Acoustic Shadowing to Facilitate Ultrasound Guided Arterial Cannulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Aim and background: Ultrasound-guided arterial catheterization is a frequently performed procedure. Additional techniques such as acoustic shadowing-assisted ultrasound may be useful in improving success rate. This systematic review aimed to assess the efficacy of acoustic shadowing assisted ultrasound for arterial catheterization. Materials and methods: PubMed, Medline, EMBASE, Cochrane Library, EMCARE, and MedNar were searched in January 2024. Randomized controlled trials comparing the first attempt success rate of arterial catheterization using acoustic shadowing ultrasound vs unassisted ultrasound were included. Data were pooled for risk ratios (RRs) using the random-effects model. Subgroup analysis was conducted based on a single or double acoustic line. Sensitivity analysis was undertaken after excluding pediatric data. The certainty of evidence (COE) was assessed using the GRADE framework. Results: Six randomized controlled trials (n = 777) were included. A meta-analysis found the first attempt success rate is significantly higher in the acoustic ultrasound group (n = 6, RR: 0.47, 95% CI: 0.34-0.66, p ≤ 0.00001). Hematoma formation was significantly less in the acoustic ultrasound group (n = 6, RR: 0.52, 95% CI: 0.34-0.80, p = 0.003). First attempt success was significantly higher in the single acoustic line ultrasound (USG) group compared to the unassisted ultrasound group (n = 3, RR: 0.41, 95% CI: 0.28-0.59, p ≤ 0.00001). Sensitivity analysis after excluding pediatric data was similar to the primary analysis (n = 5, RR: 0.50, 95% CI: 0.33-0.70, p ≤ 0.00001). Certainty of evidence was "Moderate" for the first attempt cannulation. Conclusions: Acoustic shadowing-assisted ultrasound improved first-attempt arterial catheterization success rate and was associated with reduced hematoma formation. How to cite this article: Mishra L, Rath C, Wibrow B, Anstey M, Ho K. Acoustic Shadowing to Facilitate Ultrasound Guided Arterial Cannulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2024;28(7):677-685.

Long-Term Echocardiographic and Clinical Outcomes After Invasive and Non-Invasive Therapies for Sub-Massive and Massive Acute Pulmonary Embolism.

AIM: Acute pulmonary embolism (PE) is a significant cause of mortality in the hospital setting. The objective of this study was to outline the long-term outcomes after surgical and non-surgical management for patients with massive and submassive PE. METHODS: Population cohort observational study evaluating all patients who presented to three tertiary hospitals in the state of Western Australia with access to cardiothoracic services over 5 years (2013-2018). Reviewed notes of all patients as well as radiology, linked mortality data and all available echocardiography studies at the primary hospital. RESULTS: In total, 245 patients were identified, of which 41 received surgical management and 204 non-surgical management; demographic data was similar. Clinically, the surgical group had higher rates of shock requiring vasopressors, severe bradycardia, or cardiopulmonary resuscitation prior to intervention. The 28-day mortality was not statistically significantly different between the surgical embolectomy group (2/41 [4.2%]) and the non-surgical group (17/201 [8.3%]) (p=0.382). There was no difference in 12-month mortality, including when this was adjusted for vasopressors, right ventricular (RV) strain, troponin, and brain natriuretic peptide. In the massive PE sub-group, 28-day mortality was not significantly different: 2/29 (6.9%) surgical group vs 7/34 (20.2%) non-surgical group (p=0.064). Higher rates of severe RV impairment and dilatation were present in the surgical group. All patients with available echocardiography studies at outpatient follow-up returned to normal or mild RV impairment. CONCLUSION: Patients who presented with massive or submassive PE had similar outcomes whether treated with surgical or non-surgical management. Surgical embolectomy is a safe option in a cardiothoracic centre setting.

Associations between body mass index, biological age and frailty in the critically ill.

