ORCID Profile
0000-0002-0169-0600
Current Organisation
Austin Health
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Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1053/J.JVCA.2016.12.019
Abstract: To compare the physiology of apneic oxygenation with low-tidal-volume (VT) ventilation during harvesting of the left internal mammary artery. Prospective, single-center, randomized trial. Single-center teaching hospital. The study comprised 24 patients who underwent elective coronary artery bypass grafting surgery. Apneic oxygenation (apneic group: 12 participants) and low-VT ventilation (low-VT group: 12 participants) (2.5 mL/kg ideal body weight) for 15 minutes during harvesting of the left internal mammary artery. The primary endpoint was an absolute change in partial pressure of arterial carbon dioxide (PaCO Apneic oxygenation caused a greater degree of hypercarbia and respiratory acidemia compared with low-VT ventilation. Neither technique had deleterious effects on PAP or cardiac function. Both techniques provided adequate ease of surgical access.
Publisher: Portico
Date: 2011
DOI: 10.4137/CMRT.S5150
Publisher: Springer Science and Business Media LLC
Date: 19-08-2020
DOI: 10.1186/S12871-020-01113-8
Abstract: Our study aimed to test the hypothesis that the addition of intrathecal morphine (ITM) results in reduced postoperative opioid use and enhanced postoperative analgesia in patients undergoing open liver resection using a standardized enhanced recovery after surgery (ERAS) protocol with multimodal analgesia. A retrospective analysis of 216 adult patients undergoing open liver resection between June 2010 and July 2017 at a university teaching hospital was conducted. The primary outcome was the cumulative oral morphine equivalent daily dose (oMEDD) on postoperative day (POD) 1. Secondary outcomes included postoperative pain scores, opioid related complications, and length of hospital stay. We also performed a cost analysis evaluating the economic benefits of ITM. One hundred twenty-five patients received ITM (ITM group) and 91 patients received usual care (UC group). Patient characteristics were similar between the groups. The primary outcome - cumulative oMEDD on POD1 - was significantly reduced in the ITM group. Postoperative pain scores up to 24 h post-surgery were significantly reduced in the ITM group. There was no statistically significant difference in complications or hospital stay between the two study groups. Total hospital costs were significantly higher in the ITM group. In patients undergoing open liver resection, ITM in addition to conventional multimodal analgesic strategies reduced postoperative opioid requirements and improved analgesia for 24 h after surgery, without any statistically significant differences in opioid-related complications, and length of hospital stay. Hospital costs were significantly higher in patients receiving ITM, reflective of a longer mandatory stay in intensive care. Registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) under ACTRN12620000001998 .
Publisher: SAGE Publications
Date: 05-2020
Abstract: The oxygen concentration (FiO 2 ) and arterial oxygen tension (PaO 2 ) delivered in patients undergoing major surgery is poorly understood. We aimed to assess current practice with regard to the delivered FiO 2 and the resulting PaO 2 in patients undergoing major surgery. We performed a retrospective cohort study in a tertiary hospital. Data were collected prospectively as part of a larger randomised controlled trial but were analysed retrospectively. Patients were included if receiving controlled mandatory ventilation and arterial line monitoring. Anaesthetists determined the FiO 2 and the oxygenation saturation (SpO 2 ) targets. An arterial blood gas (ABG) was obtained 15–20 minutes after induction of anaesthesia, immediately before the emergence phase of anaesthesia and 15 minutes after arrival in the post-anaesthesia care unit (PACU). We defined hyperoxaemia as a PaO 2 of mmHg and included a further threshold of PaO 2 mmHg. We studied 373 patients. The median (interquartile range (IQR)) lowest intraoperative FiO 2 and SpO 2 values were 0.45 (IQR 0.4–0.5) and 97% (IQR 96–98%), respectively, with a median PaO 2 on the first and second ABG of 237 mmHg (IQR 171–291 mmHg) and 189 mmHg (IQR 145–239 mmHg), respectively. In the PACU, the median lowest oxygen flow rate was 6 L/min (IQR 3–6 L/min), and the PaO 2 was 158 mmHg (IQR 120–192 mmHg). Hyperoxaemia occurred in 82%, 73% and 54% of participants on the first and second intraoperative and postoperative ABGs respectively. A PaO 2 of mmHg occurred in 64%, 41% and 21% of these blood gases, respectively. In an Australian tertiary hospital, a liberal approach to FiO 2 and PaO 2 was most common and resulted in a high incidence of perioperative hyperoxaemia.
