Utility of NICaS Non-Invasive Hemodynamic Monitoring in Critically Ill Patients with COVID-19.

(1) Background: COVID-19 presented many challenges to effective treatments, such as managing cardiovascular insufficiency while mitigating risks to healthcare providers. This study utilized NICaS, a non-invasive hemodynamic monitor that provides advanced data via whole-body impedance analysis. We investigated the associated trends in hemodynamic parameters obtained by the NICaS device and their correlation with in-hospital all-cause mortality during COVID-19 hospitalization in the intensive care unit. (2) Methods: Data from 29 patients with COVID-19 admitted to the intensive care unit and monitored with NICaS between April 2020 and February 2021 were analyzed retrospectively. (3) Results: Decreasing cardiac output and cardiac power were significantly associated with death. Total peripheral resistance was significantly increasing in non-survivors as was total body water percentage. Those admitted with a heart rate above 90 beats per minute had a significantly reduced survival. (4) Conclusions: Non-invasive hemodynamic monitoring via the NICaS device is simple and effective in evaluating critically ill patients with COVID-19 and may help guide clinical management via remote monitoring. Controlling tachycardia may help ensure adequate oxygen supply-demand ratio. A hint toward a beneficiary effect of a restrictive fluid balance may be observed.

The Prevalence of Post-traumatic Stress Disorder as Part of Post-ICU Syndrome among Israeli ICU Survivors.

BACKGROUND: Survivors of critical illness are at increased risk of long-term impairments, referred to as post-intensive care unit (ICU) syndrome (PICS). Post-traumatic stress disorder (PTSD) is common among ICU survivors with reported rates of up to 27%. The prevalence of PTSD among Israeli ICU survivors has not been reported to date. OBJECTIVES: To evaluate the prevalence of new onset PTSD diagnosed in a post-ICU clinic at a tertiary center in Israel. METHODS: We conducted a retrospective, single center, cohort study. Data were collected from medical records of all patients who visited the Tel Aviv Sourasky Medical Center post-ICU clinic between October 2017 and June 2020. New onset PTSD was defined as PTSD diagnosed by a certified board psychiatrist during the post-ICU clinic visit. Data were analyzed using descriptive statistics. RESULTS: Overall, 39 patients (mean age 51 ± 17 years, 15/39 females [38%]) attended the post-ICU clinic during the study period. They were evaluated 82 ± 57 days after hospital discharge. After excluding 7 patients due to missing proper psychiatric analysis, 32 patients remained eligible for the primary analysis. New PTSD was diagnosed in one patient (3%). CONCLUSIONS: We found lower incidence of PTSD in our cohort when compared to existing literature. Possible explanations include different diagnostic tools and low risk factors rate. Unique national, cultural, and/or religious perspectives might have contributed to the observed low PTSD rate. Further research in larger study populations is required to establish the prevalence of PTSD among Israeli ICU survivors.

Preoperative cognitive impairment and postoperative delirium among Holocaust survivors who achieved longevity.

BACKGROUND: Holocaust survivors (HS) experience higher rates of physiological and psychological morbidities, increasing their vulnerability to perioperative complications. Limited information exists regarding their perioperative neurocognitive disorders. This study aimed to assess the rates of preoperative cognitive impairment, postoperative delirium, and other complications among HS aged 75+ undergoing elective surgery. METHODS: This is a single-center retrospective cohort study that analyzed prospectively collected data. All surgical patients born before 1945 who underwent elective noncardiac surgery at a tertiary hospital in Israel during 2020-2021 were included. The HS group was identified through the hospital's information system. Preoperative cognitive impairment was assessed using the Mini-Cog test. Postoperative delirium was defined as a combined outcome, which included a positive 4A's-Test (4AT) result during the postanesthesia care unit stay up to the second postoperative day, a positive 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) test administered by the geriatric team, and identification through the medical records using the Chart-based Delirium Identification Instrument (CHART-DEL). We used multivariable regression to assess the risk factors for postoperative delirium. RESULTS: Out of 1332 eligible patients, 422 (32%) were HS, while the others served as controls. Both groups had a similar rate of preoperative cognitive impairment (24%, p = 0.89) and postoperative delirium (16%, p = 0.95). HS exhibited a higher risk of the composite adverse events (24% vs. 20%, p = 0.05, aOR [95% CI] 1.3 [1.0-1.7]), driven mainly by falls during hospitalization (4% vs. 2%, p = 0.03, aOR 2.1 [1.1-4.1]). HS patients were more likely to be childless (33% vs. 11%, p = 0.001) and had higher rates of chronic antidepressant and benzodiazepine use. CONCLUSIONS: HS achieving longevity do not face increased risks of preoperative cognitive impairment and postoperative delirium. However, special care is still warranted due to their elevated rate of other complications during hospitalization.

