PRODIGY score predicts respiratory depression in the post-anesthesia care unit: A post-hoc analysis.

Surgical patients who experience respiratory depressive episodes (RDEs) during their post-anesthesia care unit (PACU) admission are at a higher risk of developing subsequent respiratory complications in general care wards. A risk assessment tool for PACU RDEs has not been previously assessed. The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) score is an assessment tool that uses baseline patient variables to categorize patients into low, intermediate, or high risk groups for RDEs in general care wards. This study assessed whether PRODIGY groups are associated with PACU RDEs. This analysis utilized data from a previous observational trial of PACU RDEs detected by capnography. PRODIGY scores were retrospectively calculated, and the number and duration of respiratory alerts were compared among PRODIGY groups. Twenty-six (29.9%) patients were classified as low risk, 29 (33.3%) as intermediate risk, and 32 (36.8%) as high risk. A total of 3,580 alerts were recorded in the PACU, 47% of which were apnea episodes lasting ≥ 10 seconds. The total number and duration of alerts were highest in high risk group patients (median 56 [IQR 12 - 87] alerts per patient vs 22 [9 - 37] in low risk and 26 [13 - 42] in intermediate risk patients, P = 0.035; 303 [123 - 885] seconds vs 177 [30 - 779] in low risk and 301 [168 - 703] in intermediate risk patients, P = 0.042). Poisson regression analysis indicated that the rate of RDEs in the high PRODIGY risk group was higher than in the intermediate (rate ratio estimate = 2.01 [95% CI 1.86 - 2.18], P < 0.001) and low (rate ratio estimate = 2.25 [95% confidence interval 2.07 - 2.45], P < 0.001) risk groups. This analysis suggests that the PRODIGY score may be useful in assessing the risk of PACU RDEs. Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT02707003.

Assessing evidence on the impacts of nature-based interventions for climate change mitigation: a systematic map of primary and secondary research from subtropical and tropical terrestrial regions.

BACKGROUND: Nature-based interventions (NbIs) for climate change mitigation include a diverse set of interventions aimed at conserving, restoring, and/or managing natural and modified ecosystems to improve their ability to store and sequester carbon and avoid greenhouse gas (GHG) emissions. Recent projections estimate that terrestrial NbIs can lead to more than one-third of the climate change mitigation necessary to meet the Paris Climate Agreement by 2030. Further, these interventions can provide co-benefits in the form of social and ecological outcomes. Despite growing recognition of the potential benefits, a clear characterization of the distribution and occurrence of evidence which supports linkages between different types of NbIs and outcomes for climate change mitigation, ecosystems, and people remains poorly understood. METHODS: This systematic map assesses the evidence base on the links between NbIs and climate change mitigation, social, and ecological outcomes in tropical and subtropical terrestrial regions. We searched three bibliographic databases, 65 organization websites, and conducted backward citation chasing within 39 existing evidence syntheses to identify relevant articles. Additionally, we reached out to key informants for additional sources of evidence. We then used machine learning to rank returned results by relevance at the title and abstract stage and manually screened for inclusion using predefined criteria at the title, abstract, and full text stages. We extracted relevant meta-data from included articles using an a priori coding scheme. Lastly, we conducted a targeted, complementary search to identify relevant review and synthesis articles to provide broader context for the findings of the systematic map. REVIEW FINDINGS: We included 948 articles in this systematic map. Most of the evidence base (56%) examined links between protection, natural resource management, and restoration interventions with changes to 'proxy' outcomes for climate change mitigation (changes to land condition, land cover, and/or land use). Other areas with high occurrence of articles included linkages between interventions within natural resource management and trees in croplands categories and changes to aboveground carbon storage and/or sequestration (17% of articles). A key knowledge gap was on measured changes in GHG emissions across all intervention types (6% of articles). Overall, articles in the evidence base did not often assess changes in co-benefits alongside direct or indirect changes for climate change mitigation (32%). In most cases, the evidence base contained studies which did not explicitly test for causal linkages using appropriate experimental or quasi-experimental designs. CONCLUSIONS: The evidence base for NbIs is significant and growing; however, key gaps in knowledge hamper the ability to inform ongoing and future investment and implementation at scale. More comprehensive evidence is needed to support causal inference between NbIs and direct outcomes for climate change mitigation to better determine additionality, permanence, leakage, and other unintended consequences. Similarly, priorities emerging from this map include the need for coordinated and harmonized efforts to collect diverse data types to better understand whether and how other outcomes (e.g. social, ecological) of NbIs can be achieved synergistically with mitigation objectives. Understanding potential benefits and trade-offs of NbIs is particularly urgent to inform rapidly expanding carbon markets for nature.