BACKGROUND: The relationship between body mass index (BMI) and outcomes in the acute care setting is controversial, with evidence suggesting that obesity is either protective - which is also called obesity paradox - or associated with worse outcomes. The purpose of this study was to assess whether BMI was related to frailty and biological age, and whether BMI remained predictive of mortality after adjusting for frailty and biological age. SUBJECTS: Of the 2950 patients who had a biological age estimated on admission to the intensive care unit, 877 (30 %) also had BMI and frailty data available for further analysis in this retrospective cohort study. METHODS: Biological age of each patient was estimated using the Levine PhenoAge model based on results of nine blood tests that were reflective of DNA methylation. Biological age in excess of chronological age was then indexed to the local study context by a linear regression to generate the residuals. The associations between BMI, clinical frailty scale, and the residuals were first analyzed using univariable analyses. Their associations with mortality were then assessed by multivariable analysis, including the use of a 3-knot restricted cubic spline function to allow non-linearity. RESULTS: Both frailty (p = 0.003) and the residuals of the biological age (p = 0.001) were related to BMI in a U-shaped fashion. BMI was not related to hospital mortality, but both frailty (p = 0.015) and the residuals of biological age (OR per decade older than chronological age 1.50, 95 % confidence interval [CI] 1.04-2.18; p = 0.031) were predictive of mortality after adjusting for chronological age, diabetes mellitus and severity of acute illness. CONCLUSIONS: BMI was significantly associated with both frailty and biological age in a U-shaped fashion but only the latter two were related to mortality. These results may, in part, explain why obesity paradox could be observed in some studies.

A Prospective Cohort Study Characterizing Incidence of Dural Venous Sinus Thrombosis in Traumatic Brain Injury Patients with Skull Fractures.

BACKGROUND: Limited retrospective data suggest that dural venous sinus thrombosis (DVST) in traumatic brain injury (TBI) patients with skull fractures is common and associated with significant morbidity and mortality. Prospective data accurately characterizing the incidence of DVST in patients with high-risk TBI are sparse but are needed to develop evidence-based TBI management guidelines. METHODS: After obtaining institutional approval, 36 adult patients with TBI with skull fractures admitted to an Australian level III adult intensive care unit between April 2022 and January 2023 were prospectively recruited and underwent computed tomography venography or magnetic resonance venography within 72 hours of injury. When available, daily maximum intracranial pressure was recorded. RESULTS: Dural venous sinus abnormality was common (36.1%, 95% confidence interval 22.5%-52.4%) and strongly associated with DVST (P = 0.003). The incidence of DVST was 13.9% (95% confidence interval 6.1%-28.7%), which was lower than incidence reported in previous retrospective studies. Of DVSTs confirmed by computed tomography venography, 80% occurred in patients with extensive skull fractures including temporal or parietal bone fractures in conjunction with occipital bone fractures (P = 0.006). However, dural venous sinus abnormality and DVST were not associated with an increase in maximum daily intracranial pressure within the first 7 days after injury. CONCLUSIONS: Dural venous sinus abnormality was common in TBI patients with skull fractures requiring intensive care unit admission. DVST was confirmed in more than one third of these patients, especially patients with concomitant temporal or parietal and occipital bone fractures. Computed tomography venography is recommended for this subgroup of TBI patients.

A single post-exposure oxime RS194B treatment rapidly reactivates acetylcholinesterase and reverses acute symptoms in macaques exposed to diethylphosphorothioate parathion and chlorpyrifos insecticides.

