Pub Date : 2024-07-15DOI: 10.1016/j.bjao.2024.100301
Background
The damage that may be caused to the operating table and patients under general anaesthesia when a large earthquake occurs is unclear. We aimed to evaluate the movement and damage to operating tables and patients under general anaesthesia during an earthquake.
Methods
An operating table with a manikin resembling a patient on it was placed on a shaking table, and seismic waves were input into the shaking table. The effects of seismic waves were evaluated by altering surgical positions (supine and head-down positions), operating tables, flooring material, seismic waves, and output. We observed the movement of the operating table and measured the acceleration of the operating table and manikin head.
Results
Under 90% output of long-period seismic waves, the operating table with the supine manikin was overturned. Under experimental conditions that did not cause rocking, shaking such as tilting of the operating table caused stronger acceleration in the manikin's head than in the operating table. There was no clear relationship between operating table rocking and maximum acceleration as a result of programmed seismic waves. In long-period earthquakes, rocking and overturning occurred >60 s after the onset of shaking, whereas in direct earthquakes, rocking occurred within 10 s.
Conclusions
An earthquake could cause strong acceleration of the patient's head under general anaesthesia, and operating tables may overturn or shake violently. Regarding patient safety, further measures to prevent overturning should be considered.
{"title":"Operating table stability and patient safety during an earthquake based on the results of a shaking table experiment","authors":"","doi":"10.1016/j.bjao.2024.100301","DOIUrl":"10.1016/j.bjao.2024.100301","url":null,"abstract":"<div><h3>Background</h3><p>The damage that may be caused to the operating table and patients under general anaesthesia when a large earthquake occurs is unclear. We aimed to evaluate the movement and damage to operating tables and patients under general anaesthesia during an earthquake.</p></div><div><h3>Methods</h3><p>An operating table with a manikin resembling a patient on it was placed on a shaking table, and seismic waves were input into the shaking table. The effects of seismic waves were evaluated by altering surgical positions (supine and head-down positions), operating tables, flooring material, seismic waves, and output. We observed the movement of the operating table and measured the acceleration of the operating table and manikin head.</p></div><div><h3>Results</h3><p>Under 90% output of long-period seismic waves, the operating table with the supine manikin was overturned. Under experimental conditions that did not cause rocking, shaking such as tilting of the operating table caused stronger acceleration in the manikin's head than in the operating table. There was no clear relationship between operating table rocking and maximum acceleration as a result of programmed seismic waves. In long-period earthquakes, rocking and overturning occurred >60 s after the onset of shaking, whereas in direct earthquakes, rocking occurred within 10 s.</p></div><div><h3>Conclusions</h3><p>An earthquake could cause strong acceleration of the patient's head under general anaesthesia, and operating tables may overturn or shake violently. Regarding patient safety, further measures to prevent overturning should be considered.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000455/pdfft?md5=fa1ddc34d5f768d4844c3e073dd76060&pid=1-s2.0-S2772609624000455-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141622767","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01DOI: 10.1016/j.bjao.2024.100294
Julia Y. Nicklas , Alina Bergholz , Francesco Däke , Hanh H.D. Pham , Marie-Christin Rabe , Hanna Schlichting , Sophia Skrovanek , Moritz Flick , Karim Kouz , Marlene Fischer , Cynthia Olotu , Jakob R. Izbicki , Oliver Mann , Margit Fisch , Barbara Schmalfeldt , Karl-Heinz Frosch , Thomas Renné , Linda Krause , Christian Zöllner , Bernd Saugel
Background
It remains unknown whether there is a causal relationship between intraoperative hypotension and postoperative neurocognitive disorders. We tested the hypothesis that personalised—compared to routine—intraoperative blood pressure management reduces the incidence of postoperative neurocognitive disorders in patients having major noncardiac surgery.
Methods
In this single-centre trial, 328 elective major noncardiac surgery patients were randomly allocated to receive personalised blood pressure management (i.e. maintaining intraoperative mean arterial pressure [MAP] above preoperative baseline MAP from automated 24-h blood pressure monitoring) or routine blood pressure management (i.e. maintaining MAP above 65 mm Hg). The primary outcome was the incidence of neurocognitive disorders (composite of delayed neurocognitive recovery and delirium) between postoperative days 3 and 7.
