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Transfusion Requirements in Cardiac Surgery III (TRICS III), a multi-center randomized controlled trial, demonstrated clinical non-inferiority for restrictive versus liberal RBC transfusion for patients undergoing cardiac surgery. However, it is uncertain if transfusion strategy affects long-term health-related quality of life (HRQOL).In this planned sub-study of Australian patients in TRICS III, we sought to determine the non-inferiority of restrictive versus liberal transfusion strategy on long-term HRQOL and to describe clinical outcomes 24 months postoperatively. The restrictive strategy involved transfusing RBCs when hemoglobin was7.5 g/dl; the transfusion triggers in the liberal group were: 9.5 g/L intraoperatively,9.5 g/L in intensive care, or8.5 g/dl on the ward. HRQOL assessments were performed using the 36-item short form survey version 2 (SF-36v2). Primary outcome was non-inferiority of summary measures of SF-36v2 at 12 months, (non-inferiority margin: -0.25 effect size; restrictive minus liberal scores). Secondary outcomes included non-inferiority of HRQOL at 18 and 24 months.Six hundred seventeen Australian patients received allocated randomization; HRQOL data were available for 208/311 in restrictive and 217/306 in liberal group. After multiple imputation, non-inferiority of restrictive transfusion at 12 months was not demonstrated for HRQOL, and the estimates were directionally in favor of liberal transfusion. Non-inferiority also could not be concluded at 18 and 24 months. Sensitivity analyses supported these results. There were no differences in quality-adjusted life years or composite clinical outcomes up to 24 months after surgery.The non-inferiority of a restrictive compared to a liberal transfusion strategy was not established for long-term HRQOL in this dataset.

ImportancePostoperative complications are increasing, risking patients’ health and health care sustainability. High-acuity postoperative units may benefit outcomes, but existing data are very limited.ObjectiveTo evaluate whether a new high-acuity postoperative unit, advanced recovery room care (ARRC), reduces complications and health care utilization compared with usual ward care (UC).Design, Setting, and ParticipantsIn this observational cohort study, adults who were undergoing noncardiac surgery at a single-center tertiary adult hospital, anticipated to stay in hospital for 2 or more nights, were scheduled for postoperative ward care, and at medium risk (defined as predicted 30-day mortality of 0.7% to 5% by the National Safety Quality Improvement Program risk calculator) were included. Allocation to ARRC was based on bed availability. From 2405 patients assessed for eligibility with National Safety Quality Improvement Program risk scoring, 452 went to ARRC and 419 to UC, with 8 lost to 30-day follow-up. Propensity scoring identified 696 patients with matched pairs. Patients were treated between March and November 2021, and data were analyzed from January to September 2022.InterventionsARRC is an extended postanesthesia care unit (PACU), staffed by anesthesiologists and nurses (1 nurse to 2 patients) collaboratively with surgeons, with capacity for invasive monitoring and vasoactive infusions. ARRC patients were treated until the morning after surgery, then transferred to surgical wards. UC patients were transferred to surgical wards after usual PACU care.Main Outcome and MeasuresThe primary end point was days at home at 30 days. Secondary end points were health facility utilization, medical emergency response (MER)–level complications, and mortality. Analyses compared groups before and after propensity scoring matching.ResultsOf 854 included patients, 457 (53.5%) were male, and the mean (SD) age was 70.0 (14.4) years. Days at home at 30 days was greater with ARRC compared with UC (mean [SD] time, 17 [11] vs 15 [11] days; P = .04). During the first 24 hours, more patients were identified with MER-level complications in ARRC (43 [12.4%] vs 13 [3.7%]; P P = .03). Length of hospital stay, hospital readmissions, emergency department visits, and mortality were similar.Conclusions and RelevanceFor medium-risk patients, brief high-acuity care with ARRC allowed enhanced detection and management of early MER-level complications, which was followed by a decreased incidence of subsequent MER-level complications after discharge to the ward and by increased days at home at 30 days.

Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2–9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68–0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79–0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.