Millions of individuals globally suffer from inadvertent, occupational or self-harm exposures from organophosphate (OP) insecticides, significantly impacting human health. Similar to nerve agents, insecticides are neurotoxins that target and inhibit acetylcholinesterase (AChE) in central and peripheral synapses in the cholinergic nervous system. Post-exposure therapeutic countermeasures generally include administration of atropine with an oxime to reactivate the OP-inhibited AChE. However, animal model studies and recent clinical trials using insecticide-poisoned individuals have shown minimal clinical benefits of the currently approved oximes and their efficacy as antidotes has been debated. Currently used oximes either reactivate poorly, do not readily cross the blood-brain barrier (BBB), or are rapidly cleared from the circulation and must be repeatedly administered. Zwitterionic oximes of unbranched and simplified structure, for example RS194B, have been developed that efficiently cross the BBB resulting in reactivation of OP-inhibited AChE and dramatic reversal of severe clinical symptoms in mice and macaques exposed to OP insecticides or nerve agents. Thus, a single IM injection of RS194B has been shown to rapidly restore blood AChE and butyrylcholinesterase (BChE) activity, reverse cholinergic symptoms, and prevent death in macaques following lethal inhaled sarin and paraoxon exposure. The present macaque studies extend these findings and assess the ability of post-exposure RS194B treatment to counteract oral poisoning by highly toxic diethylphosphorothioate insecticides such as parathion and chlorpyrifos. These OPs require conversion by P450 in the liver of the inactive thions to the active toxic oxon forms, and once again demonstrated RS194B efficacy to reactivate and alleviate clinical symptoms within 60 mins of a single IM administration. Furthermore, when delivered orally, the Tmax of RS194B at 1-2 h was in the same range as those administered IM but were maintained in the circulation for longer periods greatly facilitating the use of RS194B as a non-invasive treatment, especially in isolated rural settings.

Monitoring anti-Xa Levels to Optimize Low-Molecular-Weight-Heparin Thromboprophylaxis in High-Risk Hospitalized Patients: A Stratified Meta-Analysis.

It is uncertain whether monitoring or targeting anti-Xa levels is necessary when using low-molecular-weight-heparin (LMWH) to prevent venous thromboembolism (VTE). This stratified meta-analysis assessed whether monitoring trough or peak anti-Xa levels with LMWH dosing would reduce risk of VTE. Twelve non-randomized studies involving 3604 hospitalized patients met the inclusion criteria and were subject to meta-analysis. Eight studies assessed the association between VTE and peak anti-Xa levels (between .2 and .5 IU/ml) and four studies assessed the benefits of targeting the trough anti-Xa levels (>.1 IU/ml). Achieving an adequate peak or trough anti-Xa level was associated with a reduced risk of VTE (random-effects model odds ratio [OR] .52, 95% confidence interval [CI] .34-.77; P = .001, I2 = 30% and P-value for heterogeneity = .171) compared with using a fixed standard dose of LMWH. Targeting the trough level (OR .40, 95%CI 0.22-.75, P = .004) appeared to be more effective than targeting the peak level (OR .62, 95%CI 0.37-1.03, P = .066), although a formal interaction analysis did not confirm they were statistically different (ratio of ORs = 1.52, 95%CI 0.68-3.40; z score = 1.03, P = .306). Targeting a higher anti-Xa level did not appear to increase the risk of bleeding or transfusion (OR 1.20, 95%CI 0.46-3.17, P = .707).

Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage: A systematic review of published prediction models with risk of bias and clinical applicability assessment.

