A Randomized Trial of Manual Phone Calls Versus Automated Text Messages for Peripheral Nerve Block Follow-Ups.

Mobile phone applications (apps) have been used for patient follow-up in the postoperative period, specifically to assess for complications and patient satisfaction. Few studies have evaluated their use in regional anesthesia. The objective of this study was to compare follow-up response rates using manual phone calls versus an automated patient outreach (APO) app for peripheral nerve block patients. We hypothesized that the response rate would be higher in the APO group. A mobile app, "JeffAnesthesia," was developed, which sends notifications to patients to answer survey questions in the app. We randomly assigned patients who received peripheral nerve blocks for postoperative pain to either a manual phone call or an APO app group, with follow-up in each category occurring between postoperative days (POD) 14-21 and 90-100. In total, 60 patients were assigned to the phone call group and 60 patients to the APO app group. Between POD 14-21, 9 (15%) patients were reached in the manual phone call arm, and 16 (26.7%) patients were reached in the APO arm (p = 0.117). At POD 90-100, follow-up was successful with 5 (8.2%) in the manual phone call group vs. 3 (5.0%) patients in the APO app group (p = 0.300). Overall response rate was poor, with comparable response rates between groups. The APO method may reduce time spent by anesthesia staff on follow-up calls, but our data do not suggest this method improves response rates significantly. Further studies are needed to better understand the reasons for the poor response rate and strategies for improvement.

Patient-Centered Anesthesia Triage System Predicts ASA Physical Status.

BACKGROUND: The purpose of this study was to validate a patient-centered anesthesia triage system (PCATS) by examining its association with, and predictive value of, ASA physical status (PS) classification. ASA PS classification is a widely used indicator of health status and the predictor of risk of perioperative complications. Thus, ASA PS is a good triage point such that healthy surgical patients (ASA PS I and II) undergoing low-complexity surgery are assessed by telephone, whereas less-healthy patients (ASA PS III and IV) or those patients undergoing highly complex surgery are seen in person at a presurgical clinic. However, ASA PS is not commonly available in electronic health records or easily determined by nonanesthesiologists. PCATS criteria, including the number of prescription medications used daily, body mass index (BMI), age, and surgical complexity, are readily available in electronic health records. Nonclinical scheduling personnel can use PCATS to make appropriate preassessment appointments for elective surgical patients before surgery. METHODS: After getting approval from the University of Florida IRB for an exempt study, 300 consecutive patients scheduled in the presurgical clinic over a 1-week span were retrospectively enrolled. Each of the records was reviewed and collated for study identification number, number of prescription medications, BMI, and ASA PS classification assigned on the day of surgery. In addition, a surgical complexity score was assigned to each procedure (high, moderate, minimal).The association between PCATS and individual PCATS criteria and ASA PS was assessed by χ test. The utility of PCATS to discriminate between ASA PS classifications was assessed using receiver operating characteristic (ROC) curves as well as other indicators of clinical validity: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive clinical utility index ([CIU+] = sensitivity × PPV) and negative CIU ([CIU-] = specificity × PPV). RESULTS: BMI (P = .002), age (P = .01), surgical complexity (P < .0001), and number of prescriptions (P < .001) were significantly associated with ASA PS. Definitions included as PCATS criteria were BMI > 35, age > 80 years, 5 or more prescriptions, and high surgical complexity. Eighty-seven percent of patients with any PCATS criterion were ASA PS classification III or IV. From ROC curve analysis, PCATS emerged as a significant, and moderately good, predictor of ASA PS class (area under the curve = 0.75, 95% confidence interval [CI], 0.69-0.83). PCATS was highly sensitive (0.88, 95% CI, 0.84-0.92) and specific (0.74; 95% CI, 0.61-0.86), and had excellent utility in confirmation/case finding (CUI+ = 0.83, 95% CI, 0.82-0.84) and moderate utility in screening out cases (CUI- = 0.43, 95% CI, 0.41-0.44). CONCLUSIONS: PCATS serves as a useful, and valid, predictor of ASA PS classification. Thus, it may also serve as a tool to triage patients to an appropriate venue for preoperative assessment that can be utilized by nonclinical schedulers. Using a simple tool such as PCATS may help streamline the presurgical patient experience and improve clinic staff utilization.

