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Posthuma LM, Breteler MJM, Lirk PB, Nieveen van Dijkum EJ, Visscher MJ, Breel JS, Wensing CAGL, Schenk J, Vlaskamp LB, van Rossum MC, Ruurda JP, Dijkgraaf MGW, Hollmann MW, Kalkman CJ, Preckel B. 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. Front Med (Lausanne) 2024; 10:1295499. [PMID: 38249988 PMCID: PMC10796990 DOI: 10.3389/fmed.2023.1295499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
- Linda M. Posthuma
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
| | | | - Philipp B. Lirk
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiologie, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Els J. Nieveen van Dijkum
- Department of Surgery, Amsterdam University Medical Center, Location University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Maarten J. Visscher
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
| | - Jennifer S. Breel
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
| | - Carin A. G. L. Wensing
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
| | - Jimmy Schenk
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, Netherlands
| | - Lyan B. Vlaskamp
- Department of Anesthesiologie, University Medical Center, Utrecht, Netherlands
| | | | - Jelle P. Ruurda
- Department of Gastro-Intestinal and Oncologic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marcel G. W. Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Location AMC, Amsterdam, Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, Netherlands
| | - Cor J. Kalkman
- Department of Anesthesiologie, University Medical Center, Utrecht, Netherlands
| | - Benedikt Preckel
- Department of Anesthesiologie, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, Netherlands
- Amsterdam Cardiovascular Science, Diabetes and Metabolism, Amsterdam, Netherlands
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Abstract
During the course of surgical interventions, complications mostly occur in the postoperative period. Slight clinical indications can be observed, which precede a significant deterioration of the patient's condition. On the general ward vital parameters, such as heart and breathing frequencies are measured every 4-8 h. Even if the monitoring of critically ill patients is increased to every 2 h and the measurement of vital functions takes 10 min, the patient is only monitored for 120 min in a 24 h period and remains postoperatively on the general ward without monitoring for 22 out of 24 h. New wireless monitoring systems are available to continuously register some vital functions with the aid of wearable sensors. These systems can alert and alarm ward personnel if the patient's condition deteriorates. Although the optimal monitoring system does not yet exist and implementation of these new wireless monitoring systems might involve some risks, these new methods offer a great opportunity to optimize surveillance of postoperative patients on the general ward.
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Affiliation(s)
- B Preckel
- Academisch Medisch Centrum AMC, Afdeling Anesthesiologie, Amsterdam Universitair Medische Centra, Meibergdreef 9, 1105 AZ, Amsterdam, Niederlande.
| | - L M Posthuma
- Academisch Medisch Centrum AMC, Afdeling Anesthesiologie, Amsterdam Universitair Medische Centra, Meibergdreef 9, 1105 AZ, Amsterdam, Niederlande
| | - M J Visscher
- Academisch Medisch Centrum AMC, Afdeling Anesthesiologie, Amsterdam Universitair Medische Centra, Meibergdreef 9, 1105 AZ, Amsterdam, Niederlande
| | - M W Hollmann
- Academisch Medisch Centrum AMC, Afdeling Anesthesiologie, Amsterdam Universitair Medische Centra, Meibergdreef 9, 1105 AZ, Amsterdam, Niederlande
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Hulst AH, Visscher MJ, Godfried MB, Thiel B, Gerritse BM, Scohy TV, Bouwman RA, Willemsen MGA, Hollmann MW, Preckel B, DeVries JH, Hermanides J. Liraglutide for perioperative management of hyperglycaemia in cardiac surgery patients: a multicentre randomized superiority trial. Diabetes Obes Metab 2020; 22:557-565. [PMID: 31749275 PMCID: PMC7079116 DOI: 10.1111/dom.13927] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 12/13/2022]
Abstract
AIMS Most cardiac surgery patients, with or without diabetes, develop perioperative hyperglycaemia, for which intravenous insulin is the only therapeutic option. This is labour-intensive and carries a risk of hypoglycaemia. We hypothesized that preoperative administration of the glucagon-like peptide-1 receptor agonist liraglutide reduces the number of patients requiring insulin for glycaemic control during cardiac surgery. MATERIALS AND METHODS In this randomized, blinded, placebo-controlled, parallel-group, balanced (1:1), multicentre randomized, superiority trial, adult patients undergoing cardiac surgery in four Dutch tertiary hospitals were randomized to receive 0.6 mg subcutaneous liraglutide on the evening before surgery and 1.2 mg after induction of anaesthesia or matching placebo. Blood glucose was measured hourly and controlled using an insulin-bolus algorithm. The primary outcome was insulin administration for blood glucose >8.0 mmol/L in the operating theatre. Research pharmacists used centralized, stratified, variable-block, randomization software. Patients, care providers and study personnel were blinded to treatment allocation. RESULTS Between June 2017 and August 2018, 278 patients were randomized to liraglutide (139) or placebo (139). All patients receiving at least one study drug injection were included in the intention-to-treat analyses (129 in the liraglutide group, 132 in the placebo group). In the liraglutide group, 55 (43%) patients required additional insulin compared with 80 (61%) in the placebo group and absolute difference 18% (95% confidence interval 5.9-30.0, P = 0.003). Dose and number of insulin injections and mean blood glucose were all significantly lower in the liraglutide group. We observed no difference in the incidence of hypoglycaemia, nausea and vomiting, mortality or postoperative complications. CONCLUSIONS Preoperative liraglutide, compared with placebo, reduces insulin requirements while improving perioperative glycaemic control during cardiac surgery.
