Feasibility of Focused Cardiac Ultrasound Performed by Trainees During Cesarean Delivery.

BACKGROUND: Anesthesiology experts advocate for formal education in maternal critical care, including the use of focused cardiac ultrasound (FCU) in high-acuity obstetric units. While benefits and feasibility of FCU performed by experts have been well documented, little evidence exists on the feasibility of FCU acquired by examiners with limited experience. The primary aim of this study was to assess how often echocardiographic images of sufficient quality to guide clinical decision-making were attained by trainees with limited experience performing FCU in term parturients undergoing cesarean delivery (CD). METHODS: In this prospective cohort study, healthy term parturients (American Society of Anesthesiologists [ASA] ≤ 3, ≥37 weeks of gestation) with singleton pregnancy, body mass index (BMI) <40 kg/m2, and no history of congenital and acquired cardiac disease undergoing scheduled, elective CD were recruited by a trainee. After undergoing standardized training, including an 8-hour online E-learning module, a 1-day hands-on FCU course, and 20 to 30 supervised scans until the trainee was assessed competent in image acquisition, 8 trainees with limited FCU experience performed apical 4-chamber (A4CH), parasternal long-axis (PLAX), and short-axis (PSAX) view preoperatively after spinal anesthesia (SPA) and intraoperatively after neonatal delivery (ND). Obtained FCU images were graded 1 to 5 by 2 blinded instructors (1 = no image to 5 = perfect image obtainable; ≥3 defined as image quality sufficient for clinical decision-making). RESULTS: Following the screening of 95 women, 8 trainees with limited FCU experience each performed a median of 5 [3-8] FCUs in a total of 64 women. Images of sufficient quality were obtainable in 61 (95.3 %) and 57 (89.1 %) of women after SPA and ND, respectively. FCU images of perfect image quality were obtainable in 9 (14.1 %) and 7 (10.9 %) women preoperatively after SPA and intraoperatively after ND, respectively. A PLAX, PSAX, and A4CH view with grade ≥3 was obtained in 53 (82.8 %), 58 (90.6 %) and 40 (62.5 %) of women preoperatively after SPA and in 50 (78.1 %), 49 (76.6 %), and 29 (45.3 %) of women intraoperatively after ND. Left ventricular function could be assessed in 39 of 40 women (97.5 %) preoperatively after SPA and 39 of 40 (97.5%) intraoperatively after ND. Right ventricular function could be assessed in 31 of 40 (77.5 %) after SPA and in 23 of 40 (59%) after ND. We observed a difference in image grading between different trainees in the AP4CH-view (P = .0001). No difference in image grading was found between preoperative and intraoperative FCUs. CONCLUSIONS: FCU is feasible in the parturient undergoing CD and images of sufficient quality for clinical decision-making were obtained by trainees with limited experience in almost all parturients. Image acquisition and quality in the A4CH view may be impacted by the individual trainee performing the FCU.

Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action.

The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..

Critical care in obstetrics.

Leading causes of intensive care unit (ICU) admission include hemorrhage, hypertensive disorders of pregnancy, and sepsis. Although the incidence of ICU admission in pregnancy may be low, this does not account for critical illness in labor and delivery or maternity unit suites, which is as high as 1-3%. Most admissions, for example, to an ICU unit occur in the postpartum period, where studies have shown a range from 62 to 92% of admissions occurring during this period. A total of 60% of maternal deaths have been reported as preventable, with a delay in diagnosis and prompt medical treatment cited as primary factors, prompting for early recognition of high-risk obstetric patients. Recently, comorbidity-based screening tools, which quantify a patient's medical comorbidity burden, have been developed and validated in predicting ICU admission and death. Noninvasive ultrasonography such as point-of-care ultrasonography becomes essential in determining hemodynamic status, guides resuscitation, and manages cardiovascular dysfunction.

Causes of health inequities.

PURPOSE OF REVIEW: A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions. RECENT FINDINGS: Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death. SUMMARY: Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).

Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care.

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

Critical care in obstetrics: a strategy for addressing maternal mortality.

