Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis.

BACKGROUND: Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income. METHODS: We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level. RESULTS: We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04). CONCLUSIONS: Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.

Global Comparison of Communication of End-of-Life Decisions in the ICU.

BACKGROUND: Prolonging life in the ICU increasingly is possible, so decisions to limit life-sustaining therapies frequently are made and communicated to patients and families or surrogates. Little is known about worldwide communication practices and influencing factors. RESEARCH QUESTION: Are there regional differences in end-of-life communication practices in ICUs worldwide? STUDY DESIGN AND METHODS: This analysis of data from a prospective, international study specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6 months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively for each ICU using a 12-point questionnaire developed previously. RESULTS: Of 87,951 patients admitted, 12,850 died or experienced a limitation of therapy (14.6%). Of these, 1,199 patients (9.3%) were known to have an advance directive, and wishes were elicited from 6,456 patients (50.2%). Limitations of life-sustaining therapy were implemented for 10,401 patients (80.9%), 1,970 (19.1%) of whom had mental capacity at the time, and were discussed with 1,507 patients (14.5%) and 8,461 families (81.3%). Where no discussions with patients occurred (n = 8,710), this primarily was because of a lack of mental capacity in 8,114 patients (93.2%), and where none occurred with families (n = 1,622), this primarily was because of unavailability (n = 720 [44.4%]). Regional variation was noted for all end points. In generalized estimating equation (GEE) analyses, the odds for discussions with the patient or family increased by 30% (OR, 1.30; 95% CI, 1.18-1.44; P < .001) for every one-point increase in the Ethical Practice Score and by 92% (OR, 1.92; 95% CI, 1.28-2.89; P = .002) in the presence of an advance directive. INTERPRETATION: End-of-life communication with patients and families or surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes.

Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality.

Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.

Beyond the Nuts and Bolts: Tele-Critical Care Patients, Workflows, and Activity Patterns.

Background: Tele-critical care (TCC) adoption has been slow since its emergence in the early 2000s. The COVID-19 pandemic has renewed interest in telemedicine and may spur expansion or development of new TCC programs. This narrative addresses the Cleveland Clinic TCC service, (eHospital) to promote exchange of ideas to continually optimize the practice for current and future users. Methods: A descriptive narrative methodology is used in this report. Results: Cleveland Clinic's eHospital was established in 2014 to support nighttime critical care across system hospitals. It encompasses a tiered system of two-way audiovisual communication, telemetry, software platform that integrates the electronic health record, and a proprietary risk stratification algorithm for targeted electronic surveillance. The TCC team includes intensivists, advanced care providers, and registered nurses. Three coverage models evolved depending on onsite clinician availability. More than 133,000 patients have been served by eHospital to date, and span the typical spectrum of critical illness. Along with universal monitoring, ∼18% of patients received active interventions, the most common of which are categorized. Patterns of activity, typical workflows, and adaptations of bedside best practices are also described. Bookending the work shift are sign outs focused on pending critical issues, unstable patients, and those who can be triaged out of the intensive care unit. In between, TCC teams round periodically and interact with bedside teams. Conclusions: TCC adoption has proceeded slowly. Some acceleration is anticipated in a post-COVID-19 pandemic world. Our experience highlights operational practices that can facilitate successful TCC practice.

A Multicenter Evaluation of Survival After In-Hospital Cardiac Arrest in Coronavirus Disease 2019 Patients.

