Using implementation science to decrease variation and high opioid administration in a surgical ICU.

BACKGROUND: High doses and prolonged duration of opioids are associated with tolerance, dependence, and increased mortality. Unfortunately, despite recent efforts to curb outpatient opioid prescribing because of the ongoing epidemic, utilization remains high in the intensive care setting, with intubated patients commonly receiving infusions with a potency much higher than doses required to achieve pain control. We attempted to use implementation science techniques to monitor and reduce excessive opioid prescribing in ventilated patients in our Surgical ICU. METHODS: We conducted a prospective study investigating opioid administration in a closed SICU at an academic medical center over 18 months. Commonly accepted conversions were used to aggregate daily patient opioid use. Patients with a history of chronic opioid use and those being treated with an ICP monitor/drain, neuromuscular blocker, or ECMO were excluded. If the patient spent a portion of a day on a ventilator, that day's total was included in the "vent group." MMEs per patient were collected for each patient and assigned to the on-call intensivist. Intensivists were blinded to the data for the first seven months. They were then provided with academic detailing followed by audit & feedback over the subsequent 11 months, demonstrating how opioid utilization during their time in the SICU compared to the unit average and a blinded list of the other attendings. Student's T-tests were performed to compare opioid utilization before and after initiation of academic detailing and audit & feedback. RESULTS: Opioid utilization in patients on a ventilator decreased by 20.1% during the feedback period, including less variation among all intensivists and a 30.9% reduction by the highest prescribers. CONCLUSION: Implementation science approaches can effectively reduce variation in opioid prescribing, especially for high outliers in a SICU. These interventions may reduce the risks associated with prolonged use of high-dose opioids. LEVEL OF EVIDENCE: Prospective pre-post-intervention, Level II.

Impact of Pendent Ammonium Groups on Solubility and Cycling Charge Carrier Performance in Nonaqueous Redox Flow Batteries.

The synthesis, characterization, electrochemical performance, and theoretical modeling of two base-metal charge carrier complexes incorporating a pendent quaternary ammonium group, [Ni(bppn-Me3)][BF4], 3', and [Fe(PyTRENMe)][OTf]3, 4', are described. Both complexes were produced in high yield and fully characterized using NMR, IR, and UV-vis spectroscopies as well as elemental analysis and single-crystal X-ray crystallography. The solubility of 3' in acetonitrile showed a 283% improvement over its neutral precursor, whereas the solubility of complex 4' was effectively unchanged. Cyclic voltammetry indicates an ∼0.1 V positive shift for all waves, with some changes in reversibility depending on the wave. Bulk electrochemical cycling demonstrates that both 3' and 4' can utilize the second more negative wave to a degree, whereas 4' ceases to have a reversible positive wave. Flow cell testing of 3' and 4' with Fc as the posolyte reveals little improvement to the cycling performance of 3' compared with its parent complex, whereas 4' exhibits reductions in capacity decay when cycling either negative wave. Postcycling CVs indicate that crossover is the likely source of capacity loss in complexes 3, 3', and 4' because there is little change in the CV trace. Density functional theory calculations indicate that the ammonium group lowers the HOMO energy in 3' and 4', which may impart stability to cycling negative waves while making positive waves less accessible. Overall, the incorporation of a positively charged species can improve solubility, stored electron density, and capacity decay depending on the complex, features critical to high energy density redox flow battery performance.

Hydrazine Energy Storage: Displacing N2 H4 from the Metal Coordination Sphere.

Hydrogen carriers, such as hydrazine (N2 H4 ), may facilitate long duration energy storage, a vital component for resilient grids by enabling more renewable energy generation. Lanthanide coordination chemistry with N2 H4 as well as efforts to displace N2 H4 from the metal coordination sphere to develop an efficient catalytic production cycle were detailed. Modeling the equilibrium of different ligand coordination, it was predicted that strong sigma donor molecules would be required to displace N2 H4 . Monitoring competition experiments with nuclear magnetic resonance confirmed that trimethyl phosphine oxide, dimethylformamide, and dimethyl sulfoxide displaced N2 H4 in large or small lanthanide complexes.

A Comparative Review of Metal-Based Charge Carriers in Nonaqueous Flow Batteries.

