Feasibility of computer-assisted vasopressor infusion using continuous non-invasive blood pressure monitoring in high-risk patients undergoing renal transplant surgery.
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ABSTRACT:
SUBMITTER: Joosten A
PROVIDER: S-EPMC8104119 | biostudies-literature | 2020 Oct
REPOSITORIES: biostudies-literature
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Feasibility of computer-assisted vasopressor infusion using continuous non-invasive blood pressure monitoring in high-risk patients undergoing renal transplant surgery.
Joosten Alexandre A Coeckelenbergh Sean S Alexander Brenton B Cannesson Maxime M Rinehart Joseph J
Anaesthesia, critical care & pain medicine 20200405 5
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Project description:Postoperative hypotension is common (occurring in one third of patients) and is associated with worse clinical outcomes. The LiDCO CNAP (continuous non-invasive arterial pressure) device measures haemodynamics but has not been widely adopted in ward environments. Improved early detection of hypotension by CNAP might guide interventions to improve clinical outcomes. We aimed to find the proportion of patients who tolerated LiDCO CNAP for 12 h postoperatively, to unmask episodes of hypotension detected by continuous monitoring and to characterise the haemodynamic profile at the time of hypotension. In this feasibility study, patients undergoing major elective surgery were continuously postoperatively monitored using CNAP. Haemodynamic data gathered from CNAP, including nSVRI (nominal systemic vascular resistance index), nSVI (nominal stroke volume index), SVV (stroke volume variation) and blood pressure, were analysed using Microsoft Excel and GraphPad Prism 8. 104 patients (age (mean ± sd): 68 ± 14, male (56%)) had CNAP sited postoperatively. 39% tolerated the CNAP device for at least 12 h. Within the 104 patients a mean of 81.2 min of hypotension detected by CNAP was not detected by usual care. The proportion of low/normal/high nSVI was 71%, 27% and 2%, nSVRI was 43%, 17% and 40%, respectively. CNAP monitoring was not tolerated for 12 h in the majority of patients. There were many episodes of hypotension unmasked through continuous monitoring. Based on the advanced haemodynamic data provided it is possible that the underlying cause of a third of postoperative hypotensive episodes is vasodilation rather than hypovolaemia.Trial registry number: NCT04010058 (ClinicalTrials.gov) Date of registration: 08/07/2019.
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Project description:BackgroundAnterior two-thirds corpus callosotomy is an effective palliative neurosurgical procedure for drug-refractory epilepsy that is most commonly used to treat drop-attacks. Laser interstitial thermal therapy is a novel stereotactic ablative technique that has been utilised as a minimally invasive alternative to resective and disconnective open neurosurgery. Case series have reported success in performing laser anterior two-thirds corpus callosotomy. Computer-assisted planning algorithms may help to automate and optimise multi-trajectory planning for this procedure.ObjectiveTo undertake a simulation-based feasibility study of computer-assisted corpus callostomy planning in comparison with expert manual plans in the same patients.MethodsTen patients were selected from a prospectively maintained database. Patients had previously undergone diffusion-weighted imaging and digital subtraction angiography as part of routine SEEG care. Computer-assisted planning was performed using the EpiNav™ platform and compared to manually planned trajectories from two independent blinded experts. Estimated ablation cavities were used in conjunction with probabilistic tractography to simulate the expected extent of interhemispheric disconnection.ResultsComputer-assisted planning resulted in significantly improved trajectory safety metrics (risk score and minimum distance to vasculature) compared to blinded external expert manual plans. Probabilistic tractography revealed residual interhemispheric connectivity in 1/10 cases following computer-assisted planning compared to 4/10 and 2/10 cases with manual planning.ConclusionComputer-assisted planning successfully generates multi-trajectory plans capable of LITT anterior two-thirds corpus callosotomy. Computer-assisted planning may provide a means of standardising trajectory planning and serves as a potential new tool for optimising trajectories. A prospective validation study is now required to determine if this translates into improved patient outcomes.
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Project description:BackgroundRapid neuromuscular block reversal at the end of major abdominal surgery is recommended to avoid any postoperative residual block. To date, no study has evaluated sugammadex performance after rocuronium administration in patients undergoing liver transplantation. This is a randomized controlled trial with the primary objective of assessing the neuromuscular transmission recovery time obtained with sugammadex versus neostigmine after rocuronium induced neuromuscular blockade in patients undergoing orthotopic liver transplantation.MethodsThe TOF-Watch SX®, calibrated and linked to a portable computer equipped with TOF-Watch SX Monitor Software®, was used to monitor and record intraoperative neuromuscular block maintained with a continuous infusion of rocuronium. Anaesthetic management was standardized as per our institution's internal protocol. At the end of surgery, neuromuscular moderate block reversal was obtained by administration of 2 mg/kg of sugammadex or 50 mcg/kg of neostigmine (plus 10 mcg/kg of atropine).ResultsData from 41 patients undergoing liver transplantation were analysed. In this population, recovery from neuromuscular block was faster following sugammadex administration than neostigmine administration, with mean times±SD of 9.4 ± 4.6 min and 34.6 ± 24.9 min, respectively (p < 0.0001).ConclusionSugammadex is able to reverse neuromuscular block maintained by rocuronium continuous infusion in patients undergoing liver transplantation. The mean reversal time obtained with sugammadex was significantly faster than that for neostigmine. It is important to note that the sugammadex recovery time in this population was found to be considerably longer than in other surgical settings, and should be considered in clinical practice.Trial registrationClinicalTrials.govNCT02697929 (registered 3rd March 2016).