Publisher: Springer Science and Business Media LLC
Date: 07-03-2023
DOI: 10.1186/S12871-023-01998-1
Abstract: We recently reported the results for a large randomized controlled trial of low tidal volume ventilation (LTVV) versus conventional tidal volume (CTVV) during major surgery when positive end expiratory pressure (PEEP) was equal between groups. We found no difference in postoperative pulmonary complications (PPCs) in patients who received LTVV. However, in the subgroup of patients undergoing laparoscopic surgery, LTVV was associated with a numerically lower rate of PPCs after surgery. We aimed to further assess the relationship between LTVV versus CTVV during laparoscopic surgery. We conducted a post-hoc analysis of this pre-specified subgroup. All patients received volume-controlled ventilation with an applied PEEP of 5 cmH 2 O and either LTVV (6 mL/kg predicted body weight [PBW]) or CTVV (10 mL/kg PBW). The primary outcome was the incidence of a composite of PPCs within seven days. Three hundred twenty-eight patients (27.2%) underwent laparoscopic surgeries, with 158 (48.2%) randomised to LTVV. Fifty two of 157 patients (33.1%) assigned to LTVV and 72 of 169 (42.6%) assigned to conventional tidal volume developed PPCs within 7 days (unadjusted absolute difference, − 9.48 [95% CI, − 19.86 to 1.05] p = 0.076). After adjusting for pre-specified confounders, the LTVV group had a lower incidence of the primary outcome than patients receiving CTVV (adjusted absolute difference, − 10.36 [95% CI, − 20.52 to − 0.20] p = 0.046). In this post-hoc analysis of a large, randomised trial of LTVV we found that during laparoscopic surgeries, LTVV was associated with a significantly reduced PPCs compared to CTVV when PEEP was applied equally between both groups. Australian and New Zealand Clinical Trials Registry no: 12614000790640.
Publisher: Wiley
Date: 26-10-2022
DOI: 10.1111/CEN.14621
Abstract: Sodium–glucose cotransporter 2 inhibitors (SGLT2i) have been associated with diabetic ketoacidosis at the time of colonoscopy. This study aimed to identify factors associated with ketone concentrations in SGLT2i‐treated type 2 diabetes compared with non‐SGLT2i‐treated diabetes, and those with impaired fasting glycaemia (IFG) and normoglycaemia. Cross‐sectional, multicentre, observational study June–December 2020 in four Australian tertiary hospitals. Capillary glucose and ketones were measured in people undergoing colonoscopy: 37 SGLT2i‐treated and 105 non‐SGLT2i‐treated type 2 diabetes, 65 IFG and 151 normoglycaemia. Body mass index (BMI), age, glucose, fasting duration and where relevant, HbA1c and time since last SGLT2i dose. In SGLT2i‐treated diabetes, BMI ( ρ = −0.43 [95% confidence interval: −0.67, −0.11]) and duration since last SGLT2i dose ( ρ = −0.33 [−0.60, 0.00]) correlated negatively with increasing ketones, but there was no correlation with fasting duration. In non‐SGLT2i‐treated diabetes, BMI correlated negatively ( ρ = −0.24 [−0.42, −0.05]) and fasting duration positively ( ρ = 0.26 [0.07, 0.43]) with ketones. In IFG participants, only fasting duration correlated with ketones ( ρ = 0.28 [0.03, 0.49]). In normoglycaemic participants, there were negative correlations with BMI ( ρ = −0.20 [−0.35, −0.04]) and fasting glucose ( ρ = −0.31 [−0.45, −0.15]) and positive correlations with fasting duration ( ρ = 0.20 [0.04, 0.35]) and age ( ρ = 0.19 [0.03, 0.34]). Multiple regression analysis of the entire cohort showed BMI, age and fasting glucose remained independently associated with ketones, but in SGLT2i‐treated participants only BMI remained independently associated. In SGLT2i‐treated diabetes, lower BMI was a novel risk factor for higher ketones precolonoscopy. Pending larger confirmatory studies, extra vigilance for ketoacidosis is warranted in these people.
