Race and Intention to Breastfeed are the Strongest Predictors of Exclusive Breastfeeding: a Retrospective Study.

INTRODUCTION: Racial disparities exist in maternal and neonatal care including breastfeeding (BF). The purpose of this study is to assess factors associated with BF success by race with a specific focus on pre-birth BF plan and time duration from birth until initiation of skin-to-skin contact and from birth to the first feed or breastfeed. METHODS: A database query of our electronic medical records was performed for all patients who had a vaginal delivery that met our study criteria. Demographic information, pre-delivery feeding plan (exclusive BF, exclusive formula, or mixed), time to first feed and first breastfeed, and time to skin-to-skin were compared among different postpartum feeding practices (exclusive BF, exclusive formula, mixed), and compared across race/ethnic groups using ANOVA, Chi-square, and Fisher's exact statistical tests as appropriate. Logistic regression was used to investigate the independent effect of each variable on exclusive BF. RESULTS: The study analyzed 12,578 deliveries. There was a significant difference in intended feeding plans among the different racial groups. Approximately 61% of Black patients intended to exclusively BF as compared to 79% of the other groups. Overall, 3994 (32%) patients breastfed exclusively, 872 (7%) exclusively used formula, and 7712 (61%) used a mix of breast and formula. White patients were most likely to exclusively BF (35%) and Black patients were least likely (21%), p < 0.001. Our model found that self-identified race and pre-delivery feeding plan were the strongest predictors of exclusive BF. CONCLUSIONS: The main findings of this study are that self-identified race and intention to BF are the strongest predictors of exclusive BF. Black patients intend to BF at a significantly lower rate than other racial groups, for reasons not determined by this study, and this affects feeding practice. Our findings are notable because prehospital intention to BF can be modified by outreach, education, and changes to in-hospital practices.

A System to Improve Compliance with Electrocardiography Electrode Expiration Tracking.

BACKGROUND: Electrocardiography (ECG) electrodes require special expiration tracking after the manufacturer's packaging is opened. Compliance with this requirement, however, can be inconsistent. The authors tested the efficacy of a device that provides for expiration tracking of bulk-packaged electrodes to improve compliance. METHODS: The device tested is a bin with an automated countdown timer that could be used for storing and dispensing open ECG electrodes. Seven operating rooms were inspected three times each before and after implementation of the device. Compliance with expiration dating of open electrodes was recorded for each inspection. RESULTS: Compliance was found in 3 of the 21 (14.3%) baseline inspections. Following implementation of the devices, compliance was found in 20 of 21 (95.2%) inspections. This increase in compliance was statistically significant (p < 0.01). CONCLUSION: A storage and dispensing device with automated countdown timer significantly improved compliance with expiration dating regulations for bulk-packaged ECG electrodes. It also has the potential to reduce supply cost, packaging waste, and inconvenience compared with individually wrapped electrodes.

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.

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.

System for Storage, Dispensing, and Tracking Expiration of Electrocardiography Electrodes.

Electrocardiography electrodes have expiration dates that are foreshortened once the manufacturer's packaging is opened. A system is described for storing and dispensing these perishable electrodes while tracking their new expiration date for safety and regulatory purposes.

Self-reported Race/Ethnicity and Intraoperative Occult Hypoxemia: A Retrospective Cohort Study.

BACKGROUND: Pulse oximetry is ubiquitous in anesthesia and is generally a reliable noninvasive measure of arterial oxygen saturation. Concerns regarding the impact of skin pigmentation and race/ethnicity on the accuracy of pulse oximeter accuracy exist. The authors hypothesized a greater prevalence of occult hypoxemia (arterial oxygen saturation [Sao2] less than 88% despite oxygen saturation measured by pulse oximetry [Spo2] greater than 92%) in patients undergoing anesthesia who self-reported a race/ethnicity other than White. METHODS: Demographic and physiologic data, including self-reported race/ethnicity, were extracted from a departmental data warehouse for patients receiving an anesthetic that included at least one arterial blood gas between January 2008 and December 2019. Calculated Sao2 values were paired with concurrent Spo2 values for each patient. Analysis to determine whether Black, Hispanic, Asian, or Other race/ethnicities were associated with occult hypoxemia relative to White race/ethnicity within the Spo2 range of 92 to 100% was completed. RESULTS: In total, 151,070 paired Sao2-Spo2 readings (70,722 White; 16,011 Black; 21,223 Hispanic; 8,121 Asian; 34,993 Other) from 46,253 unique patients were analyzed. The prevalence of occult hypoxemia was significantly higher in Black (339 of 16,011 [2.1%]) and Hispanic (383 of 21,223 [1.8%]) versus White (791 of 70,722 [1.1%]) paired Sao2-Spo2 readings (P < 0.001 for both). In the multivariable analysis, Black (odds ratio, 1.44 [95% CI, 1.11 to 1.87]; P = 0.006) and Hispanic (odds ratio, 1.31 [95% CI, 1.03 to 1.68]; P = 0.031) race/ethnicity were associated with occult hypoxemia. Asian and Other race/ethnicity were not associated with occult hypoxemia. CONCLUSIONS: Self-reported Black and Hispanic race/ethnicity are associated with a greater prevalence of intraoperative occult hypoxemia in the Spo2 range of 92 to 100% when compared with self-reported White race/ethnicity.

