#7. Post-operative Continuous Monitoring

TopMedTalk.

Desiree Chappell: Well hello and welcome to TopMedTalk. We are at Euroanesthesia 2022 in beautiful Milan, Italy, coming to you live from this very busy trade exhibition. I'm Desiree Chappell and I'm joined by Monty Mythen, my cohost. Hello Monty.

Monty Mythen: Good morning, Desiree.

Desiree Chappell: It is.

Monty Mythen: It's good to be here.

Desiree Chappell: It is good to be here. Day Two.

Monty Mythen: Day two of the wonderful European Society of Anesthesia Intensive Care Annual Meeting.

Desiree Chappell: That's right. Uh, lotsa buzz.

Monty Mythen: It's, it's-

Desiree Chappell: Can you hear it in the back? (laughs)

Monty Mythen: ... (laughs) it's very, it's very noisy in here.

Desiree Chappell: (laughs) It's very noisy in here.

Monty Mythen: I hope it's not coming through to everyone listening on the podcast end of things. But we're battling against the noise.

Desiree Chappell: We are. Uh,

Monty Mythen:, it is wonderful to be in person seeing all of our friends from around the world. We're waving to everybody right now. (laughs)

Desiree Chappell: As they go around the room. Um, so that's, uh, that's super exciting. Anything, uh, new that you've heard in the last couple days?

Monty Mythen: Oh, I think we're gonna get to that in a second. Went to an absolutely wonderful session led by one of our guests yesterday afternoon.

Desiree Chappell: Yeah.

Monty Mythen: And I think we're gonna talk about that and then follow him with some conversations that related to some of the launch things we heard about on the GE Healthcare stand that we're, we're sitting on at the moment.

Desiree Chappell: That's right. We wanted to thank them for, um, having us this year on their booth at E, uh, at, uh, the Euroanesthesia 2022. We'll let's get right into it. We wanted to introduce our first guest, Dr. Dan Sessler from the Cleveland Clinic. Hello, Dan. How are you?

Dan Sessler: Good morning.

Desiree Chappell: Thank you for being here.

Dan Sessler:  It's a pleasure.

 

Desiree Chappell: ... Thank you so much for being here. Uh, Dan, for everyone listening, tell us a little bit more about yourself.

Dan Sessler: Well, I, I Chair the Department of Outcomes Research at the Cleveland Clinic. I also direct the Outcomes Research Consortium. The consortium is the oldest and largest clinical anesthesia research group. Uh, we're quite productive. We publish a full paper every two and a half days.

Desiree Chappell: Oh. I was gonna say, I, I thought there was a lot coming outta that. I (laughs) didn't realize

Dan Sessler: (laughs)

Desiree Chappell: ... that's how busy you are.

Dan Sessler: Yeah. Well the Consortium has published more than 1600 full papers.

Desiree Chappell: Wow. Wow.

Dan Sessler: But-

Desiree Chappell: That's interesting.

Dan Sessler: ... to put that in perspective, that's equivalent to every paper in every issue of a journal like Anesthesiology for 12 years running.

Desiree Chappell: Wh- (laughs) Oh my gosh. Well, congratulations to, uh, you guys in the team there. That's, that's very impressive actually. Um, Dan, you've been very busy personally with, um, some research that you've been involved with over the years. Tell us just a little bit more about some of your research interests.

Dan Sessler: Okay. Uh, our primary interest is perioperative outcomes.

Desiree Chappell: Mm-hmm.

Dan Sessler: And particularly, perioperative mortality. And by perioperative mortality, I mean postoperative mortality

Desiree Chappell: Mm-hmm.

Dan Sessler:... because intraoperative mortality is now so rare that it's hard to quantify.

Desiree Chappell: Mm-hmm.

Dan Sessler: On the other hand, we lose a lotta patients postoperatively. About two percent of inpatients over the age of 45 die within a month after surgery.

Desiree Chappell: Mm.

Dan Sessler: And again, to provide some perspective around this, if the 30 days after surgery were considered a disease, it would be the third leading cause of death in the United States.

Desiree Chappell: Hm.

Dan Sessler: We lose a lotta patients after surgery. Reasonable question, of course, is what's killing them?

Desiree Chappell: Yeah.

Dan Sessler: And the answer turns out to be uncontrolled surgical bleeding that we probably can't do that much about and myocardial injury that possibly we can.

Desiree Chappell: Interesting.

Dan Sessler: And so, we've been very interested in myocardial injury and one of the, uh, factors that's associated with myocardial injury, the only modifiable factor, is blood pressure. And there are, uh, strong associations between hypotension and myocardial injury. So, so we've been quite interested in that.

Desiree Chappell: Yeah.

Monty Mythen: S- so, Dan, I went to your, as, uh, many of us at the table did yesterday, to your wonderful session which I think was an inaugural session of the ESA that's going to be an annual event. Could you expand on that briefly and then we'll just go into a little bit of the

Dan Sessler: Okay.

Monty Mythen: ... content.

Dan Sessler: Wi- with pleasure.

Monty Mythen: (laughs)

Dan Sessler: The, the Consortium has always had a session at the ASA meeting. And until a few years ago, it was a private session. So it was ASA, the, uh, sponsor. They gave us a room but it was a private session. And then a few years ago we made it public so it's now a regular ASA session. For the first time this year, we have an out-of-research consortium late-breaking session at the ESA and so that started yesterday. We had five presentations about four major thousand-patient-plus trials.