Results
The primary outcome, neurocognitive disorders, occurred in 18 of 147 patients (12%) assigned to personalised and 21 of 148 patients (14%) assigned to routine blood pressure management (odds ratio [OR]=0.84, 95% confidence interval [CI]: 0.40–1.75, P=0.622). Delayed neurocognitive recovery occurred in 17 of 146 patients (12%) assigned to personalised and 17 of 145 patients (12%) assigned to routine blood pressure management (OR=0.99, 95% CI: 0.45–2.17, P=0.983). Delirium occurred in 2 of 157 patients (1%) assigned to personalised and 4 of 158 patients (3%) assigned to routine blood pressure management (OR=0.50, 95% CI: 0.04–3.53, P=0.684).
Conclusions
Personalised intraoperative blood pressure management maintaining preoperative baseline MAP neither reduced the incidence of the composite primary outcome neurocognitive disorders between postoperative days 3 and 7 nor the incidences of the components of the composite primary outcome—delayed neurocognitive recovery and delirium—compared to routine blood pressure management in patients having major noncardiac surgery.
{"title":"Personalised blood pressure management during major noncardiac surgery and postoperative neurocognitive disorders: a randomised trial","authors":"Julia Y. Nicklas , Alina Bergholz , Francesco Däke , Hanh H.D. Pham , Marie-Christin Rabe , Hanna Schlichting , Sophia Skrovanek , Moritz Flick , Karim Kouz , Marlene Fischer , Cynthia Olotu , Jakob R. Izbicki , Oliver Mann , Margit Fisch , Barbara Schmalfeldt , Karl-Heinz Frosch , Thomas Renné , Linda Krause , Christian Zöllner , Bernd Saugel","doi":"10.1016/j.bjao.2024.100294","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100294","url":null,"abstract":"<div><h3>Background</h3><p>It remains unknown whether there is a causal relationship between intraoperative hypotension and postoperative neurocognitive disorders. We tested the hypothesis that personalised—compared to routine—intraoperative blood pressure management reduces the incidence of postoperative neurocognitive disorders in patients having major noncardiac surgery.</p></div><div><h3>Methods</h3><p>In this single-centre trial, 328 elective major noncardiac surgery patients were randomly allocated to receive personalised blood pressure management (i.e. maintaining intraoperative mean arterial pressure [MAP] above preoperative baseline MAP from automated 24-h blood pressure monitoring) or routine blood pressure management (i.e. maintaining MAP above 65 mm Hg). The primary outcome was the incidence of neurocognitive disorders (composite of delayed neurocognitive recovery and delirium) between postoperative days 3 and 7.</p></div><div><h3>Results</h3><p>The primary outcome, neurocognitive disorders, occurred in 18 of 147 patients (12%) assigned to personalised and 21 of 148 patients (14%) assigned to routine blood pressure management (odds ratio [OR]=0.84, 95% confidence interval [CI]: 0.40–1.75, <em>P</em>=0.622). Delayed neurocognitive recovery occurred in 17 of 146 patients (12%) assigned to personalised and 17 of 145 patients (12%) assigned to routine blood pressure management (OR=0.99, 95% CI: 0.45–2.17, <em>P</em>=0.983). Delirium occurred in 2 of 157 patients (1%) assigned to personalised and 4 of 158 patients (3%) assigned to routine blood pressure management (OR=0.50, 95% CI: 0.04–3.53, <em>P</em>=0.684).</p></div><div><h3>Conclusions</h3><p>Personalised intraoperative blood pressure management maintaining preoperative baseline MAP neither reduced the incidence of the composite primary outcome neurocognitive disorders between postoperative days 3 and 7 nor the incidences of the components of the composite primary outcome—delayed neurocognitive recovery and delirium—compared to routine blood pressure management in patients having major noncardiac surgery.</p></div><div><h3>Clinical trial registration</h3><p>ClinicalTrials.gov (NCT03442907).</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000388/pdfft?md5=9bf430a1b6ab4396283951ce3a7e2b68&pid=1-s2.0-S2772609624000388-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141487223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-24DOI: 10.1016/j.bjao.2024.100291
Johannes M. Wirkus , Fabienne Goss , Matthias David , Erik K. Hartmann , Kimiko Fukui , Irene Schmidtmann , Eva Wittenmeier , Gunther J. Pestel , Eva-Verena Griemert
Background
Pulse wave transit time (PWTT) shows promise for monitoring intravascular fluid status intraoperatively. Presently, it is unknown how PWTT mirrors haemodynamic variables representing preload, inotropy, or afterload.
Methods
PWTT was measured continuously in 24 adult volunteers. Stroke volume was assessed by transthoracic echocardiography. Volunteers underwent four randomly assigned manoeuvres: ‘Stand-up’ (decrease in preload), passive leg raise (increase in preload), a ‘step-test’ (adrenergic stimulation), and a ‘Valsalva manoeuvre’ (increase in intrathoracic pressure). Haemodynamic measurements were performed before and 1 and 5 min after completion of each manoeuvre. Correlations between PWTT and stroke volume were analysed using the Pearson correlation coefficient.