BACKGROUND: Pre-treatment rebleeding following aneurysmal subarachnoid hemorrhage (aSAH) increases the risk of death and a poor neurological outcome. Current guidelines recommend aneurysm treatment "as early as feasible after presentation, preferably within 24 h of onset" to mitigate this risk, a practice termed ultra-early treatment. However, ongoing debate regarding whether ultra-early treatment is independently associated with reduced re-bleeding risk, together with the recognition that re-bleeding occurs even in centres practicing ultra-early treatment due to the presence of other risk-factors has resulted in a renewed need for patient-specific re-bleed risk prediction. Here, we systematically review models which seek to provide patient specific predictions of pre-treatment rebleeding risk. METHODS: Following registration on the International prospective register of systematic reviews (PROSPERO) CRD 42023421235; Ovid Medline (Pubmed), Embase and Googlescholar were searched for English language studies between 1st May 2002 and 1st June 2023 describing pre-treatment rebleed prediction models following aSAH in adults ≥18 years. Of 763 unique records, 17 full texts were scrutinised with 5 publications describing 4 models reviewed. We used the semi-automated template of Fernandez-Felix et al. incorporating the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist and the Prediction model Risk Of Bias ASsessment Tool (PROBAST) for data extraction, risk of bias and clinical applicability assessment. To further standardize risk of bias and clinical applicability assessment, we also used the published explanatory notes for the PROBAST tool and compared the aneurysm treatment practices each prediction model's formulation cohort experienced to a prespecified benchmark representative of contemporary aneurysm treatment practices as outlined in recent evidence-based guidelines and published practice pattern reports from four developed countries. RESULTS: Reported model discriminative performance varied between 0.77 and 0.939, however, no single model demonstrated a consistently low risk of bias and low concern for clinical applicability in all domains. Only the score of Darkwah Oppong et al. was formulated using a patient cohort in which the majority of patients were managed in accordance with contemporary, evidence-based aneurysm treatment practices defined by ultra-early and predominantly endovascular treatment. However, this model did not undergo calibration or clinical utility analysis and when applied to an external cohort, its discriminative performance was substantially lower that reported at formulation. CONCLUSIONS: No existing prediction model can be recommended for clinical use in centers practicing contemporary, evidence-based aneurysm treatment. There is a pressing need for improved prediction models to estimate and minimize pre-treatment re-bleeding risk.

Flattening the biological age curve by improving metabolic health: to taurine or not to taurine, that' s the question.

The aging population is an important issue around the world especially in developed countries. Although medical advances have substantially extended life span, the same cannot be said for the duration of health span. We are seeing increasing numbers of elderly people who are frail and/or have multiple chronic conditions; all of these can affect the quality of life of the elderly population as well as increase the burden on the healthcare system. Aging is mechanistically related to common medical conditions such as diabetes mellitus, ischemic heart disease, cognitive decline, and frailty. A recently accepted concept termed 'Accelerated Biological Aging' can be diagnosed when a person's biological age-as measured by biomarkers of DNA methylation-is older than their corresponding chronological age. Taurine, a conditionally essential amino acid, has received much attention in the past few years. A substantial number of animal studies have provided a strong scientific foundation suggesting that this amino acid can improve cellular and metabolic health, including blood glucose control, so much that it has been labelled one of the 'longevity amino acids'. In this review article, we propose the rationale that an adequately powered randomized-controlled-trial (RCT) is needed to confirm whether taurine can meaningfully improve metabolic and microbiome health, and biological age. This trial should incorporate certain elements in order to provide the much-needed evidence to guide doctors, and also the community at large, to determine whether this promising and inexpensive amino acid is useful in improving human metabolic health.

Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study.

Background: Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. Methods: We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14 mL kg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Findings: Female patients (n = 480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4 mL kg-1 min-1 for females and 22.3 mL kg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: -0.04, 0.22). Interpretation: Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. Funding: There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.

Biological age is superior to chronological age in predicting hospital mortality of the critically ill.

Biological age is increasingly recognized as being more accurate than chronological age in determining chronic health outcomes. This study assessed whether biological age, assessed on intensive care unit (ICU) admission, can predict hospital mortality. This retrospective cohort study, conducted in a tertiary multidisciplinary ICU in Western Australia, used the Levine PhenoAge model to estimate each patient's biological age (also called PhenoAge). Each patient's PhenoAge was calibrated to generate a regression residual which was equivalent to biological age unexplained by chronological age in the local context. PhenoAgeAccel was a dichotomized measure of the residuals, and its presence suggested that one was biologically older than the corresponding chronological age. Of the 2950 critically ill adult patients analyzed, 291 died (9.9%) before hospital discharge. Both PhenoAge and its residuals (after regressing on chronological age) had a significantly better ability to differentiate between hospital survivors and non-survivors than chronological age (area under the receiver-operating-characteristic curve 0.648 and 0.654 vs. 0.547 respectively). Being phenotypically older than one's chronological age was associated with an increased risk of mortality (PhenoAgeAccel hazard ratio [HR] 1.997, 95% confidence interval [CI] 1.568-2.542; p = 0.001) in a dose-related fashion and did not reach a plateau until at least a 20-year gap. This adverse association remained significant (adjusted HR 1.386, 95% CI 1.077-1.784; p = 0.011) after adjusted for severity of acute illness and comorbidities. PhenoAgeAccel was more prevalent among those with pre-existing chronic cardiovascular disease, end-stage renal failure, cirrhosis, immune disease, diabetes mellitus, or those treated with immunosuppressive therapy. Being phenotypically older than one's chronological age was more common among those with comorbidities, and this was associated with an increased risk of mortality in a dose-related fashion in the critically ill that was not fully explained by comorbidities and severity of acute illness.

