Quality Improvement Projects and Anesthesiology Graduate Medical Education: A Systematic Review.

Quality improvement (QI) projects are essential components of graduate medical education and healthcare organizations to improve patient outcomes. We systematically reviewed the literature on QI projects in anesthesiology graduate medical education programs to assess whether these projects are leading to publications. A literature search was conducted in July 2023, using PubMed, Embase, and the Central Register of Controlled Trials (CENTRAL) for articles describing QI initiatives originating within the United States and applicable to anesthesiology residency training programs. The following data were collected: intervention(s), sample size (number of participants or events), outcome metric(s), result(s), and conclusion(s). One hundred and fifty publications were identified, and 31 articles met the inclusion criteria. A total of 2,259 residents and 72,889 events were included in this review. Educational modalities, such as simulation, training sessions, or online curricula, were the most prevalent interventions in the included studies. Pre-intervention and post-intervention assessments were the most common outcome metrics reported. Our review of the literature demonstrates that few QI projects performed within anesthesiology training programs lead to published manuscripts. Further research should aim at increasing the impact of required QI projects within the sponsoring institution and specialty.

Application of online to offline teaching mode in the training of non-anesthesiology residents in the department of anesthesiology: a randomized, controlled trial.

Objective: To explore the effect of applying the online to offline teaching mode in the training of non-anesthesiology residents in department of anesthesiology. Trial design: The randomized controlled trial was performed on non-anesthesiology residents from Affiliated Jiangning Hospital of Nanjing Medical University. Methods: All selected residents were randomly divided into the traditional teaching group (Group T) and the online to offline teaching group (Group O) by the random number table method. Traditional teaching mode was used in Group T, while the online to offline teaching mode was used in Group O. The training period lasted for two months. At the end of the training, theoretical and clinical skills were assessed for all residents, and students' satisfaction scores on teaching were investigated from the aspects of teaching mode, stimulating learning interest, improving learning process and teaching satisfaction. The teaching efficiency was compared and analyzed in the two groups. Results: In total, 39 cases in Group O and 38 cases in Group T were included in the statistical analysis. Compared with Group T, theory test scores, clinical skills test scores, and overall scores improved significantly in Group O (82.2 ± 8.1 vs. 91.3 ± 7.6; 85.1 ± 4.7 vs. 93.3 ± 5.4 and 83.4 ± 6.4 vs. 92.1 ± 6.7, respectively, p < 0.01). Compared with Group T, scores on teaching mode, stimulating learning interest, improving learning process and teaching satisfaction were higher in Group O (81.1 ± 6.9 vs. 93.7 ± 5.2; 83.6 ± 5.8 vs. 91.6 ± 6.4; 82.4 ± 5.3 vs. 90.9 ± 4.8 and 82.1 ± 5.9 vs. 92.1 ± 5.5, respectively, p < 0.01). Conclusion: The online to offline teaching mode can improve the level of professional theory and clinical skill operation, and teaching satisfaction of the non-anesthesiology residents in department of anesthesiology, thus improving the teaching effectiveness.

Intraoperative Dexamethasone is associated with a lower risk of respiratory failure in Thoracic Surgery: Observational cohort study (SURTHODEX).

BACKGROUND: Postoperative complications, particularly respiratory complications, are of significant clinical concern in patients undergoing elective thoracic surgery. Dexamethasone (DXM), commonly administered to prevent postoperative nausea and vomiting (PONV), has potential anti-inflammatory effects that might be beneficial in reducing these complications. We aimed to investigate whether intraoperative DXM administration could mitigate the occurrence of respiratory complications following elective thoracic surgery. METHODS: We conducted a single-center observational study, including patients who underwent elective thoracic surgery from 2012 to 2020. The primary outcome was the onset of acute respiratory failure within 7 days post-surgery. Secondary outcomes encompassed other postoperative complications, duration of hospital stay, and mortality within 30 days post-surgery. An overlap propensity score analysis was employed to estimate the treatment effect. RESULTS: We included 1,247 adult patients, 897 who received dexamethasone (DXM) and 350 who served as controls. Intraoperative dexamethasone administration was associated with a significant reduction in respiratory complications with an adjusted relative risk (RR) of 0.65 (95% CI: 0.43-0.97). There was also a significant decline in composite infectious criteria with an adjusted RR of 0.76 (95% CI: 0.63-0.93). Cardiac complications were also assessed as a composite criterion, and a significant reduction was observed (adjusted RR, 0.68; 95% CI, 0.51-0.9). However, there were no association with mechanical complications, mortality within 30 days (adjusted RR of 0.43, 95% CI: 0.17-1.09) or in the length of hospital stay (adjusted RR of 0.85, 95% CI: 0.71-1.02). CONCLUSIONS: Dexamethasone administration was associated with a reduction in postoperative respiratory complications. Further prospective studies are needed to confirm these findings.