The acute rise in maternal morbidity and mortality in the United States is in part because of an increasingly medically complex obstetrical population. An estimated 1% to 3% of all obstetrical patients require intensive care, making timely delivery and availability of critical care imperative. The shifting landscape in obstetrical acuity places a burden on obstetrical providers, many of whom have limited experience in identifying and responding to critical illness. The levels of maternal care definitions by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine designate hospitals based on the availability of obstetrical resources and highlight the need for critical care resources and expertise. The growing need for critical care skills in the evolving contemporary obstetrical landscape serves as an opportunity to redefine the concept of delivery of care for high-risk obstetrical patients. We summarized the key tenets in the prevention of maternal morbidity and mortality, including the use of evidence-based tools for risk stratification and timely referral of patients to facilities with appropriate resources; innovative pathways for hospitals to provide critical care consultations on labor and delivery; and training of obstetrical providers in high-yield critical care skills, such as point-of-care ultrasonography. These critical care-focused interventions are key in addressing an increasingly complex obstetrical patient population while providing an educational foundation for the training of future obstetrical providers.

Key Population Health Outcomes for Children with Medical Complexity: A Systematic Review.

INTRODUCTION: Despite the significant healthcare policy and program implications, a summary measure of health for children with medical complexity (CMC) has not been identified. It is unclear whether existing population health approaches apply to CMC. We conducted a systematic review of the existing peer-reviewed research literature on CMC to describe the health outcomes currently measured for CMC. METHODS: We searched MEDLINE and PsycINFO by linking combinations of key words from three groups of concepts: (1) pediatric, (2) medical complexity, and (3) chronicity or severity. Study eligibility criteria were research studies including CMC with any outcome reported. Data on the outcomes were systematically extracted. Iterative content analysis organized outcomes into conceptual domains and sub-domains. RESULTS: Our search yielded 3853 articles. After exclusion criteria were applied, 517 articles remained for data extraction. Five distinct outcome domains and twenty-four sub-domains emerged. Specifically, 50% of the articles studied healthcare access and use; 43% family well-being; 39% child health and well-being; 38% healthcare quality; and 25% adaptive functioning. Notably lacking were articles examining routine child health promotion as well as child mental health and outcomes related to family functioning. CONCLUSIONS: Key health domains for CMC exist. Adaptations of existing sets of metrics and additional tools are needed to fully represent and measure population health for CMC. This approach may guide policies and programs to improve care for CMC.

Presencia de anticuerpos IgG antihelicobacter pylori en suero no se relaciona a factores de riesgo y síntomas de la enfermedad ácido-péptica en adultos jóvenes / Presence of anti-helicobacter pylori IgG antibodies in serum is not related to risk factors and symptoms of acid-peptic disease in young adults

Objetivo: determinar el valor diagnóstico de anticuerpos IgG anti-Helicobacter pylori ante sospecha clínica de enfermedad ácido-péptica en adultos jóvenes. Sujetos y métodos: estudiantes de la Carrera de Medicina de la Universidad Central del Ecuador que consintieron participar en una encuesta en línea y extracción de sangre venosa que fue sometida a una prueba inmunoenzimática para detección de anticuerpos. Resultados: se incluyeron 225 partícipes con un una edad promedio de 20 años; el estudio inmunoenzomático fue positivo en el 32,88% de muestras. La existencia de IgG anti-H. pylori no se relacionó estadísticamente a la presencia o ausencia de antecedentes patológicos personales, familiares o sociales. La acumulación de dos o tres síntomas no se relacionó con el hallazgo serológico. Conclusión: las pruebas serológicas para diagnóstico de gastritis o para tamizaje no son adecuadas para éste grupo de edad, toda vez que su positividad no se relaciona a síntomas, factores de riesgo conocidos de infección gástrica o desarrollo de patologías

Aims: to determine the diagnostic value of anti-Helicobacter pylori IgG antibodies in case of clinical suspicion of acid-peptic disease in young adults. Subjects and methods: students of the Medicine School of the Central University of Ecua- dor who agreed to participate in an online survey and venous blood collection that was sub- jected to an immunoenzymatic test for antibody detection. Results: 225 participants with an average age of 20 years were included; the immunoen- zomatic study was positive in 32.88% of samples. The existence of IgG anti H.pylori was not statistically related to the presence or absence of personal, family or social pathological his- tory. The accumulation of two or three symptoms was not related to the serological finding. Conclusion: serological tests for diagnosis of gastritis or screening are not suitable for this age group, since its positivity is not related to symptoms, known risk factors of gastric infec- tion or development of pathologies.

