Welcome to the fifth issue of Cure&Care: Journal of Perioperative Medicine.
Ensuring adequate oxygenation of vital organs during surgery is crucial for successful outcomes so appropriate management of oxygenation requires accurate and reliable monitoring. Insufficient oxygenation of tissues and vital organs can, in some instances, result in permanent tissue damage and life-threatening conditions; there may also be a negative impact on healthcare resources. In this issue, we focus on the topic of monitoring cerebral and tissue oxygenation during surgery and minimally invasive extracorporeal circulation (MiECC) and the use of current technologies such as near infra-red spectroscopy (NIRS). In addition, we review best practice guidelines with regards to postoperative delirium (POD) in clinical practice.
Cardiac surgery is evolving to become ‘more physiological’. The use of oxygen monitoring techniques to detect oxygen level changes is highly valuable and enables surgeons and anaesthetists to make immediate changes to management as appropriate. As described in our ‘hot topic’ articles, MiECC, pulse oximetry and NIRS-based oximetry techniques enable a ‘more physiological’ approach to cardiac surgery and are associated with advantages as well as limitations. While pulse oximetry is widely used, there is a paucity of evidence to show improved outcomes for patients compared with not using pulse oximetry. NIRS is showing promise for becoming integrated within routine clinical practice for indications that extend beyond tissue oxygenation.
There is still some headway to be made with NIRS, as highlighted by Professor Jens K. Rolighed Larsen et al., who provide their expert opinion on the pitfalls in the methodology of NIRS and its challenges and future applications. There are still gaps in the evidence base for NIRS, including how NIRS readings correlate with neurological adverse events.
MiECC, a system providing ‘more physiological’ perfusion, offers the potential for improving patient outcomes as well as addressing morbidity observed with conventional cardiopulmonary bypass (CPB) systems. We spoke with Professor Kyriakos Anastasiadis who highlighted that MiECC enables ‘goal-directed perfusion’, based on real-time monitoring, to provide the opportunity for optimum perfusion in a range of patients. Some clinical evidence demonstrates organ protection with MiECC; the technique is likely to pave the way forward for cardiac surgery in high-risk patients.
Cure&Care spoke with Professor Julien Amour on applications of NIRS for cerebral oximetry and somatic tissue oxygenation. NIRS has demonstrated its potential in tissue oxygenation monitoring; however, several research needs remain. These include further evidence to support the use of the different NIRS instruments, signals that penetrate at levels deeper than the current threshold and devices that monitor the whole brain, not just the anterior cortex. To enable NIRS to be widely used, these issues must be urgently addressed.
Optimal POD monitoring, and subsequent management in patients who show signs of delirium, is imperative for all surgical patients, especially the elderly. Newly updated European Society of Anaesthesiology guidelines have been published and we spoke with Dr Finn Radtke about discussing their implementation into clinical practice. While successful surgical procedures, including appropriate processed electroencephalogram and oxygenation monitoring, are essential for favourable patient outcomes, post-surgical monitoring is also crucial. Delirium, if not detected and managed in a timely manner, can be detrimental for patients. The guidelines will require training of medical and nursing staff; however, they provide clear guidance on applying them in routine clinical practice.
Remote monitoring is valuable for hospitals, medical staff and patients. Professor Felix Balzer discussed with us the design and implementation of a remote monitoring and decision support system at the Charité – Universitätsmedizin, Berlin. Remote monitoring can provide doctors and nurses not physically close to patients with real-time information on vital signs and other appropriate medical information to support care decisions. There are information technology, legal and ethical considerations when implementing such a service into a hospital setting; once these requirements have been met, remote monitoring facilities should have a positive impact on hospital resources and infrastructure.
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We hope that you find this fifth issue of Cure&Care: Journal of Perioperative Medicine both insightful and of value, with learnings you can share with colleagues and implement into your everyday practice to benefit patients.
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With warm regards,
David Green and Gudrun Kunst
King’s College Hospital, London, UK
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