In Australia, sterile gowns are considered an essential component of aseptic technique for all neuraxial procedures. However, guidelines from professional societies vary worldwide, and the Australian ...and New Zealand College of Anaesthetists' (ANZCA) guidelines are the oldest currently in use. In the USA, Canada and Brazil, gowning is not considered to be a routine requirement when undertaking neuraxial anaesthesia. Recent guidelines published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI; 2020) acknowledge the importance of aseptic technique in central neuraxial blocks, but no longer state that gowning is required (as did the previous version of the guidance). However, AAGBI guidelines do recommend gowning for neuraxial procedures involving immunocompromised patients. The European and American Societies of Regional Anaesthesia (ESRA, ASRA) 2022 practice advisory guidelines recommend gowning for central neuraxial catheter placement in paediatric patients. ASRA guidelines state that routine gowning is not required for adults, and ESRA does not have guidelines relevant to gowning for adult patients. No explanation is given for this difference in recommendations.
Purpose
We set out to develop a real-time computerised decision support system (CDSS) embedded in the electronic health record (EHR) with information on risk factors, estimated risk, and ...guideline-based advice on treatment strategy in order to improve adherence to cardiovascular risk management (CVRM) guidelines with the ultimate aim of improving patient healthcare.
Methods
We defined a project plan including the scope and requirements, infrastructure and interface, data quality and study population, validation and evaluation of the CDSS.
Results
In collaboration with clinicians, data scientists, epidemiologists, ICT architects, and user experience and interface designers we developed a CDSS that provides ‘live’ information on CVRM within the environment of the EHR. The CDSS provides information on cardiovascular risk factors (age, sex, medical and family history, smoking, blood pressure, lipids, kidney function, and glucose intolerance measurements), estimated 10-year cardiovascular risk, guideline-compliant suggestions for both pharmacological and non-pharmacological treatment to optimise risk factors, and an estimate on the change in 10-year risk of cardiovascular disease if treatment goals are adhered to. Our pilot study identified a number of issues that needed to be addressed, such as missing data, rules and regulations, privacy, and patient participation.
Conclusion
Development of a CDSS is complex and requires a multidisciplinary approach. We identified opportunities and challenges in our project developing a CDSS aimed at improving adherence to CVRM guidelines. The regulatory environment, including guidance on scientific evaluation, legislation, and privacy issues needs to evolve within this emerging field of eHealth.
To evaluate the available published evidence of the effects of extracorporeal cardiopulmonary resuscitation (ECPR) in the prehospital setting on clinical outcomes in patients with out-of-hospital ...cardiac arrest.
A systematic review and meta-analysis designed according to the Preferred Reporting Items for Systematic Reviews an Meta-Analyses guidelines.
In the prehospital setting.
All randomized control trials (RCTs) and observational trials using pre-hospital ECPR in adult patients (>17 years).
Prehospital ECPR.
The study authors searched Medline, Embase, and PUBMED for all RCTs and observational trials. The studies were assessed for clinical, methodologic, and statistical heterogeneity. The primary outcome was survival at hospital discharge. The study outcomes were aggregated using random-effects meta-analysis of means or proportions as appropriate. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence. Four studies were included, with a total of 222 patients receiving prehospital ECPR (mean age = 51 years 95% CI 44-57, 81% of patients were male (CI 74-87), and 60% patients had a cardiac cause for their arrest (95% CI 43-76). Overall survival at discharge was 23.4% (95% CI 15.5-33.7; I2 = 62%). The pooled low-flow time was 61.1 minutes (95% CI 45.2-77.0; I2 = 97%). The quality of evidence was assessed to be low, and the overall risk of bias was assessed to be serious, with confounding being the primary source of bias.
No definitive conclusions can be made as to the efficacy of prehospital ECPR in refractory cardiac arrest. Higher quality evidence is required.
Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the ...international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of standardised and valid cardiovascular outcomes for use in future perioperative clinical trials.
We identified currently used perioperative cardiovascular outcomes by a systematic review of the anaesthesia and perioperative medicine literature (PubMed/Ovid, Embase, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 55 clinician researchers worldwide. Cardiovascular outcomes were first shortlisted and the most suitable definitions determined. These cardiovascular outcomes were then assessed for validity, reliability, feasibility, and clarity.
We identified 18 cardiovascular outcomes. Participation in the three Delphi rounds was 100% (n=19), 71% (n=55), and 89% (n=17), respectively. A final list of nine cardiovascular outcomes was elicited from the consensus: myocardial infarction, myocardial injury, cardiovascular death, non-fatal cardiac arrest, coronary revascularisation, major adverse cardiac events, pulmonary embolism, deep vein thrombosis, and atrial fibrillation. These nine cardiovascular outcomes were rated by the majority of experts as valid, reliable, feasible, and clearly defined.
These nine consensus cardiovascular outcomes can be confidently used as endpoints in clinical trials designed to evaluate perioperative interventions with the goal of improving perioperative outcomes.
Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised ...Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials.
