Standard Clinical Monitoring Research Articles

Early Dysglycemia Is Detectable Using Continuous Glucose Monitoring in Very Young Children at Risk of Type 1 Diabetes.

Continuous glucose monitoring (CGM) can detect early dysglycemia in older children and adults with presymptomatic type 1 diabetes (T1D) and predict risk of progression to clinical onset. However, CGM data for very young children at greatest risk of disease progression are lacking. This study aimed to investigate the use of CGM data measured in children being longitudinally observed in the Australian Environmental Determinants of Islet Autoimmunity (ENDIA) study from birth to age 10 years. Between January 2021 and June 2023, 31 ENDIA children with persistent multiple islet autoimmunity (PM Ab+) and 24 age-matched control children underwent CGM assessment alongside standard clinical monitoring. The CGM metrics of glucose SD (SDSGL), coefficient of variation (CEV), mean sensor glucose (SGL), and percentage of time >7.8 mmol/L (>140 mg/dL) were determined and examined for between-group differences. The mean (SD) ages of PM Ab+ and Ab- children were 4.4 (1.8) and 4.7 (1.9) years, respectively. Eighty-six percent of eligible PM Ab+ children consented to CGM wear, achieving a median (quartile 1 [Q1], Q3) sensor wear period of 12.5 (9.0, 15.0) days. PM Ab+ children had higher median (Q1, Q3) SDSGL (1.1 [0.9, 1.3] vs. 0.9 [0.8, 1.0] mmol/L; P < 0.001) and CEV (17.3% [16.0, 20.9] vs. 14.7% [12.9, 16.6]; P < 0.001). Percentage of time >7.8 mmol/L was greater in PM Ab+ children (median [Q1, Q3] 8.0% [4.4, 13.0] compared with 3.3% [1.4, 5.3] in Ab- children; P = 0.005). Mean SGL did not differ significantly between groups (P = 0.10). CGM is feasible and well tolerated in very young children at risk of T1D. Very young PM Ab+ children have increased SDSGL, CEV, and percentage of time >7.8 mmol/L, consistent with prior studies involving older participants.

Detecting flap compromise: an updated review of techniques to monitor microsurgical flaps post-operatively in breast reconstruction

Breast reconstructive surgery utilizing free tissue transfer has revolutionized the restoration of aesthetic and functional outcomes for patients. Even for the most routine free flap procedures, substantial hospital resources and costs are necessary. The effectiveness of free flap surgery, along with any reconstructive procedure, hinges upon meticulous patient selection, thorough pre-operative planning, well-informed peri-operative decision-making, and diligent post-operative monitoring and care for the patient. This article presents a review of standard clinical care monitoring techniques during the post-operative period, as well as the diverse strategies currently employed for post-operative flap monitoring.

Wearable sensors for prediction of intraamniotic infection in women with preterm premature rupture of membranes: a prospective proof of principle study

PurposeTo evaluate the use of wearable sensors for prediction of intraamniotic infection in pregnant women with PPROM.Materials and methodsIn a prospective proof of principle study, we included 50 patients diagnosed with PPROM at the University Hospital Zurich between November 2017 and May 2020. Patients were instructed to wear a bracelet during the night, which measures physiological parameters including wrist skin temperature, heart rate, heart rate variability, and breathing rate. A two-way repeated measures ANOVA was performed to evaluate the difference over time of both the wearable device measured parameters and standard clinical monitoring values, such as body temperature, pulse, leucocytes, and C-reactive protein, between women with and without intraamniotic infection.ResultsAltogether, 23 patients (46%) were diagnosed with intraamniotic infection. Regarding the physiological parameters measured with the bracelet, we observed a significant difference in breathing rate (19 vs 16 per min, P < .01) and heart rate (72 vs 67 beats per min, P = .03) in women with intraamniotic infection compared to those without during the 3 days prior to birth.In parallel to these changes standard clinical monitoring values were significantly different in the intraamniotic infection group compared to women without infection in the 3 days preceding birth.ConclusionOur results suggest that wearable sensors are a promising, noninvasive, patient friendly approach to support the early detection of intraamniotic infection in women with PPROM. However, confirmation of our findings in larger studies is required before implementing this technique in standard clinical management.