What evidence exists on the links between natural climate solutions and climate change mitigation outcomes in subtropical and tropical terrestrial regions? A systematic map protocol.

Background: Natural climate solutions (NCS)-actions to conserve, restore, and modify natural and modified ecosystems to increase carbon storage or avoid greenhouse gas (GHG) emissions-are increasingly regarded as important pathways for climate change mitigation, while contributing to our global conservation efforts, overall planetary resilience, and sustainable development goals. Recently, projections posit that terrestrial-based NCS can potentially capture or avoid the emission of at least 11 Gt (gigatons) of carbon dioxide equivalent a year, or roughly encompassing one third of the emissions reductions needed to meet the Paris Climate Agreement goals by 2030. NCS interventions also purport to provide co-benefits such as improved productivity and livelihoods from sustainable natural resource management, protection of locally and culturally important natural areas, and downstream climate adaptation benefits. Attention on implementing NCS to address climate change across global and national agendas has grown-however, clear understanding of which types of NCS interventions have undergone substantial study versus those that require additional evidence is still lacking. This study aims to conduct a systematic map to collate and describe the current state, distribution, and methods used for evidence on the links between NCS interventions and climate change mitigation outcomes within tropical and sub-tropical terrestrial ecosystems. Results of this study can be used to inform program and policy design and highlight critical knowledge gaps where future evaluation, research, and syntheses are needed. Methods: To develop this systematic map, we will search two bibliographic databases (including 11 indices) and 67 organization websites, backward citation chase from 39 existing evidence syntheses, and solicit information from key informants. All searches will be conducted in English and encompass subtropical and tropical terrestrial ecosystems (forests, grasslands, mangroves, agricultural areas). Search results will be screened at title and abstract, and full text levels, recording both the number of excluded articles and reasons for exclusion. Key meta-data from included articles will be coded and reported in a narrative review that will summarize trends in the evidence base, assess gaps in knowledge, and provide insights for policy, practice, and research. The data from this systematic map will be made open access. Supplementary Information: The online version contains supplementary material available at 10.1186/s13750-022-00268-w.

What evidence exists on the links between natural climate solutions and climate change mitigation outcomes in subtropical and tropical terrestrial regions? A systematic map protocol.

BACKGROUND: Natural climate solutions (NCS)-actions to conserve, restore, and modify natural and modified ecosystems to increase carbon storage or avoid greenhouse gas (GHG) emissions-are increasingly regarded as important pathways for climate change mitigation, while contributing to our global conservation efforts, overall planetary resilience, and sustainable development goals. Recently, projections posit that terrestrial-based NCS can potentially capture or avoid the emission of at least 11 Gt (gigatons) of carbon dioxide equivalent a year, or roughly encompassing one third of the emissions reductions needed to meet the Paris Climate Agreement goals by 2030. NCS interventions also purport to provide co-benefits such as improved productivity and livelihoods from sustainable natural resource management, protection of locally and culturally important natural areas, and downstream climate adaptation benefits. Attention on implementing NCS to address climate change across global and national agendas has grown-however, clear understanding of which types of NCS interventions have undergone substantial study versus those that require additional evidence is still lacking. This study aims to conduct a systematic map to collate and describe the current state, distribution, and methods used for evidence on the links between NCS interventions and climate change mitigation outcomes within tropical and sub-tropical terrestrial ecosystems. Results of this study can be used to inform program and policy design and highlight critical knowledge gaps where future evaluation, research, and syntheses are needed. METHODS: To develop this systematic map, we will search two bibliographic databases (including 11 indices) and 67 organization websites, backward citation chase from 39 existing evidence syntheses, and solicit information from key informants. All searches will be conducted in English and encompass subtropical and tropical terrestrial ecosystems (forests, grasslands, mangroves, agricultural areas). Search results will be screened at title and abstract, and full text levels, recording both the number of excluded articles and reasons for exclusion. Key meta-data from included articles will be coded and reported in a narrative review that will summarize trends in the evidence base, assess gaps in knowledge, and provide insights for policy, practice, and research. The data from this systematic map will be made open access.

Characterization of respiratory compromise and the potential clinical utility of capnography in the post-anesthesia care unit: a blinded observational trial.

