[Show abstract][Hide abstract] ABSTRACT: To assess the relationship between the addition of advanced monitoring variables and changes in clinical decision-making. A 15-questions survey was anonymously emailed to international experts and physician members of five anesthesia societies which focused on assessing treatment decisions of clinicians during three realistic clinical scenarios measured at two distinct time points. The first is when typical case information and basic monitoring (T1) were provided, and then once again after the addition of advanced monitoring variables (T2). We hypothesized that the addition of advanced variables would increase the incidence of an optimal therapeutic decision (a priori defined as the answer with the highest percentage of expert agreement) and decrease the variability among the physician's suggested treatments. The survey was completed by 18 experts and 839 physicians. Overall, adding advanced monitoring did not significantly increase physician response accuracy, with the least substantial changes noted on questions related to volume expansion or vasopressor administration. Moreover, advanced monitoring data did not significantly decrease the high level of initial practice variability in physician suggested treatments (P = 0.13), in contrast to the low variability observed within the expert group (P = 0.039). Additionally, 5-10 years of practice (P < 0.0001) and a cardiovascular subspecialty (P = 0.048) were both physician characteristics associated with a higher rate of optimal therapeutic decisions. The addition of advanced variables was of limited benefit for most physicians, further indicating the need for more in depth education on the clinical value and technical understanding of such variables.
Full-text · Article · Dec 2015 · Journal of Clinical Monitoring and Computing
[Show abstract][Hide abstract] ABSTRACT: Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered.
Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them.
The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration.
We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.
[Show abstract][Hide abstract] ABSTRACT: Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare that to matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload independent state, defined as percent of case time with stroke volume variation less than or equal to 12%.
Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic, or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias.
40 patients were enrolled, 5 ultimately excluded, and 25 match pairs were found from the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, p = 0.008). There was no difference in case mean or final stroke volume index (45 ± 10 vs. 43 ± 9, and 45 ± 11 vs. 42 ± 11, respectively) or mean arterial pressure (79 ± 8 vs. 83 ± 9). Case-end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 vs.88 ± 13, p = 0.003).
In this case control study with propensity matching, clinician use of the closed-loop assistance resulted in a greater portion of case time spent in a preload independent state throughout surgery when compared to manual delivery of goal-directed fluid therapy.
ClinicalTrials.gov Identifier: NCT02020863 , Date of registration: December 19, 2013.
Full-text · Article · Dec 2015 · Critical care (London, England)
[Show abstract][Hide abstract] ABSTRACT: Although surgery has become much safer, it has also becoming increasingly more complex and perioperative complications continue to impact millions of patients worldwide each year. Perioperative hemodynamic optimization utilizing Goal Directed Therapy (GDT) has attracted considerable interest within the last decade due to its ability to improve postoperative short and long-term outcomes in patients undergoing higher risk surgeries. The concept of GDT in this context can be loosely defined as collecting data from minimally invasive hemodynamic monitors with the intention of using such data (flow-related parameters and/or dynamic parameters of fluid responsiveness) to titrate therapeutic interventions (intravenous fluids and/or inotropic therapy administration) with the ultimate aim of optimizing end organ tissue perfusion. Recently, the increasing amount of evidence supporting the implementation of GDT strategies has been considered so robust as to allow for the creation of national recommendations in the United Kingdom (UK), France, and Europe. These recommendations from such influential scientific societies and the potential clinical and economic benefits of GDT protocols need to also be examined within the current shift from a "pay for service" to a "pay for performance" health care system. This shift is strongly encouraged within emerging systems such as the Perioperative Surgical Home (PSH) paradigm from the United States. As a result, hospitals and clinicians around the world have become increasingly incentivized to implement perioperative hemodynamic optimization using GDT strategies within their departments. Unfortunately, its adoption continues to be quite limited and a lack of standardized criteria for perioperative fluid administrations has resulted in significant clinical variability among practitioners. This current review will provide a brief up-to-date overview of GDT, discuss current clinical practice, analyze why implementation has been limited and finally, describe the newer closed-loop GDT concept along with its potential risks and benefits.