IMPORTANCE: In-hospital cardiac arrest survival among coronavirus disease 2019 patients has been reported to range from 0% to 12%. These numbers are significantly lower than reported prepandemic in-hospital cardiac arrest survival rates of approximately 20-25% in the United States for non-coronavirus disease 2019 patients. OBJECTIVE: To assess the incidence of in-hospital cardiac arrest survival of coronavirus disease 2019 patients. DESIGN: A retrospective cohort study of adult patients with coronavirus disease 2019 subsequently found to have in-hospital cardiac arrest and underwent cardiopulmonary resuscitation (cardiopulmonary resuscitation). SETTING: Multiple hospitals of the Cleveland Clinic Health System. PATIENTS: All adult patients (age ≥ 18 yr) admitted to Cleveland Clinic Health System with a diagnosis of coronavirus disease 2019 who experienced in-hospital cardiac arrest requiring cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS: From March 01, 2020 to October 15, 2020, 3,555 patients with coronavirus disease 2019 were hospitalized; 1,372 were admitted to the ICU; 58 patients had in-hospital cardiac arrest. Median age of this cohort was 66.5 years (interquartile range, 55.0-76.0 yr). Patients were predominantly male (62.5%), White (53.4%), with a median body mass index of 29.7 (interquartile range, 25.8-34.6). Most in-hospital cardiac arrests were in critical care environments (ICU), 51 of 58 (87.9%); seven of 58 (12.1%) were on ward locations. Thirty-four of 58 patients (58.6%) were on mechanical ventilation prior to in-hospital cardiac arrest with a median duration of mechanical ventilation of 9 days (interquartile range, 2-18 d). Twenty-four of 58 patients (44%) were on vasopressors prior to arrest. Initial arrest rhythm was pulseless electrical activity at (63.8%), asystole (29.3%), and pulseless ventricular tachycardia/fibrillation (6.9%). Of the 58 patients, 35 (60.3%) attained return of spontaneous circulation, and 13 of 58 (22.4%) were discharged alive. CONCLUSIONS: We report a 22% survival to discharge after in-hospital cardiac arrest in coronavirus disease 2019 patients, a survival rate similar to before the coronavirus disease 2019 pandemic.

A Novel Method to Improve Perfusion of Ex Vivo Pumped Human Kidneys.

OBJECTIVE: To determine if addition of the S-nitrosylating agent ethyl nitrite (ENO) to the preservation solution can improve perfusion parameters in pumped human kidneys. BACKGROUND: A significant percentage of actively stored kidneys experience elevations in resistance and decreases in flow rate during the ex vivo storage period. Preclinical work indicates that renal status after brain death is negatively impacted by inflammation and reduced perfusion-processes regulated by protein S-nitrosylation. To translate these findings, we added ENO to the preservation solution in an attempt to reverse the perfusion deficits observed in nontransplanted pumped human kidneys. METHODS: After obtaining positive proof-of-concept results with swine kidneys, we studied donated human kidneys undergoing hypothermic pulsatile perfusion deemed unsuitable for transplantation. Control kidneys continued to be pumped a 4°C (ie, standard of care). In the experimental group, the preservation solution was aerated with 50 ppm ENO in nitrogen. Flow rate and perfusion were recorded for 10 hours followed by biochemical analysis of the kidney tissue. RESULTS: In controls, perfusion was constant during the monitoring period (ie, flow rate remained low and resistance stayed high). In contrast, the addition of ENO produced significant and sustained reductions in resistance and increases in flow rate. ENO-treated kidneys had higher levels of cyclic guanosine monophosphate, potentially explaining the perfusion benefits, and increased levels of interleukin-10, suggestive of an anti-inflammatory effect. CONCLUSIONS: S-Nitrosylation therapy restored the microcirculation and thus improved overall organ perfusion. Inclusion of ENO in the renal preservation solution holds promise to increase the number and quality of kidneys available for transplant.

Association Between Perioperative Hypotension and Delirium in Postoperative Critically Ill Patients: A Retrospective Cohort Analysis.

