Anesthetic considerations in interventional pulmonology.

PURPOSE OF REVIEW: In this review, we highlight the important anesthetic consideration that relate to interventional bronchoscopic procedures for the management of central airway obstruction due to anterior mediastinal masses, endoluminal endobronchial obstruction, peripheral bronchoscopy for diagnosis and treatment of lung nodules, bronchoscopic lung volume reduction and medical pleuroscopy for diagnosis and management of pleural diseases. RECENT FINDINGS: The advent of the field of Interventional Pulmonology has allowed for minimally invasive options for patients with a wide range of lung diseases which at times have replaced more invasive surgical procedures. Ongoing research has shed light on advancement in anesthetic techniques and management strategies that have increased the safety during peri-operative management during these complex procedures. Current evidence focusing on the anesthetic techniques is presented here. SUMMARY: The field of Interventional Pulmonology requires a tailored anesthetic approach. Recent advancements and ongoing research have focused on expanding the partnership between the anesthesiologist and interventional pulmonologists which has led to improved outcomes for patients undergoing these procedures.

Nasal Intubation is not Associated with "Smoother" Emergence from General Anesthesia for Carotid Endarterectomy: A Case-Cohort Study.

BACKGROUND: Postoperative hematoma after carotid endarterectomy (CEA) is a devastating complication and may be more likely in patients with uncontrolled hypertension and coughing on emergence from anesthesia. We sought to determine if intubation with a nasal endotracheal tube (ETT)-instead of an oral ETT-is associated with "smoother" (i.e., less hemodynamic instability) emergence from general anesthesia for CEA. METHODS: Patients receiving CEA between December 2015 and September 2021 at a single tertiary academic medical center were included. We examined the electronic anesthesia records for 323 patients who underwent CEA during the 6-year study period and recorded consecutive systolic blood pressure (SBP) values during the 10 minutes before extubation as a surrogate for "smoothness" of the emergence. RESULTS: Intubation with a nasal ETT, when compared with intubation with an oral ETT, was not associated with any difference in maximum, minimum, average, median, or standard deviation of serial SBP values in the 10 minutes before extubation. The average SBP on emergence for patients with an oral ETT was 141 mm Hg and with a nasal ETT was 144 mm Hg (P = 0.562). The maximum SBP for patients with oral and nasal ETTs were 170 mm Hg and 174 mm Hg, respectively (P = 0.491). There were also no differences in the qualitative "smoothness" of emergence or in the percentage of patients who required an intravenous dose of 1 or more antihypertensive medications. The incidence of postoperative complications was similar between the 2 groups. CONCLUSIONS: When SBP is used as a surrogate for smoothness of emergence from general anesthesia for CEA, intubation with a nasal ETT was not associated with better hemodynamic stability compared to intubation with an oral ETT.

Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation.

INTRODUCTION: Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors' cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020. METHODS: The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors' institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients' time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium. RESULTS: The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers' satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients. DISCUSSION: The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.

High-Flow Nasal Cannula Oxygen in Patients Having Anesthesia for Advanced Esophagogastroduodenoscopy: HIFLOW-ENDO, a Randomized Clinical Trial.

BACKGROUND: Over 6 million esophagogastroduodenoscopy (EGD) procedures are performed in the United States each year. Patients having anesthesia for advanced EGD procedures, such as interventional procedures, are at high risk for hypoxemia. METHODS: Our primary study aim was to evaluate whether high-flow nasal cannula (HFNC) oxygen reduces the incidence of hypoxemia during anesthesia for advanced EGD. Secondarily, we studied whether HFNC oxygen reduces hypercarbia or hypotension. After obtaining written informed consent, adults having anesthesia for advanced EGD, expected to last longer than 15 minutes, were randomly assigned to receive HFNC oxygen or standard nasal cannula (SNC) oxygen. The primary outcome was occurrence of one or more hypoxemia events during anesthesia, defined by arterial oxygen saturation <92% for at least 15 consecutive seconds. Secondary outcomes were occurrence of one or more hypercarbia or hypotension events. A hypercarbia event was defined by a transcutaneous CO2 measurement 20 mm Hg or more above baseline, and a hypotension event was defined by a mean arterial blood pressure measurement 25% or more below baseline. RESULTS: Two hundred seventy-one adult patients were enrolled and randomized, and 262 patients completed study procedures. Eight randomized patients did not complete study procedures due to changes in their anesthesia or endoscopy plan. One patient was excluded from analysis because their procedure was aborted after 1 minute. Patients who received HFNC oxygen (N = 132) had a significantly lower incidence of hypoxemia than those who received SNC oxygen (N = 130; 21.2% vs 33.1%; hazard ratio [HR] = 0.59 [95% confidence interval {CI}, 0.36-0.95]; P = .03). There was no difference in the incidence of hypercarbia or hypotension between the groups. The HR for hypercarbia with HFNC oxygen was 1.29 (95% CI, 0.89-1.88; P = .17), and the HR for hypotension was 1.25 (95% CI, 0.86-1.82; P = .25). CONCLUSIONS: HFNC oxygen reduces the incidence of hypoxemia during anesthesia for advanced EGD and may offer an opportunity to enhance patient safety during these procedures.