EXPRESS: Propofol alleviates spinal cord ischemia-reperfusion injury by preserving PI3K/AKT/GIT1 axis.

Spinal cord ischemia-reperfusion injury (SCIRI) is a major contributor for neurological damage and mortality associated with spinal cord dysfunction. This study aims to explore the possible mechanism of Propofol and GIT1 in regulating SCIRI in rat models. SCIRI rat models were established and injected with Propofol, OE-GIT1 or PI3K inhibitor (LY294002). The neurological function was assessed using Tarlov scoring system and H&E staining was applied to observe morphology changes in spinal cord tissues. Cell apoptosis, blood-spinal cord barriers (BSCB) permeability and inflammatory cytokines were determined by TUNEL staining, EB staining and ELISA, respectively. RT-qPCR and western blot were used to detect the expression levels of GIT1, eNOS, PI3K/AKT signal pathway and apoptosis-related proteins. SCIRI rats had decreased expressions of GIT1 and PI3K/AKT-related proteins, whose expressions can be elevated in response to Propofol treatment. LY294002 can also decrease GIT1 expression level in SCIRI rats. Propofol can attenuate neurological dysfunction induced by SCIRI, decrease spinal cord tissue injury and BSCB permeability in addition to suppressing cell apoptosis and inflammatory cytokines, whereas further treatment by LY294002 can partially reverse the protective effect of Propofol on SCIRI. Propofol can activate PI3K/AKT signal pathway to increase GIT1 expression level, thus attenuating SCIRI in rat models.

Local Anesthetics, Local Anesthetic Systemic Toxicity (LAST), and Liposomal Bupivacaine.

Local anesthetics have played a vital role in the multimodal analgesia approach to patient care by decreasing the use of perioperative opioids, enhancing patient satisfaction, decreasing the incidence of postoperative nausea and vomiting, decreasing the length of hospital stay, and reducing the risk of chronic postsurgical pain. The opioid-reduced anesthetic management for perioperative analgesia has been largely successful with the use of local anesthetics during procedures such as peripheral nerve blocks and neuraxial analgesia. It is important that practitioners who use local anesthetics are aware of the risk factors, presentation, and management of local anesthetic systemic toxicity (LAST).

An Innovative Use of Point-of-Care Ultrasound for Identification and Management of a Rare and Uncommon Perioperative Complication: Periorbital Emphysema Following Sinus Surgery in a Pediatric Patient.

Periorbital emphysema is a rare complication following functional endoscopic sinus surgery (FESS) with potential sight-threatening consequences. We present a case of an eight-year-old male who developed periorbital emphysema after FESS for allergic fungal sinusitis. Prompt diagnosis was made using point-of-care ultrasound (POCUS), facilitating timely intervention and conservative management. This case underscores the importance of perioperative imaging to identify lamina papyracea abnormalities, smooth extubation to prevent complications, and the innovative use of POCUS in diagnosing perioperative orbital emphysema and managing it conservatively while examining the eye at regular intervals. These findings highlight the significance of vigilance during FESS procedures and the utility of POCUS in diagnosing and managing rare perioperative complications.

Ethical and practical considerations of pediatric refusal in clinical anesthesia: An educational review.

Children commonly refuse induction of anesthesia. Anesthesia providers must then decide whether to honor the child's dissent or to proceed over objection. In some circumstances, a forced induction involves restraining the child, incurring both practical and ethical harms to the patient-provider encounter. This educational review explores the practical dilemma encountered when a child dissents to induction of anesthesia. In the course of exploring this dilemma, dissent and associated terms are defined and compared, and the prominent ethical underpinnings regarding pediatric decision-making are described to clarify dissent as an ethical and practical concept. Important legal and professional standards are summarized, and practice trends are discussed to depict the current state of practice, including novel approaches to honoring pediatric dissent for elective surgeries. This information is then used to invite providers to consider where they ethically situate themselves within a legally and professionally defined space of acceptable practice. Finally, these considerations are synthesized to discuss important nuances regarding pediatric refusal, and some key questions are presented for clinicians to ponder as they consider their practice of choosing whether to honor pediatric dissent at induction.

