The Development and Implementation of Evidence-Based Preanesthesia Assessment Tools for LVAD Patients Undergoing Non-Cardiac Procedures

Abstract A university-affiliated tertiary medical center with a newly developed Advanced Heart Failure and Mechanical Circulatory Support program identified the need to implement a more systematic approach to the preanesthesia assessment process for patients with a Left Ventricular Assist Device (LVAD) undergoing noncardiac procedures and standardized guidelines to determine the best blood pressure monitoring system for patients with an LVAD during these noncardiac procedures. A multidisciplinary panel of clinical experts developed an LVAD Preanesthesia Toolkit using standard recommendations identified via evidence-based literature and expert opinion. The Toolkit included an LVAD Preanesthesia Assessment (VaPA) tool and an LVAD Blood Pressure Monitoring Decision Tree. The Toolkit initiative utilized a checklist to promote safety and enhance access to LVAD-specific resource tools for anesthesia providers. An online education module outlining the details of the initiative was distributed to targeted users prior to a pilot implementation of the VaPA tool into clinical practice. Data collection concerning education dissemination revealed that 27.2% of anesthesia providers had reviewed and verbalized their understanding of the initiative. An analysis of the effectiveness of the VaPA tool was conducted in a 5-month retrospective review of electronic health records for LVAD patients undergoing noncardiac procedures. Outcome data revealed 100% accuracy in preanesthesia assessment documentation. Results indicated improved consistencies in documenting the LVAD specific components of the preanesthesia assessment

Evolutionary dynamics of emblematic Araucaria species (Araucariaceae) in New Caledonia:Nuclear and chloroplast markers suggest recent diversification, introgression, and a tight link between genetics and geography within species

BACKGROUND: New Caledonia harbours a highly diverse and endemic flora, and 13 (out of the 19 worldwide) species of Araucaria are endemic to this territory. Their phylogenetic relationships remain largely unresolved. Using nuclear microsatellites and chloroplast DNA sequencing, we focused on five closely related Araucaria species to investigate among-species relationships and the distribution of within-species genetic diversity across New Caledonia. RESULTS: The species could be clearly distinguished here, except A. montana and A. laubenfelsii that were not differentiated and, at most, form a genetic cline. Given their apparent morphological and ecological similarity, we suggested that these two species may be considered as a single evolutionary unit. We observed cases of nuclear admixture and incongruence between nuclear and chloroplast data, probably explained by introgression and shared ancestral polymorphism. Ancient hybridization was evidenced between A. biramulata and A. laubenfelsii in Mt Do, and is strongly suspected between A. biramulata and A. rulei in Mt Tonta. In both cases, extensive asymmetrical backcrossing eliminated the influence of one parent in the nuclear DNA composition. Shared ancestral polymorphism was also observed for cpDNA, suggesting that species diverged recently, have large effective sizes and/or that cpDNA experienced slow rates of molecular evolution. Within-species genetic structure was pronounced, probably because of low gene flow and significant inbreeding, and appeared clearly influenced by geography. This may be due to survival in distinct refugia during Quaternary climatic oscillations. CONCLUSIONS: The study species probably diverged recently and/or are characterized by a slow rate of cpDNA sequence evolution, and introgression is strongly suspected. Within-species genetic structure is tightly linked with geography. We underline the conservation implications of our results, and highlight several perspectives. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12862-014-0171-6) contains supplementary material, which is available to authorized users