Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients.

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

Pre-operative patient optimization to prevent postoperative pulmonary complications-Insights and roles for the respiratory therapist: A narrative review.

BACKGROUND: The preoperative period has gained recognition as a crucial time to identify and manage preoperative medical conditions for preventing perioperative complications. Consequently, preoperative clinics have now become an essential component of perioperative care at many large hospitals. As the prevalence of preoperative clinics continues to grow, and the field of perioperative medicine progresses, respiratory therapists (RTs) will inevitably find a growing role to participate in preoperative patient optimization to mitigate pulmonary complications. METHODS: Keyword searches on perioperative pulmonary complications were conducted on the Medline database via PubMed and identified over 2000 candidate articles for review. Articles were included if they were English only and resulted with one or more of the following search terms; pulmonary complications, postoperative complications, postoperative pulmonary complications (PPCs), prehabilitation, incentive spirometry, smoking cessation, noninvasive ventilation. Preference was given for meta-analyses, randomized controlled trials, and systematic reviews. Publications within the past two decades were given additional preference toward final inclusion. The authors discussed eligible articles in group meetings over the span of multiple years to assess relevance and quality of data for narrowing eligible articles to the final selection of publications for the review. FINDINGS: The following narrative review examines preoperative optimization strategies to prevent PPCs and highlight areas where RTs may play a key role. After examining challenges in defining PPCs, the review examines key risk models available to predict PPCs and their implications for subsequent discussion on preventive measures that RTs may assist with in a multidisciplinary team. CONCLUSION: RTs can reduce the health care burden of PPCs by assisting fellow perioperative clinicians in providing respiratory care for patients with premorbid conditions. While much of our review focused on pre-existing pulmonary pathologies and both the pharmacological and nonpharmacological optimization of these pathologies, there are other factors contributing to PPCs deserving future exploration.

Impact of Diabetes Mellitus on Outcomes in Patients with Left Ventricular Assist Devices.

Heart failure (HF) represents a significant health burden in the United States, resulting in substantial mortality and healthcare costs. Through the array of treatment options available, including lifestyle modifications, medications, and implantable devices, HF management has evolved. Left ventricular assist devices (LVADs) have emerged as a crucial intervention, particularly in patients with advanced HF. However, the prevalence of comorbidities such as diabetes mellitus (DM) complicates treatment outcomes. By elucidating the impact of DM on LVAD outcomes, this review aims to inform clinical practice and enhance patient care strategies for individuals undergoing LVAD therapy. Patients with DM have higher rates of hypertension, dyslipidemia, peripheral vascular disease, and renal dysfunction, posing challenges to LVAD management. The macro/microvascular changes that occur in DM can lead to cardiomyopathy and HF. Glycemic control post LVAD implantation is a critical factor affecting patient outcomes. The recent literature has shown significant decreases in hemoglobin A1c following LVAD implantation, representing a possible bidirectional relationship between DM and LVADs; however, the clinical significance of this decrease is unclear. Furthermore, while some studies show increased short- and long-term mortality in patients with DM after LVAD implantation, there still is no literature consensus regarding either mortality or major adverse outcomes in DM patients.

The Acute Effect of Chamomile Intake on Blood Coagulation Tests in Healthy Volunteers: A Randomized Trial.

BACKGROUND: Chamomile administration may have desirable effects in the perioperative setting. Current practice, however, discourages perioperative chamomile use due to a theoretical increase in bleeding. Therefore, we evaluated if chamomile acutely (within 4 h of ingestion) prolongs coagulation assays. METHODS: Eight healthy volunteers were randomized to receive 2 interventions in a crossover design: (a) single dose of chamomile extract capsule (500 mg) and (b) single dose of chamomile tea (3 g in 150 mL water). Interventions were separated at least 3 days apart from each other. Blood was sampled pre-ingestion, 2 h post-ingestion, and 4 h post-ingestion for each intervention. The primary outcome was the maximal change in prothrombin time (PT) before vs after each intervention. Secondary outcomes included changes in international normalized ratio, activated partial thromboplastin time, thrombin time, reptilase time, and fibrinogen levels. RESULTS: All 8 subjects completed the study. The average pre-ingestion PT values for tea and capsules were 11.9 (1.1) s and 12.0 (0.9) s, respectively. Tea significantly increased the average maximum PT by 0.7 (0.2) s (P = 0.0078). Extract capsules increased the maximum PT by 0.3 (0.2) s (P = 0.06). Neither PT prolongation met the predefined 10% threshold for clinical significance. No significant changes in secondary outcomes were observed. CONCLUSIONS: Chamomile tea ingestion prolongs PT. However, the clinical significance of this is unclear at this time and warrants further investigation. ClinicalTrials.gov Registration Number: NCT05272475.

Effect of chamomile intake on blood coagulation tests in healthy volunteers: a randomized, placebo-controlled, crossover trial.