The utility of capnography to detect early respiratory compromise in surgical patients after anesthesia is unclear due to limited prospective data. The purpose of this trial was to determine the frequency and duration of capnography-detected respiratory adverse events in the post-anesthesia care unit (PACU). In this prospective observational trial, 250 consenting patients undergoing elective surgery with general anesthesia were monitored by standard monitoring together with blinded capnography and pulse oximetry monitoring. The capnography notification settings were adjusted to match nursing (Level II) and physician (Level I) alarm thresholds. 163 (95%) patients had a Level II notification and 135 (78%) had a Level I notification during standard monitoring. The most common events detected by the capnography monitor included hypocapnia, apnea, tachypnea, bradypnea and hypoxemia, with silent notification duration for these events ranging from 17 ± 13 to 189 ± 127 s. During standard monitoring, 15 respiratory adverse events were reported, with 8 events occurring when valid blinded/silenced capnography and pulse oximetry data was collected simultaneously. Capnography and the Integrated Pulmonary Index™ algorithm (IPI) detected respiratory adverse events earlier than standard monitoring in 75% and 88% of cases, respectively, with an average early warning time of 8 ± 11 min. Three patients' blinded capnography was unblinded to facilitate clinical care. Respiratory adverse events are frequent in the PACU, and the addition of capnography and IPI to current standard monitoring provides potentially clinically relevant information on respiratory status, including early warning of some respiratory adverse events.Trial registration ClinialTrials.gov Identifier NCT02707003 (https://clinicaltrials.gov/ct2/show/NCT02707003).

Inaccuracy of a continuous arterial pressure waveform monitor when used for congenital cardiac catheterization.

OBJECTIVE: To determine the accuracy of a continuous cardiac output monitor (FloTrac sensor) for measuring cardiac index in children with congenital heart disease undergoing cardiac catheterization. Cardiac index is a critical hemodynamic parameter measured during catheterizations in children with congenital heart disease. This has been challenging to measure accurately and many clinicians rely on predictive equations for calculating cardiac index. DESIGN: Prospective, nonrandomized trial. SETTING: Tertiary care congenital heart center. PATIENTS: Consecutive participants ≤18 years old undergoing clinically indicated cardiac catheterizations from September 2014 through August 2015. INTERVENTIONS: Oxygen consumption was measured using the Vmax Encore 229 monitor attached to the ventilator circuit. The FloTrac transducer with third generation software was connected to a pigtail catheter in the descending aorta and cardiac index was obtained. OUTCOME MEASURES: Cardiac index by the Fick equation using measured oxygen consumption was compared to cardiac index from the FloTrac sensor using paired t-test and Bland-Altman analysis. RESULTS: 39 participants (median age 5.1 years, 1.5-18.3, 64% female) were studied. Cardiac index by FloTrac was higher than cardiac index by Fick (6.4 ± 3.4 vs 3.7 ± 1.2 L/min/m2 , P < .001). Bland-Altman analysis showed a consistent overestimation of cardiac index by FloTrac which worsened as cardiac index increased (mean bias 2.7 L/min/m2 , 95% limits of agreement -4.2, 9.5). CONCLUSIONS: The results of this study show that the FloTrac sensor provides cardiac index measures which are not accurate enough to justify use in children with congenital heart disease undergoing catheterization. Further studies may allow for modifications of the algorithms to obtain more accurate cardiac index in this population.

Noninvasive cardiac output measurement in heart failure subjects on circulatory support.

BACKGROUND: Pulmonary artery catheter (PAC) thermodilution is commonly used in the perioperative cardiac surgical intensive care unit for measurement and management of central hemodynamics despite questions about effectiveness, difficulty of use, and safety. USCOM is a noninvasive continuous wave Doppler device for direct measurement of cardiac output (CO) and is an alternative to PAC. USCOM validation has predominantly been in the cardiac surgical intensive care unit against PAC, despite the recognized limitations in reliability of the method. We compared USCOM CO measurements with the CardioWest, an orthotopic total artificial heart (TAH), in heart failure (HF) subjects during controlled interventions. METHOD: CO, stroke volume (SV), and heart rate (HR) were measured in a blinded fashion using the CardioWest and the USCOM device in TAH HF patients. Five-hundred eight paired measures from 18 examinations of seven subjects were acquired as flow was varied by the CardioWest controller. Bland-Altman analysis was used to compare agreement. RESULTS: Mean values and standard deviations (+/-SD) for CO, SV, and HR by CardioWest and USCOM were 7.33 +/- 0.46 and 7.34 +/- 0.51 L/min, 56.2 +/- 3.8 and 56.6 +/- 3.8 mL, and 131 +/- 3 and 130 +/- 4 bpm, respectively. CO ranged from 5.2 to 9.3 L/min. The mean differences between methods for CO, SV, and HR were -0.01 +/- 0.23 L/min, -0.34 +/- 1.97 mL, and 0.9 +/- 2.3 bpm, respectively, with mean percentage differences of -0.3%, -0.6%, and 0.7%. The percentage limits of agreement for CO, SV, and HR were 6.4%, 7.1%, and 3.6%. DISCUSSION: USCOM is a feasible and accurate method for noninvasive measurement and monitoring of CO in TAH HF patients and may have a wider application in diagnosis and management of cardiovascular disease.