Biological age as a predictor of unplanned intensive care readmission during the same hospitalization.

BACKGROUND: Biological age is increasingly being recognized as an important predictor of health but its utility in acute care setting remains uncertain. OBJECTIVE: We assessed whether biological age on intensive care unit (ICU) admission can predict unplanned ICU readmission during the same hospitalization. METHODS: The Levine PhenoAge model based on biomarkers of DNA methylation was used to determine each patient's biological age. The difference between PhenoAge and chronological age was indexed to the local context by regressing PhenoAge on chronological age using linear regression. A positive residual implied one's biological age was older than the corresponding chronological age compared to other patients - defined as PhenoAgeAccel. RESULTS: Of the 2950 patients included, 153 (5.2%) had unplanned ICU readmission. Chronological age, Acute Physiology and Chronic Health Evaluation II score, the use of mechanical ventilation, vasopressor, or renal replacement therapy were not significantly different between those with and without readmission. PhenoAgeAccel was, however, more common among those who had unplanned ICU readmission (52% vs 43%, p =0.031). Quantitatively, the degree of phenotypical age above chronological age exhibited a 'dose-related' relationship with the risk of readmission (odds ratio 1.12, 95% confidence interval 1.01-1.24; p=0.040) after adjusting for chronological age, comorbidities, and severity of acute illness in the index (first) ICU admission. CONCLUSION: Biological age was predictive of unplanned ICU readmission during the same hospitalization.

Dose-related relationship between ergothioneine concentrations and risk of preeclampsia.

The study by Kenny et al. is of considerable importance. They concluded that there was a weak association between the ergothioneine levels and maternal age, and if a threshold was set at the 90th percentile of the reference range in the control population (≥462 ng/ml), only one of these 97 women (1%) developed preeclampsia, versus 96/397 (24.2%) whose ergothioneine level was below this threshold. These results suggest that there might be a dichotomized association between ergothioneine concentrations and preeclampsia; and only a high ergothioneine level over 90th percentile of the control population could be protective against preeclampsia. With the kind supply of the dataset from the authors, further analysis using univariable as well as multivariable analyses were performed while allowing for non-linearity between ergothioneine concentrations and risk of preeclampsia using a 3-knot restricted cubic spline function. The univariable results showed that ergothioneine had a significant non-linear association with preeclampsia and it would start to offer protective effect from 300 ng/ml onward. The results were similar to the multivariable analysis. In addition, the analysis also confirmed that body mass index was significantly associated with an increased risk of preeclampsia.

The association between intraoperative cardiopulmonary bypass power and complications after cardiac surgery.

