Hypoventilation in the PACU is associated with hypoventilation in the surgical ward: Post-hoc analysis of a randomized clinical trial

Objective: To evaluate the association between early postoperative hypoventilation in the last hour of the post -anesthesia care unit (PACU) stay and hypoventilation during the rest of the first 48 postoperative hours in the surgical ward. Design: Sub-analysis of a clinical trial. Setting: PACU and surgical wards of a single medical center. Patients: Adults having abdominal surgery under general anesthesia. Interventions: Monitoring with a respiratory volume monitor from admission to PACU until the earlier of 48 h after surgery or discharge. Measurements: The exposure was having at least one low minute-ventilation (MV) event during the last hour of PACU stay, defined as MV lower than 40% the predicted value lasting at least 1 min. The primary outcome was low MV events lasting at least 2 min during the rest of the first 48 postoperative hours, while in the surgical ward. The secondary outcome was the rate of low MV events per monitored hour. Main results: Data of 292 patients were analyzed, of which 20 (6.8%) patients had a low MV event in PACU. Low MV events in the surgical ward were found in 81 (28%) patients. All patients who had low MV events in PACU had events again in the ward, while 61/272 (22%) had an event in the ward but not in PACU. The incidence rate of low MV events per hour was 24 (95% CI: 13, 46) among patients having an event in the PACU, and 2 (1, 4) among those who did not. Conclusions: In adults recovering from abdominal surgery, events of hypoventilation during the first post-operative hour are associated with similar events during the rest of the first 48 postoperative hours, with positive predictive value approaching 100%. Sixty-one patients had ward hypoventilation that was not preceded by hypoventilation in PACU

The effect of chest compression frequency on the quality of resuscitation by lifeguards. A prospective randomized crossover multicenter simulation trial

BACKGROUND: The ability to perform high-quality cardiopulmonary resuscitation is one of the basic skills for lifeguards. The aim of the study was to assess the influence of chest compression frequency on the quality of the parameters of chest compressions performed by lifeguards. METHODS: This prospective observational, randomized, crossover simulation study was performed with 40 lifeguards working in Warsaw, Wroclaw, and Poznan, Poland. The subjects then participated in a target study, in which they were asked to perform 2-min cycles of metronome-guided chest compressions at different rates: 80, 90, 100, 110, 120, 130, 140, and 150 compressions per minute (CPM). RESULTS: The study involved 40 lifeguards. Optimal chest compression score calculated by manikin software was achieved for 110-120 CPM. Chest compression depth achieved 53 (interquartile range [IQR] 52-54) mm, 56 (IQR 54-57) mm, 52.5 (IQR 50-54) mm, 53 (IQR 52-53) mm, 50 (IQR 49-51) mm, 47 (IQR 44-51) mm, 41 (IQR 40-42) mm, 38 (IQR 38-43) mm for 80, 90, 100, 110, 120, 130, 140 and 150 CPM, respectively. The percentage of chest compressions with the correct depth was lower for rates exceeding 120 CPM. CONCLUSIONS: The rate of 100-120 CPM, as recommended by international guidelines, is the optimal chest compression rate for cardiopulmonary resuscitation performed by lifeguards. A rate above 120 CPM was associated with a dramatic decrease in chest compression depth and overall chest compression quality. The role of full chest recoil should be emphasized in basic life support training

Generalizability of nociception level as a measure of intraoperative nociceptive stimulation: a retrospective analysis

BackgroundNociception-guided intraoperative opioid administration might help reduce postoperative pain. A commonly used and validated nociception monitor system is nociception level (NOL), which provides the nociception index, ranging from 0 to 100, with 0 representing no nociception and 100 representing extreme nociception. We tested the hypothesis that NOL responses are similar in men and women given remifentanil and fentanyl, across various types of anesthesia, as a function of American Society of Anesthesiologists physical status designations, and over a range of ages and body morphologies.MethodsWe conducted a retrospective cohort analysis of trial data from eight prospective NOL validation studies. Among 522 noncardiac surgical patients enrolled in these studies, 447 were included in our analysis. We assessed NOL responses to various noxious and non-noxious stimuli.ResultsThe average NOL in response to 315 noxious stimuli was 47 ± 15 (95% CI = 45–49). The average NOL in response to 361 non-noxious stimuli was 10 ± 12 (95% CI = 9–11). NOL responses were similar in men and women, in patients given remifentanil and fentanyl, across various types of anesthesia, as a function of American Society of Anesthesiologists physical status designations, and over a range of ages and body morphologies.ConclusionNociception level appears to provide accurate estimates of intraoperative nociception over a broad range of patients and anesthetic conditions.Perioperative Medicine: Efficacy, Safety and Outcome (Anesthesiology/Intensive Care