Structured abstract Objectives Diabetics may have diminished survival after coronary artery bypass grafting even with multiple arterial revascularization. We compared multi-arterial versus single-arterial grafting survival in diabetic and non-diabetic patients undergoing primary isolated bypass surgery. Methods This is a retrospective analysis of the Australian and New Zealand Society of Cardiac-Thoracic Surgical Database from June 2001 to January 2020. Patients were classified as having either single or multiple arterial grafting irrespective of the number of venous grafts. The end-points were long-term all-cause mortality and 30-day clinical outcomes, which was compared in 1:1 propensity score matched patients. Cox regression model was used to assess interactions between diabetes and the treatment effect of multi-arterial grafting, reported as hazard ratios and confidence intervals. Short-term outcomes were compared with McNemar’s paired t-test. Results From 69,624 patients, matching generated 17,474 non-diabetic and 10,989 diabetic patient pairs. At a median [interquartile range] of 5.9 [3.2–9.6] years postoperative, mortality was significantly lower after multi-arterial grafting for both diabetic (hazard ratio, 0.83; 95% confidence interval, 0.76–0.90, P Conclusions Multi-arterial grafting was associated with improved overall survival compared to single arterial grafting for both non-diabetic and diabetic patients.

Objective The purpose of this study was to determine the safety and feasibility of subacute upper limb resistance exercise on sternal micromotion and pain and the reliability of sternal ultrasound assessment following cardiac surgery via median sternotomy. Methods This experimental study used a pretest–posttest design to investigate the effects of upper limb resistance exercise on the sternum in patients following their first cardiac surgery via median sternotomy. Six bilateral upper limb machine-based exercises were commenced at a base resistance of 20 lb (9 kg) and progressed for each participant. Sternal micromotion was assessed using ultrasound at the mid and lower sternum at 2, 8, and 14 weeks postsurgery. Intrarater and interrater reliability was calculated using intraclass correlation coefficients (ICCs). Participant-reported pain was recorded at rest and with each exercise using a visual analogue scale. Results Sixteen adults (n = 15 males; 71.3 [SD = 6.2] years of age) consented to participate. Twelve participants completed the study, 2 withdrew prior to the 8-week assessment, and 2 assessments were not completed at 14 weeks due to assessor unavailability. The highest median micromotion at the sternal edges was observed during the bicep curl (median = 1.33 mm; range = −0.8 to 2.0 mm) in the lateral direction and the shoulder pulldown (median = 0.65 mm; range = −0.8 to 1.6 mm) in the anterior–posterior direction. Furthermore, participants reported no increase in pain when performing any of the 6 upper limb exercises. Interrater reliability was moderate to good for both lateral–posterior (ICC = 0.73; 95% CI = 0.58 to 0.83) and anterior–posterior micromotion (ICC = 0.83; 95% CI = 0.73 to 0.89) of the sternal edges. Conclusion Bilateral upper limb resistance exercises performed on cam-based machines do not result in sternal micromotion exceeding 2.0 mm or an increase in participant-reported pain. Impact Upper limb resistance training commenced as early as 2 weeks following cardiac surgery via median sternotomy and performed within the safe limits of pain and sternal micromotion appears to be safe and may accelerate postoperative recovery rather than muscular deconditioning.

It is uncertain if the long-term biological behavior of the radial artery as a conduit for coronary bypass surgery has a similar resistance to the development of atherosclerosis as for the internal mammary artery. We aimed to examine long-term angiographic patency and disease-free patency (perfect patency) for internal mammary artery, radial artery, and saphenous vein grafts.A retrospective, single-center, individual patient cohort study of angiographic observations from patients' latest postoperative angiogram from 1997 to 2020 was performed. Analysis was per anastomosis and assessed for patency and perfect patency. A generalized linear mixed model premised upon logistic regression was used to minimize confounding bias.A total of 983 patients with 3064 grafts were included, with a median follow-up of 8.6 (interquartile range, 4.4-12.6) years after the operation. Multivariable analysis revealed differences for radial (patency, 86.9%; perfect patency, 86.4%) and internal mammary artery (patency, 93.9%; perfect patency, 93.5%) versus saphenous vein graft (patency, 72.8%; perfect patency, 46.2%). There were no differences between the 2 arterial conduits for patency (odds ratio, 1.40; 95% CI, 0.85-2.33; P = .189) and perfect patency (odds ratio, 1.14; 95% CI, 0.71-1.84; P = .578). If a conduit was patent, then 99.4% of radial artery, 99.6% of internal mammary artery, and 63.5% of saphenous vein graft were reported as perfectly patent.Radial artery and internal mammary artery had similar patency and perfect patency while both were superior to saphenous vein graft.

