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Continuous monitoring of the respiratory rate is crucial in an acute care setting. Contact respiratory monitoring modalities such as capnography and thoracic impedance pneumography are prone to artifacts, causing false alarms. Moreover, their cables can restrict patient behavior or interrupt patient care. A microwave Doppler sensor is a novel non-contact continuous respiratory rate monitor. We compared respiratory rate measurements performed with a microwave Doppler sensor mounted on the ceiling of an intensive care unit with those obtained by conventional methods in conscious and spontaneously breathing patients. Participants' respiratory rate was simultaneously measured by visual counting of chest wall movements for 60 s; a microwave Doppler sensor; capnography, using an oxygen mask; and thoracic impedance pneumography, using electrocardiogram electrodes. Bland-Altman analysis for repeated measures was performed to calculate bias and 95% limits of agreement between the respiratory rate measured by visual counting (reference) and that measured by each of the other methods. Among 52 participants, there were 336 (microwave Doppler sensor), 275 (capnography), and 336 (thoracic impedance pneumography) paired respiratory rate data points. Bias (95% limits of agreement) estimates were as follows: microwave Doppler sensor, 0.3 (- 6.1 to 6.8) breaths per minute (bpm); capnography, - 1.3 (- 8.6 to 6.0) bpm; and thoracic impedance pneumography, 0.1 (- 4.4 to 4.7) bpm. Compared to visual counting, the microwave Doppler sensor showed small bias; however, the limits of agreement were similar to those observed in other conventional methods. Our monitor and the conventional ones are not interchangeable with visual counting.Trial registration number: UMIN000032021, March/30/2018.

Background Evidence in non-ischaemic cardiogenic shock (CS), especially regarding prognostic markers and use of mechanical circulatory support (MCS), is scarce. Aim The aim of this study was to evaluate left ventricular ejection fraction (LVEF) as a prognostic marker as well as a factor to guide the use of MCS in non-ischaemic CS. Methods In this international observational study, patients with non-ischaemic CS (e.g. caused by severe de-novo or acute on chronic heart failure; but not by acute myocardial infarction) treated with or without MCS from 18 tertiary-care centers in five countries were enrolled. Cox regression models adjusted for age, sex, SCAI class, lactate, prior resuscitation, mechanical ventilation and pH were fitted to evaluate the association between LVEF and 30-day mortality as well as the interaction between MCS use, LVEF and 30-day mortality. Results A total of 807 patients were enrolled, of whom 387 (47,9%) were treated with and 418 (52.1%) without MCS; mean age was 63 [interquartile range (IQR) 51.5–72) years, 601 (74.5%) were male, 486 (60.2%) had acute on chronic heart failure, 221 (32.7%) had an ischaemic cardiomyopathy and 277 (34.5%) had prior cardiac arrest. The baseline LVEF was 20 (IQR 15–30) % and baseline lactate was 4.9 (IQR 2.6–8.5) mmol/l. There was no significant association between LVEF and 30-day mortality risk [hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.74–1.22 if LVEF was considered as a continuous variable; HR 1.09, 95% CI 0.83–1.44 if LVEF was considered as a categorical variable with ≤20% vs. >20%]. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with a depressed LVEF (HR 0.74, 95% CI 0.52–1.05, interaction-p = 0.04). Conclusion In this retrospective, multicenter, international study of patients with non-ischaemic CS, LVEF was not a predictor of 30-day mortality risk. However, we observed a significant interaction between MCS use and LVEF, indicating a lower morality risk with MCS use only in patients with a depressed LVEF. This provides rationale to use LVEF as a parameter to guide MCS therapy in non-ischaemic CS, and calls for a randomized trial on this topic. Funding Acknowledgement Type of funding sources: None.

Background and purpose Activation of the immune system correlates with the severity and the prognosis of patients with heart failure (HF). Here, we aim to identify and characterize long non-coding RNAs (lncRNAs) as a potential mechanistic link between the activation of the immune system and the pathophysiology of HF. Methods and results Using next-generation sequencing we found a yet uncharacterized lncRNA to be significantly upregulated in peripheral blood mononuclear cells of ischemic cardiomyopathy patients compared to controls, which we named Heat4 – Heart-disease associated transcript 4 (N=4; 2.05-fold increase; p Conclusion The lncRNA Heat4 is elevated in the blood of patients with HF. Heat4 limits the extent of the inflammatory response of non-classical monocytes and leads to a faster regeneration after vascular injury. Heat4 is located in the cytoplasm of monocytes interacting with the pro-inflammatory proteins IP1/IP2 and repealing their extracellular release. Modulating Heat4 levels may represent a novel strategy for treatment of cardiovascular diseases with impaired vascular functions. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Projektfoerderung im Bereich der Herzmedizin, Leipzig