BACKGROUND: Postoperative delirium is common in critically ill patients, with a reported incidence of 11%-43%, and is associated with significant morbidity and cost. Perioperative hypotension and consequent brain hypoperfusion may contribute. We, therefore, tested the hypotheses that intraoperative and postoperative hypotension are associated with critical care delirium. METHODS: We included 1083 postoperative patients who were admitted directly from an operating room to the surgical intensive care unit. Delirium was assessed with the Confusion Assessment Method for Intensive Care Unit patients at 12-hour intervals. We used a confounder-adjusted Cox proportional hazard survival model to assess the association between the amount of intraoperative hypotension, which was measured as the time-weighted average of mean arterial pressure <65 mm Hg, and delirium while in critical care. Thereafter, we used a Cox model with the lowest mean arterial pressure on each intensive care day as a time-varying covariate to assess the relationship between critical care hypotension and delirium, adjusted for confounders and amount of intraoperative hypotension. RESULTS: Three hundred seventy-seven (35%) patients had delirium within the first 5 postoperative days in the surgical intensive care unit. Intraoperative hypotension was moderately associated with higher odds of postoperative delirium. The adjusted hazard ratio associated with 1 mm Hg increase in time-weighted average of mean arterial pressure <65 mm Hg was 1.11 (95% confidence interval [CI], 1.03-1.20; P = .008). Postoperatively, a 10 mm Hg reduction in the lowest mean pressure on each day in the critical care unit was significantly associated with a higher hazard of delirium, with an adjusted hazard ratio 1.12 (95% CI, 1.04-1.20; P = .003). CONCLUSIONS: Both intraoperative and postoperative hypotension are associated with delirium in postoperative critical care patients. The extent to which these relationships are causal remains unknown, but to the extent that they are, hypotension prevention may help reduce delirium and should be studied in prospective clinical trials.

"Wishes Unknown: " A Case Report.

We report the case of a 55-year-old woman who required extracorporeal membrane oxygenation for extreme respiratory distress after a liver transplant and eventually died. As is so often the case, this patient's values and wishes were not documented before she had a risky surgical procedure. Anesthesiologists, in partnership with surgeons, can participate in preoperative discussions exploring wishes and values and document them in advance directives which will help clinicians respect patients' preferences.

Association Between Mean Arterial Pressure and Acute Kidney Injury and a Composite of Myocardial Injury and Mortality in Postoperative Critically Ill Patients: A Retrospective Cohort Analysis.

OBJECTIVES: Hypotension thresholds that provoke renal injury, myocardial injury, and mortality in critical care patients remain unknown. We primarily sought to determine the relationship between hypotension and a composite of myocardial injury (troponin T ≥ 0.03 ng/mL without nonischemic cause) and death up to 7 postoperative days. Secondarily, we considered acute kidney injury (creatinine concentration ≥ 0.3 mg/dL or 1.5 times baseline). DESIGN: Retrospective cohort. SETTING: Surgical ICU at an academic medical center. PATIENTS: Two-thousand eight-hundred thirty-three postoperative patients admitted to the surgical ICU. INTERVENTIONS: A Cox proportional hazard survival model was used to assess the association between lowest mean arterial pressure on each intensive care day, considered as a time-varying covariate, and outcomes. In sensitivity analyses hypotension defined as pressures less than 80 mm Hg and 70 mm Hg were also considered. MEASUREMENTS AND MAIN RESULTS: There was a strong nonlinear (quadratic) association between the lowest mean arterial pressure and the primary outcome of myocardial injury after noncardiac surgery or mortality, with estimated risk increasing at lower pressures. The risk of myocardial injury after noncardiac surgery or mortality was an estimated 23% higher at the 25th percentile (78 mm Hg) of lowest mean arterial pressure compared with at the median of 87 mm Hg, with adjusted hazard ratio (95% CI) of 1.23 (1.12-1.355; p < 0.001). Overall results were generally similar in sensitivity analyses based on every hour of mean arterial pressure less than 80 mm Hg and any mean arterial pressure less than 70 mm Hg. Post hoc analyses showed that the relationship between ICU hypotension and outcomes depended on the amount of intraoperative hypotension. The risk of acute kidney injury increased over a range of minimum daily pressures from 110 mm Hg to 50 mm Hg, with an adjusted hazard ratio of 1.27 (95% CI, 1.18-1.37; p < 0.001). CONCLUSIONS: Increasing amounts of hypotension (defined by lowest mean arterial pressures per day) were strongly associated with myocardial injury, mortality, and renal injury in postoperative critical care patients.