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.

Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.RéSUMé: Les complications pulmonaires du coronavirus (COVID-19) constituent ses manifestations cliniques les plus fréquentes. De récentes observations cliniques ont fait émerger deux phénotypes : le phénotype à élastance faible ou type L (low), et le phénotype à élastance élevée, ou type H (high). La présentation clinique, la physiopathologie, les mécanismes pulmonaires, ainsi que les observations radiologiques et échographiques de ces deux différents phénotypes sont différents. L’approche thérapeutique variera par conséquent selon le phénotype des patients atteints de COVID-19 souffrant d’insuffisance respiratoire.

Background Where each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period. Methods Research protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or “string sign” conduits. Perfect patency was present in patent grafts if there was no lumen irregularity. Results Fifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032. When both arterial conduits were combined, perfect patency, P P = 0.017, were superior to SVG. Conclusions All but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perfect patency and overall patency compared to saphenous vein grafts.

BACKGROUND: There is a concern that midazolam, when used as a component of sedation for colonoscopy, may impair cognition and prolong recovery. We aimed to identify whether midazolam produced short- and longer-term effects on multiple dimensions of recovery including cognition.METHODS: A 2-center double-blinded, placebo-controlled, parallel-group, randomized, phase IV study with a 1:1 allocation ratio was conducted in adults >= 18 years of age undergoing elective outpatient colonoscopy, with sufficient English language proficiency to complete the Postoperative Quality of Recovery Scale (PostopQRS). Participants were administered either midazolam (0.04 mg.kg(-1)) or an equivalent volume of 0.9% saline before sedation with propofol with or without an opiate. The primary outcome was incidence of recovery in the cognitive domain of the PostopQRS on day 3 after colonoscopy, which was analyzed using a chi(2) test. Secondary outcomes included recovery in other domains of the PostopQRS over time, time to eye-opening, and hospital stay, and patient and endoscopist satisfaction. All hypotheses were defined before recruitment.RESULTS: During September 2015 to June 2018, 406 patients were allocated to either midazolam (n = 201) or placebo (n = 205), with one withdrawn before allocation. There was no significant difference in recovery in the cognitive domain of the PostopQRS on day 3 after colonoscopy (midazolam 86.8% vs placebo 88.7%, odds ratio, 0.838; 95% confidence interval [CI], 0.42-1.683; P = .625). Furthermore, there was no difference in recovery over time in the cognitive domain of the PostopQRS (P = .534). Overall recovery of the PostopQRS increased over time but was not different between groups. Furthermore, there were no differences between groups for nociceptive, emotive, activities-of-daily-living domains of the PostopQRS. Patient and endoscopist satisfaction were high and not different. There were no differences in time to eye-opening (midazolam 9.4 +/- 12.8 minutes vs placebo 7.3 +/- 0.7 minutes; P = .055), or time to hospital discharge (midazolam 103.4 +/- 1.4 minutes vs placebo 98.4 +/- 37.0 minutes; P = .516).CONCLUSIONS: The addition of midazolam 0.04 mg.kg(-1) as adjunct to propofol and opiate sedation for elective colonoscopy did not show evidence of any significant differences in recovery in the cognitive domain of the PostopQRS, overall quality of recovery as measured by the PostopQRS, or emergence and hospital discharge times. The use of midazolam should be determined by the anesthesiologist.