The association between midazolam premedication and postoperative delirium - a retrospective cohort study.

STUDY OBJECTIVE: To evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DESIGN: Retrospective cohort study. SETTING: A single tertiary academic medical center. PATIENTS: Patients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. INTERVENTIONS: Midazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MEASUREMENTS: The primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. MAIN RESULTS: In total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82-1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. CONCLUSIONS: Our results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.

Virtual reality and 3D printing in clinical anesthesia: a case series of two years' experience in a single tertiary medical centre.

PURPOSE: Anatomically correct patient-specific models made from medical imaging can be printed on a three-dimensional (3D) printer or turned into a virtual reality (VR) program. Until recently, use in anesthesia has been limited. In 2019, the anesthesia department at Tel Aviv Medical Center launched a 3D program with the aim of using 3D modelling to assist in preoperative anesthesia planning. METHODS: A retrospective review of all relevant patients between July 2019 and June 2021 referred for preoperative airway planning with 3D modelling. Patient files were reviewed for correlation between the model-based airway plan and the actual airway plan, the type of model used, and any anesthetic complications related to airway management. RESULTS: Twenty patients were referred for 3D modelling. Of these, 15 models were printed, including 12 children requiring one lung ventilation. Five patients had VR reconstructions, including three with mediastinal masses. One patient had both a 3D-printed model and a VR reconstruction. There were two cases (10%) where the model plan did not correlate with the final airway plan and one case where a model could not be created because of poor underlying imaging. For the remaining 17 cases, the plan devised on the model matched the final airway plan. There were no anesthetic complications. CONCLUSIONS: Three-dimensional modelling and subsequent printing or VR reconstruction are feasible in clinical anesthesia. Its routine use for patients with challenging airway anatomy correlated well with the final clinical outcome in most cases. High-quality imaging is essential.

RéSUMé: OBJECTIF: Des modèles anatomiquement corrects spécifiques à un·e patient·e réalisés à partir de l'imagerie médicale peuvent être imprimés sur une imprimante tridimensionnelle (3D) ou transformés en programme de réalité virtuelle (RV). Jusqu'à récemment, l'utilisation de cette modalité était limitée en anesthésie. En 2019, le service d'anesthésie du centre médical de Tel Aviv a lancé un programme 3D dans le but d'utiliser la modélisation 3D pour faciliter la planification préopératoire de l'anesthésie. MéTHODE: Nous avons réalisé un examen rétrospectif de toute la patientèle concernée référée pour une planification préopératoire des voies aériennes avec modélisation 3D entre juillet 2019 et juin 2021. Les dossiers des patient·es ont été examinés pour déterminer la corrélation entre le plan de prise en charge des voies aériennes fondé sur le modèle et le plan fondé sur les voies aériennes réelles, le type de modèle utilisé et toute complication anesthésique liée à la prise en charge des voies aériennes. RéSULTATS: Vingt patient·es ont été référé·es pour la modélisation 3D. À partir de cette cohorte, 15 modèles ont été imprimés, dont 12 pour des enfants nécessitant une ventilation pulmonaire. Cinq patient·es ont bénéficié de reconstructions en RV, dont trois avec des masses médiastinales. Un modèle imprimé en 3D et une reconstruction en RV ont été créés pour une personne. Il y a eu deux cas (10 %) où le plan modèle n'était pas corrélé avec le plan des voies aériennes final et un cas où il n'a pas été possible de créer un modèle en raison d'une mauvaise imagerie sous-jacente. Pour les 17 cas restants, le plan conçu sur le modèle correspondait au plan final de prise en charge des voies aériennes. Il n'y a pas eu de complications anesthésiques. CONCLUSION: La modélisation tridimensionnelle et l'impression ultérieure ou la reconstruction en RV sont réalisables en anesthésie clinique. Leur utilisation systématique pour les patient·es présentant une anatomie difficile au niveau des voies aériennes était bien corrélée avec le résultat clinique final dans la plupart des cas. Une imagerie de haute qualité est essentielle.

Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study).

OBJECTIVE: To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium. BACKGROUND: Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years. METHODS: Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes. RESULTS: Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days]. CONCLUSIONS: One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.