Aim To evaluate the impact of timing of active left ventricular (LV) unloading in relation to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation on outcomes of patients with cardiogenic shock (CS). Methods and results Data from 421 patients with CS treated with active LV unloading on top of VA-ECMO at 18 tertiary-care centers in 4 countries were collected. Only patients in whom both devices were implanted within 24 hours of each other were considered and patients were stratified by timing of device implantation in early vs. delayed active LV unloading (e.g. active LV unloading before vs. after VA-ECMO). Cox and logistic regression models (adjusted for age, sex, lactate, cardiopulmonary resuscitation (CPR), VA-ECMO assisted CPR and enrollment center) were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as several safety outcomes. Overall, 310 (73.6%) patients were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (hazard ratio 0.63, 95% confidence interval 0.46–0.87) and a higher likelihood of weaning from mechanical ventilation (odds ratio 1.25, 95% confidence interval 1.03–1.52), but not with more complications. Importantly, postponing active LV unloading in these patients was associated with higher mortality risk (Figure 1), and lower likelihood of successful weaning from mechanical ventilation. Conclusion This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO as a primary treatment strategy, as opposed to a bail-out approach. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Unrestricted research grant from Abiomed

Background The aim of this study was to evaluate mechanical circulatory support (MCS) for the treatment of non-ischemic cardiogenic shock (CS). Methods Data from 1,030 consecutive patients with non-ischemic CS treated with or without MCS at 16 tertiary-care centers were retrospectively collected. The association between MCS and 30-day mortality was assessed in a 1:1 propensity score matched cohort. Results MCS was used in 406 (39%) patients. MCS treated patients presented with more severe CS (lactate 5.4 vs. 4.1 mmol/l, systolic blood pressure 80 vs. 83 mmHg, higher SCAI class) and with more disease modifiers (prior cardiac arrest 42.4 vs. 36.1%, mechanical ventilation 78.4 vs. 56.5%). After matching, 272 patients treated with were compared vs. 272 patients treated without MCS. MCS was associated with a lower 30-day mortality (hazard ratio 0.77, 95% confidence interval 0.60–0.98, Figure 1). This finding was consistent through all tested sub-groups except when ejection fraction was considered, indicating an association especially in patients with an ejection fraction ≤20%. Complications occurred more frequently in patients with MCS; e.g. severe bleedings (21.8 vs. 9.2%) and access-site related ischemia (6.6 vs. 0%). Conclusion In patients with non-ischemic CS, MCS use was associated with lower 30-day mortality as compared to medical therapy only, particularly in patients with a lower ejection fraction. This provides rationale for randomized trials to validate these findings. Funding Acknowledgement Type of funding sources: None.

Background and purpose Cardiogenic shock (CS) remains the leading cause of death in acute myocardial infarction (AMI), with high mortality rates of 40–50%. The long non-coding RNA (lncRNA) Heat4 is associated with the inflammatory response of non-classical monocytes. Previous experimental work shows that this mechanism may be important in heart failure (HF) and during regeneration after vascular injury. Here, we investigate the association of Heat4 with survival in patients with chronic HF and assessed its regulation in AMI and CS. Methods and results Heat4 was elevated in the blood of HF patients compared to age-matched non-failing controls (+5.2-fold; HF: N=63; Controls: N=38; p Conclusion The lncRNA Heat4 is upregulated in the blood of patients with chronic heart failure, acute myocardial infarction and cardiogenic shock. In CS, Heat4 is dynamically regulated. These data set the stage to further assess Heat4 blood levels as a strategy for risk stratification and potential treatment target in HF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Projektfoerderung im Bereich der Herzmedizin, Leipzig