A school-based public health model to reduce oral health disparities.

OBJECTIVES: Although dental decay is preventable, it remains the most common pediatric chronic disease. We describe a public health approach to implementing a scalable and sustainable school-based oral health program for low-income urban children. METHODS: The Los Angeles Trust for Children's Health, a nonprofit affiliated with the Los Angeles Unified School District, applied a public health model and developed a broad-based community-coalition to a) establish a District Oral Health Nurse position to coordinate oral health services, and b) implement a universal school-based oral health screening and fluoride varnishing program, with referral to a dental home. Key informant interviews and focus groups informed program development. Parent surveys assessed preventative oral health behaviors and access to oral health services. Results from screening exams, program costs and rates of reimbursement were recorded. RESULTS: From 2012 to 2015, six elementary schools and three dental provider groups participated. Four hundred ninety-one parents received oral health education and 89 served as community oral health volunteers; 3,399 screenings and fluoride applications were performed on 2,776 children. Sixty-six percent of children had active dental disease, 27 percent had visible tooth decay, and 6 percent required emergent care. Of the 623 students who participated for two consecutive years, 56 percent had fewer or no visible caries at follow-up, while only 17 percent had additional disease. Annual program cost was $69.57 per child. CONCLUSIONS: Using a broad based, oral health coalition, a school-based universal screening and fluoride varnishing program can improve the oral health of children with a high burden of untreated dental diseases.

Experts' Perspectives Toward a Population Health Approach for Children With Medical Complexity.

OBJECTIVE: Because children with medical complexity (CMC) display very different health trajectories, needs, and resource utilization than other children, it is unclear how well traditional conceptions of population health apply to CMC. We sought to identify key health outcome domains for CMC as a step toward determining core health metrics for this distinct population of children. METHODS: We conducted and analyzed interviews with 23 diverse national experts on CMC to better understand population health for CMC. Interviewees included child and family advocates, health and social service providers, and research, health systems, and policy leaders. We performed thematic content analyses to identify emergent themes regarding population health for CMC. RESULTS: Overall, interviewees conveyed that defining and measuring population health for CMC is an achievable, worthwhile goal. Qualitative themes from interviews included: 1) CMC share unifying characteristics that could serve as the basis for population health outcomes; 2) optimal health for CMC is child specific and dynamic; 3) health of CMC is intertwined with health of families; 4) social determinants of health are especially important for CMC; and 5) measuring population health for CMC faces serious conceptual and logistical challenges. CONCLUSIONS: Experts have taken initial steps in defining the population health of CMC. Population health for CMC involves a dynamic concept of health that is attuned to individual, health-related goals for each child. We propose a framework that can guide the identification and development of population health metrics for CMC.

Managing Maternal Sepsis: Early Warning Criteria to ECMO.

Maternal sepsis is now a leading cause of direct maternal death during pregnancy. This review addresses the latest advances in the identification and management of critically ill parturients. Specifically, this review will focus on the vulnerability of pregnant women to sepsis, the utility of early warning criteria in the identification of the septic parturient, emphasize the immediate antibiotic management of suspected sepsis, and elaborate upon the latest understanding in the ventilatory management of parturients with sepsis.

Utilization of "Stand-By" Extracorporeal Membrane Oxygenation in a High-Risk Parturient With Methamphetamine-Associated Cardiomyopathy Undergoing Dilation and Evacuation: A Case Report.

Parturients may present with evidence of acute heart failure or respiratory distress during the peripartum period. This case report documents utilization of "stand-by" extracorporeal membrane oxygenation (ECMO) for a 40-year-old woman with a history of severe left ventricular dysfunction who presented for elective dilation and evacuation of triplets at 20 weeks' gestation. The patient's medical history was significant for hypertension, diabetes mellitus, methamphetamine use (acute/chronic), and cardiac-respiratory arrest before her previous emergent cesarean delivery. The patient underwent general anesthesia with the placement of peripheral venous and arterial cannulas for "stand-by" ECMO. The patient remained stable throughout the procedure, and "stand-by" ECMO was not initiated; the patient was discharged 5 days' postprocedure. The use of "stand-by" ECMO in the parturient with severe cardiopulmonary dysfunction is still in its infancy. Centers managing populations of both high-risk parturients and nonparturients may consider development of algorithms for implementation and utilization of ECMO.