Analysis of urgent/emergent conversions from monitored anesthesia care to general anesthesia with airway instrumentation.

BACKGROUND: Monitored Anesthesia Care (MAC) is an anesthetic service involving the titration of sedatives/analgesics to achieve varying levels of sedation while avoiding general anesthesia (GA) and airway instrumentation. The goal of our study was to determine the overall incidence of conversion from MAC to general anesthesia with airway instrumentation and elucidate reasons and risk factors for conversion. METHODS: In this retrospective observational study, all non-obstetric adult patients who received MAC from July 2002 to July 2015 at Mount Sinai Hospital were electronically screened for inclusion via a clinical database. Patient, procedure, anesthetic, and practitioner data were all collected and analyzed to generate descriptive analyses. Subsequent univariate and multivariate analyses were used to identify specific risk factors associated with conversion to GA. RESULTS: Overall, 0.50% (1097/219,061) of MAC cases were converted to GA. Approximately half of conversions were due to the patient's "intolerance" of MAC (with or without failed regional anesthesia), while the other half were due to physiologic derangements. Body mass index, male sex, American Society of Anesthesiologists Physical Status Classification, anesthesia team composition, and surgical specialty were all associated with risk of conversion to GA. CONCLUSIONS: This is one of the first and largest retrospective studies aimed at identifying reasons and risk factors associated with the conversion of MAC to GA. These findings may be used to help better anticipate or prevent these events.

New-onset intra-operative hyperthermia in a large surgical patient population: A retrospective observational study.

BACKGROUND: Intra-operative hypothermia has been extensively investigated. However, the incidence of intra-operative hyperthermia has not been investigated in detail. OBJECTIVE: The main objective of this study was to assess the incidence and risk factors of new-onset intra-operative hyperthermia in a large surgical patient population. DESIGN: Retrospective database review. SETTING: Tertiary-care teaching hospital. PATIENTS: Patients undergoing surgery with general anaesthesia between 1 January 2002 and 31 December 2017 were included. MAIN OUTCOME MEASURES: The primary outcome measurement was new-onset intra-operative hyperthermia (>37.5 °C). A logistic regression model was fitted to identify risk factors for intra-operative hyperthermia. RESULTS: A total of 103 648 patients were included in the final analyses. The incidence of new-onset hyperthermia in the overall patient cohort was 6.45%, reaching 20 to 30% after prolonged (>8 h) surgery, and was up to 26.5% in paediatric patients. The use of forced air active patient warming, larger amounts of fluid administration, longer surgery, younger age and smaller body size were all independently associated with intra-operative hyperthermia. The adoption of the Surgical Care Improvement Project (SCIP) temperature measures was associated with an increased incidence of intra-operative hyperthermia. CONCLUSION: Mild intra-operative hyperthermia is not uncommon particularly in longer procedures and small children.

Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States.

BACKGROUND: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Efficacy and Usability of a Novel Barrier Device for Preventing Injection Port Contamination: A Pilot Simulation Study.

Contamination of intravenous (IV) ports and stopcocks has been associated with postoperative infections. We tested the usability and efficacy of a novel passive shielding device to prevent such contamination even in the absence of hand hygiene or port disinfection. In a desktop setting with deliberately contaminated hands, qualitative port contamination was detected after 5/60 (8.3%; 95% confidence interval [CI], 2.8-18.4) control port injections versus 0/60 (0%; 95% CI, 0-6.0) shielded injections (P = .025). In clinical simulations with a quantitative bioburden assay (measured in relative light units [RLUs]), median (interquartile range [IQR]) postsimulation bioburden was 46 (32-53) vs 27 (21-42) RLU for the control versus intervention groups (P = .036), yielding a median shift of -13 RLU (95% CI, -2 to -26) in favor of the shielding. Usability of the device was acceptable to practitioners.