In light of the worsening opioid epidemic and nationwide parenteral opioid shortage, our institution created an enhanced recovery after surgery (ERAS) protocol. Our objective was to evaluate our initial experience transitioning to ERAS in cardiac surgery. An institutional cardiac ERAS protocol was implemented in April 2018, consisting of opioid-sparing analgesia, liberalization of fasting and activity restrictions, and goal-directed standardization of perioperative care. Clinical outcomes, opioid administration, and pain scores of patients undergoing nonemergent cardiac surgery were reviewed from March 2017 to July 2018. Patients were propensity score matched into pre-ERAS and transition-to-ERAS (t-ERAS) cohorts and compared by univariate analysis. Of 467 patients, 236 patients were well-matched (118 per cohort). The transition to ERAS resulted in a 79% reduction in morphine equivalents through postoperative day 1 (359.3 mg pre-ERAS vs 75.4 mg ERAS, P0.0001). Despite less opioid utilization, t-ERAS patients reported lower pain scores (median 4.88 vs 4.14, P = 0.011). There was no difference in mortality (2% vs 0%, P = 0.498) or postoperative complications including initial hours ventilated (5.3 vs 5.2 hours, P = 0.380), prolonged ventilation (9.3% vs 6.8%, P = 0.473), renal failure (3.4% vs 2.5%, P = 0.701), and ICU length of stay (58.3 vs 70.4 hours, P = 0.272). The transition to cardiac ERAS resulted in significantly reduced opioid administration and improved patient pain scores while maintaining excellent outcomes. Well-supported, multidisciplinary teams of cardiac surgeons, anesthesiologists, and intensivists can dramatically reduce opioid use without sacrificing pain control or excellent clinical outcomes.

BACKGROUND: While total sleep duration and rapid eye movement (REM) sleep duration have been associated with long-term mortality in non-surgical cohorts, the impact of preoperative sleep on postoperative outcomes has not been well-studied. METHODS: In this secondary analysis of a prospective observational cohort study, patients who recorded at least 1 sleep episode using a consumer wearable device in the 7 days before elective colorectal surgery were included. 30-day postoperative outcomes among those who did and did not receive at least 6 hours of total sleep, as well as those who did and did not receive at least 1 hour of rapid eye movement (REM) sleep were compared. RESULTS: 34 out of 95 (35.8%) patients averaged at least 6 hours of sleep per night, while 44 out of 82 (53.7%) averaged 1 hour or more of REM sleep. Patients who slept less than 6 hours had similar postoperative outcomes compared to those who slept 6 hours or more. Patients who averaged less than 1 hour of REM sleep, compared to those who achieved 1 hour or more of REM sleep, had significantly higher rates of complication development (29.0% vs. 9.1%, P=0.02), and return to the OR (10.5% vs. 0%, P=0.04). After adjustment for confounding factors, increased REM sleep duration remained significantly associated with decreased complication development (increase in REM sleep from 50 to 60 min: OR 0.72, P=0.009; REM sleep ≥ 1 hour: OR 0.22, P=0.03). CONCLUSION: In this cohort of patients undergoing elective colorectal surgery, those who developed a complication within 30 days were less likely to average at least 1 hour of REM sleep in the week before surgery than those who did not develop a complication. Preoperative REM sleep duration may represent a risk factor for surgical complications, however additional research is necessary to confirm this relationship.

Human beings are predisposed to identifying false patterns in statistical noise, a likely survival advantage during our evolutionary development. Moreover, humans seem to prefer "positive" results over "negative" ones. These two cognitive features lay a framework for premature adoption of falsely positive studies. Added to this predisposition is the tendency of journals to "overbid" for exciting or newsworthy manuscripts, incentives in both the academic and publishing industries that value change over truth and scientific rigour, and a growing dependence on complex statistical techniques that some reviewers do not understand. The purpose of this article is to describe the underlying causes of premature adoption and provide recommendations that may improve the quality of published science.

The proliferation of wearable technology presents a novel opportunity for perioperative activity monitoring; however, the association between perioperative activity level and readmission remains underexplored. This study sought to determine whether physical activity data captured by wearable technology before and after colorectal surgery can be used to predict 30-day readmission. In this prospective observational cohort study of adults undergoing elective major colorectal surgery (January 2018 to February 2019) at a single institution, participants wore an activity monitor 30 days before and after surgery. The primary outcome was return to baseline percentage, defined as step count on the day before discharge as a percentage of mean preoperative daily step count, among readmitted and non-readmitted patients. 94 patients had sufficient data available for analysis, of which 16 patients (17.0%) were readmitted within 30 days following discharge. Readmitted patients achieved a lower return to baseline percentage compared to patients who were not readmitted (median 15.1% vs. 31.8%; P = 0.004). On multivariable analysis adjusting for readmission risk and hospital length of stay, an absolute increase of 10% in return to baseline percentage was associated with a 40% decreased risk of 30-day readmission (odds ratio 0.60; P = 0.02). Analysis of the receiver operating characteristic curve identified 28.9% as an optimal return to baseline percent threshold for predicting readmission. Achieving a higher percentage of an individual’s preoperative baseline activity level on the day prior to discharge after major colorectal surgery is associated with decreased risk of 30-day hospital readmission.