Invited for this month's cover is the joint redox flow battery team from Sandia and Los Alamos National Laboratories. The cover image shows the stylized components of a redox flow battery (RFB) in the foreground, with renewable sources of energy generation in the background. The Review itself is available at 10.1002/cssc.202002354.

A Comparative Review of Metal-Based Charge Carriers in Nonaqueous Flow Batteries.

Energy storage is becoming the chief barrier to the utilization of more renewable energy sources on the grid. With independent service operators aiming to acquire gigawatts in the next 10-20 years, there is a large need to develop a suite of new storage technologies. Redox flow batteries (RFB) may be part of the solution if certain key barriers are overcome. This Review focuses on a particular kind of RFB based on nonaqueous media that promises to meet the challenge through higher voltages than the organic and aqueous variants. This class of RFB is divided into three groups: molecular, macromolecular, and redox-targeted systems. The growing field of theoretical modeling is also reviewed and discussed.

ROTEM as a Predictor of Mortality in Patients With Severe Trauma.

BACKGROUND: Hemorrhage, especially when complicated by coagulopathy, is the most preventable cause of death in trauma patients. We hypothesized that assessing hemostatic function using rotational thromboelastometry (ROTEM) or conventional coagulation tests can predict the risk of mortality in patients with severe trauma indicated by an injury severity score greater than 15. METHODS: We retrospectively reviewed trauma patients with an injury severity score >15 who were admitted to the emergency department between November 2015 and August 2017 in a single level I trauma center. Patients with available ROTEM and conventional coagulation data (partial thromboplastin time [PTT], prothrombin time [PT], and international normalized ratio) were included in the study cohort. Logistic regression was performed to assess the relationship between coagulation status and mortality. RESULTS: The study cohort included 301 patients with an average age of 47 y, and 75% of the patients were males. Mortality was 23% (n = 68). Significant predictors of mortality included abnormal APTEM (thromboelastometry (TEM) assay in which fibrinolysis is inhibited by aprotinin (AP) in the reagent) parameters, specifically a low APTEM alpha angle, a high APTEM clot formation time, and a high APTEM clotting time. In addition, an abnormal international normalized ratio significantly predicted mortality, whereas abnormal PT and PTT did not. CONCLUSIONS: A low APTEM alpha angle, an elevated APTEM clot formation time, and a high APTEM clotting time significantly predicted mortality, whereas abnormal PT and PTT did not appear to be associated with increased mortality in this patient population. Viscoelastic testing such as ROTEM appears to have indications in the management and stabilization of trauma patients.

Linked Picolinamide Nickel Complexes as Redox Carriers for Nonaqueous Flow Batteries.

The use of nickel complexes utilizing non-innocent ligands based on picolinamide to function as redox carriers in flow batteries was explored. The picolinamide moiety was linked together with -CH2 CH2 - (bpen), -CH2 CH2 CH2 - (bppn), and -C6 H4 - (bpb) moieties, resulting in two, three, and four quasi-reversible waves, respectively, for the nickel complexes and >3 V difference between the outermost positive and negative waves. The redox events were theoretically modelled for each complex, showing excellent agreement (<0.3 V difference) between the experimental and modelled potentials. Bulk cycling of the most soluble complex, Ni(bppn), indicated only one of the three waves was reversible. Therefore, Ni(bppn) has the ability to act as a negative charge redox carrier in flow cells.

Efficacy of the Abdominal Aortic Junctional Tourniquet-Torso Plate in a Lethal Model of Noncompressible Torso Hemorrhage.

BACKGROUND: The Abdominal Aortic Junctional Tourniquet, when modified with an off-label, prototype, accessory pressure distribution plate (AAJT-TP), has the potential to control noncompressible torso hemorrhage in prolonged field care. METHODS: Using a lethal, noncompressible torso hemorrhage model, 24 male Yorkshire swine (81kg-96kg) were randomly assigned into two groups (control or AAJT-TP). Anesthetized animals were instrumented and an 80% laparoscopic, left-side liver lobe transection was performed. At 10 minutes, the AAJT-TP was applied and inflated to an intraabdominal pressure of 40mmHg. At 20 minutes after application, the AAJT-TP was deflated, but the windlass was left tightened. Animals were observed for a prehospital time of 60 minutes. Animals then underwent damage control surgery at 180 minutes, followed by an intensive care unit-phase of care for an additional 240 minutes. Survival was the primary end point. RESULTS: Compared with Hextend, survival was not significantly different in the AAJT-TP group (ρ = .564), nor was blood loss (3.3L ± 0.5L and 3.0L ± 0.5L, respectively; p = .285). There was also no difference in all physiologic parameters between groups at the end of the study or end of the prehospital phase. Three of 12 AAJT-TP animals had an inferior vena cava thrombus. CONCLUSION: The AAJT-TP did not provide any survival benefit compared with Hextend alone in this model of noncompressible torso hemorrhage.