Zika virus: review and obstetric anesthetic clinical considerations.

STUDY OBJECTIVES: To review the clinical and basic science literature regarding Zika viral illness and highlight relevant findings for obstetric anesthesiologists. This review provides a global review of Zika viral illness, transmission patterns, pathophysiology of disease, and anesthetic management of the parturient with Zika viral illness and associated comorbidities. DESIGN: Systematic review. SETTING: Large academic hospital. SUBJECTS: None. INTERVENTIONS: None. MEASUREMENTS: None. MAIN RESULTS: None. CONCLUSION: With the rapid spread of Zika virus and expected increase of spread in the summer of 2016, this review provides anesthesiologists with current recommendations, physiologic alterations, and anesthetic considerations in regard to the parturient with Zika viral illness and associated diseases.

Impella™ Left Ventricular Assist Device for Acute Peripartum Cardiomyopathy After Cesarean Delivery.

Peripartum cardiomyopathy is a rare form of heart failure with significant perioperative implications. In this case report, we describe a 34-year-old gravida 5, parity 3, patient who was admitted for an elective cesarean delivery. During the delivery, the patient developed sudden cardiac arrest and was emergently intubated in the operating room. An emergent transesophageal echocardiogram revealed a left ventricular ejection fraction of 10% with global biventricular hypokinesis. Urgent multidisciplinary consultations led to the rapid implementation of the Impella™ 2.5 for ventricular support. The patient recovered ventricular function within 4 days and recovered to baseline function.

Perioperative factors associated with HCAHPS responses of 2,758 surgical patients.

OBJECTIVE: To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey responses. DESIGN: Retrospective analysis. SETTING: Single tertiary care, academic, urban, level-1 trauma center. PARTICIPANTS: Final cohort represents 2,758 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS. EXPOSURES: Responses to four HCAHPS questions were compared against 19 perioperative treatments and events. MEASURES: Positive and negative responses to HCAHPS questions. RESULTS: Patients responding affirmatively with a "9" or "10" to "what number would you use to rate this hospital" were associated with decreased lengths of hospitalization, greater lengths of surgery, decreased intraoperative opioid equianalgesic doses, greater preoperative midazolam doses, shorter post anesthesia care unit (PACU) lengths of stay and decreased last PACU numerical rating scale (NRS) pain scores. Patients responding affirmatively with "yes, definitely" to "would you recommend this hospital to your family" were associated with decreased last PACU NRS pain scores. Patients responding affirmatively with "yes, always" to "How often did the hospital staff do everything to help with your pain" were associated with decreased hospital lengths of stay, decreased chronic benzodiazepine use, greater chronic NSAID use, and decreased PACU lengths of stay. Patients responding affirmatively with "yes, always" to "how often was your pain well controlled" were associated with decreased chronic opioid use, decreased chronic benzodiazepine use, greater chronic NSAID use, increased length of surgery, decreased last PACU NRS pain score, and decreased first PACU NRS pain scores. Subgroup analysis of patients undergoing different types of surgery further characterized factors associated with HCAHPS responses among different surgical populations. CONCLUSIONS: These data suggest that demographic factors, preadmission medications, and PACU pain scores but not analgesic medications are associated with patient satisfaction with regards to both pain management and overall satisfaction.