Factors Associated With Delirium in Surgical Intensive Care Unit Patients Treated With Supplemental Melatonin: A Case-Cohort Study.

OBJECTIVES: Intensive care unit (ICU) delirium is a common neuropsychiatric syndrome that confers significant morbidity and mortality. Melatonin is an endogenous neurohormone involved with regulating sleep-wake cycles and has been found to be disturbed in ICU delirium. We hypothesized that there are independent factors that predict delirium in a cohort of patients on melatonin in the surgical ICU (SICU). METHODS: A retrospective, observational case-cohort analysis of adult SICU patients was conducted. Cases were defined by testing positive on the Confusion Assessment Method for the ICU (CAM-ICU). Delirioprotective and deliriogenic factors were assessed prior to the studied melatonin administration. RESULTS: Forty-one CAM-ICU-positive cases and 59 CAM-ICU-negative controls were included. Higher mean Acute Physiology and Chronic Health Evaluation II scores were associated with delirium in univariable analysis. Stratified analysis found a higher incidence of delirium in baseline CAM-ICU-positive patients who experienced emergency surgery within 24 hours of admission compared with baseline CAM-ICU-negative patients after melatonin administration. CONCLUSIONS: This study describes the use of melatonin in the SICU and characterizes the patients who receive it. Further research is needed to determine the role of melatonin in deliriogenesis and to clarify its utility as a delirioprotectant for postsurgical, critical care patients.

Surgical Versus Medical Team Assignment and Secondary Palliative Care Services for Patients Dying in a Cardiac Hospital.

BACKGROUND:: Secondary palliative care (SPC) provides several benefits for patients with cardiovascular disease, but historically, it has been underutilized in this population. Prior research suggests a low rate of SPC consultation by surgical teams in general, but little is known about how surgical teams utilize SPC in the setting of severe cardiovascular disease. AIM:: To determine if surgical team assignment affects the probability of SPC for inpatients dying of cardiovascular disease. DESIGN:: Retrospective, cohort study. METHODS:: We identified all inpatients at a large cardiac hospital who had anticipated death under the care of a cardiology, cardiac surgery, or vascular surgery team in 2016. Our primary outcome was referral to SPC, including palliative medicine consultation or inpatient hospice care. Informed by univariate analysis, we created a multivariable logistic regression model, the significance of which was assessed with the Wald test. RESULTS:: Two hundred thirty-seven patients were included in our analysis: 93 (39%) received SPC and 144 (61%) were "missed opportunities." Secondary palliative care was less frequent in patients assigned to a surgical, versus medical, team (11% vs 47%, P < .001). On multivariate analysis, surgical versus medical team assignment was the strongest risk-adjusted predictor of SPC (odds ratio [OR]: 0.10, P < .001). Other predictors of SPC included do not resuscitate status on admission (OR: 14, P < .001), length of stay (OR = 1.05/day, P < .001), and having Medicare (OR = 3.9, P = .002). CONCLUSIONS:: Primary inpatient care by a surgical team had a strong inverse relationship with SPC. This suggests a possible cultural barrier within surgical disciplines to SPC.

Induced hypothermia in patients with septic shock and respiratory failure (CASS): a randomised, controlled, open-label trial.

