BACKGROUND:The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, ...introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training.
METHODS:For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data.
RESULTS:Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%.
CONCLUSIONS:Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.
Cardiac output (CO) monitoring based on pulse contour analysis (Vigileo-FloTrac) has the potential to be used for goal-directed fluid therapy in the perioperative setting. However, factors such as ...vasopressor usage may impact Vigileo-FloTrac's reliability in tracking CO changes. We tested third-generation Vigileo-FloTrac system's ability to accurately measure the changes in CO induced by vasopressor administration and increased preload in comparison with esophageal Doppler measurements.
In 33 anesthetized patients, CO was monitored simultaneously by the third-generation Vigileo-FloTrac and esophageal Doppler. Hemodynamic challenges included phenylephrine (to increase vasomotor tone), ephedrine (to increase myocardial contractility and heart rate), and whole-body tilting (to increase preload). Measurements were performed before and after each intervention.
Overall, 176 pairs of CO measurements were obtained. The difference between paired pulse contour and Doppler measurements of CO was 0.14 ± 2.13 L/min (mean ± SD), and the percentage error (2 SD of the difference divided by the mean CO of the reference method) was 66%. The trending ability of pulse contour versus Doppler was 23% (concordance, the percentage of the total number of data points that are in 1 of the 2 quadrants of agreement) after phenylephrine treatment, 69% (concordance) after ephedrine treatment, and 96% (concordance) after whole-body tilting.
The pulse contour method of measuring CO, as implemented in the third-generation Vigileo-FloTrac device, accurately tracks changes in CO when preload changes. However, the pulse contour method does not accurately track changes in CO induced with phenylephrine and ephedrine.
To evaluate if using regional anesthesia for post-operative pain control for patients who underwent ankle ORIF is associated with a decrease in length of stay.
Multicenter retrospective cohort study.
...Inpatient perioperative.
12,468 inpatients (2007 to 2016) who received ankle ORIF with and without regional anesthesia for pain control.
Regional Anesthesia for postoperative pain control.
Hospital length of stay along with multiple covariates.
The median quartiles hospital length of stay of the non-regional anesthesia and regional anesthesia cohorts were 1 day 0, 2 days and 0 days 0, 1 day, respectively (p < 0.0001). On multivariable Cox regression analysis, the use of regional anesthesia was associated with decreased time to hospital discharge (HR 1.09, 95% CI 1.03–1.14, p = 0.002). Using 1:2 propensity score matching, the median quartiles hospital length of stay between the non-regional anesthesia and regional anesthesia matched cohorts were 0 days 0, 1 day (range = 0–56 days) and 0 day 0, 1 day (range = 0–33 days), respectively (p = 0.013).
The use of regional anesthesia for post-operative pain control was associated with a decreased length of stay for patients undergoing ankle ORIF.
•Ankle ORIF can be a very painful procedure frequently requiring hospital admission.•Using regional anesthesia for postoperative pain control is still rarely used.•Decreased length of stay is associated with the use of regional anesthesia for ankle ORIF.•Popliteal sciatic peripheral nerve block may help decrease length of stay.
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Abstract
Background
The potential benefit of regional interventions for simple lumpectomy breast cancer surgeries has not been well investigated. Understanding which patients to
not
offer a regional ...intervention to can be just as important as knowing which would benefit. It is unclear whether fascial plane blocks, such as serratus anterior plane (SAP) block, should be routinely performed for less extensive breast surgeries. Therefore, our goal in this retrospective cohort study was to evaluate the association of integrating SAP blocks into a standard perioperative multimodal analgesia plan in patients undergoing simple lumpectomies (without node biopsies) with perioperative opioid consumption. As secondary outcomes, we also analyzed postoperative pain scores and post-anesthesia care unit (PACU) length of stay.
Methods
This was a single institution retrospective cohort study (surgical site infiltration only versus SAP block cohorts) assessing the association of SAP blocks to our outcomes of interest. In the adjusted analysis, we created matched cohorts using 1:1 (surgical site infiltration only: SAP block) propensity-score matching using nearest neighbor-matching without replacement. To compare the primary and secondary outcomes in the matched cohorts, we used the Wilcoxon signed rank test. A
P
-value of < 0.05 was considered statistically significant.
Results
There were 419 patients included in the analysis, in which 116 (27.7%) received a SAP block preoperatively in addition to our standard perioperative analgesia plan. In an unadjusted analysis, no differences were seen in perioperative opioid consumption, PACU pain scores, and PACU length of stay. Among the matched cohorts, the median quartile perioperative opioid consumption in the surgical site infiltration only versus SAP block cohorts were 10 mg 10, 13.25 mg and 10 mg 7, 15 mg, respectively (
P
= 0.16). No differences were seen in the other outcomes.
Conclusions
In this study, we evaluated the impact of SAP blocks on patients undergoing simple lumpectomies, which are relatively less involved breast surgeries. We concluded that routine use of preoperative regional anesthesia is not beneficial for these specific patients. Future studies should focus on identifying patients that would directly benefit from regional interventions.
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Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize ...intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate.
The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications.
The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.
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In patients undergoing high-risk surgery, it is recommended to titrate fluid administration using stroke volume or a dynamic variable of fluid responsiveness (FR). However, this strategy usually ...requires the use of a hemodynamic monitor and/or an arterial catheter. Recently, it has been shown that variations of central venous pressure (ΔCVP) during an alveolar recruitment maneuver (ARM) can predict FR and that there is a correlation between CVP and peripheral venous pressure (PVP). This prospective study tested the hypothesis that variations of PVP (ΔPVP) induced by an ARM could predict FR.
