An observational trial comparing a novel continuous glucose monitor (GlySure) with standard intermittent point-of-care testing
Balciunas, M.*1, Klein, AA.2, Vuylsteke, A.2, Blaskovics, I.3, Cole, O.3, Salaunkey, K.2.
1 Locum Consultant in Cardiothoracic Anaesthesia and Intensive Care, Papworth NHS Foundation Trust, UK.
2 Consultant in Cardiothoracic Anaesthesia and Intensive Care, Papworth NHS Foundation Trust, UK.
3 Fellow in Cardiothoracic Anaesthesia and Intensive Care, Papworth NHS Foundation Trust, UK.
Purpose: Continuous glucose monitoring is designed to facilitate glycaemic control and to reduce frequency of episodes of hypo- and hyper-glycaemia that have been associated with increased morbidity and mortality. The aim of our observational study was to evaluate the diagnostic accuracy of a novel continuous intravascular glucose monitoring system – GlySure.
Methods: Non-randomised, non-treatment prospective study was performed in a single tertiary 28 bedded cardiothoracic critical care unit at Papworth Hospital. We compared patients’ glucose levels obtained from the Glysure (GlySure Limited, UK) with the reference value given by RAPIDLab1200 (Siemens Healthcare GmbH, Germany) blood gas analyser. Mean absolute relative deviation and consensus error grid analysis was used to compare the accuracy of the novel system with the reference method.
Results: Nine post cardiac surgery patients were monitored for a total of 149 hours (16.5±3.1 per patient) and 103 paired blood glucose samples were obtained (11.4±2.4 per patient). The measured glucose level did not differ significantly between control and novel devices (8.4±1.7mmol/L vs 8.6±1.5mmol/L, p=0.38, respectively). We found strong positive correlation between the novel device and reference (r=0.75; p < 0.001). The mean absolute relative deviation of the continuous glucose measurements was 9.6%. Consensus error grid analysis of the data showed that 85.5% of paired data points were in zone A and 14.5% -in zone B.
Conclusions: We found a good correlation between the novel continuous intravascular glucose measurement system “Glysure”; and the reference method. Implementation of continuous intravascular glucose monitoring may provide accurate continuous glucose measurement with lower medical staff workload.
Nutritional immunomodulation and short-term postoperative outcomes in malnourished patients undergoing cardiac surgery
Svetikiene M1, Isajevas V1, Vicka V2, Rackauskaite S2, Ringaitiene D1, Sipylaite J1
1Clinic of Anaesthesiology and Intensive Care, Vilnius University, Faculty of Medicine, Vilnius, Lithuania
2Vilnius University, Faculty of Medicine, Vilnius, Lithuania
Rationale. The research in cardiac surgery field underlines the importance of malnutrition (MN) and appropriate nutritional therapy. The aim of this study is to determine whether nutritional immunomodulation (IM) has an effect on short-term outcomes in patients undergoing cardiac surgery.
Methods. This was a randomised control study. Patients scheduled for elective cardiac surgery were enrolled using selection criteria designed to form a low operative risk homogenous MN cohort. The patients were randomised into IM and control groups. The IM group was supplemented with immune nutrients for 5 postoperative days. The short-term postoperative outcomes were defined using Society of Thoracic Surgeons (STS) definitions. The differences between the groups were evaluated by Fishers exact and Mann-Whitney tests. The regression analysis was conducted to determine the effect of IM on STS outcomes.
Results. 36 patients were enrolled into study, 50% of them were men (n=18). 47.2% (n=17) were assigned to the IM group and 52.8% (n=19) to the control group. There were no differences in the operative risk measured by STS as well as there were no differences in demographic, operative and immune markers amongst the groups (p>0.05). The analysis of STS outcomes distribution among the IM and control groups revealed the higher rates of prolonged stay in hospital in the control group (57.9% (n=11) vs 17.6% (n=3) p=0.019). Furthermore, the median postoperative stay was higher in the control group (16 [14-19] vs 13.0 [10.5-14.0] p=0.004). Logistic regression analysis determined 6.42 times lesser risk of the prolonged hospitalisation for the IM group (95% CI: 1.37-30.05 p=0.018). However, there were no relationships with IM and other STS outcomes.
