ADVANCING CARDIOVASCULAR ANESTHESIA MANAGEMENT: A COMPREHENSIVE REVIEW OF PORTABLE AND CONTINUOUS MONITORING DEVICES FOR ENHANCED PATIENT OUTCOMES

: This study reviewed the current literature on using portable and continuous monitoring devices in the context of cardiovascular anesthesia. The inclusion criteria focused on peer-reviewed articles published in English between 2010 and 2024, covering clinical trials, observational studies, systematic reviews, and meta-analyses. Excluded were studies not directly related to cardiovascular anesthesia, case reports, and articles without full-text availability. The review aimed to assess the relevance and currency of information on applying these monitoring technologies to improve patient care and outcomes during cardiovascular procedures. Key findings, limitations, and future research directions are discussed.


INTRODUCTION
Cardiovascular anesthesia management has seen significant advancements in recent years, particularly with the introduction and refinement of portable and continuous monitoring devices.These technologies have revolutionized how anesthesiologists monitor and manage patients during cardiac procedures, offering real-time data and enhancing the ability to detect and respond to critical changes in patient status.This review explores the current landscape of portable and continuous monitoring devices in cardiovascular anesthesia, their impact on patient care, and their potential to improve outcomes. 1Molecular Dynamics and Modeling Laboratory (DynMolLab) 2 Centro Universitário Christus (Unichristus). 3 Instituto master de ensino presidente Antônio Carlos. 4Santa Casa de Misericórdia de Vitoria Higher School of Sciences -EMESCAM.Santa Luíza -Vitória -ES -Brazil.Molecular Dynamics and Modeling Laboratory (DynMolLab) 5 Molecular Dynamics and Modeling Laboratory (DynMolLab).
Cardiovascular anesthesia is inherently complex, requiring meticulous attention to hemodynamic stability, myocardial function, and systemic perfusion.Traditional monitoring methods, while effective, often provide intermittent data points that may miss transient yet clinically significant events.The advent of portable and continuous monitoring devices addresses this limitation by offering uninterrupted, real-time physiological data (1).
These devices encompass various technologies, including continuous non-invasive blood pressure monitors, electrical cardiometry for cardiac output assessment, and advanced electrocardiographic (ECG) monitoring systems.Each tool contributes a more comprehensive understanding of the patient's cardiovascular status throughout the perioperative period.
The importance of such detailed monitoring cannot be overstated in the context of cardiovascular anesthesia.Even brief periods of hemodynamic instability, such as hypotension or myocardial ischemia, can have significant consequences on patient outcomes.Detecting and addressing these events promptly is crucial for preventing postoperative complications and improving overall patient care (2).This review will explore the various types of portable and continuous monitoring devices available, their mechanisms of action, and their clinical applications.We will explore how these technologies integrate into the workflow of cardiovascular anesthesia and examine their impact on decision-making processes.Additionally, we will discuss the potential limitations and challenges associated with implementing these devices in clinical practice.This review synthesizes the latest research and clinical evidence to provide a comprehensive overview of the role of portable and continuous monitoring devices in cardiovascular anesthesia.Our goal is to offer insights into how these technologies can be optimally utilized to enhance patient safety, improve clinical outcomes, and advance the field of cardiovascular anesthesia management.

METHODOLOGY
This narrative review comprehensively examines the role of portable and continuous monitoring devices in cardiovascular anesthesia.A systematic literature search was performed using multiple electronic databases, including PubMed, Scopus, Web of Science, and ScienceDirect.The search strategy employed a combination of Medical Subject Headings (MeSH) terms and keywords related to cardiovascular anesthesia, portable monitoring devices, and continuous monitoring.
The primary search terms included: "cardiovascular anesthesia," "cardiac anesthesia," "portable monitoring devices," "continuous monitoring," "non-invasive blood pressure monitoring," "cardiac output monitoring," and "electrocardiographic monitoring."These terms were combined using Boolean operators to refine the search results.
The inclusion criteria for the selected studies were: published in the English language; Peer-reviewed articles Published between 2010 and 2024 to ensure relevance and currency of information; Studies focusing on portable or continuous monitoring devices in the context of cardiovascular anesthesia; Clinical trials; observational studies; systematic reviews; and metaanalyses.
Exclusion criteria included Studies not directly related to cardiovascular anesthesia, Case reports, small case series, and Articles without full-text availability.
The initial search yielded over 1,000 articles.After removing duplicates and applying the inclusion and exclusion criteria, approximately 200 articles were selected for full-text review.The final selection of articles for inclusion in this review was based on their relevance, methodological quality, and potential impact on the field of cardiovascular anesthesia.
Data extraction from the selected articles focused on the types of monitoring devices, their mechanisms of action, clinical applications, impact on patient outcomes, and potential limitations.Special attention was given to studies that compared traditional monitoring methods and newer portable or continuous monitoring technologies.
The extracted information was synthesized and organized into thematic sections to provide a comprehensive overview of portable and continuous monitoring in cardiovascular anesthesia.Where applicable, meta-analyses and systematic reviews were given priority to provide the highest level of evidence.This methodological approach allowed for thoroughly exploring the topic, ensuring the review captures the most current and relevant information in cardiovascular anesthesia monitoring.