BACKGROUND: Chamomile is consumed worldwide for enjoyment and its potentially desirable properties. Widespread patient resource websites, however, discourage preoperative chamomile intake, lest bleeding could worsen. This precaution, though, stems largely from indirect evidence in one case report. To evaluate if chamomile ingestion impacts coagulation assays via coumarin-like substances, we designed a randomized, placebo-controlled, crossover study. MATERIALS AND METHODS: Healthy volunteers were randomized to three interventions in a cross-over-design spanning 5 weeks per subject. Interventions included 7-day consumption of chamomile tea (3 tea bags × 3 times daily = 9 tea bags daily), a chamomile extract capsule (3 times daily), or a placebo capsule (3 times daily). A 7-day washout period elapsed between intervention periods. The primary outcome was the change in prothrombin time (PT) before vs. after each intervention. Secondary outcomes included changes in the international normalized ratio (INR), activated partial thromboplastin time (aPTT), thrombin time (TT), reptilase time (RT), and fibrinogen (FG) surrounding each intervention. RESULTS: All 12 enrolled subjects were randomized and completed the study. The primary outcome of PT change (mean ± SD) was similar across interventions (chamomile tea = - 0.2 ± 0.4 s, extract capsule = - 0.2 ± 0.4 s, and placebo capsule = 0.1 ± 0.5 s; p = 0.34). INR change was 0 s (p = 0.07) for each intervention. The aPTT, TT, RT, and FG, did not change significantly across interventions (p = 0.8, p = 0.08, p = 0.8, and p = 0.2 respectively). CONCLUSIONS: Chamomile intake by tea or capsule does not prolong PT. These findings challenge the notion to avoid perioperative chamomile intake in patients not taking warfarin. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05006378; Principal Investigator: Jonathon Schwartz, M.D.; Registered August 16, 2021.

Effects of insertion speed and trocar stiffness on the accuracy of needle position for brachytherapy.

PURPOSE: In prostate brachytherapy, accurate positioning of the needle tip to place radioactive seeds at its target site is critical for successful radiation treatment. During the procedure, needle deflection leads to seed misplacement and suboptimal radiation dose to cancerous cells. In practice, radiation oncologists commonly use high-speed hand needle insertion to minimize displacement of the prostate as well as the needle deflection. Effects of speed during needle insertion and stiffness of trocar (a solid rod inside the hollow cannula) on needle deflection are studied. METHODS: Needle insertion experiments into phantom were performed using a 2(2) factorial design (2 parameters at 2 levels), with each condition having replicates. Analysis of the deflection data included calculating the average, standard deviation, and analysis of variance (ANOVA) to find significant single and two-way interaction factors. RESULTS: The stiffer tungsten carbide trocar is effective in reducing the average and standard deviation of needle deflection. The fast insertion speed together with the stiffer trocar generated the smallest average and standard deviation for needle deflection for almost all cases. CONCLUSIONS: The combination of stiff tungsten carbide trocar and fast needle insertion speed are important to decreasing needle deflection. The knowledge gained from this study can be used to improve the accuracy of needle insertion during brachytherapy procedures.

Precision grid and hand motion for accurate needle insertion in brachytherapy.

PURPOSE: In prostate brachytherapy, a grid is used to guide a needle tip toward a preplanned location within the tissue. During insertion, the needle deflects en route resulting in target misplacement. In this paper, 18-gauge needle insertion experiments into phantom were performed to test effects of three parameters, which include the clearance between the grid hole and needle, the thickness of the grid, and the needle insertion speed. Measurement apparatus that consisted of two datum surfaces and digital depth gauge was developed to quantify needle deflections. METHODS: The gauge repeatability and reproducibility (GR&R) test was performed on the measurement apparatus, and it proved to be capable of measuring a 2 mm tolerance from the target. Replicated experiments were performed on a 2(3) factorial design (three parameters at two levels) and analysis included averages and standard deviation along with an analysis of variance (ANOVA) to find significant single and two-way interaction factors. RESULTS: Results showed that grid with tight clearance hole and slow needle speed increased precision and accuracy of needle insertion. The tight grid was vital to enhance precision and accuracy of needle insertion for both slow and fast insertion speed; additionally, at slow speed the tight, thick grid improved needle precision and accuracy. CONCLUSIONS: In summary, the tight grid is important, regardless of speed. The grid design, which shows the capability to reduce the needle deflection in brachytherapy procedures, can potentially be implemented in the brachytherapy procedure.

Management of postoperative nausea and vomiting in the context of an Enhanced Recovery after Surgery program.

