An innovative textbook: design and implementation.

BACKGROUND: The 'flipped classroom' instructional strategy has gained much momentum in educational discourse, yet no single educational offering exists in postgraduate medical education (PME) to systematically replace the lecture element of didactic sessions. This article describes the design and implementation of Clinical Anesthesia Fundamentals, the first known textbook in PME addressing this gap in resources through the integration of full-length interactive multimedia-enhanced video lectures. The 'flipped classroom' instructional strategy has gained much momentum in educational discourse INNOVATION: The textbook was developed in alignment with the content outline for the specialty provided by the American Board of Anesthesiology. Its accompanying video lectures, produced at the Media Lab in the Department of Anesthesiology at Boston University Medical Center (BUMC), cover the topics in each chapter of the textbook and include review questions featuring explanatory feedback. EVALUATION: Following a 5-month trial period at the BUMC Anesthesiology Residency Program, the complete resident class (25 of 25; 100%) participated in an anonymous, Institutional Review Board (IRB) -approved, five-point Likert-type scale survey assessing an underlying variable of preference for the use of multimedia learning tools. DISCUSSION: Survey results suggest that residents favour technology-enhanced learning environments in which textbooks are coupled with interactive multimedia, and the 'flipped classroom' approach is employed. Although the development of digital videos requires time and financial investment, the improved accessibility and uniform delivery of didactic content are two positive outcomes. CONCLUSION: This textbook provides an example for educators wishing to learn how to capitalise on advances in technology to further enhance learning and accessibility. Further studies could address the impact of this approach on the academic performance of residents.

The Surgical Care Improvement Project Antibiotic Guidelines: Should We Expect More Than Good Intentions?

Since 2006, the Surgical Care Improvement Project (SCIP) has promoted 3 perioperative antibiotic recommendations designed to reduce the incidence of surgical site infections. Despite good evidence for the efficacy of these recommendations, the efforts of SCIP have not measurably improved the rates of surgical site infections. We offer 3 arguments as to why SCIP has fallen short of expectations. We then suggest a reorientation of quality improvement efforts to focus less on reporting, and incentivizing adherence to imperfect metrics, and more on creating local and regional quality collaboratives to educate clinicians about how to improve practice. Ultimately, successful quality improvement projects are behavioral interventions that will only succeed to the degree that they motivate individual clinicians, practicing within a particular context, to do the difficult work of identifying failures and iteratively working toward excellence.

Aortic valve replacement for critical aortic stenosis after bilateral lung transplantation.

Four years after bilateral lung transplantation, a 62-year-old man with critical aortic stenosis required aortic valve replacement. This is the first report of aortic valve replacement after bilateral lung transplantation. Anesthetic and surgical management are described.

New utility for an old tool: can a simple gait speed test predict ambulatory surgical discharge outcomes?

OBJECTIVE: The primary aims of this study were to design prediction models based on a functional marker (preoperative gait speed) to predict readiness for home discharge time of 90 mins or less and to identify those at risk for unplanned admissions after elective ambulatory surgery. DESIGN: This prospective observational cohort study evaluated all patients scheduled for elective ambulatory surgery. Home discharge readiness and unplanned admissions were the primary outcomes. Independent variables included preoperative gait speed, heart rate, and total anesthesia time. The relationship between all predictors and each primary outcome was determined in separate multivariable logistic regression models. RESULTS: After adjustment for covariates, gait speed with adjusted odds ratio of 3.71 (95% confidence interval, 1.21-11.26), P = 0.02, was independently associated with early home discharge readiness of 90 mins or less. Importantly, gait speed dichotomized as greater or less than 1 m/sec predicted unplanned admissions, with odds ratio of 0.35 (95% confidence interval, 0.16-0.76, P = 0.008) for those with speeds 1 m/sec or greater in comparison with those with speeds less than 1 m/sec. In a separate model, history of cardiac surgery with adjusted odds ratio of 7.5 (95% confidence interval, 2.34-24.41; P = 0.001) was independently associated with unplanned admissions after elective ambulatory surgery, when other covariates were held constant. CONCLUSIONS: This study demonstrates the use of novel prediction models based on gait speed testing to predict early home discharge and to identify those patients at risk for unplanned admissions after elective ambulatory surgery.

Lack of effectiveness of the pulmonary artery catheter in cardiac surgery.