Conclusions. The postoperative nutritional IM shortens the postoperative stay in hospital after cardiac surgery. These findings ground the need of further studies designed to establish the link between the IM and overall morbidity of the patients.
Nutritional immunomodulation in malnourished patients undergoing cardiac surgery
Svetikiene M1, Ringaitiene D1, Isajevas V1, Vicka V2, Rackauskaite S2, Malickaite R3, Jurgauskiene L3, Ringaitiene D1, Serpytis M1, , Sipylaite J1
1Clinic of Anaesthesiology and Intensive Care, Vilnius University, Faculty of Medicine, Vilnius, Lithuania
2Vilnius University, Faculty of Medicine, Vilnius, Lithuania
3Clinic of Cardiovascular Diseases, Vilnius University, Faculty of Medicine, Vilnius, Lithuania
Rationale. The research in cardiac surgery field underlines the relationship of malnutrition (MN) and immune function. The aim of this study is to determine whether nutritional immunomodulation is effective in patients undergoing cardiac surgery.
Methods. This was a randomised control study. The patients scheduled for elective cardiac surgery were enrolled using selection criteria designed to form a low operative risk homogenous MN cohort. The patients were randomised into immunomodulation (IM) and control groups. The IM group was supplemented with immune nutrients for five postoperative days. The immune function was tested on the surgery and on the 6th postoperative day by sampling blood for CD4 count, CD8 count and CD4/CD8 ratio. The differences between and within the groups were evaluated with Independent Samples t-test and regression analysis.
Results. 36 patients were enrolled into the study, 47.2% (n=17) of them in IM group and 52.8% (n=19) in control group. 50% of them were men (n=18) with a whole groups mean age of 70.36±4.79 and operative risk of 1.58±0.53 as measured by Euroscore II. There were no differences in demographic, operative and immune markers amongst the IM and control groups on the surgery day (p>0.05). On the 6th postoperative day there was an increase in CD4/CD8 ratio in the IM group (2.31±0.92 vs 3.02±1.34 p=0.001), mainly as a result of decrease in the CD8 count (26.26±8.57 vs 21.14±7.11 p=0.003). There were no changes of these markers in the control group, as well as there were no changes in the CD4 count. The linear regression analysis of the CD4/CD8 ratios within the groups revealed the strong correlation in the IM group (R=0.884 p<0.001) and only weak correlation in the control group (R=0.535 p=0.018).
Conclusions. The postoperative nutritional immunomodulation is beneficial for cardiac surgery patients. These patients tend to have higher CD4/CD8 ratios, which grounds the presumption of better immune function and clinical outcome.
Perioperative pulmonary aspiration in Tartu University Hospital during 2011-2014
Ehrlich HE, Karjagin J
Department of Anaesthesiology, Tartu University Hospital, Tartu, Estonia
Aspiration pneumonitis is a rare anaesthesia-related complication which is caused by perioperative regurgitation and aspiration of gastric contents. The objective of our study was to retrospectively determine the incidence, management and risk factors of perioperative aspiration pneumonitis cases in Tartu University Hospital during 2011-2014. Similar studies have been done in other centres but there is a lack of data about perioperative aspiration pneumonitis in Estonia.
We performed a retrospective cross-sectional study. Our study group included 80133 anaesthesia cases in Tartu University Hospital during 2011-2014 (both adults and children) from which 17387 (21.7 %) were emergency cases. We found 44 patients with confirmed regurgitation of gastric contents using our anaesthetic incidence reporting database and electronic health records. Perioperative aspiration was discriminated from passive regurgitation by presence of gastric contents in tracheobronhial tree and/or radiographic evidence. Cases were studied individually by one researcher to determine the diagnosis, risk factors and management of these patients.