BACKGROUND: Animal models of serious infection suggest that 24 h of induced hypothermia improves circulatory and respiratory function and reduces mortality. We tested the hypothesis that a reduction of core temperature to 32-34°C attenuates organ dysfunction and reduces mortality in ventilator-dependent patients with septic shock. METHODS: In this randomised, controlled, open-label trial, we recruited patients from ten intensive care units (ICUs) in three countries in Europe and North America. Inclusion criteria for patients with severe sepsis or septic shock were a mean arterial pressure of less than 70 mm Hg, mechanical ventilation in an ICU, age at least 50 years, predicted length of stay in the ICU at least 24 h, and recruitment into the study within 6 h of fulfilling inclusion criteria. Exclusion criteria were uncontrolled bleeding, clinically important bleeding disorder, recent open surgery, pregnancy or breastfeeding, or involuntary psychiatric admission. We randomly allocated patients 1:1 (with variable block sizes ranging from four to eight; stratified by predictors of mortality, age, Acute Physiology and Chronic Health Evaluation II score, and study site) to routine thermal management or 24 h of induced hypothermia (target 32-34°C) followed by 48 h of normothermia (36-38°C). The primary endpoint was 30 day all-cause mortality in the modified intention-to-treat population (all randomly allocated patients except those for whom consent was withdrawn or who were discovered to meet an exclusion criterion after randomisation but before receiving the trial intervention). Patients and health-care professionals giving the intervention were not masked to treatment allocation, but assessors of the primary outcome were. This trial is registered with ClinicalTrials.gov, number NCT01455116. FINDINGS: Between Nov 1, 2011, and Nov 4, 2016, we screened 5695 patients. After recruitment of 436 of the planned 560 participants, the trial was terminated for futility (220 [50%] randomly allocated to hypothermia and 216 [50%] to routine thermal management). In the hypothermia group, 96 (44·2%) of 217 died within 30 days versus 77 (35·8%) of 215 in the routine thermal management group (difference 8·4% [95% CI -0·8 to 17·6]; relative risk 1·2 [1·0-1·6]; p=0·07]). INTERPRETATION: Among patients with septic shock and ventilator-dependent respiratory failure, induced hypothermia does not reduce mortality. Induced hypothermia should not be used in patients with septic shock. FUNDING: Trygfonden, Lundbeckfonden, and the Danish National Research Foundation.

Increased Intraoperative Fluid Administration Is Associated with Severe Primary Graft Dysfunction After Lung Transplantation.

BACKGROUND: Severe primary graft dysfunction (PGD) is a major cause of early morbidity and mortality in patients after lung transplantation. The etiology and pathophysiology of PGD is not fully characterized and whether intraoperative fluid administration increases the risk for PGD remains unclear from previous studies. Therefore, we tested the hypothesis that increased total intraoperative fluid volume during lung transplantation is associated with the development of grade-3 PGD. METHODS: This retrospective cohort analysis included patients who had lung transplantation at the Cleveland Clinic between January 2009 and June 2013. We used multivariable logistic regression with adjustment for donor, recipient, and perioperative confounding factors to examine the association between total intraoperative fluid administration and development of grade-3 PGD in the initial 72 postoperative hours. Secondary outcomes included time to initial extubation and intensive care unit length of stay. RESULTS: Grade-3 PGD occurred in 123 of 494 patients (25%) who had lung transplantation. Patients with grade-3 PGD received a larger volume of intraoperative fluid (median 5.0 [3.8, 7.5] L) than those without grade-3 PGD (3.9 [2.8, 5.2] L). Each intraoperative liter of fluid increased the odds of grade-3 PGD by approximately 22% (adjusted odds ratio, 1.22; 95% confidence interval [CI], 1.12-1.34; P <0.001). The volume of transfused red blood cell concentrate was associated with grade-3 PGD (1.1 [0.0, 1.8] L for PGD-3 vs 0.4 [0.0, 1.1 for nongrade-3 PGD] L; adjusted odds ratio, 1.7; 95% CI, 1.08-2.7; P = 0.002). Increased fluid administration was associated with longer intensive care unit stay (adjusted hazard ratio, 0.92; 97.5% CI, 0.88-0.97; P < 0.001) but not with time to initial tracheal extubation (hazard ratio, 0.97; 97.5% CI, 0.93-1.02; P = 0.17). CONCLUSIONS: Increased intraoperative fluid volume is associated with the most severe form of PGD after lung transplant surgery. Limiting fluid administration may reduce the risk for development of grade-3 PGD and thus improve early postoperative morbidity and mortality after lung transplantation.