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Project description:ObjectiveTo determine the feasibility of using audio computer-assisted self-interviewing (ACASI) for data collection in developing countries, and to compare responses to questions eliciting sensitive information about sexual behavior using ACASI versus computer-assisted personal interviewing (CAPI) in five developing countries.DesignA feasibility study determined whether ACASI could be used in populations in developing countries. A follow-up, randomized crossover study compared responses to questions eliciting sensitive information about sexual behavior using ACASI versus CAPI.MethodsThe NIMH Collaborative HIV/STD Prevention Trial conducted a feasibility study of ACASI in convenience samples in China, India, Peru, and Russia, then a randomized crossover ACASI versus CAPI study among volunteers in these countries plus Zimbabwe.ResultsApproximately equal numbers of men and women completed the feasibility study; the results suggested a high comfort level among participants. Married respondents in China and India appeared to give unreliable responses on sexual activity. In the crossover study, the pattern of responses to sensitive questions showed few differences. In China, higher rates of sexual risk were reported on CAPI. In Peru and Russia, differences by mode were found in the number of partners in the past year.ConclusionDespite variable computer experience and literacy, feasibility study participants reported ease in completing ACASI, and preferred a computer to an interviewer for answering sensitive questions, or had no preference. In the crossover study, most participants gave similar responses on both modes of survey administration. ACASI appears to be feasible in these settings, although low literacy may pose problems if participants cannot clarify questions.
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Project description:BackgroundDysregulations of blood glucose (BG) are associated with adverse outcome in critical illness; controlling BG to target appears to improve outcome. Since BG-control is challenging in daily intensive care practice BG-control remains poor especially in patients with rapidly fluctuating BG. To improve BG-control and to avoid deleterious hypoglycemia, automated online-measurement tools are advocated. We thus evaluated the point-accuracy of the subcutaneous Sentrino® Continuous Glucose Monitoring System (CGM, Medtronic Diabetes, Northridge, California) in patients undergoing extracorporeal cardiac life support (ECLS) for cardiogenic shock.MethodsManagement of BG was performed according to institute's standard aiming at BG-levels between 100-145 mg/dl. CGM-values were recorded without taking measures into therapeutic account. Point-accuracy in comparison to intermittent BG-measurement by the ABL-blood-gas analyzer was determined.ResultsCGM (n = 25 patients) correlated significantly with ABL-values (r = 0.733, p<0.001). Mean error from standard was 15.0 mg/dl (11.9%). 44.2% of the readings were outside a 15% range around ABL-values. In one of 635 paired data-points, ABL revealed hypoglycemia (BG 32 mg/dl) whereas CGM did not show hypoglycemic values (132mg/dl).ConclusionsCGM reveals minimally invasive BG-values in critically ill adults with dynamically impaired tissue perfusion. Because of potential deviations from standard, CGM-readings must be interpreted with caution in specific ICU-populations.
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Project description:Introduction: Vasopressor infusions are essential in treating and preventing intraoperative hypotension. Closed-loop vasopressor therapy outperforms clinicians when the target is set at a mean arterial pressure (MAP) baseline, but little is known on the performance metrics of closed-loop vasopressor infusions when systolic arterial pressure (SAP) is the controlled variable. Methods: Patients undergoing intermediate- to high-risk abdominal surgery were included in this prospective cohort feasibility study. All patients received norepinephrine infusion through a computer controlled closed-loop system that targeted SAP at 130 mmHg. The primary objective was to determine the percent of case time in hypotension or under target defined as SAP below 10% of the target (SAP < 117 mmHg). Secondary objectives were the percent of case time “above target” (SAP > 10% of the target or >143 mmHg) and “in target” (within 10% of the SAP target or SAP between 117 and 143 mmHg). Results: A total of 12 patients were included. The closed-loop system infused norepinephrine for a median of 94.6% (25−75th percentile: 90.0−98.0%) of case time. The percentage of case time in hypotension or under target was only 1.8% (0.9−3.6%). The percentages of case time “above target” and “in target” were 4.7% (3.2−7.5%) and 92.4% (90.1−96.3%), respectively. Conclusions: This closed-loop vasopressor system minimizes intraoperative hypotension and maintains SAP within 10% of the target range for >90% of the case time in patients undergoing intermediate- to high-risk abdominal surgery.
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Project description:BackgroundWe have previously shown bone marrow-derived mesenchymal stem cells (MSCs) may shift immune responses toward anti-inflammatory pathways and stabilize the course of obstructive chronic lung allograft syndrome (o-CLAD) after lung transplantation. In this study, we measured the response of lower dose infusions.MethodsWe infused low-dose MSCs intravenously in 13 patients who had developed moderate-to-severe o-CLAD. Three had previously received an infusion of MSCs from a different donor and were re-dosed at 1 × 106 MSC/kg, while 5 received a first dose at 1 × 106 MSC/kg and five received an even lower dose at 0.5 × 106 MSC/kg. We recorded pulmonary function tests before and after infusion, and patients were followed clinically for 12 months.ResultsInfusions were well tolerated, and no significant adverse events were recorded in the first 30 days. There was significant decline (mean ± SD) in forced vital capacity (FVC) (3.49 ± 1.03 vs 3.18 ± 0.94 L, P = .03) and forced expiratory volume in 1 second (FEV1) (2.28 ± 0.86 vs 1.77 ± 0.49 L, P = .04) over the year preceding infusion. FVC (3.18 ± 0.94 vs 3.46 ± 0.99 L, P = .53) and FEV1 was not significantly changed (1.77 ± 0.49 vs 1.88 ± 0.75, P = .72) when comparing values immediately prior to infusion to those obtained 1 year after infusion, indicating a possible stabilizing effect on lung function decline due to o-CLAD.ConclusionIntravenous infusions of bone marrow-derived MSCs are well tolerated in lung transplant recipients with moderate-to-severe CLAD. Low-dose MSCs appear to slow progression of CLAD in some patients.
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