A Prospective Observational Cohort Study of Language Preference and Preoperative Cognitive Screening in Older Adults: Do Language Disparities Exist in Cognitive Screening and Does the Association Between Test Results and Postoperative Delirium Differ Based on Language Preference?

BACKGROUND: A greater percentage of surgical procedures are being performed each year on patients 65 years of age or older. Concurrently, a growing proportion of patients in English-speaking countries such as the United States, United Kingdom, Australia, and Canada have a language other than English (LOE) preference. We aimed to measure whether patients with LOE underwent cognitive screening at the same rates as their English-speaking counterparts when routine screening was instituted. We also aimed to measure the association between preoperative Mini-Cog and postoperative delirium (POD) in both English-speaking and LOE patients. METHODS: We conducted a single-center, observational cohort study in patients 65 years old or older, scheduled for surgery and evaluated in the preoperative clinic. Cognitive screening of older adults was recommended as an institutional program for all patients 65 and older presenting to the preoperative clinic. We measured program adherence for cognitive screening. We also assessed the association of preoperative impairment on Mini-Cog and POD in both English-speaking and LOE patients, and whether the association differed for the 2 groups. A Mini-Cog score ≤2 was considered impaired. Postoperatively, patients were assessed for POD using the Confusion Assessment Method (CAM) and by systematic chart review. RESULTS: Over a 3-year period (February 2019-January 2022), 2446 patients 65 years old or older were assessed in the preoperative clinic prior. Of those 1956 patients underwent cognitive screening. Eighty-nine percent of English-speaking patients underwent preoperative cognitive screening, compared to 58% of LOE patients. The odds of having a Mini-Cog assessment were 5.6 times higher (95% confidence interval [CI], 4.6-7.0) P < .001 for English-speaking patients compared to LOE patients. In English-speaking patients with a positive Mini-Cog screen, the odds of having postop delirium were 3.5 times higher (95% CI, 2.6-4.8) P < .001 when compared to negative Mini-Cog. In LOE patients, the odds of having postop delirium were 3.9 times higher (95% CI, 2.1-7.3) P < .001 for those with a positive Mini-Cog compared to a negative Mini-Cog. The difference between these 2 odds ratios was not significant (P = .753). CONCLUSIONS: We observed a disparity in the rates LOE patients were cognitively screened before surgery, despite the Mini-Cog being associated with POD in both English-speaking and LOE patients. Efforts should be made to identify barriers to cognitive screening in limited English-proficient older adults.

Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study.

BACKGROUND: Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery. METHODS: Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality. RESULTS: A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve-receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve-receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]). CONCLUSIONS: Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium.

Perioperative Brain Health in the Older Adult: A Patient Safety Imperative.

While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.

Science Without Conscience Is but the Ruin of the Soul: The Ethics of Big Data and Artificial Intelligence in Perioperative Medicine.

Artificial intelligence-driven anesthesiology and perioperative care may just be around the corner. However, its promises of improved safety and patient outcomes can only become a reality if we take the time to examine its technical, ethical, and moral implications. The aim of perioperative medicine is to diagnose, treat, and prevent disease. As we introduce new interventions or devices, we must take care to do so with a conscience, keeping patient care as the main objective, and understanding that humanism is a core component of our practice. In our article, we outline key principles of artificial intelligence for the perioperative physician and explore limitations and ethical challenges in the field.

Humanistic medicine in anaesthesiology: development and assessment of a curriculum in humanism for postgraduate anaesthesiology trainees.