Impact of a focused transthoracic echocardiography training course for rescue applications among anesthesiology and critical care medicine practitioners: a prospective study.

OBJECTIVE: To investigate the impact of a sequence of educational interventions in a one-day course on focused transthoracic echocardiography (FOTE) by anesthesia and critical care practitioners. DESIGN: A prospective analysis of the educational data. SETTING: Educational setting in two academic medical centers and a medical meeting workshop organized by one of these institutions. PARTICIPANTS: Fifty-six anesthesia and critical care providers, divided into three groups, participated separately in a FOTE training course. INTERVENTIONS: All participants received a sequence of educational intervention as follows: A standardized, multiple-choice pretest; a lecture on cardiac and lung ultrasound; and a FOTE "hands-on" training session. The same standardized test was administered and graded as a posttest. MEASUREMENTS AND MAIN RESULTS: Fifty-six professionals attended the course in three separate groups: The first were cardiothoracic anesthesia fellows (n = 16) (group 1), the second included critical care practitioners (n = 21) (group 2), and the third were general anesthesiologists (n = 19) (group 3). Parasternal views were most difficult to obtain for all groups (58.1, 63.8, and 58%, respectively). The mean written test scores increased from 14.9±2 to 21.0±2.3 in group 1; from 12.3±3.8 to 19.2±3.7 in group 2; 12±3.5 to 21±2.4 in group 3, (p = 0.0003, 0.00005, 0.0001, respectively). CONCLUSIONS: A FOTE training course improves image acquisition skills and knowledge to the same level independently of professional background and level of experience in critical care ultrasound.

Sensitivity to volatile anesthetics in patients with dementia: a case-control analysis.

BACKGROUND: Patients with dementia are thought to be more sensitive to anesthesia, although volatile anesthetic requirement has not specifically been evaluated in this population. We tested the hypothesis that patients with dementia having non-cardiac surgery have a lower ratio of bispectral index (BIS) to minimal alveolar concentration (MAC) during the five minutes immediately preceding incision, thus exhibiting deeper hypnotic levels at a given MAC fraction. METHODS: We obtained records from our database registry on patients who had volatile general anesthesia during their most recent operation. We excluded patients premedicated with midazolam. Patients with dementia were identified and their diagnosis was confirmed by chart review. Each patient with dementia was successfully matched with a maximum of five patients without dementia using a multivariate nearest-neighbor distance-matching algorithm restricted to the following criteria: American Society of Anesthesiologists physical status, age, five-minute pre-incision time-weighted average (TWA) estimated effect-site concentration of propofol and fentanyl, and use of remifentanil. Our primary outcome was the TWA BIS-to-MAC ratio during the five minutes immediately preceding incision. RESULTS: We analyzed 31 patients with dementia matched with 151 patients without dementia. Median [quartiles] TWA BIS-to-MAC ratios for the matched patients were 85 [73, 100] for the patients with dementia and 78 [73, 84] for the patients without dementia. The percent difference in mean BIS-to-MAC ratios between patients with dementia and patients without dementia was 9% (95% confidence interval: -9% to 29%) (P = 0.35, Wald test). CONCLUSIONS: Our results do not support the hypothesis that patients with dementia are more sensitive to volatile anesthetics than patients without dementia.

Deceased donor hyperglycemia and liver graft dysfunction.