Effect of combined intraoperative use of the Nociception Level (NOL) and bispectral (BIS) indexes on desflurane administration

BackgroundCurrently, nociception monitors are not part of standard anaesthesia care. We investigated whether combined intraoperative nociception (NOL index) and anaesthesia (BIS index) monitoring during general anaesthesia would reduce anaesthetics consumption and enhance intraoperative safety and postoperative recovery when compared to standard of care monitoring (SOC). MethodsIn this randomised study, we included 60 patients undergoing colonic surgery under desflurane/remifentanil anaesthesia and epidural analgesia. Patients received either standard monitoring or combined BIS + NOL index monitoring. In the monitored group, remifentanil infusion was titrated to achieve a NOL index below 20. Desflurane was adjusted to BIS values (45–55). In the SOC group, remifentanil and desflurane were titrated on vital signs and MAC. The primary outcome was intraoperative desflurane consumption. ResultsFifty-five patients were analysed. Desflurane administration was reduced in the monitored group from 0.25 ± 0.05 to 0.20 ± 0.06 mL kg−1 h−1 (p < 0.001). The cumulative time with a BIS under 40 was significantly higher in the SOC group with a median time of 12.6 min (95% CI: 0.6–80.0) versus 2.0 min (95% CI: 0.3–5.83) (p = 0.023). Time for extubation was significantly shorter in the monitored group: 4.4 min (95% CI: 2.4–4.9) versus 6.28 min (95% IC: 5.0–8.2) (p = 0.003). We observed no differences in remifentanil or phenylephrine requirements during anaesthesia or in postoperative outcome measures, such as postoperative pain, opioid consumption, neurocognitive recovery. ConclusionCombined intraoperative monitoring of anaesthesia and nociception during colonic surgery resulted in less desflurane consumption and quicker extubation time compared to standard clinical care monitoring.

Comparative therapeutic efficacy of interferon alfa-2b and combination lopinavir/ritonavir plus interferon alfa-2b against SARS-CoV-2

BackgroundThe outbreak of coronavirus disease 2019 (COVID-19) posed an enormous threat to public health. The use of antiviral drugs in patients with this disease have triggered people’s attentions. Whether interferon alfa-2b or lopinavir/ritonavir (LPV/r) plus interferon alfa-2b treatment can against SARS-CoV-2 was unknown. The objectives of this study was to evaluate the efficacy and safety of interferon alfa-2b and LPV/r plus interferon alfa-2b for SARS-CoV-2 infection in adult patients hospitalized with COVID-19.MethodsThis is a retrospective cohort study of 123 patients confirmed SARS-CoV-2 infection by PCR on nasopharyngeal swab and symptoms between Jan. 13 and Apr. 23, 2020. All patients received standard supportive care and regular clinical monitoring. Patients were assigned to standard care group (n = 12), interferon alfa-2b group (n = 44), and combination LPV/r plus interferon alfa-2b group (n = 67). The primary endpoints were duration of required oxygen support and virus clearance time. Associations between therapies and these outcomes were assessed by Cox proportional hazards regression.ResultsBaseline clinical characteristics were not significantly different among the three groups (P > 0.05). No significant associations were observed between LPV/r/interferon alfa-2b and faster SARS-CoV-2 RNA clearance (HR, 0.85 [95% confidence interval (CI) 0.45–1.61]; P = 0.61 in interferon alfa-2b group vs HR, 0.59 [95% CI 0.32–1.11]; P = 0.10 in LPV/r plus interferon alfa-2b group). Individual therapy groups also showed no significant association with duration of required oxygen support. There were no significant differences among the three groups in the incidence of adverse events (P > 0.05).ConclusionsIn patients with confirmed SARS-CoV-2 infection, no benefit was observed from interferon alfa-2b or LPV/r plus interferon alfa-2b treatment. The findings may provide references for treatment guidelines of patients with SARS-CoV-2 infection.

