Metabolic support for patients on extra-corporeal membrane oxygenation.

PURPOSE OF REVIEW: The purpose of the review is to summarize recent research on metabolic support during extracorporeal membrane oxygenation. In this review, we cover the evidence on nutritional supplementation, both the route of supplementation, timing of initiation of supplementation as well as quantities of supplementation needed. In addition, we discuss the recent trend in awake extracorporeal membrane oxygenation (ECMO) and its benefits to patients. RECENT FINDINGS: As ECMO use continues to increase over the last few years, for both cardiovascular as well as respiratory failure, the need to optimize the metabolic states of patients has arisen. Increasing evidence has pointed towards this hitherto unexplored domain of patient care having a large impact on outcomes. Additionally, strategies such as awake ECMO for select patients has allowed them to preserve muscle mass which could aid in a faster recovery. SUMMARY: There is a role of optimal metabolic support in the early recovery of patients on ECMO that is currently under-recognized. Future directions of research that aim to improve post ECMO outcomes must focus on this area.

Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams.

PURPOSE: Despite increased clinician awareness of systemic racism, lack of substantial action toward antiracism exists within health care. Clinical staff perspectives, particularly those of racial-ethnic minorities/persons of color (POC) who disproportionately occupy support staff roles with less power on the team, can yield insights into barriers to progress and can inform future efforts to advance diversity, equity, and inclusion (DEI, also referred to as EDI) within health care settings. This qualitative study explored the perspectives of staff members on race and role power dynamics within community health clinic teams. METHODS: We conducted semistructured 45-minute interviews with staff members working in community health clinics in a large urban health care system from May to July 2021. We implemented purposeful recruitment to oversample POC and support staff and to achieve equal representation from the 13 community health clinics in the system. Interviews were audio recorded, transcribed, and analyzed over 6 months using a critical-ideological paradigm. Themes reflecting experiences related to race and role power dynamics were identified. RESULTS: Our cohort had 60 participants: 42 (70%) were support staff (medical assistants, front desk clerks, care navigators, nurses) and 18 (30%) were clinicians and clinic leaders. The large majority of participants were aged 26 to 40 years (60%), were female (83%), and were POC (68%). Five themes emerged: (1) POC face hidden challenges, (2) racial discrimination persists, (3) power dynamics perpetuate inaction, (4) interpersonal actions foster safety and equity, and (5) system-level change is needed for cultural shift. CONCLUSIONS: Understanding the race and role power dynamics within care teams, including experiences of staff members with less power, is critical to advancing DEI in health care.

Antithrombin during veno-venous extracorporeal membrane oxygenation with heparin anticoagulation: A single-center cohort study.

INTRODUCTION: Antithrombin (AT) is a natural anticoagulant essential to enhancing the unfractionated heparin (UFH) anticoagulant effect. Its supplementation in the management of UFH-based anticoagulation during veno-venous extracorporeal membrane oxygenation (VV ECMO) has a strong pathophysiological rationale. METHODS: This is a single-center, retrospective cohort study of adult VV ECMO patients with anticoagulation maintained by UFH targeting an activated partial thromboplastin time (aPTT) of 40-50 s and AT activity >80%. We compare anticoagulation management and survival outcomes between AT subpopulations, defined by a threshold AT activity ≥80%. Linear and logistic regression analyses were used to evaluate the variation in AT activity and its association with ICU survival. RESULTS: In 244 patients enrolled from 2009 to 2022, anticoagulation was maintained by a median heparin dose of 11.4 IU/kg/h [IQR: 8.2-14.7] with a mean aPTT of 46.1 s (±7.3) and AT activity of 88.9% (±17.0). A lower mean aPTT, higher dose of UFH and shorter fraction of time without UFH were associated with higher AT activity (p < .01). Higher AT activity showed a consistent association with ICU survival (for 10% increase of AT, odds ratio for ICU mortality: 0.95; 95% CI 0.93-0.97; p value <.01). CONCLUSIONS: There is a positive association between AT activity and UFH requirements but no significant difference in the rate of bleeding events. A higher mean AT during VV ECMO was associated with ICU survival. Future studies are needed to differentiate between exogenously supplemented versus endogenous AT effect.

Erector spinae plane block versus paravertebral block for postoperative pain management in thoracic surgery: a systematic review and meta-analysis.