Invasive hemodynamics may provide a more nuanced assessment of cardiac function and risk phenotyping in patients undergoing cardiac surgery. The systemic pulse pressure (SPP) to central venous pressure (CVP) ratio represents an integrated index of right and left ventricular function and thus may demonstrate an association with valvular heart surgery outcomes. This study hypothesized that a low SPP/CVP ratio would be associated with mortality in valvular surgery patients.This retrospective cohort study examined adult valvular surgery patients with preoperative right heart catheterization from 2007 through 2016 at a single tertiary medical center (n = 215). Associations between the SPP/CVP ratio and mortality were investigated with univariate and multivariate analyses.Among 215 patients (age 69.7 ± 12.4 years; 55.8% male), 61 died (28.4%) over a median follow-up of 5.9 years. A SPP/CVP ratio7.6 was associated with increased mortality (relative risk 1.70, 95% confidence interval [CI] 1.08-2.67, p = .019) and increased length of stay (11.56 ± 13.73 days vs. 7.93 ± 4.92 days, p = .016). It remained an independent predictor of mortality (adjusted odds ratio 3.99, 95% CI 1.47-11.45, p = .008) after adjusting for CVP, mean pulmonary artery pressure, aortic stenosis, tricuspid regurgitation, smoking status, diabetes mellitus, dialysis, and cross-clamp time.A low SPP/CVP ratio was associated with worse outcomes in patients undergoing valvular heart surgery. This metric has potential utility in preoperative risk stratification to guide patient selection, prognosis, and surgical outcomes.

In patients at high risk of respiratory complications, pulse oximetry may not adequately detect hypoventilation events. Previous studies have proposed using thermography, which relies on infrared imaging, to measure respiratory rate (RR). These systems lack support from real-world feasibility testing for widespread acceptance. This study enrolled 101 spontaneously ventilating patients in a post-anesthesia recovery unit. Patients were placed in a 45° reclined position while undergoing pulse oximetry and bioimpedance-based RR monitoring. A thermography camera was placed approximately 1 m from the patient and pointed at the patient’s face, recording continuously at 30 frames per second for 2 min. Simultaneously, RR was manually recorded. Offline imaging analysis identified the nares as a region of interest and then quantified nasal temperature changes frame by frame to estimate RR. The manually calculated RR was compared with both bioimpedance and thermographic estimates. The Pearson correlation coefficient between direct measurement and bioimpedance was 0.69 (R2 = 0.48), and that between direct measurement and thermography was 0.95 (R2 = 0.90). Limits of agreement analysis revealed a bias of 1.3 and limits of agreement of 10.8 (95% confidence interval 9.07 to 12.5) and − 8.13 (− 6.41 to − 9.84) between direct measurements and bioimpedance, and a bias of −0.139 and limits of agreement of 2.65 (2.14 to 3.15) and − 2.92 (− 2.41 to 3.42) between direct measurements and thermography. Thermography allowed tracking of the manually measured RR in the post-anesthesia recovery unit without requiring patient contact. Additional work is required for image acquisition automation and nostril identification. Electronic supplementary material The online version of this article (10.1007/s10877-020-00595-8) contains supplementary material, which is available to authorized users.

The authors discuss minimally invasive and noninvasive cardiac output monitoring technologies available in the clinical practice and how to evaluate these systems objectively.

