Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers.

INTRODUCTION: Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW). METHODS: Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics. RESULTS: Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU). CONCLUSIONS: Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.

Prophylactic Intra-Aortic Balloon Counterpulsation in High Risk Cardiac Surgery: The PINBALL Pilot Multicentre, Registry-Linked, Randomised, Controlled Feasibility Trial.

BACKGROUND: Prophylactic intra-aortic balloon counterpulsation (IABC) is commonly used in selected patients undergoing coronary artery bypass graft (CABG) surgery, but definitive evidence is lacking. The aim of the multicentre PINBALL Pilot randomised controlled trial (RCT) was to assess the feasibility of performing a definitive trial to address this question. METHODS: Patients listed for CABG surgery with impaired left ventricular function and at least one additional risk factor for postoperative low cardiac output syndrome were eligible for inclusion if the treating surgical team was uncertain as to the benefit of prophylactic IABC. The primary outcome of feasibility was based on exceeding a pre-specified recruitment rate, protocol compliance and follow-up. RESULTS: The recruitment rate of 0.5 participants per site per month did not meet the feasibility threshold of two participants per site per month and the study was stopped early after enrolment of 24 out of the planned sample size of 40 participants. For 20/24 (83%) participants, preoperative IABC use occurred according to study assignment. Six (6)-month follow-up was available for all enrolled participants, [IABC 1 death (8%) vs. control 1 death (9%), p = 0.95]. CONCLUSION: The PINBALL Pilot recruitment rate was insufficient to demonstrate feasibility of a multicentre RCT of prophylactic IABC in high risk patients undergoing CABG surgery.

Six-Month Outcomes After High-Risk Coronary Artery Bypass Graft Surgery and Preoperative Intra-aortic Balloon Counterpulsation Use: An Inception Cohort Study.

OBJECTIVE: To inform the design of a pivotal randomized controlled trial of prophylactic intra-aortic balloon counterpulsation (IABC) in patients undergoing coronary artery bypass graft (CABG) at high risk of postoperative low cardiac output syndrome (LCOS). DESIGN: Inception cohort study. SETTING: A total of 13 established cardiac centers in Australia, Canada, New Zealand, and the United Kingdom. PARTICIPANTS: Adult patients were eligible for inclusion if they were listed for CABG surgery and had 2 or more LCOS risk factors (low ejection fraction, severe left main coronary artery disease, redo sternotomy, unstable angina). INTERVENTIONS: Outcomes of interest were a composite outcome of in-hospital mortality, postoperative acute myocardial infarction (AMI), acute kidney injury (AKI), or stroke as well as 6-month vital status and quality of life using the EuroQol 5-dimensional questionnaire (EQ5D). MEASUREMENTS AND MAIN RESULTS: The study included 136 participants over a 29-month period. Overall, in-hospital and 6-month mortality occurred in 7 (5%) and 11 (8%) participants, respectively. The composite outcome occurred in 60 (44%). The mean increase in EQ5D summary index at 6 months was 0.10 (standard deviation 0.24, p = 0.01). Perioperative AMI, AKI, or stroke significantly decreased the odds of a clinically meaningful improvement in quality of life (odds ratio 0.32; 95% confidence interval 0.13-0.79; p = 0.014). Preoperative IABC was used in 39 participants and did not predict postoperative outcomes. CONCLUSIONS: The study identified a group of patients at risk of LCOS in whom CABG surgery was associated with a substantial burden of perioperative morbidity. Preoperative IABC use was variable, supporting the need for further research.

Continuous intra-arterial blood glucose monitoring using quenched fluorescence sensing in intensive care patients after cardiac surgery: phase II of a product development study.

PURPOSE: Variations in blood glucose (BG), hyperglycaemia and hypoglycaemia are associated with adverse clinical outcomes in intensive care unit patients. Continuous glucose monitoring (CGM) offers the potential to improve BG control, leading to improved patient outcomes. In our product development study, we determined the safety and performance of the GluCath Intravascular CGM System for up to 48 hours in 20 patients admitted to the ICU after cardiac surgery. METHODS: The GluCath system uses a quenched chemical fluorescence mechanism to optically measure glucose in blood. After undergoing elective cardiac surgery, 20 patients had a GluCath sensor inserted through a preexisting radial artery (RA) catheter, and BG was monitored for up to 48 hours. Qualitative measures included effects on patient care, blood pressure monitoring, and ease of blood sampling through the arterial catheter. Safety assessment of the sensor involved ultrasound (US) monitoring for intra-arterial thrombi. Quantitative measures were the accuracy of the sensor in comparison with the reference analyser, and the proportion of paired BG measurements that were compliant with the ISO15197:2003 and CLSI POCT 12-A3 accuracy reference standards. BG was managed according to usual protocols. RESULTS: Twenty sensors were successfully deployed through pre-existing RA catheters and stayed in the RA of the 20 patients for between 6 and 48 hours, with a median time of 45.0 hours (interquartile range, 42.0-47.3 hours). Sixteen of the inserted sensors (80%) remained in situ for more than 40 hours. Three catheters were removed due to clinically significant sampling difficulty or waveform dampening. Two patients had US evidence of a thrombus; in neither patient was the sensor removed early, and there were no significant sequelae or adverse effects detected. For the 758 paired measurements available for performance analysis, reference BG values ranged between 5.3 mmol/L and 12.8 mmol/L. Of the 758 paired sensor measurements, 735 (97.0%) met the ISO15197:2003 criteria (within 20% of a reference measurement when BG is ≥ 4.2 mmol/L [75 mg/dL]), and 648 (85.5%) met the CLSI POCT 12-A3 criteria (within 12.5% of a reference measurement when the BG level is ≥ 5.6 mmol/L [100mg/dL] and within 0.67 mmol/L [12 mg/dL] when the BG level is < 5.6mmol/L [100 mg/dL]). The aggregate mean absolute relative difference (MARD) between the sensor and the reference BG was 6.4%, with individual sensor MARDs ranging from 3.6% to 12.4%. CONCLUSIONS: The GluCath system, using quenched fluorescence sensing, was safe and showed acceptable accuracy when deployed for up to 48 hours in ICU patients after elective cardiac surgery.