Remote Monitoring of Critically-Ill Post-Surgical Patients: Lessons from a Biosensor Implementation Trial.

Biosensors represent one of the numerous promising technologies envisioned to extend healthcare delivery. In perioperative care, the healthcare delivery system can use biosensors to remotely supervise patients who would otherwise be admitted to a hospital. This novel technology has gained a foothold in healthcare with significant acceleration due to the COVID-19 pandemic. However, few studies have attempted to narrate, or systematically analyze, the process of their implementation. We performed an observational study of biosensor implementation. The data accuracy provided by the commercially available biosensors was compared to those offered by standard clinical monitoring on patients admitted to the intensive care unit/perioperative unit. Surveys were also conducted to examine the acceptance of technology by patients and medical staff. We demonstrated a significant difference in vital signs between sensors and standard monitoring which was very dependent on the measured variables. Sensors seemed to integrate into the workflow relatively quickly, with almost no reported problems. The acceptance of the biosensors was high by patients and slightly less by nurses directly involved in the patients’ care. The staff forecast a broad implementation of biosensors in approximately three to five years, yet are eager to learn more about them. Reliability considerations proved particularly troublesome in our implementation trial. Careful evaluation of sensor readiness is most likely necessary prior to system-wide implementation by each hospital to assess for data accuracy and acceptance by the staff.

Use of wireless respiratory rate sensor monitoring during opioid patient-controlled analgesia after gynaecological surgery

Background and Aims:Respiratory depression is a rare but serious complication during opioid administration. Therefore, early detection of signs of deterioration is paramount. The current standard of care of using manual intermittent respiratory rate (RR) measurement is labour intensive and inefficient. We evaluated a wireless sensor monitor, Aingeal (Renew Health Ltd, Ireland), to continuously monitor RR, heart rate (HR) and temperature compared to standard clinical measurements.Methods:Patients who underwent major gynaecological operations and received postoperative opioid patient-controlled analgesia were recruited. Patients were connected to the sensor monitor via a central station software platform. The primary outcome was comparison of RR between sensor and nursing monitoring, with secondary outcomes being HR and temperature between two methods. Feedback from patients and healthcare providers was also collected. Bland-Altman analyses were used to compare the vital signs recorded in sensor against those in patient's electronic record.Results:A total of 1121 hours of vital signs data were analysed. Bias for RR was -0.90 (95% confidence interval (CI): -9.39, 7.60) breaths/min between nursing and averaged sensor readings. Bias for heart rate was -1.12 (95% CI: -26.27, 24.03) and bias for temperature was 1.45 (95% CI: -5.67, 2.76) between the two methods.Conclusion:There is satisfactory agreement of RR measurements, as well as HR and temperature measurements, by the wireless sensor monitor with standard clinical intermittent monitoring with overall good user experience.

Associations of Body Weight and Waist Circumference with Psychopathology, Substance Use, and Well-Being in an Adult Transdiagnostic Sample

Prior studies have established inconsistent associations between body weight and mental health. However, most work has relied on body mass index (BMI) and examination of a single mental health variable. The present study examined associations of BMI and waist circumference with multiple mental health variables in a transdiagnostic psychiatric sample. Nursing staff measured waist circumference and calculated the BMI of 742 adults (54.6% female, 45.4% male) presenting for psychiatric treatment. Participants completed the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), Behavior and Symptom Identification Scale (BASIS-24), and Mental Health Continuum-Short Form (MHC-SF) as part of standard clinical monitoring. Suicide risk was assessed using the clinician-administered Mini International Neuropsychiatric Interview (M.I.N.I.). For curve fit estimation regression models, we entered BMI and waist circumference as independent variables separately; we entered seven dependent variables separately: 1) depression, 2) anxiety, 3) substance use, 4) self-harm, 5) interpersonal functioning, 6) well-being, and 7) suicide risk. Increased BMI was associated with decreased well-being and increased depression. Increased waist circumference was associated with worse interpersonal functioning. Non-linear (quadratic) associations were observed between weight and depression, substance use, self-harm, and suicide. Most of the sample was White and only 2.6% was in the underweight category, limiting broad applicability of findings. Cross-sectional design precludes causal attributions. Given associations between well-being, depression, interpersonal functioning, substance use, self-harm, and suicide with weight, findings may be used to inform mental health treatment, particularly by tailoring interventions to high-risk weight categories (underweight, obese) in psychiatric populations.