RESULTS
The integration of portable and continuous monitoring devices in cardiovascular anesthesia has transformed patient care, offering unprecedented insights into real-time physiological changes during cardiac procedures.This section will explore the various types of monitoring devices, their clinical applications, and their impact on patient outcomes.

Continuous Non-Invasive Blood Pressure Monitoring
Continuous non-invasive blood pressure (CNIBP) monitoring significantly advances traditional intermittent cuff measurements.These devices employ various technologies to provide beat-to-beat blood pressure data without arterial cannulation.

Volume Clamp Method
The volume clamp method, pioneered by Finapres technology, uses a finger cuff to maintain a constant arterial volume through dynamic cuff pressure adjustment.This technique allows for continuous tracking of arterial pressure waveforms (3).A study by Ameloot et al.
(2013) demonstrated that CNIBP measurements using the volume clamp method showed good agreement with invasive arterial measurements in critically ill patients, with a mean bias of -2.6 mmHg for mean arterial pressure (4).In adult cardiac surgery, Malik et al. (2014) compared electrical cardiometry with thermodilution cardiac output measurements in 30 patients undergoing coronary artery bypass grafting.They reported a good correlation between the two methods (r = 0.84), with a percentage error of 29.5%, within the clinically acceptable range (9).

Pulse Contour Analysis
Pulse contour analysis systems, such as the FloTrac/Vigileo and LiDCOrapid, derive cardiac output from the arterial pressure waveform.These devices offer a less invasive alternative to pulmonary artery catheterization.A meta-analysis by Peyton and Chong (2010) examined the accuracy of minimally invasive cardiac output monitoring devices, including pulse contour analysis systems.They found an overall percentage error of 41.3% compared to thermodilution, suggesting that further refinement of these technologies may be necessary (10).

Advanced Electrocardiographic Monitoring
Electrocardiographic (ECG) monitoring has long been a mainstay in cardiovascular anesthesia, but recent advancements have expanded its utility beyond traditional ST-segment analysis.

Multimodal ECG Monitoring
Multimodal ECG monitoring combines various analytical techniques, such as STsegment analysis, T-wave alternans, and heart rate variability, to comprehensively assess myocardial ischemia and autonomic dysfunction.A systematic review by Kertai et al. (2012)   found that multimodal ECG monitoring could improve the detection of perioperative myocardial ischemia and predict postoperative adverse cardiac events in cardiac surgery patients (13).

Wireless ECG Monitoring
Wireless ECG monitoring systems, such as the Zio Patch and the BodyGuardian system, allow for continuous, uninterrupted data collection during the perioperative period.
These devices can detect arrhythmias, ischemic events, and other cardiac abnormalities that may be missed with traditional intermittent monitoring.A Steinberg et al. ( 2017) study demonstrated that the Zio Patch could identify significantly more arrhythmias than standard telemetry monitoring in patients undergoing cardiac surgery (14).

Wearable ECG Monitoring
Wearable ECG monitoring devices, such as smartwatches and patches, have gained prominence in the consumer market and are increasingly being explored for clinical applications.These technologies have the potential to provide continuous, long-term monitoring of cardiac activity outside the hospital setting, enabling early detection of postoperative complications.However, their integration into perioperative care requires further research to establish clinical validity and utility.

Challenges and Limitations
While the incorporation of portable and continuous monitoring devices in cardiovascular anesthesia has shown promising results, challenges, and limitations remain that need to be addressed.

Accuracy and Reliability
Ensuring the accuracy and reliability of these monitoring technologies is crucial, as inaccurate measurements can lead to inappropriate clinical decisions and potentially harm patients.Ongoing research and development are necessary to refine the algorithms and algorithms used in these devices, particularly in the context of rapidly changing physiological states during cardiac procedures.

Integration into Workflow
Seamless integration of these monitoring devices into the existing workflow of cardiovascular anesthesia teams is essential for their effective utilization.Challenges may arise regarding data interpretation, alarm management, and efficient integration with electronic medical records.Comprehensive training and education of anesthesia providers are necessary to maximize the benefits of these technologies.

Cost and Resource Allocation
Implementing portable and continuous monitoring devices can have significant financial and resource implications.Careful consideration must be given to their costeffectiveness, especially in resource-constrained healthcare settings.Balancing the potential benefits with the financial burden is an ongoing challenge that requires further research and policy-level discussions.As the field continues to evolve, it is crucial for anesthesia providers to stay abreast of the latest developments and to critically evaluate the integration of these monitoring devices into their clinical practice.By leveraging the capabilities of these technologies, cardiovascular anesthesia teams can optimize their decision-making processes, anticipate and respond to critical events more effectively, and ultimately deliver superior patient care.
Future research should focus on further refining the accuracy and reliability of these monitoring devices, addressing workflow integration challenges, and evaluating their longterm impact on patient outcomes.Collaborative efforts between clinicians, researchers, and device manufacturers will be essential in driving the continued advancement of cardiovascular anesthesia management.