Intraoperative hypotension and perioperative acute ischemic stroke in patients having major elective non-cardiovascular non-neurological surgery.

PURPOSE: The association between intraoperative hypotension and perioperative acute ischemic stroke is not well described. We hypothesized that intraoperative hypotension would be associated with perioperative acute ischemic stroke. METHODS: Four-year retrospective cohort study of elective non-cardiovascular, non-neurological surgical patients. Characteristics of patients who had perioperative acute ischemic stroke were compared against those of patients who did not have acute ischemic stroke. Multivariable logistic regression was used to determine whether hypotension was independently associated with increased odds of perioperative acute ischemic stroke. RESULTS: Thirty-four of 9816 patients (0.3%) who met study inclusion criteria had perioperative acute ischemic stroke. Stroke patients were older and had more comorbidities including hypertension, coronary artery disease, diabetes mellitus, active tobacco use, chronic obstructive pulmonary disease, cerebral vascular disease, atrial fibrillation, and peripheral vascular disease (all P < 0.05). MAP < 65 mmHg was not associated with increased odds of acute ischemic stroke when modeled as a continuous or categorical variable. MAP < 60 mmHg for more than 20 min was independently associated with increased odds of acute ischemic stroke, OR = 2.67 [95% CI = 1.21 to 5.88, P = 0.02]. CONCLUSION: Our analysis suggests that when MAP is less than 60 mmHg for more than 20 min, there is increased odds of acute ischemic stroke. Further studies are needed to determine what MAP should be targeted during surgery to optimize cerebral perfusion and limit ischemic stroke risk.

Isolated platelet concentrate transfusion during surgery: a single-center observational cohort study.

BACKGROUND: Surgical patients receive platelet concentrates (PCs) for a variety of indications. However, there is limited evidence for efficacy or dosing of PCs. STUDY DESIGN AND METHODS: We performed a retrospective cohort study of surgical patients receiving isolated PC transfusion at a single academic tertiary medical center during 1 year. The primary outcome was reoperation for a bleeding complication. Bleeding complication rates were compared in patients transfused for different indications, and multivariable logistic regression was performed to determine variables associated with bleeding complications. RESULTS: Approximately 1% of surgical patients (n = 205), including 7% of cardiac surgery patients, received an isolated PC transfusion. Cardiac surgery patients accounted for 47% of isolated PC transfusions, followed by neurosurgery (19%) and gastrointestinal surgery (13%). Most patients (81%) received a single apheresis unit of PC. Common indications were antiplatelet drugs (50%), thrombocytopenia (19%), congenital platelet disorders (2%), and both thrombocytopenia and antiplatelet drugs (12%). Bleeding complications occurred in 23% of patients, with the lowest bleeding complication rate observed in patients transfused for antiplatelet drugs (13%) and the highest rate in patients transfused for thrombocytopenia with or without antiplatelet drugs (40% and 38%, respectively). Bleeding complications were more common in noncardiac surgery but had no association with transfusion indication. CONCLUSION: Despite transfusion for conventionally accepted indications, patients who received an isolated PC transfusion experienced a high rate of bleeding complications, particularly noncardiac surgery patients. Further studies are needed to establish optimal dosing, timing, and indications for perioperative PC transfusion.