BACKGROUND Portal vein Doppler ultrasound pulsatility measured by transoesophageal echocardiography is a marker of the haemodynamic impact of venous congestion in cardiac surgery. We investigated whether the presence of abnormal portal vein flow pulsatility is associated with a longer duration of invasive life support and postoperative complications in high-risk patients. METHODS In this multicentre cohort study, pulsed-wave Doppler ultrasound assessments of portal vein flow were performed during anaesthesia before initiation of cardiopulmonary bypass (before CPB) and after separation of cardiopulmonary bypass (after CPB). Abnormal pulsatility was defined as portal pulsatility fraction (PPF) ≥50% (PPF50). The primary outcome was the cumulative time in perioperative organ dysfunction (TPOD) requiring invasive life support during 28 days. Secondary outcomes included major postoperative complications. RESULTS 373 patients, 71 (22.0%) had PPF50 before CPB and 77 (24.9%) after CPB. PPF50 was associated with longer duration of TPOD (median [inter-quartile range]; before CPB: 27 h [11-72] vs 19 h [8.5-42], P=0.02; after CPB: 27 h [11-61] vs 20 h [8-42], P=0.006). After adjusting for confounders, PPF50 before CPB showed significant association with TPOD. PPF50 after CPB was associated with a higher rate of major postoperative complications (36.4% vs 20.3%, P=0.006). CONCLUSIONS Abnormal portal vein flow pulsatility before cardiopulmonary bypass was associated with longer duration of life support therapy after cardiac surgery in high-risk patients. Abnormal portal vein flow pulsatility after cardiopulmonary bypass separation was associated with a higher risk of major postoperative complications although this association was not independent of other factors. CLINICAL TRIAL REGISTRATION NCT03656263.

Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2–5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.

BackgroundBetween 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved since then, this study aimed to determine whether there has been a corresponding improvement in survival.MethodsA retrospective study of Aboriginal patients with RHD in the Northern Territory, Australia, having their first valve surgery between 1997 and 2016. Survival was examined using Kaplan-Meier and Cox regression analysis.FindingsThe cohort included 281 adults and 61 children. The median (IQR) age at first surgery was 31 (18–42) years; 173/342 (51%) had a valve replacement, 113/342 (33%) had a valve repair and 56/342 (16%) had a commissurotomy. There were 93/342 (27%) deaths during a median (IQR) follow-up of 8 (4–12) years. The overall 10-year survival was 70% (95% CI: 64% to 76%). It was 62% (95% CI: 53% to 70%) in those having valve replacement. There were 204/281 (73%) adults with at least 1 preoperative comorbidity. Preoperative comorbidity was associated with earlier death, the risk of death increasing with each comorbidity (HR: 1.3 (95% CI: 1.2 to 1.5), p50 mm Hg before surgery (HR 1.9 (95% CI: 1.2 to 3.1) p=0.007) were independently associated with death.InterpretationSurvival after valve replacement for RHD in this region of Australia has not improved. Although the patients were young, many had multiple comorbidities, which influenced long-term outcomes. The increasing prevalence of complex comorbidity in the region is a barrier to achieving optimal health outcomes.

AIM To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. MATERIALS AND METHODS The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold

Focused cardiac ultrasound (FCU) training in critical care is restricted by availability of instructors. Supervised training may be substituted by self-directed learning with an ultrasound simulator guided by automated electronic learning, enabling scalability.We prospectively compared learning outcomes in novice critical care physicians after completion of a supervised one-and-a-half-day workshop model with a self-guided course utilizing a simulator over four weeks. Both groups had identical pre-workshop on-line learning (20h). Image quality scores were compared using FCU performed on humans without pathology. Interpretive knowledge was compared using 20MCQ tests.Of 161 eligible, 145 participants consented. Total Image quality scores were higher in the Simulator group (95.2% vs. 66.0%, P .001) and also higher for each view (all P .001). Interpretive knowledge was not different before (78.6% vs. 79.0%) and after practical training (74.7% vs. 76.1%) and at 3 months (81.0% vs. 77.0%, all P .1). Including purchase of the simulator and ultrasound equipment, the simulator course required lower direct costs (AUD$796 vs. $1724 per participant) and instructor time (0.5 vs.1.5 days) but similar participant time (2.8 vs. 3.0 days).Self-directed learning with ultrasound simulators may be a scalable alternative to conventional supervised teaching with human models.

Aims To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy. Methods This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer’s Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively. Results The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001). Conclusion Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.

