Pressure injury treatment by intermittent electrical stimulation (PROTECT-2): protocol for a multicenter randomized clinical trial.

BACKGROUND: Pressure ulcers account for a substantial fraction of hospital-acquired pathology, with consequent morbidity and economic cost. Treatments are largely focused on preventing further injury, whereas interventions that facilitate healing remain limited. Intermittent electrical stimulation (IES) increases local blood flow and redistributes pressure from muscle-bone interfaces, thus potentially reducing ulcer progression and facilitating healing. METHODS: The Pressure Injury Treatment by Intermittent Electrical Stimulation (PROTECT-2) trial will be a parallel-arm multicenter randomized trial to test the hypothesis that IES combined with routine care reduces sacral and ischial pressure injury over time compared to routine care alone. We plan to enroll 548 patients across various centers. Hospitalized patients with stage 1 or stage 2 sacral or ischial pressure injuries will be randomized to IES and routine care or routine care alone. Wound stage will be followed until death, discharge, or the development of an exclusion criteria for up to 3 months. The primary endpoint will be pressure injury score measured over time. DISCUSSION: Sacral and ischial pressure injuries present a burden to hospitalized patients with both clinical and economic consequences. The PROTECT-2 trial will evaluate whether IES is an effective intervention and thus reduces progression of stage 1 and stage 2 sacral and ischial pressure injuries. TRIAL REGISTRATION: ClinicalTrials.gov NCT05085288 Registered October 20, 2021.

Wearable sensors for monitoring the internal and external workload of the athlete.

The convergence of semiconductor technology, physiology, and predictive health analytics from wearable devices has advanced its clinical and translational utility for sports. The detection and subsequent application of metrics pertinent to and indicative of the physical performance, physiological status, biochemical composition, and mental alertness of the athlete has been shown to reduce the risk of injuries and improve performance and has enabled the development of athlete-centered protocols and treatment plans by team physicians and trainers. Our discussions in this review include commercially available devices, as well as those described in scientific literature to provide an understanding of wearable sensors for sports medicine. The primary objective of this paper is to provide a comprehensive review of the applications of wearable technology for assessing the biomechanical and physiological parameters of the athlete. A secondary objective of this paper is to identify collaborative research opportunities among academic research groups, sports medicine health clinics, and sports team performance programs to further the utility of this technology to assist in the return-to-play for athletes across various sporting domains. A companion paper discusses the use of wearables to monitor the biochemical profile and mental acuity of the athlete.

Wearable sensors for monitoring the physiological and biochemical profile of the athlete.

Athletes are continually seeking new technologies and therapies to gain a competitive edge to maximize their health and performance. Athletes have gravitated toward the use of wearable sensors to monitor their training and recovery. Wearable technologies currently utilized by sports teams monitor both the internal and external workload of athletes. However, there remains an unmet medical need by the sports community to gain further insight into the internal workload of the athlete to tailor recovery protocols to each athlete. The ability to monitor biomarkers from saliva or sweat in a noninvasive and continuous manner remain the next technological gap for sports medical personnel to tailor hydration and recovery protocols per the athlete. The emergence of flexible and stretchable electronics coupled with the ability to quantify biochemical analytes and physiological parameters have enabled the detection of key markers indicative of performance and stress, as reviewed in this paper.

"Wishes Unknown: " A Case Report.

We report the case of a 55-year-old woman who required extracorporeal membrane oxygenation for extreme respiratory distress after a liver transplant and eventually died. As is so often the case, this patient's values and wishes were not documented before she had a risky surgical procedure. Anesthesiologists, in partnership with surgeons, can participate in preoperative discussions exploring wishes and values and document them in advance directives which will help clinicians respect patients' preferences.

Dose of Early Therapeutic Mobility: Does Frequency or Intensity Matter?

OBJECTIVE: Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. DESIGN: Randomized interventional study with repeated measures and blinded assessment of outcomes. SETTING: Four adult intensive care units (ICUs) in two academic medical centers. SUBJECTS: Fifty-four patients with > 48 hr of mechanical ventilation (MV). INTERVENTION: Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. MEASUREMENTS: Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. MAIN RESULTS: Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. CONCLUSION: Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

Complexity Analysis of Decision-Making in the Critically Ill.

RATIONALE: Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life. OBJECTIVE: To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness. METHODS: A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death. MEASUREMENTS: Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan. MAIN RESULTS: Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential. CONCLUSION: Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.