BACKGROUND: Low cardiac power (product of flow and pressure) has been shown to be associated with mortality in patients with cardiogenic shock after acute myocardial infarction, but has not been studied in cardiac surgical patients. This study's hypothesis was that cardiac power during cardiopulmonary bypass for cardiac surgery would have a greater association with adverse events than either flow or MAP (mean arterial pressure) alone. METHODS: We undertook a retrospective observational study using patient data from February 2015 to March 2022 undergoing cardiac surgery at Fiona Stanley Hospital in Perth Australia. Excluded were patient age less than 18 years old, patients undergoing thoracic transplantation, ventricular assist devices, off pump cardiac surgery and aortic surgery. The primary outcome was a composite outcome of 30-days mortality, stroke or new-onset renal insufficiency. RESULTS: Overall, 1984 cardiac surgeries were included in the analysis. Neither duration nor area below thresholds tested for power, MAP or flow was associated with the primary composite outcome. However, we found that an area below MAP thresholds 35-50 mmHg was associated with new renal insufficiency (adjusted odds ratio 1.17 [95% CI 1.02 to 1.35] for patients spending 10 min at 10 mmHg below 50 mmHg MAP compared to those who did not). CONCLUSIONS: This study suggests that MAP during cardiopulmonary bypass, but not power or flow, was an independent risk factor for adverse renal outcomes for cardiac surgical patients.

Incidence of factor XII deficiency in critically ill patients with a prolonged activated partial thromboplastin time: a prospective observational study.

Limited data is available on factor XII deficiency in critically ill patients with prolonged activated partial thromboplastin time (aPTT). The association of factor XII deficiency with an increased risk of thromboembolism is unclear. This prospective observational study assessed the incidence of factor XII deficiency among critically ill patients with prolonged aPTT (>40 s), whether factor XII deficiency manifesting as prolonged aPTT was associated with an increased risk of thromboembolism, and clotting time on a viscoelastic (ROTEM) test was useful to predict factor XII deficiency. Of the 40 included patients, 48% [95% confidence interval (CI) 33-63) had a factor XII deficiency (mean ±â€Šstandard deviation of factor XII level of all patients: 54% ±â€Š29%). Factor XII levels were not significantly correlated with the measured aPTT ( r  = -0.163, P  = 0.315). Factor XII deficiency was significantly more common in patients who were less critically ill ( P  = 0.027), but it was not significantly related to Disseminated Intravascular Coagulation scores ( P  = 0.567). The incidence of symptomatic venous thromboembolism ( P  = 0.246), allogeneic blood transfusion ( P  = 0.816), and hospital mortality ( P  = 0.201) were not significantly different between those with and without factor XII deficiency. The clotting time on the viscoelastic test was not predictive of factor XII deficiency (area under the receiver-operating characteristic = 0.605, P  = 0.264). Factor XII deficiency was common in critically ill patients with a prolonged aPTT. There was no association between factor XII deficiency and risk of thromboembolism. The clotting time on ROTEM was not predictive of the presence of factor XII deficiency.

Rebleeding following aneurysmal subarachnoid hemorrhage before 'endovascular first' treatment: a retrospective case-control study of published scoring systems.

BACKGROUND: Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, 'endovascular first' manner. METHODS: On retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan-Meier (KM) survival curve analyses were performed. RESULTS: The majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liu et al. had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Oppong et al. (C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshout et al. (C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816). CONCLUSIONS: For aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.

Dexamethasone and persistent wound pain: a prespecified analysis of the randomised Perioperative Administration of Dexamethasone and Infection (PADDI) trial.

BACKGROUND: Dexamethasone is commonly administered intraoperatively to prevent postoperative nausea and vomiting and is believed to have analgesic properties. It is unknown whether it has an impact on chronic wound pain. METHODS: In this prespecified embedded superiority substudy of the randomised PADDI trial, patients undergoing non-urgent noncardiac surgery received dexamethasone 8 mg or placebo intravenously after induction of anaesthesia, and were followed up for 6 months postoperatively. The primary outcome was the incidence of pain in the surgical wound at 6 months. Secondary outcomes included acute postoperative pain and correlates of chronic postsurgical pain. RESULTS: We included 8478 participants in the modified intention-to-treat population (4258 in the dexamethasone group and 4220 in the matched placebo group). The primary outcome occurred in 491 subjects (11.5%) in the dexamethasone arm and 404 (9.6%) subjects in the placebo arm (relative risk 1.2, 95% confidence interval 1.06-1.41, P=0.003). Maximum pain scores at rest and on movement in the first 3 postoperative days were lower in the dexamethasone group compared with the control group {median 5 (inter-quartile range [IQR] 3.0-8.0) vs 6 (IQR 3.0-8.0) and median 7 (IQR 5.0-9.0) vs 8 (IQR 6.0-9.0), P<0.001 for both}. Severity of postoperative pain was not predictive of chronic postsurgical pain. The severity of chronic postsurgical pain and the frequency of neuropathic features did not differ between treatment groups. CONCLUSION: Administration of dexamethasone 8 mg i.v. was associated with an increase in the risk of pain in the surgical wound 6 months after surgery. CLINICAL TRIAL REGISTRATION: ACTRN12614001226695.