Monty Mythen: So, Dan, within that, uh, we heard results about [inaudible 00:04:37] which is, uh, running and running and its possible association with ventilation-induced lung injury. We heard about warming and I wanna ask you about that very briefly before we get onto the final thing which was the tranexamic acid and the blood pressure trials.

Dan Sessler: Yeah.

Monty Mythen: E- expand on the, the warming one for a second first.

Dan Sessler: Mm-hmm. Uh, with pleasure. So, this is the Protect Trial. Uh, protect tested the hypothesis that very aggressive intraoperative warming would reduce a composite of myocardial complications. The secondary outcomes were surgical site infection and transfusion requirement. Patients were randomized to a target temperature of 35.5 degrees or 37 degrees during surgery and we had very good compliance. The actual temperatures were 35.6 degrees and 37.1 degrees. So the exposure was beautifully controlled. 5,056 patients were randomized. We had more than 99% 30-day followup.

Monty Mythen: Wow.

Dan Sessler: And, and the results were clear; there was absolutely no effect on cardiovascular outcomes, surgical site infection, or transfusion requirement.

Monty Mythen: Uh, and really, it was brought up in the session yesterday, you spoke to it very well. We have a bad tendency to call those negative trials. In other words, the implication is somehow it was a, a waste of effort or a dumb idea

Dan Sessler: Right.

Monty Mythen: ... whereas, it was actually t- it's a very important result.

Dan Sessler: Eh, it is. And I actually wrote an editorial about this for Anesthesiology, uh, saying don't call them negative.

Desiree Chappell: Mm.

Dan Sessler: Um, so it's, it's not a good term. So neutral or robustly equivocal or something like that is, is a better outcome. And this is a good example. The relative risk for complications was essentially one. The confidence centers w- were really tight. This was not an under power trial. Th- this was robustly, uh

Desiree Chappell: Mm.

Dan Sessler: ... neutral outcome, so we can rely on these results.

Desiree Chappell: You know, it's great news actually, uh, with many of the hospitals that we work with, um, with Northstar Anesthesia. And one of the biggest conversations and the most time that people spend in the OR talking about is hypothermia

Dan Sessler: Mm-hmm.

Desiree Chappell: ... and temperature management. And so, I'm

Dan Sessler: (laughs)

Desiree Chappell: ... well I'm (laughs) so excited that we have the, you know

Dan Sessler: Okay.

Desiree Chappell: ... a little bit more data and some answers (laughs).

Dan Sessler: Okay. Now, this doesn't mean that hypothermia doesn't matter. It doesn't mean that you don't need to monitor the temperature.

Desiree Chappell: For sure.

Dan Sessler: And it doesn't mean that you don't need to warm patients. What it means is that the harm threshold is no higher than 35.5 degrees.

Desiree Chappell: Yeah.

Dan Sessler: So, the 36 degrees that's used in lots and lotsa standards which was literally pulled outta the air is, is just wrong. But it, it's

Desiree Chappell: No, that's what I'm saying. That's why I'm so (laughs)

Dan Sessler: ... it should be 35.5. (laughs).

Desiree Chappell: I'm so excited. (laughs)

Monty Mythen: So, I'm gonna move this on to POISE-3, the third in the POISE series and this was a factorial, a large trial, multi-centered, it's an actual trial, factorial design. And the first paper I think has already published in the New England Journal of Medicine, Dan?

Dan Sessler: Correct.

Monty Mythen: Can, can you tell us about the factorial design?

Dan Sessler: Yes.

Monty Mythen: There's a lot to squeeze in. Because then we'll talk about the, the first result, the tranexamic acid. Then we'll talk about blood pressure.

Dan Sessler: Okay. Uh, factorial designs are, are one of the, uh, trial innovations that's, uh, being increasingly used and for good reason. Because with a factorial design, you can answer two or more questions simultaneously. So that, that's obviously very efficient. Conceptually, even better than it sounds because if you do two independent trials, you can't tell what happens if you combine an intervention.

Desiree Chappell: Mm.

Dan Sessler: With a factorial design, you can look at the interaction time, term, and tell whether these interventions interact additively, whether they antagonize each other or whether they might be synergistic. So factorial designs are really powerful. POISE-3 had two factors. One was tranexamic acid and the second was blood pressure control. So patients were randomized to tranexamic acid or placebo and to hypotension prevention or hypertension prevention.

Desiree Chappell: Mm-hmm.

Monty Mythen: And I'll bring you back to that in a second but we're gonna concentrate on the rest of the podcast about blood pressure. But the tranexami- eh, the takeaway from the tranexamic acid trial results, so a big trial. About nine and a half thousand

Dan Sessler: Yeah.

Monty Mythen: ... patients.

Dan Sessler: Correct.

Monty Mythen: A hundred plus countries, uh, no. 20 plus countries is, uh, all, yeah.

Dan Sessler: It's 120 centers in about 20 countries.

Monty Mythen: So

Dan Sessler: 9500 patients in rough.

Monty Mythen: ... so a huge ef- well, what's the takeaway from the tranexamic acid trial?

