Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient ...can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.
Purpose of review
The in-person preanesthesia visit serves multiple purposes including identification and optimization of comorbid conditions as well as patient education. However, it imposes a ...significant burden on patients and healthcare providers. In this review, we define the scope of telemedicine and present the most up-to-date literature supporting its role for the preanesthesia evaluation. The opportunities and challenges are discussed and approaches to implementation of telemedicine in preanesthesia care are offered. Finally, the future of telemedicine as it pertains to preanesthesia care is examined.
Recent findings
Although telemedicine for preanesthesia practice was proposed almost two decades ago, the COVID-19 pandemic has accelerated its implementation. The potential benefits of telemedicine include improved patient satisfaction as well as the ability to provide cost-effective specialty services while reducing the burden on healthcare providers. Limitations to telemedicine include lack of technology, training, regulatory barriers, and an inability to perform a physical exam.
Summary
Telemedicine will continue to expand and its application to the preanesthesia evaluation is a clear example of how technology will revolutionize anesthesia practice. In order for telemedicine to continue to expand in the postpandemic period, steps must be taken to ensure that healthcare facilities and providers keep up with the times.
Purpose
Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data ...from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation.
Methods
A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2–0.3 mg/kg,
n
= 400) or ketamine (1–2 mg/kg,
n
= 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival.
Results
Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference − 7.8, 95% confidence interval − 13, − 2.4,
p
= 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference − 2.7, 95% confidence interval − 9.3, 3.9,
p
= 0.294).
Conclusion
While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.
Listeria monocytogenes, a food-borne pathogen that infects immunocompromised patients, enters and proliferates within mammalian cells by taking advantage of host cell machinery. While entry into ...macrophages and other phagocytic cells occurs constitutively, intracellular invasion of nonphagocytic cells, such as epithelial and endothelial cells, occurs through induced phagocytosis. Invasion of these nonphagocytic cell types is under the control of the secreted L. monocytogenes protein internalin B (InlB), which directly associates with and activates the receptor tyrosine kinase Met. Activation of Met by InlB has previously been shown to be potentiated by binding of glycosaminoglycans to the GW domains of this protein. We studied the interaction between heparin and full-length InlB as well as a truncated, functional form of InlB to understand the mode of interaction between these two molecules. InlB preferred long-chain (≥dp14) heparin oligosaccharides, and the interaction with heparin fit a complicated binding model with a dissociation constant in the nanomolar range. While there are various explanations for this complicated binding model, one supported by our data involves binding and rebinding of InlB to multiple binding sites on heparin in a positive and weakly cooperative manner. This mode is consistent with enhancement of interaction of InlB with glycosaminoglycans for activation of Met.
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