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BACKGROUND: Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF. METHODS: One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1–2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method. RESULTS: LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%. CONCLUSIONS: All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.
Background The overall risk of post‐operative nausea and vomiting (PONV) after general anaesthesia is reportedly 20%–40%. The first episode of PONV may occur early in the post‐anaesthesia care unit (PACU) or later at the ward or after discharge at home in an ambulatory setting. This study aimed to investigate and describe the risk of early PONV in a PACU, and we hypothesised that patients and perioperative factors were associated with early PONV. Methods This single‐centre retrospective observational study was conducted in a Swedish county hospital from January to June 2017 and included adult patients who underwent surgical procedures under general anaesthesia. Perioperative data were obtained by reviewing the local registry for surgical procedures, medical records and anaesthesia and post‐operative charts. Early PONV was defined as PONV occurring up to 4 hours post‐operatively at the PACU. Any notification in the medical records, perioperative charts or the registry regarding nausea, vomiting or PONV treatment was regarded as PONV. Univariate and multivariate analyses were performed for factors associated with early PONV. Results A total of 2030 patients were included in the study, of which 9.6% (n = 194) experienced early PONV. Factors associated with a high risk of early PONV were suboptimal PONV prophylaxis, need for opioids, female sex, body mass index >35 kg m−2 and major surgery and anaesthesia time ≥60 minutes. Conclusion We found that every 10th patient under general anaesthesia experienced early PONV. Suboptimal PONV prophylaxis and previously acknowledged risk factors for PONV were associated with early PONV.
BackgroundDeterioration after ICU discharge may lead to readmission or even death. Interventions (eg, critical care transition programs) have been developed to improve the clinical handover between the ICU and the ward. We conducted a systematic review with meta‐analysis and trial sequential analysis (TSA) according to Cochrane Handbook and Grading of recommendations, assessment, development and evaluations (GRADE) methodology to assess the impact of these interventions on readmission and death (PROSPERO, no CRD42019121746).MethodsWe searched PubMed/MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Register for Controlled Trials from inception until January 2019. We included historically controlled studies that evaluated critical care transition programs in adults discharged from the ICU. Readmission and in‐hospital mortality were the primary outcomes. Risk of bias, publications bias, and the quality of evidence were assessed with the ROBINS‐Itool, funnel plot and GRADE, respectively.ResultsFifteen observational studies were included (11 in meta‐analysis). All studies had at least serious risk of bias. ICU discharge within a critical care transition program modestly reduced the risk of readmission (RR 0.78; 95% CI: 0.64‐0.96; TSA‐adjusted 95% CI: 0.59‐1.03) but not in‐hospital mortality (RR 0.82; 95% CI: 0.64‐1.06; TSA‐adjusted 95% CI: 0.49‐1.37). There was substantial heterogeneity among studies. TSA indicated lack of firm evidence. The GRADE quality of evidence on outcomes was very low.ConclusionsWe found no clear benefit in terms of reducing risk of readmission or death after ICU discharge, however, with overall very low certainty of evidence.
BackgroundPreserving perfusion pressure during anesthesia induction is crucial. Standardized anesthesia methods, alert fluid therapy and vasoactive drugs may help maintain adequate hemodynamic conditions throughout the induction procedure. In this randomized study, we hypothesized that a pre‐operative volume bolus based on lean body weight would decrease the incidence of significant blood pressure drops (BPD) after induction with target‐controlled infusion (TCI) or rapid sequence induction (RSI).MethodsEighty individuals scheduled for non‐cardiac surgery were randomized to either a pre‐operative colloid fluid bolus of 6 ml kg−1 lean body weight or no bolus, and then anesthetized by means of TCI or RSI. The main outcome measure was blood pressure drops below the mean arterial pressure 65 mm Hg during the first 20 minutes after anesthesia induction. ClinicalTrials.com Identifier: NCT03394833.ResultsPre‐operative fluid therapy decreased the incidence of BPDs fivefold, from 23 of 40 (57.5%) individuals without fluids to 5 of 40 (12.5%) with fluid management, P < .001. The mean BPD was greater in the groups without pre‐operative fluids compared to the groups with fluid management; 53 ± 18 mm Hg vs 43 ± 14 mm Hg, P = .007. The overall mean volume of pre‐operative fluid bolus infused was 387 ± 52 ml. There was no difference in hemodynamic stability between TCI and RSI. No correlation was shown between incidence of BPDs and increasing age, medication, hypertension, diabetes, renal failure, or low physical capacity.ConclusionsPre‐operative fluid bolus decreased the incidence of significant blood pressure drops during TCI and RSI induction of general anesthesia.
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