Comparison of adequacy of anaesthesia monitoring with standard clinical practice monitoring during routine general anaesthesia: An international, multicentre, single-blinded randomised controlled trial.

Previous studies have suggested that monitoring the levels of both hypnosis and antinociception could reduce periods of inadequate anaesthesia. However, the evidence regarding associated benefits of this monitoring is still limited. The primary objective of this study was to confirm that guidance of anaesthesia by depth of hypnosis and antinociception monitoring decreases the number of inadequate anaesthesia events in comparison with standard clinical practice. A multicentre, single-blinded, randomised controlled trial. The study was conducted in four European University hospitals in four different countries between December 2013 and November 2016. The study population consisted of a total of 494 adult patients undergoing elective surgery requiring tracheal intubation. The patients were allocated to one of two groups. The first group was treated using Entropy for depth of hypnosis and surgical pleth index to determine depth of antinociception (adequacy of anaesthesia group; AoA group). The second group was monitored using standard monitoring alone (control group). Anaesthesia was conducted with target-controlled infusions of propofol and remifentanil. The primary outcome of the study was the number of total unwanted events for example signs of inadequately light or unintentionally deep anaesthesia. Evidence of inadequate anaesthesia had an incidence of around 0.7 events per patient in both groups with no difference between groups (P = 0.519). In the AoA group, the overall consumption of propofol was significantly reduced (6.9 vs. 7.5 mg kg h, P = 0.008) in comparison with the control group. The consumption of remifentanil was equal in both groups. The times to emergence [8.0 vs. 9.6 min (P = 0.005)] and full recovery in the postanaesthesia care unit (P = 0.043) were significantly shorter in the AoA group. No differences were seen in postoperative pain scores or in the use of analgesics. In the current study, the guidance of total intravenous anaesthesia by Entropy and surgical pleth index in comparison with standard monitoring alone was not able to validate reduction of unwanted anaesthesia events. However, there was a reduction in the use of propofol, and shorter times for emergence and time spent in the postanaesthesia care unit. at ClinicalTrials.gov NCT01928875.

Benefits and boundaries of processed electroencephalography (pEEG) monitors when they do not concur with standard anesthetic clinical monitoring: lights and shadows.

Numerous clinical conditions that have a direct effect on electroencephalography (EEG) cerebral function could also directly influence brain function monitors (BFM) indices. There is no conventional comparator technology for BFM assessment. The conventional comparator technology used as a benchmark for assessing BFMs technologies chosen by the UK National Institute for Health and Care Excellence (NICE) to reflect the currently used standards in the National Health Service (NHS), was demarcated as "standard anesthetic clinical monitoring" and precisely defined as "the combination of routine clinical observation and electronic monitoring used in clinical practice to assess the adequacy of anesthesia." Because BFMs are EEG-derived parameters, all conditions that can "alter" the raw EEG signal would subsequently change BFM indices to reflect other unrelated EEG events of patient-dependent pathophysiologic perturbations. In many instances we are often confronted with disparate BFM values that do not concur with "standard anesthetic clinical monitoring". Changes in BFM indices during acute cerebral pathology would be highly beneficial to trained informed clinicians as it alerts to something they would not otherwise be aware was happening. This fact-based, citation-supported, narrative review article provides better understanding of BFMs' limitations through examining various published reports of all values that did not coincide with a "standard anesthetic clinical monitoring" whether arising from an underlying alteration of patients' own EEG or those due to shortcomings in the BFM design or performance. The notion of just "riding the numbers" seems to be not a good anesthesia practice; rather we should interpret these BFM indices within context and limitations.