Dan Sessler: The tranexamic acid works and, and that's not super surprising because many previous small trials have shown this. But this is, uh, by far the largest (laughs) but in order of magnitude or something like that. Uh, it shows clearly that tranexamic acid reduces bleeding, it reduces transfusion requirements and importantly, it shows that it does not increase cardiovascular events because the cardiovascular events after surgery are Type 2 infarctions. There's supply demand mismatch and coronary thrombus is probably

Desiree Chappell: Mm-hmm.

Dan Sessler: ... one of the factors.

Desiree Chappell: Mm-hmm.

Dan Sessler: So it was quite possible that tranexamic acid, while reducing transfusion requirements, would promote cardiovascular events. And it turns out that's not true with a way, a fair degree of confidence we can say that doesn't happen.

Desiree Chappell: No, 'cause some

Monty Mythen: 'Cause, 'cause some people might look away and say, well, it made it, some difference to bleeding, but it didn't make an obvious difference to, you know, what we refer to as outcomes, you know, very meaningful longterm outcomes. But the thing that was, uh, brought up in the presentation is, there's a blood shortage so the amount of blood that could be saved, that didn't need to be transfused, makes a huge difference.

Dan Sessler: Well. There's not enough blood in the world.

Monty Mythen: Mm.

Dan Sessler: So people who need transfusions don't always get them. That's not so true in Western countries, but in many countries, uh, people simply don't get the blood they need. Tranexamic acid is generic, it's been around forever, it's dirt cheap, uh, it appears to be incredibly safe. There's no reason not to use it. Another thing that came out of this is it wasn't just, uh, big operations and high risk for bleeding. It helped across the entire spectrum of operations. So even though surgeons say, “Oh, I'm not gonna have bleeding in this operation,” which they say for every operation, (laughs) okay? You still should give 'em tranexamic acid because some of them will actually have major bleeding and if you have the tranexamic acid on board, it prevents a catastrophe. So it wasn't just transfusions. Uh, uh, it also reduced major life threatening bleeding related events.

Monty Mythen: Brilliant. So that's out there. People can read it in the New England Journal of Medicine. Now the second component of it, which is what we're gonna talk about for the rest of this podcast, is the blood pressure story. And this was an m- more complicated thing to try and assimilate in your presentation.

Dan Sessler: It i- it is. Yes.

Monty Mythen: Can you give it y- your best shot, elevator pitch? (laughs)

Dan Sessler: Okay. So, uh, this was a fac- a partial factorial randomized trial. So not everybody who qualified for the tranexamic acid part qualified for the blood pressure part of the study. To be in the blood pressure part of the study, patients had to be taking antihypertensive medications. So the result was that we had only, as it were, 7500 patients. Now, 7500 patients, of course, is still a huge trial and the results are, are highly, highly, uh, clear. Uh, patients were randomized to hypotension prevention which meant keeping intraoperative mean arterial pressure above 80 millimeters of mercury and delaying the restart of their chronic antihypertensive medications for three days. Patients randomized to hypertension prevention, uh, were allowed to become hypotensive to s- uh, as low as 65 millimeters of mercury during surgery, but some got lower than that. Uh, and their antihypertensive medication for restarted immediately after surgery.

Dan Sessler: So, intraoperative blood pressures ended up differing. They'll, there was about a 30 minute difference in the amount of hypotension between 60 and 69 millimeters of mercury. An unfortunate limitation of the trial is that we don't know what happened within that range.

Monty Mythen: Mm.

Dan Sessler: So, it's possible that most of that hypotension was well above 65 and not that many patients were down around 60. Starting or restarting antihypertensive medications seems to have almost no effect on postoperative blood pressure. And, and that's important because myocardia linter after non-cardiac surgery as far as we can tell does not occur intraoperatively. It occurs postoperatively. 94% of these events would occur within two days after surgery, but probably not actually during surgery.

Monty Mythen: So that's where I want to take this with the, for the last section of this and we'll introduce an- nother guest in a second. Is, are we calling all these trials negative [inaudible 00:14:28], is it, is it just that we might just be looking in the wrong place?

Dan Sessler: Okay.

Monty Mythen: We're looking under the, the, the, we're looking under the lamp but not looking where we dropped the keys.

Dan Sessler: Right. Okay. So I need to give you the results.

Monty Mythen: Mm-hmm.

Dan Sessler: The, the results were that it didn't make any difference.

Monty Mythen: Okay. (laughs)

Dan Sessler: [inaudible 00:14:42] randomized too. Yeah. Hypertension avoidance or hypertension avoidance. (laughs)

Monty Mythen: I was taking it as a given at this stage. (laughs)

Dan Sessler: Okay. Um, no, it did not make any difference. Um, it's that doesn't of course mean that blood pressure doesn't matter, uh, because there was almost no hypertension below 60 millimeters of mercury. Without question, hypotension at some level enters organs. We just don't know what the threshold is. And a limitation of POISE-3 is that it doesn't really tell us where the threshold is. Uh, s- it's somewhere between 60 and, and 69. Perhaps might be a little bit lower than 60, but personally, I would not leave a patient sitting at 60 millimeters of mercury for the whole case. The, the bulk of available evidence granted some, lots of it's observational, is that that's probably harmful. So POISE-3 helps but it doesn't tell us exactly what the threshold is. There is another trial called Guardian that's already started

Desiree Chappell: Mm-hmm.