Results
‘Stand-up’ caused an immediate increase in PWTT (mean change +55.9 ms, P-value <0.0001, 95% confidence interval 46.0–65.7) along with an increase in mean arterial pressure and heart rate and a drop in stroke volume (P-values <0.0001). Passive leg raise caused an immediate drop in PWTT (mean change −15.4 ms, P-value=0.0024, 95% confidence interval −25.2 to −5.5) along with a decrease in mean arterial pressure (P-value=0.0052) and an increase in stroke volume (P-value=0.001). After 1 min, a ‘step-test’ caused no significant change in PWTT measurements (P-value=0.5716) but an increase in mean arterial pressure and heart rate (P-values <0.0001), without changes in stroke volume (P-value=0.1770). After 5 min, however, PWTT had increased significantly (P-value <0.0001). Measurements after the Valsalva manoeuvre caused heterogeneous results.
Conclusion
Noninvasive assessment of PWTT shows promise to register immediate preload changes in healthy adults. The clinical usefulness of PWTT may be hampered by late changes because of reasons different from fluid shifts.
Clinical trial registration
German clinical trial register (DRKS, ID: DRKS00031978, https://www.drks.de/DRKS00031978).
{"title":"Changes of pulse wave transit time after haemodynamic manoeuvres in healthy adults: a prospective randomised observational trial (PWTT volunteer study)","authors":"Johannes M. Wirkus , Fabienne Goss , Matthias David , Erik K. Hartmann , Kimiko Fukui , Irene Schmidtmann , Eva Wittenmeier , Gunther J. Pestel , Eva-Verena Griemert","doi":"10.1016/j.bjao.2024.100291","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100291","url":null,"abstract":"<div><h3>Background</h3><p>Pulse wave transit time (PWTT) shows promise for monitoring intravascular fluid status intraoperatively. Presently, it is unknown how PWTT mirrors haemodynamic variables representing preload, inotropy, or afterload.</p></div><div><h3>Methods</h3><p>PWTT was measured continuously in 24 adult volunteers. Stroke volume was assessed by transthoracic echocardiography. Volunteers underwent four randomly assigned manoeuvres: ‘Stand-up’ (decrease in preload), passive leg raise (increase in preload), a ‘step-test’ (adrenergic stimulation), and a ‘Valsalva manoeuvre’ (increase in intrathoracic pressure). Haemodynamic measurements were performed before and 1 and 5 min after completion of each manoeuvre. Correlations between PWTT and stroke volume were analysed using the Pearson correlation coefficient.</p></div><div><h3>Results</h3><p>‘Stand-up’ caused an immediate increase in PWTT (mean change +55.9 ms, <em>P</em>-value <0.0001, 95% confidence interval 46.0–65.7) along with an increase in mean arterial pressure and heart rate and a drop in stroke volume (<em>P</em>-values <0.0001). Passive leg raise caused an immediate drop in PWTT (mean change −15.4 ms, <em>P</em>-value=0.0024, 95% confidence interval −25.2 to −5.5) along with a decrease in mean arterial pressure (<em>P</em>-value=0.0052) and an increase in stroke volume (<em>P</em>-value=0.001). After 1 min, a ‘step-test’ caused no significant change in PWTT measurements (<em>P</em>-value=0.5716) but an increase in mean arterial pressure and heart rate (<em>P</em>-values <0.0001), without changes in stroke volume (<em>P</em>-value=0.1770). After 5 min, however, PWTT had increased significantly (<em>P</em>-value <0.0001). Measurements after the Valsalva manoeuvre caused heterogeneous results.</p></div><div><h3>Conclusion</h3><p>Noninvasive assessment of PWTT shows promise to register immediate preload changes in healthy adults. The clinical usefulness of PWTT may be hampered by late changes because of reasons different from fluid shifts.</p></div><div><h3>Clinical trial registration</h3><p>German clinical trial register (DRKS, ID: DRKS00031978, <span>https://www.drks.de/DRKS00031978</span><svg><path></path></svg>).</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000352/pdfft?md5=0dd3d5a6914c994bf4f9976fd77ca79f&pid=1-s2.0-S2772609624000352-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141487224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Effects of opioid-based versus opioid-free anaesthesia on blinded nociception level index values during laparoscopic gastric bypass surgery: a secondary analysis of a randomised double-blind trial","authors":"Sean Coeckelenbergh , Teodora Oltean , Anne-Catherine Dandrifosse , Matthieu Clanet , Alexandre Joosten","doi":"10.1016/j.bjao.2024.100295","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100295","url":null,"abstract":"","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S277260962400039X/pdfft?md5=0e78a6a9de705ae3f8db08fb2cb564ce&pid=1-s2.0-S277260962400039X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141434500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-20DOI: 10.1016/j.bjao.2024.100288
John E. Rubin , Vanessa Ng , Justin Chung , Nicolas Salvatierra , Brady Rippon , Diana Khatib , Natalia I. Girardi , Kane O. Pryor , Roniel Y. Weinberg , Silis Jiang , Sherif Khairallah , Stephanie L. Mick , Tiffany R. Tedore
Background
Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h.