A Rare Case of Parietal Skull Fibrosarcoma: Reconstruction with Free Myocutaneous Flap and Infrared Thermography Monitoring

Fibrosarcoma of the skull is an extremely rare condition. We report a case of a male patient surgically treated by radical tumor excision and plastic reconstruction with a free myocutaneous latissimus dorsi flap. Revascularization on the side of the intervention was verified intraoperatively by using an infrared thermography camera in the follow-up period to evaluate flap vitality in addition to standard clinical monitoring. We observed no complications and achieved a good aesthetic result.

Assessing ventilatory instability using the response to spontaneous sighs during sleep in preterm infants.

Periodic breathing (PB) is common in newborns and is an obvious manifestation of ventilatory control instability. However, many infants without PB may still have important underlying ventilatory control instabilities that go unnoticed using standard clinical monitoring. Methods to detect infants with "subclinical" ventilatory control instability are therefore required. The current study aimed to assess the degree of ventilatory control instability using simple bedside recordings in preterm infants. Respiratory inductance plethysmography (RIP) recordings were analyzed from ~20 minutes of quiet sleep in 20 preterm infants at 36 weeks post-menstrual age (median [range]: 36 [34-40]). The percentage time spent in PB was also calculated for each infant (%PB). Spontaneous sighs were identified and breath-by-breath measurements of (uncalibrated) ventilation were derived from RIP traces. Loop gain (LG, a measure of ventilatory control instability) was calculated by fitting a simple ventilatory control model (gain, time-constant, delay) to the post-sigh ventilatory pattern. For comparison, periodic inter-breath variability was also quantified using power spectral analysis (ventilatory oscillation magnitude index [VOMI]). %PB was strongly associated with LG (r2 = 0.77, p < 0.001) and moderately with the VOMI (r2 = 0.21, p = 0.047). LG (0.52 ± 0.05 vs. 0.30 ± 0.03; p = 0.0025) and the VOMI (-8.2 ± 1.1 dB vs. -11.8 ± 0.9 dB; p = 0.026) were both significantly higher in infants that displayed PB vs. those without. LG and VOMI determined from the ventilatory responses to spontaneous sighs can provide a practical approach to assessing ventilatory control instability in preterm infants. Such simple techniques may help identify infants at particular risk for ventilatory instabilities with concomitant hypoxemia and its associated consequences.

Long-term clinical effects of enzyme replacement therapy in MPS II

BackgroundWe report clinical results of long-term enzyme replacement therapy in Polish population of patients with mucopolysaccharidosis type II (MPS II). The therapy was deemed ineffective and was discontinued in the majority of them but reaching the consensus on ineffectiveness of enzyme replacement required often several years. MethodsThe standard clinical monitoring parameters such as: six-minute walking test, pulmonary function tests, severity of organomegaly and of heart dysfunction, proved to be hardly helpful in many cases. This was caused by young age of patients, their physical and intellectual disabilities as well as by various disease courses. ResultsOn contrary, linear growth and body weight dynamics proved to be useful indicators of the presence or absence of an overall anabolic effect of enzymatic therapy. However, proper growth pattern in affected children or significant body weight increase in already adult patients were rare and could be detected in less than 50% of milder cases only. No such effects were observed in patients with more severe disease form. ConclusionIn our opinion, body weight dynamics is a useful clinical indicator of treatment responsiveness in patients with MPS II.

Advanced monitoring in traumatic brain injury: microdialysis.

Here, we review the present state-of-the-art of microdialysis for monitoring patients with severe traumatic brain injury, highlighting the newest developments. Microdialysis has evolved in neurocritical care to become an established bedside monitoring modality that can reveal unique information on brain chemistry. A major advance is recent consensus guidelines for microdialysis use and interpretation. Other advances include insight obtained from microdialysis into the complex, interlinked traumatic brain injury disorders of electrophysiological changes, white matter injury, inflammation and metabolism. Microdialysis has matured into being a standard clinical monitoring modality that takes its place alongside intracranial pressure and brain tissue oxygen tension measurement in specialist neurocritical care centres, as well as being a research tool able to shed light on brain metabolism, inflammation, therapeutic approaches, blood-brain barrier transit and drug effects on downstream targets. Recent consensus on microdialysis monitoring is paving the way for improved neurocritical care protocols. Furthermore, there is scope for future improvements both in terms of the catheters and microdialysate analyser technology, which may further enhance its applicability.