INTRODUCTION: The 2018 guidelines for enhanced recovery in thoracic surgery recommend paravertebral block (PVB) for postoperative pain management. However, recent studies demonstrate that erector spinae plane block (ESPB) achieves similar postoperative pain control with reduced block-related complications. EVIDENCE ACQUISITION: We conducted a meta-analysis of randomized controlled trials to evaluate the analgesic efficacy and safety of ESPB versus PVB for pain management after thoracic surgery. PubMed, Embase, and Scopus were searched through December 2022 (PROSPERO registration - CRD42023395593). Primary outcomes were postoperative pain scores, resting at 6, 12, 24, and 48 hours, and at movement at 24 and 48 hours. Secondary outcomes included opioid consumption at 24 and 48 hours, and incidence of postoperative nausea and vomiting or block-related complications in the first 48 hours. EVIDENCE SYNTHESIS: Ten randomized control trials enrolling a total of 624 total patients were included. There were no significant differences in pain scores, resting or at movement, at any time points except reduced resting pain scores at 12 hours with PVB (mean difference [MD]) 0.60, 95% confidence interval [CI] 0.32 to 0.88). Opioid consumption demonstrated no significant differences at 24 hours; PVB reduced opioid consumption at 48 hours (MD 0.40, 95% CI -0.09 to 0.89). There were no significant differences in postoperative nausea or vomiting. ESPB exhibited a nonsignificant trend toward reduced cumulative block-related complications (risk difference [RD] 0.05, 95% CI -0.10 to 0.00). CONCLUSIONS: Compared with PVB, ESPB is safe and demonstrates no clinically significant differences in pain management after thoracic surgery.

Telemedicine in Patients Affected by Chronic Liver Disease: A Scoping Review of Clinical Outcomes and the Devices Evaluated.

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Measuring Performance on the ABCDEF Bundle During Interprofessional Rounds via a Nurse-Based Assessment Tool.

BACKGROUND: Nurse-led rounding checklists are a common strategy for facilitating evidence-based practice in the intensive care unit (ICU). To streamline checklist workflow, some ICUs have the nurse or another individual listen to the conversation and customize the checklist for each patient. Such customizations assume that individuals can reliably assess whether checklist items have been addressed. OBJECTIVE: To evaluate whether 1 critical care nurse can reliably assess checklist items on rounds. METHODS: Two nurses performed in-person observation of multidisciplinary ICU rounds. Using a standardized paper-based assessment tool, each nurse indicated whether 17 items related to the ABCDEF bundle were discussed during rounds. For each item, generalizability coefficients were used as a measure of reliability, with a single-rater value of 0.70 or greater considered sufficient to support its assessment by 1 nurse. RESULTS: The nurse observers assessed 118 patient discussions across 15 observation days. For 11 of 17 items (65%), the generalizability coefficient for a single rater met or exceeded the 0.70 threshold. The generalizability coefficients (95% CIs) of a single rater for key items were as follows: pain, 0.86 (0.74-0.97); delirium score, 0.74 (0.64-0.83); agitation score, 0.72 (0.33-1.00); spontaneous awakening trial, 0.67 (0.49-0.83); spontaneous breathing trial, 0.80 (0.70-0.89); mobility, 0.79 (0.69-0.87); and family (future/past) engagement, 0.82 (0.73-0.90). CONCLUSION: Using a paper-based assessment tool, a single trained critical care nurse can reliably assess the discussion of elements of the ABCDEF bundle during multidisciplinary rounds.

Coupling of acceptor-substituted diazo compounds and tertiary thioamides: synthesis of enamino carbonyl compounds and their pharmacological evaluation.

This paper describes the synthesis of enamino carbonyl compounds by the copper(i)-catalyzed coupling of acceptor-substituted diazo compounds and tertiary thioamides. We plan to use this method to synthesize indolizidine (-)-237D analogs to find α6-selective antismoking agents. Therefore, we also performed in silico α6-nAchRs binding studies of selected products. Compounds with low root-mean-square deviation values showed more favorable binding free energies. We also report preliminary pharmacokinetic data on indolizidine (-)-237D and found it to have weak activity at CYP3A4. In addition, as enamino carbonyl compounds are also known for antimicrobial properties, we screened previously reported and new enamino carbonyl compounds for antibacterial, antimicrobial, and antifungal properties. Eleven compounds showed significant antimicrobial activities.

Ruthenium catalyzed synthesis of enaminones.

The Grubbs first-generation catalyst has been found to be an effective catalyst for the synthesis of enaminones by coupling thioamides with α-diazodicarbonyl compounds. The reaction is successful in converting primary, secondary, and tertiary thioamides into their corresponding enaminones. The reaction is also suitable for the synthesis of chiral enaminones.