Impact of a Hemoglobin Trigger Communication Tool on Perioperative Transfusion in Cardiac Surgery.

OBJECTIVES: Blood transfusion represents an important and potentially modifiable risk in the daily practice of cardiac surgery. The risk profile and increasing cost of transfusion led us to study the effect of different maneuvers, interventions, or surgical techniques to minimize transfusion while maintaining patient safety. This study compares postoperative outcomes before and after incorporating a verbal hemoglobin (Hb) trigger during the surgical timeout in which the surgeon and anesthesiologist preemptively agree on a threshold for packed red blood cell (PRBC) administration in the perioperative period. METHODS: The authors performed a chart review of patients who underwent cardiac surgery from July 2013 through June 2014 at our institution. Patients who underwent surgery from July 2013 through December 2013 served as the pre-Hb trigger group, and patients who underwent surgery from January 2014 through June 2014 served as the post-Hb trigger group. Information collected included patient demographics, type of cardiac surgery, preoperative Hb, Hb trigger, and intraoperative and postoperative variables. The primary outcome was the incidence of PRBC transfusions. Secondary outcomes included the incidence of frozen plasma (FP) transfusion, mechanical ventilation beyond postoperative day 1, and 30-day mortality. RESULTS: The study included 191 patients, with 84 in the pre-Hb trigger group and 107 in the post-Hb trigger group. Intraoperative PRBC transfusions did not decrease in the posttrigger group compared with the pretrigger group (pretrigger 51.4% vs posttrigger 52.4%, P = 1.0); however, intraoperative FP administration was lower in the posttrigger group (65.4% vs 50.0%, P = 0.038). Postoperative mechanical ventilation beyond postoperative day 1 also was significantly lower in the posttrigger group compared with the pretrigger group (27.1% vs 14.3%, P = 0.035). CONCLUSIONS: Implementation of a verbal Hb trigger during the surgical timeout was associated with a reduction in FP administration and duration of mechanical ventilation, but not a decrease in PRBC transfusion and mortality.

A Quality Improvement Project to Decrease Perioperative and Periprocedural Corneal Abrasions.

PURPOSE: We assessed our institution's rate of perioperative and periprocedural corneal abrasions (CAs) and implemented a quality improvement project to improve our detection of CAs and decrease their incidence by at least 25% over 12 months. DESIGN: Retrospective review before and after initiation of a quality improvement project at a single tertiary care institution METHODS: We retrospectively reviewed surgical and procedural patients requiring any type of anesthesia care over three 1-year time periods (2014-2015, 2016-2017, and 2017-2018). Using an electronic pharmacy-based query to identify patients who received proparacaine eye drops in the recovery room, we were able to estimate our incidence of CA during these time periods. We implemented a best practice plan to standardize CA prevention, diagnosis, and treatment after determining our baseline incidence of CA. FINDINGS: Our baseline incidence rate of perioperative and periprocedural CAs was 0.22% (43/19,790 anesthetics) in the 2014-2015 time period. In the 2016-2017 and 2017-2018 time periods, the incidence rate was reduced to 0.09% (21/23,652 anesthetics) and 0.1% (23/23,825 anesthetics), respectively. The use of a standardized CA prevention, diagnosis, and treatment plan reduced the relative risk of CAs by 59% in 2016-2017 (P < .001) and 56% in 2017-2018 (P = .001) compared to baseline, with an absolute reduction of 13% and 12% over those time periods. CONCLUSION: Our data suggests that the adoption of a simple, standardized perioperative and periprocedural CA prevention, diagnosis, and treatment plan can result in sustained reductions in the occurrence of perioperative CAs.

Effect of nano cerium oxide on soybean (Glycine max L. Merrill) crop exposed to environmentally relevant concentrations.

This study evaluated the uptake and translocation of cerium nanoparticles (CeO2 NPs) and soluble Ce(NO3)3 by soybean plants (Glycine max L. Merrill) under the whole plant life-cycle and relevant environmental concentrations, 0.062 and 0.933 mg kg-1, which represent maximal values for 2017 in agricultural soils and sludge treated soils, respectively. The experiments were carried out using a nutrient solution. Cerium was detected in the soybean roots epidermis and cortex, leaves, and grains, but it neither impaired plant development nor grain yield. The concentration of Ce in the shoot increased as a function of time for plants treated with Ce(NO3)3, while it remained constant for plants treated with CeO2 NPs. It means that CeO2 NPs were absorbed in the same rate as biomass production, which suggests that they are taken up and transported by water mass flow. Single-particle inductively coupled plasma mass spectrometry revealed clusters of CeO2 NPs in leaves of plants treated with 25 nm CeO2 NPs (ca. 30-45 nm). The reprecipitation of soluble cerium from Ce(NO3)3 within the plant was not confirmed. Finally, bioconcentration factors above one were found for the lowest concentrated treatments. Since soybean is a widespread source of protein for animals, we draw attention to the importance of evaluating the effects of Ce entrance in the food chain and its possible biomagnification.