Some neurological complications following surgery have been related to a mismatch in cerebral oxygen supply and demand that may either lead to more subtle changes of brain function or overt complications like stroke or coma. Discovery of a perioperative neurological complication may be outside the treatment window, thereby making prevention an important focus. Early commercial devices used differential spectroscopy to measure relative changes from baseline of 2 chromophores: oxy- and deoxyhemoglobin. It was the introduction of spatially resolved spectroscopy techniques that allowed near-infrared spectroscopy (NIRS)-based cerebral oximetry as we know it today. Modern cerebral oximeters measure the hemoglobin saturation of blood in a specific "optical field" containing arterial, capillary, and venous blood, not tissue oxygenation itself. Multiple cerebral oximeters are commercially available, all of which have technical differences that make them noninterchangeable. The mechanism and meaning of these measurements are likely not widely understood by many practicing physicians. Additionally, as with many clinically used monitors, there is a lack of high-quality evidence on which clinicians can base decisions in their effort to use cerebral oximetry to reduce neurocognitive complications after surgery. Therefore, the Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together an international team of multidisciplinary experts including anesthesiologists, surgeons, and critical care physicians to objectively survey the literature on cerebral oximetry and provide consensus, evidence-based recommendations for its use in accordance with the GRading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature. The group produced the following consensus recommendations: (1) interpreting perioperative cerebral oximetry measurements in the context of a preinduction baseline value; (2) interpreting perioperative cerebral oximetry measurements in the context of the physiologic variables that affect them; (3) using caution in comparing cerebral oximetry values between different manufacturers; (4) using preoperative cerebral oximetry to identify patients at increased risk of adverse outcomes after cardiac surgery; (5) using intraoperative cerebral oximetry indexed to preinduction baseline to identify patients at increased risk of adverse outcomes after cardiac surgery; (6) using cerebral oximetry to identify and guide management of acute cerebral malperfusion during cardiac surgery; (7) using an intraoperative cerebral oximetry-guided interventional algorithm to reduce intensive care unit (ICU) length of stay after cardiac surgery. Additionally, there was agreement that (8) there is insufficient evidence to recommend using intraoperative cerebral oximetry to reduce mortality or organ-specific morbidity after cardiac surgery; (9) there is insufficient evidence to recommend using intraoperative cerebral oximetry to improve outcomes after noncardiac surgery.

Despite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.An ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).We included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P 0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P 0.001), lower peak pain scores (7 [5-9] vs 8 [7-9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P 0.001) were found after the introduction of the ERAS protocol.Implementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications. Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naive patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications. 707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p

The implementation of protocolized care pathways has resulted in major improvements in surgical outcomes. Additional gains will require focused efforts to alter preexisting risk. Prehabilitation programs provide a promising avenue for risk reduction.This study used wearable technology to monitor activity levels before colorectal surgery to evaluate the impact of preoperative activity on postoperative outcomes.This was a prospective nonrandomized observational study.The study was conducted at a large academic medical center.Patients undergoing elective colorectal surgery from January 2018 to February 1, 2019, were included.Patients were trained in the usage of wearable activity-tracking devices and instructed to wear the device for 30 days before surgery. Patients were stratified as active (≥5000 steps per day) and inactive (5000 steps per day) based on preoperative step counts. Univariate analyses compared postoperative outcomes. Multivariable regression models analyzed the impact of preoperative activity on postoperative complications, adjusting for each patient's baseline risk as calculated using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. Models were rerun without the addition of activity and the predictive ability of the models compared.Ninety-nine patients were included, with 40 (40.4%) classified as active. Active patients experienced fewer overall complications (11/40 (27.5%) vs 33/59 (55.9%); p = 0.005) and serious complications (2/40 (5%) vs 12/59 (20.3%); p = 0.032). Increased preoperative activity was associated with a decreased risk of any postoperative complication (OR = 0.386; p = 0.0440) on multivariable analysis. The predictive ability of the models for complications and serious complications was improved with the addition of physical activity.The study was limited by its small sample size and single institution.There is significant room for improvement in baseline preoperative activity levels of patients undergoing colorectal surgery, and poor activity is associated with increased postoperative complications. These data will serve as the basis for an interventional trial investigating whether wearable devices help improve surgical outcomes through a monitored preoperative exercise program. See Video Abstract at http://links.lww.com/DCR/B145. TECNOLOGÍA PORTÁTIL EN EL PERÍODO PERIOPERATORIO: PREDICCIÓN DEL RIESGO DE COMPLICACIONES POSTOPERATORIAS EN PACIENTES SOMETIDOS A CIRUGÍA COLORRECTAL ELECTIVA: La implementación de vías de atención protocolizadas ha dado lugar a importantes mejoras en los resultados quirúrgicos. Para obtener más beneficios será necesario realizar esfuerzos concentrados para modificar el riesgo preexistente. Los programas de rehabilitación proporcionan una vía prometedora para la reducción del riesgo.Este estudio utilizó tecnología portátil para monitorear los niveles de actividad antes de la cirugía colorrectal para evaluar el impacto de la actividad preoperatoria en los resultados postoperatorios.Estudio observacional prospectivo no aleatorizado.Gran centro médico académico.Pacientes sometidos a cirugía colorrectal electiva desde enero de 2018 hasta el 1 de febrero de 2019.Los pacientes fueron entrenados en el uso de dispositivos portátiles para el seguimiento de la actividad y se les indicó usar el dispositivo durante 30 días antes de la cirugía. Los pacientes fueron estratificados como activos (5000 pasos / día) e inactivos (5000 pasos / día) en base a los recuentos de pasos preoperatorios. Los análisis univariados compararon los resultados postoperatorios. Los modelos de regresión multivariable analizaron el impacto de la actividad preoperatoria en las complicaciones postoperatorias, ajustando el riesgo de referencia de cada paciente según lo calculado utilizando la Calculadora de riesgo quirúrgico del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos. Los modelos se volvieron a ejecutar sin agregar actividad, y se comparó la capacidad de predicción de los modelos.Noventa y nueve pacientes fueron incluidos con 40 (40.4%) clasificados como activos. Los pacientes activos experimentaron menos complicaciones generales [11/40 (27,5%) frente a 33/59 (55,9%); p = 0,005] y complicaciones graves [2/40 (5%) frente a 12/59 (20,3%); p = 0,032]. El aumento de la actividad preoperatoria se asoció con una disminución del riesgo de cualquier complicación postoperatoria (OR 0.386, p = 0.0440) en el análisis multivariable. La capacidad predictiva de los modelos para complicaciones y complicaciones graves mejoró con la adición de actividad física.Tamaño de muestra pequeño, una sola institución.Existe un margen significativo para mejorar los niveles basales de actividad preoperatoria de los pacientes de cirugía colorrectal, y la escasa actividad se asocia con mayores complicaciones postoperatorias. Estos datos servirán de base para un ensayo intervencionista que investigue si los dispositivos portátiles ayudan a mejorar los resultados quirúrgicos a través de un programa de ejercicio preoperatorio monitoreado. Consulte Video Resumen en http://links.lww.com/DCR/B145.

