Development and validation of a machine learning method to predict intraoperative red blood cell transfusions in cardiothoracic surgery.

Accurately predicting red blood cell (RBC) transfusion requirements in cardiothoracic (CT) surgery could improve blood inventory management and be used as a surrogate marker for assessing hemorrhage risk preoperatively. We developed a machine learning (ML) method to predict intraoperative RBC transfusions in CT surgery. A detailed database containing time-stamped clinical variables for all CT surgeries from 5/2014-6/2019 at a single center (n = 2410) was used for model development. After random forest feature selection, surviving features were inputs for ML algorithms using five-fold cross-validation. The dataset was updated with 437 additional cases from 8/2019-8/2020 for validation. We developed and validated a hybrid ML method given the skewed nature of the dataset. Our Gaussian Process (GP) regression ML algorithm accurately predicted RBC transfusion amounts of 0 and 1-3 units (root mean square error, RMSE 0.117 and 1.705, respectively) and our GP classification ML algorithm accurately predicted 4 + RBC units transfused (area under the curve, AUC = 0.826). The final prediction is the regression result if classification predicted < 4 units transfused, or the classification result if 4 + units were predicted. We developed and validated an ML method to accurately predict intraoperative RBC transfusions in CT surgery using local data.

Advanced airway management and respiratory care in decompensated pulmonary hypertension.

Meticulous risk stratification is essential when considering intubation of a patient with decompensated pulmonary hypertension (dPH). It is paramount to understand both the pathophysiology of dPH (and associated right ventricular failure) and the complications related to a high-risk intubation before attempting the procedure. There are few recommendations in this area and the literature, guiding these recommendations, is limited to expert opinion and very few case reports/case series. This review will discuss the complex pathophysiology of dPH, the complications associated with intubation, the debates surrounding induction agents, and the available options for the intubation procedure, with specific emphasis on the emerging role for awake fiberoptic intubation. All patients should be evaluated for candidacy for veno-arterial extracorporeal membrane oxygen as a bridge to recovery, lung transplantation, or pulmonary endarterectomy prior to intubation. Only an experienced proceduralist who is both comfortable with high-risk intubations and the pathophysiology of dPH should perform these intubations.

Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel.

Diagnostic point-of-care ultrasound (PoCUS) has emerged as a powerful tool to help anesthesiologists guide patient care in both the perioperative setting and the subspecialty arenas. Although anesthesiologists can turn to guideline statements pertaining to other aspects of ultrasound use, to date there remains little in the way of published guidance regarding diagnostic PoCUS. To this end, in 2018, the American Society of Anesthesiologists chartered an ad hoc committee consisting of 23 American Society of Anesthesiologists members to provide recommendations on this topic. The ad hoc committee convened and developed a committee work product. This work product was updated in 2021 by an expert panel of the ad hoc committee to produce the document presented herein. The document, which represents the consensus opinion of a group of practicing anesthesiologists with established expertise in diagnostic ultrasound, addresses the following issues: (1) affirms the practice of diagnostic PoCUS by adequately trained anesthesiologists, (2) identifies the scope of practice of diagnostic PoCUS relevant to anesthesiologists, (3) suggests the minimum level of training needed to achieve competence, (4) provides recommendations for how diagnostic PoCUS can be used safely and ethically, and (5) provides broad guidance about diagnostic ultrasound billing.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: recommendations.

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications.

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.

The Year in Perioperative Echocardiography: Selected Highlights From 2019.

This article is the fourth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board, for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles targetted the use of perioperative echocardiography in general.

Strain Imaging: An Everyday Tool for the Perioperative Echocardiographer.

Strain analysis allows for global and regional analysis of myocardial function and has been shown to be an independent predictor of outcomes after cardiac surgery. Strain imaging offers advantages over traditional EF measurements in that it is relatively angle independent, it is less dependent upon loading conditions, it is reproducible, it does not rely on geometric assumptions, and it can detect subclinical systolic dysfunction. Limitations of strain analysis include high temporal resolution requirements, a strong dependence on image quality, and inter-vendor variability. In addition, there is a paucity of data on the intraoperative applications of strain. The ASE has defined a global longitudinal strain of -20% measured by transthoracic echocardiography to be considered normal, with less negative values considered abnormal. Presently, there are no published guidelines on the normal values of strain with transesophageal echocardiography (TEE). However, multiple studies have shown that a reduction in intraoperative strain assessed with TEE has been shown to be an independent predictor of complications during cardiac surgery. Accordingly, further incorporation of intraoperative strain analysis with TEE could aid in prognostication for patients undergoing cardiac surgery. As perioperative strain analysis continues to advance, an understanding of these concepts is imperative for perioperative echocardiographers. It is the authors' goal to show that strain imaging can provide a reliable and objective measure that can be performed in real time to aid in decision-making and perioperative risk stratification.

Secondary-Sphere Chlorolanthanide(III) Complexes with a 1,3,5-Triazine-Based Ligand Supported by Anion-π, π-π, and Hydrogen-Bonding Interactions.