Publisher: American Diabetes Association
Date: 28-12-2022
DOI: 10.2337/DCI21-0048
Publisher: Elsevier BV
Date: 10-2014
DOI: 10.1053/J.JVCA.2013.10.005
Abstract: The primary objective of this study was to establish the relationship among tricuspid annular velocity (S'), tricuspid annular plane systolic excursion (TAPSE), and stroke volume (SV) in a cardiac surgical population with and without right ventricular (RV) dysfunction. The secondary objective was to assess the effect of ephedrine on these relationships in a population without RV dysfunction. Prospective, nonrandomized, unblinded study. Single tertiary-level, university-affiliated hospital. Twenty-seven patients undergoing elective coronary artery bypass grafting with no evidence of RV dysfunction (Group 1). Sixteen ventilated postcardiac surgical patients with suspected RV dysfunction (Group 2). Ten mg of intravenous ephedrine to Group 1 only. Using transthoracic echocardiography, S' and TAPSE were measured using color tissue Doppler applied at the RV base in a 4-chamber view. SV was calculated using thermodilution. Six patients in Group 1 and 6 patients in Group 2 were excluded because of poor imaging or ineligibility. Modest correlation was found between TAPSE and SV in Group 1 (R = 0.50, p<0.001). There was no correlation between TAPSE and SV in Group 2. There was no correlation between S' and SV in both groups. In Group 1, the relationship between TAPSE and S' was curvilinear (R = 0.74 pre-ephedrine, p<0.001 R = 0.64, p = 0.009 post-ephedrine). There was no relationship between TAPSE and S' in Group 2. Ephedrine increased S' and TAPSE. The TAPSE-S' relationship was not significantly altered. In the presence of RV dysfunction, TAPSE did not correlate with cardiac output. In the absence of RV dysfunction, the relationship between TAPSE and S' described a curvilinear relationship.
Publisher: Springer Science and Business Media LLC
Date: 16-12-2022
DOI: 10.1186/S13054-022-04230-7
Abstract: Acute kidney injury (AKI) is common in the critically ill. Inadequate renal medullary tissue oxygenation has been linked to its pathogenesis. Moreover, renal medullary tissue hypoxia can be detected before biochemical evidence of AKI in large mammalian models of critical illness. This justifies medullary hypoxia as a pathophysiological biomarker for early detection of impending AKI, thereby providing an opportunity to avert its evolution. Evidence from both animal and human studies supports the view that non-invasively measured bladder urinary oxygen tension (PuO 2 ) can provide a reliable estimate of renal medullary tissue oxygen tension (tPO 2 ), which can only be measured invasively. Furthermore, therapies that modify medullary tPO 2 produce corresponding changes in bladder PuO 2 . Clinical studies have shown that bladder PuO 2 correlates with cardiac output, and that it increases in response to elevated cardiopulmonary bypass (CPB) flow and mean arterial pressure. Clinical observational studies in patients undergoing cardiac surgery involving CPB have shown that bladder PuO 2 has prognostic value for subsequent AKI. Thus, continuous bladder PuO 2 holds promise as a new clinical tool for monitoring the adequacy of renal medullary oxygenation, with its implications for the recognition and prevention of medullary hypoxia and thus AKI.
