Handheld Point-of-Care Ultrasound: Safety Considerations for Creating Guidelines.

BACKGROUND: Compared to traditional ultrasound machines, emerging handheld point-of-care-ultrasound (HPOCUS) systems exhibit superior portability and affordability. Thus, they have been increasingly embraced in the intensive care setting. However, there is scarce data on patient safety and current regulatory body guidelines are lacking. Here, we critically appraise the literature with a focus on the merits, concerns, and framework of existing POCUS guidelines. Subsequently, we provide recommendations for future regulatory guidelines. METHODS: A comprehensive literature review was conducted using the PubMed database employing the key words "point-of-care/handheld/portable ultrasound" and "guidelines" alone, in combination, and using thesaurus terms. Eligible articles were scrutinized for description of potential benefits and concerns of HPOCUS, especially from a patient safety perspective, as well as currently existing POCUS practice guidelines. Data was extracted, reported thematically using a narrative synthesis approach, then subsequently used to guide our proposed guidelines. RESULTS: The most widely reported benefits of HPOCUS include superior portability, affordability, imaging, facilitation of expedited diagnosis and management, and integration with medical workplace flow. However, major barriers to adoption include device security/patient confidentiality and patient safety. Furthermore, except for a policy published by the American College of Emergency Physicians (ACEP) in 2018, there are few other national regulatory guidelines pertaining to handheld POCUS. In light of this, we propose a framework for HPOCUS guideline development to address these and other concerns. Such guidelines include training and credentialing, bioengineering approval, and strategic integration with electronic medical record systems. CONCLUSION: HPOCUS can be a powerful tool for expedited diagnosis and management guidance. However, there is limited data regarding patient safety and current regulatory body guidelines are lacking. Our assessment illuminates that there remain many unsolved problems about HPOCUS, and in turn, we propose guidelines to address safe regulation and implementation.

The Silent Threat of Hypokalemia after High Voltage Electrical Injuries: A Case Study and Review of the Literature.

High-voltage electrical injuries, especially from lightning strikes, can cause life-threatening complications due to extreme temperature and voltage exposure. While burns and cardiac complications have been widely described, the documentation of metabolic imbalances, particularly hypokalemia, has not been as prevalent. This report focuses on a patient with profound transient hypokalemia following a lightning strike, alongside a review of three similar cases of transient hypokalemia from the literature. Our patient, a previously healthy young man, was struck by lightning and subsequently suffered transient hypokalemia with lower extremity sensory changes, which resolved after the normalization of serum potassium levels. While the exact underlying mechanisms of transient hypokalemia following high-voltage electrical injuries are unknown, we propose a multifactorial mechanism, which includes massive intracellular shifts of potassium due to elevated epinephrine levels and the prevention of potassium efflux through the electrical disruption of voltage-gated potassium channels. Our report underscores the importance of recognizing hypokalemia in patients with high-voltage electrical injuries and contributes to the understanding of the complex mechanisms involved. Further research is necessary to understand the connection between cellular changes induced by high-voltage exposure and their effects on metabolism, particularly in relation to hypokalemia.

Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review.

Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.

Preoperative Carbohydrate Load Does Not Alter Glycemic Variability in Diabetic and Non-Diabetic Patients Undergoing Major Gynecological Surgery: A Retrospective Study.

Background/Objectives: Elevated glycemic variability (GV) has been associated with postoperative morbidity. Traditional preoperative fasting guidelines may contribute to high GV by driving the body into catabolism. Enhanced recovery after surgery (ERAS) protocols that include a preoperative carbohydrate load (PCL) reduce hospital length of stay and healthcare costs; however, it remains unclear whether PCL improves GV in surgical patients. The aim of this retrospective study was to determine the effect of a PCL on postoperative GV in diabetic and non-diabetic patients having gynecological surgery. Methods: Retrospective data were collected on patients who had gynecological surgery before and after the rollout of an institutional ERAS protocol that included PCL ingestion. The intervention group included patients who underwent surgery in 2019 and were enrolled in the ERAS protocol and, therefore, received a PCL. The control group included patients who underwent surgery in 2016 and, thus, were not enrolled in the protocol. The primary endpoint was GV, calculated by the coefficient of variance (CV) and glycemic lability index (GLI). Results: A total of 63 patients in the intervention group and 45 in the control were analyzed. GV was not statistically significant between the groups for CV (19.3% vs. 18.6%, p = 0.65) or GLI (0.58 vs. 0.54, p = 0.86). Postoperative pain scores (4.5 vs. 5.2 p = 0.23) and incentive spirometry measurements (1262 vs. 1245 p = 0.87) were not significantly different. A subgroup analysis of patients with and without type 2 diabetes mellitus revealed no significant differences in GV for any of the subgroups. Conclusions: This retrospective review highlights the need for additional GV research, including consensus agreement on a gold standard GV measurement. Large-scale prospective studies are needed to test the effectiveness of the PCL in reducing GV.