Premature Macrophage Activation by Stored Red Blood Cell Transfusion Halts Liver Regeneration Post-Partial Hepatectomy in Rats.

Liver resection is a common treatment for various conditions and often requires blood transfusions to compensate for operative blood loss. As partial hepatectomy (PHx) is frequently performed in patients with a pre-damaged liver, avoiding further injury is of paramount clinical importance. Our aim was to study the impact of red blood cell (RBC) resuscitation on liver regeneration. We assessed the impact of RBC storage time on liver regeneration following 50% PHx in rats and explored possible contributing molecular mechanisms using immunohistochemistry, RNA-Seq, and macrophage depletion. The liver was successfully regenerated after PHx when rats were transfused with fresh RBCs (F-RBCs). However, in rats resuscitated with stored RBCs (S-RBCs), the regeneration process was disrupted, as detected by delayed hepatocyte proliferation and lack of hypertrophy. The delayed regeneration was associated with elevated numbers of hemorrhage-activated liver macrophages (Mhem) secreting HO-1. Depletion of macrophages prior to PHx and transfusion improved the regeneration process. Gene expression profiling revealed alterations in numerous genes belonging to critical pathways, including cell cycle and DNA replication, and genes associated with immune cell activation, such as chemokine signaling and platelet activation and adhesion. Our results implicate activated macrophages in delayed liver regeneration following S-RBC transfusion via HO-1 and PAI-1 overexpression.

In-hospital mortality of patients requiring unplanned postoperative ventilatory support: a multicenter observational study.

BACKGROUND: Most patients who are admitted non-intubated to surgery are extubated at surgery conclusion. Yet, 1-2% require unplanned postoperative ventilatory support. The outcome of these patients has not been thoroughly evaluated to date and is the focus of the present study. METHODS: Two-center observational study assessing characteristics and outcomes of surgical patients with unplanned mechanical ventilation during PACU stay between 2017 and 2019. Patients who arrived intubated to the operating room or were transferred directly to the intensive care unit (ICU) were excluded. The co-primary aims were to assess overall in-hospital mortality and to compare mortality between patients who were extubated in PACU and those who were discharged from PACU still intubated. The secondary aims were to compare postoperative respiratory infection and unplanned admissions to the ICU. Multivariate logistic regression was used to compare the groups and adjust for potential confounding variables. RESULTS: Overall, 698 patients were included. Of these, 135 died during hospital stay (mortality rate 19.3%, compared with 1.0% overall postoperative in-hospital mortality). Patients who still required ventilatory support at PACU discharge were significantly sicker, majority needed emergency surgery, and had more complicated surgical course compared to those who were extubated in PACU. In addition, their mortality rate [36% vs. 9%, adjusted OR (95% CI) 5.8 (3.8-8.8), p < 0.001], postoperative respiratory infection, and unplanned admission to ICU rates were also significantly higher. CONCLUSION: Unplanned postoperative mechanical ventilation is associated with noteworthy morbidity and mortality, with significantly higher rates in those of need for protracted (vs. short) mechanical ventilation. The remarkable mortality rate in patients extubated shortly after arriving to the PACU emphasizes the need for further studies to explore prompting factors and whether we can intervene to improve patients' outcome.

Changes in mean systemic filling pressure as an estimate of hemodynamic response to anesthesia induction using propofol.

BACKGROUND: Even a small change in the pressure gradient between the venous system and the right atrium can have significant hemodynamic effects. Mean systemic filling pressure (MSFP) is the driving force of the venous system. As a result, MSFP has a significant effect on cardiac output. We aimed to test the hypothesis that the hemodynamic instability during induction of general anesthesia by intravenous propofol administration is caused by changes in MSFP. METHODS: We prospectively collected data from 15 patients undergoing major surgery requiring invasive hemodynamic monitoring. Hemodynamic parameters, including MSFP, were measured before and after propofol administration and following intubation, using venous return curves at a no-flow state induced by a pneumatic tourniquet. RESULTS: A significant decrease in MSFP was observed in all study patients after propofol administration (median (IQR) pressure 17 (9) mmHg compared with 25 (7) before propofol administration, p = 0.001). The pressure gradient for venous return (MSFP - central venous pressure; CVP) also decreased following propofol administration from 19 (8) to 12 (6) mmHg, p = 0.001. Central venous pressure did not change. CONCLUSIONS: These results support the hypothesis that induction of anesthesia with propofol causes a marked reduction in MSFP. A possible mechanism of propofol-induced hypotension is reduction in preload due to a decrease in the venous vasomotor tone.