Dan Sessler: ... that will randomize 6,250 patients. These will be higher risk patients. All the patients will require an arterial catheter. The blood pressure control will be a lot tighter and we will have near continuous blood pressures in these patients so we'll be able to identify a threshold.

Monty Mythen: A- and what do you aim for the, 'cause the higher threshold group, the one that we thought was going to try and achieve an 80, for example, did not look as though many patients got to the 80. Will that be more so in the Guardian draw?

Dan Sessler: In, in Guardian, the h- higher threshold will be 85 millimeters of mercury and in the lower group, based on the POISE-3 results, we're actually hoping that we have blood pressures in the 60 to 65 range because I suspect that the threshold is in that range.

Monty Mythen: So, Desiree, we have another guest?

Desiree Chappell: We do.

Monty Mythen: We get to do postop now. (laughs)

Desiree Chappell: Yeah. And I was just gonna say (laughs), so switching gears a little bit, you know, for what you were talking about, Dan, that we're seeing a lot more happen in the postop, you know, phase of the surgical continuum. That's why I wanted to bring our next guest in, Frederic Michard from Lausuns- Lucerne, Switzerland. Say it right, I never say that right, do I? (laughs)

Frederic Michard: What?

Desiree Chappell: Lausanne.

Frederic Michard: Ah. Lausanne, yeah, okay.

Desiree Chappell: Lausanne. So it's beautiful, beautiful.

Monty Mythen: (laughs)

Frederic Michard: Yeah, yeah. Don't worry. (laughs)

Desiree Chappell: Frederic, you are a l- a guest of, uh, of TopMedTalk before. Thank you so much for joining us again.

Frederic Michard: Always a pleasure, uh, Desiree and Monty.

Desiree Chappell: Yeah.

Frederic Michard: I think last time we did this was years ago, before the COVID, right?

Desiree Chappell: It was. Yeah, yeah, yeah. It was actually at ESA, uh, 2019.

Frederic Michard: Yeah, you're right.

Desiree Chappell: Whenever we were in Vienna. Yeah.

Frederic Michard: Just before the COVID, yeah.

Desiree Chappell: Just before COVID. So, Frederic, it, this is a space that you've been, uh, involved, uh, in a lot with postop monitoring and care and, and leaning in with enhanced recovery and things like that. Um, what is your take on, on, uh, some of the stuff we've been talking about today?

Frederic Michard: I mean, uh, I obviously fully agree with Dan, uh, when he said, um, I think the very first thing you said is that we need now to focus on first the body management because this is when patients develop complication. I mean, and it's desirous just dramatically improve the, um, what's done during surgery and as you said very well, Dan, and I very often quote one of your editorials, uh, first of all the mortality is 1,000 times higher than intra-operative mortality. So obviously, uh, everybody can understand that if we want to now move the needle, further improve patient safety, I think we need to find solution for the postoperative barrier. It's kind of obvious.

Desiree Chappell: Yeah. Absolutely. Well, I mean, that is one thing that y- I feel like we've been doing things the same way for a very long time and, and not seeing a lotta difference. Where are we headed? In what direction are we headed when it comes to postop monitoring and, and doing things better?

Frederic Michard: So, we, we actually did a survey recently or last year we did a survey but it was published was completely the new, uh, upend version of the British Journal of Anesthesia. It's a survey we did in Europe and in the US. Uh, we had the four tier academic centers, uh, who participated. And so, from that survey we learned, first of all that today current practices spot check, you know? Vital signs spot check by nurses, on average, every four to six hours in, uh, the US. Every eight to 12 hours, uh, in Europe. And so that's how we do it. And so, as you know, as soon as patients leave the step-down unit or actually the OR and then they go to the surgical wards where usually surgeons are not there because they are logically in their [inaudible 00:19:14] room and, and there are very few nurses as compared to the nurse-patient ratio we, we benefit from in, in the step-down unit or in the ACU.

Monty Mythen: And that, and that, so that's, if we're, we, we're honest about that, that's shocking, isn't it? And it's, uh

Frederic Michard: ... Shocking, I would not say it's shocking. But obviously

Monty Mythen: Are you not shocked?

Frederic Michard: ... that's where we can improve- I'm not shocked because, you know

Monty Mythen: Okay.

Frederic Michard: ... I, I'm, I'm a French guy. So if you

Desiree Chappell: Well not, not, uh, the f- (laughs)

Monty Mythen: (laughs)

Frederic Michard: ... if you have in mind the [inaudible 00:19:38] the system in France, I'm not sure it's, at least it's not anymore an example.

Desiree Chappell: Yeah.

Frederic Michard: But, but, uh, but generally there was, there is a lot of room for improvement.

Desiree Chappell: Yeah, Dan, uh, did you wanna insert a comment?

Dan Sessler: We, we monitor patients after surgery the way we did 50 years ago. This technique dates back half, half a century. But half a century ago, patients were admitted two days before surgery. We didn't operate on anybody over 60. We didn't do big operations. Patients stayed in the hospital for two weeks after surgery. The average acuity in the hospitals 50 years ago was, uh, uh, relatively low. Now, most patients go home, you have to be four plus sick, you get admitted the morning of surgery and kicked out two days later. The acuity is just really high but we're still monitoring the same way we did 50 years ago. That's inappropriate. These patients should be treated like ICU patients 'cause they're four plus sick.