Estudio de la función diastólica y las alteraciones de la geometría cardiaca en pacientes hipertensos del Servicio de Cardiología del Hospital Nacional Daniel Alcides Carrión, mayo 2008 / Study of diastolic function and alterations of cardiac geometry in hypertensive patients from the cardiology department of the National Hospital Daniel Alcides Carrion, May 2008

Antecedentes. La hipertensión arterial es una causa de morbimortalidad cardiovascular, de remodelamiento de la aurícula izquierda y del ventrículo izquierdo y de alteración de la función diastólica. Objetivos. Caracterizar los parámetros ecocardiográficos de función diastólica y las alteraciones geométricas los pacientes hipertensos sometidos a un ecocardiograma transtorácico durante el mes de mayo de 2008 en el Servicio de Cardiología del Hospital Daniel Alcides Carrión. Material y métodos. Estudio observacional, descriptivo, transversal explicativo. Se incluyeron 36 pacientes hipertensos del Servicio de Cardiología del Hospital Daniel Alcides Carrión atendidos durante el mes de mayo de 2008. Todos fueron sometidos a un ecocardiograma Doppler color, para evaluar los parámetros diastólicos Doppler convencionales y por Doppler tisular. Resultados. Hubo 36 pacientes en el estudio. La edad promedio fue 69,2 + 8,4 años; tiempo de enfermedad promedio, 9,8 años; el 69,4%, de sexo femenino y el índice de masa corporal promedio, 28,7 + 5,6 kg/m2. Los pacientes tenían un índice de masa ventricular izquierda de 114,5 + 27,7 g/m2 y un grosor de pared relativo, de 0,5 + 0,1. El 72,2% tenía hipertrofia concéntrica del ventrículo izquierdo. El volumen indexado promedio de la aurícula izquierda fue de 41,2 + 14,7 cm3/m2. El Doppler tisular mostró una onda EÆ septal de 8,19 + 2,16 cm/s y una relación E/EÆ de 11,07 + 2,88. La prevalencia de disfunción diastólica fue 69,4%; la disfunción diastólica leve fue de 44,4% y la disfunción diastólica moderada, de 25%. La severidad de la disfunción diastólica se correlacionó significativamente con un mayor volumen de la aurícula izquierda (p = 0,007) y no hubo una correlación significativa con el índice de masa ventricular izquierda (p = 0,6). Conclusiones. Estos datos indican que la disfunción diastólica en los pacientes hipertensos es prevalente...

Competividad económica-ambiental para la cadena de lácteos de Bolivia

Las cadenas de lácteos de Cochabamba, Santa Cruz y La Paz se plasman mediante interrelaciones y vínculos entre los diferentes segmentos y actores que intervienen en ellas,Los actores, asi como los eslabonamientos, pueden tener un alcance municipal, provincial, nacional e internacional, es decir cruzan fronteras de diferentes ámbitos geográficos. Por otro lado, los diferentes procesoso económicos que se llevan a cabo en las cadenas de lácteos, se ven afectados por fuerzas provenientes de un segmento dominante de la cadena, que tiene connotaciones, entre otros, en la fijación de cantidades, precios, determinación de barreras de entrada-salida y la obtención de ganancias, de los segmentos ubicados hacia atrás y hacia adelante, a los que, por tanto influye en su organización y perspectivas de inversión

Teoría y práctica del enfoque cadenas globales de mercancías en América Latina

La globalización plantea la necesidad de comprender fenómenos económicos ligados a la configuración de nuevas vinculaciones entre empresas que transgredan la relación estricta del mercado. Al mismo tiempo que se está desarrollando una aumento en la interdependencia económica entre países, el acceso a las nuevas tecnologías, asi como a las cadenas de distribución y comercialización se van conviertiendo en elementos cruciales de la competividad

gestión economica - ambiental en las cadenas globales de mercancias en Bolivia

El análisis de mejoramiento orientado a nivel sectorial tiene como fuente principal la información proporcionada por las etapas de ACV( definición de la meta, análisis de inventario, clasificación y evalación), lo que demuestra que el ACV es una técnica que no solo permite mejorar el proceso productivo a nivel de las empresas, sino que tambien proporciona información para explorar, en pos de lograr una competitividad sostenible a partir de la incorporación del aspecto ambiental en la actividad económica del sector. En consecuencia el ACV se constituye en una técnica que permite tomar medidas que reduzcan los efectos negativos para el medio ambiente a lo largo de la cadena productiva, los cualea afectan la competitividad; es decir proporciona criterios para reforzar la contetividad, mas aun cuando un sector como el agroindustrial quesero costarricense entre preciones crecientes para internalizar las externalidades