[Show abstract][Hide abstract] ABSTRACT: Contrary to the intraoperative period, the current perioperative environment is known to be fragmented and expensive. One of the potential solutions to this problem is the newly proposed perioperative surgical home (PSH) model of care. The PSH is a patient-centred micro healthcare system, which begins at the time the decision for surgery is made, is continuous through the perioperative period and concludes 30 days after discharge from the hospital. The model is based on multidisciplinary involvement: coordination of care, consistent application of best evidence/best practice protocols, full transparency with continuous monitoring and reporting of safety, quality, and cost data to optimize and decrease variation in care practices. To reduce said variation in care, the entire continuum of the perioperative process must evolve into a unique care environment handled by one perioperative team and coordinated by a leader. Anaesthesiologists are ideally positioned to lead this new model and thus significantly contribute to the highest standards in transitional medicine. The unique characteristics that place Anaesthesiologists in this framework include their systematic role in hospitals (as coordinators between patients/medical staff and institutions), the culture of safety and health care metrics innate to the specialty, and a significant role in the preoperative evaluation and counselling process, making them ideal leaders in perioperative medicine.
[Show abstract][Hide abstract] ABSTRACT: Point-of-care (POC) ultrasonography can be defined as ultrasonography brought to the patient and performed by the provider in real time. Anesthesiologists commonly use this modality to aid regional anesthesia and central vascular access. However, as POC ultrasonography has been further developed, utility of this technology has increased in the areas of hemodynamic monitoring, cardiopulmonary function, and other areas that are relevant for the perioperative physician. This manuscript seeks to provide a review of the literature of point-of-care ultrasound topics that are relevant for the anesthesiologist. These topics will include (I) assessment of preload and fluid responsiveness, (II) assessment of mechanisms of hypotension and shock, (III) evaluation of pulmonary function, (IV) advanced vascular access, and (V) additional areas of POC ultrasound for perioperative improvement. Finally, this manuscript will suggest a novel POC ultrasound curriculum that integrates the components of this review into a comprehensive perioperative ultrasound examination, abbreviated as FORESIGHT (focused, perioperative, risk, evaluation, sonography, involving, gastro-abdominal, hemodynamic, and trans-thoracic ultrasound) exam.
[Show abstract][Hide abstract] ABSTRACT: Several minimally-invasive technologies are available for cardiac output (CO) measurement in children, but the accuracy and precision of these devices have not yet been evaluated in a systematic review and meta-analysis. We conducted a comprehensive search of the medical literature in PubMed, Cochrane Library of Clinical Trials, Scopus, and Web of Science from its inception to June 2014 assessing the accuracy and precision of all minimally-invasive CO monitoring systems used in children when compared with CO monitoring reference methods. Pooled mean bias, standard deviation, and mean percentage error of included studies were calculated using a random-effects model. The inter-study heterogeneity was also assessed using an I(2) statistic. A total of 20 studies (624 patients) were included. The overall random-effects pooled bias, and mean percentage error were 0.13 ± 0.44 l min(-1) and 29.1 %, respectively. Significant inter-study heterogeneity was detected (P < 0.0001, I(2) = 98.3 %). In the sub-analysis regarding the device, electrical cardiometry showed the smallest bias (-0.03 l min(-1)) and lowest percentage error (23.6 %). Significant residual heterogeneity remained after conducting sensitivity and subgroup analyses based on the various study characteristics. By meta-regression analysis, we found no independent effects of study characteristics on weighted mean difference between reference and tested methods. Although the pooled bias was small, the mean pooled percentage error was in the gray zone of clinical applicability. In the sub-group analysis, electrical cardiometry was the device that provided the most accurate measurement. However, a high heterogeneity between studies was found, likely due to a wide range of study characteristics.
