, web-based cross-sectional survey.

SETTING

Online survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC).

PARTICIPANTS

Members of the EACTAIC.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 156 responses from 44 countries were received, with a completion rate of 99%. The response rate was 16.6%. Most respondents (76%) practiced cardiac anesthesia in European hospitals, and most respondents stated that a multidisciplinary endocarditis team was not established at their center, that cardiac anesthesiologists appeared to be involved infrequently in those teams (36%), and that they were not involved in decision-making on indication and timing of surgery (88%). In contrast, the cardiac anesthesiologist performed intraoperative antibiotic therapy (62%) and intraoperative transesophageal echocardiography (90%). Furthermore, there was a relative heterogeneity concerning perioperative monitoring, as well as for coagulation and transfusion management.

CONCLUSIONS

This international survey evaluated current practice among cardiac anesthesiologists in the perioperative management of patients with infective endocarditis and the anesthesiologist's role in multidisciplinary decision-making. Heterogeneity in treatment approaches was identified, indicating relevant knowledge gaps that should encourage further clinical research to optimize treatment and postoperative outcomes in this specific population.

Does Regular Practice with a "Flexible Bronchoscopy Simulator" Improve Fibreoptic Intubation Skills in Experts and Novices? A Randomized Controlled Study

BACKGROUND

The appropriate management of a "difficult airway" remains a challenge for novices and experienced anaesthetists. With the current available airway technologies, e.g., video laryngoscopy, flexible bronchoscopy (fibreoptic intubation (FOI)) for endotracheal intubation is decreasing, likely diminishing caregiver skills. We investigated whether bronchoscopy simulator training improved FOI skills.

METHODS

72 volunteers, consisting of anaesthetists, anaesthesia residents, and nurses, performed six exercises on a bronchoscopy simulator. At baseline and after 12 months, the six exercises included one serious game (to train agility), two basic airways, and three difficult airways. After a baseline assessment, subjects were randomly allocated to the intervention group (with) or control group without bronchoscopy simulator training every six weeks for 10 min using a preloaded serious game. The primary outcome was the difference in the time to reach the carina after 12 months, as measured objectively by the simulator. The level of stress and FOI confidence after 12 months were secondary outcomes.

RESULTS

The control and intervention groups had a similar time to reach the carina in difficult airway cases and the reported stress levels, at baseline and 12 months, showed no difference. In contrast, the intervention group's self-reported confidence in FOI skills improved more.

CONCLUSIONS

Although participants rated higher in confidence, practicing FOI skills on an airway simulator with an agility game did not increase their performance in simulated challenging airway instances.

Patients with infective endocarditis undergoing cardiac surgery have distinct ROTEM profiles and more bleeding complications compared to patients without infective endocarditis

BACKGROUND

The coagulation system is crucial in the pathogenesis of infective endocarditis and undergoes significant changes during course of the disease. However, little is known about the implications of those changes in the perioperative period. Aim of the present study was to delineate the specific coagulation patterns and their clinical consequence in patients undergoing cardiac surgery due to infective endocarditis.

METHODS

In this single-centre, exploratory, prospective observational study, we investigated the incidence and degree of coagulopathy in patients with (n = 31) and without infective endocarditis (n = 39) undergoing cardiac valve surgery. The primary outcome was the differences between these two groups in rotational thromboelastometry (ROTEM) results before, during and after surgery. The secondary outcomes were the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements.

RESULTS

Most ROTEM parameters in EXTEM, INTEM and FIBTEM assays were significantly altered in patients with infective endocarditis. Clotting time in the EXTEM assay was significantly prolonged in the endocarditis group at all time-points, while all clot firmness parameters (A5, A10 and MCF) were significantly increased. The heparin sensitivity index was significantly lower in the endocarditis group (median index 0.99 vs 1.17s. IU-1.kg-1, p = .008), indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications as assessed by the universal definition of perioperative bleeding score (OR 3.0, p = .018), and more patients with endocarditis underwent early re-exploration (p = .018).

CONCLUSIONS

The findings of this exploratory investigation show significantly altered coagulation profiles in patients with infective endocarditis, with concomitant hyper- and hypocoagulability. Furthermore, the incidence of bleeding complications and transfusion requirements were increased in patients with endocarditis. These results show the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis. Existing point-of-care coagulation testing guided algorithms for optimizing perioperative coagulation management possibly need to be adjusted for these high-risk patients undergoing cardiac surgery.

Atrial fibrillation: a retrospective chart review of complications, morbidity and mortality at 30 days

Introduction

Atrial fibrillation (AF) increasingly burdens medical health systems. Electrical cardioversion (ECV) forms an important rhythm control treatment for AF. Complications associated with this procedure include stroke and other arrhythmias.

Currently, institutional sedation protocols state that patients have to be admitted if 24-hour supervision by family or friends cannot be provided. This implies increased costs, both financially and by occupying a hospital bed. We anticipate that this strategy of admitting patients will become a problem in the future due to the rapid increase of AF patient due to aging of the population.

Purpose

Our aim is to analyse the incidence, type and timing of complications, to determine whether additional supervision is justified.

Methods

This was a retrospective single-centre study, in a large tertiary care hospital in the Netherlands. The study was approved by the Ethical Commission, registered with the Netherlands Trial Register (NL9433). Patients were contacted, those who did not object to the reuse of care data were included. Data was extracted from the electronic patient file, entered into a research database, and analysed. This study includes all eligible elective ECV's performed under general anaesthesia, in 2019. We analysed at the number of documented complications within 2 hours (T1), between 2 and 24 hours (T2) and within 30 days of the ECV (T3).

Results

In total, 370 patients were approached, 7 patients refused consent and 363 unique patients with 564 ECV procedures were included. The majority were male (66%), mean age 65±12 years, BMI 28±6 kg/m2, 49% smoker (current or past), 19% had previously undergone a form of AF ablation, 115 (32%) patients underwent ≥2 ECV's (range 2–11), and 6 patients were admitted due to a social indication.

In T1, 22 complications in 16 ECV's were documented, mostly unrelated to anaesthesia: asystole (3, >5 seconds asystole during/after procedure), hypotension (8), extreme bradycardia (8), chest-wall burn pain (1), and arrhythmias other than AF that developed after ECV (2). Nine complications in 7 ECVs (bradycardia, asystole and arrhythmias) were considered severe enough for admission, 5 patients were diagnosed with SSS/brady-tachy syndrome and were implanted with a pacemaker later.

In T2, 11 complications were documented: bradycardia (1), skin pain (3), muscle pain (2), fatigue (4), fainting and palpitations (1). The latter patient developed bradycardia and recurrent AF, and was readmitted.In T3, 15 complications were documented of which 5 were severe (CVA, angina, heart failure, arrhythmias).

Conclusion

Based on this retrospective analysis of all eligible ECV's in a large tertiary hospital, performed in 2019, complications in T2 (1,8%) needed no further treatment. We therefore conclude that it seems safe to discharge patients to their homes without extra supervision after sedation ECV

Funding Acknowledgement

Type of funding sources: None.