Validation of a wearable forehead sleep recorder against polysomnography in sleep staging and desaturation events in a clinical sample.

STUDY OBJECTIVES: Wearable sleep recording devices may be a helpful alternative method for polysomnography (PSG) due to their higher accessibility and comfort as well as lower cost, but their validities need to be examined. The aim of this study was to evaluate the accuracy of a novel single-channel, electroencephalography-based wearable forehead sleep recorder (UMindSleep) to assess sleep staging and oxygen desaturation. METHODS: Two hundred and three Chinese adults recruited from a sleep medicine center underwent an overnight study wearing UMindSleep and PSG simultaneously. Sleep parameters including sleep staging and oxygen desaturation index were compared between UMindSleep and PSG. RESULTS: A total of 195,349 valid epochs from 197 participants (171 with obstructive sleep apnea, 86.8%) were included in analyses of sleep staging. Sensitivities of UMindSleep compared to PSG were 79.7% for wake, 85.8% for light sleep, 79.4% for deep sleep, and 82.7% for rapid eye movement sleep. Specificities were 95.3% for wake, 83.4% for light sleep, 97.0% for deep sleep, and 96.8% for rapid eye movement sleep. Furthermore, the kappa agreements of 0.69-0.79 were indicative of a substantial agreement for sleep staging between UMindSleep and PSG. Sensitivity and specificity regarding oxygen desaturation index were 93.4% and 88.9%, yielding a kappa coefficient of 0.82. CONCLUSIONS: Our findings suggest that UMindSleep may serve as a feasible, accurate, and dependable device for screening of sleep disorders (eg, obstructive sleep apnea) and assessing sleep structure. CITATION: Chen X, Jin X, Zhang J, Ho KW, Wei Y, Cheng H. Validation of a wearable forehead sleep recorder against polysomnography in sleep staging and desaturation events in a clinical sample. J Clin Sleep Med. 2023;19(4):711-718.

Long-term outcomes after using retrievable vena cava filters in major trauma patients with contraindications to prophylactic anticoagulation.

PURPOSE: To investigate the long-term outcomes of using vena cava filters to prevent symptomatic pulmonary embolism (PE) in major trauma patients who have contraindications to prophylactic anticoagulation. METHODS: This was an a priori sub-study of a randomized controlled trial (RCT) involving long-term outcome data of 223 patients who were enrolled in Western Australia. State-wide clinical information system, radiology database and death registry were used to assess long-term outcomes, including incidences of venous thromboembolism, venous injury and mortality beyond day-90 follow-up. RESULTS: The median follow-up time of 198 patients (89%) who survived beyond 90 days was 65 months (interquartile range 59-73). Ten patients (5.1%) died after day-90 follow-up; and four patients developed venous thromboembolism, including two with symptomatic PE, all allocated to the control group (0 vs 4%, p = 0.043). Inferior vena cava injuries were not recorded in any patients. The mean total hospitalization cost, including the costs of the filter and its insertion and removal, to prevent one short- or long-term symptomatic PE was A$284,820 (€193,678) when all enrolled patients were considered. The number of patients needed to treat (NNT = 5) and total hospitalization cost to prevent one symptomatic PE (A$1,205 or €820) were, however, substantially lower when the filter was used only for patients who could not be anticoagulated within seven days of injury. CONCLUSION: Long-term complications related to retrievable filters were rare, and the cost of using filters to prevent symptomatic PE was acceptable when restricted to those who could not be anticoagulated within seven days of severe injury.