Overcoming Barriers: A Comprehensive Review of Chronic Pain Management and Accessibility Challenges in Rural America.

In the United States (U.S.), chronic pain poses substantial challenges in rural areas where access to effective pain management can be limited. Our literature review examines chronic pain management in rural U.S. settings, identifying key issues and disparities. A comprehensive search of PubMed, Web of Science, and Google Scholar identified high-quality studies published between 2000 and 2024 on chronic pain management in the rural U.S. Data were categorized into thematic areas, including epidemiology, management challenges, current strategies, research gaps, and future directions. Key findings reveal that rural populations have a significantly higher prevalence of chronic pain and are more likely to experience severe pain. Economic and systemic barriers include a shortage of pain specialists, limited access to nonpharmacologic treatments, and inadequate insurance coverage. Rural patients are also less likely to engage in beneficial modalities like physical therapy and psychological support due to geographic isolation. Additionally, rural healthcare providers more often fulfill multiple medical roles, leading to burnout and decreased quality of care. Innovative approaches such as telehealth and integrated care models show the potential to improve access and outcomes. Our review highlights the need for increased telehealth utilization, enhanced provider education, and targeted interventions to address the specific pain needs of rural populations.

Bibliometric Indices As Indicators of Research Output: Analyzing Anesthesiologists as a Paradigm for Surgical Disciplines.

Anesthesiology is one of the increasingly competitive surgical specialties with a growing emphasis on scholarly activity. A metric of productivity and citation influence, the Hirsch index (h-index), can help identify mentors capable of guiding postgraduate trainees toward successful academic achievements. This study sought to determine associations between h-indices or m-quotients and manuscript publication in anesthesiology. Using the American Society of Anesthesiologists (ASA) website, accepted abstracts from the ASA Annual Meetings from 2019 to 2021 were screened (n=2146). The first author (FAHi) and senior author (SAHi) h-indices, as well as the first author (FAMq) and senior author (SAMq) m-quotients, were collected for each abstract using the Scopus database. Whether an accepted abstract was subsequently published as a manuscript in a peer-reviewed journal was also noted, along with the number of days between ASA presentation and publication date. Linear and logistic regression models were used for statistical analyses. In total, 348 (34.4%) of the 1012 eligible abstracts were published as manuscripts. Mean FAHi, SAHi, FAMq, and SAMq, were significantly higher for accepted ASA abstracts that were later published in peer-reviewed journals compared to accepted abstracts that were not published (p<0.001). FAHi, SAHi, FAMq, and SAMq had significant positive associations with odds of publication (p=0.002; p<0.001; p=0.006; p<0.001, respectively). There was no statistical significance between FAHi, SAHi, FAMq, or SAMq and the number of days between ASA presentation and publication. Our study uniquely demonstrates the positive, direct association between h-indices and m-quotients with the probability of publication in anesthesiology. We propose that bibliometric indices are adapted to provide a refined perspective of a physician-scientist's capabilities. Postgraduate trainees can use these indices to discern research mentors primed to foster academic excellence.

Propofol-Based Anesthesia Maintenance and/or Volatile Anesthetics during Intracranial Aneurysm Repair: A Comparative Analysis of Neurological Outcomes.

BACKGROUND: Volatile and intravenous anesthetics have substantial effects on physiological functions, notably influencing neurological function and susceptibility to injury. Despite the importance of the anesthetic approach, data on its relative risks or benefits during surgical clipping or endovascular treatments for unruptured intracranial aneurysms (UIAs) remains scant. We investigated whether using volatile anesthetics alone or in combination with propofol infusion yields superior neurological outcomes following UIA obliteration. METHODS: We retrospectively reviewed 1001 patients who underwent open or endovascular treatment for UIA, of whom 596 had short- and long-term neurological outcome data (modified Rankin Scale) recorded. Multivariable ordinal regression analysis was performed to examine the association between the anesthetic approach and outcomes. RESULTS: Of 1001 patients, 765 received volatile anesthetics alone, while 236 received propofol infusion and volatile anesthetics (combined anesthetic group). Short-term neurological outcome data were available for 619 patients and long-term data for 596. No significant correlation was found between the anesthetic approach and neurologic outcomes, irrespective of the type of procedure (open craniotomy or endovascular treatment). The combined anesthetic group had a higher rate of ICU admission (p < 0.001) and longer ICU and hospital length of stay (LOS, p < 0.001). Similarly, a subgroup analysis revealed longer ICU and hospital LOS (p < 0.0001 and p < 0.001, respectively) in patients who underwent endovascular UIA obliteration under a combined anesthetic approach (n = 678). CONCLUSIONS: The addition of propofol to volatile anesthetics during UIA obliteration does not provide short- or long-term benefits to neurologic outcomes. Compared to volatile anesthetics alone, the combination of propofol and volatile anesthetics may be associated with an increased rate of ICU admission, as well as longer ICU and hospital LOS.