CONTEXT: Hyperglycemia is common in deceased donors, and provokes numerous adverse events in hepatocytic mitochondria. OBJECTIVE: To determine whether hyperglycemia in deceased donors is associated with graft dysfunction after orthotopic liver transplant. METHODS: Charts on 572 liver transplants performed at the Cleveland Clinic between January 2005 and October 2010 were reviewed. The primary measure was time-weighted averages of donors' glucose measurements. Liver graft dysfunction was defined as (1) primary nonfunction as indicated by death or retransplant or (2) liver graft dysfunction as indicated by an aspartate amino transferase level greater than 2000 U/L or prothrombin time greater than 16 seconds during the first postoperative week. The relationship of interest was estimated by using a multivariable logistic regression. RESULTS: The incidence of graft dysfunction was 25%. No significant relationship was found between the range of donor glucose measurements and liver graft dysfunction after donor characteristics were adjusted for (P= .14, Wald test, adjusted odds ratio [95% CI] for liver graft dysfunction corresponding to a relative doubling in time-weighted average for donor glucose of 1.43 [0.89-2.30]). The results thus do not suggest that strict glucose control in donors is likely to improve graft quality.

Comparable graft and patient survival in lean and obese liver transplant recipients.

Obesity is among the great health problems facing Americans today. More than 32% of the US population is considered obese on the basis of a body mass index (BMI) exceeding 30 kg/m(2) . Obesity increases the risk for numerous perioperative complications, but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplantation performed at the Cleveland Clinic between April 2005 and June 2011 in 2 groups: obese patients with a BMI ≥ 38 kg/m(2) and lean patients with a BMI between 20 and 26 kg/m(2) . We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting with the inverse propensity score. After we controlled for observed confounding, no significant differences were observed in graft/patient survival between obese and lean patients (P = 0.30). The estimated hazard ratio for obese patients to experience graft failure or death was 1.19 [95% confidence interval (CI) = 0.85-1.67]. There were 134 patients who had follow-up for more than 3 years, and they included 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome were significantly greater for obese patients (46%) versus lean patients (21%; odds ratio = 4.76, 99.5% CI = 1.66-13.7, P < 0.001). However, no significant association between obesity and any other long-term adverse outcomes was found. In conclusion, this study shows that transplant outcomes were comparable for lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplantation.

Trasplante cardíaco. Características del donante cardíaco en Uruguay / Heart transplantation. Profile of heart donor in Uruguay

El propósito de este análisis es determinar el perfil y el mantenimiento del donante cardíaco en Uruguay, las causas de descarte preextracción y evolución de la mortalidad en lista y días de espera hasta el trasplante. Material y método: se realizó una revisión de los donantes reales durante la actividad de la coordinación de trasplante, período 2000-2002. Resultados: se transplantaron 38 corazones, 79 por ciento de los cuales correspondieron a donantes mayores de 15 años con una edad promedio de 33,6 años, siendo el stroke la causa de muerte más frecuente (50 por ciento). El inotrópico utilizado con más frecuencia en el mantenimiento del donante fue la dopamina, logrando un descenso significativo de la dosis de 7,96±8,57 a 4,81±3,36 ug/Kg/min (p<0,05). La única variable que diferenció el perfil de ambos donantes fue la dosis final de dopamina: 8,23±7,5 versus 4,81±3,36 ug/Kg/min (p<0,05). Se trasplantan un promedio de 12,6 corazones por año, tasa de transplante cardíaco de 4,1 pmp/año, lo que representa casi una duplicación de la misma respecto a período de 1996-1999 (2,21 pmp/año). Se evidencia un descenso del 60 por ciento en los días de espera hasta el trasplante y una reducción de la mortalidad en lista del 52 al 25 por ciento. Conclusiones: la tasa de donación cardíaca en nuestro país es buena en el ámbito latinoamericano, pero con una baja tasa de pacientes en lista de espera. Se destaca un alto porcentaje de descarte por falta de receptor. El desarrollo de la coordinación ha logrado un descenso de la mortalidad en lista así como en los días de espera hasta el trasplante. El mantenimiento ha sido adecuado, no habiendo tenido pérdidas de donantes por parada cardíaca