Revisiting the relevance of economic theory to hotel revenue management education and practice in the era of Big Data

Abstract This paper explores the role of economics in hospitality education and industry practice, with a particular focus on revenue management, and puts forward an argument for a return to the inclusion of economic theory in UK hospitality education, not seen since the 1990s. Given the increasing amounts of pricing data available to both managers and customers and the consequent market complexities now seen, developing economic literacy is demonstrated to be a crucial skill required for future hospitality graduates, allowing them to make successful revenue decisions and sense-check with confidence the decisions made by automated revenue systems. Economic literacy is defined as a balanced understanding of economic theory that can be applied in real-life business scenarios, extending beyond simple consideration of supply and demand to a mixture of neoclassical and behavioural approaches to economics

Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3) : a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery

Altres ajuts: Canadian Institutes of Health Research (CIHR, FDN-143302); General Research Fund (14104419), Research Grant Council, Hong Kong SAR, China; National Health and Medical Research Council, Funding Schemes (NHMRC Project Grant 1162362), Australia; McMaster University Department of Medicine Career Research Award and a Physicians' Services Incorporated (PSI) Foundation Mid-Career Clinical Research Award.Background: For patients undergoing noncardiac surgery, bleeding and hypotension are frequent and associated with increased mortality and cardiovascular complications. Tranexamic acid (TXA) is an antifibrinolytic agent with the potential to reduce surgical bleeding; however, there is uncertainty about its efficacy and safety in noncardiac surgery. Although usual perioperative care is commonly consistent with a hypertension-avoidance strategy (i.e., most patients continue their antihypertensive medications throughout the perioperative period and intraoperative mean arterial pressures of 60 mmHg are commonly accepted), a hypotension-avoidance strategy may improve perioperative outcomes. Methods: The PeriOperative Ischemic Evaluation (POISE)-3 Trial is a large international randomized controlled trial designed to determine if TXA is superior to placebo for the composite outcome of life-threatening, major, and critical organ bleeding, and non-inferior to placebo for the occurrence of major arterial and venous thrombotic events, at 30 days after randomization. Using a partial factorial design, POISE-3 will additionally determine the effect of a hypotension-avoidance strategy versus a hypertension-avoidance strategy on the risk of major cardiovascular events, at 30 days after randomization. The target sample size is 10,000 participants. Patients ≥45 years of age undergoing noncardiac surgery, with or at risk of cardiovascular and bleeding complications, are randomized to receive a TXA 1 g intravenous bolus or matching placebo at the start and at the end of surgery. Patients, health care providers, data collectors, outcome adjudicators, and investigators are blinded to the treatment allocation. Patients on ≥ 1 chronic antihypertensive medication are also randomized to either of the two blood pressure management strategies, which differ in the management of patient antihypertensive medications on the morning of surgery and on the first 2 days after surgery, and in the target mean arterial pressure during surgery. Outcome adjudicators are blinded to the blood pressure treatment allocation. Patients are followed up at 30 days and 1 year after randomization. Discussion: Bleeding and hypotension in noncardiac surgery are common and have a substantial impact on patient prognosis. The POISE-3 trial will evaluate two interventions to determine their impact on bleeding, cardiovascular complications, and mortality. Trial registration: ClinicalTrials.gov NCT03505723. Registered on 23 April 2018

Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3): a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery

Background For patients undergoing noncardiac surgery, bleeding and hypotension are frequent and associated with increased mortality and cardiovascular complications. Tranexamic acid (TXA) is an antifibrinolytic agent with the potential to reduce surgical bleeding; however, there is uncertainty about its efficacy and safety in noncardiac surgery. Although usual perioperative care is commonly consistent with a hypertension-avoidance strategy (i.e., most patients continue their antihypertensive medications throughout the perioperative period and intraoperative mean arterial pressures of 60 mmHg are commonly accepted), a hypotension-avoidance strategy may improve perioperative outcomes. Methods The PeriOperative Ischemic Evaluation (POISE)-3 Trial is a large international randomized controlled trial designed to determine if TXA is superior to placebo for the composite outcome of life-threatening, major, and critical organ bleeding, and non-inferior to placebo for the occurrence of major arterial and venous thrombotic events, at 30 days after randomization. Using a partial factorial design, POISE-3 will additionally determine the effect of a hypotension-avoidance strategy versus a hypertension-avoidance strategy on the risk of major cardiovascular events, at 30 days after randomization. The target sample size is 10,000 participants. Patients ≥45 years of age undergoing noncardiac surgery, with or at risk of cardiovascular and bleeding complications, are randomized to receive a TXA 1 g intravenous bolus or matching placebo at the start and at the end of surgery. Patients, health care providers, data collectors, outcome adjudicators, and investigators are blinded to the treatment allocation. Patients on ≥ 1 chronic antihypertensive medication are also randomized to either of the two blood pressure management strategies, which differ in the management of patient antihypertensive medications on the morning of surgery and on the first 2 days after surgery, and in the target mean arterial pressure during surgery. Outcome adjudicators are blinded to the blood pressure treatment allocation. Patients are followed up at 30 days and 1 year after randomization. Discussion Bleeding and hypotension in noncardiac surgery are common and have a substantial impact on patient prognosis. The POISE-3 trial will evaluate two interventions to determine their impact on bleeding, cardiovascular complications, and mortality. Trial registration ClinicalTrials.gov NCT03505723. Registered on 23 April 2018