The Year in Review: Anesthesia for Congenital Heart Disease 2023.

This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.

Abdominal Organ Transplantation: Noteworthy Literature in 2023.

This review highlights noteworthy literature published in 2023 and pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We feature 9 studies from 593 peer-reviewed papers on pancreatic transplantation, 3 from 194 on intestinal transplantation, and 28 from over 4513 on kidney transplantation. The liver transplantation section includes a special focus on 20 studies from 5666 clinical trial publications. We explore a broad range of topics, including donor management, perioperative recipient management, and innovative pharmacologic and mechanical interventions tested for the improvement of patient and graft outcomes and survival.

Anaesthesiologic Considerations for Intraoperative ECMO Anticoagulation During Lung Transplantation: A Single-Centre, Retrospective, Observational Study.

Background: Extracorporeal membrane oxygenation (ECMO) is frequently used during lung transplantation. Unfractionated heparin (UFH) is mainly used as part of ECMO support for anticoagulation. One of the most common perioperative complications is bleeding, which high-dose UFH can aggravate. Methods: We retrospectively analyzed (n = 141) patients who underwent lung transplantation between 2020 and 2022. All subjects (n = 109) underwent central cannulated VA ECMO with successful intraoperative ECMO weaning. Patients on ECMO bridge, postoperative ECMO, heart-lung transplants and transplants without ECMO were excluded. The dose of UFH for the entire surgical procedure, blood loss and consumption of blood derivatives intraoperatively and 48 h after ICU admission were recorded. Surgical revision for postoperative bleeding were analyzed. Thrombotic complications, mortality and long-term survival were evaluated. Results: Lower doses of UFH administered for intraoperative ECMO anticoagulation contribute to a reduction in intraoperative blood derivates consumption and blood loss with no thrombotic complications related to the patient or the ECMO circuit. Lower doses of UFH may lead to a decreased incidence of surgical revision for hemothorax. Conclusion: Lower doses of UFH as part of intraoperative ECMO anticoagulation might reduce the incidence of complications and lead to better postoperative outcomes.

Comprehensive overview of the anesthesiology research landscape: A machine Learning Analysis of 737 NIH-funded anesthesiology primary Investigator's publication trends.

Background: Anesthesiology plays a crucial role in perioperative care, critical care, and pain management, impacting patient experiences and clinical outcomes. However, our understanding of the anesthesiology research landscape is limited. Accordingly, we initiated a data-driven analysis through topic modeling to uncover research trends, enabling informed decision-making and fostering progress within the field. Methods: The easyPubMed R package was used to collect 32,300 PubMed abstracts spanning from 2000 to 2022. These abstracts were authored by 737 Anesthesiology Principal Investigators (PIs) who were recipients of National Institute of Health (NIH) funding from 2010 to 2022. Abstracts were preprocessed, vectorized, and analyzed with the state-of-the-art BERTopic algorithm to identify pillar topics and trending subtopics within anesthesiology research. Temporal trends were assessed using the Mann-Kendall test. Results: The publishing journals with most abstracts in this dataset were Anesthesia & Analgesia 1133, Anesthesiology 992, and Pain 671. Eight pillar topics were identified and categorized as basic or clinical sciences based on a hierarchical clustering analysis. Amongst the pillar topics, "Cells & Proteomics" had both the highest annual and total number of abstracts. Interestingly, there was an overall upward trend for all topics spanning the years 2000-2022. However, when focusing on the period from 2015 to 2022, topics "Cells & Proteomics" and "Pulmonology" exhibit a downward trajectory. Additionally, various subtopics were identified, with notable increasing trends in "Aneurysms", "Covid 19 Pandemic", and "Artificial intelligence & Machine Learning". Conclusion: Our work offers a comprehensive analysis of the anesthesiology research landscape by providing insights into pillar topics, and trending subtopics. These findings contribute to a better understanding of anesthesiology research and can guide future directions.