Publisher: SAGE Publications
Date: 14-03-2022
Publisher: BMJ
Date: 12-2022
DOI: 10.1136/BMJOPEN-2022-068933
Abstract: Cryopreservation at −80°C in dimethylsulphoxide extends platelet shelf-life from 7 days to 2 years. Only limited comparative trial data supports the safety and effectiveness of cryopreserved platelets as a treatment for surgical bleeding. Cryopreserved platelets are not currently registered for civilian use in most countries. CLIP-II and CLIPNZ-II are harmonised, blinded, multicentre, randomised, controlled clinical non-inferiority trials comparing bleeding, transfusion, safety and cost outcomes associated with cryopreserved platelets versus conventional liquid platelets as treatment for bleeding in cardiac surgery. CLIP-II is planning to enrol patients in 12 tertiary hospitals in Australia CLIPNZ-II will recruit in five tertiary hospitals in New Zealand. The trials use near-identical protocols aside from details of cryopreserved platelet preparation. Patients identified preoperatively as being at high risk of requiring a platelet transfusion receive up to three units of study platelets if their treating doctor considers platelet transfusion is indicated. The primary endpoint is blood loss through the surgical drains in the 24 hours following intensive care unit (ICU) admission after surgery. Other endpoints are blood loss at other time points, potential complications, adverse reactions, transfusion and fluid requirement, requirement for procoagulant treatments, time to commencement of postoperative anticoagulants, delay between platelet order and commencement of infusion, need for reoperation, laboratory and point-of-care clotting indices, cost, length of mechanical ventilation, ICU and hospital stay, and mortality. Transfusing 202 (CLIP-II) or 228 (CLIPNZ-II) patients with study platelets will provide 90% power to exclude the possibility of greater than 20% inferiority in the primary endpoint. If cryopreserved platelets are not inferior to liquid-stored platelets, the advantages of longer shelf-life would justify rapid change in clinical practice. Cost-effectiveness analyses will be incorporated into each study such that, should clinical non-inferiority compared with standard care be demonstrated, the hospitals in each country that would benefit most from changing to a cryopreserved platelet blood bank will be known. CLIP-II was approved by the Austin Health Human Research Ethics Committee (HREC/54406/Austin-2019) and by the Australian Red Cross Lifeblood Ethics Committee (2019#23). CLIPNZ-II was approved by the New Zealand Southern Health and Disability Ethics Committee (21/STH/66). Eligible patients are approached for informed consent at least 1 day prior to surgery. There is no provision for consent provided by a substitute decision-maker. The results of the two trials will be submitted separately for publication in peer-reviewed journals. NCT03991481 and ACTRN12621000271808.
Publisher: Elsevier BV
Date: 09-2022
DOI: 10.1053/J.JVCA.2022.05.023
Abstract: Poor medullary oxygenation is implicated in the evolution of acute kidney injury. The authors sought to determine if increasing systemic flow and mean arterial pressure could improve urine oxygen tension (PuO Randomized crossover study. University-affiliated hospital. Twenty adult patients undergoing cardiopulmonary bypass (CPB) with expected cross-cl time of >60 minutes and estimated glomerular filtration rate of >30 mL/min/1.73m Sequential 20-minute periods of 2 interventions: Intervention H ("High") or Intervention N ("Normal"). The order of interventions was determined by randomization. Intervention H: targeted CPB flow 3.0 L/min/m PuO PuO
Publisher: Springer Science and Business Media LLC
Date: 11-04-2022
DOI: 10.1007/S00520-022-07014-5
Abstract: The aim of this study is to ascertain the analgesic efficacy and total oral morphine equivalent daily dose (OMEDD) effect of a buprenorphine-based analgesic protocol in the treatment of severe Oral Mucositis (OM). This is a retrospective cohort study. This study was done in a single Quaternary Referral Centre, Haematology Unit. Fifty-four stem cell transplant patients suffering at least grade 3 oral mucositis (OM), 24 prior to [Pr-I] and 30 subsequent to [Po-I] a buprenorphine-based OM analgesic protocol. We analysed data from the above subjects with the primary outcome measure of difference in total OMEDDs from all opioid types and administration routes, and secondary outcome measures of area under the curve (AUC) of 11-point Numerical Rating Scale (NRS-11) pain assessments, sedation scores and respiratory rate. Post-protocol patients' total OMEDD requirements were significantly reduced [Pr-I: 1961 (1365)mg Po-I: 928 (625)mg, p = 0.02], as were total NRS-11:hours AUC on swallowing [Pr-I: 54(24) score-hours Po-I: 41(18) score-hours, p < 0.001]. There were no significant differences in objective measures of OM severity between groups (Number of Grade 3 or 4 OM severity assessments [mean (SD)] Pr-I: 5 (6.2) Po-I: 7 (5.1) or number of days Neutrophil count 0.0 or 0.1 × 10 Use of Buprenorphine via transdermal, sublingual and intravenous Patient Controlled Analgesia (PCA) delivery as part of an analgesic protocol for severe post stem cell transplant oral mucositis in adult patients appears to significantly reduce opioid requirements and pain on swallowing. Further randomised prospective work is required to confirm these associations.