Comparison of five video laryngoscopes and conventional direct laryngoscopy : Investigations on simple and simulated difficult airways on the intubation trainer

INTRODUCTION Securing the airway with a tracheal tube is essential in emergency situations, in the intensive care setting as well as during anesthesia for surgery and other interventions. Current methods of airway assessment are poor screening tests for predicting difficult direct laryngoscopy due to a generally low positive predictive value; therefore, successful endotracheal intubation requires a high level of expertise, regular training and practice and sometimes additional tools. Currently, several video laryngoscopes (VL) with different designs are commercially available and have been investigated in a wide variety of settings. To our knowledge there is no prospective study evaluating and comparing performance among these three groups of VL; therefore, the aim of this study was to compare performance of five VL and conventional direct laryngoscopy in an intubation manikin model, both in a normal and simulated difficult intubation setting. METHODS In this study 10 residents, 12 senior staff physicians and 5 anesthesia nurses, all experienced in conventional direct laryngoscopy and inexperienced with VL underwent theoretical and hands-on training with all VL lasting 60 min. Afterwards participants performed intubation with all 5 VL and conventional direct laryngoscopy in a randomized sequence using an intubation manikin with normal intubation settings. Thereafter participants performed intubation in a simulated difficult intubation setting using the same intubation manikin with a neck collar to immobilize the cervical spine. In this study, the C-MAC(®) with Macintosh blade size 3, GlideScope(®) size 3, McGrath(®) series 5, King Vision(®) and Airtraq(®) size 2 were used. Time to intubation served as primary outcome and time to glottis visualization, number of intubation attempts, success rate and subjective evaluation of difficulty served as secondary outcomes. RESULTS In the normal intubation setting, time to intubation ranged from 16.0 s (conventional direct laryngoscopy) to 34.3 s (McGrath). GlideScope and conventional direct laryngoscopy were successful in 100 % followed by C-MAC (96.7 %), Airtraq (88.9 %), King Vision (77.8 %) and McGrath VL (44.4 %). In the simulated difficult intubation setting, time to intubation ranged between 20.3 s (Airtraq) and 26.7 s (McGrath). Success rate with C-MAC was 100 %, followed by GlideScope (96.7 %), Airtraq (85.2 %), conventional direct laryngoscopy (85.2 %), King Vision (81.5 %) and McGrath VL (70.4 %). CONCLUSION In the manikin with normal intubation setting, conventional direct laryngoscopy using a Macintosh blade was convincing and superior to any VL used in this study. During simulated difficult intubation, a blade with video transmission, such as C-MAC and the GlideScope were superior compared to conventional direct laryngoscopy and any other VL tested

Sponges in an extreme environment: suberitids from the quasi-marine Satonda Island crater lake (Sumbawa, Indonesia)

Sponges are rare in extreme environments, and very little is known about their adaptations to such settings. Evidence from two species in a marine-derived midwater stratified crater lake on Satonda Island (Sumbawa, Indonesia) suggests their production of gemmules (resting bodies), a rare trait in marine sponges but common in freshwater forms, may be a survival mechanism in the lake's harsh environment. With its epilimnion hydrochemistry—characterized by changing alkalinity, salinity, and O2 levels over the region's wet and dry seasons—the lake sustains only a few marine macroscopic organisms, among them the suberitid sponges Protosuberites lacustris comb. nov. and Suberites sp. (Hadromerida: Suberitida). Both species belong to the same group as sponges reported from other marine-derived lakes with strongly varying and extreme environmental (especially chemical) parameters. The morphological characters, taxonomic position, ecological adaptations, environmental conditions, and biota associated with the sponges in this ecologically unique site are presented here