Peripheral Nerve Blockade for Open Inguinal Hernia Repair in a Patient With Severe Cardiopulmonary Disease.

Patients with severe cardiopulmonary morbidity present a unique challenge to peri- and intraoperative providers. Inducing general anesthesia in this patient population poses the risk of adverse events that could lead to poor surgical outcomes, prolonged debilitation, or death. Therefore, it is important that anesthesiologists become comfortable with preoperative evaluation as well as alternative strategies to providing surgical anesthesia. This case report details the clinical course of a patient with severe cardiopulmonary morbidity who underwent open inguinal hernia repair without oral or intravenous sedation after receiving multi-level paravertebral blocks in addition to isolated ilioinguinal and iliohypogastric nerve blocks. This medically challenging case provides educational value regarding preoperative evaluation, pertinent anatomy and innervation, and the importance of patient-centered care and communication.

Mortality rates in Norwegian HEMS-a retrospective analysis from Central Norway.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) provide rapid and specialized care to critically ill or injured patients. Norwegian HEMS in Central Norway serves an important role in pre-hospital emergency medical care. To grade the severity of patients, HEMS uses the National Advisory Committee for Aeronautics' (NACA) severity score. The objective of this study was to describe the short- and long term mortality overall and in each NACA-group for patients transported by HEMS Trondheim using linkage of HEMS and hospital data. METHODS: The study used a retrospective cohort design, aligning with the STROBE recommendations. Patient data from Trondheim HEMS between 01.01.2017 and 31.12.2019 was linked to mortality data from a hospital database and analyzed. Kaplan Meier plots and cumulative mortality rates were calculated for each NACA group at day one, day 30, and one year and three years after the incident. RESULTS: Trondheim HEMS responded to 2224 alarms in the included time period, with 1431 patients meeting inclusion criteria for the study. Overall mortality rates at respective time points were 10.1% at day one, 13.4% at 30 days, 18.5% at one year, and 22.3% at three years. The one-year cumulative mortality rates for each NACA group were as follows: 0% for NACA 1 and 2, 2.9% for NACA 3, 10.1% for NACA 4, 24.7% for NACA 5 and 49.5% for NACA 6. Statistical analysis with a global log-rank test indicated a significant difference in survival outcomes among the groups (p < 2⋅10- 16). CONCLUSION: Among patients transported by Trondheim HEMS, we observed an incremental rise in mortality rates with increasing NACA scores. The study further suggests that a one-year follow-up may be sufficient for future investigations into HEMS outcomes.

Perioperative Care of a Child With Hyperthyroidism.

In pediatric-aged patients, hyperthyroidism generally results from the autoimmune disorder, Graves' disease (GD). Excessive levels of thyroid hormones (triiodothyronine and thyroxine) result in irritability, emotional lability, nervousness, tremors, palpitations, tachycardia, and arrhythmias. The risk of morbidity and mortality is increased when surgical intervention is required in patients with hyperthyroidism due to the potential for the development of thyroid storm (TS). A 3-year, 1-month-old child with a past medical history of GD presented for total thyroidectomy when pharmacologic control with methimazole was not feasible due to intolerance following development of a serum sickness-like illness. Prior to surgery, his thyrotoxicosis symptoms worsened with fever, tachycardia, diaphoresis, and hypertension. He subsequently developed TS and was admitted to the pediatric intensive care unit where management included hydrocortisone, potassium iodide, and ß-adrenergic blockade with esmolol and propranolol. Thyroid studies improved prior to surgery, and a total thyroidectomy was successfully completed. Corticosteroid therapy was slowly tapered as an outpatient, and he was discharged home on hospital day 9. Following discharge, his signs and symptoms of thyrotoxicosis resolved, and he was started on oral levothyroxine replacement therapy. The remainder of his postoperative and post-discharge course were unremarkable. Only two case reports of perioperative pediatric TS have been published in the past 20 years. Our case serves as an important reminder of the signs of TS in children and to outline the treatment options in a pediatric patient, especially in those unable to tolerate first-line pharmacologic therapies such as methimazole or propylthiouracil.

Bridging the gap: understanding Belgian anesthesiologists' proficiency and training demands in gastric point-of-care ultrasound, a case-based survey.