BACKGROUND: An unintended consequence of medical technologies is loss of personal interactions and humanism between patients and their healthcare providers, leading to depersonalisation of medicine. As humanism is not integrated as part of formal postgraduate anaesthesiology education curricula, our goal was to design, introduce, and evaluate a comprehensive humanism curriculum into anaesthesiology training. METHODS: Subject-matter experts developed and delivered the humanism curriculum, which included interactive workshops, simulation sessions, formal feedback, and patient immersion experience. The effectiveness of the programme was evaluated using pre- and post-curriculum assessments in first-year postgraduate trainee doctors (residents). RESULTS: The anaesthesiology residents reported high satisfaction scores. Pre-/post-Jefferson Scale of Patient Perceptions of Physician Empathy showed an increase in empathy ratings with a median improvement of 12 points (range; P=0.013). After training, patients rated the residents as more empathetic (31 [4] vs 22 [5]; P<0.001; 95% confidence interval [CI]: 7-12) and professional (47 [3] vs 35 [8]; P<0.001; 95% CI: 9-16). Patient overall satisfaction with their anaesthesia provider improved after training (51 [6] vs 37 [10]; P<0.001; 95% CI: 10-18). Patients rated their anxiety lower in the post-training period compared with pretraining (1.8 [2.3] vs 3.6 [1.6]; P=0.001; 95% CI: 0.8-2.9). Patient-reported pain scores decreased after training (2.3 [2.5] vs 3.8 [2.1]; P=0.010; 95% CI: 0.4-2.8). CONCLUSIONS: Implementation of a humanism curriculum during postgraduate anaesthesiology training was well accepted, and can result in increased physician empathy and professionalism. This may improve patient pain, anxiety, and overall satisfaction with perioperative care.

Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents.

BACKGROUND: The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training. METHODS: For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data. RESULTS: Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%. CONCLUSIONS: Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.

Closed-loop assisted versus manual goal-directed fluid therapy during high-risk abdominal surgery: a case-control study with propensity matching.

INTRODUCTION: Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%. METHODS: Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias. RESULTS: A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, P =0.008). There was no difference in case mean or final stroke volume index (45 ± 10 versus 43 ± 9 and 45 ± 11 versus 42 ± 11, respectively) or mean arterial pressure (79 ± 8 versus 83 ± 9). Case end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 versus 88 ± 13, P =0.003). CONCLUSION: In this case-control study with propensity matching, clinician use of closed-loop assistance resulted in a greater portion of case time spent in a preload-independent state throughout surgery compared with manual delivery of goal-directed fluid therapy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02020863. Registered 19 December 2013.

Accuracy and precision of continuous noninvasive arterial pressure monitoring compared with invasive arterial pressure: a systematic review and meta-analysis.

BACKGROUND: Continuous noninvasive arterial pressure monitoring devices are available for bedside use, but the accuracy and precision of these devices have not been evaluated in a systematic review and meta-analysis. METHODS: The authors performed a systematic review and meta-analysis of studies comparing continuous noninvasive arterial pressure monitoring with invasive arterial pressure monitoring. Random-effects pooled bias and SD of bias for systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure were calculated. Continuous noninvasive arterial pressure monitoring was considered acceptable if pooled estimates of bias and SD were not greater than 5 and 8 mmHg, respectively, as recommended by the Association for the Advancement of Medical Instrumentation. RESULTS: Twenty-eight studies (919 patients) were included. The overall random-effect pooled bias and SD were -1.6 ± 12.2 mmHg (95% limits of agreement -25.5 to 22.2 mmHg) for systolic arterial pressure, 5.3 ± 8.3 mmHg (-11.0 to 21.6 mmHg) for diastolic arterial pressure, and 3.2 ± 8.4 mmHg (-13.4 to 19.7 mmHg) for mean arterial pressure. In 14 studies focusing on currently commercially available devices, bias and SD were -1.8 ± 12.4 mmHg (-26.2 to 22.5 mmHg) for systolic arterial pressure, 6.0 ± 8.6 mmHg (-10.9 to 22.9 mmHg) for diastolic arterial pressure, and 3.9 ± 8.7 mmHg (-13.1 to 21.0 mmHg) for mean arterial pressure. CONCLUSIONS: The results from this meta-analysis found that inaccuracy and imprecision of continuous noninvasive arterial pressure monitoring devices are larger than what was defined as acceptable. This may have implications for clinical situations where continuous noninvasive arterial pressure is being used for patient care decisions.

High-fidelity simulation enhances ACLS training.