Anesthetic Management of Patients After Traumatic Injury With Resuscitative Endovascular Balloon Occlusion of the Aorta.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver for noncompressible torso hemorrhage. To our knowledge, this single-center brief report provides the most extensive anesthetic data published to date on patients who received REBOA. As anticipated, patients were critically ill, exhibiting lactic acidosis, hypotension, hyperglycemia, hypothermia, and coagulopathy. All patients received blood products during their index operations and received less inhaled anesthetic gas than normally required for healthy patients of the same age. This study serves as an important starting point for clinician education and research into anesthetic management of patients undergoing REBOA.

Point Prevalence Study of Mobilization Practices for Acute Respiratory Failure Patients in the United States.

OBJECTIVE: Early mobility in mechanically ventilated patients is safe, feasible, and may improve functional outcomes. We sought to determine the prevalence and character of mobility for ICU patients with acute respiratory failure in U.S. ICUs. DESIGN: Two-day cross-sectional point prevalence study. SETTING: Forty-two ICUs across 17 Acute Respiratory Distress Syndrome Network hospitals. PATIENTS: Adult patients (≥ 18 yr old) with acute respiratory failure requiring mechanical ventilation. INTERVENTIONS: We defined therapist-provided mobility as the proportion of patient-days with any physical or occupational therapy-provided mobility event. Hierarchical regression models were used to identify predictors of out-of-bed mobility. MEASUREMENTS AND MAIN RESULTS: Hospitals contributed 770 patient-days of data. Patients received mechanical ventilation on 73% of the patient-days mostly (n = 432; 56%) ventilated via an endotracheal tube. The prevalence of physical therapy/occupational therapy-provided mobility was 32% (247/770), with a significantly higher proportion of nonmechanically ventilated patients receiving physical therapy/occupational therapy (48% vs 26%; p ≤ 0.001). Patients on mechanical ventilation achieved out-of-bed mobility on 16% (n = 90) of the total patient-days. Physical therapy/occupational therapy involvement in mobility events was strongly associated with progression to out-of-bed mobility (odds ratio, 29.1; CI, 15.1-56.3; p ≤ 0.001). Presence of an endotracheal tube and delirium were negatively associated with out-of-bed mobility. CONCLUSIONS: In a cohort of hospitals caring for acute respiratory failure patients, physical therapy/occupational therapy-provided mobility was infrequent. Physical therapy/occupational therapy involvement in mobility was strongly predictive of achieving greater mobility levels in patients with respiratory failure. Mechanical ventilation via an endotracheal tube and delirium are important predictors of mobility progression.

Recreational marijuana use is not associated with worse outcomes after renal transplantation.

As marijuana (MJ) legalization is increasing, kidney transplant programs must develop listing criteria for marijuana users. However, no data exist on the effect of MJ on kidney allograft outcomes, and there is no consensus on whether MJ use should be a contraindication to transplantation. We retrospectively reviewed 1225 kidney recipients from 2008 to 2013. Marijuana use was defined by positive urine toxicology screen and/or self-reported recent use. The primary outcome was death at 1 year or graft failure (defined as GFR<20 mL/min/1.73 m2 ). The secondary outcome was graft function at 1 year. Using logistic regression analyses, we compared these outcomes between MJ users and non-users. Marijuana use was not associated with worse primary outcomes by unadjusted (odds ratio 1.07, 95% CI 0.45-2.57, P=.87) or adjusted (odds ratio 0.79, 95% CI 0.28-2.28, P=.67) analysis. Ninety-two percent of grafts functioned at 1 year. Among these, the mean creatinine (1.52, 95% CI 1.39-1.69 vs 1.46, 95% CI 1.42-1.49; P=.38) and MDRD GFR (50.7, 95% CI 45.6-56.5 vs 49.5, 95% CI 48.3-50.7; P=.65) were similar between groups. Isolated recreational MJ use is not associated with poorer patient or kidney allograft outcomes at 1 year. Therefore, recreational MJ use should not necessarily be considered a contraindication to kidney transplantation.