To determine whether brief ultrasound-guided treatment of hemodynamic shock and respiratory failure immediately before emergency noncardiac surgery reduced 30-day mortality.Parallel, nonblinded, randomized trial with 1:1 allocation to control and intervention groups.Twenty-eight major hospitals within China.Six-hundred sixty patients ≥14 years of age, scheduled for emergency noncardiac surgery with evidence of shock (heart rate120 beat/min, systolic blood pressure90 mmHg or requiring inotrope infusion), or respiratory failure (Pulse Oxygen Saturation92%, respiratory rate20 beat/min, or requiring mechanical ventilation).A brief (15 minutes) focused ultrasound of ventricular filling and function, lung, and peritoneal spaces, with predefined treatment recommendation based on the ultrasound was performed before surgery or standard care.The primary outcome was 30-day mortality. Secondary outcomes included changes in medical or surgical diagnosis and management due to ultrasound, intensive care unit, and hospital stay and cost, and Short Form-8 quality-of-life scores. Although there were frequent changes in diagnosis (82%) and management (49%) after the ultrasound, mortality at 30 days was not different between groups (50 [15.7%] v 53 [16.3%]; odds ratio 1.05, 0.69-1.6, p = 0.826). There were no differences in the secondary outcomes of the days spent in the hospital (mean 13.8 days, 95% confidence interval [CI] 12.1-15.6 v 14.4 d, 11.8-17.1, p = 0.718) or intensive care unit (mean 9.3 days, 95% CI 7.7-11.0 v 8.7 d, 7.2-10.2, p = 0.562), hospital cost (USD$14.5K, 12.2-16.7 v 13.7, 11.5-15.9, p = 0.611) or Short Form-8 scores at one year (mean 80.9, 95% CI 78.4-83.3 v 79.7, 76.9-82.5, p = 0.54) between participants allocated to the ultrasound and control groups.In critically ill patients with hemodynamic shock or respiratory failure, a focused ultrasound-guided management did not reduce 30-day mortality but led to frequent changes in diagnosis and patient management.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research. post-print 2.282 KB

PURPOSE: To establish the test–retest and inter‐rater reliability of lumbar multifidus (LM) and iliocostalis lumborum (IL) muscle thickness and echogenicity as derived using ultrasound imaging. METHODS: Ultrasound images of the LM and IL were collected from 11 healthy participants on two occasions, 1 week apart, by two independent assessors. Measures of LM and IL thickness and echogenicity were subject to test–retest and inter‐rater reliability, which was assessed by calculation of an F statistic, the interclass correlation coefficient (ICC), the standard error of measurement, 95% confidence intervals and Bland–Altman plots. This study was given approval by The University of Melbourne Behavioural and Social Sciences Human Ethics Sub‐Committee (ref: 1749845). RESULTS: Assessors A and B showed good to excellent test–retest reliability for LM thickness (ICC(3,3) A: 0.89 and B: 0.98), LM echogenicity (ICC(3,3) A: 0.93 and B: 0.95) and IL echogenicity (ICC(3,3) A: 0.87 and B: 0.83). Test–retest reliability for IL thickness was poor for Assessor A but excellent for Assessor B. Both assessors demonstrated excellent inter‐rater reliability for LM thickness and echogenicity (ICC(2,3): 0.79 and 0.94), but poor reliability for IL thickness and echogenicity (ICC(2,3): 0.00 and 0.39). CONCLUSIONS: Inter‐rater and test–retest reliability was excellent for LM but was less reliable for measures of the IL muscle.