Wearable Devices for Sports: New Integrated Technologies Allow Coaches, Physicians, and Trainers to Better Understand the Physical Demands of Athletes in Real time.

Elite-level athletes and professional sports teams are continually searching for opportunities to improve athletic performance and gain a competitive advantage on the field. Advances in technology have provided new avenues to maximize player health and safety. Over the last decade, time?motion analysis systems, such as video recording and computer digitization, have been used to measure human locomotion and improve sports performance. While these techniques were state of the art at the time, their usefulness is inhibited by the questionable validity of the acquired data, the labor-intensive nature of collecting data with manual hand-notation techniques, and their inability to track athlete position, movement, displacement, and velocity.

Permissible Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction.

BACKGROUND: Repair of hernias with loss of domain can lead to elevated intraabdominal pressure. The authors aimed to characterize the effects of elective hernia repair on intraabdominal pressure, as well as its predictors and association with negative outcomes. METHODS: Patients undergoing elective hernia repair requiring myofascial release had intraabdominal and pulmonary plateau pressures measured preoperatively, postoperatively, and on the morning of the first postoperative day. Loss of domain was measured by preoperative computed tomography. Outcome measures included predictors of an increase in plateau pressure, respiratory complications, and acute kidney injury. RESULTS: Following 50 consecutive cases, diagnoses of intraabdominal hypertension (92 percent), abdominal compartment syndrome (16 percent), and abdominal perfusion pressure less than 60 mmHg (24 percent) were determined. Changes in intraabdominal pressure (preoperative, 12.7 ± 4.0 mmHg; postoperative, 18.2 ± 5.4 mmHg; postoperative day 1, 12.9 ± 5.2 mmHg) and abdominal perfusion pressure (preoperative, 74.7 ± 15.7; postoperative, 70.0 ± 14.4; postoperative day 1, 74.9 ± 11.6 mmHg) consistently resolved by postoperative day 1, and were not associated with respiratory complications or acute kidney injury. Patients who remained intubated postoperatively for an elevation in pulmonary plateau pressure (≥6 mmHg) all demonstrated an improvement in plateau pressure by postoperative day 1 (preoperative, 18.9 ± 4.5 mmHg; postoperative, 27.4 ± 4.0 mmHg; postoperative day 1, 20.1 ± 3.7 mmHg), and could be identified preoperatively as having a hernia volume of greater than 20 percent of the abdominal cavity (p < 0.001), but were still more likely to have postoperative respiratory events (p = 0.01). CONCLUSIONS: Elevated intraabdominal pressure following elective hernia repair requiring myofascial releases is common but transient. Change in plateau pressure by 6 mmHg or more following repair can be expected with a loss of domain greater than 20 percent and is a more useful surrogate than intraabdominal pressure measurements with regard to predicting postoperative pulmonary complications. The perception and management of elevated intraabdominal pressure should be considered distinct and "permissible" in this context.

VINSIA: visual navigator for surgical information access.

Information access at the point of care presents a different set of requirements than those for traditional search engines. Critical care in remote (e.g., battle field) and rural settings not only requires access to clinical guidelines and medical libraries with surgical precision but also with minimal user effort and time. Our development of a graphical, anatomy-driven navigator called Visual Navigator for Surgical Information Access (VINSIA) fulfills the goal for providing evidence-based clinical decision support, specifically in perioperative and critical care settings, to allow rapid and precise information access through a portable stand-alone system. It comes with a set of unique characteristics: (a) a high precision, interactive visual interface driven by human anatomy; (b) direct linkage of anatomical structures to associated content such as clinical guidelines, literature, and medical libraries; and (c) an administrative content management interface allowing only an accredited, expert-level curator to edit and update the clinical content to ensure accuracy and currency. We believe that the deployment of VINSIA will improve quality, safety, and evidence-based standardization of patient care.

Hemodynamic and related challenges: monitoring and regulation in the postoperative period.

The clinician caring for patients in the immediate postoperative period must maintain a high index of suspicion for the development of complications. Evolving illness manifests itself throughout the continuum of care and must be recognized and aggressively managed to ensure optimal outcome. This article discusses common hemodynamic problems encountered in the postanesthesia care unit. These problems are presented in a clinical framework that is familiar to experienced practitioners and recognizable to trainees. This article reviews of these common problems including relevant physiologic principles; effects on hemodynamics; and a logical approach to evaluation, monitoring, and management of a complex postoperative patient.

Predicting severe postoperative respiratory complications following abdominal wall reconstruction.