Early Guided Palliative Care Communication for Patients With COVID-19 Receiving ECMO.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) combined with COVID-19 presents challenges (eg, isolation, anticipatory grief) for patients and families. OBJECTIVE: To (1) describe characteristics and outcomes of patients with COVID-19 receiving ECMO, (2) develop a practice improvement strategy to implement early, semistructured palliative care communication in ECMO acknowledgment meetings with patients' families, and (3) examine family members' experiences as recorded in clinicians' notes during these meetings. METHODS: Descriptive observation of guided, in-depth meetings with families of patients with COVID-19 receiving ECMO, as gathered from the electronic medical record of a large urban academic medical center. Most meetings were held within 3 days of initiation of ECMO. RESULTS: Forty-three patients received ECMO between March and October 2020. The mean patient age was 44 years; 63% of patients were Hispanic/Latino, 19% were Black, and 7% were White. Documentation of the ECMO acknowledgment meeting was completed for 60% of patients. Fifty-six percent of patients survived to hospital discharge. Family discussions revealed 7 common themes: hope, reliance on faith, multiple family members with COVID-19, helping children adjust to a new normal, visitation restrictions, gratitude for clinicians and care, and end-of-life discussions. CONCLUSION: Early and ongoing provision of palliative care is feasible and useful for highlighting a range of experiences related to COVID-19. Palliative care is also useful for educating patients and families on the benefits and limitations of ECMO therapy.

Sustained Implementation of an Evidence-Based Extubation Checklist Reduced Extubation Failure in Trauma Patients.

Extubation failure remains a challenge in the perioperative setting. The aim of this intervention was to decrease the rate of perioperative extubation failure through the utilization of an extubation checklist. A five-item evidence-based extubation readiness checklist was implemented at a level I trauma center on all patients who were electively extubated in the operating room (OR). Extubation failure rates before and after implementation of the checklist were compared. Of 26,867 trauma patients extubated in the OR after the intervention, 84 cases (0.31%) failed extubation in the immediate postoperative period. A significant and sustained decrease in extubation failure rate per case performed was observed between the pre- and post-checklist period (OR, 0.33; 95% CI, 0.19, 0.56; P < 0.001). Partial (vs full) checklist completion, higher ASA physical status score, advanced age, and longer case length were independently associated with increased odds of extubation failure in the postintervention period.

Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms.

BACKGROUND: High levels of platelet inhibition have been associated with hemorrhagic complications following Pipeline embolization of intracranial aneurysms. We therefore titrate clopidogrel dosing to maintain a moderate level of platelet inhibition using the VerifyNow P2Y12 assay. However, many patients demonstrate dramatic increases in platelet inhibition following treatment despite being on a consistent antiplatelet regimen. We therefore elected to explore the incidence of this phenomenon and possible predisposing factors. METHODS: All successful Pipeline aneurysm treatments performed at our institution from 2011 to 2019 with moderate procedure-day platelet inhibition levels as indicated by a VerifyNow PRU of 60-235 were included. Patients who received glycoprotein IIb/IIIa inhibitors and those treated for ruptured/symptomatic lesions were excluded. The incidence of excessive platelet inhibition defined by a PRU<60 within 8 weeks of treatment was noted. Multivariable logistic regression was performed to determined independent predictors of the phenomenon. RESULTS: Some 190 treatments were performed in 178 qualifying patients. A post-procedure PRU <60 occurred following 79% of treatments, documented on average after 8.5 (range 1-47) days. A higher procedure day hematocrit level (P=0.003, OR 1.09, 95% CI 1.029 to 1.152) was an independent predictor of reaching a PRU <60, while intra-procedural midazolam exposure (P=0.044, OR 0.44, 95% CI 0.201 to 0.980) and a higher procedure-day PRU (P=0.047, OR 0.99, 95% CI 0.982 to 1.000) were associated with a reduced odds. Time-since-procedure and hematocrit levels were associated with excessive platelet inhibition when excluding patients who initially demonstrated hyperresponse. CONCLUSION: Elevations in platelet inhibition were frequently observed following flow diversion with Pipeline.

Impact of Pandemic Response on Training Experience of Anesthesiology Residents in an Academic Medical Center: A Retrospective Cohort Study.