Lung ultrasound (LUS) imaging as a point-of-care diagnostic tool for lung pathologies has been proven superior to X-ray and comparable to CT, enabling earlier and more accurate diagnosis in real-time at the patient's bedside. The main limitation to widespread use is its dependence on the operator training and experience. COVID-19 lung ultrasound findings predominantly reflect a pneumonitis pattern, with pleural effusion being infrequent. However, pleural effusion is easy to detect and to quantify, therefore it was selected as the subject of this study, which aims to develop an automated system for the interpretation of LUS of pleural effusion. A LUS dataset was collected at the Royal Melbourne Hospital which consisted of 623 videos containing 99,209 2D ultrasound images of 70 patients using a phased array transducer. A standardized protocol was followed that involved scanning six anatomical regions providing complete coverage of the lungs for diagnosis of respiratory pathology. This protocol combined with a deep learning algorithm using a Spatial Transformer Network provides a basis for automatic pathology classification on an image-based level. In this work, the deep learning model was trained using supervised and weakly supervised approaches which used frame- and video-based ground truth labels respectively. The reference was expert clinician image interpretation. Both approaches show comparable accuracy scores on the test set of 92.4% and 91.1%, respectively, not statistically significantly different. However, the video-based labelling approach requires significantly less effort from clinical experts for ground truth labelling.

OBJECTIVES: To investigate the specific clinical features of pain following cardiac surgery and evaluate the information derived from different pain measurement tools used to quantify and describe pain in this population. METHODS: A prospective observational study was undertaken at two tertiary care hospitals in Australia. Seventy-two (72) adults (mean age, 63±11 years) were included following cardiac surgery via a median sternotomy. Participants completed the Patient Identified Cardiac Pain using numeric and visual prompts (PICP), the McGill Pain Questionnaire-Short Form version 2 (MPQ-2) and the Medical Outcome Study 36-item version 2 (SF-36v2) Bodily Pain domain (BP), which were administered prior to hospital discharge, 4 weeks and 3 months postoperatively. RESULTS: Participants experienced a high incidence of mild (n=45, 63%) to moderate (n=22, 31%) pain prior to discharge, which reduced at 4 weeks postoperatively: mild (n=28, 41%) and moderate (n=5, 7%) pain; at 3 months participants reported mild (n=14, 20%) and moderate (n=2, 3%) pain. The most frequent location of pain was the anterior chest wall, consistent with the location of the surgical incision and graft harvest. Most participants equated "pressure/weight" to "aching" or a "heaviness" in the chest region (based on descriptor of pain in the PICP) and the pain topography was persistent at 4 weeks and 3 months postoperatively. Each pain measurement tool provided different information on pain location, severity and description, with significant change (p

Introduction Mild cognitive impairment is considered a precursor to dementia and significantly impacts upon quality of life. The prevalence of mild cognitive impairment is higher in the post-surgical cardiac population than in the general population, with older age and comorbidities further increasing the risk of cognitive decline. Exercise improves neurogenesis, synaptic plasticity and inflammatory and neurotrophic factor pathways, which may help to augment the effects of cognitive decline. However, the effects of resistance training on cognitive, functional and overall patient-reported recovery have not been investigated in the surgical cardiac population. This study aims to determine the effect of early moderate-intensity resistance training, compared to standard care, on cognitive recovery following cardiac surgery via a median sternotomy. The safety, feasibility and effect on functional recovery will also be examined. Methods This study will be a prospective, pragmatic, pilot randomised controlled trial comparing a standard care group (low-intensity aerobic exercise) and a moderate-intensity resistance training group. Participants aged 18 years and older with coronary artery and/or valve disease requiring surgical intervention will be recruited pre-operatively and randomised 1:1 to either the resistance training or standard care group post-operatively. The primary outcome, cognitive function, will be assessed using the Alzheimer’s Disease Assessment Scale and cognitive subscale. Secondary measures include safety, feasibility, muscular strength, physical function, multiple-domain quality of recovery, dynamic balance and patient satisfaction. Assessments will be conducted at baseline (pre-operatively) and post-operatively at 2 weeks, 8 weeks, 14 weeks and 6 months. Discussion The results of this pilot study will be used to determine the feasibility of a future large-scale randomised controlled trial that promotes the integration of early resistance training into existing aerobic-based cardiac rehabilitation programs in Australia. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001430325p. Registered on 9 October 2017. Universal Trial Number (UTN): U1111-1203-2131.