Methods
We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery.
Results
Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (−62, 95% confidence interval −108 to −16; P<0.01) and 48 h (−50, 95% CI −97 to −2.2; P=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC.
Conclusions
This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.
{"title":"Efficacy of parasternal peripheral nerve catheters versus no block for median sternotomy: a single-centre retrospective study","authors":"John E. Rubin , Vanessa Ng , Justin Chung , Nicolas Salvatierra , Brady Rippon , Diana Khatib , Natalia I. Girardi , Kane O. Pryor , Roniel Y. Weinberg , Silis Jiang , Sherif Khairallah , Stephanie L. Mick , Tiffany R. Tedore","doi":"10.1016/j.bjao.2024.100288","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100288","url":null,"abstract":"<div><h3>Background</h3><p>Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h.</p></div><div><h3>Methods</h3><p>We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery.</p></div><div><h3>Results</h3><p>Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (−62, 95% confidence interval −108 to −16; <em>P</em><0.01) and 48 h (−50, 95% CI −97 to −2.2; <em>P</em>=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC.</p></div><div><h3>Conclusions</h3><p>This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000327/pdfft?md5=b2dc117c938cb27a0cec1461b69ab4f9&pid=1-s2.0-S2772609624000327-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141434499","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-13DOI: 10.1016/j.bjao.2024.100293
Richard H. Epstein , Réka Nemes , Johnathan R. Renew , Sorin J. Brull
Background
Current guidelines recommend quantitative neuromuscular block monitoring during neuromuscular blocking agent administration. Monitors using surface electromyography (EMG) determine compound motor action potential (cMAP) amplitude or area under the curve (AUC). Rigorous evaluation of the interchangeability of these methods is lacking but necessary for clinical and research assurance that EMG interpretations of the depth of neuromuscular block are not affected by the methodology.
Methods
Digitised EMG waveforms were studied from 48 patients given rocuronium during two published studies. The EMG amplitudes and AUCs were calculated pairwise from all cMAPs classified as valid by visual inspection. Ratios of the first twitch (T1) to the control T1 before administration of rocuronium (T1c) and train-of-four ratios (TOFRs) were compared using repeated measures Bland–Altman analysis.
Results
Among the 2419 paired T1/T1c differences where the average T1/T1c was ≤0.2, eight (0.33%) were outside prespecified clinical limits of agreement (−0.148 to 0.164). Among the 1781 paired TOFR differences where the average TOFR was ≥0.8, 70 (3.93%) were outside the prespecified clinical limits of agreement ((−0.109 to 0.134). Among all 7286 T1/T1c paired differences, the mean bias was 0.32 (95% confidence interval 0.202–0.043), and among all 5559 paired TOFR differences, the mean bias was 0.011 (95% confidence interval 0.0050–0.017). Among paired T1/T1c and TOFR differences, Lin's concordance correlation coefficients were 0.98 and 0.995, respectively. Repeatability coefficients for T1/T1c and TOFR were <0.08, with no differences between methods.
Conclusions
Quantitative assessment neuromuscular block depth is clinically interchangeable when calculated using cMAP amplitude or the AUC.
