Practitioner dashboard feedback improves glycemic but not temperature compliance during cardiac surgery: A single center retrospective analysis.

STUDY OBJECTIVE: To determine the association of practitioner dashboard feedback of intraoperative glycemic and temperature control on maintenance of normoglycemia and normothermia. DESIGN: Retrospective review. SETTING: Single tertiary care institution. PATIENTS: Patients over the age of 18 undergoing cardiac surgery from February 17, 2021 through February 16, 2023. During the study interval, 15 anesthesiologists providing care during 2255 procedures were analyzed: 1114 prior to the individual faculty dashboard distribution and 1141 after commencement of dashboard distribution. INTERVENTIONS: On February 17, 2022, anesthesia faculty members began receiving monthly individualized dashboards indicating their personal intraoperative glycemic and temperature compliance rates. MEASUREMENTS: Baseline patient demographic characteristics, surgical and cardiopulmonary bypass times, perioperative temperature and glucose concentrations, and the incidence of sternal wound infections. Glycemic compliance was defined as final serum glucose between 80 and 180 mg/dL. Temperature compliance was defined as an average temperature during the final 30 min of the surgical procedure between 35 and 37.3 °C inclusive. MAIN RESULTS: Dashboard distribution was associated with a significant decrease in the average glucose concentration (median location shift by -6 mg% (95% confidence interval (CI) -8, -4), p < 0.001) from 157 mg/dL to 152 mg/dL and final glucose concentration (median location shift by -17 mg/dL (95% CI -19, -14, p < 0.001) from 161 mg/dL to 145 mg/dL. The intervention was associated with an improvement in glycemic compliance from 71.4% to 87.1% (odds ratio (OR): 2.71(95% CI 2.19, 3.37, p < 0.001)). There were no significant differences in final temperature (36.3 °C [Q1, Q3: 36.0, 36.6] vs. 36.3 °C [Q1, Q3: 36.0, 36.7] (p = 0.232)) with the intervention nor were there any statistically significant differences in temperature compliance (93.9% vs. 92.9%, OR: 0.79 (95% CI 0.55-1.14, p = 0.25). There were no statistically significant changes in the incidence of superficial, deep, or any wound infections with the intervention. CONCLUSIONS: Individualized practitioner dashboard distribution may be an effective tool to increase intraoperative glycemic control.

A Web-Based Reporting System for Reviewing Local Practice Patterns of Anesthesiologists Derived from the Electronic Medical Record.

After completion of training, anesthesiologists may have fewer opportunities to see how colleagues practice, and their breadth of case experiences may also diminish due to specialization. We created a web-based reporting system based on data extracted from electronic anesthesia records that allows practitioners to see how other clinicians practice in similar cases. One year after implementation, the system continues to be utilized by clinicians.

Liver-specific FGFR4 knockdown in mice on an HFD increases bile acid synthesis and improves hepatic steatosis.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease with increased risk in patients with metabolic syndrome. There are no FDA-approved treatments, but FXR agonists have shown promising results in clinical studies for NAFLD management. In addition to FXR, fibroblast growth factor receptor FGFR4 is a key mediator of hepatic bile acid synthesis. Using N-acetylgalactosamine-conjugated siRNA, we knocked down FGFR4 specifically in the liver of mice on chow or high-fat diet and in mouse primary hepatocytes to determine the role of FGFR4 in metabolic processes and hepatic steatosis. Liver-specific FGFR4 silencing increased bile acid production and lowered serum cholesterol. Additionally, we found that high-fat diet-induced liver steatosis and insulin resistance improved following FGFR4 knockdown. These improvements were associated with activation of the FXR-FGF15 axis in intestinal cells, but not in hepatocytes. We conclude that targeting FGFR4 in the liver to activate the intestinal FXR-FGF15 axis may be a promising strategy for the treatment of NAFLD and metabolic dysfunction.

Visual Analytics to Leverage Anesthesia Electronic Health Record.

BACKGROUND: Visual analytics is the science of analytical reasoning supported by interactive visual interfaces called dashboards. In this report, we describe our experience addressing the challenges in visual analytics of anesthesia electronic health record (EHR) data using a commercially available business intelligence (BI) platform. As a primary outcome, we discuss some performance metrics of the dashboards, and as a secondary outcome, we outline some operational enhancements and financial savings associated with deploying the dashboards. METHODS: Data were transferred from the EHR to our departmental servers using several parallel processes. A custom structured query language (SQL) query was written to extract the relevant data fields and to clean the data. Tableau was used to design multiple dashboards for clinical operation, performance improvement, and business management. RESULTS: Before deployment of the dashboards, detailed case counts and attributions were available for the operating rooms (ORs) from perioperative services; however, the same level of detail was not available for non-OR locations. Deployment of the yearly case count dashboards provided near-real-time case count information from both central and non-OR locations among multiple campuses, which was not previously available. The visual presentation of monthly data for each year allowed us to recognize seasonality in case volumes and adjust our supply chain to prevent shortages. The dashboards highlighted the systemwide volume of cases in our endoscopy suites, which allowed us to target these supplies for pricing negotiations, with an estimated annual cost savings of $250,000. Our central venous pressure (CVP) dashboard enabled us to provide individual practitioner feedback, thus increasing our monthly CVP checklist compliance from approximately 92% to 99%. CONCLUSIONS: The customization and visualization of EHR data are both possible and worthwhile for the leveraging of information into easily comprehensible and actionable data for the improvement of health care provision and practice management. Limitations inherent to EHR data presentation make this customization necessary, and continued open access to the underlying data set is essential.