2,4,6-Dipicolylamine-functionalized 1,3,5-triazine (dpat) was isolated. When reacted with LaCl3, compound [(LaCl6)(H3dpat)][H2O]2 (1) formed, which crystallized in the monoclinic P21/n space group with parameters a = 11.47 Å, b = 19.22 Å, c = 20.98 Å, V = 4652.02 Å, and ß = 90.53°. When reacted with NdCl3, the complex [NdCl3(H2O)4(H3dpat)][Cl]3(MeOH)2 (2) crystallized in the monoclinic P21/n space group with unit cell parameters a = 20.05 Å, b = 12.81 Å, c = 20.64 Å, V = 5004.40 Å, and ß = 110.20°. In both cases, the dpat ligand forms a bowl-shaped cavity that partially envelops the LnIII-containing central unit, which is anionic in 1 and neutral in 2. The formation of these outer-sphere complexes is supported by secondary interactions, including π-π stacking, hydrogen bonding, and anion-π between the chlorolanthanide(III) fragment and the electron-deficient 1,3,5-triazine ring. Evidence of protonation of the pyridine rings in dpat was substantiated through the isolation of [H2dpat][Cl]2 (3). This compound crystallized in the monoclinic C2/c space group with parameters a = 11.93 Å, b = 20.22 Å, c = 15.28 Å, V = 3664.97 Å, and ß = 94.35°. Four pyridine rings are pairwise protonated in 3. dpat showed a moderate ability to extract LaIII from an aqueous to an organic phase, indicating its potential, through judicious manipulation of secondary-sphere interactions, as the starting point for efficient extractants for LnIII ions.

Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU-A Retrospective Review.

OBJECTIVE: The most effective method of image guidance for venovenous extracorporeal membrane oxygenation is not known. The authors' objectives were to define the frequency of successful initial cannulation using echocardiographic guidance in the intensive care unit, as well as to determine the frequency of subsequent adjustments. Additional aims were to illustrate cannula malposition problems and to describe features associated with difficult cannulation. DESIGN: Retrospective consecutive case series analysis. SETTING: Single tertiary care university hospital. PARTICIPANTS: Forty-five patients treated with venovenous extracorporeal membrane oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The most common causes of respiratory failure were pneumonia, aspiration, and inhalational burn injury. Sixty-two percent survived to discharge. Initial cannulation was successful in 39 cases (87%). Adverse events included 5 cases of cannula malposition and 1 case of hemorrhagic shock. During the course of extracorporeal membrane oxygenation, 17 patients (38%) required echo-guided cannula position adjustments. There were no fatal complications. Factors associated with difficult cannulation included extremes of size, a prominent Eustachian valve, and an anterior guidewire bending in the right atrium. Younger age was associated positively with survival. There was no significant association between adverse events during cannulation and survival. CONCLUSIONS: Dual-lumen venovenous extracorporeal membrane oxygenation cannulation in the intensive care unit under echo guidance has a high initial success rate, but many patients require subsequent repositioning. Echocardiography can define cannula position in sufficient detail to identify malposition precisely and to guide repositioning.

Anion-π and H-Bonding Interactions Supporting Encapsulation of [Ln(NO3)6/5]3-/2- (Ln = Nd, Er) with a Triazine-Based Ligand.

Reaction of NdIII and ErIII nitrate salts with a 1,3,5-tris(dipicolylamine)-triazine (dpat) ligand yielded two unprecedented examples of [Ln(NO3)6/5]3-/2- (Ln = Nd, Er) moieties completely encapsulated by the ligands. They are found in the two new complexes, [(H3dpat)2][(Nd(NO3)6)2]·2CH3CN (1), and the related [(H3dpat)2][(Er(NO3)5)3]·3CH3CN·2H2O (2). The structures of the complexes are similar and they crystallize in the triclinic P-1 space group with a = 12.1630(3), b = 12.2694(3), c = 17.6357(5) Å, V = 2611.10(12) Å3, and a = 14.3372(4), b = 17.1271(4), c = 25.2207(7) Å, V = 5934.7(3) Å3, respectively. Anion-π interactions, which are reported here for the first time for LnIII ion complexes, hydrogen bonding interactions and π-π stacking support the formation of the encapsulated species. Evidence of the protonated dpat ligand in 1 and 2 was found through isolation of (H2dpat)(NO3)2. Finally, the pH-dependent ability of the ligand to extract LaIII and nitrate ions from aqueous into toluene solution is demonstrated.

Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation.

Cardiac arrest is one of the most challenging patient presentations managed by emergency care providers, and echocardiography can be instrumental in the diagnosis, prognosis, and treatment guidance in these critically ill patients. Transesophageal echocardiography has many advantages over transthoracic echocardiography in a cardiac arrest resuscitation. As transesophageal echocardiography is implemented more widely at the point of care during cardiac arrest resuscitations, guidelines are needed to assist emergency providers in acquiring the equipment and skills necessary to successfully incorporate it into the management of cardiac arrest victims.

Implementation of national practice guidelines to reduce waste and optimize patient value.

