A Review Evaluating Intravascular Access for High Volume Resuscitation: Can You Keep Up?

Anesthetists and anesthesiologists are frequently in the unique position of administering high-volume resuscitation in the setting of hemorrhage, hypovolemia, or vasodilatory shock.  The ability to rapidly infuse intravenous (IV) fluid solutions differs vastly for different types and sizes of IV access. In patients that may require rapid large volume resuscitation, it is critical to understand the capacity of existing IV devices.  Selecting the most appropriate IV access for patients can be paramount in preventing hypotension, end organ dysfunction, and even death. This article objectively reviews and compares the flow rates of commonly used central and peripheral intravenous devices to demonstrate the influence of catheter length and radius.   &nbsp

Genetic predisposition may not improve prediction of cardiac surgery-associated acute kidney injury

Background: The recent integration of genomic data with electronic health records has enabled large scale genomic studies on a variety of perioperative complications, yet genome-wide association studies on acute kidney injury have been limited in size or confounded by composite outcomes. Genome-wide association studies can be leveraged to create a polygenic risk score which can then be integrated with traditional clinical risk factors to better predict postoperative complications, like acute kidney injury.Methods: Using integrated genetic data from two academic biorepositories, we conduct a genome-wide association study on cardiac surgery-associated acute kidney injury. Next, we develop a polygenic risk score and test the predictive utility within regressions controlling for age, gender, principal components, preoperative serum creatinine, and a range of patient, clinical, and procedural risk factors. Finally, we estimate additive variant heritability using genetic mixed models.Results: Among 1,014 qualifying procedures at Vanderbilt University Medical Center and 478 at Michigan Medicine, 348 (34.3%) and 121 (25.3%) developed AKI, respectively. No variants exceeded genome-wide significance (p < 5 × 10−8) threshold, however, six previously unreported variants exceeded the suggestive threshold (p < 1 × 10−6). Notable variants detected include: 1) rs74637005, located in the exonic region of NFU1 and 2) rs17438465, located between EVX1 and HIBADH. We failed to replicate variants from prior unbiased studies of post-surgical acute kidney injury. Polygenic risk was not significantly associated with post-surgical acute kidney injury in any of the models, however, case duration (aOR = 1.002, 95% CI 1.000–1.003, p = 0.013), diabetes mellitus (aOR = 2.025, 95% CI 1.320–3.103, p = 0.001), and valvular disease (aOR = 0.558, 95% CI 0.372–0.835, p = 0.005) were significant in the full model.Conclusion: Polygenic risk score was not significantly associated with cardiac surgery-associated acute kidney injury and acute kidney injury may have a low heritability in this population. These results suggest that susceptibility is only minimally influenced by baseline genetic predisposition and that clinical risk factors, some of which are modifiable, may play a more influential role in predicting this complication. The overall impact of genetics in overall risk for cardiac surgery-associated acute kidney injury may be small compared to clinical risk factors

Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study

Objective: To evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do not translate into an increased risk of postoperative respiratory complications. Design: Hospital based registry study. Setting: Academic tertiary care hospital and two affiliated community hospitals in Massachusetts, United States. Participants: 69 265 consecutively enrolled patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation. Interventions Protective ventilation, defined as a median positive end expiratory pressure (PEEP) of 5 cmH2O or more, a median tidal volume of less than 10 mL/kg of predicted body weight, and a median plateau pressure of less than 30 cmH2O. Main outcome measure Composite outcome of major respiratory complications, including pulmonary edema, respiratory failure, pneumonia, and re-intubation. Results: Of the 69 265 enrolled patients 34 800 (50.2%) received protective ventilation and 34 465 (49.8%) received non-protective ventilation intraoperatively. Protective ventilation was associated with a decreased risk of postoperative respiratory complications in multivariable regression (adjusted odds ratio 0.90, 95% confidence interval 0.82 to 0.98, P=0.013). The results were similar in the propensity score matched cohort (odds ratio 0.89, 95% confidence interval 0.83 to 0.97, P=0.004). A PEEP of 5 cmH2O and median plateau pressures of 16 cmH2O or less were associated with the lowest risk of postoperative respiratory complications. Conclusions: Intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. A PEEP of 5 cmH2O and a plateau pressure of 16 cmH2O or less were identified as protective mechanical ventilator settings. These findings suggest that protective thresholds differ for intraoperative ventilation in patients with normal lungs compared with those used for patients with acute lung injury

An observational study of end-tidal carbon dioxide trends in general anesthesia

PURPOSE: Despite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO METHODS: This retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016. The primary outcome was a time-weighted average area-under-the-curve (TWA-AUC) for four ETCO RESULTS: Both TWA-AUC and median ETCO CONCLUSIONS: Between 2008 and 2016, intraoperative ETC

Genomic Relationships, Novel Loci, and Pleiotropic Mechanisms across Eight Psychiatric Disorders

Genetic influences on psychiatric disorders transcend diagnostic boundaries, suggesting substantial pleiotropy of contributing loci. However, the nature and mechanisms of these pleiotropic effects remain unclear. We performed analyses of 232,964 cases and 494,162 controls from genome-wide studies of anorexia nervosa, attention-deficit/hyper-activity disorder, autism spectrum disorder, bipolar disorder, major depression, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome. Genetic correlation analyses revealed a meaningful structure within the eight disorders, identifying three groups of inter-related disorders. Meta-analysis across these eight disorders detected 109 loci associated with at least two psychiatric disorders, including 23 loci with pleiotropic effects on four or more disorders and 11 loci with antagonistic effects on multiple disorders. The pleiotropic loci are located within genes that show heightened expression in the brain throughout the lifespan, beginning prenatally in the second trimester, and play prominent roles in neurodevelopmental processes. These findings have important implications for psychiatric nosology, drug development, and risk prediction.Peer reviewe

Surgical volume estimates using national or state databases can reasonably disregard missing cases from patients undergoing multiple surgeries on the same day other than for cardiac, vascular, and trauma cases

•Administrative data are often used for estimates of surgery in the United States.•Patients having multiple, separate surgeries on the same day cannot be resolved.•We modeled multiple surgeries in administrative sources with hospital surgical data.•Other than cardiac, vascular, and trauma, the incidence of multiple surgery was low.•For most specialties, undercounting of volume can be ignored in administrative data. Large administrative data sources such as the National Inpatient Sample are frequently used to estimate the incidence of surgery in the United States. These sources do not identify unique surgical cases (often containing multiple procedures). Investigators routinely assume that all surgical procedures on a given day comprise a single case, ignoring returns to the operating room (e.g., to address a complication). We estimated the inaccuracy of this assumption using 11 years of electronic data from 2 large academic hospitals. An administrative database would have underestimated the actual case count by 0.22% (99% UCL = 0.25%) and 0.19% (99% UCL = 0.22%), respectively. Patients undergoing cardiac or vascular surgery had a much greater underestimation of case counts (99% UCL 1.72% and 1.60%, and 99% UCL 1.06% and 1.09%, respectively) than other specialties (99% UCL for each specialty <1.0%, including orthopedics, otolaryngology, and urology). The trauma surgery 99% UCL undercount was 1.7% at the one hospital where this could be measured. For most specialties, inferring overall surgical case frequency using administrative data based on an assumption of no returns to the surgical suite is reasonable. However, adjustment for cardiac, vascular, and trauma surgical caseloads using such sources should be considered