BACKGROUND: The pulmonary artery catheter (PAC) continues to be used for monitoring of hemodynamics in patients undergoing coronary artery bypass graft (CABG) surgery despite concerns raised in other settings regarding both effectiveness and safety. Given the relative paucity of data regarding its use in CABG patients, and given entrenched practice patterns, we assessed the impact of PAC use on fatal and nonfatal CABG outcomes as practiced at a diverse set of medical centers. METHODS: Using a formal prospective observational study design, 5065 CABG patients from 70 centers were enrolled between November 1996 and June 2000 using a systemic sampling protocol. Propensity score matched-pair analysis was used to adjust for differences in likelihood of PAC insertion. The predefined composite endpoint was the occurrence of any of the following: death (any cause), cardiac dysfunction (myocardial infarction or congestive heart failure), cerebral dysfunction (stroke or encephalopathy), renal dysfunction (dysfunction or failure), or pulmonary dysfunction (acute respiratory distress syndrome). Secondary variables included treatment indices (inotrope use, fluid administration), duration of postoperative intubation, and intensive care unit length of stay. After categorization based on PAC and transesophageal echocardiography use (both, neither, PAC only, transesophageal echocardiography only), we performed the primary analysis contrasting PAC only and neither (total, 3321 patients), from which propensity paring yielded 1273 matched pairs. RESULTS: The primary endpoint occurred in 271 PAC patients versus 196 without PAC (21.3% vs.15.4%; adjusted odds ratio [AOR], 1.68; 95% confidence interval [CI], 1.24 to 2.26; P<0.001). The PAC group had an increased risk of all-cause mortality, 3.5% vs 1.7% (AOR, 2.08; 95% CI, 1.11 to 3.88; P=0.02) and an increased risk of cardiac (AOR, 1.58; 95% CI, 1.14 to 2.20; P=0.007), cerebral (AOR, 2.02; 95% CI, 1.08 to 3.77; P=0.03) and renal (AOR, 2.47; 95% CI, 1.68 to 3.62; P<0.001) morbid outcomes. PAC patients received inotropic drugs more frequently (57.8% vs 50.0%; P<0.001), had a larger positive IV fluid balance after surgery (3220 mL vs 3022 mL; P=0.003), and experienced longer time to tracheal extubation (15.40 hours [11.28/20.80] versus 13.18 hours [9.58/19.33], median plus Q1/Q3 interquartile range; P<0.0001). Use of PAC was also associated with prolonged intensive care unit stay (14.5% vs 10.1%; AOR, 1.55; 95% CI, 1.06 to 2.27; P=0.02). CONCLUSIONS: Use of a PAC during CABG surgery was associated with increased mortality and a higher risk of severe end-organ complications in this propensity-matched observational study. A randomized controlled trial with defined hemodynamic goals would be ideal to either confirm or refute our findings.

A case of adjustable pressure-limiting (APL) valve failure.

The adjustable pressure-limiting (APL) valve controls airway pressure during manual ventilation. Failure of the APL valve during induction of anesthesia may occur, and the anesthesiologist must be aware of solutions for this occurrence.

Ascending aortic aneurysms: asymmetrical differences in aortic cross-sectional wall motion detected by epiaortic echocardiography.

OBJECTIVE: To evaluate in vivo cross-sectional conformational changes of ascending aortic wall excursion in patients undergoing resection for aortic aneurysm with those undergoing elective coronary artery bypass grafting (CABG) using epi-aortic echocardiography. DESIGN: A prospective observational investigation. SETTING: A single tertiary care university hospital. PARTICIPANTS: Thirty-four patients undergoing elective ascending aorta resection and 23 elective CABG patients. INTERVENTION: In an open-chest model and with use of an epi-aortic echocardiographic probe, measurements of aortic wall excursion were made on the ascending aortic aneurysms. Control measurements were made on the transitional neck portions of the aneurysmal aortas (internal control) and CABG aortas (external control). MEASUREMENTS AND MAIN RESULTS: The aortic aneurysm measurements exhibited no difference (2.8%, p < 0.62) between the excursion of the anterior and posterior walls. In contrast, under similar hemodynamic conditions, the anterior wall of the aneurysm neck moved 48.2% (p < 0.0004) more than the posterior wall. Similarly, in the CABG control group, the anterior wall moved 24% (p < 0.027) more than the posterior wall. CONCLUSION: This in vivo study documented a lack of asymmetric aortic wall motion in ascending aortic aneurysms. In contrast, both the internal and external control groups (aneurysm neck and CABG) demonstrated asymmetric wall motion. The lack of asymmetric wall motion may be an important aspect of aneurysm pathophysiology and key to the development of management strategies for timing of surgical intervention.

Inside the black box: current policies and concerns with the United States Food and Drug Administration's highest drug safety warning system.