Continuous intra-arterial blood glucose monitoring using quenched fluorescence sensing: a product development study.

BACKGROUND: Continuous glucose monitoring (CGM) has the potential to improve the management of blood glucose (BG) and so improve patient safety and outcomes in intensive care units. The GluCath Intravascular CGM (IV-CGM) System (GluMetrics) uses a novel quenched chemical fluorescence sensing mechanism to measure BG. OBJECTIVE: We aimed to assess the safety and performance of the GluCath IV-CGM for a 24-hour period in 20 patients admitted to an ICU after cardiac surgery. METHODS: Heparin-bonded sensors were deployed via a standard 20-gauge radial arterial catheter inserted for routine care in 21 participants after cardiac surgery. Sensors were inserted shortly after ICU admission and BG was monitored for up to 24 hours. After an in vivo calibration, the system recorded BG every minute. Ultrasound examinations checked for sensor position and the presence of thrombus. Outcome measures were qualitative (ease of use, interference with clinical care, blood pressure monitoring and blood sampling) and quantitative (accuracy in comparison with hourly measurements from a reference analyser). BG was managed according to usual protocols. RESULTS: Of 21 sensors deployed, one failed and one was malpositioned due to operator error. A total of 488 reference samples were collected, with BG concentrations ranging from 4.7mmol/L to 13.4 mmol/L. Calibration samples, samples from the malpositioned sensor and six samples affected by technical errors were excluded. Of 437 paired sensor and reference measurements used to assess accuracy, 353 (80.8%) met International Organization for Standardization standard 15197: 2003 criteria (within 20% of reference when BG≥4.2mmol/L). The aggregate mean absolute relative difference (MARD) was 13.0%, with the MARD for individual sensors ranging from 4.7% to 33.5%. Preremoval ultrasounds detected clinically insignificant intravascular thrombus in five of 21 patients (23.8%). No sensor interfered with clinical care, haemodynamic monitoring or blood sampling. There were no device related serious adverse events. CONCLUSIONS: In this product development study, use of the GluCath system for 24 hours after cardiac surgery had no adverse effect on haemodynamic monitoring, arterial blood sampling or clinical care. Overall accuracy was acceptable in the context of the first phase of a product development study.

Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study).

BACKGROUND: Commonly used sedatives/analgesics can increase the risk of postoperative complications, including delirium. This double-blinded study assessed the neurobehavioral, hemodynamic, and sedative characteristics of dexmedetomidine compared with morphine-based regimen after cardiac surgery at equivalent levels of sedation and analgesia. METHODS: A total of 306 patients at least 60 yr old were randomized to receive dexmedetomidine (0.1-0.7 microg x kg(-1) x h(-1)) or morphine (10-70 microg x kg(-1) x h(-1)) with open-label propofol titrated to a target Motor Activity Assessment Scale of 2-4. Primary outcome was the prevalence of delirium measured daily via Confusion Assessment Method for intensive care. Secondary outcomes included ventilation time, additional sedation/analgesia, and hemodynamic and adverse effects. RESULTS: Of all sedation assessments, 75.2% of dexmedetomidine and 79.6% (P = 0.516) of morphine treatment were in the target range. Delirium incidence was comparable between dexmedetomidine 13 (8.6%) and morphine 22 (15.0%) (relative risk 0.571, 95% confidence interval [CI] 0.256-1.099, P = 0.088), however, dexmedetomidine-managed patients spent 3 fewer days (2 [1-7] versus 5 [2-12]) in delirium (95% CI 1.09-6.67, P = 0.0317). The incidence of delirium was significantly less in a small subgroup requiring intraaortic balloon pump and treated with dexmedetomidine (3 of 20 [15%] versus 9 of 25 [36%]) (relative risk 0.416, 95% CI 0.152-0.637, P = 0.001). Dexmedetomidine-treated patients were more likely to be extubated earlier (relative risk 1.27, 95% CI 1.01-1.60, P = 0.040, log-rank P = 0.036), experienced less systolic hypotension (23% versus 38.1%, P = 0.006), required less norepinephrine (P < 0.001), but had more bradycardia (16.45% versus 6.12%, P = 0.006) than morphine treatment. CONCLUSION: Dexmedetomidine reduced the duration but not the incidence of delirium after cardiac surgery with effective analgesia/sedation, less hypotension, less vasopressor requirement, and more bradycardia versus morphine regimen.