BACKGROUND: Medical student training and experience in cardiac arrest situations is limited. Traditional Advanced Cardiac Life Support (ACLS) teaching methods are largely unrealistic with rare personal experience as team leader. Yet Postgraduate Year 1 residents may perform this role shortly after graduation. PURPOSES: We expanded our ACLS teaching to a "Resuscitation Boot Camp" where we taught 2010 ACLS to 19 pregraduation students in didactic (12 hours) and experiential (8 hours) format. METHODS: Immediately before the course, we recorded students performing an acute coronary syndrome/ventricular fibrillation (VF) scenario. As a final test, we recorded the same scenario for each student. Primary outcomes were time to cardiopulmonary resuscitation (CPR) and defibrillation (DF). Secondary measures were total scenario score, dangerous actions, proportion of students voicing "ventricular fibrillation," 12-lead ST-elevation myocardial infarction (STEMI) interpretation, and care necessary for return of spontaneous circulation (ROSC). Two expert ACLS instructors scored both performances on a 121-point scale, with each student serving as their own control. We used t tests and McNemar tests for paired data with statistical significance at p<.05. RESULTS: Before instruction, average time from arrest to CPR was 112 seconds and to first DF 3.01 minutes. Students scored 45±9/121 points and 9/19 (49%) performed dangerous actions. After instruction, time to CPR was 12 seconds (p=004) and to first DF 1.53 minutes (p=.03). Time to DF was delayed as students showed mastery of bag-valve-mask ventilation before DF. After instruction, students scored 97±4/121 points (p<.0001) with no dangerous actions. Before training, only 4 of 19 (21%) students performed both CPR and DF within 2 minutes, and 3 of these had ROSC. After training, 14 of 19 (74%) achieved CPR+DF≤2 minutes (p=.002), and all had ROSC. Before training, 5 of 19 (26%) students said "VF" and 4 of 19 obtained an ECG, but none identified STEMI. After training, corresponding performance was 13 of 19 "VF" (68%, p=021) and 100% ECG and STEMI identification (p<.05). CONCLUSIONS: This course significantly improved knowledge and psychomotor skills. Critical actions required for resuscitation were much more common after training. ACLS training including high-fidelity simulation decreases time to CPR and DF and improves performance during resuscitation.

Closed-loop fluid administration compared to anesthesiologist management for hemodynamic optimization and resuscitation during surgery: an in vivo study.

BACKGROUND: Closed-loop systems have been designed to assist practitioners in maintaining stability of various physiologic variables in the clinical setting. In this context, we recently performed in silico testing of a novel closed-loop fluid management system that is designed for cardiac output and pulse pressure variation monitoring and optimization. The goal of the present study was to assess the effectiveness of this newly developed system in optimizing hemodynamic variables in an in vivo surgical setting. METHODS: Sixteen Yorkshire pigs underwent a 2-phase hemorrhage protocol and were resuscitated by either the Learning Intravenous Resuscitator closed-loop system or an anesthesiologist. Median hemodynamic values and variation of hemodynamics were compared between groups. RESULTS: Cardiac index (in liters per minute per square meter) and stroke volume index (in milliliters per square meter) were higher in the closed-loop group compared with the anesthesiologist group over the protocol (3.7 [3.4-4.1] vs 3.5 [3.2-3.9]; 95% Wald confidence interval, -0.5 to -0.23; P < 0.0005 and 40 [34-45] vs 36 [31-38]; 95% Wald confidence interval, -5.9 to -3.1; P < 0.0005, respectively). There was no significant difference in total fluid administration between the closed-loop and anesthesiologist groups (3685 [3230-4418] vs 3253 [2735-3926] mL; 95% confidence interval, -1651 to 431; P = 0.28). Closed-loop group animals also had lower coefficients of variance of cardiac index and stroke volume index during the protocol (11% [10%-16%] vs 22% [18%-23%]; confidence interval, 0.8%-12.3%; P = 0.02 and 11% [8%-16%] vs 17% [13%-21%]; confidence interval, 0.2%-11.4%; P = 0.04, respectively). CONCLUSION: This in vivo study building on previous simulation work demonstrates that the closed-loop fluid management system used in this experiment can perform fluid resuscitation during mild and severe hemorrhages and is able to maintain high cardiac output and stroke volume while reducing hemodynamic variability.

Humoral immunity against SARS-CoV-2 evoked by heterologous vaccination groups using the CoronaVac (Sinovac) and BNT162b2 (Pfizer/BioNTech) vaccines in Chile.