Near-infrared spectroscopy in vegetables and humans: An observational study.

BACKGROUND: Cerebral near-infrared spectroscopy (NIRS) of tissue oxygen saturation is claimed to be a surrogate marker for global cerebral perfusion. Increasingly, NIRS target-based therapy has been used during cardiac surgery in the hope of decreasing the incidence of adverse neurological outcome. OBJECTIVES: We report NIRS values for some common vegetables and faculty at a world-class medical institution. DESIGN: Observational nonblinded study. SETTING: Single tertiary care institution and local urban vegetable market. PARTICIPANTS: Five yams (Dioscorea cayenensis), five courgettes (Cucurbita pepo) and five butternut squashes (Cucurbita moschata) were studied. Five cardiothoracic surgeons and anaesthesiologists were the control group. INTERVENTIONS: None. MAIN OUTCOME MEASURES: NIRS value of each species. RESULTS: Mean NIRS value for the control group was 71% [95% confidence interval (CI) 68 to 74] and was similar to that of the yellow squashes [75% (95% CI 74 to 76)]. These values were significantly greater than the NIRS measurements of both the butternut squash and yam [63% (95% CI 62 to 64) and 64% (95% CI 63 to 65), respectively, P < 0.01]. CONCLUSION: Commonly eaten vegetables have NIRS measurements similar to those seen in healthy humans.

Noncardiac entrapment of a pulmonary artery catheter during heart transplantation: inadvertent cannulation and perforation of the internal thoracic vein.

Placement of a central venous catheter into an internal thoracic vein occurs in approximately 2% of all catheterizations. A case in which a pulmonary artery catheter was trapped within the internal thoracic vein during orthotopic heart transplantation is presented.

Laboratory point-of-care monitoring in the operating room.

PURPOSE OF REVIEW: The fundamental advantage of point-of-care testing (POCT) is rapid acquisition of laboratory data. This is particularly advantageous in the operative arena because of the urgency of timeliness in anesthetic patient care. Technology is persistently evolving, such that it is imperative to regularly review available devices and investigate new devices that emerge each year. This review provides a comprehensive, current summary of POCT most pertinent to the anesthesiologist, and recent investigations that evaluate them. RECENT FINDINGS: Perioperative POCT includes arterial blood gas monitoring, chemistry, co-oximetry panels, parathyroid hormone assays, and coagulation testing. Parathyroid hormone assays continue to guide surgical resection of the parathyroid glands. Coagulation testing aids anesthesiologists in diagnosis of coagulopathy as well as therapeutic optimization of anticoagulants such as clopidogrel and aspirin. SUMMARY: POCT, although generally found to be more expensive compared to laboratory testing, has been shown to quicken result time. POCT will continue to be useful in the realm of anesthesiology in management of the surgical patient to guide drug therapy, surgical strategy, and medical management. A major challenge to POCT continues to be developing platforms to configure, organize, and distribute laboratory results as well as minimizing cost.

A mission-based productivity compensation model for an academic anesthesiology department.

INTRODUCTION: We replaced a nearly fixed-salary academic physician compensation model with a mission-based productivity model with the goal of improving attending anesthesiologist productivity. METHODS: The base salary system was stratified according to rank and clinical experience. The supplemental pay structure was linked to electronic patient records and a scheduling database to award points for clinical activity; educational, research, and administrative points systems were constructed in parallel. We analyzed monthly American Society of Anesthesiologist (ASA) unit data for operating room activity and physician compensation from 2000 through mid-2007, excluding the 1-yr implementation period (July 2004-June 2005) for the new model. RESULTS: Comparing 2005-2006 with 2000-2004, quarterly ASA units increased by 14% (P = 0.0001) and quarterly ASA units per full-time equivalent increased by 31% (P < 0.0001), while quarterly ASA units per anesthetizing location decreased by 10% (P = 0.046). Compared with a baseline year (2001), Instructor and Assistant Professor faculty compensation increased more than Associate Professor and Professor faculty (P < 0.001) in both pre- and postimplementation periods. There were larger compensation increases for the postimplementation period compared with preimplementation across faculty rank groupings (P < 0.0001). Academic and educational output was stable. DISCUSSION: Implementing a productivity-based faculty compensation model in an academic department was associated with increased mean supplemental pay with relatively fewer faculty. ASA units per month and ASA units per operating room full-time equivalent increased, and these metrics are the most likely drivers of the increased compensation. This occurred despite a slight decrease in clinical productivity as measured by ASA units per anesthetizing location. Academic and educational output was stable.