The
ClearSight system, an evolution of the Finapres technology, combines the volume clamp method with physiological calibration algorithms.Juri et al. (2018) conducted a prospective observational study comparing ClearSight with invasive arterial monitoringduring cardiac surgery.They reported a clinically acceptable agreement between the two methods, with a percentage error of 29% for systolic blood pressure and 27% for mean arterial pressure(5).

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Applanation Tonometry Applanation tonometry devices, such as the T-Line system, use a pressure sensor placed over the radial artery to capture arterial waveforms.A study by Meidert et al. (2014) compared the T-Line system with invasive arterial monitoring in patients undergoing major abdominal surgery.They found a good correlation between the two methods, with a mean bias of -1.0 mmHg for mean arterial pressure and limits of agreement of ±12.4 mmHg (6).The clinical significance of CNIBP monitoring in cardiovascular anesthesia is underscored by the ability to detect short periods of hypotension that may be missed with intermittent measurements.Sessler et al. (2019) conducted a large retrospective cohort study.They found that even brief episodes of intraoperative hypotension (mean arterial pressure <65 mmHg for ≥1 minute) were associated with an increased risk of acute kidney injury and myocardial injury(7).Continuous Cardiac Output MonitoringAccurate assessment of cardiac output is crucial in cardiovascular anesthesia to guide fluid management and vasoactive therapy.Several noninvasive and minimally invasive technologies have emerged to provide continuous cardiac output monitoring.2.1 Electrical Cardiometry Electrical cardiometry uses changes in thoracic electrical bioimpedance to estimate stroke volume and cardiac output.Coté et al. (2015) evaluated the use of electrical cardiometry in 402 pediatric patients undergoing various surgical procedures.They found that the technology successfully tracked hemodynamic events and responses to interventions, with a strong correlation (r = 0.86) between electrical cardiometry-derived cardiac index and that obtained by transthoracic echocardiography (8).
However, more recent studies have shown improved performance of newer generation devices.Smetkin et al. (2017) evaluated the fourth-generation FloTrac algorithm in patients undergoing off-pump coronary artery bypass grafting.They reported improved accuracy compared to earlier versions, with a percentage error of 27.5% compared to thermodilution measurements (11).The clinical utility of continuous cardiac output monitoring extends beyond mere measurement.These devices allow for real-time assessment of fluid responsiveness and the effects of therapeutic interventions.For instance, Biais et al. (2013) demonstrated that pulse contour-derived stroke volume variation could accurately predict fluid responsiveness in patients undergoing major abdominal surgery, with an area under the receiver operating characteristic curve of 0.88 (12).
The integration of advanced ECG monitoring technologies into cardiovascular anesthesia practice can improve the detection of myocardial ischemia, arrhythmias, and autonomic dysfunction, ultimately enhancing the ability to guide therapeutic interventions and optimize patient outcomes.DISCUSSIONImpact on Patient OutcomesThe adoption of portable and continuous monitoring devices in cardiovascular anesthesia has demonstrated a positive impact on patient outcomes.Several studies have highlighted the benefits of these technologies in various aspects of perioperative care.Improved Hemodynamic StabilityThe real-time data CNIBP provides, as well as continuous cardiac output monitoring, allow for more precise titration of fluid therapy and vasoactive medications, leading to better hemodynamic stability.A randomized controlled trial by Scheeren et al. (2013) found that goaldirected hemodynamic treatment guided by a cardiac output monitoring device (LiDCOrapid) resulted in reduced postoperative complications and a shorter length of hospital stay in highrisk surgical patients (15).Reduced Postoperative Complications Advanced ECG monitoring and other continuous monitoring devices enable the enhanced detection of critical events, such as myocardial ischemia and arrhythmias, which can facilitate early intervention and prevention of postoperative complications.A retrospective study by Karim et al. (2020) demonstrated that implementing a multimodal ECG monitoring program in cardiac surgery patients significantly reduced postoperative atrial fibrillation and acute kidney injury (16).Improved Survival Outcomes Portable and continuous monitoring devices facilitate improved intraoperative management and prevention of perioperative complications, which may also translate into better long-term survival outcomes.A meta-analysis by Peyton et al. (2014) found that minimally invasive cardiac output monitoring, including pulse contour analysis, significantly reduced 30-day mortality in high-risk surgical patients (17).

CONCLUSION
Advances in portable and continuous monitoring devices have revolutionized the field of cardiovascular anesthesia, offering real-time physiological data and enhanced patient surveillance.From continuous noninvasive blood pressure monitoring to advanced electrocardiographic analysis, these technologies have the potential to improve hemodynamic stability, reduce postoperative complications, and ultimately enhance patient outcomes.