Funding Acknowledgements Type of funding sources: None. Background Left atrial reservoir strain (LARS) provides prognostic information in various patient groups and might help to detect elevated filling pressures. Patients with diastolic dysfunction experience worse outcomes after transcatheter aortic valve implantation (TAVI), but Doppler-derived measurements might be hampered by atrial fibrillation, mitral valve disease or impaired image quality. Aim of the current study is to elucidate the prognostic value of LASR in patients undergoing TAVI. Methods All consecutive patients undergoing TAVI at a single tertiary care hospital between 01/2018 and 12/2018 were included if discharge echo and follow-up was available. LASR was derived from 2-D-speckle-tracking averaged apical 2- and 4-chamber view. Patients were grouped in 3 tertiles according to LASR. Primary outcome was a composite of all-cause death and readmission for worsening heart failure. Results Overall, 606 patients were available (Age 80 years (IQR 77-84)), including 53% woman. LASR was significantly impaired over tertiles (T1 21.4 (IQR 18.3-24.5), T2 13.0 (IQR 11.3-14.6), T3 7.1 (IQR 5.4-8.4), p On multivariable Cox-regression analysis LASR was a significant factor to predict outcome (HR 0.95, CI 0.91-0.99, p = 0.02). Conclusion Impaired LASR is associated with impaired outcomes in patients undergoing TAVI.

Non-alcoholic fatty liver disease (NAFLD) is a potentially serious liver disease that affects approximately one-quarter of the global adult population, causing a substantial burden of ill health with wide-ranging social and economic implications. It is a multisystem disease and is considered the hepatic component of metabolic syndrome. Unlike other highly prevalent conditions, NAFLD has received little attention from the global public health community. Health system and public health responses to NAFLD have been weak and fragmented, and, despite its pervasiveness, NAFLD is largely unknown outside hepatology and gastroenterology. There is only a nascent global public health movement addressing NAFLD, and the disease is absent from nearly all national and international strategies and policies for non-communicable diseases, including obesity. In this global Delphi study, a multidisciplinary group of experts developed consensus statements and recommendations, which a larger group of collaborators reviewed over three rounds until consensus was achieved. The resulting consensus statements and recommendations address a broad range of topics — from epidemiology, awareness, care and treatment to public health policies and leadership — that have general relevance for policy-makers, health-care practitioners, civil society groups, research institutions and affected populations. These recommendations should provide a strong foundation for a comprehensive public health response to NAFLD. © 2021, Springer Nature Limited.

The authors have requested that this preprint be removed from Research Square.