Desiree Chappell: Yeah. Absolutely.

Frederic Michard: And so, what we learn as well from that survey

Desiree Chappell: Yes.

Frederic Michard: ... that there is a big, uh, contrast between what's done and, uh, what, uh, anesthesiologists are expecting. And clearly, I mean, in that survey if I remember well, 91% of them believe that continuous monitoring should now be offered to patients. I believe that remote wireless monitoring should be, uh, available simply because we all know from, uh, [inaudible 00:20:57] and programs that early mobilization is a key element, uh, for faster recovery. So, so there is almost a consensus, uh, regarding the fact we need to start using these new technologies, uh, to, uh, upgrade the way we monitor our patient in the wards and ultimately possibly improve at them.

Desiree Chappell: Yeah, for sure. Let's talk about some of the issues that we see postoperatively and then, what are some of the solutions that are coming out? So, we talked about hypo- you know, hypotension, hypertension, issues with blood pressure, hemodynamic instability is one. Respiratory issues as well are a problem, right?

Dan Sessler: Re- respiratory issues are, are important because they're preventable.

Desiree Chappell: Yes.

Dan Sessler: I wou- nobody should die in a hospital from respiratory failure because we can treat respiratory failure.

Desiree Chappell: Mm-hmm.

Dan Sessler: Uh, it's not, by far, the most common cause of death.

Desiree Chappell: No.

Dan Sessler: Cardiovascular events are, are 10 or 100 times as common as respiratory events. It's just that the respiratory events are completely preventable so they, there's no excuse for them.

Desiree Chappell: Mm-hmm.

Dan Sessler: Uh, so we need to monitor patients in the hospital a lot better than we do now. Effectively we need continuous monitoring.

Desiree Chappell: Mm.

Dan Sessler: Uh, we've, we've shown twice now that intraoperatively, if you have continuous monitoring, you detect twice as much hypotension

Desiree Chappell: Yeah, yeah.

Dan Sessler: ... as if you measure every five minutes. Okay, well imagine if you're measuring every four or six or eight hours how much you're gonna miss. Well we've actually studied that.

Desiree Chappell: Right.

Dan Sessler: Y- you miss, uh, a lot of it. Nurses miss 90% of serious hypoxemic episodes. That, that is saturations less than 90 for an hour continuously. They're, they're missed. Now, it's not that the nurses are doing anything wrong. This is not a criticism of nursing. This is part of the system. If you have nurses only wander by every four hours as in our studies, and remember in many hospitals it's less, of course they're gonna miss events that happen within the four hours. The only way to solve it is continuous monitoring.

Frederic Michard: Of course, I agree with Dan that [inaudible 00:23:01] is not acceptable because it's one of the, is unpreventable. On the other hand, it's, it's definitely not the most criminal respiratory complication. Uh, there is a very nice study by the group of, uh, [inaudible 00:23:12] published a few years ago in critical care medicine looking at triggers for rapid response team activations.

Dan Sessler: Yeah.

Frederic Michard: And then you realize that it's more or less 25, 25, 25, 25% for a high heart rate, a low SP02, uh, high respiratory rate or low blood pressure. These are the main triggers for rapid response team activation. So if you focus on respiratory rate, for instance, it's much more of an rise in respiratory rates that would be an issue. It could be related to pneumonia. It could be related, uh, to a tumor or embolism, you know? It's, it's not only [inaudible 00:23:50] respiratory operation. I understand we often focus on that

Desiree Chappell: We do.

Frederic Michard: ... because once again, it's 100% preventable. It's not acceptable, but it's definitely not the most common issue, uh, from a respiratory standpoint.

Desiree Chappell: I'm so glad that you bring that up because it's very true and we do get focused on the, you know, the opioid depression. Um, but there's a lot of other things going on. It's really har- it's really so easy to miss. We don't do the monitoring. But some of monitoring technology that we have out on the floors, it's not great. If, if someone has a continuous pulse ox, you know, all they have to do is mess with their hair and, you know, move around a little bit and it's, you know, you get alarm fatigue because it just keeps going off and you miss a lotta things that way. What are some of the technologies coming down the pipe that is a little bit more, um, user friendly?

Frederic Michard: So, yes, uh, I mean, it's, it's a good point. Uh, over the last five years I would say many companies, uh, developed, uh, new solutions

Desiree Chappell: Mm-hmm.

Frederic Michard: ... for monitoring patients on the wards. As I said already, they are wireless, uh, but as you mention, they also have, uh, new software, uh, able to filter if not all, at least most artifact-

Dan Sessler: Yeah.

Frederic Michard: ... 'cause once again we are interested in monitoring ambulatory patients now. So you can imagine the

Dan Sessler: Yeah.

Frederic Michard: ... level of artifacts we have. Uh, and so, as I mentioned, you know, I think that's the top four. Uh, in a perfect world, we should be able to monitor ISPO2, heart rates, and by the way, that's what we do with a pulse oximeter.

Dan Sessler: Yeah.