BACKGROUND: Pulmonary aspiration syndrome remains a significant complication of general anesthesia, particularly in unfasted patients. Gastric point-of-care ultrasound (POCUS) allows for both qualitative and quantitative assessment of gastric content, providing a safe and reliable method to assess gastric emptying and reduce the risk of aspiration during general anesthesia. METHODS: The survey was distributed to Belgian certified anesthesiologists and trainees between April 2020 and June 2021. Participants received a simulated clinical case of a patient at risk of gastric aspiration, created and approved by two certified anesthesiologists trained to perform gastric POCUS. The objectives of this study were to assess recognition of high-risk clinical situations for gastric aspiration, awareness of the gastric POCUS and its indications, and knowledge of the technical and practical conditions of the procedure among respondents trained in the technique. Furthermore, the study assessed the state of training in gastric POCUS, the desire for education, and the practical availability of ultrasound equipment. The survey used conditional branching to ensure unbiased responses to POCUS-related questions. It included multiple-choice questions, quantitative variables, and 5-point Likert scales. The margin of error was calculated using Daniel's formula, corrected for a finite population. RESULTS: The survey was conducted among 323 anesthesiologists. Only 20.8% (27) recognized the risk of a full stomach based on the patient's history. Anesthesiologists who recognized the indication for gastric POCUS and were trained in the procedure demonstrated good recall of the practical conditions for performing the procedure and interpreting the results. Only 13.08% (31) of all respondents had received training in gastric POCUS, while 72.57% (172) expressed interest in future training. Furthermore, 80.17% (190) of participants had access to adequate ultrasound equipment and 78.90% (187) supported teaching gastric POCUS to anesthesia trainees. CONCLUSIONS: This survey offers insight into the epidemiology, clinical recognition, knowledge, and utilization of gastric POCUS among Belgian anesthesia professionals. The results emphasize the significance of proper equipment and training to ensure the safe and effective implementation of gastric POCUS in anesthesia practice. Additional efforts should focus on improving training and promoting the integration of gastric POCUS into daily clinical practice.

The modern anesthesiologist's manual: the development and maintenance of an anesthesia case reference application.

Anesthesia clinicians care for patients undergoing a wide range of procedures, making access to reliable references crucial. However, existing resources have key limitations. This technical report describes the development of an in-house anesthesia case reference application designed for use in a tertiary academic hospital. Additionally, it details our experiences in maintaining this system over a 22-month period and compares this system to alternative resources. Utilizing JavaScript and the React library, we developed a cross-platform perioperative reference application. Over fifty articles, encompassing anesthetic considerations for various surgical disciplines, have been created. Furthermore, we conducted a preliminary analysis of analytics data. In the 22 months since the application's inception, the application has garnered over 22,000 views from local users. While there are more than 150 registered users, the number of unregistered users accessing the application on the hospital network remains unknown. Notably, 70% of users accessed the application through a mobile device. The most popular articles centered around procedures with diverse and specific surgeon preferences. Currently, the reported case reference application is routinely utilized by anesthesia clinicians at our institution. Future endeavors will concentrate on establishing a robust content management workflow to broaden the coverage of topics.

The Development of Extensive Subcutaneous Emphysema Following Robotic Total Abdominal Colectomy Due to Lynch Syndrome: A Case Report.

Subcutaneous emphysema, the presence of air in the subcutaneous layer of the skin, is a possible result of surgical, infectious, or spontaneous etiologies. Although usually self-limiting, the development of subcutaneous emphysema in the perioperative period has been associated with delayed extubation and the development of complications such as pneumomediastinum, pneumoperitoneum, and pneumothorax and can worsen clinical outcomes in these patients. Here, we report the case of a 57-year-old male patient who presented to the operating room (OR) for a robotic total colectomy due to Lynch syndrome. The procedure was complicated by the development of diffuse, severe subcutaneous emphysema, which was recognized by palpable crepitus and obscuration of anatomical landmarks during an attempted transversus abdominis plane (TAP) block for pain control prior to patient extubation. The decision was made to leave the patient intubated and managed postoperatively in the ICU, where radiographic and computerized tomography (CT) scans confirmed the severity of subcutaneous emphysema. Hemodynamic and respiratory status were managed in the ICU and on postoperative day 3 the patient passed an endotracheal cuff leak test and was extubated. The patient was transferred to a surgical step-down on postoperative day 7 and following the resolution of ileus and acute kidney injury (AKI), he was discharged from the hospital on postoperative day 17.