The concept of Enhanced Recovery after Surgery (ERAS) emerged at the turn of the millennium and quickly gained footing worldwide leading to the establishment of institutional ERAS protocols and subspecialty guidelines. While the use of postoperative nausea and vomiting (PONV) prophylaxis predates ERAS by a significant extent, the emergence of ERAS amplified the importance of antiemetic prophylaxis in perioperative care and drew attention to the truly multifactorial nature of postoperative gastrointestinal dysfunction. The following discussion will review key paradigms behind PONV prophylaxis and ERAS, highlight the interrelationship between these two endeavors, and then explore subspecialty ERAS guidelines that uniquely influence PONV prophylaxis. Attention will center on the ERAS Society guidelines (ESGs) as the primary representative of current ERAS practice, though many deviations from the guidelines exist within the literature and institutional practices.

Surrogate Preferences on the Physician Orders for Life-Sustaining Treatment Form.

BACKGROUND AND OBJECTIVES: The purpose of this study is to compare treatment preferences of patients to those of surrogates on the Physician Orders for Life-Sustaining Treatment (POLST) forms. RESEARCH DESIGN AND METHODS: Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST) forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression models estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteristics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site). RESULTS: Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24-0.65]; p < .001). This model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regression grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00). DISCUSSION AND IMPLICATIONS: Our study took into consideration variation at the patient, clinician, and site level, and showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making processes for patients versus surrogates when the POLST paradigm is employed.

Diving in a warming world: the thermal sensitivity and plasticity of diving performance in juvenile estuarine crocodiles (Crocodylus porosus).

Air-breathing, diving ectotherms are a crucial component of the biodiversity and functioning of aquatic ecosystems, but these organisms may be particularly vulnerable to the effects of climate change on submergence times. Ectothermic dive capacity is thermally sensitive, with dive durations significantly reduced by acute increases in water temperature; it is unclear whether diving performance can acclimate/acclimatize in response to long-term exposure to elevated water temperatures. We assessed the thermal sensitivity and plasticity of 'fright-dive' capacity in juvenile estuarine crocodiles (Crocodylus porosus; n = 11). Crocodiles were exposed to one of three long-term thermal treatments, designed to emulate water temperatures under differing climate change scenarios (i.e. current summer, 28°C; 'moderate' climate warming, 31.5°C; 'high' climate warming, 35°C). Dive trials were conducted in a temperature-controlled tank across a range of water temperatures. Dive durations were independent of thermal acclimation treatment, indicating a lack of thermal acclimation response. Acute increases in water temperature resulted in significantly shorter dive durations, with mean submergence times effectively halving with every 3.5°C increase in water temperature (Q 10 0.17, P < 0.001). Maximal dive performances, however, were found to be thermally insensitive across the temperature range of 28-35°C. These results suggest that C. porosus have a limited or non-existent capacity to thermally acclimate sustained 'fright-dive' performance. If the findings here are applicable to other air-breathing, diving ectotherms, the functional capacity of these organisms will probably be compromised under climate warming.

Munc-18-2 regulates exocytosis of H(+)-ATPase in rat inner medullary collecting duct cells.

Exocytic insertion of H(+)-ATPase into the apical membrane of inner medullary collecting duct (IMCD) cells is dependent on a soluble N-ethylmaleimide-sensitive factor (NSF) attachment protein target receptor (SNARE) complex. In this study we determined the role of Munc-18 in regulation of IMCD cell exocytosis of H(+)-ATPase. We compared the effect of acute cell acidification (the stimulus for IMCD exocytosis) on the interaction of syntaxin 1A with Munc-18-2 and the 31-kDa subunit of H(+)-ATPase. Immunoprecipitation revealed that cell acidification decreased green fluorescent protein (GFP)-syntaxin 1A and Munc-18-2 interaction by 49 +/- 7% and increased the interaction between GFP-syntaxin 1A and H(+)-ATPase by 170 +/- 23%. Apical membrane Munc-18-2 decreased by 27.5 +/- 4.6% and H(+)-ATPase increased by 246 +/- 22%, whereas GP-135, an apical membrane marker, did not increase. Pretreatment of IMCD cells with a PKC inhibitor (GO-6983) diminished the previously described changes in Munc-18-2-syntaxin 1A interaction and redistribution of H(+)-ATPase. In a pull-down assay of H(+)-ATPase by glutathione S-transferase (GST)-syntaxin 1A bound to beads, preincubation of beads with an approximately twofold excess of His-Munc-18-2 decreased H(+)-ATPase pulled down by 64 +/- 16%. IMCD cells that overexpress Munc-18-2 had a reduced rate of proton transport compared with control cells. We conclude that Munc-18-2 must dissociate from the syntaxin 1A protein for the exocytosis of H(+)-ATPase to occur. This dissociation leads to a conformational change in syntaxin 1A, allowing it to interact with H(+)-ATPase, synaptosome-associated protein (SNAP)-23, and vesicle-associated membrane protein (VAMP), forming the SNARE complex that leads to the docking and fusion of H(+)-ATPase vesicles.