BACKGROUND: Catecholamine inotropes are frequently used after cardiopulmonary bypass (CPB) but may have undesirable effects. The aim was to identify whether the routine use of inhaled pulmonary vasodilators might reduce the requirement for inotrope drugs after cardiac surgery. METHODS: Retrospective cohort study of sequential patients undergoing cardiac surgery at the Royal Melbourne Hospital performed by a single surgeon and anesthesia care team, within 14 months before and after routine implementation of inhaled pulmonary vasodilators, August 2017. Milrinone 4 mg and iloprost 20 µg were inhaled using a vibrating mesh nebulizer (Aerogen) before initiation of CPB and at chest closure. Other aspects of clinical management were unaltered over the time period. Two investigators blinded to each other extracted data from electronic and written medical records. The primary outcome was any use of inotropes in the perioperative period; a Fisher exact test was used to analyze any differences between the 2 groups. Demographic data, hemodynamic data, and use of inotropes and vasopressors were collected from induction of anesthesia to 36 hours postoperative in the intensive care unit (ICU). Hospital and ICU length of stay, cost, and complications were collected. RESULTS: Any use of inotropes was significantly lower with inhaled pulmonary dilators (62.5% vs 86.8%, odds ratio [95% confidence interval {CI}], 0.253 (0.083-0.764); P = .011), including intraoperative inotrope use (37.5% vs 86.8%, odds ratio [95% CI], 0.091 (0.03-0.275); P < .001). ICU length of stay was significantly lower with inhaled pulmonary dilators (45 hours, interquartile range [IQR], 27-65 vs 50 hours, IQR, 45-74; P = .026). There were no significant differences among major postoperative complications or costs between groups. CONCLUSIONS: Routine use of inhaled milrinone 4 mg and iloprost 20 µg before and after CPB is associated with reduced postoperative inotrope use.

In the context of the coronavirus disease 2019 (COVID-19) pandemic, lung ultrasound has emerged as an accurate and reliable alternative for assessment of lung pathology. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular and broken aspect of the pleural line, and sub-pleural consolidation. Consolidations are usually a late finding appearing during the second week since symptoms onset. Translating into the practice, lung ultrasound can improve diagnostic accuracy and contribute with relevant information to the triage of these patients. It can be used as part of the routinely assessment of patients admitted to the medical ward allowing early identification of disease progression. Among patients mechanically ventilated, it is useful evaluating response to prone position and/or recruiting maneuvers. Finally, in all the previous scenarios, lung ultrasound may also detect common complications seen in these patients such as cardiogenic pulmonary edema and pulmonary embolism. In this review, we have summarized the information available and suggest simple algorithm to incorporate lung ultrasound into the assessment of COVID-19 patients.

Obtaining quality of recovery is an abstract construct that is the ultimate goal of each perioperative experience. Modern recovery has progressed from being defined as a purely unidimensional, short-term outcome to a multidimensional concept that is occurring along a time trajectory and which extends beyond the traditional immediate postoperative period. Meta-analyses and systemic reviews have revealed the most commonly reported outcome measures used to evaluate enhanced recovery after surgery (ERAS) pathways to be hospital length of stay and 30-day readmission rates. Concept analyses and the rise of patient-centered care have led to a call for measurement of recovery within ERAS programs to be extended to include both patient-centric and contextual variables through which to assess these traditional outcomes. Recovery assessment variables may be objective or subjective and are prone to bias due to lack of context or susceptibility to response shift, respectively. Recovery assessment infers a comparison of a patient to a preoperative comparator—ideally their own preoperative baseline. Ideally, recovery is assessed using a multidimensional dichotomous recovery assessment tool that has the infrastructure to provide recovery outcomes to both patient and clinician in real time.

Ultrasound is increasingly being adopted into anaesthesia and intensive care practice. The range of ultrasound examination has also increased from transoesophageal echocardiography in cardiac surgery and ultrasound-guided nerve blocks and vascular access, to examination of the heart, lungs, abdomen and deep veins. Typically, the use of ultrasound is focused or basic, designed to be performed by the anaesthetist at the patient's bedside in real time to answer clinical questions and to direct therapy. Ultrasound is not performed in isolation, but used to complement clinical evaluation, and accordingly can be considered as 'ultrasound-assisted perioperative evaluation'. Whilst there is good evidence that ultrasound improves diagnostic accuracy and in turn alters management, there are few data examining whether ultrasound leads to improved clinical outcomes. This review will examine multiple uses of perioperative ultrasound with case studies to illustrate potential utility.