Clopidogrel treatment before coronary artery bypass graft surgery increases postoperative morbidity and blood product requirements.

OBJECTIVES: An increasing number of patients are referred for coronary artery bypass graft surgery while treated with clopidogrel. This agent inhibits the platelet P2Y12 adenosine-5'-diphosphate (ADP) receptor, which results in an inhibition of platelet aggregation. The aim of this study was to determine the effect of preoperative clopidogrel treatment on postoperative bleeding, mortality, and morbidity in patients after coronary artery bypass graft surgery. DESIGN: Retrospective cohort study. SETTING: University hospital (single institution). PARTICIPANTS: One hundred forty-four patients who underwent isolated coronary artery bypass graft surgery. INTERVENTIONS: Seventy-two patients who received clopidogrel during the preoperative period formed the study group. Seventy-two patients (matched based on age, sex, and preoperative risk profile) served as the control group. MEASUREMENTS AND MAIN RESULTS: Clopidogrel-treated patients received significantly more platelet (4.4 +/- 5.7 v 1.3 +/- 3.2 U, p < 0.001) and red blood cell (5.1 +/- 4.2 v 2.6 +/- 2.6 U, p < 0.001) transfusions compared with the control group. All-cause mortality and morbidity were significantly higher in clopidogrel-treated patients (n = 7, 9% v n = 1, 1%; p = 0.031). In addition, the lengths of stay in the intensive care unit and the hospital were significantly longer in these patients (2.5 +/- 2.7 v 1.4 +/- 0.9 days, p = 0.002; 9.9 +/- 11 v 6 +/- 2.5 days, p = 0.003). Despite an increased morbidity in the clopidogrel group, the midterm survival was similar between the 2 groups (1-year and 5-year survival 97% +/- 2% and 95.7% +/- 3% v 100% +/- 0% and 87% +/- 10%, respectively; p = 0.885). CONCLUSIONS: Preoperative clopidogrel is associated with increased transfusion requirement after coronary artery bypass graft surgery. The present data suggest that all-cause mortality and major morbidity may also increase in these patients. In clopidogrel-treated patients, coronary artery bypass graft surgery should be delayed in the absence of specific medical indications as recommended by recent American Heart Association guidelines.

Anesthetic consideration for descending thoracic aortic aneurysm repair.

Anesthesia for surgery of the aorta poses some of the most difficult challenges for anesthesiologists. Major hemodynamic and physiologic stresses and sophisticated techniques of extracorporeal support are superimposed on patients with complex medical disease states. In this review, etiologies, natural history, and surgical techniques of thoracic aortic aneurysm are presented. Anesthetic considerations are discussed in detail, including the management of distal perfusion using partial cardiopulmonary bypass. Considerations of spinal cord protection, including management of proximal hypertension, cerebral spinal fluid drainage, and pharmacological therapies, are presented.

Curriculum planning: a needs assessment for complementary and alternative medicine education in residency.

BACKGROUND AND OBJECTIVES: The curricular needs in complementary and alternative medicine (CAM) of family medicine residents are unknown. Our objective was to assess perceptions of knowledge, attitudes, practice behaviors, and interest toward CAM by family medicine residents. METHODS: A questionnaire was administered to family medicine residents (n=153) throughout one state. RESULTS: The response rate was 77% (118/153), with an equal distribution of first-, second-, and third-year residents. Respondents reported minimal knowledge of CAM and low awareness of CAM resources. Many do not routinely ask patients about their CAM usage. Most respondents reported discomfort advising their patients of the risks and benefits of CAM therapies, and most were interested in learning about CAM. While prior training made a difference in responses, gender and training level did not. Whites were more likely to have had prior training in CAM than non-whites. CONCLUSIONS: Family medicine residents in Arkansas may not have enough training in CAM. Given the growing popularity of these modalities among the general public, residents might benefit from training and education in CAM.

Oxidative stress causes heart failure with impaired mitochondrial respiration.

Elderly people insidiously manifest the symptoms of heart failure, such as dyspnea and/or physical disabilities in an age-dependent manner. Although previous studies suggested that oxidative stress plays a pathological role in the development of heart failure, no direct evidence has been documented so far. In order to investigate the pathological significance of oxidative stress in the heart, we generated heart/muscle-specific manganese superoxide dismutase-deficient mice. The mutant mice developed progressive congestive heart failure with specific molecular defects in mitochondrial respiration. In this paper, we showed for the first time that the oxidative stress caused specific morphological changes of mitochondria, excess formation of superoxide (O(2)(*)(-)), reduction of ATP, and transcriptional alterations of genes associated with heart failure in respect to cardiac contractility. Accordingly, administration of a superoxide dismutase mimetic significantly ameliorated the symptoms. These results implied that O(2)(*)(-) generated in mitochondria played a pivotal role in the development and progression of heart failure. We here present a bona fide model for human cardiac failure with oxidative stress valuable for therapeutic interventions.