Digital Quality Improvement Approach Reduces the Need for Rescue Antiemetics in High-Risk Patients: A Comparative Effectiveness Study Using Interrupted Time Series and Propensity Score Matching Analysis.

BACKGROUND: Affecting nearly 30% of all surgical patients, postoperative nausea and vomiting (PONV) can lead to patient dissatisfaction, prolonged recovery times, and unanticipated hospital admissions. There are well-established, evidence-based guidelines for the prevention of PONV; yet physicians inconsistently adhere to them. We hypothesized that an electronic medical record-based clinical decision support (CDS) approach that incorporates a new PONV pathway, education initiative, and personalized feedback reporting system can decrease the incidence of PONV. METHODS: Two years of data, from February 17, 2015 to February 16, 2016, was acquired from our customized University of California Los Angeles Anesthesiology perioperative data warehouse. We queried the entire subpopulation of surgical cases that received general anesthesia with volatile anesthetics, were ≥12 years of age, and spent time recovering in any of the postanesthesia care units (PACUs). We then defined PONV as the administration of an antiemetic medication during the aforementioned PACU recovery. Our CDS system incorporated additional PONV-specific questions to the preoperative evaluation form, creation of a real-time intraoperative pathway compliance indicator, initiation of preoperative PONV risk alerts, and individualized emailed reports sent weekly to clinical providers. The association between the intervention and PONV was assessed by comparing the slopes from the incidence of PONV pre/postintervention as well as comparing observed incidences in the postintervention period to what we expected if the preintervention slope would have continued using interrupted time series analysis regression models after matching the groups on PONV-specific risk factors. RESULTS: After executing the PONV risk-balancing algorithm, the final cohort contained 36,796 cases, down from the 40,831 that met inclusion criteria. The incidence of PONV before the intervention was estimated to be 19.1% (95% confidence interval [CI], 17.9%-20.2%) the week before the intervention. Directly after implementation of the CDS, the total incidence decreased to 16.9% (95% CI, 15.2%-18.5%; P = .007). Within the high-risk population, the decrease in the incidence of PONV went from 29.3% (95% CI, 27.6%-31.1%) to 23.5% (95% CI, 20.5%-26.5%; P < .001). There was no significant difference in the PONV incidence slopes over the entire pre/postintervention periods in the high- or low-risk groups, despite an abrupt decline in the PONV incidence for high-risk patients within the first month of the CDS implementation. CONCLUSIONS: We demonstrate an approach to reduce PONV using individualized emails and anesthesia-specific CDS tools integrated directly into a commercial electronic medical record. We found an associated decrease in the PACU administration of rescue antiemetics for our high-risk patient population.

Does A Low 6-Minute Walk Distance Predict Elevated Postoperative Troponin?

Our study of 100 major vascular and renal transplant patients evaluated the 6-minute walk test (6MWT) as an indicator of perioperative myocardial injury, using troponin as a marker. Using logistic regression and the area under the receiving operator characteristic curve, we compared the 6MWT to the Revised Cardiac Risk Index and metabolic equivalents. Only the 6MWT was associated with elevated postoperative troponins (95% CI, 0.98-0.99). However, the 6MWT area under the receiving operator characteristic curve (0.71 [95% CI, 0.57-0.85]) was not different from the Revised Cardiac Risk Index (P = .23) or metabolic equivalents (P = .14). The 6MWT may have a role in cardiac risk stratification in the perioperative setting.

Impella 5.5 Bridge to Heart Transplant: An Institutional Series and a Closer Look at Device Removal Technique.

Limited donor organ availability often necessitates mechanical circulatory support, and recently the Impella 5.5, as a bridge to heart transplant. Of 175 Impella 5.5-supported patients at our institution, 45 underwent transplantation in the largest series to date, for whom we analyzed outcomes. Two methods of complete device explant were evaluated: central Impella transection and removal via axillary graft. Median Impella days were 25 (16-41); median waitlist days were 21 (9-37). Eighty-nine percent (40/45) of patients had device placement via right axillary artery. Seventy-six percent (34/45) underwent central transection for device removal. Four patients (8.9%) required short-term venoarterial extracorporeal membranous oxygenation (VA ECMO) postoperatively for primary graft dysfunction (PGD). Two patients (4.4%) suffered postoperative stroke. Five patients (11.1%) required new RRT postoperatively. One patient (2.2%) returned to the operating room (OR) for axillary graft bleeding. A higher chance of procedural complications was found with the axillary removal technique (p = 0.014). Median intensive care unit (ICU) days, length of stay (LOS), and postoperative days to discharge were 46 (35-63), 59 (49-80), and 18 (15-24), respectively. Ninety-eight percent (44/45) survived to discharge. Thirty-day survival was 95.6% (43/45), with 1 year survival at 90.3% (28/31). Eighty-eight percent (37/42) remain without rejection. In our institutional experience, Impella 5.5 is a safe and reliable bridge to transplant.

Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications.

BACKGROUND: Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications. METHODS: Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation. RESULTS: The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07). CONCLUSION: The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

Sepsis: a review of therapeutics and considerations for anesthesiologists.

Sepsis and septic shock remain a major cause of morbidity and mortality. The complexity of the disease pathophysiology has resulted in a rich area of research on etiology and therapeutics. Anesthesiologists will often encounter the syndrome in their routine practice. This review summarizes some of the basic concepts of therapeutics and some novel therapeutics that are pertinent to anesthesia.

Intractable Bleeding Following an Awake Bedside Injection Laryngoplasty in a Patient on KVAD ECMO.

INTRODUCTION: Awake injection laryngoplasty (IL) is becoming increasingly utilized in the inpatient setting, especially as a therapeutic option for patients with vocal fold immobility immediately following cardiothoracic surgery. While prior studies consistently demonstrate complication rates below 3%, significant bleeding has not been reported as a major complication in any awake IL case series. The objective of this report is to highlight a case of intractable bleeding following awake inpatient bedside IL in a patient on KVAD (Koji Takeda Ventricular Assist Device) extracorporeal membrane oxygenation (ECMO). METHODS: Case Report. RESULTS: A 24-year-old female admitted to the cardiac ICU for asystole was placed on KVAD ECMO for heart failure of unknown etiology. She was extubated and listed for cardiac transplant. On postoperative day 14, she underwent a left vocal fold injection at bedside to treat fold paralysis with a large glottic gap causing her complete aphonia, dysphagia, and chronic aspiration. Seven hours post procedure, the patient had to be reintubated due to intractable bleeding. A direct laryngoscopy was performed at bedside and continuous trickle of blood from the injection site at the superior posterior lateral surface of the vocal fold was stopped using a combination of epi-pledgets and hemostatic matrix. The same procedure had to be performed again due to further bleeding 2 days later and permanent hemostasis was achieved. During the week post injection, the patient required transfusion of 5 units of pRBC's. One month later the patient underwent successful orthotopic heart transplantation and was transferred from the ICU to a stepdown unit, and then a rehabilitation unit. No further IL hemorrhage occurred. CONCLUSION: Although a few studies have discussed the safety of IL in patients receiving anticoagulation, this case report demonstrates intractable bleeding requiring intubation and intervention to achieve hemostasis in a patient on KVAD ECMO. This report highlights the importance of weighing the risks and benefits of vocal fold injection in this patient population.

Preoperative risk stratification of critically ill patients.

STUDY OBJECTIVE: Risk assessment historically emphasized cardiac morbidity and mortality in elective, outpatient, non-cardiac surgery. However, critically ill patients increasingly present for therapeutic interventions. Our study investigated the relationship of American Society of Anesthesiologists (ASA) class, revised cardiac risk index (RCRI), and sequential organ failure assessment (SOFA) score with survival to discharge in critically ill patients with respiratory failure. DESIGN: Retrospective cohort analysis over a 21-month period. SETTING: Five adult intensive care units (ICUs) at a single tertiary medical center. PATIENTS: Three hundred fifty ICU patients in respiratory failure, who underwent 501 procedures with general anesthesia. MEASUREMENTS: Demographic, clinical, and surgical variables were collected from the pre-anesthesia evaluation forms and preoperative ICU charts. The primary outcome was survival to discharge. MAIN RESULTS: Ninety-six patients (27%) did not survive to discharge. There were significant differences between survivors and non-survivors for ASA (3.7 vs. 3.9, p=0.001), RCRI (1.6 vs. 2.0, p=0.003), and SOFA score (8.1 vs. 11.2, p<0.001). Based on the area under the receiver operating characteristic curve for these relationships, there was only modest discrimination between the groups, ranging from the most useful SOFA (0.68) to less useful RCRI (0.60) and ASA (0.59). CONCLUSIONS: This single center retrospective study quantified a high perioperative risk for critically ill patients with advanced airways: one in four did not survive to discharge. Preoperative ASA score, RCRI, and SOFA score only partially delineated survivors and non-survivors. Given the existing limitations, future research may identify assessment tools more relevant to discriminating survival outcomes for critically ill patients in the perioperative environment.

Transitioning from 1:1 to 1: 2 Supervision in Anesthesia Training: A Descriptive Survey.