BACKGROUND: The financial health care crisis has provided the platform to drive operational improvements at US health care facilities. This has led to adoption of lean operation principles by many health care organizations as a means of eliminating waste and improving operational efficiencies and overall value to patients. We believe that standardized implementation of national practice guidelines can provide the framework to help to reduce financial waste. MATERIALS AND METHODS: We analyzed our institutional preoperative electrocardiogram (ECG) ordering practices for patients undergoing elective surgery at our institution from February-March, 2012 to identify utilization and review compliance with American Heart Association guidelines. We then implemented an ECG ordering algorithm based on these guidelines and studied changes in ordering patterns, associated cost savings and hospital billing for the same period in 2013. RESULTS: From February-March 2012, 677 noncardiac surgical procedures were performed at our institution, and 312 (46.1%) had a preoperative ECG. After implementation of our evidence-based ECG ordering algorithm for the same period in 2013, 707 noncardiac surgical cases were performed, and 120 (16.9%) had a preoperative ECG. Preoperative ECG utilization dropped 63% with an annual institutional cost savings of $72,906 and $291,618 in total annual health care savings. Based on our data, US-wide implementation of our evidence-based ECG ordering algorithm could save the US health care system >$1,868,800,000 per year. CONCLUSIONS: Here, we demonstrate that standardized application of a national practice guideline can be used to eliminate nearly $2 billion per year in waste from the US health care system.

The Effect of Perioperative Rescue Transesophageal Echocardiography on the Management of Trauma Patients.

To evaluate the effect of rescue transesophageal echocardiography (TEE) on the management of trauma patients, we reviewed imaging and charts of unstable trauma patients at a level I trauma center. Critical rescue TEE findings included acute right ventricular failure, stress cardiomyopathy, type B aortic dissection, mediastinal air, and dynamic left ventricular outflow tract obstruction. Left ventricular filling was classified as low (underfilled) in 57% of all cases. Rescue TEE revealed a variety of new diagnoses and led to a change in resuscitation strategy about half of the time.

Abbreviated right-sided heart echocardiogram and the STOP-Bang questionnaire-a useful relationship for preoperative patient evaluation?

STUDY OBJECTIVE: The aims of this study were to (1) explore the incidence of right-sided heart dysfunction (RHD) and STOP-Bang questionnaire responses consistent with obstructive sleep apnea (OSA) and (2) assess the relationship between patients with STOP-Bang questionnaire responses consistent with OSA and echocardiographic findings suggestive of RHD. DESIGN: Observational study. SETTING: Tertiary academic center preoperative clinic. PATIENTS: Two hundred patients presenting for elective surgery to the University of Utah preoperative clinic. INTERVENTION: Abbreviated transthoracic right-sided echocardiogram and STOP-Bang questionnaire. MEASUREMENTS: Tricuspid annular plane systolic excursion, tissue Doppler-derived tricuspid lateral annular systolic velocity (S'), and the tricuspid inflow E wave to tricuspid annular tissue Doppler e' wave ratio (E/e') for the presence of RHD, as well as responses to STOP-Bang questionnaire. MAIN RESULTS: A total of 140 echocardiograms were analyzed after exclusion of participants with incomplete STOP-Bang questionnaires and inadequate images. Thirty-five patients (25%) reported 5 or more positive responses to the STOP-Bang questionnaire. Forty-six patients (35%) had abnormal right-sided heart measurements. Of the 35 patients with STOP-Bang scores 5 or greater, 11 (31%) had evidence of RHD. No correlation was observed between STOP-Bang scores and the echocardiography metrics of RHD. CONCLUSIONS: This preliminary study suggests that there are numerous sources of RHD, among one of which is sleep apnea, and/or the STOP-Bang questionnaire is not a sensitive tool for predicting RHD. We conclude that although the STOP-Bang questionnaire is easy to implement in a preoperative clinical setting, it is not useful in identifying patients at risk for RHD.

Cervical Spine Fracture Presenting as an Orthostatic Headache Secondary to Cerebral Spinal Fluid Leak.

BACKGROUND: Head injuries are a common chief complaint encountered in the emergency department (ED). A cerebrospinal fluid (CSF) leak resulting from such injuries is uncommon, but has potentially debilitating consequences if undiagnosed. CASE REPORT: A 34-year-old male patient presented to the ED with complaints of an orthostatic headache after a bicycle accident that occurred 5 days prior to presentation. He presented with a nonfocal neurologic examination. Computed tomography (CT) of the head was without significant pathology. CT angiography of the neck, performed due to a concern about traumatic arterial dissection, revealed C7 spinal fractures, but no evidence of dissection or occlusion of the arteries in the neck. Lying flat, he appeared comfortable but became quite symptomatic upon sitting upright or standing. Based on this finding, a CSF leak was suspected and he was admitted for symptom control and more detailed imaging to rule out such a leak. He was found, on magnetic resonance imaging, to have epidural CSF collections consistent with the suspected leak. In addition to immobilization for the cervical spine fracture, he was treated for orthostatic headaches conservatively with good outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although this syndrome is still considered rare compared to other posttraumatic injuries, there is a growing body of evidence suggesting it may be underdiagnosed. Additionally, the signs and symptoms of this syndrome are nonspecific, with the exclusion of the orthostatic headache, and may be readily attributed to other diagnoses.