Publisher: Massachusetts Medical Society
Date: 27-09-2018
Publisher: Springer Science and Business Media LLC
Date: 19-04-2012
DOI: 10.1007/S12630-012-9700-1
Abstract: Pulmonary hypertension impacts negatively on right ventricular function however, understanding pulmonary vasculature can be difficult. Data from invasive monitoring or traditional echocardiography may not represent the full extent of pulmonary arterial disease. An important element missing from invasive monitoring is the ability to take into account the effects of pulsatile flow therefore, mean pressures and mean flows are employed in the calculation of pulmonary vascular resistance. Traditional echocardiography yields right ventricular systolic pressures but only in the presence of tricuspid regurgitation. In these Perioperative Cardiovascular Rounds, we show the utility of interpreting pulmonary artery (PA) pulsed-wave Doppler (PWD) and colour-flow Doppler in the assessment of the pulmonary vasculature, and we describe the physiology behind their genesis. We show these concepts in a case vignette involving a patient in a low cardiac output state after a complex re-do sternotomy. Additionally, we describe four distinct patterns of PA PWD tracings and illustrate the ability of PA PWD analysis to assess the pulmonary vasculature in both a qualitative and semi-quantitative way. In the critical care setting, it is vital to understand alterations in the pulmonary circulation, and analysis of PA PWD can provide additional information to complement data from other sources.
Publisher: Wiley
Date: 17-11-2022
DOI: 10.1111/DOM.14591
Abstract: To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. The multinational, open‐label, randomized controlled TRICS‐III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold g/L) compared with a liberal strategy (Hb g/L for operating room or intensive care unit or g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate‐to‐high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all‐cause death, stroke, myocardial infarction, and new‐onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679 liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93‐1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68‐1.59] vs. no diabetes OR 1.02 [0.85‐1.22] P interaction = .92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21‐0.36] no diabetes OR [95% CI] 0.40 [0.35‐0.47] P interaction = .04). The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 22-09-2022
DOI: 10.1097/EJA.0000000000001601
Abstract: Studies in critically ill patients suggest a relationship between mechanical power (an index of the energy delivered by the ventilator, which includes driving pressure, respiratory rate, tidal volume and inspiratory pressure) and complications. We aimed to assess the association between intra-operative mechanical power and postoperative pulmonary complications (PPCs). Post hoc analysis of a large randomised clinical trial. University-affiliated academic tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. Adult patients undergoing major noncardiothoracic, nonintracranial surgery. Dynamic mechanical power was calculated using the power equation adjusted by the respiratory system compliance ( C RS ). Multivariable models were used to assess the independent association between mechanical power and outcomes. The primary outcome was the incidence of PPCs within the first seven postoperative days. The secondary outcome was the incidence of acute respiratory failure. We studied 1156 patients (median age [IQR]: 64 [55 to 72] years, 59.5% men). Median mechanical power adjusted by C RS was 0.32 [0.22 to 0.51] (J min −1 )/(ml cmH 2 O −1 ). A higher mechanical power was also independently associated with increased risk of PPCs [odds ratio (OR 1.34, 95% CI, 1.17 to 1.52) P 0.001) and acute respiratory failure (OR 1.40, 95% CI, 1.21 to 1.61 P 0.001). In patients receiving ventilation during major noncardiothoracic, nonintracranial surgery, exposure to a higher mechanical power was independently associated with an increased risk of PPCs and acute respiratory failure. Australia and New Zealand Clinical Trials Registry no: 12614000790640.
Publisher: SAGE Publications
Date: 09-2016
DOI: 10.1177/0310057X1604400504
Abstract: For accurate spectral Doppler valvular evaluation, intraoperative sonographers must use transoesophageal echocardiographic (TOE) views that offer optimal incident angles. We hypothesised that views added to the 2013 American Society of Echocardiography/Society of Cardiovascular Anesthesiologists (ASE/SCA) standard views and other novel views we have described of the tricuspid (TV) and pulmonary valves (PV) offered superior incident angles to those included in the origina 1999 ASE/SCA recommendations for comprehensive intraoperative TOE examination. We compared the acquisition feasibility and incident angles obtained by these views in 62 patients undergoing elective cardiac surgery, who received TOE monitoring as standard care. Overall, the 2013 ASE/SCA standard and novel views provided superior incident angles for the TV (28% and 66% of patients) whereas the 1999 ASE/SCA standard views provided superior incident angles for the PV (79% of patients, P .0001). The novel 90° mid-oesophageal modified bicaval view (90°MEMBC) and the 1999 ASE/SCA standard aortic arch short-axis view (AoArSAX) obtained best incident angles for the TV (mean [95% confidence interval] 13° [10°-16°]) and PV (5° [3°-7°]) respectively. PV view acquisition feasibility between the 1999 ASE/SCA standard, 2013 ASE/SCA standard and novel views was not significantly different (acquisition rate difference 11%, P .11). We conclude that the 2013 ASE/SCA TV standard and novel views obtained superior incident angles for the tricuspid, but not pulmonary valves. We recommend that ntraoperative sonographers consider the use of these views, particularly when incident angles obtained with standard views are suboptimal.