Major Pulmonary Resection for Non-Small Cell Lung Carcinoma during the COVID-19 Pandemic-Single Israeli Center Cross-Sectional Study.

BACKGROUND: The highly contagious COVID-19 has created unprecedented challenges in providing care to patients with resectable non-small cell lung carcinoma (NSCLC). Surgical management now needs to consider the risks of malignant disease progression by delaying surgery, and those of COVID-19 transmission to patients and operating room staff. The goal of our study was to describe our experience in providing both emergent and elective surgical procedures for patients with NSCLC during the COVID-19 pandemic in Israel, and to present our point of view regarding the safety of performing lung cancer surgery. METHODS: This observational cross-sectional study included all consecutive patients with NSCLC who operated at Tel Aviv Medical Center, a large university-affiliated hospital, from February 2020 through December 2020, during the COVID-19 pandemic in Israel. The patients' demographics, COVID-19 preoperative screening results, type and side of surgery, pathology results, morbidity and mortality rates, postoperative complications, including pulmonary complications management, and hospital stay were evaluated. RESULTS: Included in the study were 113 patients, 68 males (60.2%) and 45 females (39.8%), with a median age of 68.2 years (range, 41-89). Of these 113 patients, 83 (73.5%) underwent video-assisted thoracic surgeries (VATS), and 30 (26.5%) underwent thoracotomies. Fifty-five patients (48.7%) were preoperatively screened for COVID-19 and received negative results. Fifty-six postoperative complications were reported in 35 patients (30.9%). A prolonged air leak was detected in 11 patients (9.7%), atrial fibrillation in 11 patients (9.7%), empyema in 5 patients (4.4%), pneumonia in 9 patients (7.9%) and lobar atelectasis in 7 patients (6.2%). Three patients (2.7%) with postoperative pulmonary complications required mechanical ventilation, and two of them (1.6%) underwent tracheostomy. Two patients (1.6%) were postoperatively diagnosed as positive for COVID-19. CONCLUSIONS: Our data demonstrate the feasibility and efficacy of implementing precautionary strategies to ensure the safety of lung cancer patients undergoing pulmonary resection during the COVID-19 pandemic. The strategy was equally effective in protecting the surgical staff and healthcare providers, and we recommend performing lung cancer surgery during the pandemic era.

Pro-Con Debate: Cardiac Troponin Measurement as Part of Routine Follow-up of Myocardial Damage Following Noncardiac Surgery.

Elevated troponin levels within 3 days of surgery, independent of the presence of symptoms, are strongly linked to increased risk of short- and long-term morbidity and mortality. However, the value of screening with troponin measurements is controversial. The Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery recommends measuring daily troponin for 48 to 72 hours after surgery in high-risk patients. Nevertheless, others doubt this recommendation, in part because postoperative elevated levels of troponin describe very little in terms of disease or event-specific pathogenesis and etiology, and thus, tailoring an intervention remains a challenge. This Pro-Con debate offers evidence-based data to stimulate physician understanding of daily practice and its significance in this matter, and assist in determining whether to use (Pro) or not to use (Con) this surveillance.

Perioperative Oral Pregabalin Results in Postoperative Pain Scores Equivalent to Those of Interscalene Brachial Plexus Block After Arthroscopic Rotator Cuff Repair: A Randomized Clinical Trial.

PURPOSE: To compare the analgesic effects of pregabalin to those of single-shot interscalene brachial plexus block (ISBPB) in adults having arthroscopic rotator cuff (RC) repair, as well as ISBPB's effect on postoperative opioid consumption, patient satisfaction, and opioid-related adverse effects. METHODS: In this randomized trial, 79 adults having arthroscopic RC repair were randomized to receive perioperative oral pregabalin (Lyrica, twice daily starting the evening before surgery, for a total of 4 doses) or single-shot ISBPB (20 ml of bupivacaine 0.25%). Intra- and postoperative management was standardized. The primary outcome was median self-reported pain score (on a visual analog scale of 0 to 100) at rest during the initial 10 postoperative days. Other outcomes included pain during activity, postoperative opioid consumption, opioid-related adverse effects, quality of recovery, and pain satisfaction score. RESULTS: Of 71 eligible patients, 59 were analyzed, of whom 29 received pregabalin and 30 received ISBPB. Groups were similar regarding demographic, baseline, and intraoperative variables. Median pain score at rest over the 10 postoperative days was 51 (interquartile range 26, 76) in the pregabalin group and 52 (22, 74) in the ISBPB group (difference 0.5 points; 95% confidence interval [CI] -3.2 to 6.3; P = .53). Opioid consumption during the initial 10 postoperative days was also similar (difference in median 90 mg of morphine equivalents; 95% CI -32 to 177.5; P = .12). No differences were found in any other outcome. CONCLUSIONS: Perioperative use of pregabalin in adults undergoing arthroscopic RC repair provided analgesia comparable to that of ISBPB for 10 days after surgery. LEVEL OF EVIDENCE: II, randomized controlled trial (high dropout rate).