Anaesthetic interventions for prevention of awareness during surgery.

General anaesthesia is usually associated with unconsciousness. 'Awareness' is when patients have postoperative recall of events or experiences during surgery. 'Wakefulness' is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016; MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a handsearch of the citations in the review. We did not search trial registries. We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteer studies, studies of patients prior to skin incision, intensive care unit studies, and studies that only randomized different word presentations for memory tests (not anaesthetic interventions).Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review.The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503 participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87 to have possible awareness, and 65 to have definite awareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75).We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness.We graded the quality of the evidence as low or very low in the 'Summary of findings' tables for the five comparisons.Most of the secondary outcomes in this review were not reported in the included RCTs. Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses, reduced the risk of awareness.

Abstract: A Novel Text Messaging Alert System Used with Continuous Tissue Oximetry Monitoring to Improve Free Flap Outcomes

INTRODUCTION: The time to detection of vascular compromise is a significant predictor of free flap salvage outcomes as early re-exploration has been shown to improve the salvage rate for failing free flaps. Continuous transcutaneous near-infrared tissue oximetry is an objective, quantitative method of detecting flap vascular compromise and has been shown to allow earlier re-exploration and higher salvage rates than clinical assessment alone. We designed a novel text messaging system to improve communication using tissue oximetry monitoring. MATERIALS AND METHODS: A retrospective review was performed of a prospectively collected database of all microsurgical breast reconstructions from 2008 to 2015. A novel text messaging system was introduced in 2013 and programmed to send text messages alert when the tissue oximetry readings suggested potential flap compromise based on established thresholds. Patient demographics and complications, including rate of re-exploration and flap loss (partial and total) were assessed. RESULTS: There were 900 autologous microsurgical breast free flaps during the study period: 614 were monitored with standard clinical monitoring and tissue oximetry compared with 286 flaps with the additional text messaging system. There were 27 unplanned returns to the operating room in the tissue oximetry group and 5 in the text messaging group with 1 complete flap loss in each group. Re-exploration occurred sooner as a result of these text message alerts (17.5 vs. 26.6 hours postoperatively), however, did not achieve statistical significance. CONCLUSIONS: We were able to demonstrate the use of a novel text messaging system for tissue oximetry. This alert system shows promise in identifying impending flap loss with rapid notification of the surgical team. Improved communication and identification of failing free flaps will allow for an even further improvement of salvage rates. DISCLOSURE/FINANCIAL SUPPORT:This work was not supported by any external sources of funding. None of the authors have any financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Effect of benazepril and robenacoxib and their combination on glomerular filtration rate in dogs.

Combined use of angiotensin-converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs may induce acute kidney injury, especially when combined with diuretics. The objective of this investigation was to evaluate the effect of benazepril, robenacoxib and their combination in healthy dogs. In each of two studies (studies 1 and 2), 32 beagle dogs were randomized into one of four groups in a parallel-group design. Groups received once-daily oral treatment for 7days with placebo, benazepril, robenacoxib or benazepril plus robenacoxib. In study 2, all dogs received additionally 2mg/kg furosemide orally twice daily. The primary endpoint was the glomerular filtration rate (GFR) estimated from the plasma clearance of iohexol. Secondary endpoints included standard clinical monitoring and, in study 2, plasma renin activity, urine volume, specific gravity and aldosterone concentration and water intake. Administration of furosemide induced diuresis, reduced GFR and activated the renin-aldosterone-angiotensin system. Benazepril and robenacoxib, administered alone or in combination, were tolerated well, did not decrease GFR with or without co-administration of furosemide and significantly reduced urinary aldosterone concentrations. No increased risk of acute kidney injury was identified with the combination of benazepril and robenacoxib in healthy dogs. Different effects might occur in dogs with heart or renal disease.