PURPOSE OF REVIEW: To evaluate the United States Food and Drug Administration use of the black-box warning system to promote drug safety and to examine the droperidol black-box warning as a case study. RECENT FINDINGS: Scientific studies report that there is no basis to issue a black-box warning for perioperative administration of droperidol for postoperative nausea and vomiting on the basis of the potential of adverse cardiac events (prolongation of the QT interval and/or development of torsades de pointes). SUMMARY: Rather than relying on well conducted clinical investigations, the Food and Drug Administration subjectively issued a black-box warning to droperidol, which effectively removed droperidol from clinical practice for the indication of postoperative nausea and vomiting. Newer data suggest that the incidence of prolongation of the QT interval and the occurrence of torsades de pointes is similar to more expensive alternative medications used to treat postoperative nausea and vomiting.

Scientific principles and clinical implications of perioperative glucose regulation and control.

Development of hyperglycemia after major operations is very common and is modulated by many factors. These factors include perioperative metabolic state, intraoperative management of the patient, and neuroendocrine stress response to surgery. Acute insulin resistance also develops perioperatively and contributes significantly to hyperglycemia. Hyperglycemia is associated with poor outcomes in critically ill and postsurgical patients. A majority of the investigations use the term "hyperglycemia" very loosely and use varying thresholds for initiating treatment. Initial studies demonstrated improved outcomes in critically ill, postsurgical patients who received intensive glycemic control (IGC) (target serum glucose <110 mg/dL). These results were quickly extrapolated to other clinical areas, and IGC was enthusiastically recommended in the perioperative period. However, there are few studies investigating the value of intraoperative glycemic control. Moreover, recent prospective trials have not been able to show the benefit of IGC; neither an appropriate therapeutic glycemic target nor the true efficacy of perioperative glycemic control has been fully determined. Practitioners should also appreciate technical nuances of various glucose measurement techniques. IGC increases the risk of hypoglycemia significantly, which is not inconsequential in critically ill patients. Until further specific data are accumulated, it is prudent to maintain glucose levels <180 mg/dL in the perioperative period, and glycemic control should always be accompanied by close glucose monitoring.

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin-induced thrombocytopenia with thrombosis.

BACKGROUND: Direct thrombin inhibitors (DTIs) provide an alternative method of anticoagulation for patients with a history of heparin-induced thrombocytopenia (HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB). In the following report, a 65-year-old critically ill patient with a suspected history of HITT was administered argatroban for anticoagulation on bypass during heart transplantation. The patient required massive transfusion support (55 units of red blood cells, 42 units of fresh-frozen plasma, 40 units of cryoprecipitate, 40 units of platelets, and three doses of recombinant Factor VIIa) for severe intraoperative and postoperative bleeding. STUDY DESIGN AND METHODS: Plasma samples from before and after CPB were analyzed postoperatively for argatroban concentration using a modified ecarin clotting time (ECT) assay. RESULTS: Unexpectedly high concentrations of argatroban were measured in these samples (range, 0-32 microg/mL), and a prolonged plasma argatroban half life (t(1/2)) of 514 minutes was observed (published elimination t(1/2) is 39-51 minutes [< or = 181 minutes with hepatic impairment]). CONCLUSIONS: Correlation of plasma argatroban concentration versus the patient's coagulation variables and clinical course suggest that prolonged elevated levels of plasma argatroban may have contributed to the patient's extended coagulopathy. Because DTIs do not have reversal agents, surgical teams and transfusion services should remain aware of the possibility of massive transfusion events during anticoagulation with these agents. This is the first report to measure plasma argatroban concentration in the context of CPB and extended coagulopathy.

The new Food and Drug Administration drug package insert: implications for patient safety and clinical care.

The United States Food and Drug Administration (FDA) is the scientific, regulatory, and public health agency that regulates many products, including food products, drugs, medical devices, radiation emitting devices, and cosmetics for the federal government of the United States. The FDA's mission is to assure that consumer products made and sold in the United States are safe, effective, and pure. The purpose of the package insert (also known as prescription drug product insert or professional labeling) is to provide detailed drug information compiled and distributed by the drug manufacturer, after FDA review and approval. In 2006, the standard format for the package insert was changed in an attempt to make it more user-friendly and a more efficient resource tool for practitioners. According to the Institute of Medicine, in-hospital adverse drug reactions occur at a rate of 400,000 per year and incur $3.5 billion of extra hospital expense. It is expected that the new package insert format will enhance rapid access to important pharmacologic information and improve patient safety by decreasing medication errors.