{"title":"Area under the curve and amplitude of the compound motor action potential are clinically interchangeable quantitative measures of neuromuscular block: a method comparison study","authors":"Richard H. Epstein , Réka Nemes , Johnathan R. Renew , Sorin J. Brull","doi":"10.1016/j.bjao.2024.100293","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100293","url":null,"abstract":"<div><h3>Background</h3><p>Current guidelines recommend quantitative neuromuscular block monitoring during neuromuscular blocking agent administration. Monitors using surface electromyography (EMG) determine compound motor action potential (cMAP) amplitude or area under the curve (AUC). Rigorous evaluation of the interchangeability of these methods is lacking but necessary for clinical and research assurance that EMG interpretations of the depth of neuromuscular block are not affected by the methodology.</p></div><div><h3>Methods</h3><p>Digitised EMG waveforms were studied from 48 patients given rocuronium during two published studies. The EMG amplitudes and AUCs were calculated pairwise from all cMAPs classified as valid by visual inspection. Ratios of the first twitch (T<sub>1</sub>) to the control T<sub>1</sub> before administration of rocuronium (T<sub>1</sub>c) and train-of-four ratios (TOFRs) were compared using repeated measures Bland–Altman analysis.</p></div><div><h3>Results</h3><p>Among the 2419 paired T<sub>1</sub>/T<sub>1</sub>c differences where the average T<sub>1</sub>/T<sub>1</sub>c was ≤0.2, eight (0.33%) were outside prespecified clinical limits of agreement (−0.148 to 0.164). Among the 1781 paired TOFR differences where the average TOFR was ≥0.8, 70 (3.93%) were outside the prespecified clinical limits of agreement ((−0.109 to 0.134). Among all 7286 T<sub>1</sub>/T<sub>1</sub>c paired differences, the mean bias was 0.32 (95% confidence interval 0.202–0.043), and among all 5559 paired TOFR differences, the mean bias was 0.011 (95% confidence interval 0.0050–0.017). Among paired T<sub>1</sub>/T<sub>1</sub>c and TOFR differences, Lin's concordance correlation coefficients were 0.98 and 0.995, respectively. Repeatability coefficients for T<sub>1</sub>/T<sub>1</sub>c and TOFR were <0.08, with no differences between methods.</p></div><div><h3>Conclusions</h3><p>Quantitative assessment neuromuscular block depth is clinically interchangeable when calculated using cMAP amplitude or the AUC.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000376/pdfft?md5=3d4c5eb200cc642afc513f84d40c84e7&pid=1-s2.0-S2772609624000376-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141325514","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-01DOI: 10.1016/j.bjao.2024.100290
Tamaralayefa Agbiki , Richard Arm , David W. Hewson , Sandor Erdody , Andrew M. Norris , Ricardo Correia , Sergiy Korposh , Barrie R. Hayes-Gill , Arash Shahidi , Stephen P. Morgan
Introduction
Leakage of orogastric secretions past the cuff of a tracheal tube is a contributory factor in ventilator-associated pneumonia. Current bench test methods specified in the International Standard for Anaesthetic and Respiratory Equipment (EN ISO 5361:2023) to test cuff leakage involve using a glass or plastic rigid cylinder model of the trachea. There is a need for more realistic models to inform cuff leakage.
Methods
We used human computerised tomography data and additive manufacturing (3D printing), combined with casting techniques to fabricate a bio-inspired synthetic tracheal model with analogous tissue characteristics. We conducted cuff leakage tests according to EN ISO 5361:2023 and compared results for high-volume low-pressure polyvinyl chloride and polyurethane cuffs between the rigid cylinder trachea with our bio-inspired model.
Results
The tracheal model demonstrated close agreement with published tracheal tissue hardness for cartilaginous and membranous soft tissues. For high-volume low-pressure polyvinyl chloride cuffs the leakage rate was >50% lower in the bio-inspired tracheal model compared with the rigid cylinder model (151 [8] vs 261 [11] ml h−1). For high-volume low-pressure polyurethane cuffs, much lower leakage rates were observed than polyvinyl chloride cuffs in both models with leakage rates higher for the bio-inspired trachea model (0.1 [0.2] vs 0 [0] ml h−1).
Conclusion
A reproducible tracheal model that incorporates the mechanical properties of the human trachea can be manufactured from segmented CT images and additive manufactured moulds, providing a useful tool to inform future cuff development, leakage testing for industrial applications, and clinical decision-making. There are differences between cuff leakage rates between the bio-inspired model and the rigid cylinder recommended in EN ISO 5361:2023. The bio-inspired model could lead to more accurate and realistic cuff leakage rate testing which would support manufacturers in refining their designs. Clinicians would then be able to choose better tracheal tubes based on the outcomes of this testing.
