Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury.

BACKGROUND: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. METHODS: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). RESULTS: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. CONCLUSIONS: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

Novel Initiative Increasing GDMT Use Among Patients With Heart Failure With Reduced Ejection Fraction.

Guideline-directed medical therapy utilization in patients with heart failure with reduced ejection fraction (HFrEF) remains low despite benefits in morbidity and mortality. The authors describe a unique quality improvement initiative designed to increase angiotensin receptor-neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA) utilization in outpatients with HFrEF in a large cardiology practice, whereby eligible patients were identified in a standardized review process and medication utilization rates were linked to group quality metrics. Eligible HFrEF patients were defined as having a left ventricular ejection fraction (LVEF) ≤40% and NYHA functional class II to IV level of symptoms. Those with an LVEF >40%, no documented LVEF, or with NYHA functional class I symptoms were excluded. ARNI utilization was defined as any dose of sacubitril/valsartan prescribed, and MRA utilization was defined as any dose of either spironolactone or eplerenone prescribed. Group quality metric targets were set at >25% ARNI prescription and >60% MRA prescription in eligible patients. Following project implementation, ARNI utilization rose from 31% to 67% and MRA increased from 28% to 66%. Establishing clear quality metrics and formulating a proactive evaluation process was associated with a significant increase in prescription rates.

The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium.

BACKGROUND: In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. METHODS: Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. RESULTS: Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10(-5) (95% confidence interval [CI], 4.5 × 10(-5) to 23.1 × 10(-5)). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10(-5)). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). CONCLUSIONS: In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

Press pause before send: a case in point.

There are many ways in which our digital era is influencing development. There is greater difficulty in delaying gratification, interference in the growth of the capacity for empathy, more trouble in developing the ability to relate face-to-face, and overuse of two-dimensional communication. All of these have implications for clinical work. This article presents a case in point, and some suggestions for ways to attempt to address these difficulties. It is suggested that the clinical situation itself is uniquely valuable as an antidote to the problems posed by the technological world of today.

The coming-out process of young lesbian and bisexual women: are there butch/femme differences in sexual identity development?

Research on lesbian and bisexual women has documented various biological and behavioral differences between butch and femme women. However, little research has examined whether differences exist in sexual identity development (i.e., the coming-out process). The present study examined longitudinally potential butch/femme differences in sexual identity formation and integration among an ethnically diverse sample of 76 self-identified lesbian and bisexual young women (ages 14-21 years). A composite measure of butch/femme identity classified 43% as butch and 51% as femme. Initial comparisons found butch/femme differences in sexual identity (i.e., nearly all butches identified as lesbian, but about half of femmes identified as bisexual), suggesting the need to examine this confound. Comparisons of lesbian butches, lesbian femmes, and bisexual femmes found that lesbian butches and femmes generally did not differ on sexual identity formation, but they differed from bisexual femmes. Lesbian butches and femmes had sexual behaviors and a cognitive sexual orientation that were more centered on women than those of bisexual femmes. With respect to sexual identity integration, lesbian butches were involved in more gay social activities, were more comfortable with others knowing about their homosexuality, and were more certain, comfortable, and accepting of their sexual identity than were bisexual femmes. Fewer differences were found between lesbian femmes and bisexual femmes or between lesbian butches and lesbian femmes. The findings suggest that sexual identity formation does not differ between butch or femme women, but differences are linked to sexual identity as lesbian or bisexual. Further, the findings that lesbian femmes sometimes differed from lesbian butches and at other times from bisexual femmes on sexual identity integration suggest that neither sexual identity nor butch/femme alone may explain sexual identity integration. Research examining the intersection between sexual identity and butch/ femme is needed.

Anesthesia information management system implementation: a practical guide.

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error. This collaborative effort summarizes essential considerations for successful AIMS implementation, including product evaluation, assessment of information technology needs, resource availability, leadership roles, and training.

Taxane modulation of anesthetic sensitivity in surgery for nonmetastatic breast cancer.