We studied 60 consecutive patients scheduled for high-risk abdominal surgery, excluding those with preoperative cardiac arrhythmias or right ventricular dysfunction. All patients had a peripheral venous catheter, a central venous catheter and a radial arterial catheter linked to a pulse contour monitoring device. PVP was always measured via an 18-gauge catheter inserted at the antecubital fossa. Then an ARM consisting of a standardized gas insufflation to reach a plateau of 30 cmH
O for 30 s was performed before skin incision. Invasive mean arterial pressure (MAP), pulse pressure, heart rate, CVP, PVP, pulse pressure variation (PPV), and stroke volume index (SVI) were recorded before ARM (T1), at the end of ARM (T2), before volume expansion (T3), and one minute after volume expansion (T4). Receiver-operating curves (ROC) analysis with the corresponding grey zone approach were performed to assess the ability of ∆PVP (index test) to predict FR, defined as an ≥ 10% increase in SVI following the administration of a 4 ml/kg balanced crystalloid solution over 5 min.
∆PVP during ARM predicted FR with an area under the ROC curve of 0.76 (95%CI, 0.63 to 0.86). The optimal threshold determined by the Youden Index was a ∆PVP value of 5 mmHg (95%CI, 4 to 6) with a sensitivity of 66% (95%CI, 47 to 81) and a specificity of 82% (95%CI, 63 to 94). The AUC's for predicting FR were not different between ΔPVP, ΔCVP, and PPV.
During high-risk abdominal surgery, ∆PVP induced by an ARM can moderately predict FR. Nevertheless, other hemodynamic variables did not perform better.
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Mobile health diagnostics have demonstrated effectiveness in detecting and managing chronic diseases. This method comparison study aims to assess the accuracy and precision of the previously ...evaluated OptiBP™ technology over a four-week study period. This device uses optical signals recorded by placing a patient's fingertip on a smartphone's camera to estimate blood pressure (BP).
In adult participants without cardiac arrhythmias and minimal interarm blood pressure difference (systolic arterial pressure (SAP) < 15 mmHg or diastolic arterial pressure (DAP) < 10 mmHg), three pairs of 30 s BP measurements with the OptiBP™ (test method) were simultaneously compared using three pairs of measurements with the non-invasive oscillometric brachial cuff (reference method) on the opposite arm over a period of four consecutive weeks at a rate of two measurements per week (one in the morning and one in the afternoon). The agreement of BP values between the two technologies was analyzed using Bland-Altman and error grid analyses. The performance of the smartphone application was investigated using the International Organization for Standardization (ISO) definitions, which require the bias ± standard deviation (SD) between two technologies to be lower than 5 ± 8 mmHg.
Among the 65 eligible volunteers, 53 participants had adequate OptiBP™ BP values. In 12 patients, no OptiBP™ BP could be measured due to inadequate signals. Only nine participants had known chronic arterial hypertension and 76% of those patients were treated. The mean bias ± SD between both technologies was -1.4 mmHg ± 10.1 mmHg for systolic arterial pressure (SAP), 0.2 mmHg ± 6.5 mmHg for diastolic arterial pressure (DAP) and -0.5 mmHg ± 6.9 mmHg for mean arterial pressure (MAP). Error grid analyses indicated that 100% of the pairs of BP measurements were located in zones A (no risk) and B (low risk).
In a cohort of volunteers, we observed an acceptable agreement between BP values obtained with the OptiBP
and those obtained with the reference method over a four-week period. The OptiBP
fulfills the ISO standards for MAP and DAP (but not SAP). The error grid analyses showed that 100% measurements were located in risk zones A and B. Despite the need for some technological improvements, this application may become an important tool to measure BP in the future.
Acute kidney injury (AKI) occurs frequently after liver transplant surgery and is associated with significant morbidity and mortality. While the impact of intraoperative hypotension (IOH) on ...postoperative AKI has been well demonstrated in patients undergoing a wide variety of non-cardiac surgeries, it remains poorly studied in liver transplant surgery. We tested the hypothesis that IOH is associated with AKI following liver transplant surgery.
This historical cohort study included all patients who underwent liver transplant surgery between 2014 and 2019 except those with a preoperative creatinine > 1.5 mg/dl and/or who had combined transplantation surgery. IOH was defined as any mean arterial pressure (MAP) < 65 mmHg and was classified according to the percentage of case time during which the MAP was < 65 mmHg into three groups, based on the interquartile range of the study cohort: "short" (Quartile 1, < 8.6% of case time), "intermediate" (Quartiles 2-3, 8.6-39.5%) and "long" (Quartile 4, > 39.5%) duration. AKI stages were classified according to a "modified" "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. Logistic regression modelling was conducted to assess the association between IOH and postoperative AKI. The model was run both as a univariate and with multiple perioperative covariates to test for robustness to confounders.
Of the 205 patients who met our inclusion criteria, 117 (57.1%) developed AKI. Fifty-two (25%), 102 (50%) and 51 (25%) patients had short, intermediate and long duration of IOH respectively. In multivariate analysis, IOH was independently associated with an increased risk of AKI (adjusted odds ratio OR 1.05; 95%CI 1.02-1.09; P < 0.001). Compared to "short duration" of IOH, "intermediate duration" was associated with a 10-fold increased risk of developing AKI (OR 9.7; 95%CI 4.1-22.7; P < 0.001). "Long duration" was associated with an even greater risk of AKI compared to "short duration" (OR 34.6; 95%CI 11.5-108.6; P < 0.001).
Intraoperative hypotension is independently associated with the development of AKI after liver transplant surgery. The longer the MAP is < 65 mmHg, the higher the risk the patient will develop AKI in the immediate postoperative period, and the greater the likely severity. Anesthesiologists and surgeons must therefore make every effort to avoid IOH during surgery.
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