Lung Transplantation Using a Hybrid Extracorporeal Membrane Oxygenation Circuit.

Extracorporeal circulation (ECC) support using intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LTx) is now a routine practice for many high volume centers. Circuits that are dedicated to ECMO alone can be expensive and do not allow full cardiopulmonary bypass (CPB) to be performed. We describe our technique of instituting venoarterial ECMO during LTx using a less-expensive hybrid circuit that facilitates easy and immediate conversion to full CPB if needed, without interruption of ECC.

Induction of General Anesthesia and Mask Ventilation With a Full-Face Continuous Positive Airway Pressure Mask in a Patient With a Nose Deformity.

Mask ventilation (MV) is an essential component of airway management and can be lifesaving in situations where the placement of a secure airway device proves challenging. Effective MV requires a seal to be created between the mask and the face to maintain patency of the external airway structures and can be difficult in the setting of facial abnormalities or facial trauma. Here we describe a case in which a continuous positive airway pressure (CPAP) mask was used for anesthesia induction and MV in an 85-year-old man who underwent a plastic surgery reconstruction of the left nasal dorsum and ala following a Mohs surgery, which had prevented the use of conventional face mask. An effective seal was achieved, and anesthesia was successfully induced with the mask. We reviewed the literature and discussed alternative approaches for face mask use in the setting of facial abnormalities where the use of a conventional mask is unfeasible.

Zinc uptake from ZnSO4 (aq) and Zn-EDTA (aq) and its root-to-shoot transport in soybean plants (Glycine max) probed by time-resolved in vivo X-ray spectroscopy.

This study investigated the dynamic of zinc (Zn) uptake and the root-to-shoot Zn-transport when supplied as ZnSO4 (aq) or Zn-EDTA (aq) in soybean seedlings using in vivo X-ray fluorescence (XRF) and X-ray absorption spectroscopy (XANES). The time-resolved X-ray fluorescence showed that plants absorbed ca. 10-fold more Zn from ZnSO4 (aq) than from Zn-EDTA (aq). However, the uptake velocity did not influence the amount of Zn in the stem. It let furthermore appear that the plants were able to reduce the absorption of Zn from Zn-EDTA (aq) earlier than ZnSO4 (aq). Thus, the entrance of Zn2+ into the roots is not necessarily accompanied by SO42-(aq). Regardless the source, the Zn distribution and its transport in the stem were spatially correlated to the bundles and cortex nearby the epidermal cells. Its chemical speciation showed that Zn is neither transported as ZnSO4(aq) nor as Zn-EDTA(aq), indicating that these compounds are retained in the roots or biotransformed on in the root-solution interface. Zn2+ was long-distance transported complexed by organic molecules such as histidine, malate, and citrate, and the proportion of ligands was affected by the concentration of Zn2+ in the stem rather than by the type of Zn source.

In Vivo Evaluation of Zn Foliar Uptake and Transport in Soybean Using X-ray Absorption and Fluorescence Spectroscopy.

Understanding the mechanisms of absorption and transport of foliar nutrition is a key step towards the development of advanced fertilization methods. This study employed X-ray fluorescence (XRF) and X-ray absorption near edge spectroscopy (XANES) to trace the in vivo absorption and transport of ZnO and ZnSO4(aq) to soybean leaves (Glycine max). XRF maps monitored over 48 h showed a shape change of the dried ZnSO4(aq) droplet, indicating Zn2+ absorption. Conversely, these maps did not show short movement of Zn from ZnO. XRF measurements on petioles of leaves that received Zn2+ treatments clarified that the Zn absorption and transport in the form of ZnSO4(aq) was faster that of ZnO. Solubility was the major factor driving ZnSO4(aq) absorption. XANES speciation showed that in planta Zn is transported coordinated with organic acids. Because plants demand Zn during their entire lifecycle, the utilization of sources with different solubilities can increase Zn use efficiency.

La2O3 Nanoparticles: Study of Uptake and Distribution in Pfaffia glomerata (Spreng.) Pedersen by LA-ICP-MS and µ-XRF.

The production and use of nanoparticles (NPs) in different fields increased in the last years. However, some NPs have toxicological properties, making these materials potential emerging pollutants. Therefore, it is important to investigate the uptake, transformation, translocation, and deposition of NPs in plants. In this work, laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) and micro X-ray fluorescence (µ-XRF) were used to investigate the uptake and translocation of La2O3 NPs to stem and leaves of Pfaffia glomerata (Spreng.) Pedersen after in vitro cultivation of plants in the presence of 400 mg L-1 of La2O3 NPs. By using LA-ICP-MS and µ-XRF, image of the spatial distribution of La in the leaves was obtained, where higher concentration of La was observed in the main veins. Differences in the signal profile of La in leaves of plants cultivated in the presence of bulk La2O3 (b-La2O3) and La2O3 NPs were observed. Sharp peaks of La indicated that NPs were transported to the stems and leaves of plants treated with La2O3 NPs. Both LA-ICP-MS and µ-XRF techniques have shown to be useful for detecting NPs in plants, but LA-ICP-MS is more sensitive than µ-XRF and allowed better detection and visualization of La distribution in the whole leaf.