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic substantially altered operations at hospitals that support graduate medical education. We examined the impact of the pandemic on an anesthesiology training program with respect to overall case volume, subspecialty exposure, procedural skill experience, and approaches to airway management. Methods Data for this single center, retrospective cohort study came from an Institutional Review Board approved repository for clinical data. Date ranges were divided into the following phases in 2020: Pre-Pandemic (PP), Early Pandemic (EP), Recovery 1 (R1), and Recovery 2 (R2). All periods were compared to the same period from 2019 for case volume, anesthesia provider type, trainee exposure to Accreditation Council for Graduate Medical Education (ACGME) index case categories, airway technique, and patient variables. Results 15,087 cases were identified, with 5,598 (37.6%) in the PP phase, 1,570 (10.5%) in the EP phase, 1,451 (9.7%) in the R1 phase, and 6,269 (42.1%) in the R2 phase. There was a significant reduction in case volume during the EP phase compared to the corresponding period in 2019 (-55.3%; P < .001) that improved but did not return to baseline by the R2 phase (-17.6%; P < .001). ACGME required minimum cases were reduced during the EP phase compared to 2019 data for pediatric cases (age < 12 y, -72.1%; P < .001 and age < 3 y, -53.5%; P < .006) and cardiopulmonary bypass cases (52.3%, P < .003). Surgical subspecialty case volumes were significantly reduced in the EP phase except for transplant surgery. By the R2 phase, all subspecialty volumes had recovered except for plastic surgery (14.9 vs. 10.5 cases/week; P < .006) and surgical endoscopy (59.2 vs. 40 cases/week; P < .001). Use of video laryngoscopy (VL) and rapid sequence induction and intubation (RSII) also increased from the PP to the EP phase (24.6 vs. 79.6%; P < .001 and 10.3 vs. 52.3%; P < .001, respectively) and remained elevated into the R2 phase (35.2%; P < 0.001 and 23.1%; P < .001, respectively). Conclusions The COVID-19 pandemic produced significant changes in surgical case exposure for a relatively short period. The impact was short-lived, with sufficient remaining time to meet the annual ACGME program minimum case requirements and procedural experiences. The longer-term impact may be a shift towards the increased use of VL and RSII, which became more prevalent during the early phase of the pandemic.

A Retrospective Analysis of Respiratory Complications under General Anesthesia during EBUS-TBNA.

Background: EBUS-TBNA is an established technique for diagnostically sampling intrathoracic masses and lymph nodes. While the procedure is commonly conducted under general anesthesia (GA), little is known regarding the association between anesthetic management and perioperative respiratory complications. Here, we aim to evaluate this association among patients presenting for EBUS-TBNA. Methods: 586 patients receiving GA for EBUS-TBNA between 2012 and 2018 were retrospectively evaluated. The primary endpoint was the occurrence of perioperative respiratory complications and the secondary endpoint was procedure end to OR exit time (minutes). Respiratory complications were defined as episodes of severe (SpO2 <85%) or prolonged (SpO2<90% for >5 min) hypoxemia, bronchospasm, and postoperative ventilation that could not be directly attributed to procedural invasiveness. Results: Among all patients, 79 (13.5%) had respiratory complications. Four patient characteristics were associated with respiratory complications: home oxygen use (OR 2.39; 95% CI 1.26-4.45; P = 0.007), pre-existing respiratory disease (OR 2.01; CI 1.21-3.29; P = 0.005), ASA class (P = 0.03), and albuterol administration intra-operatively (OR 2.22; CI 1.23-3.92; P = 0.007). No anesthetic factors were found to be statistically significant. Procedures with respiratory complications had a longer duration (mean time 88.7 min vs. 111.8 min; P = 0.00009), prolonged time to extubation (mean time 11.9 min vs. 14.2 min; P = 0.039), and stayed in the room longer after extubation (mean time 18.4 min vs. 23.1 min; P = 0.0016). When comparing types of GA, there were no significant differences between volatile anesthetics versus TIVA (12.7% vs. 14.6%, P = 0.54). Conclusions: Pre-existing patient characteristics, as opposed to anesthetic factors, are associated with respiratory complications during EBUS-TBNA.

Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice.

A retained surgical item (RSI) can be a devastating and costly procedural complication. Although the current incidence of RSIs is unknown, perioperative personnel routinely perform surgical counts according to their facility's policies and procedures to prevent this sentinel event. The American College of Surgeons, The Joint Commission, and AORN emphasize the importance of communication and standardized protocols for the counting of surgical items. However, there is a lack of current evidence to support specific recommendations for the counting of items during endovascular procedures. After the occurrence of RSIs during endovascular procedures at our facility, we convened an interdisciplinary workgroup, conducted an analysis of root causes, reviewed the available literature, and revised the existing policy. This article reviews the available literature on RSIs, describes root causes, discusses recommendations from national organizations, and describes the process that we used to create the policy changes at our facility.