Unusual Complication of the Nuss Procedure: Fistulization of the Internal Thoracic Artery to the Pulmonary Artery.

Although minimally invasive repair of pectus excavatum has been shown to have a low complication rate in large series, several case reports have documented life-threatening complications, including bleeding and cardiac perforation. We present a rare case of an arteriovenous malformation from the internal thoracic artery to the pulmonary artery caused by occlusion of the internal thoracic artery by the Nuss bar followed by an unidentified angiogenic process. The patient became symptomatic and required transcatheter coil embolization.

Novel shunt modification with an adjustable stent-embedded "fenestrated" septal occluder in a patient with pulmonary hypertension.

A 60-year-old woman with progressive dyspnea and cyanosis, O2-dependent pulmonary hypertension despite optimal medical therapy and remote atrial septostomy presented with worsening cyanosis and right-to-left shunting. The creation of a "fenestrated" ASD closure device with the insertion of a peripheral stent through an AMPLATZER™ ASD closure device was deployed to minimize right to left shunting and allow for enlargement of the shunt if needed. This case demonstrates the benefit of diminishing a right to left shunt with a self-fabricated fenestrated AMPLATZER device to improve symptoms in pulmonary hypertension patients with a pre-existing ASD.

A Model for Assessment of Catheterization Risk in Adults With Congenital Heart Disease.

The purpose of this study was to define the risk for adults with congenital heart disease who underwent cardiac catheterization and to propose a precatheterization risk scoring system. Data were prospectively collected using a multicenter registry of the Congenital Cardiovascular Interventional Study Consortium. The occurrence of serious adverse events (SAE) was correlated with 12 predefined variables. Catheterization RISk in Adult patients (CRISA) score was derived using multivariate logistic regression with backward elimination model selection method. The CRISA score was compared with the American Society of Anesthesiology score and a consensus-derived, 20-point risk score based on their ability to predict SAE. From June 2008 to September 2017, 300 adjudicated SAE's occurred in 7317 catheterization procedures (overall SAE rate 4.1%) performed in adults over 18 years of age at 27 contributing centers. Nine of the 12 tested variables were ultimately included in the CRISA score. CRISA score positively correlated with risk of SAE, and was superior to American Society of Anesthesiology and the 20-point risk score in predicting SAE. Minimal (CRISA score 0 to 2), low (3 to 7), moderate (8 to 10) and high (≥11) risk categories were identified, corresponding to 0.5%, 3.2%, 7.9%, and 16.7% risk of SAE, respectfully. In conclusion, the CRISA score reliably predicts risk of SAE in adults with congenital heart disease who underwent cardiac catheterization and may be useful for preprocedural risk assessment.

Persistent acidosis after reperfusion-A prognostic indicator of increased 30-day and in-hospital postoperative mortality in liver transplant recipients.

During liver transplantation, the patient is at risk of developing progressive lactic acidosis. Following reperfusion, correction of acidosis may occur. In some patients, acidosis will worsen, a phenomenon referred to as persistent acidosis after reperfusion (PAAR). We compared postoperative outcomes in patients who manifested PAAR vs those that did not. All adult patients undergoing liver transplantation from 2002 to 2015 were included. PAAR is defined by the presence of a significant negative slope coefficient for base excess values measured after hepatic artery anastomosis through 72 hours postoperatively. Primary outcome was a composite of 30-day and in-hospital mortality. Secondary outcomes included: ICU LOS, total hospital LOS, and re-transplantation rate within 7 days. PAAR occurred in 10% of the transplant recipients. Patients with PAAR had higher MELD, BMI, and eGFR and demonstrated a longer median ICU LOS and hospital median LOS with a trend toward mortality difference. But, after propensity matching, the mortality rate difference became significantly higher in patients with PAAR compared with matched controls while the ICU LOS differences disappeared. The re-transplantation rates were similar also between the PAAR and no PAAR groups. The cohort with PAAR had a significant 30-day and in-hospital increase in mortality after propensity score matching.