导言口腔分泌物通过气管导管充气罩囊泄漏是导致呼吸机相关性肺炎的一个因素。麻醉和呼吸设备国际标准》（EN ISO 5361:2023）中规定的当前测试袖带泄漏的台架测试方法涉及使用气管的玻璃或塑料硬质圆柱体模型。我们利用人体计算机断层扫描数据和增材制造（3D 打印）技术，结合铸造技术，制造出具有类似组织特征的生物启发合成气管模型。我们根据 EN ISO 5361:2023 标准进行了充气罩囊泄漏测试，并比较了硬质圆柱体气管与我们的生物启发模型之间的高容量低压聚氯乙烯和聚氨酯充气罩囊的测试结果。对于大容量低压聚氯乙烯袖套，生物启发气管模型的泄漏率比刚性圆柱体模型低 50%（151 [8] vs 261 [11] ml h-1）。对于高容量低压聚氨酯袖带，在两种模型中观察到的泄漏率都比聚氯乙烯袖带低得多，而生物启发气管模型的泄漏率更高（0.1 [0.2] vs 0 [0] ml h-1）。生物启发模型与 EN ISO 5361:2023 推荐的硬质圆柱体之间的袖带泄漏率存在差异。生物启发模型可以带来更准确、更真实的袖带泄漏率测试，从而为制造商改进设计提供支持。这样，临床医生就能根据测试结果选择更好的气管导管。
{"title":"Fabrication and assessment of a bio-inspired synthetic tracheal tissue model for tracheal tube cuff leakage testing","authors":"Tamaralayefa Agbiki , Richard Arm , David W. Hewson , Sandor Erdody , Andrew M. Norris , Ricardo Correia , Sergiy Korposh , Barrie R. Hayes-Gill , Arash Shahidi , Stephen P. Morgan","doi":"10.1016/j.bjao.2024.100290","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100290","url":null,"abstract":"<div><h3>Introduction</h3><p>Leakage of orogastric secretions past the cuff of a tracheal tube is a contributory factor in ventilator-associated pneumonia. Current bench test methods specified in the International Standard for Anaesthetic and Respiratory Equipment (EN ISO 5361:2023) to test cuff leakage involve using a glass or plastic rigid cylinder model of the trachea. There is a need for more realistic models to inform cuff leakage.</p></div><div><h3>Methods</h3><p>We used human computerised tomography data and additive manufacturing (3D printing), combined with casting techniques to fabricate a bio-inspired synthetic tracheal model with analogous tissue characteristics. We conducted cuff leakage tests according to EN ISO 5361:2023 and compared results for high-volume low-pressure polyvinyl chloride and polyurethane cuffs between the rigid cylinder trachea with our bio-inspired model.</p></div><div><h3>Results</h3><p>The tracheal model demonstrated close agreement with published tracheal tissue hardness for cartilaginous and membranous soft tissues. For high-volume low-pressure polyvinyl chloride cuffs the leakage rate was >50% lower in the bio-inspired tracheal model compared with the rigid cylinder model (151 [8] <em>vs</em> 261 [11] ml h<sup>−1</sup>). For high-volume low-pressure polyurethane cuffs, much lower leakage rates were observed than polyvinyl chloride cuffs in both models with leakage rates higher for the bio-inspired trachea model (0.1 [0.2] <em>vs</em> 0 [0] ml h<sup>−1</sup>).</p></div><div><h3>Conclusion</h3><p>A reproducible tracheal model that incorporates the mechanical properties of the human trachea can be manufactured from segmented CT images and additive manufactured moulds, providing a useful tool to inform future cuff development, leakage testing for industrial applications, and clinical decision-making. There are differences between cuff leakage rates between the bio-inspired model and the rigid cylinder recommended in EN ISO 5361:2023. The bio-inspired model could lead to more accurate and realistic cuff leakage rate testing which would support manufacturers in refining their designs. Clinicians would then be able to choose better tracheal tubes based on the outcomes of this testing.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000340/pdfft?md5=313287c12f8885d591d42355dc0c8f68&pid=1-s2.0-S2772609624000340-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141303407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-01DOI: 10.1016/j.bjao.2024.100289
Malcolm A. West , Saqib Rahman , Sandy Jack , Michael P.W. Grocott , Denny Z.H. Levett , the Perioperative Exercise Testing and Training Society (POETTS), Yasir Rashid , John Griffiths , Martin Ezra , Lyndsay Ayres , Helen Neville-Webbe , Muhammad Shafiq Javed , Milind Shrotri , Iftikhar Khan , David Whitmore , Pradeep Prabhu , David Timbrell , Sophie Allen , Andrew O. Packham , David Sharpe , Mark Edwards
Background
Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment.
Methods
Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses.
Results
Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien–Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and VE/VCO2 at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival.
Conclusions
VO2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision.
