Preprocedural fasting policies for patients receiving tube feeding: A national survey.

BACKGROUND: Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures. METHODS: The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated. RESULTS: The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed. CONCLUSIONS: Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

Perioperative Handoff Enhancement Opportunities Through Technology and Artificial Intelligence: A Narrative Review.

BACKGROUND: Perioperative handoffs occur as patients progress through preoperative, intraoperative, and postoperative phases of care. These may occur between clinicians from the same or different role groups, between different care units, for brief breaks during the course of a surgery, or at shift or service changes. Perioperative handoffs occur during a period of increased vulnerability, as teams must convey critical information at a time of high cognitive load, with many potential distractions. METHODS: A search of MEDLINE was conducted for biomedical literature pertaining to perioperative handoffs and technology, electronic tools, and artificial intelligence. The reference lists of identified articles were reviewed, and additional citations were included if relevant. These articles were abstracted to summarize the current literature, and to frame the opportunity for enhanced opportunities to improve perioperative handoffs through technology and artificial intelligence. RESULTS: Several efforts to date have incorporated electronic tools to improve perioperative handoffs but have been limited by imprecision in selecting handoff elements, increased task burden for clinicians, interrupted workflows, physical barriers, and lack of institutional support for their implementation. At the same time, artificial intelligence (AI) and machine learning (ML) are being applied across healthcare, but their use in and integration into handoff workflows have not yet been studied. Use of existing technology including mobile applications, barcode scanners, and radio-frequency identification (RFID) tags to advance perioperative safety has only begun and similarly has not been applied to handoffs. CONCLUSION: In this narrative review, we synthesize prior research on electronic tools for perioperative handoffs, limitations of current tools and barriers to their implementation, and the use of AI and ML in perioperative care. We then discuss potential opportunities to further integrate healthcare technologies and apply AI-derived solutions in the concept of a "smart handoff" with the aim of reducing harm from handoffs and improving patient safety.

Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review.

Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.

Gray & white matter tissue contrast differentiates Mild Cognitive Impairment converters from non-converters.

The clinical relevance of gray/white matter contrast ratio (GWR) in mild cognitive impairment (MCI) remains unknown. This study examined baseline GWR and 3-year follow-up diagnostic status in MCI. Alzheimer's Disease Neuroimaging Initiative MCI participants with baseline 1.5 T MRI and 3-year follow-up clinical data were included. Participants were categorized into two groups based on 3-year follow-up diagnoses: 1) non-converters (n = 69, 75 ± 7, 26 % female), and 2) converters (i.e., dementia at follow-up; n = 69, 75 ± 7, 30 % female) who were matched on baseline age and Mini-Mental State Examination scores. Groups were compared on FreeSurfer generated baseline GWR from structural images in which higher values represent greater tissue contrast. A general linear model, adjusting for APOE-status, scanner type, hippocampal volume, and cortical thickness, revealed that converters evidenced lower GWR values than non-converters (i.e., more degradation in tissue contrast; p = 0.03). Individuals with MCI who convert to dementia have lower baseline GWR values than individuals who remain diagnostically stable over a 3-year period, statistically independent of cortical thickness or hippocampal volume.

Adverse vascular risk is related to cognitive decline in older adults.

BACKGROUND: Cardiovascular disease (CVD) and related risk factors are associated with Alzheimer's disease (AD). This association is less well-defined in normal cognition (NC) or prodromal AD (mild cognitive impairment, MCI). OBJECTIVE: Cross-sectionally and longitudinally relate a vascular risk index to cognitive outcomes among elders free of clinical dementia. METHODS: 3,117 MCI (74 ± 8 years, 56% female) and 6,603 NC participants (72 ± 8 years, 68% female) were drawn from the National Alzheimer's Coordinating Center. A composite measure of vascular risk was defined using the Framingham Stroke Risk Profile (FSRP) score (i.e., age, systolic blood pressure, anti-hypertensive medication, diabetes, cigarette smoking, CVD history, atrial fibrillation). Ordinary linear regressions and generalized linear mixed models related baseline FSRP to cross-sectional and longitudinal cognitive outcomes, separately for NC and MCI, adjusting for age, gender, race, education, and follow-up time (in longitudinal models). RESULTS: In NC participants, increasing FSRP was related to worse baseline global cognition, information processing speed, and sequencing abilities (p-values <0.0001) and a worse longitudinal trajectory on all cognitive measures (p-values <0.0001). In MCI, increasing FSRP correlated with worse longitudinal delayed memory (p = 0.004). In secondary models using an age-excluded FSRP score, associations persisted in NC participants for global cognition, naming, information processing speed, and sequencing abilities. CONCLUSIONS: An adverse vascular risk profile is associated with worse cognitive trajectory, especially global cognition, naming, and information processing speed, among NC elders. Future studies are needed to understand how effective management of CVD and related risk factors can modify cognitive decline to identify the ideal timeframe for primary prevention implementation.