Entropy vs standard clinical monitoring using total intravenous anesthesia during transvaginal oocyte retrieval in patients for in vitro fertilization

Study objectiveDay care surgery is an important arena for monitors of anesthetic depth where minimizing drug use is essential for rapid turnover. Underdosage, on the other hand, carries the risks of intraoperative awareness and pain. Transvaginal oocyte retrieval (TVOR), often performed under total intravenous anesthesia using propofol and fentanyl in Indian patients, is a procedure of special interest because, in addition to the above concerns, toxic effects of propofol on oocytes have been described. We have studied the role of entropy monitor, a depth of anesthesia monitor, in optomising drug titration and facilitating distinction between analgesic and hypnotic components of anesthesia. DesignProspective randomized controlled study. SettingOperating theater and postoperative recovery area. PatientsOne hundred twenty American Society of Anesthesiologists class I and II female patients coming to the IVF centre for TVOR under total intravenous anesthesia using propofol and fentanyl. They were randomly allocated into 2 groups: Group EM (drugs titrated as per entropy values: state entropy and response entropy) and group CM (drugs titrated as per standard clinical monitoring). InterventionNone. MeasurementsTotal propofol consumption (TP), total fentanyl consumption (TF), on-table recovery time (T1), time to discharge (T2), intraoperative awareness (A). Main resultsPatients in group EM demonstrated 6.7% lesser consumption of propofol (P= .01), 10.9% more consumption of fentanyl (P= .007) and 1 minute faster recovery on-table (P= .009) as compared to group CM. In the PACU, only 10% patients of group EM required supplemental analgesia as opposed to 28.3% in CM group (P= .01). Time to discharge was similar in both groups and no intraoperative awareness was noted. ConclusionEntropy monitor is a useful tool allowing distinction between analgesic and hypnotic components of general anesthesia in patients undergoing TVOR and facilitating drug titration accordingly. Its impact on intraoperative awareness needs to be further evaluated.

A Novel Free Flap Monitoring System Using Tissue Oximetry with Text Message Alerts.

Background The time to detection of vascular compromise is a significant predictor of free flap salvage outcomes as early reexploration improves salvage rates. Continuous transcutaneous near-infrared tissue oximetry is an objective, quantitative method of detecting flap vascular compromise and has been shown to allow earlier reexploration and higher salvage rates than clinical assessment alone. We designed a novel text messaging system to improve communication using tissue oximetry monitoring. Methods A retrospective review was performed of a prospectively collected database of all microsurgical breast reconstructions from 2008 to 2015. A novel text messaging system was introduced in 2013 and programmed to send text messages alert when the tissue oximetry readings suggested potential flap compromise based on established thresholds. Patient demographics and complications, including rate of reexploration and flap loss were assessed. Results There were 900 autologous microsurgical breast free flaps during the study period: 614 were monitored with standard clinical monitoring and tissue oximetry compared with 286 flaps with the additional text messaging system. There were 27 unplanned returns to the operating room in the tissue oximetry group and 5 in the text messaging group with 1 complete flap loss in each group. Reexploration occurred sooner as a result of these text message alerts (17.5 vs. 26.6 hours postoperatively), however, it did not achieve statistical significance. Conclusions We were able to demonstrate the use of a novel text messaging system for tissue oximetry. This alert system shows promise in identifying impending flap loss with rapid notification of the surgical team.

Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect

Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed. A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts--standard clinical monitoring and standard clinical monitoring plus tissue oximetry--and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience. A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p < 0.001). The number of complete flap losses decreased from 11 (2.9 percent) to one (0.1 percent) with the use of tissue oximetry (p < 0.001). Subgroup analysis demonstrated significantly fewer reexplorations in the third tertile. Inclusion of continuous tissue oximetry in the postoperative monitoring protocol of microsurgical breast reconstruction is associated with significantly improved salvage rates and fewer flap losses. Furthermore, learning curve assessment demonstrates that use of tissue oximetry can decrease the rate of reexploration over time.