Publisher: Springer Science and Business Media LLC
Date: 21-01-2022
DOI: 10.1186/S12871-021-01531-2
Abstract: The use of sublingual buprenorphine (SLBup) for acute pain after major abdominal surgery may offer the potential advantages of unique analgesic properties and more reliable absorption during resolving ileus. We hypothesized that complete opioid transition to SLBup rather than oral oxycodone (OOxy) in the early postoperative period after major abdominal surgery would reduce hospital length of stay, and acute pain and total OMEDD (Oral Morphine Equivalent Daily Dose) requirements in the first 24 h from post-parenteral opioid transition. We reviewed 146 patients who had undergone elective and emergency abdominal surgery under our quaternary referral centre’s Upper Gastro-Intestinal and Colo-Rectal Surgical Units 6 months before and after the introduction of complete postoperative transition to sublingual buprenorphine, rather than oral oxycodone, in July 2017. Our primary endpoint was 24-hourly post-transition OMEDDs secondary endpoints were 24-hourly post-transition Mean NRS-11 pain scores on movement (POM) and length of hospital stay (LOS). Univariate analysis and linear multivariate regression analyses were used to quantify effect size and identify surgical, patient & other analgesic factors associated with these outcome measures. Patients transitioning to SLBup had reduced 24-hourly post-transition OMEDD requirements on postoperative day 2 (POD) (26 mg less, p = 0.04) and NRS-11 POM at POD1 (0.7 NRS-11 units less, p = 0.01). When adjusting for patient, surgical and special analgesic factors, SLBup was associated with a similar reduction in OMEDDs (Unstandardised beta-coefficient -26 mg, p = 0.0001), but not NRS-11 POM ( p = 0.47) or hospital LOS ( p = 0.16). Our change of practice from use of OOxy to SLBup as primary transition opioid from patient-controlled analgesia delivered full opioid agonists was associated with a clinically significant decrease in 24-hourly post-parenteral opioid transition OMEDDs and improved NRS-11 POM, but without an association with hospital LOS after major abdominal surgery. Further prospective randomized work is required to confirm these observed associations and impact on other important patient-centred outcomes.
Publisher: Elsevier BV
Date: 08-2020
Publisher: American Medical Association (AMA)
Date: 09-2020
Publisher: Springer Science and Business Media LLC
Date: 16-05-2022
DOI: 10.1186/S12871-022-01689-3
Abstract: Low tidal volume (V T ) ventilation and its associated increase in arterial carbon dioxide (PaCO 2 ) may affect postoperative neurologic function. We aimed to test the hypothesis that intraoperative low V T ventilation affect the incidence of postoperative ICD-10 coded delirium and/or the need for antipsychotic medications. This is a post-hoc analysis of a large randomized controlled trial evaluating low vs. conventional V T ventilation during major non-cardiothoracic, non-intracranial surgery. The primary outcome was the incidence of ICD-10 delirium and/or the use of antipsychotic medications during hospital stay, and the absolute difference with its 95% confidence interval (CI) was calculated. We studied 1206 patients (median age of 64 [55–72] years, 59.0% males, median ARISCAT of 26 [19–37], and 47.6% of ASA 3). ICD-10 coded delirium and /or antipsychotic medication use was diagnosed in 11.2% with similar incidence between low and conventional V T ventilation (11.1% vs. 11.3% absolute difference, -0.24 [95%CI, -3.82 to 3.32] p = 0.894). There was no interaction between allocation group and type of surgery. In adult patients undergoing major surgery, low V T ventilation was not associated with increased risk of ICD-10 delirium and/or the use of antipsychotic medications during hospital stay. ANZCTR Identifier: ACTRN12614000790640 .