STUDY OBJECTIVE AND DESIGN: The mechanism of action of commonly used general anesthetics is largely unknown. One hypothesized mechanism is through modulation of microtubule stability. Taxanes, a subset of chemotherapeutic drugs known to alter microtubule stability and commonly used to treat breast cancer, offer a natural experiment to test our hypothesis that patients exposed to taxanes prior to surgery, as compared to after surgery, would have a partial resistance to general anesthetics. SETTING, PATIENTS, AND MEASUREMENTS: The anesthetic record of adult women with nonmetastatic breast cancer was used to obtain changes in heart rate and blood pressure surrounding incision, and the amount of inhaled anesthetic agent, induction, and rescue drugs administered. MAIN RESULTS: Change in blood pressure in response to incision was significantly higher in the neoadjuvant group (P = .03), whereas change in heart rate was not (P = .53). A greater amount of morphine was administered in the neoadjuvant group (26.3 vs 15.5 mg, P = .02), although not a higher concentration of inhaled anesthetics (P = .15). CONCLUSION: These results suggest that the alteration of microtubule stability is one of a number of mechanisms of inhaled anesthetics.

Near-infrared spectroscopy cerebral oxygen saturation thresholds for hypoxia-ischemia in piglets.

Detection of cerebral hypoxia-ischemia remains problematic in neonates. Near-infrared spectroscopy, a noninvasive bedside technology has potential, although thresholds for cerebral hypoxia-ischemia have not been defined. This study determined hypoxic-ischemic thresholds for cerebral oxygen saturation (SCO2) in terms of EEG, brain ATP, and lactate concentrations, and compared these values with CBF and sagittal sinus oxygen saturation (SVO2). Sixty anesthetized piglets were equipped with near-infrared spectroscopy, EEG, laser-Doppler flowmetry, and a sagittal sinus catheter. After baseline, SCO2 levels of less than 20%, 20% to 29%, 30% to 39%, 40% to 49%, 50% to 59%, 60% to 79%, or 80% or greater were recorded for 30 minutes of normoxic normocapnia, hypercapnic hyperoxia, or bilateral carotid occlusion with or without arterial hypoxia. Brain ATP and lactate concentrations were measured biochemically. Logistic and linear regression determined the SCO2, CBF, and SVO2 thresholds for abnormal EEG, ATP, and lactate findings. Baseline SCO2 was 68 + 5%. The SCO2 thresholds for increased lactate, minor and major EEG change, and decreased ATP were 44 +/- 1%, 42 +/- 5%, 37 +/- 1%, and 33 +/- 1%. The SCO2 correlated linearly with SVO2 (r = 0.98) and CBF (r = 0.89), with corresponding SVO2 thresholds of 23%, 20%, 13%, and 8%, and CBF thresholds (% baseline) of 56%, 52%, 42%, and 36%. Thus, cerebral hypoxia-ischemia near-infrared spectroscopy thresholds for functional impairment are SCO2 33% to 44%, a range that is well below baseline SCO2 of 68%, suggesting a buffer between normal and dysfunction that also exists for CBF and SVO2.

Acute circulatory actions of intravenous amiodarone loading in cardiac surgical patients.

BACKGROUND: The duration, severity, and cause of hypotension after intravenous amiodarone has not been well characterized in anesthetized cardiac surgical patients. Because amiodarone is tolerated in patients with advanced cardiac disease, we hypothesized that left ventricular systolic performance is preserved despite hypotension during amiodarone loading. METHODS: In a prospective double-blind trial, 30 patients undergoing coronary artery bypass graft (CABG) surgery were randomly assigned to receive intravenous amiodarone (n = 15) or placebo (n = 15). Cardiac output (CO), mixed venous oxygen saturation (SVO), arterial blood pressure (systolic blood pressure [SBP], diastolic blood pressure [DBP], mean arterial pressure [MAP]), pulmonary artery pressure, and central venous pressure (CVP) were recorded. Transesophageal echocardiographic left ventricular end-diastolic area (EDA), end-systolic area (ESA), fractional area change (FAC), and end-systolic wall stress (ESWS) were measured every 5 minutes. RESULTS: Mean arterial pressure, SBP, and DBP decreased over time after drug administration in both groups (p < 0.05). At 6 minutes, amiodarone decreased the MAP by 14 mm Hg (p = 0.004) and placebo decreased the MAP by 4 mm Hg. The change in MAP, SBP, and DBP between groups was statistically different for the first 15 minutes after drug administration. Hypotension requiring intervention occurred in 3 of 15 after amiodarone and 0 of 15 after placebo (p = 0.22). The mean heart rate was 11.5 beats per minute less after amiodarone (p < 0.02), but pulmonary artery pressure, CVP, SVO, and FAC were not different between groups. CONCLUSIONS: Intravenous amiodarone decreased heart rate and caused a significant, but transient decrease in arterial pressure in the first 15 minutes after administration. Left ventricular performance was maintained suggesting that selective arterial vasodilation was the primary cause of drug-induced hypotension.