Impact of Ligand Substitutions on Multielectron Redox Properties of Fe Complexes Supported by Nitrogenous Chelates.

Redox flow batteries (RFBs) have recently been recognized as a potentially viable technology for scalable energy storage. To take full advantage of RFBs, one possible approach for achieving high energy densities is to maximize a number of redox events by utilizing charge carriers capable of multiple one-electron transfers within the electrochemical window of solvent. However, past efforts to develop more efficient electrolytes for nonaqueous RFBs have mostly been empirical. In this manuscript, we shed light on design principles by theoretically investigating the effects of systematically substituting pyridyl moieties with imine ligands within a series of Fe complexes with some experimental validation. We found that such replacement is an effective strategy for reducing the molecular weight-to-charge ratios of these complexes. Simultaneously, calculations suggest that the reduction potentials and ligand-based redox activity of such substituted N-heterocyclic Fe compounds might be maintained within their +4 → -1 charge states. Additionally, by theoretically examining the role of coordination geometry, vis-à-vis reducing the number of redox noninnocent ligands within the first coordination sphere, we have demonstrated that Fe complexes with one such ligand were also capable of supporting multielectron reduction events and exhibited reduction potentials similar to their parent analogs supported by two or three of the same multidentate ligands. However, some differences in redox nature within the lower (+2 → -1) charge states were also noticed. Specifically, complexes containing two bidentate ligands, or one tridentate ligand, exhibited ligand-based reductions, whereas compounds with one bidentate ligand exhibited metal-centered reductions. The current results pave the way toward the design of the next-generation of Fe complexes with lower molecular weights and greater stored energy for redox flow batteries.

Early-Lanthanide(III) Acetonitrile-Solvento Adducts with Iodide and Noncoordinating Anions.

Dissolution of LnI3 (Ln = La, Ce) in acetonitrile (MeCN) results in the highly soluble solvates LnI3(MeCN)5 [Ln = La (1), Ce (2)] in good yield. The ionic complex [La(MeCN)9][LaI6] (4), containing a rare homoleptic La(3+) cation and anion, was also isolated as a minor product. Extending this chemistry to NdI3 results in the consistent formation of the complex ionic structure [Nd(MeCN)9]2[NdI5(MeCN)][NdI6][I] (3), which contains an unprecedented pentaiodide lanthanoid anion. Also described is the synthesis, isolation, and structural characterization of several homoleptic early-lanthanide MeCN solvates with noncoordinating anions, namely, [Ln(MeCN)9][AlCl4]3 [Ln = La (5), Ce (6), Nd (7)]. Notably, complex 6 is the first homoleptic cerium MeCN solvate reported to date. All reported complexes were structurally characterized by X-ray crystallography, as well as by IR spectroscopy and CHN elemental analysis. Complexes 1-3 were also characterized by thermogravimetric analysis coupled with mass spectrometry to further elucidate their bulk composition in the solid-state.

Lewis base assisted B-H bond redistribution in borazine and polyborazylene.

Lewis bases react with borazine and polyborazylene, yielding borane adducts. In the case of NH3 (l), ammonia-borane (AB) is formed and quantified using NMR spectroscopy against an internal standard. Calculations indicate that the formation of B(NH2)3 may provide the driving force of this redistribution. Given the complexity and expense of currently known spent AB regeneration pathways, it is suggested that this redistribution chemistry be used to recover AB and improve regeneration methods.

Potassium(I) amidotrihydroborate: structure and hydrogen release.