No preview · Article · Aug 2015 · International Journal of Clinical Monitoring and Computing
[Show abstract][Hide abstract] ABSTRACT: The perceptions of anesthesiologists of US health care finance reform are germane to informing the future of our specialty. For this reason, we sought to assess anesthesiologists' views of their own importance in cost-reduction strategies. In addition, respondents were asked a series of questions related to the Perioperative Surgical Home.
A cross-sectional survey was sent through email to 6000 randomly chosen active members of the American Society of Anesthesiologists. Respondents were asked to indicate what level of responsibility they perceive stakeholders to have in reducing the cost of health care and perioperative care delivery. Respondents were then asked to describe their relative enthusiasm for cost-reduction strategies. To validate the primary outcome, we took advantage of the American Society of Anesthesiologists' recent focus on the Perioperative Surgical Home to ask a series of related questions as comparators.
Thirty-eight percent (95% confidence interval, 35-42) of respondents indicated that physicians bear "major responsibility" for cost reduction, 58% (55-61) indicated that physicians bear "some responsibility," and 4%, only a small fraction (0.7-7.5) indicated that physicians bear "no responsibility." Respondents also indicated that other entities listed bear "major responsibility" for cost reduction including hospitals (57% [54-61]) and insurance companies (54% [51-57]). Comparator data from questions not designed to directly measure the primary outcome are reported, including questions about the Perioperative Surgical Home.
US anesthesiologists surveyed perceive other stakeholders, such as hospitals and insurance companies, as having a major responsibility in cost reduction. Furthermore, they are not enthusiastic about substantial financial reform such as cuts to Medicare payments.
No preview · Article · Jul 2015 · Anesthesia and analgesia
[Show abstract][Hide abstract] ABSTRACT: The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training.
For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data.
Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%.
Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.
[Show abstract][Hide abstract] ABSTRACT: Perioperative Goal Directed Therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention.
This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/h and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database).
In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 [7.1-13.0] ml/kg/h in the pre- and 6.6 [4.7-9.5] ml/kg/h in the post-implementation period (p<0.01). LOS decreased from 10 [6-16] days to 7 [5-11] days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE=0.054, p=0.0002) indicating that with the other conditions being held the same, introducing intervention reduced LOS by 18 % (95 % CI: 9 %-27 %). The incidence of NSQIP complications decreased from 39 % to 25 % (p=0.04).
These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries.
Clinicaltrials.gov NCT02057653 . Registered 17 December 2013.
Preview · Article · Jun 2015 · Critical care (London, England)
[Show abstract][Hide abstract] ABSTRACT: Determination of hemoglobin (Hb) concentration is essential for the detection of anemia and hemorrhage and is widely used to evaluate a patient for a possible blood transfusion. Although commonly accepted as intrinsic to the process, traditional laboratory measurements of Hb are invasive, intermittent, and time-consuming. Noninvasive Hb (NIHb)-monitoring devices have recently become available and promise the potential for detecting sudden changes in a patient's Hb level. In addition to reduced delays in clinical intervention, these devices also allow for a reduction in patient discomfort, infection risk, required personnel, and long-term costs. Unfortunately, it has been shown that many clinical factors can influence their accuracy.
Many studies have been published on the accuracy and precision of NIHb-monitoring devices in various clinical settings. A recent meta-analysis has shown a small mean difference but wide limits of agreement between NIHb and laboratory measurements, indicating that caution should be used by physicians when making clinical decisions based on this device.
NIHb measurements may currently be considered to be a supplemental tool for monitoring trends in Hb concentration, but are not currently developed enough to replace an invasive approach. Moreover, further studies are still required before implementing NIHb in the clinical decision-making process. Specifically, no studies have demonstrated that this technology improves clinical outcomes or patient safety.
No preview · Article · Mar 2015 · Current opinion in critical care