Optimizing Outcomes in Urological Surgery: Postoperative Care.

INTRODUCTION: Understanding best practices in perioperative care is critical for quality of care for our urology patients. We compiled a single, concise resource that provides recommendations for optimizing postoperative outcomes in patients undergoing urological surgery. METHODS: Optimal postoperative care includes minimizing complications, optimizing recovery and improving patient outcomes. The assembled White Paper multidisciplinary writing team included experts in a number of different areas (urologists, nurses, anesthesiologists) to address a comprehensive set of topics that urological providers face when caring for postoperative patients. This article provides a summary of key elements to optimize postoperative care in adult urological surgery, including in-hospital considerations, transition/discharge, and followup and surveillance. RESULTS: In-hospital postoperative considerations include checklists, handoffs for safe transitions from the anesthesia to surgical team, level of care planning and enhanced recovery after surgery (ERAS®). Embedded in ERAS are postoperative nutrition, mobilization, wound care, judicious use of catheters and drains, and postoperative medications and transfusions. As the patient transitions to the outpatient setting, the urologist must provide clear and readable postoperative education, which includes medication management and coordinated followup with primary care providers and home health as needed. Finally, followup visits should be carefully considered using innovative methods such as telehealth and patient reported outcomes to elevate postoperative and long-term care. CONCLUSIONS: This article summarizes postoperative factors that may impact surgical outcomes in urology. By understanding and applying best practices for postoperative care, urologists can optimize the quality of care for their patients.

Improving Postoperative Handoff in a Surgical Intensive Care Unit.

BACKGROUND: Evidence-based research demonstrates that postoperative formalized handoff improves communication and satisfaction among hospital staff members, leading to improved patient outcomes. OBJECTIVE: To improve postoperative patient safety in the surgical intensive care unit of a tertiary academic medical center. METHODS: A verbal and written formal reporting method was designed, implemented, and evaluated. The intervention created an admission "time-out," allowing the handoff from surgical and anesthesia teams to the intensive care unit team and bedside nurses to occur in a more structured manner. Before and 1 year after implementation of the intervention, nurses completed surveys on the quality of postoperative handoff. RESULTS: After the intervention, the proportion of nurses who reported receiving handoff from the surgical team increased from 20% to 60% (P < .001). More nurses felt satisfied with the surgical handoff (46% before vs 74% after the intervention; P < .001), and more nurses frequently felt included in the handoff process (42% vs 74%; P < .001). Nurses perceived improved communication with surgical teams (93%), anesthesia teams (89%), and the intensive care unit team (94%), resulting in a perception of better patient care (88%). CONCLUSION: After implementation of a systematic multidisciplinary handoff process, surgical intensive care nurses reported improved frequency and completeness of the postoperative handoff process, resulting in a perception of better patient care.

Trehalose effectiveness as a cryoprotectant in 2D and 3D cell cultures of human embryonic kidney cells.

Post cryopreservation viability of human embryonic kidney (HEK) cells under two-dimensional (2D) and three-dimensional (3D) culture conditions was studied using trehalose as the sole cryoprotective agent. An L9 (34) Taguchi design was used to optimize the cryoprotection cocktail seeding process prior to slow-freezing with the specific aim of maximizing cell viability measured 7 days post thaw, using the combinatorial cell viability and in-vitro cytotoxicity WST assay. At low (200 mM) and medium (800 mM) levels of trehalose concentration, encapsulation in alginate offered a greater protection to cryopreservation. However, at the highest trehalose concentration (1200 mM) and in the absence of the pre-incubation step, there was no statistical difference at the 95% CI (p = 0.0212) between the viability of the HEK cells under 2D and 3D culture conditions estimated to be 17.9 ± 4.6% and 14.0 ± 3.6%, respectively. A parallel comparison between cryoprotective agents conducted at the optimal levels of the L9 study, using trehalose, dimethylsulfoxide and glycerol in alginate microcapsules yielded a viability of 36.0 ± 7.4% for trehalose, in average 75% higher than the results associated with the other two cell membrane-permeating compounds. In summary, the effectiveness of trehalose has been demonstrated by the fact that 3D cell cultures can readily be equilibrated with trehalose before cryopreservation, thus mitigating the cytotoxic effects of glycerol and dimethylsulfoxide.