ASA Physical Status Determination by General Internists and Impact on Cardiac Risk Assessment.

OBJECTIVES: Estimating cardiac risk is important for preoperative evaluation, and several risk calculators incorporate the American Society of Anesthesiologists (ASA) physical status score. The purpose of this study was to determine the concordance of ASA scores assigned by general internists and anesthesiologists and assess whether discrepancies affected cardiac risk estimation. METHODS: This observational study included military veterans evaluated in a preoperative evaluation clinic at a single center during a 12-month period. ASA scores were recorded by General Internal Medicine residents under the supervision of a General Internal Medicine attending, performing a preoperative medical consultation, and were compared with ASA scores assigned by an anesthesiologist on the day of surgery. ASA scores and Gupta Cardiac Risk Scores incorporating each ASA score were compared. RESULTS: Data were collected on 206 patients, 163 of whom had surgery within 90 days and were included. ASA scores were concordant in 60 patients (37.3%), whereas the ASA scores were rated lower by the general internist in 101 (62.0%) and higher in 2 (1.2%). Interrater reliability was low (κ = 0.08), and general internist scores were significantly lower than anesthesiologist scores (P < 0.01). Gupta Cardiac Risk Scores were calculated for 160 patients, and they exceeded 1% in 14 patients using the anesthesiologist ASA score, compared with 5 patients using the general internist score. CONCLUSIONS: ASA scores assigned by general internists in this study were significantly lower than those assigned by anesthesiologists, and these discrepancies in the ASA score can lead to substantially different conclusions about cardiac risk.

Erosion of heterogeneous rock drives diversification of Appalachian fishes.

The high levels of biodiversity supported by mountains suggest a possible link between geologic processes and biological evolution. Freshwater biodiversity is high not only in tectonically active settings but also in tectonically quiescent montane regions such as the Appalachian Mountains. We show that erosion through different rock types drove allopatric divergence between lineages of the Greenfin Darter (Nothonotus chlorobranchius), a fish species endemic to rivers draining metamorphic rocks in the Tennessee River basin in the United States. In the past, metamorphic rock preferred by N. chlorobranchius was more widespread, but as erosion exposed other rock types, lineages of this species were progressively isolated in tributaries farther upstream, where metamorphic rock remained. Our results suggest a geologic mechanism for initiating allopatric diversification in mountains long after tectonic activity ceases.

Hidden species diversity in an iconic living fossil vertebrate.

Ancient, species-poor lineages persistently occur across the Tree of life. These lineages are likely to contain unrecognized species diversity masked by the low rates of morphological evolution that characterize living fossils. Halecomorphi is a lineage of ray-finned fishes that diverged from its closest relatives before 200 Ma and is represented by only one living species in eastern North America, the bowfin, Amia calva Linnaeus. Here, we use double digest restriction-site-associated DNA sequencing and morphology to illuminate recent speciation in bowfins. Our results support the delimitation of a second living species of Amia, with the timing of diversification dating to the Plio-Pleistocene. This delimitation expands the species diversity of an ancient lineage that is integral to studies of vertebrate genomics and development, yet is facing growing conservation threats driven by the caviar fishery.

Genomic and phenotypic divergence informs translocation strategies for an endangered freshwater fish.

Translocation, the movement of organisms for conservation purposes, can result in unintended introgression if genetic material flows between populations in new ways. The Bluemask Darter Etheostoma akatulo is a federally endangered species of freshwater fish inhabiting the Caney Fork River system and three of its tributaries (Collins River, Rocky River, and Cane Creek) in Tennessee. The current conservation strategy for Bluemask Darters involves translocating the progeny of broodstock from the Collins River (in the west) to the Calfkiller River (in the east) where the species had been extirpated. In this study, we use ddRAD sequence data from across the extant range to assess this translocation strategy in light of population structure, phylogeny, and demography. We also include museum specimen data to assess morphological variation among extant and extirpated populations. Our analyses reveal substantial genetic and phenotypic disparities between a western population in the Collins River and an eastern population encompassing the Rocky River, Cane Creek, and upper Caney Fork, the two of which shared common ancestry more than 100,000 years ago. Furthermore, morphological analyses classify 12 of 13 Calfkiller River specimens with phenotypes consistent with the eastern population. These results suggest that current translocations perturb the evolutionary boundaries between two delimited populations. Instead, we suggest that repopulating the Calfkiller River using juveniles from the Rocky River could balance conflicting signatures of demography, diversity, and divergence. Beyond conservation, the microgeographic structure of Bluemask Darter populations adds another puzzle to the phylogeography of the hyperdiverse freshwater fishes in eastern North America.

Implementation of an enhanced recovery program for lower extremity bypass.