BACKGROUND: Patients undergoing abdominal wall reconstruction are at risk of developing major postoperative respiratory complications. The authors attempted to identify factors predictive of respiratory complications following abdominal wall reconstruction. METHODS: All patients who underwent complex abdominal wall reconstruction over a 2-year period were reviewed. The primary endpoint studied was severe respiratory complication, defined as respiratory insufficiency requiring intubation or transfer to a higher level of care. RESULTS: Sixty patients underwent complex abdominal wall reconstruction during the study period. The incidence of respiratory complications was 20 percent. Factors predictive of postoperative respiratory complication included age (p = 0.05), American Society of Anesthesiologists score (p = 0.04), and hernia defect size (p = 0.01). In addition, patients who developed respiratory complications were more likely to have had a greater change in plateau pressure (5.8 versus 2.3 cmH(2)O; p = 0.01). The greater the change in plateau pressure, the greater the risk of developing a respiratory complication: for a change in plateau pressure greater than or equal to 6 cmH(2)O, the odds ratio was 8.67; for a change in plateau pressure greater than or equal to 9 cmH(2)O, the odds ratio was 11.5. CONCLUSIONS: Respiratory complications following abdominal wall reconstruction can be serious and are associated with prolonged hospitalizations. Patients with an increase in their plateau pressure of greater than 6 cmH(2)O are at an increased risk of severe postoperative respiratory complications.

Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study.

BACKGROUND: Determining the optimal timing and progression of mobility exercise has the potential to affect functional recovery of critically ill adults. This study compared standard care with care delivered using a mobility protocol. We examined the effects of exercise on vital signs and inflammatory biomarkers and the effects of the nurse-initiated mobility protocol on outcomes. METHODS: Prospective, repeated measures study with a control (standard care) and intervention (protocol) period. RESULTS: 75 heterogeneous subjects admitted to a Medical or Surgical intensive care unit (ICU) were enrolled. In <5% of exercise periods, there was a concerning alteration in respiratory rate or peripheral oxygen saturation; no other adverse events occurred. Findings suggested the use of a protocol with one 20 minute episode of exercise daily for 2 or more days reduced ICU length of stay. Duration of exercise was linked to increased IL-10, suggesting brief episodes of low intensity exercise positively altered inflammatory dysregulation in this sample. CONCLUSION: A growing body of evidence demonstrates that early, progressive exercise has significant benefits to intubated adults. These results should encourage clinicians to add mobility protocols to the care of ICU adults and lead to future studies to determine optimal "dosing" of exercise in ICU patients.

Effectiveness trial of an intensive communication structure for families of long-stay ICU patients.

BACKGROUND: Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. METHODS: One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. RESULTS: Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. CONCLUSIONS: The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Steroids and risk factors for airway compromise in multilevel cervical corpectomy patients: a prospective, randomized, double-blind study.

STUDY DESIGN: Prospective, randomized, double-blind study. OBJECTIVE: To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients. SUMMARY OF BACKGROUND DATA: We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation. METHODS: We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway. RESULTS: Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001). CONCLUSION: Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

Risk factors for delayed extubation after single-stage, multi-level anterior cervical decompression and posterior fusion.

Airway difficulties after single-stage, multilevel anterior and posterior cervical surgery are potentially life-threatening complications. Although extubation delays can occur, overnight intubation can reduce the risk of postoperative airway emergencies. Our protocol was as follows: all patients were kept intubated overnight in an intensive care unit and examined by the intensive care unit staff each morning. Readiness for extubation was based on the cuff-leak test, and extubation done on patients beyond the first postoperative day was considered delayed. Eleven patients were extubated on the first postoperative day (group 1), and 11 extubated beyond day 1 (group 2). No airway emergencies occurred. Patient factors-age, weight, smoking, medical comorbidities, American Society of Anesthesiologist class-were not significantly related to extubation delay. There were no differences between groups in the number of anterior and posterior levels or anterior and posterior operative times. Delayed extubation was significantly related to total operative time (8.2 hours vs. 10.6 hours), volume of crystalloid replacement (3,627 cm3 vs. 6,218 cm3) and intraoperative blood transfused (0.7 units vs. 3.1 units); approaching significance was increased blood loss (1,238 mL vs. 2,820 mL). We have found intraoperative factors-operative time, crystalloid volume, blood loss and replacement-rather than patient characteristics, to be risk factors for delayed extubation. Good communication with anesthesia staff and careful attention to postoperative airway management is essential after single-stage, multilevel anterior cervical decompression and posterior fusion.