BACKGROUND Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS The study was conducted at a large academic medical center. PATIENTS All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACION DE UN PROTOCOLO DE RECUPERACION ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CANCER COLORRECTAL:: El inicio tardio de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cancer colorrectal. Los protocolos de recuperacion acelerada colorrectales dan lugar a una disminucion de las complicaciones y la duracion de estancia hospitalaria; sin embargo, el impacto de la recuperacion acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administracion a tiempo de la quimioterapia adyuvante despues de la cirugia de cancer colorrectal, con la hipotesis de que la implementacion de un protocolo de recuperacion acelerada daria lugar a que mas pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administracion de quimioterapia adyuvante a tiempo despues de la reseccion del cancer colorrectal antes y despues de la implementacion de un protocolo de recuperacion acelerada.Centro medico academico grande.Todos los pacientes que se sometieron a resecciones de cancer colorrectal no emergentes con intencion curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenian indicacion de quimioterapia adyuvante, que recibieron quimioterapia sistemica preoperatoria o no tenian registros medicos de oncologia disponibles.Los pacientes se compararon antes y despues de la implementacion de la recuperacion acelerada, con la tasa de administracion de quimioterapia adyuvante a tiempo como el resultado primario. La administracion de quimioterapia adyuvante se considero a tiempo si se inicio ≤8 semanas despues de la operacion, y el tratamiento se considero retrasado / omitido si se inicio> 8 semanas despues de la operacion (retrasado) o nunca fue recibido (omitido). La regresion logistica multivariable identifico predictores de administracion de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusion, con 189 (52.1%) pacientes sometidos a cirugia despues de la implementacion de recuperacion acelerada. Los grupos difirieron en el abordaje laparoscopico y la duracion media del procedimiento; ambos factores fueron mayores despues de la recuperacion acelerada. Significativamente mas pacientes recibieron quimioterapia a tiempo despues de la implementacion de recuperacion acelerada (p = 0.007). La recuperacion acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseno retrospectivo, tipo ¨antes y despues¨ no aleatorizado.La recuperacion acelerada se asocio con la recepcion de quimioterapia adyuvante a tiempo. Debido a que el inicio rapido de la quimioterapia adyuvante mejora la supervivencia en el cancer colorrectal, en el futuro sera necesario investigar los resultados oncologicos a largo plazo para evaluar el impacto potencial de la recuperacion acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

The accumulation of tracheobronchial secretions may contribute to a deterioration in pulmonary function and its early detection is important. In this study, we analyzed the respiratory sound spectrum in patients with intratracheal secretion, and compared acoustic characteristics before and after therapeutic endotracheal suctioning. After review of anesthetic records of liver transplant recipients, we included recipients with identified intratracheal secretion during surgery. Intraoperative breath sounds recorded through esophageal stethoscope were sampled in 20 s-period before and after suctioning of secretion and analyzed using fast Fourier transform. We also analyzed normal breath sounds from recipients without any respiratory problem as control group. The maximal power (dBmMax), total power from whole frequency range of 80–500 Hz (Pt), total power of each frequency range (80–200 Hz, P80–200; 200–300 Hz, P200–300; 300–400 Hz, P300–400; 400–500 Hz, P400–500), and their ratio (P80–200/Pt, P200–300/Pt, P300–400/Pt, P400–500/Pt) were compared. Breath sounds were obtained from 20 recipients; 9 pairs of breath sound before and after suctioning of secretion and 11 normal breath sounds. Patients with intratracheal secretion showed significantly higher P80–200, P200–300, P300–400, P400–500 when compared to the those of normal control patients (P = 0.003, P = 0.002, and P = 0.009, respectively), while dBmMax did not differ. Elimination of secretions attenuated P80–200, P200–300, P300–400, and P400–500 by 22.4%, 25.7%, 48.5%, and 15.3%, respectively (P = 0.002, 0.024, 0.009, and 0.016, respectively). Identifying the presence of intratracheal secretions with power ratio at 80–200 Hz and 300–400 Hz showed the highest area under the curve of 0.955 in receiver operating characteristic curve analysis. We suggest that spectral analysis of breath sounds obtained from the esophageal stethoscope might be a useful non-invasive respiratory monitor for accumulation of intratracheal secretion. Further prospective studies to evaluate the utility of acoustic analysis in surgical patients are warranted.

Arterial blood pressure monitoring is a major part of the decision-making process for every anesthetic. It is important to recognize the advantages, disadvantages, and limitations of available measurement modalities as well as have some understanding of the engineering principles on which these measurements are based. Oscillometry is by far the most common modality used but is limited by its intermittent nature and inaccuracy during hypotension and hypertension. Arterial catheterization is the gold standard for measuring blood pressure but is an invasive procedure that is expensive and not without risk of harm to the patient. Volume clamp and tonometric technologies are relatively new and allow for continuous noninvasive monitoring of the blood arterial waveform, but their accuracy when compared with oscillometry is not well described, and they have not been widely incorporated into standard practice. Additional research is needed to determine whether continuous noninvasive blood pressure monitors can improve outcomes.

