Publications by authors named "Vanessa Moll"

43 Publications

Intra-abdominal hypertension in cardiac surgery patients: a multicenter observational sub-study of the Accuryn registry.

J Clin Monit Comput 2022 Jun 13. Epub 2022 Jun 13.

Department of Anesthesiology, Division of Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA.

Intra-abdominal hypertension (IAH) is frequently present in the critically ill and is associated with increased morbidity and mortality. Conventionally, intermittent 'spot-check' manual measurements of bladder pressure in those perceived as high risk are used as surrogates for intra-abdominal pressure (IAP). True patterns of IAH remain unknown. We explored the incidence of IAH in cardiac surgery patients and describe the intra-and postoperative course of IAP using a novel, high frequency, automated bladder pressure measurement system. Sub-analysis of a prospective, multicenter, observational study (NCT04669548) conducted in three large academic medical centers. Continuous urinary output (CUO) and IAP measurements were observed using the Accuryn Monitoring System (Potrero Medical, Hayward, CA). Data collected included demographics, hemodynamic support, and high-frequency IAP and CUO. One Hundred Thirty-Seven cardiac surgery patients were analyzed intraoperatively and followed 48 h postoperatively in the intensive care unit. Median age was 66.4 [58.3, 72.0] years, and 61% were men. Median Foley catheter dwell time was 56.0 [46.8, 77.5] hours, and median baseline IAP was 6.3 [4.0, 8.1] mmHg. 93% (128/137) of patients were in IAH grade I, 82% (113/137) in grade II, 39% (53/137) in grade III, and 5% (7/137) in grade IV for at least 12 cumulative hours. For maximum consecutive duration of IAH, 84% (115/137) of patients spent at least 12 h in grade I, 62% (85/137) in grade II, 18% (25/137) in grade III, and 2% (3/137) in grade IV IAH. During the first 48 h after cardiac surgery, IAH is common and persistent. Improved and automated monitoring of IAP will increase the detection of IAH-which normally would remain undetected using traditional intermittent monitoring methods.
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http://dx.doi.org/10.1007/s10877-022-00878-2DOI Listing
June 2022

Continuous Monitoring of Intra-abdominal Pressure in Severe Acute Pancreatitis Leads to Early Detection of Abdominal Compartment Syndrome: A Case Report.

Cureus 2022 Apr 29;14(4):e24606. Epub 2022 Apr 29.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA.

Acute pancreatitis is a risk factor for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Immediate detection and management of IAH and ACS are critical for patient survival. Obtaining accurate and consistent intra-abdominal pressure and urinary output with high frequency is challenging, but critical for effective patient management. The presented case is of a 40-year-old man with a history of chronic alcoholism who developed severe acute pancreatitis. The patient was fluid resuscitated for distributive shock; hypoxic respiratory failure, intubation, and anuria followed. Real-time monitoring of urinary output and intra-abdominal pressure (IAP) allowed for early recognition of acute kidney injury (AKI) and ACS leading to early surgical intervention. Normalized IAP returned renal function and re-establishment of stable hemodynamics without vasopressors.
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http://dx.doi.org/10.7759/cureus.24606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9057312PMC
April 2022

Automated Intra-abdominal Pressure Monitoring During Orthotopic Heart Transplant Leads to Early Diagnosis and Treatment of Intraoperative Abdominal Compartment Syndrome-A Case Report.

Front Surg 2022 28;9:812288. Epub 2022 Feb 28.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States.

We describe a case of spontaneous retroperitoneal hematoma leading to abdominal compartment syndrome and organ failure during a complicated orthotopic heart transplantation in a patient previously on mechanical circulatory support. After the patient had been weaned of cardiopulmonary bypass, the patient suddenly became hemodynamically unstable despite good LV and RV function. While the patient was resuscitated, high intra-abdominal pressures were noted on a novel monitor measuring real-time intra-abdominal pressures and urinary output. The early detection of high intra-abdominal pressures led to a swift decompressive laparotomy with the detection of retroperitoneal hematoma and subsequent hemodynamic stabilization.
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http://dx.doi.org/10.3389/fsurg.2022.812288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8919394PMC
February 2022

Urinary catheter monitoring of intra-abdominal pressure after major abdominal surgery, a cost-benefit analysis.

J Med Econ 2022 Jan-Dec;25(1):412-420

Depts of Surgery and Critical Care, University of Utah, Salt Lake City, UT, USA.

Objective: To estimate costs and benefits associated with measurement of intra-abdominal pressure (IAP).