Frederic Michard: It's not heart rate, it's pulse rates but, as you know, it's very close. Uh, we have tools to monitor respiratory rates. Uh, we have wireless tools now available. And, and the last one is blood pressure and maybe then on, to say something about that because, uh, I think blood pressure monitoring is also very important or would be very important on, in the [inaudible 00:25:32]. But today it remains something very challenging to, to measure and to monitor accurately.

Dan Sessler: Uh, Frederic, that's a, that's an excellent point. Blood pressure is the single most important thing postoperatively. And it's the most difficult to measure. Uh, as you know, all of these measurements have a high degree of artifact associated with them. And e- we can't just start doing all this monitoring, generate gigabytes of data per patient, stream it to the nurses and say, “It's your problem.” It's not, that's not fair to the nurses. So this information is gonna have to go into some artificial intelligence engine that screens out a lot of artifact, things that don't make sense, and identifies patients who look as if they're getting into trouble. And even then, I wouldn't send that directly to the nurses. I would probably stream that patient's information to a bunker with 20 screens, have somebody, uh, preferably an anesthesiologist, looking at that, can pull electronic records and then identify a patient's really getting into trouble and make the call to the ward. “George, check bed 4 now.”

Desiree Chappell: It's really, uh, go ahead. What were you gonna say?

Monty Mythen: I was just saying me- it's, um, you know, perfection is the enemy of progress. We are seeking perfection of the monitoring

Desiree Chappell: Mm-hmm. Yes.

Monty Mythen: ... but there has been enormous progress. I think there are viable solutions today. Is that right, Frederic? There, there's a range of viable things-

Frederic Michard: Yes.

Monty Mythen: ... to at least start with. Because... Yeah.

Frederic Michard: Yes. And I know Dan, you had the opportunity to use some of them at the Cleveland Clinic already. You even published with a, you, wh- when you mentioned the study where you, you realized that nurses were missing, even in your very eye level and prestigious institution

Desiree Chappell: (laughs)

Frederic Michard: ... I think there were, uh, n- nurses who are missing around 80% of, uh, [inaudible 00:27:22] event and, uh, also 80% of hypoxemic events. So it's, uh, beautifully

Dan Sessler: It's n- it, it's not 50% of hypotension and about 90% of hypoxemia.

Frederic Michard: Yeah.

Dan Sessler: But that depends critically on how you define the depth and duration.

Desiree Chappell: Mm. Mm-hmm. Mm-hmm.

Frederic Michard: Yeah.

Dan Sessler: You, you get completely different answers. But the, the point is not the number. The point is that lots are missed.

Frederic Michard: Yes.

Desiree Chappell: Yeah.

Frederic Michard: Yeah, and so, so I, I, I understand the enthusiasm have done for our blood pressure of course because this is one of your many, uh, research topic. But I'm not sure, I'm not yet convinced this is the most important viable to monitor during the postoperative phase. I'm pretty convinced it's one of the top four and today if I had to rank, uh, these rivals probably, uh, respiratory rate would come first because we know from many studies this is a very from the most sensitive marker of clinical deterioration. Actually, when we look at, uh, modern software so machine learning algorithm

Desiree Chappell: Mm-hmm.

Frederic Michard: ... and, and we look at the determinants within these algorithm, w- which, which weight, uh, each variable has, uh, in, you know, detecting, uh, clinical deterioration, respiratory rate is always ranked number one. And honestly, as a clinician, I think it makes sense because we know it's not only abnormal when patients there are respiratory complications, but also when you have metabolic acidosis.

Desiree Chappell: Mm-hmm.

Frederic Michard: When you have shock, when you have pain.

Desiree Chappell: Mm-hmm. Mm-hmm.

Frederic Michard: Uh, you know, there are many different clinical situation where actually your respiratory rate is going to rise. And so that's why it is possibly the most sensitive. Of course, not the most specific. Definitely not.

Desiree Chappell: Right. Yeah.

Dan Sessler: Yeah.

Frederic Michard: But that's the most sensitive. So I would be very careful today before ranking, you know, the, the vital signs and I think once again, in a perfect world, we should be able to monitor all these top four.

Desiree Chappell: Yeah.

Dan Sessler: Uh, I, I agree. Uh, ra- ranking it is not the important goal here, uh, because all, all these things matter.

Desiree Chappell: Yeah.

Dan Sessler: And everything you know about a patient helps. Consider location. So you have accelerometer that can identify position

Desiree Chappell: Mm-hmm.

Dan Sessler: ... if you know the location. Okay. A patient who's lying flat in bed is probably fine. Patients lying flat in the bathroom probably isn't.

Desiree Chappell: (laughs)

Dan Sessler: So-

Desiree Chappell: I see what you're saying, yeah.

Dan Sessler: ... putting this all together and interpreting them in context is what's gonna really help.

Desiree Chappell: So, we're all clinicians at the table here. We've taken care of patients. We know that there's a problem. What, what is the issue, what is the barrier to adoption of things that we know we can use to do it better? Frederic, I'm gonna go with your first.

Frederic Michard: So I think first of all, until recently many of these technologies were not available.

Desiree Chappell: Mm-hmm.

Frederic Michard: Uh, second, um, as we already mentioned, it's, you need to sensor or maybe two sensors

Desiree Chappell: Mm-hmm.