BACKGROUND Pain management following major spine surgery requires high doses of opioids and is associated with a risk of opioid-induced constipation. Peripheral mu-receptor antagonists decrease the gastrointestinal complications of perioperative systemic opioid administration without antagonizing the analgesic benefits of these drugs. OBJECTIVE To investigate the impact of alvimopan in opioid-naive patients undergoing major spine surgery. METHODS Patients undergoing >3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective, randomized, double-blind study to receive either alvimopan or placebo prior to and following surgery. Opioid consumption; pain scores; and time of first oral intake, flatus, and bowel movement were recorded. RESULTS A total of 24 patients were assigned to the active group and 25 were assigned to the placebo group. There was no significant difference in demographics between the groups. Postoperatively, the alvimopan group reported earlier time to first solid intake [median (range): alvimopan: 15 h (3-25) vs placebo: 17 h (3-46), P

While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (

Background: Hepatic dysfunction plays a major role in adverse outcomes in sepsis. Volatile anesthetic agents may protect against organ dysfunction in the setting of critical illness and infection. The goal of this study was to study the impact of Sepsis-inflammation on hepatic subcellular energetics in animals anesthetized with both Propofol (intravenous anesthetic agent and GABA agonist) and Isoflurane (volatile anesthetic i.e., VAA).Methods: Sprague-Dawley rats were anesthetized with Propofol or isoflurane. Rats in each group were randomized to celiotomy and closure (control) or cecal ligation and puncture “CLP” (Sepsis-inflammation) for 8 h.Results: Inflammation led to upregulation in hepatic hypoxia-inducible factor-1 in both groups. Rats anesthetized with isoflurane also exhibited increases in bcl-2, inducible nitric oxide synthase, and heme oxygenase-1(HO-1) during inflammation, whereas rats anesthetized with Propofol did not. In rats anesthetized with isoflurane, decreased mRNA, protein (Complex II, IV, V), and activity levels (Complex II/III,IV,V) were identified for all components of the electron transport chain, leading to a decrease in mitochondrial ATP. In contrast, in rats anesthetized with Propofol, these changes were not identified after exposure to inflammation. RNA-Seq and real-time quantitative PCR (qPCR) expression analysis identified a substantial difference between groups (isoflurane vs. Propofol) in mitogen-activated protein kinase (MAPK) related gene expression following exposure to Sepsis-inflammation.Conclusions: Compared to rats anesthetized with Propofol, those anesthetized with isoflurane exhibit more oxidative stress, decreased oxidative phosphorylation protein expression, and electron transport chain activity and increased expression of organ-protective proteins.

Background Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care. Methods Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model. Results There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period. Conclusions Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.

The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects.Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions.A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.HINTERGRUND: Diese Leitlinie ( http://leitlinien.net ) fokussiert ausschließlich auf den infarktbedingten kardiogenen Schock (IKS). Beide Strategien, sowohl die kardiologisch/herzchirurgische als auch die intensivmedizinische, sind zur erfolgreichen Behandlung und zum Überleben der Patienten mit IKS essenziell. Dennoch beschäftigen sich sowohl die europäischen als auch die amerikanischen Leitlinien zu Herzinfarkt und Herzinsuffizienz und auch die Positionspapiere zum kardiogenen Schock nahezu ausschließlich mit den kardiologischen Aspekten.In einem nominalen Gruppenprozess der Delegierten der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung (DGK), der Deutschen Gesellschaft für Internistische Intensiv- und Notfallmedizin (DGIIN), der Deutschen Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG), der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), der Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin (ÖGIAIN), der Österreichischen Kardiologischen Gesellschaft (ÖKG), der Deutschen Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen (DGPR) und der Deutschen Interdisziplinären Vereinigung für Intensivmedizin (DIVI) wurden unter Leitung der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) die Evidenzen zur Diagnose, zum Monitoring und zur Therapie des IKS systematisch gesammelt und – darauf aufbauend – Empfehlungen ausgearbeitet. Lag jeweils nur geringe Evidenz zum IKS vor, wurden auch Studienergebnisse generell zu Intensivpatienten gesichtet und dargestellt, um Analogieschlüsse zu erlauben.Es wurden 95 Empfehlungen – inklusive zweier Statements – erarbeitet und darauf basierend 7 Algorithmen mit konkreten Anweisungen zum Handlungsablauf.