We undertook a systematic review to identify measures of infection and sepsis used in the perioperative literature. A multi-round Delphi consensus process that included more than 60 clinician researchers was then used to refine a recommended list of outcome measures.
A literature search yielded 1857 titles of which 255 met inclusion criteria for endpoint extraction. A long list of endpoints, with definitions and timescales, was generated and those potentially relevant to infection and sepsis circulated to the theme subgroup and then the wider StEP-COMPAC working group, undergoing a three-stage Delphi process. The response rates for Delphi rounds 1, 3, and 3 were 89% (n=8), 67% (n=62), and 80% (n=8), respectively. A set of 13 endpoints including fever, surgical site, and organ-specific infections as defined by the US Centres for Disease Control and Sepsis-3 are proposed for future use.
We defined a consensus list of standardised endpoints related to infection and sepsis for perioperative trials using an established and rigorous approach. Each endpoint was evaluated with respect to validity, reliability, feasibility, and patient centredness. One or more of these should be considered for inclusion in future perioperative clinical trials assessing infection, sepsis, or both, thereby permitting synthesis and comparison of future results.
Mortality, morbidity, and organ failure are important and common serious harms after surgery. However, there are many candidate measures to describe these outcome domains. Definitions of these ...measures are highly variable, and validity is often unclear. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid measures of mortality, morbidity, and organ failure for use in perioperative clinical trials.
Three domains of endpoints (mortality, morbidity, and organ failure) were explored through systematic literature review and a three-stage Delphi consensus process using methods consistently applied across the StEP initiative. Reliability, feasibility, and patient-centredness were assessed in round 3 of the consensus process.
A high level of consensus was achieved for two mortality time points, 30-day and 1-yr mortality, and these two measures are recommended. No organ failure endpoints achieved threshold criteria for consensus recommendation. The Clavien–Dindo classification of complications achieved threshold criteria for consensus in round 2 of the Delphi process but did not achieve the threshold criteria in round 3 where it scored equivalently to the Post Operative Morbidity Survey. Clavien–Dindo therefore received conditional endorsement as the most widely used measure. No composite measures of organ failure achieved an acceptable level of consensus.
Both 30-day and 1-yr mortality measures are recommended. No measure is recommended for organ failure. One measure (Clavien–Dindo) is conditionally endorsed for postoperative morbidity, but our findings suggest that no single endpoint offers a reliable and valid measure to describe perioperative morbidity that is not dependent on the quality of deli-vered care. Further refinement of current measures, or development of novel measures, of postoperative morbidity might improve consensus in this area.
Objective
We assessed the added value of advanced echocardiography post hoc analysis for optimal decision-making in the Heart Valve Team (HVT) using an interactive, dynamic, live visualization system ...with true three-dimensional (3-D) stereo vision.
Methods
HVT scrutinized the incremental value of 3 consecutive methods of presentation of full-volume echocardiographic data sets in terms of diagnosis and possibility of repair in 11 selected patients having mitral regurgitation (MR)(Table 1). The questionnaire investigated consecutively (a) standard two-dimensional (2-D) transesophageal echocardiography, (b) single-beat 3-D zoom of the surgical view of the mitral valve, and (c) advanced 3-D volumetric rendering technology (Personal Space Station, Vesalius 3D software, PS-Medtech, Netherlands).
Results
In 4 of 11 reviews (36%), single-beat 3-D zoom had additional value over 2-D echocardiography in terms of mechanism/adjustments or adjustment of confirmation of diagnosis. Single-beat 3-D zoom had no additional value over 2-D echocardiography in terms of proposal/probability of repair. In 7 out of 11 (64%) reviews, true stereo 3-D visualization had additional value in terms of mechanism of pathology compared to 2-D and 3-D zoom and in 5 out of 11 (45%) reviews in confirmation of diagnosis. In 3 out of 11 (27%) reviews, true stereo 3-D visualization had additional value in terms of proposal of repair and in 4 of 11 (36%) in probability of repair over 2-D and 3-D zoom.
Conclusions
Advanced easy-to-use true 3-D echocardiography limited differences in interpretation and strengthened the confidence in understanding the mechanisms and suitability for repair of mitral valve regurgitation, typically in more complex valve pathology.
Photonic sensors have many applications in a range of physical settings, from measuring mechanical pressure in manufacturing to detecting protein concentration in biomedical samples. A variety of ...sensing approaches exist, and plasmonic systems in particular have received much attention due to their ability to confine light below the diffraction limit, greatly enhancing sensitivity. Recently, quantum techniques have been identified that can outperform classical sensing methods and achieve sensitivity below the so-called shot-noise limit. Despite this significant potential, the use of definite photon number states in lossy plasmonic systems for further improving sensing capabilities is not well studied. Here, we investigate the sensing performance of a plasmonic interferometer that simultaneously exploits the quantum nature of light and its electromagnetic field confinement. We show that, despite the presence of loss, specialized quantum resources can provide improved sensitivity and resolution beyond the shot-noise limit within a compact plasmonic device operating below the diffraction limit.
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