Utility of the National Emergency Laparotomy Audit prognostic model in predicting outcomes in an Australian health system.

The Royal College of Anaesthetists was commissioned by the United Kingdom Health Quality Partnership to conduct the National Emergency Laparotomy Audit of England and Wales (NELA), to compare outcomes of patients undergoing emergency laparotomy in order to promote quality improvement. Prior to 2016 there were minimal data for emergency laparotomy patients in Australia. The aim of this cohort study was to assess the utility and applicability of the NELA model in a tertiary centre in Western Australia. NELA-related data of patients who underwent emergency laparotomy, between June 2018 and May 2020, were merged with other administrative databases and clinical records. The discriminative ability and calibration of the model were assessed by the area under the receiver operating characteristic (AUROC) curve and calibration plot, respectively. Cox proportional hazards regression was used to assess whether the NELA-predicted risks were an independent predictor of hospital mortality. Of the 502 patients included, 168 (33.5%) patients had a NELA-predicted risk >10%, and of these, 93 (55.4%) were admitted to a critical care unit in a planned fashion immediately after surgery. The NELA model had a good ability to discriminate between survivors and non-survivors (AUROC 0.892, 95% confidence intervals 0.854 to 0.93, P <0.001). However, the model was not perfectly calibrated, with the predicted risks tending to overestimate the observed risks of mortality, especially when the predicted risks were >50%. A high NELA-predicted risk remained significantly associated with mortality after adjusting for other covariates, including sepsis and plasma lactate concentration, suggesting that it is a reliable screening tool for identifying high-risk patients requiring emergency laparotomy.

End-tidal carbon dioxide in the early phase of cardiopulmonary exercise testing prior to major colorectal cancer surgery associates with postoperative outcome.

BACKGROUND: Cardiopulmonary exercise testing (CPET) objectively informs preoperative risk stratification prior to major surgery. CPET facilities are resource intensive and therefore more cost-effective triage methods are desirable for scalability. We tested two dynamic CPET parameters (end-tidal CO2 (PetCO2) and heart rate (HR)) to early phase exercise and resting diffusion capacity (DLCO) as potential point of care assessments that could be used outside of formal CPET testing facilities. METHODS: We conducted a retrospective cohort study including 84 patients who underwent CPET prior to elective major abdominal cancer surgery. Data were analyzed for PetCO2 and HR in response to early phase (2 minutes) exercise as well as resting DLCO against postoperative complications and two-year survival. Complications were classified according to Clavien-Dindo classification into less severe and severe (CD>IIIb) grades. Optimal cut points for predicting outcomes were determined using the Youden Index of receiver operating characteristic (ROC) curves. Multivariate regression modeling including both logistic and Cox proportional-hazards model adjusted to age and comorbidity burden was used to analyse the association between the selected parameters and postoperative outcomes. RESULTS: PetCO2, in response to two minutes of loaded exercise was higher in survivors than in non-survivors (median (IQR) 40.0 (4.2) mmHg vs. 34.5 (5.2) mmHg, P<0.001). There was no association between chronotropic response and postoperative outcome. The optimal cut point for predicting postoperative complications and survival was 38 mmHg and 37.1 mmHg for PetCO2, respectively. Low PetCO2 was associated with considerably lower odds of survival (OR 0.12; 95% CI 0.03, 0.47; P=0.003) and additionally increased odds of severe postoperative complications (OR 6.77; 95% CI 1.45, 38.4; P=0.019). Reduced age-predicted DLCO% <80% was associated with increased mortality (HR 5.27; 95% CI 1.09, 25.5; P=0.039). CONCLUSIONS: Assessment of DLCO at rest and dynamic assessment of PetCO2 during the early phase of exercise may potentially be developed as inexpensive point-of-care triage tools to scale objective preoperative risk assessment.