44 patients in study group had regurgitation of gastric contents and 20 cases had confirmed perioperative pulmonary aspiration. 33 patients had risk factors for regurgitation and 24 patients had multiple risk factors; the most frequent risk factors were emergency surgery and gastro-enteral pathology. Anaesthetic management did not affect the frequency of aspiration nor outcome. Patients who aspirated regurgitated gastric contents were more likely to develop respiratory symptoms. 4 patients with confirmed pulmonary aspiration died due to pulmonary complications. Incidence of perioperative regurgitation of gastric contents was 1:1821, incidence of aspiration pneumonitis 1:4007 and mortality 1:20033.
Factors influencing microvascular anastomotic thrombosis risk in free flap surgery: review of the literature
Stepanovs, J., Riga Eastern Clinical University Hospital, Riga, LATVIA
Drizlionoka-Gorovenko, K., Riga Eastern Clinical University Hospital, Riga, Latvia
Ozolina, A., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
Rovite, V., Latvian Biomedical Research and Study Center, Riga, LATVIA
Mamaja, B., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
Vanags, I., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
Background & Aim of study. Microvascular free flap surgery during the last decades has become an important part of reconstructive surgery allowing closure of various tissue defects and restoration of organs function. Despite surgical progress resulting in high rates of transferred tissue survival, risk of pedicle vessels thrombosis remains a significant problem with highly negative consequences. This review of the literature was performed in order to assess an influence of two groups of factors on development of postoperative free flap thrombosis: the preoperatively detectable patient dependent risk factors and perioperative management strategies.
Materials & Methods. A total of 108 articles from Pubmed and Science Direct databases published in 2005-2015 were analysed.
Results. In regard to the patient dependent factors sufficient evidence was identified for hypercoagulation, advanced age and certain comorbidities. Nowadays, rotational thromboelastometry (RTE) allows early hypercoagulability detection, significantly changing further patient management. Identification of flap thrombosis promoting surgery-related aspects is also essential in preoperative settings. Concerning perioperative anaesthesiological management, review demonstrated an importance of following aspects providing conditions for optimal free flap circulation: choice of anaesthesia and postoperative analgesia methods, administration of different types and amounts of fluids, proper use of blood products and vasoactive agents, temperature control.
Conclusions. More attention should be focused on timely preoperative evaluation of patient dependent risk factors, which can influence anaesthesiological and surgical tactics during and after microvascular free flap surgery. Perioperative anaesthesiological management strategy continues to be controversial therefore it should be performed based on thrombotic risk assessment and patient individual needs thus improving flap survival rates and surgical outcome.
Predictive value of preoperative hypercoagulation for free flap thrombosis in microvascular surgery patients
Stepanovs, J., Riga Eastern Clinical University Hospital, Riga, LATVIA
Drizlionoka-Gorovenko, K., Riga Eastern Clinical University Hospital, Riga, Latvia
Ozolina, A., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
Rovite, V., Latvian Biomedical Research and Study Center, Riga, LATVIA
Mamaja, B., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
Vanags, I., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
Background & Objectives. Limited information is available about prognostic value of hypercoagulation detected by rotational thromboelastometry (RTE) for transferred tissue thrombosis. The aim was to evaluate the predictive capacity of hypercoagulative RTE data.
Materials & Methods. In the prospective observational study were enrolled 51 microvascular surgery patients. Preoperatively, external thrombogenic factors and RTE data were registered. Two groups of patients: with or without hypercoagulation detected by fibrinogen/platelet ratio (FPR) ≥ 42 were compared. Association between external thrombogenic factors, hypercoagulability in RTE and surgical outcome (free flap thrombosis) was analyzed.