Laboratory Microprobe X-Ray Fluorescence in Plant Science: Emerging Applications and Case Studies.

In vivo and micro chemical analytical methods have the potential to improve our understanding of plant metabolism and development. Benchtop microprobe X-ray fluorescence spectroscopy (µ-XRF) presents a huge potential for facing this challenge. Excitation beams of 30 µm and 1 mm in diameter were employed to address questions in seed technology, phytopathology, plant physiology, and bioremediation. Different elements were analyzed in several situations of agronomic interest: (i) Examples of µ-XRF yielding quantitative maps that reveal the spatial distribution of zinc in common beans (Phaseolus vulgaris) primed seeds. (ii) Chemical images daily recorded at a soybean leaf (Glycine max) infected by anthracnose showed that phosphorus, sulfur, and calcium trended to concentrate in the disease spot. (iii) In vivo measurements at the stem of P. vulgaris showed that under root exposure, manganese is absorbed and transported nearly 10-fold faster than iron. (iv) Quantitative maps showed that the lead distribution in a leaf of Eucalyptus hybrid was not homogenous, this element accumulated mainly in the leaf border and midrib, the lead hotspots reached up to 13,400 mg lead kg-1 fresh tissue weight. These case studies highlight the ability of µ-XRF in performing qualitative and quantitative elemental analysis of fresh and living plant tissues. Thus, it can probe dynamic biological phenomena non-destructively and in real time.

Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient.

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

Lung transplantation: perioperative pharmacology and anesthetic considerations.

In the past two decades, lung transplantation has become an increasingly important surgical option for the patient with end stage lung disease. Compared with the other solid organ transplants (heart, liver and kidney), lung transplantation carries immense clinical and logistic challenges; long-term organ viability is particularly problematic, with an expected five-year mortality of 40-50%. The number of lung transplants performed in the U.S. has been increasing steadily since 1988, when UNOS (United Network for Organ Sharing) started recording statistical data. In that year, 33 cases of lung transplantation were performed. As of today, a total of 23,815 lung transplants have been performed, and the largest number of yearly lung transplants (n=1,822) was performed in 2009. From appropriate patient selection, to optimal organ selection, surgical procedure, and immediate and long-term postoperative care, the medical process involves multiple healthcare providers and requires a very well-organized and committed healthcare system to achieve optimal surgical results. Understanding the pharmacology involved in the care of the lung transplant patient is of utmost importance to achieve appropriate organ preservation, immunosuppression, hemodynamic stability, and adequate anesthetic depth, while avoiding drug toxicity and side effects. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the medications most commonly administered to this patient population, throughout the perioperative period.

Analgesic considerations for liver transplantation patients.

Orthotopic liver transplantation (OLT) recipients have been reported to have decreased perioperative opioid and intraoperative inhalational anesthetic requirements when compared to patients without liver disease undergoing other types of major abdominal surgeries. The severity of the liver disease and the process of the transplantation itself may alter the pharmacokinetic and pharmacodynamic effects of different pain medications. Chemical injury of the liver and the high degree of surgical stress may also increase the levels of neuropeptides involved in pain modulation. Per the U.S. Department of Health and Human Services Organ Procurement and Transplantation Network, more than 5,000 OLT cases are being done per year since 2000. With better understanding of the pathophysiology of liver disease and the development of perioperative anesthesia management, the recent concept of improving patient outcome following OLT includes a fast-track approach in selected patients, which may shorten or completely bypass intensive care unit stay and reduce costs. With this development, the understanding of the analgesic pharmacology in the care of the OLT patients is even more important. Proper dosage of medications can achieve adequate intraoperative anesthetic depth and postoperative pain control, while avoiding over-sedation which increases risk of prolonged postoperative mechanical ventilation. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the analgesic medications commonly administered to this patient population.

Robotic mitral valve repair: a review of anesthetic management of the first 200 patients.

OBJECTIVE: The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. DESIGN: A retrospective review. SETTING: A single tertiary referral academic hospital. PARTICIPANTS: Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. CONCLUSIONS: Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit.

Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost.

STUDY DESIGN: Single-institution retrospective study. OBJECTIVE: To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization. SUMMARY OF BACKGROUND DATA: Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown. METHODS: This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest. RESULTS: From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were $89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = -$178,899 to -$4661). CONCLUSION: Separating the anterior exposure and posterior resection phases of complex sacral tumor resection into two separate surgical episodes of care is associated with improved clinical outcomes and reduced inpatient cost.