Introduction: Severe acute respiratory syndrome virus 2 (SARS-CoV-2) has caused over million deaths worldwide, with more than 61,000 deaths in Chile. The Chilean government has implemented a vaccination program against SARS-CoV-2, with over 17.7 million people receiving a complete vaccination scheme. The final target is 18 million individuals. The most common vaccines used in Chile are CoronaVac (Sinovac) and BNT162b2 (Pfizer-Biotech). Given the global need for vaccine boosters to combat the impact of emerging virus variants, studying the immune response to SARS-CoV-2 is crucial. In this study, we characterize the humoral immune response in inoculated volunteers from Chile who received vaccination schemes consisting of two doses of CoronaVac [CoronaVac (2x)], two doses of CoronaVac plus one dose of BNT162b2 [CoronaVac (2x) + BNT162b2 (1x)], and three doses of BNT162b2 [BNT162b2 (3x)]. Methods: We recruited 469 participants from Clínica Dávila in Santiago and the Health Center Víctor Manuel Fernández in the city of Concepción, Chile. Additionally, we included participants who had recovered from COVID-19 but were not vaccinated (RCN). We analyzed antibodies, including anti-N, anti-S1-RBD, and neutralizing antibodies against SARS-CoV-2. Results: We found that antibodies against the SARS-CoV-2 nucleoprotein were significantly higher in the CoronaVac (2x) and RCN groups compared to the CoronaVac (2x) + BNT162b2 (1x) or BNT162b2 (3x) groups. However, the CoronaVac (2x) + BNT162b2 (1x) and BNT162b2 (3x) groups exhibited a higher concentration of S1-RBD antibodies than the CoronaVac (2x) group and RCN group. There were no significant differences in S1-RBD antibody titers between the CoronaVac (2x) + BNT162b2 (1x) and BNT162b2 (3x) groups. Finally, the group immunized with BNT162b2 (3x) had higher levels of neutralizing antibodies compared to the RCN group, as well as the CoronaVac (2x) and CoronaVac (2x) + BNT162b2 (1x) groups. Discussion: These findings suggest that vaccination induces the secretion of antibodies against SARS-CoV-2, and a booster dose of BNT162b2 is necessary to generate a protective immune response. In the current state of the pandemic, these data support the Ministry of Health of the Government of Chile's decision to promote heterologous vaccination as they indicate that a significant portion of the Chilean population has neutralizing antibodies against SARS-CoV-2.

High fidelity simulation based team training in urology: a preliminary interdisciplinary study of technical and nontechnical skills in laparoscopic complications management.

PURPOSE: Simulation based team training provides an opportunity to develop interdisciplinary communication skills and address potential medical errors in a high fidelity, low stakes environment. We evaluated the implementation of a novel simulation based team training scenario and assessed the technical and nontechnical performance of urology and anesthesiology residents. MATERIALS AND METHODS: Urology residents were randomly paired with anesthesiology residents to participate in a simulation based team training scenario involving the management of 2 scripted critical events during laparoscopic radical nephrectomy, including the vasovagal response to pneumoperitoneum and renal vein injury during hilar dissection. A novel kidney surgical model and a high fidelity mannequin simulator were used for the simulation. A debriefing session followed each simulation based team training scenario. Assessments of technical and nontechnical performance were made using task specific checklists and global rating scales. RESULTS: A total of 16 residents participated, of whom 94% rated the simulation based team training scenario as useful for communication skill training. Also, 88% of urology residents believed that the kidney surgical model was useful for technical skill training. Urology resident training level correlated with technical performance (p=0.004) and blood loss during renal vein injury management (p=0.022) but not with nontechnical performance. Anesthesia resident training level correlated with nontechnical performance (p=0.036). Urology residents consistently rated themselves higher on nontechnical performance than did faculty (p=0.033). Anesthesia residents did not differ in the self-assessment of nontechnical performance compared to faculty assessments. CONCLUSIONS: Residents rated the simulation based team training scenario as useful for interdisciplinary communication skill training. Urology resident training level correlated with technical performance but not with nontechnical performance. Urology residents consistently overestimated their nontechnical performance.