{"title":"Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery—a multicentre observational study","authors":"Malcolm A. West , Saqib Rahman , Sandy Jack , Michael P.W. Grocott , Denny Z.H. Levett , the Perioperative Exercise Testing and Training Society (POETTS), Yasir Rashid , John Griffiths , Martin Ezra , Lyndsay Ayres , Helen Neville-Webbe , Muhammad Shafiq Javed , Milind Shrotri , Iftikhar Khan , David Whitmore , Pradeep Prabhu , David Timbrell , Sophie Allen , Andrew O. Packham , David Sharpe , Mark Edwards","doi":"10.1016/j.bjao.2024.100289","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100289","url":null,"abstract":"<div><h3>Background</h3><p>Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment.</p></div><div><h3>Methods</h3><p>Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO<sub>2</sub> peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses.</p></div><div><h3>Results</h3><p>Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO<sub>2</sub> peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (<em>P</em>=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; <em>P</em><0.001) and Clavien–Dindo ≥3a (<em>P</em><0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; <em>P</em>=0.024, relative to ideal body weight; <em>P</em>=0.001, body surface area; <em>P</em>=0.009) and V<sub>E</sub>/VCO<sub>2</sub> at anaerobic threshold (<em>P</em>=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival.</p></div><div><h3>Conclusions</h3><p>VO<sub>2</sub> peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision.</p></div><div><h3>Clinical trial registration</h3><p>NCT03637647.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000339/pdfft?md5=7e7856a662577fb327cd5c4ab34f09ca&pid=1-s2.0-S2772609624000339-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141289567","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-01DOI: 10.1016/j.bjao.2024.100292
Kenneth Barker , Michael Stewart , Alison Rutter , Phillip D. Whitfield , Ian L. Megson
Background
Intravenous lipid emulsion is recognised as a therapy for rescue in cases of local anaesthetic toxicity, but its use in reversing overdose or toxicity related to other drugs remains the subject of debate. This in vitro study sought to expand our understanding of the importance of partitioning in determining the impact of intravenous lipid emulsion on aqueous free drug concentrations.
Methods
Twenty-seven drugs and associated metabolites were screened for the ability of intravenous lipid emulsion to reduce the amount of free drug in the aqueous phase, using specialised cassettes designed for this purpose. The relative amount of drug equilibrating across the membrane from plasma to phosphate-buffered saline was measured, using liquid chromatography–mass spectrometry, at a 6 h timepoint in plasma samples treated with intravenous lipid emulsion and paired, untreated controls.
Results
The data obtained were plotted against measures of partition (LogP and cLogD7.4) and with log-transformed non-protein bound drug. There were significant inverse correlations between the capacity for intravenous lipid emulsion to reduce drug detected in the phosphate-buffered saline compartment and LogP and cLogD7.4, and a direct association with log [non-protein-bound drug]. However, a number of drugs showed substantial variance between different plasma samples.
Conclusions
Modulation of free drug in the aqueous compartment is broadly predictable by the partition coefficient, although ramipril was identified to be an outlier in this regard. Further mechanistic and clinical exploration is merited to establish a standardised protocol for lipid emulsion therapy.
{"title":"An in vitro study to determine the impact of lipid emulsion on partitioning of a broad spectrum of drugs associated with overdose","authors":"Kenneth Barker , Michael Stewart , Alison Rutter , Phillip D. Whitfield , Ian L. Megson","doi":"10.1016/j.bjao.2024.100292","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100292","url":null,"abstract":"<div><h3>Background</h3><p>Intravenous lipid emulsion is recognised as a therapy for rescue in cases of local anaesthetic toxicity, but its use in reversing overdose or toxicity related to other drugs remains the subject of debate. This <em>in vitro</em> study sought to expand our understanding of the importance of partitioning in determining the impact of intravenous lipid emulsion on aqueous free drug concentrations.</p></div><div><h3>Methods</h3><p>Twenty-seven drugs and associated metabolites were screened for the ability of intravenous lipid emulsion to reduce the amount of free drug in the aqueous phase, using specialised cassettes designed for this purpose. The relative amount of drug equilibrating across the membrane from plasma to phosphate-buffered saline was measured, using liquid chromatography–mass spectrometry, at a 6 h timepoint in plasma samples treated with intravenous lipid emulsion and paired, untreated controls.</p></div><div><h3>Results</h3><p>The data obtained were plotted against measures of partition (LogP and cLogD<sub>7.4</sub>) and with log-transformed non-protein bound drug. There were significant inverse correlations between the capacity for intravenous lipid emulsion to reduce drug detected in the phosphate-buffered saline compartment and LogP and cLogD<sub>7.4</sub>, and a direct association with log [non-protein-bound drug]. However, a number of drugs showed substantial variance between different plasma samples.</p></div><div><h3>Conclusions</h3><p>Modulation of free drug in the aqueous compartment is broadly predictable by the partition coefficient, although ramipril was identified to be an outlier in this regard. Further mechanistic and clinical exploration is merited to establish a standardised protocol for lipid emulsion therapy.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000364/pdfft?md5=dd16f64b67dbdbf6884a24528e08459a&pid=1-s2.0-S2772609624000364-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141312756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-01DOI: 10.1016/j.bjao.2024.100296
Kazuo Ando , Masaki Sato , Shin Wakatsuki , Ryotaro Nagai , Kumiko Chino , Hinata Kai , Tomomi Sasaki , Rie Kato , Teresa Phuongtram Nguyen , Nan Guo , Pervez Sultan
Background
The expansion of artificial intelligence (AI) within large language models (LLMs) has the potential to streamline healthcare delivery. Despite the increased use of LLMs, disparities in their performance particularly in different languages, remain underexplored. This study examines the quality of ChatGPT responses in English and Japanese, specifically to questions related to anaesthesiology.