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Affiliation(s)
- Abraham H. Hulst
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
- Department of AnesthesiologyOLVGAmsterdamThe Netherlands
- Department of AnesthesiologyAmphia HospitalBredaThe Netherlands
| | - Maarten J. Visscher
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Bram Thiel
- Department of AnesthesiologyOLVGAmsterdamThe Netherlands
| | | | | | - R. Arthur Bouwman
- Department of AnesthesiologyCatharina HospitalsEindhovenThe Netherlands
| | | | - Markus W. Hollmann
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Benedikt Preckel
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - J. Hans DeVries
- Department of EndocrinologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Jeroen Hermanides
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
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Posthuma LM, Downey C, Visscher MJ, Ghazali DA, Joshi M, Ashrafian H, Khan S, Darzi A, Goldstone J, Preckel B. Remote wireless vital signs monitoring on the ward for early detection of deteriorating patients: A case series. Int J Nurs Stud 2020; 104:103515. [PMID: 32105974 DOI: 10.1016/j.ijnurstu.2019.103515] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Remote wireless monitoring is a new technology that allows the continuous recording of ward patients' vital signs, supporting nurses by measuring vital signs frequently and accurately. A case series is presented to illustrate how these systems might contribute to improved patient surveillance. METHODS AND RESULTS Five hospitals in three European countries installed a remote wireless vital signs monitoring system on medical or surgical wards. Heart rate, respiratory rate and temperature were measured by the system every 2 min. Four cases of (paroxysmal) atrial fibrillation are presented, two cases of sepsis and one case each of pyrexia, cardiogenic pulmonary edema and pulmonary embolisms. All cases show that the remote monitoring system revealed the first signs of ventilatory and circulatory deterioration before a change in the trends of the respective values became obvious by manual vital signs measurement. DISCUSSION This case series illustrates that a wireless remote vital signs monitoring system on medical and surgical wards has the potential to reduce time to detect deteriorating patients.
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Affiliation(s)
- L M Posthuma
- Department of Anaesthesiology, Amsterdam UMC, location AMC, H1-148, Amsterdam UMC, location AMC, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - C Downey
- Leeds Institute of Medical Research at St. James's, University of Leeds, United Kingdom
| | - M J Visscher
- Department of Anaesthesiology, Amsterdam UMC, location AMC, H1-148, Amsterdam UMC, location AMC, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - D A Ghazali
- Emergency Department, University Hospital of Bichat, Paris, France
| | - M Joshi
- Department of Surgery & Cancer, Academic Surgical Unit, St Mary's Hospital, Imperial College London, London, United Kingdom; Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex University Hospital, London, United Kingdom
| | - H Ashrafian
- Department of Surgery & Cancer, Academic Surgical Unit, St Mary's Hospital, Imperial College London, London, United Kingdom
| | - S Khan
- Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex University Hospital, London, United Kingdom
| | - A Darzi
- Department of Surgery & Cancer, Academic Surgical Unit, St Mary's Hospital, Imperial College London, London, United Kingdom
| | - J Goldstone
- Chief Intensivist, King Edward VII Hospital, The London Clinic and University College London Hospitals NHS Trust, London, United Kingdom
| | - B Preckel
- Department of Anaesthesiology, Amsterdam UMC, location AMC, H1-148, Amsterdam UMC, location AMC, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.
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Hulst AH, Visscher MJ, Godfried MB, Thiel B, Gerritse BM, Scohy TV, Bouwman RA, Willemsen MGA, Hollmann MW, DeVries JH, Preckel B, Hermanides J. Study protocol of the randomised placebo-controlled GLOBE trial: GLP-1 f or bridging of hyperglyca emia during cardiac surgery. BMJ Open 2018; 8:e022189. [PMID: 29866735 PMCID: PMC5988155 DOI: 10.1136/bmjopen-2018-022189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Perioperative hyperglycaemia is common during cardiac surgery and associated with postoperative complications. Although intensive insulin therapy for glycaemic control can reduce complications, it carries the risk of hypoglycaemia. GLP-1 therapy has the potential to lower glucose without causing hypoglycaemia. We hypothesise that preoperative liraglutide (a synthetic GLP-1 analogue) will reduce the number of patients requiring insulin to achieve glucose values<8 mmol l-1 in the intraoperative period. METHODS AND ANALYSIS We designed a multi-centre randomised parallel placebo-controlled trial and aim to include 274 patients undergoing cardiac surgery, aged 18-80 years, with or without diabetes mellitus. Patients will receive 0.6 mg liraglutide or placebo on the evening before, and 1.2 mg liraglutide or placebo just prior to surgery. Blood glucose is measured hourly and controlled with an insulin bolus algorithm, with a glycaemic target between 4-8 mmol l-1. The primary outcome is the percentage of patients requiring insulin intraoperatively. ETHICS AND DISSEMINATION This study protocol has been approved by the medical ethics committee of the Academic Medical Centre (AMC) in Amsterdam and by the Dutch competent authority. The study is investigator-initiated and the AMC, as sponsor, will remain owner of all data and have all publication rights. Results will be submitted for publication in a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER NTR6323; Pre-results.
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Affiliation(s)
- Abraham H Hulst
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten J Visscher
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc B Godfried
- Department of Anaesthesiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bram Thiel
- Department of Anaesthesiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bas M Gerritse
- Department of Anaesthesiology, Amphia Ziekenhuis, Breda, The Netherlands
| | - Thierry V Scohy
- Department of Anaesthesiology, Amphia Ziekenhuis, Breda, The Netherlands
| | - R Arthur Bouwman
- Department of Anaesthesiology, Catharina Ziekenhuisen, Eindhoven, The Netherlands
| | - Mark G A Willemsen
- Department of Anaesthesiology, Catharina Ziekenhuisen, Eindhoven, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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