Indications and diagnosis-specific features of maternal and neonatal peripartum intensive care unit admissions: A retrospective study.

BACKGROUND: Although peripartum intensive care unit admission indications are well-reported, clinical and laboratory details rarely are. We described admission indications and categorised laboratory values and vital signs according to admission diagnosis. METHODS: Retrospective Institutional Review Board approved study. We identified intensive care unit admission diagnosis, laboratory values and vital signs from patient charts. Groups were compared according to admission diagnoses. Data were analysed using descriptive statistics. RESULTS: We included 91 general intensive care unit admissions among 56,865 deliveries (2011-2015) with complete data. The most common admission diagnosis was postpartum haemorrhage followed by hypertensive diseases of pregnancy and respiratory complications. Women with postpartum haemorrhage had lower mean (standard deviation) platelet counts (120.2 (45.8) vs. 181.2 (109.9), p = .003) and temperatures (35.7 (1.1) vs. 36.5 (1.2), p = .002). Women with hypertensive diseases of pregnancy had higher mean (standard deviation) blood pressures (systolic 150.4 (29.1) vs. 127.4 (21.0), p = .013, diastolic 100.3 (18.7) vs. 76.1 (16.1), p = .001), creatinine (1.1 (0.6) vs. 0.8 (0.3), p = .003), urea (14.6 (7.7) vs. 10.5 (4.7), p = .005) and liver enzymes, including aspartate transaminase (258.4 (297.0) vs. 41.4 (42.9), p = .000), alanine transaminase (184.4 (199.2) vs. 35.1 (75.9), p = .000), and alkaline phosphatase (166.6 (112.6) vs. 96.0 (60.0), p = .006). Women with respiratory complications had lower mean (standard deviation) oxygen saturations (93.7 (6.1) vs. 98.0 (2.6), p = .000), and higher mean (standard deviation) temperatures (37.1 (0.8) vs. 36.0 (1.2), p = .001). CONCLUSIONS: We report differences in laboratory values and vital signs, according to intensive care unit admission diagnosis. Recognising these differences might help individualise patient assessment and care.

Escort of older people into the operating room: A feasibility study.

BACKGROUND: While special care is given to perioperative risk assessment and management of older people undergoing surgery, psychological aspects have been largely neglected. Escort presence in the operating room (OR) is common practice in the surgical paediatric and obstetric populations and may be beneficial in older people. OBJECTIVES: This study explored the feasibility of family member escort of older people into the OR and their presence until induction of anaesthesia. METHODS: Prospective observational study of older people (>70 years) undergoing surgery, who were offered an escort into the OR. The primary end point was the proportion of relatives who completed the intervention without feeling dizzy or fainting. Secondary end points related to patient, escort and medical and nursing staff perception of the process. RESULTS: Forty-four sets of patients and escorts completed the process. The primary objective assessing feasibility was concluded successfully. Secondary objectives assessed (1) satisfaction, where 93% of escorts and 75% of patients would support a repeat of this process; (2) anxiolysis, where 61% of patients reported a reduced level of anxiety; (3) although 68% of anaesthesiologists agreed this process improved patients' well-being, most nurses and anaesthesiologists believed this should not become routine practice. Interestingly, most staff support parents escorting a paediatric patient into OR. CONCLUSIONS: This is the first study exploring the feasibility of escorting older people into the OR. It shows a unique insight into patient- and family-centred care of the surgical older person. Escort presence may help alleviate anxiety and increase satisfaction. The medical and nursing staff objections must be looked at further.

The impact of data quality defects on clinical decision-making in the intensive care unit.