Methods
Anaesthesiologists proficient in both languages were recruited as experts in this study. Ten frequently asked questions in anaesthesia were selected and translated for evaluation. Three non-sequential responses from ChatGPT were assessed for content quality (accuracy, comprehensiveness, and safety) and communication quality (understanding, empathy/tone, and ethics) by expert evaluators.
Results
Eight anaesthesiologists evaluated English and Japanese LLM responses. The overall quality for all questions combined was higher in English compared with Japanese responses. Content and communication quality were significantly higher in English compared with Japanese LLMs responses (both P<0.001) in all three responses. Comprehensiveness, safety, and understanding were higher scores in English LLM responses. In all three responses, more than half of the evaluators marked overall English responses as better than Japanese responses.
Conclusions
English LLM responses to anaesthesia-related frequently asked questions were superior in quality to Japanese responses when assessed by bilingual anaesthesia experts in this report. This study highlights the potential for language-related disparities in healthcare information and the need to improve the quality of AI responses in underrepresented languages. Future studies are needed to explore these disparities in other commonly spoken languages and to compare the performance of different LLMs.
{"title":"A comparative study of English and Japanese ChatGPT responses to anaesthesia-related medical questions","authors":"Kazuo Ando , Masaki Sato , Shin Wakatsuki , Ryotaro Nagai , Kumiko Chino , Hinata Kai , Tomomi Sasaki , Rie Kato , Teresa Phuongtram Nguyen , Nan Guo , Pervez Sultan","doi":"10.1016/j.bjao.2024.100296","DOIUrl":"https://doi.org/10.1016/j.bjao.2024.100296","url":null,"abstract":"<div><h3>Background</h3><p>The expansion of artificial intelligence (AI) within large language models (LLMs) has the potential to streamline healthcare delivery. Despite the increased use of LLMs, disparities in their performance particularly in different languages, remain underexplored. This study examines the quality of ChatGPT responses in English and Japanese, specifically to questions related to anaesthesiology.</p></div><div><h3>Methods</h3><p>Anaesthesiologists proficient in both languages were recruited as experts in this study. Ten frequently asked questions in anaesthesia were selected and translated for evaluation. Three non-sequential responses from ChatGPT were assessed for content quality (accuracy, comprehensiveness, and safety) and communication quality (understanding, empathy/tone, and ethics) by expert evaluators.</p></div><div><h3>Results</h3><p>Eight anaesthesiologists evaluated English and Japanese LLM responses. The overall quality for all questions combined was higher in English compared with Japanese responses. Content and communication quality were significantly higher in English compared with Japanese LLMs responses (both <em>P</em><0.001) in all three responses. Comprehensiveness, safety, and understanding were higher scores in English LLM responses. In all three responses, more than half of the evaluators marked overall English responses as better than Japanese responses.</p></div><div><h3>Conclusions</h3><p>English LLM responses to anaesthesia-related frequently asked questions were superior in quality to Japanese responses when assessed by bilingual anaesthesia experts in this report. This study highlights the potential for language-related disparities in healthcare information and the need to improve the quality of AI responses in underrepresented languages. Future studies are needed to explore these disparities in other commonly spoken languages and to compare the performance of different LLMs.</p></div>","PeriodicalId":72418,"journal":{"name":"BJA open","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2772609624000406/pdfft?md5=17018b4a959c51babd6313efa948146d&pid=1-s2.0-S2772609624000406-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141322954","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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