Publisher: Springer Science and Business Media LLC
Date: 06-07-2017
Publisher: Baishideng Publishing Group Inc.
Date: 26-11-2019
Publisher: Wiley
Date: 06-09-2022
DOI: 10.1111/TRF.17084
Abstract: Transfusion Requirements in Cardiac Surgery III (TRICS III), a multi‐center randomized controlled trial, demonstrated clinical non‐inferiority for restrictive versus liberal RBC transfusion for patients undergoing cardiac surgery. However, it is uncertain if transfusion strategy affects long‐term health‐related quality of life (HRQOL). In this planned sub‐study of Australian patients in TRICS III, we sought to determine the non‐inferiority of restrictive versus liberal transfusion strategy on long‐term HRQOL and to describe clinical outcomes 24 months postoperatively. The restrictive strategy involved transfusing RBCs when hemoglobin was .5 g/dl the transfusion triggers in the liberal group were: .5 g/L intraoperatively, .5 g/L in intensive care, or .5 g/dl on the ward. HRQOL assessments were performed using the 36‐item short form survey version 2 (SF‐36v2). Primary outcome was non‐inferiority of summary measures of SF‐36v2 at 12 months, (non‐inferiority margin: −0.25 effect size restrictive minus liberal scores). Secondary outcomes included non‐inferiority of HRQOL at 18 and 24 months. Six hundred seventeen Australian patients received allocated randomization HRQOL data were available for 208/311 in restrictive and 217/306 in liberal group. After multiple imputation, non‐inferiority of restrictive transfusion at 12 months was not demonstrated for HRQOL, and the estimates were directionally in favor of liberal transfusion. Non‐inferiority also could not be concluded at 18 and 24 months. Sensitivity analyses supported these results. There were no differences in quality‐adjusted life years or composite clinical outcomes up to 24 months after surgery. The non‐inferiority of a restrictive compared to a liberal transfusion strategy was not established for long‐term HRQOL in this dataset.
Publisher: BMJ
Date: 02-2020
DOI: 10.1136/BMJOPEN-2019-029159
Abstract: The effects of hypercapnia on regional cerebral oxygen saturation (rSO 2 ) during surgery are unclear. We conducted a randomised controlled trial to investigate the relationship between mild hypercapnia and rSO 2 . We hypothesised that, compared with targeted normocapnia (TN), targeted mild hypercapnia (TMH) during major surgery would increase rSO 2 . A prospective, randomised, controlled trial in adult participants undergoing elective major surgery. A single tertiary centre in Heidelberg, Victoria, Australia. 40 participants were randomised to either a TMH or TN group (20 to each). TMH (partial pressure of carbon dioxide in arterial blood, PaCO 2 , 45–55 mm Hg) or TN (PaCO 2 35–40 mm Hg) was delivered via controlled ventilation throughout surgery. The primary endpoint was the absolute difference between the two groups in percentage change in rSO 2 from baseline to completion of surgery. Secondary endpoints included intraoperative pH, bicarbonate concentration, base excess, serum potassium concentration, incidence of postoperative delirium and length of stay (LOS) in hospital. The absolute difference between the two groups in percentage change in rSO 2 from the baseline to the completion of surgery was 19.0% higher in both hemispheres with TMH (p .001). On both sides, the percentage change in rSO 2 was greater in the TMH group than the TN group throughout the duration of surgery. The difference between the groups became more noticeable over time. Furthermore, postoperative delirium was higher in the TN group (risk difference 0.3, 95% CI 0.1 to 0.5, p=0.02). LOS was similar between groups (5 days vs 5 days p=0.99). TMH was associated with a stable increase in rSO 2 from the baseline, while TN was associated with a decrease in rSO 2 in both hemispheres in patients undergoing major surgery. This resulted in a clear separation of percentage change in rSO 2 from the baseline between TMH and TN over time. Our findings provide the rationale for larger studies on TMH during surgery. The Australian New Zealand Clinical Trials Registry (ACTRN12616000320459).
