Climate vulnerability assessment for Pacific salmon and steelhead in the California Current Large Marine Ecosystem.

Major ecological realignments are already occurring in response to climate change. To be successful, conservation strategies now need to account for geographical patterns in traits sensitive to climate change, as well as climate threats to species-level diversity. As part of an effort to provide such information, we conducted a climate vulnerability assessment that included all anadromous Pacific salmon and steelhead (Oncorhynchus spp.) population units listed under the U.S. Endangered Species Act. Using an expert-based scoring system, we ranked 20 attributes for the 28 listed units and 5 additional units. Attributes captured biological sensitivity, or the strength of linkages between each listing unit and the present climate; climate exposure, or the magnitude of projected change in local environmental conditions; and adaptive capacity, or the ability to modify phenotypes to cope with new climatic conditions. Each listing unit was then assigned one of four vulnerability categories. Units ranked most vulnerable overall were Chinook (O. tshawytscha) in the California Central Valley, coho (O. kisutch) in California and southern Oregon, sockeye (O. nerka) in the Snake River Basin, and spring-run Chinook in the interior Columbia and Willamette River Basins. We identified units with similar vulnerability profiles using a hierarchical cluster analysis. Life history characteristics, especially freshwater and estuary residence times, interplayed with gradations in exposure from south to north and from coastal to interior regions to generate landscape-level patterns within each species. Nearly all listing units faced high exposures to projected increases in stream temperature, sea surface temperature, and ocean acidification, but other aspects of exposure peaked in particular regions. Anthropogenic factors, especially migration barriers, habitat degradation, and hatchery influence, have reduced the adaptive capacity of most steelhead and salmon populations. Enhancing adaptive capacity is essential to mitigate for the increasing threat of climate change. Collectively, these results provide a framework to support recovery planning that considers climate impacts on the majority of West Coast anadromous salmonids.

The Afferent Limb of Rapid Response Systems: Continuous Monitoring on General Care Units.

The prevention of adverse events continues to be the focus of patient safety work. Although rapid response systems have improved the efferent limb of the patient's rescue, the detection of the patient's deterioration (the afferent limb) has not been solved. This article provides an overview of the complex issues surrounding patient surveillance by addressing the principal considerations of continuous monitoring as they relate to implementation, choice of sensors and physiologic variables, notification, and alarm balancing, as well as future research opportunities.

Characterizing novice behavior associated with learning ultrasound-guided peripheral regional anesthesia.

BACKGROUND AND OBJECTIVES: Ultrasound-guided regional anesthesia is a rapidly growing field. There exists little information regarding the competencies involved with such a practice. The objective of this exploratory study was to characterize the behavior of novices as they undertook the challenges of learning a new technique. In addition to assessing for both committed errors and accuracy, we aimed to identify previously unrecognized quality-compromising behaviors that could help structure effective training interventions. METHODS: By using detailed video analyses, the performances of 6 anesthesia residents were evaluated while on a dedicated 1-month rotation in ultrasound-guided regional anesthesia. From these video reviews, we assessed accuracy, errors committed, performance times, and searched for previously unrecognized quality-compromising behaviors. RESULTS: A total of 520 nerve blocks were videotaped and reviewed. All residents performed at least 66 nerve blocks, with an overall success rate of 93.6% and 4 complications. Both speed and accuracy improved throughout the rotation. There were a total of 398 errors committed, with the 2 most common errors consisting of the failure to visualize the needle before advancement and unintentional probe movement. Five quality-compromising patterns of behavior were identified: (1) failure to recognize the maldistribution of local anesthesia, (2) failure to recognize an intramuscular location of the needle tip before injection, (3) fatigue, (4) failure to correctly correlate the sidedness of the patient with the sidedness of the ultrasound image, and (5) poor choice of needle-insertion site and angle with respect to the probe preventing accurate needle visualization. CONCLUSIONS: Based on the analysis of the committed errors and the identification of quality-compromising behaviors, we are able to recommend important targets for learning in future training and simulation programs.

Perioperative fluid management: current consensus and controversies.

The scientific knowledge base that supports clinical decisions about perioperative fluid management continues to evolve. However, despite these advancements in the understanding of the physiology of fluid replacement, the definition of ''optimal'' perioperative fluid management remains a matter of clinical judgment. With an appreciation of the many factors, both sensible and insensible, that contribute to changes in blood and extracellular fluid volume during surgery, clinicians have tried to create reproducible and generally applicable formulas for replacement of fluid during surgery. These formulas have been challenged recently by the introduction of new tools for monitoring cardiopulmonary function, by the implementation of monitor-guided protocols for fluid management, and, more recently, by clinical data suggesting that fluid restriction may improve surgical outcomes in some clinical settings. The relative ease of pre-identified fluid replacement protocols is being slowly replaced by data-guided interventions that take into account a variety of factors. Clinicians are therefore required to tailor their fluid replacement strategies based on preoperative patient characteristics, the type of surgery and even the type of anesthetic that is utilized. Some of the benefits of this new approach range from relatively ''minor'' outcomes such as diminished nausea after surgery to preventing postoperative complications such as wound breakdown and cardiopulmonary failure.

Ultrasound-guided musculocutaneous nerve block: a description of a novel technique.

BACKGROUND AND OBJECTIVE: Localizing the musculocutaneous nerve for neural blockade is crucial to providing surgical anesthesia for the distal forearm. We present a novel approach for localizing and anesthetizing the musculocutaneous nerve. CASE REPORTS: Ten patients underwent successful ultrasound-guided musculocutaneous nerve blocks. In this technique, either a 10-MHz or a 12-MHz linear probe was placed at the junction of the pectoralis major muscle and the biceps muscle such that the axillary artery was visualized in cross section. The probe was moved towards the biceps muscle until the musculocutaneous nerve was visualized lying between the coracobrachialis and biceps muscles. A 22-gauge, 50-mm b-bevel needle was inserted under direct vision until the needle was adjacent to the nerve. Local anesthetic was then injected, which generated surgical anesthetic conditions in all patients. CONCLUSION: Ultrasound can facilitate the localization and local anesthetic block of the musculocutaneous nerve.