Frederic Michard: ... depending on what you want to monitor. We need software. We already discussed a little bit about smart software to filter artifact but also to give, uh, to digest I would say the information for nurses because, uh, the goal is not, we should not forget, too, about the nurse-to-patient ratio and smart software.

Desiree Chappell: Oh, it's terrible. Yeah.

Frederic Michard: So we cannot, you know, give too much information, uh, too often.

Desiree Chappell: Yeah. Yeah, yeah.

Frederic Michard: So we need also the development of smart software giving kind of visual information like, you know, it's green or yellow or red and as Dan said, when it's red, you need to run to the room. When it's yellow, maybe you need to have a look quickly and inform the ward physician and so on and so forth. So, it's, it's a sensor. It's an algorithm, a smart algorithm, and these are version were not available five years ago.

And in addition, and we are fi- forget that. It's a connectivity protocol.

Desiree Chappell: Mm.

Frederic Michard: Because we start to realize there are very interesting recent studies showing that if you rely on the classic blue tooths connectivity protocol

Desiree Chappell: Yes.

Frederic Michard: ... we all know there are very often disruptions.

Desiree Chappell: Mm-hmm.

Dan Sessler: Yeah.

Frederic Michard: You know? When you are listening to music

Desiree Chappell: Yup. (laughs)

Frederic Michard: ... with your, uh, wireless headphone

Desiree Chappell: (laughs) Yeah.

Dan Sessler: Mm-hmm.

Frederic Michard: ... it's not a big deal because it has nothing to do with patient safety. But if tomorrow we decide to offer continuous monitoring on the wards, we need to be sure it's gonna be reliable. Meaning that, if there is no alarm, clearly it means the patient is going well.

Desiree Chappell: Yeah.

Frederic Michard: Not the, that the patient

Desiree Chappell: Now their needs all

Frederic Michard: ... is disconnected.

Desiree Chappell: (laughs) Right.

Frederic Michard: So the third, uh, piece of the puzzle is also a medical grade, what I would define as medical grade connectivity protocols. And so far, there are companies, and I think I've been able to develop this, uh, this piece of the puzzle.

Desiree Chappell: Yeah. Dan, what are your thoughts on this? How do we get widespread adoption of better monitoring after surgery?

Dan Sessler: Okay. Well, first we need better monitors.

Desiree Chappell: Mm-hmm.

Dan Sessler: Okay. And they're being developed. Lots of companies are, are working on these monitors, but blood pressure's a challenge for, for

Desiree Chappell: It is, yeah.

Dan Sessler: ... almost all of them. So we need better monitors and these are, are extremely complicated devices and they, they need to communicate, they need to have a good battery (laughs) life. Uh, they need to be reliable. Then we need the software to interpret it. I, I really believe that it's unfair to just dump this onto a screen in, in a nursing office. That, that's, it's not fair nor will it work. Uh, the critical events will be missed. Uh, so we need the appropriate software and both of those are challenging. We don't have either yet.

Desiree Chappell: Monty, any comments on that?

Monty Mythen: I think it's, uh, oh, so now we do have, I think, some viable solutions

Desiree Chappell: Mm-hmm.

Monty Mythen: ... that are ready for evaluation in greater numbers.

Desiree Chappell: Mm-hmm.

Monty Mythen: The challenge if we roll back in that they're going to face in their institutions is the cost value discussion.

Desiree Chappell: Right. Yeah.

Monty Mythen: And right at the moment we've got that very difficult situation where we're recognizing that we don't have enough staff, we don't have enough seniority of staff, and we then look at the number of the acquisition of this at scale and we say, well, that's a big number. So we've gotta get over that. We've got to somehow

Desiree Chappell: Yeah.

Monty Mythen: ... face up to the reality of it

Dan Sessler: Mm-hmm.

Monty Mythen: ... and start to make those bold decisions and evaluate the technologies that are there at the moment. And they would improve rapidly if we start to evaluate them and embrace the opportunity [inaudible 00:33:05].

Dan Sessler: Mm. Yeah. Uh, yeah, continuous work monitoring will be the standard of care

Monty Mythen: Yeah.

Dan Sessler: ... and it will be a lot sooner than people think. Within five to 10 years it will just be required in hospitals. And the time will come when the patient walks into the hospital, something is strapped to their wrist, some electrodes stuck on

Desiree Chappell: Mm-hmm.

Dan Sessler: ... and it stays with them through the entire hospitalization and maybe after they go home as well.

Desiree Chappell: Yeah. Frederic, any thoughts on that?

Frederic Michard: Yeah, you know, today we can manage, uh, so much from home.

Desiree Chappell: Yeah (laughs).

Frederic Michard: I mean, some of you have a smart watch

Desiree Chappell: Right? Your Apple watch is, I think.

Frederic Michard: ... not even Apple. I mean-I mean any.... there are many different, you know? (laughs)

Desiree Chappell: Yeah (laughs).

Frederic Michard: But, uh, you know, you can monitor your heart rate

Desiree Chappell: Yeah. For sure.

Frederic Michard: ... you can detect A-fib, you can, uh

Desiree Chappell: Right (laughs).