Potassium(I) amidotrihydroborate (KNH(2)BH(3)) is a newly developed potential hydrogen storage material representing a completely different structural motif within the alkali metal amidotrihydroborate group. Evolution of 6.5 wt % hydrogen starting at temperatures as low as 80 degrees C is observed and shows a significant change in the hydrogen release profile, as compared to the corresponding lithium and sodium compounds. Here we describe the synthesis, structure, and hydrogen release characteristics of KNH(2)BH(3).

Recycle of tin thiolate compounds relevant to ammonia-borane regeneration.

The use of benzenedithiol as a digestant for ammonia-borane spent fuel has been shown to result in tin thiolate compounds which we demonstrate can be recycled, yielding Bu(3)SnH and ortho-benzenedithiol for reintroduction to the ammonia-borane regeneration scheme.

C-H bond activation through steric crowding of normally inert ligands in the sterically crowded gadolinium and yttrium (C5Me5)3M complexes.

Synthesis of the sterically crowded Tris(pentamethylcyclopentadienyl) lanthanide complexes, (C5Me5)3Ln, has demonstrated that organometallic complexes with unconventionally long metal ligand bond lengths can be isolated that provide options to develop new types of ligand reactivity based on steric crowding. Previously, the (C5Me5)3M complexes were known only with the larger lanthanides, La-Sm. The synthesis of even more crowded complexes of the smaller metals Gd and Y is reported here. These complexes allow an evaluation of the size/reactivity correlations previously limited to the larger metals and demonstrate a previously undescribed type of C5Me5-based reaction, namely C-H bond activation. (C5Me5)3Gd, was prepared from GdCl3 through (C5Me5)2GdCl2K(THF)2, (C5Me5)2Gd(C3H5), and [(C5Me5)2Gd][BPh4] and structurally characterized by x-ray crystallography. Although Gd3+ is redox-inactive, (C5Me5)3Gd functions as a reducing agent in reactions with 1,3,5,7-cyclooctatetraene (COT) and triphenylphosphine selenide to make (C5Me5)Gd(C8H8), [(C5Me5)2Gd]2Se2, and [(C5Me5)2Gd]2Se depending on the stoichiometry used. When the analogous synthetic method was attempted with yttrium in arene solvents, the previously characterized (C5Me5)2YR complexes (R=C6H5, CH2C6H5) were isolated instead, i.e., C-H bond activation of solvent occurred. To avoid this problem, (C5Me5)3Y was synthesized in high yield from [(C5Me5)2YH]2 and tetramethylfulvene in aliphatic solvents. Isolated (C5Me5)3Y was found to metalate benzene and toluene with concomitant formation of C5Me5H, a reaction contrary to the normal pKa values of these hydrocarbons. In this case, the normally inert (C5Me5)1- ligand engages in C-H bond activation due to the extreme steric crowding.

Photoluminescence properties of conjugated phenylacetylene monodendrons in thin films.

We report the absorption, photoluminescence (PL), and time-dependent PL of thin films of conjugated phenylacetylene monodendrons at both room temperature and at cryogenic temperature. We find that the PL properties of the monodendron thin films are significantly different from their fluorescence in dilute solution due to the presence of interactions between monodendrons in the thin film. These interactions lead to aggregate species in the thin films, which result in broader PL spectra and lower PL quantum yields than for monodendrons in dilute solution. Evidence for excimer-like aggregates in the monodendron thin films is found from time-resolved PL spectra.

Optical and photophysical properties of light-harvesting phenylacetylene monodendrons based on unsymmetrical branching.

The optical and photophysical properties of phenylacetylene dendritic macromolecules based on unsymmetrical branching are investigated using steady-state and time-dependent spectroscopy. Monodendrons, up to the fourth generation, are characterized with and without a fluorescent perylene trap at the core. The higher generation monodendrons without the perylene trap exhibit high molar extinction coefficients (>10(5) M(-1) cm(-1)) and high fluorescence quantum yields (65-81%). When a perylene trap is placed at the core, then the monodendrons typically exhibit high energy transfer quantum yields (approximately 90%), as well as subpicosecond time scale excited-state dynamics, as evidenced by ultrafast pump-probe measurements. The photophysical properties of the unsymmetrical monodendrons are compared to those of phenylacetylene monodendrons with symmetrical branching, which have been described recently. The high fluorescence quantum yields and large energy transfer quantum efficiencies exhibited by the unsymmetrical monodendrons suggest they have potential for applications in molecular-based photonics devices.