Methods: We built a cost-benefit analysis from the hospital facility perspective and time horizon limited to hospitalization for patients undergoing major abdominal surgery for the intervention of urinary catheter monitoring of IAP. We used real-world data estimating the likelihood of intra-abdominal hypertension (IAH), abdominal compartment syndrome (ACS), and acute kidney injury (AKI) requiring renal replacement therapy (RRT). Costs included catheter costs (estimated $200), costs of additional intensive care unit (ICU) days from IAH and ACS, and costs of CRRT. We took the preventability of IAH/ACS given early detection from a trial of non-surgical interventions in IAH. We evaluated uncertainty through probabilistic sensitivity analysis and the effect of individual model parameters on the primary outcome of cost savings through one-way sensitivity analysis.

Results: In the base case, urinary catheter monitoring of IAP in the perioperative period of major abdominal surgery had 81% fewer cases of IAH of any grade, 64% fewer cases of AKI, and 96% fewer cases of ACS. Patients had 1.5 fewer ICU days attributable to IAH (intervention 1.6 days vs. control of 3.1 days) and a total average cost reduction of $10,468 (intervention $10,809, controls $21,277). In Monte Carlo simulation, 86% of 1,000 replications were cost-saving, for a mean cost savings of $10,349 (95% UCI $8,978, $11,720) attributable to real-time urinary catheter monitoring of intra-abdominal pressure. One-way factor analysis showed the pre-test probability of IAH had the largest effect on cost savings and the intervention was cost-neutral at a prevention rate as low as 2%.

Conclusions: In a cost-benefit model using real-world data, the potential average in-hospital cost savings for urinary catheter monitoring of IAP for early detection and prevention of IAH, ACS, and AKI far exceed the cost of the catheter.
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http://dx.doi.org/10.1080/13696998.2022.2053383DOI Listing
March 2022

A comparison of face-to-face, brochure- and video-assisted anesthesia interviews: a qualitative randomized survey study.

Minerva Anestesiol 2022 05 24;88(5):343-351. Epub 2022 Jan 24.

Research Group Metrik, Bermuthshain, Germany.

Background: Previous studies showed mixed results for patient satisfaction by supplementing the preanesthetic assessment with written or audio-visual materials. We hypothesize that an audio-visual aid or a brochure in addition to face-to-face interview, leads to improved patient satisfaction and shortens the preanesthetic assessment duration.

Methods: We randomly assigned 1051 patients scheduled for preanesthetic assessment to three different groups: face-to-face preanesthetic interview alone (Group 1), videos before the interview (Group 2), and brochure before the interview (Group 3). All patients were asked to complete a postinterview questionnaire assessing patient satisfaction, knowledge gain, prior experience with anesthesia, and quality of supplementary media.

Results: The use of additional materials immediately before the preanesthetic interview did increase the overall patient satisfaction (F(2, 1003) = 3.10, P<0.05, ƞ=0.006) but not the interview satisfaction (F(2, 1011) = 0.756, P>0.05) nor information gain (procedure explanations F(2, 987) = 0.400, P>0.05) or quality of answered questions (F(2, 1029) = 0.769, P>0.05). A statistically significant effect on interview satisfaction (F(13,996) = 5.15, P<0.01., ƞ=0.063), overall satisfaction (F(13,988) = 4.25, P<0.01., ƞ=0.053) and given explanations (F(13, 972) = 3.132, P<0.001, ƞ=0.04) was associated with the explanation of different anesthetic techniques by the provider. No differences of response quality between the anesthesiologists was found (F(13, 1014) = 1.494, P>0.05).

Conclusions: Additional information imparted in the form of an educational brochure or videos immediately before the preanesthetic assessment and interview does not lead to higher patient satisfaction.
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http://dx.doi.org/10.23736/S0375-9393.22.15969-9DOI Listing
May 2022

White Paper on Early Critical Care Services in Low Resource Settings.

Ann Glob Health 2021 3;87(1):105. Epub 2021 Nov 3.

Muhimbili University, TZ.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.
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http://dx.doi.org/10.5334/aogh.3377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8570193PMC
January 2022

Lower AM-PAC 6-Clicks Basic Mobility Score Predicts Discharge to a Postacute Care Facility Among Patients in Cardiac Intensive Care Units.

Phys Ther 2022 01;102(1)

Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine, Atlanta, Georgia, USA.

Objective: The objective of this study was to determine the ability of the Activity Measure for Post-Acute Care "6-Clicks" Basic Mobility Short Form to predict patient discharge destination (home vs postacute care [PAC] facility) from the cardiac intensive care unit (ICU), including patients from the cardiothoracic surgical ICU and coronary care unit.

Methods: This retrospective cohort study utilized electronic medical records of patients in cardiac ICU (n = 359) in an academic teaching hospital in the southeastern region of United States from September 1, 2017, through August 31, 2018.