Intraoperative stroke volume optimization using stroke volume, arterial pressure, and heart rate: closed-loop (learning intravenous resuscitator) versus anesthesiologists.

OBJECTIVE: The authors compared the performance of a group of anesthesia providers to closed-loop (Learning Intravenous Resuscitator [LIR]) management in a simulated hemorrhage scenario using cardiac output monitoring. DESIGN: A prospective cohort study. SETTING: In silico simulation. PARTICIPANTS: University hospital anesthesiologists and the LIR closed-loop fluid administration system. INTERVENTIONS: Using a patient simulator, a 90-minute simulated hemorrhage protocol was run, which included a 1,200-mL blood loss over 30 minutes. Twenty practicing anesthesiology providers were asked to manage this scenario by providing fluids and vasopressor medication at their discretion. The simulation program was also run 20 times with the LIR closed-loop algorithm managing fluids and an additional 20 times with no intervention. MEASUREMENTS AND MAIN RESULTS: Simulated patient weight, height, heart rate, mean arterial pressure, and cardiac output (CO) were similar at baseline. The mean stroke volume, the mean arterial pressure, CO, and the final CO were higher in the closed-loop group than in the practitioners group, and the coefficient of variance was lower. The closed-loop group received slightly more fluid (2.1 v 1.9 L, p < 0.05) than the anesthesiologist group. CONCLUSIONS: Despite the roughly similar volumes of fluid given, the closed-loop maintained more stable hemodynamics than the practitioners primarily because the fluid was given earlier in the protocol and CO optimized before the hemorrhage began, whereas practitioners tended to resuscitate well but only after significant hemodynamic change indicated the need. Overall, these data support the potential usefulness of this closed-loop algorithm in clinical settings in which dynamic predictors are not available or applicable.

Visual estimation of pulse pressure variation is not reliable: a randomized simulation study.

Pulse pressure variation (PPV) can be monitored several ways, but according to recent survey data it is most often visually estimated ("eyeballed") by practitioners. It is not known how accurate visual estimation of PPV is, or whether eyeballing of PPV in goal-directed fluid therapy studies may limit the ability to blind the control group to PPV value. The goal of this study was to test the accuracy of visual estimation of PPV. Using a simulator program designed by the authors that runs on a PC, 20 residents and 19 attendings were shown five arterial pressure waveforms each with different PPV values (range 1-30 %) moving at one of three sweep speeds (6.25, 12.5, or 25 mm/s) and asked to determine the PPV. There was a weak but significant relationship between true PPV and eyeball PPV (r (2) = 0.22; p < 0.01). The agreement between true PPV and eyeball PPV was 3.3 ± 8.7 %. The mean percent error was 122 %. The rate of correct response group classification was 65 %. Mean percent error was higher the faster the waveform sweep speed (130 % at 25 mm/s vs. 117 % at 6.25 mm/s), and correct responsiveness classification lower (58 % at 25 mm/s vs. 69 % at 6.25 mm/s). The results from this study show that eyeballing the arterial pressure waveform in order to evaluate pulse pressure variation is not accurate.

The association of macronutrient deficit with functional status at discharge from the intensive care unit: a retrospective study from a single-center critical illness registry.

BACKGROUND: Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge. METHODS: We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables. RESULTS: Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs. <6000 kcal and an 8% likelihood (1.08; 95%CI 1.01-1.15) of protein deficit ≥300 vs. <300 g with each unit decrement in FSS-ICU. CONCLUSION: In our cohort of patients, macronutrient deficit over the course of critical illness was associated with worse functional status at discharge. Future studies are needed to determine whether optimized macronutrient delivery can improve outcomes in ICU survivors.

Cerebrovascular Accident Manifesting as Altered Mental Status During a Telehealth Visit: Preoperative Evaluation in the COVID-19 Era.

We present the case of a 91-year-old patient scheduled for a preoperative telehealth evaluation who was found to have altered mental status from an acute stroke. Her care, if delayed, could have caused permanent morbidity during the coronavirus disease 2019 (COVID-19) pandemic. This case highlights the digital leap the pandemic spurred: 1. telehealth in the elderly, 2. meaningful history and physical during telehealth visit, 3. family engagement and education, and 4. meaningful impact on patient outcomes.