Frederic Michard: ... I don't wear it now but I have a small bracelet from a Swiss doctor I'm not going to name but, um

Desiree Chappell: Yeah. I was gonna say, no product names.

Dan Sessler: (laughs)

Frederic Michard: ... but it, it's enough to poll system to measure your blood pressure every two hours.

Desiree Chappell: Ah.

Frederic Michard: So even when you sleep, you get your measurements

Desiree Chappell: Yeah.

Frederic Michard: ... uh, I heard that, uh, probably very soon watches will be able to give blood because values today have a [inaudible 00:34:06]. So, it's happening, uh, and, and it would be such a paradox if when you are admitted to the hospital, of course, not in the ICU but to a regular ward, then suddenly you, we lose

Desiree Chappell: It stop-

Frederic Michard: ... all these continuous information

Desiree Chappell: (laughs)

Frederic Michard: ... and we go back to what we were doing 50 years ago

Desiree Chappell: Yeah.

Frederic Michard: ... like spot check from time to time, if the nurse is not too busy.

Desiree Chappell: Yeah.

Frederic Michard: So that's why like, like, uh, Dan, I'm, I'm convinced it's going to happen anyway. It's not gonna be easy because it's, uh, it's a very big change for a surgical department, for regular wards

Desiree Chappell: Yeah.

Frederic Michard: ... uh, we'll have some pushback, but I think it's going to happen anyway.

Desiree Chappell: Yeah. Fantastic. Well, gentlemen, thank you so much for joining us today on TopMedTalk here at Euroanesthesia 2022. Dan, congratulations on POISE- 3 and the, all the good work that you've been doing. Is there any of your outcomes research group there? Amazing.

Dan Sessler: Thank you.

Desiree Chappell: Um, and Frederic, tell us a little bit more. I didn't, I didn't go into this. You're in, uh, your MiCo Consulting, right?

Frederic Michard: Yeah, yeah, yeah, yeah, yeah, I'm leading a consulting and research company based in Switzerland. And so, uh, I'm still in the research

Desiree Chappell: Yeah.

Frederic Michard: ... you know, not myself but, uh, working with, uh, with different people. Uh, for, for example, at the moment we work a lot in AI, uh, with [inaudible 00:35:16]. Uh, you know, how AI could, uh, [inaudible 00:35:17] to, uh, easily measure, uh, eco variables

Desiree Chappell: Yeah.

Frederic Michard: ... and, uh, you will see a few papers, uh, pretty soon hopefully.

Desiree Chappell: Yeah. And how would people find you if, uh, they wanted to reach out?

Frederic Michard: Oh, eh, they can check my website, uh

Desiree Chappell: Mm-hmm.

Frederic Michard: ... michardconsulting.com.

Desiree Chappell: Thank you.

Frederic Michard: Thank you very much, Desiree.

Desiree Chappell: Yes, absolutely. All right. Thanks to everyone for listening to TopMedTalk. You know you can always find us at TopMedTalk.com. We are on your favorite social media platform, Twitter, LinkedIn, Facebook. We are there. And we're gonna have some fabulous conversations the rest of the time here at, uh, the Euroanesthesia 2022. Monty, some good stuff coming up?

Monty Mythen: Some great stuff coming up.

Desiree Chappell: Yeah. Absolutely.

Monty Mythen: And then we're gonna be showing a little bit more about blood pressure

Desiree Chappell: Yeah.

Monty Mythen: ... looking at it from a couple of other different angles. But, you know

Desiree Chappell: Yeah.

Monty Mythen: ... we'll be-

Desiree Chappell: Yeah.

Monty Mythen: ... we're looking forward to a lot more conversation.

Desiree Chappell: Absolutely. Thanks so much for listening everyone. Cheers.

Monty Mythen: Thank you very much.

TopMedTalk.

Desiree Chappell: Desiree Chappell with TopMedTalk. It has been an exciting year and there is so much more to come. Now, I'm joined here with Monty Mythen. Monty, what is coming up?

Monty Mythen: Well, next, TopMedTalk are gonna be coming to you live from the European Society of Anesthesiology from Milan in Italy. You'll find us on the GE Booth in the Trade Exhibition. We'll be there until Sunday. We'll probably pop up in a few other places. So I'm there with Desiree and Sol Aronson's coming in and Henry Hale. And after that, Desiree, where do we go?

Desiree Chappell: It is time for the 25th Anniversary World Congress of Perioperative Medicine in London, right? Live.

Monty Mythen: From the UCL Campus to celebrate our 25th Anniversary. So that's really exciting. And then I think we've got the next one in August with your organization in America. Yeah.

Desiree Chappell: It is. It's in Chicago. It's the American Association of Nurse Anesthetists. Monty or I are gonna pop up there, have some great conversations, and then it's on to...

Monty Mythen: Dingle. So that takes us into the autumn and winter season. More about that to follow. Desiree Chappell: A- and then, of course, we're gonna be rounding out the year with the American Society of Anesthesiologists in New Orleans for their Annual Congress. So super excited about all the events for the year. Don't miss us. Be sure to check us out on TopMedTalk.com and on your favorite pod catcher. We are there with late breaking anesthesia and perioperative news. Right, Monty?

Monty Mythen: Absolutely. See you soon.

Desiree Chappell: Cheers.