OBJECTIVE: Poor clinical data quality might affect clinical decision making and patient treatment. This study identifies quality defects in clinical data collected automatically by bedside monitoring devices in the Intensive Care Unit (ICU) and examines their effect on clinical decisions. METHODS: Real-world data collected from 7688 patients admitted to the general ICU in a tertiary referral hospital over seven years was retrospectively analyzed. Data quality defect detection methods that use time-series analysis techniques identified two types of data quality defects: (a) completeness: the extent of non-missing values, and (b) validity: the extent of non-extreme values within the continuous range of values. Data quality defects were compared to five scenarios of medication and procedure prescriptions that are common in ICU settings: Blood-pressure reduction, blood-pressure elevation, anesthesia medications, intubation procedures, and muscle relaxant medications. RESULTS: Results from a logistic regression revealed a strong connection between data quality and the clinical interventions examined: lower validity level increased the likelihood of prescription decisions for all five scenarios, and lower completeness level increased the likelihood of prescription decisions for some scenarios. DISCUSSION: The results highlight the possible effect of data quality defects on physicians' decisions. Lower validity of certain key clinical parameters, and in some scenarios lower completeness, correlated with stronger tendency to prescribe medications or perform invasive procedures. CONCLUSIONS: Data quality defects in clinical data affect decision making even without practitioners' awareness. Thus, it is important to emphasize these effects to ICU staff, as well as to medical device manufacturers.

Cholinesterase activity in serum during general anesthesia in patients with or without vascular disease.

Maintaining hemodynamic stability during the induction and maintenance of anesthesia is one of the challenges of the anesthesiologist. Patients with vascular disease are at increased risk of instability due to imbalance between the sympathetic and parasympathetic parts of the autonomic nervous system, a balance accessible by serum cholinesterase activity. We aim to characterize the dynamics of cholinesterase activity in patients undergoing general anesthesia (GA) and surgery. This was a prospective study of 57 patients undergoing ambulatory or vascular surgery under GA. Cholinesterase activity was measured before the induction of anesthesia, after 15 min and at the end of surgery by calculating the capacity of serum acetylcholinesterase (AChE) and butyrylcholinesterase to hydrolyze AcetylThioCholine. Data on atherosclerotic disease, anesthesia management were analyzed. Both AChE and total cholinergic status (CS) decreased significantly after GA induction at 15 min and even more so by the end of surgery. Vascular surgery patients had lower baseline cholinesterase activity compared to ambulatory surgery patients. Patients requiring intraoperative administration of phenylephrine for hemodynamic support (21.1%) had a significantly lower level of AChE and CS compared to untreated patients. Our findings serve as a mirror to the sympathetic/parasympathetic imbalance during GA, with a marked decrease in the parasympathetic tone. The data of a subgroup analysis show a correlation between low cholinesterase activity and an increase in the need for hemodynamic support.

Anesthesia departments' readiness for the COVID-19 pandemic; a nationwide cross-sectional study in Israel.

BACKGROUND: The Coronavirus infectious disease 2019 (COVID-19) brings anesthesiologists and intensive care physicians to the mainstay of clinical workload and healthcare managements' focus. There are approximately 900 anesthesiologists in Israel, working in non-private hospitals. This nationwide cross-sectional study evaluated the readiness and involvement of anesthesia departments in Israel in management of the COVID-19 pandemic. The impact on anesthesiologists' health, workload, and clinical practices were also evaluated. METHODS: An online questionnaire was distributed to all of anesthesia department chairs in Israel on April 14th. Each response was identifiable on the hospital level only. Informed consent was waived since no patient data were collected. RESULTS: Response rate was 100%. A decrease of at least 40% in operating-room activity was reported by two-thirds of the departments. Anesthesiologists are leading the treatment of COVID-19 patients in 19/28 (68%) Israeli hospitals. Israel Society of Anesthesiologists' recommendations regarding intubation of COVID-19 patients were strictly followed (intubations performed by the most experienced available physician, by rapid-sequence induction utilizing video-laryngoscopy, while minimizing the number of people in the room - about 90% compliance for each). Anesthesiologists in most departments use standard personal protective equipment when caring for COVID-19 patients, including N95 masks, face shields, and water-proof gowns. Only one anesthesiologist across Israel was diagnosed with COVID-19 (unknown source of transmission). All department chairs reported emerging opportunities that advance the anesthesia profession: implementation of new technologies and improvement in caregivers' clinical capabilities (68% each), purchase of new equipment (96%), and increase in research activity (36%). CONCLUSIONS: This nationwide cross-sectional study had a complete response rate and therefore well-represents the anesthesia practice in Israel. We found that Israeli anesthesia departments are generally highly involved in the health system efforts to cope with the COVID-19 pandemic. Anesthesia and airway management are performed in a remarkably comparable manner and with proper protection of caregivers. Ambulatory anesthesia activity has dramatically decreased, but many departments find opportunities for improvement even in these challenging times.