Publisher: American Diabetes Association
Date: 25-04-2021
DOI: 10.2337/DC21-0256
Publisher: Public Library of Science (PLoS)
Date: 20-01-2023
DOI: 10.1371/JOURNAL.PONE.0280436
Abstract: This prospective observational study aimed to establish the frequency of postoperative nocturnal respiratory abnormalities among patients undergoing major surgery who received ward-level care. These abnormalities may have implications for postoperative pulmonary complications (PPCs). Eligible patients underwent blinded noninvasive continuous capnography with pulse oximetry using the Capnostream ™ 20p monitor over the first postoperative night. All patients received oxygen supplementation and patient-controlled opioid analgesia. The primary outcome was the number of prolonged apnea events (PAEs), defined as end-tidal carbon dioxide (EtCO 2 ) ≤5 mmHg for 30–120 seconds or EtCO2 ≤5 mmHg for seconds with oxygen saturation (SpO 2 ) %. Secondary outcomes were the proportion of recorded time that physiological indices were aberrant, including the apnea index (AI), oxygen desaturation index (ODI), integrated pulmonary index (IPI), and SpO 2 . Exploratory analysis was conducted to assess the associations between PAEs, PPCs, and pre-defined factors. Among 125 patients who had sufficient data for analysis, a total of 1800 PAEs occurred in 67 (53.4%) patients. The highest quartile accounted for 89.1% of all events. Amongst patients who experienced any PAEs, the median (IQR) number of PAE atient was four (2–12). As proportions of recorded time (median (IQR)), AI, ODI, and IPI were aberrant for 12.4% (0–43.2%), 19.1% (2.0–57.1%), and 11.5% (3.1–33.3%) respectively. Only age, ARISCAT, and opioid consumption/kg were associated with PPCs. PAE and aberrant indices were frequently detected on the first postoperative night. However, they did not correlate with PPCs. Future research should investigate the significance of detected aberrations.
Publisher: Springer Science and Business Media LLC
Date: 21-03-2020
DOI: 10.1007/S00380-020-01578-0
Abstract: Acute kidney injury after cardiac surgery (AKICS) is common. Previous studies examining the role that mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) may have on AKICS have not taken into account how baseline central venous pressure (CVP) and mean perfusion pressure (MPP) (i.e. MAP − CVP) can influence its evolution. To assess whether the change in MPP to the kidneys (i.e. delta MPP or DMPP) during CPB compared to baseline is an independent predictor of AKICS. After ethical approval, a retrospective observational study was performed on all patients undergoing CPB between October 2013 and June 2015 at a university-affiliated hospital. Known risk factors for the development of AKICS were recorded, as were the MPP values at baseline and during CPB. From this, statistical modelling was performed to identify predictors of postoperative AKICS. 664 patients were identified. Analysis was performed on 513 patients after exclusion. On logistic regression, significant and independent predictors of AKICS included: d20DMPP (cumulative duration of MPP values during CPB that were 20% below baseline and exceeded three consecutive minutes) ( P = 0.010) baseline CVP age pre-operative creatinine level and left ventricular (LV) dysfunction (ejection fraction (EF) 45%). On alternative modelling, the cumulative number of MPP values during CPB that were 10% below baseline was also independently associated with AKICS ( P = 0.003). Modelling without taking into account CVP also supported this association. The duration of differences in perfusion pressure to the kidneys during CPB compared to baseline is an independent predictor of AKICS.
Publisher: BMJ
Date: 20-04-2022
Publisher: Elsevier BV
Date: 2015
Publisher: Elsevier BV
Date: 09-2021
Publisher: SAGE Publications
Date: 04-2006
DOI: 10.1177/0310057X0603400221
Abstract: Monitoring devices are known to induce tachycardia in minute-ventilation rate-responsive pacemakers. This is because some monitoring devices measure the same parameter as do the pacemakers (change in thoracic impedance). Hence, the biological signal to the pacemaker is increased and is misconstrued as increased minute ventilation causing tachycardia which resolves when the monitoring device is removed. Whilst this could occur for all minute-volume rate responsive pacemakers, most reported interactions have been with the Telectronics META series. We present a case of an interaction between a Telectronics Tempo DR pacemaker (St. Jude Medical) and an Agilent Patient Care System (Philips). Failure to recognise the true nature and cause of such tachycardias may lead to mismanagement of the patient, including the inappropriate use of cardio-active medications.
Publisher: Public Library of Science (PLoS)
Date: 08-09-2023
No related grants have been discovered for Raymond Hu.