BACKGROUND: Advancement from 1:1 to 1:2 (attending to resident) supervision at the beginning of a CA-1 (clinical anesthesia) year can serve as a model for transition to milestone-based curricula. Currently most programs have an individual mixture of training and advancement criteria formed at the discretion of educational leadership. We designed a questionnaire to evaluate degree of variability at programs nationally. METHODS: After obtaining IRB approval, an anonymous survey was sent via Survey Monkey to all Anesthesiology Residency Program Directors with a link for faculty members. The survey remained open for 30 days and two reminders for completion were sent. RESULTS: Among responses from Program Directors, the following competency areas showed most agreement in being absolutely required for advancement: when to call an attending (78%), preoxygenation (60%), room preparation (81%), monitor placement (81%), machine check (77%), and airway assessment (73%). Responses from faculty identified as most important when to call the attending (82%), basic crisis management while waiting for help (64%), monitor placement (77%), machine check (79%), room preparation(77%), and airway assessment (66%). CONCLUSIONS: There are no clear guidelines for transition from 1:1 to 1:2 supervision with wide variability in the design and requirements for the transition. With only modest agreement among and between Residency Program Directors and faculty members at this clearly defined transition, the challenges of implementation of milestones at every level are significant.

Benefit of using a "bundled" consent for intensive care unit procedures as part of an early family meeting.

PURPOSE: Relatives of patients in the intensive care unit (ICU) are often dissatisfied with family-physician communication. Our prospective preintervention and postintervention study tested the hypothesis that introducing this informed consent process would improve family satisfaction with the ICU process of care. MATERIALS AND METHODS: We developed a consent form that included an introductory explanation of the main ICU interventions and a description of 8 common procedures in a surgical ICU. We administered it early in the ICU course during a scheduled family meeting. The study was a prospective preintervention and postintervention design. RESULTS: The "Family Satisfaction in the Intensive Care Unit" (FS-ICU) score was higher in the intervention than in the control group (95.4±4 vs 78.2±22, P<.001). The nursing perception of satisfaction with care was also higher in the intervention group (95.8±13 vs 71.9±28, P<.001). CONCLUSION: A bundled informed consent resulted in higher family satisfaction with the process of care in ICU.

Icodextrin causing glucose meter error and severe hypoglycemia after deceased donor renal transplant in a patient receiving continuous ambulatory peritoneal dialysis.

Hypoglycemia is a frequent problem encountered with diabetics and hospitalized patients. Although point-of-care glucose meters have revolutionized management, there are circumstances wherein glucose meter readings are inaccurate. One such example of glucose meter error occurred in a patient with end-stage renal disease receiving peritoneal dialysis who underwent renal transplantation. After surgery, the patient's laboratory testing reflected hypoglycemia, while point-of-care glucose meter testing indicated hyperglycemia. It is important to remember that the "gold standard" is the laboratory serum glucose test, and if a discrepancy from point-of-care results occurs, an investigation should be made to ascertain the reason.

Revised Cardiac Risk Index (RCRI) is a useful tool for evaluation of perioperative cardiac morbidity in kidney transplant recipients.

BACKGROUND: We evaluated a published Revised Cardiac Risk Index (RCRI) to determine if this preoperative cardiovascular risk stratification tool would be useful in the kidney transplant recipient population. METHODS: We identified all kidney transplants from 2005 to 2009 (n=1652) at our institution. We performed a detailed retrospective chart review of (a) all recipients who underwent preoperative coronary angiography (n=169) and (b) an age-matched and transplantation year-matched group who did not undergo coronary angiography (n=156). Charts were reviewed for the presence of specific preoperative cardiovascular risk factors and perioperative cardiovascular complications (as defined by RCRI plus elevation of troponin) from time of surgery to hospital discharge. The total number of risk factors for each patient was compared with the occurrence of postoperative cardiac complications to identify a possible association. RESULTS: The number of risk factors was highly predictive of cardiovascular complications (receiver operating characteristic area, 0.77; P<0.0001). History of coronary artery disease was most strongly associated (odds ratio, 20.59; confidence interval, 4.73-89.53; P=0.0001) and history of congestive heart failure was also significantly associated with cardiac complications (odds ratio, 2.95; confidence interval, 1.01-8.59; P=0.0475). CONCLUSION: The RCRI is a useful tool for cardiac risk stratification in kidney transplantation and could be used to develop protocols for intraoperative and postoperative care to minimize complications.

Relative performance of the level 1 and ranger pressure infusion devices.

UNLABELLED: Pressure infusion devices are often used to administer fluids in the operating room, but they may rarely be associated with serious venous air embolism. We studied the performance of the Level 1 and the Ranger Pressure Infusor in the laboratory. The Ranger delivered less air and delivered fluid faster than the Level 1 but did not warm fluid or blood as well. Although the Ranger device may be safer in terms of the risk of air embolism, its inferior warming performance shows that the optimal pressure infusion device has yet to be manufactured. IMPLICATIONS: Pressure infusion devices are widely used to treat patients with large-volume blood loss. The use of these devices may subject patients to the risk of venous air embolism. Our study found the new Ranger device to be superior to the widely used Level 1 in air elimination.