OBJECTIVE: Enhanced recovery programs (ERPs) have gained wide acceptance across multiple surgical disciplines to improve postoperative outcomes and to decrease hospital length of stay (LOS). However, there is limited information in the existing literature for vascular patients. We describe the implementation and early results of an ERP and barriers to its implementation for lower extremity bypass surgery. Our intention is to provide a framework to assist with implementation of similar ERPs. METHODS: Using the plan, do, check, adjust methodology, a multidisciplinary team was assembled. A database was used to collect information on patient-, procedure-, and ERP-specific metrics. We then retrospectively analyzed patients' demographics and outcomes. RESULTS: During 9 months, an ERP (n = 57) was successfully developed and implemented spanning preoperative, intraoperative, and postoperative phases. ERP and non-ERP patient demographics were statistically similar. Early successes include 97% use of fascia iliaca block and multimodal analgesia administration in 81%. Barriers included only 47% of patients achieving day of surgery mobilization and 19% receiving celecoxib preoperatively. ERP patients had decreased total and postoperative LOS compared with non-ERP patients (n = 190) with a mean (standard deviation) total LOS of 8.32 (8.4) days vs 11.14 (10.1) days (P = .056) and postoperative LOS of 6.12 (6.02) days vs 7.98 (7.52) days (P = .089). There was significant decrease in observed to expected postoperative LOS (1.28 [0.66] vs 1.82 [1.38]; P = .005). Variable and total costs for ERP patients were significantly reduced ($13,208 [$9930] vs $18,777 [$19,118; P < .01] and $29,865 [$22,110] vs $40,328 [$37,820; P = .01], respectively). CONCLUSIONS: Successful implementation of ERP for lower extremity bypass carries notable challenges but can have a significant impact on practice patterns. Further adjustment of our current protocol is anticipated, but early results are promising. Implementation of a vascular surgery ERP reduced variable and total costs and decreased total and postoperative LOS. We believe this protocol can easily be implemented at other institutions using the pathway outlined.

Enhanced Recovery After Surgery: Intraoperative Fluid Management Strategies.

Ideal fluid management is a critical component of enhanced recovery after surgery protocols and should be considered throughout the perioperative period. The goal of preoperative fluid management is for the patient to arrive to the operating room euvolemic. Intraoperative goals of fluid management are to preserve intravascular volume and minimize salt and water uptake through intravenous crystalloid infusions. Postoperatively, once patients are tolerant of oral fluid intake, intravenous fluids are not required and should be restarted only if clinically necessary. This article reviews evidence-based, best practices for intraoperative fluid management for patients undergoing surgery within an enhanced recovery after surgery pathway.

Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on racial disparities in postoperative length of stay (pLOS) after colorectal surgery. BACKGROUND: Racial disparities in surgical outcomes exist. We hypothesized that ERAS would reduce disparities in pLOS between black and white patients. METHODS: Patients undergoing ERAS in 2015 were 1:1 matched by race/ethnicity, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. After stratification by race/ethnicity, expected pLOS was calculated using the American College of Surgeons National Surgical Quality Improvement Project Risk Calculator. Primary outcome was the observed pLOS and observed-to-expected difference in pLOS. Secondary outcomes were National Surgical Quality Improvement Project postoperative complications including 30-day readmissions and mortality. Adjusted sensitivity analyses on pLOS were also performed. RESULTS: Of 420 patients (210 ERAS and 210 pre-ERAS) examined, 28.3% were black. Black and white patients were similar in age, body mass index, sex, American Anesthesia Association class, and minimally invasive approaches. Within the pre-ERAS group, black patients stayed a mean of 2.7 days longer than expected compared with white patients (P < 0.05). Overall, ERAS patients had a significantly shorter pLOS (5.7 vs 8 days) and observed-to-expected difference (-0.7 vs 1.4 days) compared with pre-ERAS patients (P < 0.01). In the ERAS group, disparities in pLOS were reduced with no differences in readmissions or mortality between black and white patients. On sensitivity analyses, race/ethnicity remained a significant predictor of pLOS among pre-ERAS patients, but not for ERAS patients. CONCLUSIONS: ERAS eliminated racial differences in pLOS between black and white patients undergoing colorectal surgery. Reduced pLOS occurred without increases in mortality, readmissions, and most postoperative complications. ERAS may provide a practical approach to reducing disparities in surgical outcomes.

Trauma-Induced Coagulopathy.

Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h. Accordingly, the management of these patients is a time-sensitive and critical affair that anesthesiologists responsible for surgical resuscitation will face. Coagulopathy associated with trauma exists in one-third of all severely injured patients upon presentation to the hospital. Trauma patients presenting with coagulopathy have significantly higher mortality. This trauma-induced coagulopathy (TIC) must be managed adroitly in the resuscitation of these patients. Recent advancements in our understanding of TIC have led to new protocols and therapy guidelines. Anesthesiologists must be aware of these to effectively manage this form of shock. TIC driven by a combination of endogenous biological processes, as well as iatrogenic causes, can ultimately lead to the lethal triad of hypothermia, acidemia, and coagulopathy. Providers should understand how to promptly diagnose TIC and be aware of the early indicators of massive transfusion. The use of common laboratory studies and patient vital signs serve as our current guide, but the importance of each is still under debate. Thromboelastography is a tool used often in the diagnosis of TIC and can be used to guide blood product transfusion. Certain pharmaceutical strategies and non-transfusion strategies also exist, which aid in the management of hemorrhagic shock. Damage control surgery, rewarming, tranexamic acid, and 1:1:1 transfusion protocols are promising methods used to treat the critically wounded. Though protocols have been developed, controversies still exist on the optimal resuscitation strategy.