Identifying Relevant Topics for Inclusion in an Ethics Curriculum for Anesthesiology Trainees: A Survey of Practitioners in the Field.

Anesthesiology training programs are tasked with equipping trainees with the skills to become medically and ethically competent in the practice of anesthesia and to be prepared to obtain board certification, yet there is currently no standardized ethics curriculum within anesthesia training programs in the United States. To bridge this gap, and to provide a validated ethics curriculum to meet the aforementioned needs, in July 2021, a survey was sent to anesthesia scholars in the field of biomedical ethics to identify key areas that should be included in such an ethics curriculum. The responses were rated on a Likert scale and ranked. This paper identifies the top ten topics identified as high priority for inclusion in an anesthesiology training program and consequently deemed most relevant to meet the educational needs of graduates of an anesthesiology residency: (1) capacity to consent; (2) capacity to refuse elective versus lifesaving treatment; (3) application of surrogate decisionmaking; (4) approach to do not resuscitate (DNR) status in the operating room; (5) patient autonomy and advance directives; (6) navigating patient beliefs that may impair care; (7) "futility" in end-of-life care: when to withdraw life support; (8) disclosure of medical errors; (9) clinical criteria for "brain death" and consequences of this definition; and (10) the impaired anesthesiologist.

Intraoperative Acute Cardiac Tamponade as a Result of Intracardiac Perforation Requiring Emergency Continuous Pericardiocentesis and Open Sternotomy: A Case Report and Literature Review of a Rare but Fatal Complication.

Intraoperative acute cardiac tamponade associated with iatrogenic intracardiac perforation from percutaneous interventional cardiac procedures is a rare but potentially catastrophic complication. We report a case of intraoperative acute hemopericardium caused by a left atrial (LA) perforation resulting in cardiac tamponade in a patient undergoing a baffling procedure for the correction of two anomalous pulmonary veins draining into her superior vena cava (SVC) that required continuous pericardiocentesis with autologous blood transfusion via the femoral vein and an emergency intraoperative transfer from the interventional cardiology cath lab to the cardiac operating room for an open sternotomy and primary repair. An 86-year-old female with known right-ventricular (RV) failure with preserved ejection fraction (left ventricular ejection fraction (LVEF): 50-55% on transesophageal echocardiography (TEE) one week prior) and atrial fibrillation was admitted for her third heat failure exacerbation in two months despite being adherent to her aggressive diuresis medication regimen. Upon her readmission and due to her symptomatic and seemingly refractory heart failure, the patient underwent a cardiac computer tomography (CT) with 3D reconstruction that showed previously undiagnosed partial anomalous pulmonary venous return (PAPVR) of two of her four pulmonary veins aberrantly draining into the SVC. This anatomic pathology was deemed to be the likely etiology of her repeated episodes of recurring heart failure exacerbations, shortness of breath, peripheral edema, and fatigue. The patient was counseled and consented to a percutaneous baffle of the two anomalous veins to redirect more of the returning pulmonary venous blood away from the SVC and to the LA. While under general endotracheal anesthesia (GETA) with a TEE in place during the procedure, the patient suddenly developed acute hypotension, tachycardia, and a reduction in expired carbon dioxide (EtCO2) was noted quickly followed by evidence of a rapidly accumulating hemopericardium on TEE. Cardiothoracic surgery was urgently consulted to the interventional cardiology cath lab while the patient underwent an emergency pericardiocentesis that momentarily alleviated her hemodynamic instability, cardiac tamponade physiology, and deteriorating overall clinical picture. While performing continuous pericardiocentesis with autologous return of the aspirated blood via femoral venous access the patient was urgently transported to the cardiac operating room and prepped for emergency sternotomy for primary repair of the LA. Following primary repair via sternotomy, multiple drains were placed and the thoracic cavity was closed with wires. The patient was immediately transported to the surgical intensive care unit (SICU) intubated, mechanically ventilated, and sedated. During this time, the patient progressively required additional vasoactive and inotropic agents to support her mean arterial pressure (MAP), and following a multidisciplinary discussion with the patient's family regarding her goals of care, the decision was made to withdraw further resuscitation efforts and the patient expired four hours later.