Acute and Chronic Kidney Disease and Cardiovascular Mortality After Major Surgery.

OBJECTIVE: The aim of the study was to determine the long-term cardiovascular-specific mortality in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) after major surgery. BACKGROUND: In surgical patients, pre-existing CKD and postoperative AKI are associated with increases in all-cause mortality. METHODS: In a single-center cohort of 51,457 adult surgical patients undergoing major inpatient surgery, long-term cardiovascular-specific mortality was modeled using a multivariable subdistributional hazards model while treating any other cause of death as a competing risk and accounting for the progression to end-stage renal disease (ESRD) after discharge. Pre-existing CKD and ESRD, and postoperative AKI were the main independent predictors. RESULTS: Before the admission, 4% and 8% of the cohort had pre-existing ESRD and CKD not requiring renal replacement therapy, respectively. During hospitalization, 39% developed AKI. At 10-year follow-up, adjusted cardiovascular-specific mortality estimates were 6%, 11%, 12%, 19%, and 27% for patients with no kidney disease, AKI with no CKD, CKD with no AKI, AKI with CKD, and ESRD, respectively (P < 0.001). This association remained after excluding 916 patients who progressed to ESRD after discharge, although it was significantly amplified among them. Compared with patients having no kidney disease, adjusted hazard ratios for cardiovascular mortality were significantly higher among patients with kidney disease, ranging from 1.95 (95% confidence interval, 1.80-2.11) for patients with de novo AKI to 5.70 (95% confidence interval, 5.00-6.49) for patients with pre-existing ESRD. CONCLUSIONS: Both AKI and CKD were associated with higher long-term cardiovascular-specific mortality compared with patients having no kidney disease.

Effect of intermittent phrenic nerve stimulation during cardiothoracic surgery on mitochondrial respiration in the human diaphragm.

OBJECTIVES: Recent studies have shown that brief periods of mechanical ventilation in animals and humans can lead to ventilator-induced diaphragmatic dysfunction, which includes muscle atrophy, reduced force development, and impaired mitochondrial function. Studies in animal models have shown that short periods of increased diaphragm activity during mechanical ventilation support can attenuate ventilator-induced diaphragmatic dysfunction but corresponding human data are lacking. The purpose of this study was to examine the effect of intermittent diaphragm contractions during cardiothoracic surgery, including controlled mechanical ventilation, on mitochondrial respiration in the human diaphragm. DESIGN: Within subjects repeated measures study. SETTING: Operating room in an academic health center. PATIENTS: Five subjects undergoing elective cardiothoracic surgery. INTERVENTIONS: In patients (age 65.6 ± 6.3 yr) undergoing cardiothoracic surgery, one phrenic nerve was stimulated hourly (30 pulses/min, 1.5 msec duration, 17.0 ± 4.4 mA) during the surgery. Subjects received 3.4 ± 0.6 stimulation bouts during surgery. Thirty minutes following the last stimulation bout, samples of diaphragm muscle were obtained from the anterolateral costal regions of the stimulated and inactive hemidiaphragms. MEASUREMENTS AND MAIN RESULTS: Mitochondrial respiration was measured in permeabilized muscle fibers with high-resolution respirometry. State III mitochondrial respiration rates (pmol O2/s/mg wet weight) were 15.05 ± 3.92 and 11.42 ± 2.66 for the stimulated and unstimulated samples, respectively (p < 0.05). State IV mitochondrial respiration rates were 3.59 ± 1.25 and 2.11 ± 0.97 in the stimulated samples and controls samples, respectively (p < 0.05). CONCLUSION: These are the first data examining the effect of intermittent contractions on mitochondrial respiration rates in the human diaphragm following surgery/mechanical ventilation. Our results indicate that very brief periods (duty cycle ~1.7%) of activity can improve mitochondrial function in the human diaphragm following surgery/mechanical ventilation.

Descending thoracic aortic surgery: update on mortality, morbidity, risk assessment and management.