Results. 51 patients with mean age 39 ± 13 years were enrolled. External thrombogenic factors were identified for 25 patients: recent trauma 15/51 (29.4%), ischemic heart disease and atherosclerosis 6/51(12%), tetra-, para paresis or neurofibromatosis 3/51 (6%), obesity + recent trauma 1/51 (2%). Hypercoagulation in RTE was detected in 15 patients ((FPR) ≥ 42), mostly in those with external thrombogenic factors -13 (52%) out of 25. The main reason (67%) was recent trauma. Patients with hypercoagulation had significantly higher values of MCFEXTEM (p <0,001), MCFINTEM (p < 0,001), MCF FIBTEM (p < 0,001). Incidence of free flap thrombosis was significantly higher in RTE hypercoagulability group, 5/15 (33%) vs. 4/36 (11%), p = 0.047. Thrombosis more often developed in patients with external thrombogenic factors, 8 vs. 1 and 8 vs. 2, p = 0.008 and p = 0.03. The AUC for hypercoagulative RTE to predict free flap failure was 0.7 (p = 0.05). The highest correlation with free flap thrombosis was found for MCFINTEM, r = 0.3; p = 0.04.
Conclusion. Rotational thromboelastometry is a suitable method to detect hypercoagulability with definite predictive capacity for postoperative free flap thrombosis and can early identify patients in higher risk for transferred tissue failure.
Noninvasive cerebral oxygen saturation monitoring during neurosurgical spine surgery in prone position
Murniece S.1,2,Skudre A.1,Stepanovs J.1,2,Vjugins J.1,Mamaja B.1,2
1 Riga Eastern University hospital,Latvia
2 Riga Stradins University,Latvia
Introduction. Cerebral oxygenation maintenance using Near infrared spectroscopy during surgery prevents complications like cognitive dysfunction and organ failure improving postoperative outcome.
Aim. To perform a systematic literature review to determine whether spinal surgery in prone position impact cerebral oxygenation(rScO2).
Materials and Methods. Relevant publications were found using PubMed with MeSH terms: (Spectroscopy,Near - Infrared),(Monitoring, Intraoperative), (Spine/surgery), (Prone position).15 patients underwent spinal surgery. rScO2 was monitored intraoperatively using INVOS 4100. NIBP, heart rate, end tidal carbon dioxide tension, peripheral oxygen saturation, rate of postoperative complications, days spent in ICU were monitored.
Results. 309 articles were found. Only 3 articles met all the criteria. Fuchs et al(2000) had 48 patients for lumbar discectomy. There were no changes in rScO2 during supine, prone, sitting position. Deiner et al(2014) had 63 patients undergoing surgery in prone position,142-lying supine(all> 68y): desaturation was 2.3 times more often for patients in prone position. Andersen et al(2014) had 52 patients undergoing surgery in prone position hypothesing that head rotation >45o affects rScO2, the neutral head position is recommended.Our results showed medium rScO2 lying supine L 75.25%, R 74.10%, in prone position L 75.05%, R 74.49%, returning on spine L 74.42%, R 74.04%. Two patients showed rScO2 decrease >8% from baseline after turning supine. There were no incidence of postoperative complications, no patients were admitted to ICU.
Conclusion. Regional cerebral oxygen saturation is a valuable intraoperative measurement in patients undergoing neurosurgical spine procedures in prone position to manage perioperative period. Based on literature patients in prone position experience decrease in cerebral oxygen saturation more often than patients lying supine.
The role of inherited trombophilia in patients undergone free flap surgery: a systemic review of the literature.
Drizlionoka- Gorovenko, K.a , Stepanovs, J.a,b, Ozoliņa, A.b,d , Ņikitina-Zaķe, Lc, Mamaja, Ba,b
a Riga Eastern Clinical University Hospital, Riga, Latvia
b Riga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia
c Latvian Biomedical Research and Study Center, Riga, Latvia
d Pauls Stradins Clinical University Hospital, Riga, Latvia
Background/Objective: The role of microvascular surgery as a part of reconstructive surgery is enhancing over the past three decades and has been technically improved such as failure rates declined to under 10 percent in most centers, nevertheless mishap due to thrombosis still occure and is detrimental for both patient and surgeon. Hereditary trombophilia is well known factor possessing icreased risk for vascular events however still beyond the scope of microvascular surgery. Detailed understanding of gene polymorphism associated with thrombosis in free flap surgery is the key to prevent intraoperative and postoperative adverse events thus facilitating patient amends and saving costs. To elucidate whether inherited trombophilia has association with free flap thrombosis a systemic review of the literature was performed.