Current post-operative recovery assessment exists as a dichotomy, maintaining objectivity whilst providing relevance to patient-centred care. Both objective and subjective measures are utilised in modern recovery assessment and are best viewed as complimentary. At institutional and provider levels, performance indicators are utilised as surrogates for quality of recovery but only if these indicators are assessed in the clinical context from which they are derived. Patient-reported outcomes prioritise the patient's perspective of symptoms and care, which are the most important aspects at the time of assessment but are limited by their susceptibility to response shift and recall bias. Ideally, quality of recovery is assessed using objective measures in concert with measures of clinical complexity and in parallel with patient-reported outcomes.

Modern recovery assessment has progressed from that which addressed purely physiological restitution in the immediate post-operative period to that which is a multi-dimensional construct existing as a continuum and which follows a predictable trajectory. Recovery tools differ in their derivation, validation and scope of assessment. Importantly, few are validated for repeat measures, an aspect crucial when assessing the temporal nature of modern recovery. Recovery can be assessed as a continuous or dichotomous outcome and as occurring within an individual patient or within a group. Dichotomisation of recovery assessment mandates that a threshold be determined, above which recovery is deemed to have occurred. Ideally, recovery is assessed as a dichotomous outcome using the patient as their own pre-operative comparator, thus allowing recovery assessment at an individual patient, as well as group, level and overall as well as within each recovery domain.

Quality of recovery is a multidimensional construct that affects individual patients in different ways and during different time periods. The evaluation of quality of recovery requires patient-reported outcome measurement tools that are sensitive in detecting change with time and are preferably objective rather than subjective by nature. Current surgical outcomes are still predominantly focused on the avoidance of complications and reduced cost. The new era of 'value-based care' implies that outcomes of importance to the patient should be a vital metric in determining quality of surgical care. However, it is critical to maintain the high standards of surgical safety and cost containment as we move forward to address value-based care. An apparently successful surgery can result in poor recovery outcomes such as cognitive decline, persistent pain, reduced functional ability, loss of independence or inability to return to work. The special edition of Best Practice will focus on the multidimensional construct of quality of recovery, how to measure it and how it may apply in different populations.

Patients with pre-surgery cognitive impairment cannot currently be assessed for cognitive recovery after surgery using the Postoperative Quality of Recovery Scale (PostopQRS), as they would mathematically be scored as recovered. We aimed to validate a novel method to score cognitive recovery in patients with low-baseline cognition, using the number of low-score tests rather than their numerical values. Face validity was demonstrated in 86 participants in whom both the Postoperative Quality of Recovery Scale and an 11-item neuropsychological battery were performed. The Postoperative Quality of Recovery Scale agreed with neuropsychological categorisation of low vs. normal cognition 74% of the time, with all but five incorrectly coded participants deviating by only one neurocognitive test. Cognitive recovery over time was comparable for groups with differing baseline cognitive function, irrespective of whether the Postoperative Quality of Recovery Scale or neuropsychological methods were used. Discriminant validation was demonstrated in a post-hoc analysis of the steroids in cardiac surgery substudy by allocating groups to normal (n = 246) or low-baseline cognition (n = 231) stratified by cognitive recovery on day 1. Recovery was similar for participants with low and normal baseline cognition. Postoperative length of stay was longer in patients with failed cognitive recovery whether they had normal mean (SD) (10.4 (10.0) vs. 8.0 (5.9) days, p = 0.02) or low-baseline cognition (12.0 (11.1) vs. 8.2 (4.7) days, p < 0.01). Overall quality, as well as cognitive, emotive and physiological recovery was independent of baseline cognition. The modified scoring method for the Postoperative Quality of Recovery Scale cognitive domain demonstrates acceptable face and discriminant validity.

Background Failed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients. Results Fifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmH2O and positive end expiratory pressure 5 cmH2O). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E′), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E′ (OR 1.27, 95% CI 1.05–1.54), left atrial area (OR 1.14, CI 1.02–1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73–61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01–1.82). Conclusions Failed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.