Face-to-face handoff: improving transfer to the pediatric intensive care unit after cardiac surgery.

The goal was to develop and implement a comprehensive, primarily face-to-face handoff process that begins in the operating room and concludes at the bedside in the intensive care unit (ICU) for pediatric patients undergoing congenital heart surgery. Involving all stakeholders in the planning phase, the framework of the handoff system encompassed a combination of a formalized handoff tool, focused process steps that occurred prior to patient arrival in the ICU, and an emphasis on face-to-face communication at the conclusion of the handoff. The final process was evaluated by the use of observer checklists to examine quality metrics and timing for all patients admitted to the ICU following cardiac surgery. The process was found to improve how various providers view the efficiency of handoff, the ease of asking questions at each step, and the overall capability to improve patient care regardless of overall surgical complexity.

Akt-mediated activation of HIF-1 in pulmonary vascular endothelial cells by S-nitrosoglutathione.

S-nitrosoglutathione (GSNO) stabilizes the alpha-subunit of hypoxia inducible factor-1 (HIF-1) in normoxic cells, but not in the presence of PI3K inhibitors. In this report, the biochemical pathway by which GSNO alters PI3K/Akt activity to modify HIF-1 expression was characterized in Cos cells and primary pulmonary vascular endothelial cells. GSNO increased Akt kinase activity--and downstream HIF-1alpha protein accumulation and DNA-binding activity--in a dose- and time-dependent manner. The PI3K inhibitors, wortmannin and LY294002, blocked these responses. Neither glutathione nor 8-bromo-cyclic GMP mimicked the GSNO-induced increases in Akt kinase activity. GSNO-induced Akt kinase activity and downstream HIF-1alpha stabilization were blocked by acivicin, an inhibitor of gamma-glutamyl transpeptidase (gammaGT), a transmembrane protein that can translate extracellular GSNO to intracellular S-nitrosocysteinylglycine. Dithiothreitol blocked GSNO-induced Akt kinase activity and HIF-1alpha stabilization. Moreover, the 3'-phosphatase of phosphoinositides, PTEN (phosphatase and tensin homolog deleted on chromosome ten) was S-nitrosylated by GSNO in pulmonary arterial endothelial cells, which was reversed by dithiothreitol and ultraviolet light. Interestingly, the abundance of S-nitrosylated PTEN also correlated inversely with PTEN activity. Taken together, these results suggest that GSNO induction of Akt appears to be mediated by S-nitrosylation chemistry rather than classic NO signaling through guanylate cyclase/cGMP. We speculate that gammaGT-dependent activation of Akt and subsequent activation of HIF-1 in vascular beds may be relevant to the regulation of HIF-1-dependent gene expression in conditions associated with oxyhemoglobin deoxygenation, as opposed to profoundly low Po(2), in the pulmonary vasculature.