Methods: An electronic databases, including PubMed, Cochrane library for articles published between 1995-2016 were analysed.
Results: A total of 148 articles, 14 case reports and 1 retrospective cohort were analyzed. Activated protein C resistance (APCR) due to heterozigosity of Factor VLaiden R506Q polymorphism, MTHFR C677T/A1298C polymorphism leading to hyperhomocysteinemia, protein S, protein C deficiency and elevated factor VIII activity have been reported as potential contributing factor to anastamotic thrombosis in microvascular free flap surgery.
Conclusion: Interaction of gene mutation, acquired hypercoagulable states and patient factors allude to free flap thrombosis in reconstructive surgery, and, of critical importance is meticulous surgical technique. Early recognition of hereditary thrombophilia as a part of preoperative patient counseling is advocated to ensure the best milieu for successful surgery.
Keywords: free flap failure, microvascular thrombosis, inherited thrombophilia, gene mutation, VLeiden/ Prothrombin G20210A, MTHFR polimorphism/mutation, Protein C/S deficiency, antithrombin deficiency, hyperhomocysteinemia.
Improvement in auditing clinical practice using electronic patient records
Dr. Agarwal R., Jurong Health, Singapore
Dr. Kale S.S. Jurong Health, Singapore
Background: Opening of the new Ng Teng Fong hospital in Singapore offered a platform for experimenting with fully paperless format. This study presents advantages of capturing data to help audits and computation of hospital wide harm rates Methods Prospective audits Key target areas such as preoperative assessment, post surgical recovery Department performance is judged by achieving targets set for the key performance indices. Continuous data collection to aid reflecting this information started since one year. Details and conclusions are periodically presented to hospital administration as well as to the Ministry of Health Examples of Key target areas Capturing adverse events in the immediate perioperative setting Capturing adverse events following regional or general anesthesia Computation of hospital wide harm rates Auditing changes in clinical practice and their impact Results With the implementation of electronic healthcare records, case notes are available round the clock over the hospital intranet. Password protection limits access and helps identify the reviewer. Results have started getting easily collected and compiled.
Nasal fibreoptic guided oral tracheal intubation : a novel technique
Dr. S. Awhad, Dept of Anaesthesia, Jurong Health, Singapore
Dr. S.S. Kale, Dept of Anaesthesia, Jurong Health, Singapore
We wish to share a novel technique of orotracheal intubation. A 46 year male patient presented with trauma following car accident. MRI showed fracture of the body of 6th cervical vertebra as well as fractured right maxilla. Right zygomatic arch and orbital floor needed emergency surgical repair as a result. The patient was wearing cervical collar, had swelling over the right cheek and had trismus. The mouth opening was restricted to 15 mm. After discussing with the maxillofacial surgeons a decision was taken to perform oral endotracheal tube placement. In order to avoid displacing the vertebral body fracture, direct laryngoscopy through oral cavity was not preferred. Instead, a fibreoptic laryngoscope was inserted through the left nostril upto laryngopharynx to provide a view of the vocal cords. Tongue was retracted and an armoured endotracheal tube was successfully placed under the vision provided by the nasally inserted fibreoptic laryngoscope. The fibreoptic laryngoscope was later inserted through the endotracheal tube to confirm correct positioning. Thus we were able to intubate the trachea using the maximum diameter of endotracheal tube inserted orally but avoiding conventional laryngoscopy with the risk of movement of cervical vertebral column and possible spinal cord compression. In similar situations where cervical spine mobility is restricted and nasal intubation is best avoided while mouth opening is also compromised this technique can offer another solution.