PURPOSE OF REVIEW: The purpose of this review is to summarize the literature on thoracic aortic surgery, as well as key management guidelines in the perioperative period. This is particularly timely, as endovascular techniques continue to evolve and become more available. RECENT FINDINGS: Endovascular treatment of thoracic aortic disease is expanding in applications and case complexity. SUMMARY: With the expanded use of endovascular techniques to treat aortic disease, midterm and long-term outcome studies and comparisons to open surgical approach are now being published with increasing frequency. This review analyzes the available literature on preventing adverse outcomes after descending thoracic aortic surgery, with specific attention to mortality, morbidity, risk assessment and management in the perioperative setting.

Trapped by a first hypothesis: How rudeness leads to anchoring.

In this article we explore the effect of encounters with rudeness on the tendency to engage in anchoring, one of the most robust and widespread cognitive biases. Integrating the self-immersion framework with the selective accessibility model (SAM), we propose that rudeness-induced negative arousal will narrow individuals' perspectives in a way that will make anchoring more likely. Additionally, we posit that perspective taking and information elaboration will attenuate the effect of rudeness on both negative arousal and subsequent anchoring. Across four experimental studies, we test the impact of exposure to rudeness on anchoring as manifested in a variety of tasks (medical diagnosis, judgment tasks, and negotiation). In a pilot study, we find that rudeness is associated with anchoring among a group of medical students making a medical diagnosis. In Study 1, we show that negative arousal mediates the effect of rudeness on anchoring among medical residents treating a patient, and that perspective taking moderates these effects. Study 2 replicates the results of Study 1 using a common anchoring task, and Study 3 builds on these results by replicating them in a negotiation setting and testing information elaboration as a boundary condition. Across the four studies, we find consistent evidence that rudeness-induced negative arousal leads to anchoring, and that these effects can be mitigated by perspective taking and information elaboration. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Outflow graft thrombectomy during HeartMate II left ventricular assist device exchange.

We report the pump exchange secondary to a detached bend relief sheath of a HeartMate II (Thoratec Corporation, Pleasanton, CA, USA) left ventricular assist device, consistent with previous Food and Drug Administration warnings. This report highlights a thrombectomy technique and reuse of the outflow graft during subcostal pump exchange in a patient with relative contraindications to repeat sternotomy.

Aortic Surgery and Deep-Hypothermic Circulatory Arrest: Anesthetic Update.

Aortic arch surgery has become increasingly complex, and novel surgical approaches have been utilized. Efforts aimed at improving neurological outcomes in this patient population have been numerous, with varying degrees of success. This article summarizes the anesthetic considerations for procedures on the aortic arch, including evidence-based outcomes with respect to temperature management, perfusion strategies, hemodynamic goals, adjunct agents, and neuromonitoring.

The Patient Visits Program: a strategy to highlight patient satisfaction and refocus organizational culture.

BACKGROUND: Seeking patient input may improve patients' perceptions of the quality of care and provide managers with helpful information for strategic decision making. In addition, the involvement of senior hospital leadership is critical to successful implementation of quality improvement initiatives and illustrates an organization's commitment to enhancing quality from the top down. IMPLEMENTING THE PVP: Senior management's Patient Visits Program (PVP) at Tufts-New England Medical Center is a structured, ongoing initiative in which senior clinicians are paired with nonclinician administrators. During an initial evaluation period (Aug 1999-Feb 2001), PVP teams visited with patients and their families on a monthly basis to talk to them about their experiences. Patient suggestions were then evaluated and acted on. DISCUSSION: The PVP has been beneficial for patients and for the hospital team members--clinicians and nonclinicians alike--who participated in the patient interviews. The PVP may serve as a mechanism to enhance organizational awareness of the importance of patient satisfaction. The program provides opportunities for immediate service recovery, and faster, broader-reaching responses to quality complaints due to the multispecialty nature of the PVP teams. In addition, based on early available data, the PVP shows promise as an interventional strategy to improve patient satisfaction scores. CONCLUSIONS: A structured, ongoing program such as the PVP is an effective strategy to highlight the value of patient satisfaction, refocus organizational culture, and generate specific suggestions for improving the quality of patient care.