Cognitive-behavioral therapy for depression in adolescents with inflammatory bowel disease: a pilot study.

OBJECTIVE: To evaluate the safety and feasibility of cognitive-behavioral therapy (CBT) for depression in physically ill adolescents. METHOD: In an open trial, 11 adolescents (12-17 years) with inflammatory bowel disease and either major or minor depression underwent 12 sessions of a manual-based CBT enhanced by social skills, physical illness narrative, and family psychoeducation components. Standardized instruments assessed pre- to posttreatment changes in depression, physical health, global psychological functioning, and social functioning. Perceived helpfulness and satisfaction with CBT were assessed. RESULTS: There were significant reductions in DSM-IV depression diagnoses and depressive symptoms and improvements in global psychological and social functioning. Adolescents' perceptions of their general health and physical functioning improved, although illness severity measures were unchanged. High subject satisfaction and helpfulness ratings for CBT were found along with no adverse events and high subject adherence. CONCLUSIONS: A manual-based CBT approach adapted to treat depression in physically ill adolescents appears to be a safe, feasible, and promising intervention.

Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study.

OBJECTIVES: This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics. METHODS: One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment. RESULTS: Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05). CONCLUSIONS: These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.

Hypothermia and the approximate entropy of the electroencephalogram.

BACKGROUND: The electroencephalogram is commonly used to monitor the brain during hypothermic cardiopulmonary bypass and circulatory arrest. No quantitative relationship between the electroencephalogram and temperature has been elucidated, even though the qualitative changes are well known. This study was undertaken to define a dose-response relationship for hypothermia and the approximate entropy of the electroencephalogram. METHODS: The electroencephalogram was recorded during cooling and rewarming in 14 patients undergoing hypothermic cardiopulmonary bypass and circulatory arrest. Data were digitized at 128 Hz, and approximate entropy was calculated from 8-s intervals. The dose-response relationship was derived using sigmoidal curve-fitting techniques, and statistical analysis was performed using analysis of variance techniques. RESULTS: The approximate entropy of the electroencephalogram changed in a sigmoidal fashion during cooling and rewarming. The midpoint of the curve averaged 24.7 degrees C during cooling and 28 degrees C (not significant) during rewarming. The temperature corresponding to 5% entropy (T 0.05 ) was 18.7 degrees C. The temperature corresponding to 95% entropy (T 0.95 ) was 31.3 degrees C during cooling and 38.2 degrees C during rewarming ( P < 0.02). CONCLUSIONS: Approximate entropy is a suitable analysis technique to quantify the electroencephalographic changes that occur with cooling and rewarming. It demonstrates a delay in recovery that is of the same magnitude as that seen with conventional interpretation of the analog electroencephalogram and extends these observations over a greater range of temperatures.

Asymptomatic Aortic Insufficiency in a Runner.

In brief The case of an asymptomatic 21-year-old male college sprinter demonstrates that aortic insufficiency may go undiagnosed despite severe underlying cardiac pathology: A murmur detected during the preparticipation exam was the first sign. Activity modification was an important initial intervention. Echocardiography documented severe aortic regurgitation. An exercise multiple gated acquisition (MUGA) scan identified abnormal ejection fractions. After valve replacement, the patient's return to competition was guided by echocardiography, exercise testing, and input of the medical team and family.