Results: The median interquartile range age of the sample was 68 years (75-60), 55% were men, the median interquartile range 6-Clicks score was 16 (20-12) at the physical therapist evaluation, and 79% of the patients were discharged to home. Higher score on 6-Clicks indicates improved function. A prediction model was constructed based on a machine learning approach using a classification tree. The classification tree was constructed and evaluated by dividing the sample into a train-test split using the Leave-One-Out cross-validation approach. The classification tree split the data into 4 distinct groups along with their predicted outcomes. Patients with a 6-Clicks score >15.5 and a score between 11.5 and 15.5 with primary insurance other than Medicare were discharged to home. Patients with a 6-Clicks score between 11.5 and 15.5 with Medicare insurance and those with a score ≤11.5 were discharged to a PAC facility.

Conclusion: Patients with lower 6-Clicks scores were more likely to be discharged to a PAC facility. Patients without Medicare insurance had to be significantly lower functioning, as indicated by lower 6-Clicks scores for PAC facility placement than those with Medicare insurance.

Impact: The ability of 6-Clicks along with primary insurance to determine discharge destination allows for early discharge planning from cardiac ICUs.
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http://dx.doi.org/10.1093/ptj/pzab252DOI Listing
January 2022

Underrecognized and Facing Burnout: Promoting Resilience in Respiratory Therapy.

Respir Care 2021 11;66(11):1777-1778

Department of AnesthesiologyEmory University School of MedicineAtlanta, Georgia.

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http://dx.doi.org/10.4187/respcare.09659DOI Listing
November 2021

The Coronavirus Disease 2019 Pandemic Impacts Burnout Syndrome Differently Among Multiprofessional Critical Care Clinicians-A Longitudinal Survey Study.

Crit Care Med 2022 03;50(3):440-448

Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA.

Objectives: To determine the impact of coronavirus disease 2019 on burnout syndrome in the multiprofessional ICU team and to identify factors associated with burnout syndrome.

Design: Longitudinal, cross-sectional survey.

Setting: All adult ICUs within an academic health system.

Subjects: Critical care nurses, advanced practice providers, physicians, respiratory therapists, pharmacists, social workers, and spiritual health workers were surveyed on burnout in 2017 and during the coronavirus disease 2019 pandemic in 2020.

Interventions: None.

Measurements And Main Results: Burnout syndrome and contributing factors were measured using the Maslach Burnout Inventory of Health and Human Service and Areas of Worklife Survey. Response rates were 46.5% (572 respondents) in 2017 and 49.9% (710 respondents) in 2020. The prevalence of burnout increased from 59% to 69% (p < 0.001). Nurses were disproportionately impacted, with the highest increase during the pandemic (58-72%; p < 0.0001) with increases in emotional exhaustion and depersonalization, and personal achievement decreases. In contrast, although burnout was high before and during coronavirus disease 2019 in all specialties, most professions had similar or lower burnout in 2020 as they had in 2017. Physicians had the lowest rates of burnout, measured at 51% and 58%, respectively. There was no difference in burnout between clinicians working in ICUs who treated coronavirus disease 2019 than those who did not (71% vs 67%; p = 0.26). Burnout significantly increased in females (71% vs 60%; p = 0.001) and was higher than in males during the pandemic (71% vs 60%; p = 0.01).

Conclusions: Burnout syndrome was common in all multiprofessional ICU team members prior to and increased substantially during the pandemic, independent of whether one treated coronavirus disease 2019 patients. Nurses had the highest prevalence of burnout during coronavirus disease 2019 and had the highest increase in burnout from the prepandemic baseline. Female clinicians were significantly more impacted by burnout than males. Different susceptibility to burnout syndrome may require profession-specific interventions as well as work system improvements.
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http://dx.doi.org/10.1097/CCM.0000000000005265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8855765PMC
March 2022

A Screening Tool to Detect Chronic Critically Ill Cardiac Surgery Patients at Risk for Low Levels of Testosterone and Somatomedin C: A Prospective Observational Pilot Study.

Cureus 2021 May 28;13(5):e15298. Epub 2021 May 28.

Anesthesiology, Emory University School of Medicine, Atlanta, USA.

Objective The neuroendocrine response to critical illness is dichotomous as it is adaptive during the acute phase then transitions to maladaptive as critical illness becomes prolonged in 25-30% of patients. Presently, monitoring all critically ill patients for endocrinopathies is not the standard of care. However, given the negative impact on patient prognosis, a need to identify those at risk for endocrinopathies, may exist. Thus, a screening tool to identify endocrinopathies along the somatotroph and gonadal axes in a cardiothoracic surgery population was developed. Methods A prospective observational pilot study was conducted in two cardiothoracic surgery intensive care units (ICU) within a multi-site healthcare system. Total testosterone and somatomedin C levels were obtained from 20 adult patients who remained in the ICU for greater than seven days after cardiothoracic surgery and were tolerating nutrition, had a risk of malnutrition and a mobility score of moderate to dependent assistance. Results Twenty patients were included for descriptive analysis (seven females). Thirteen patients tested low for total testosterone, with males more likely to have a testosterone-related endocrinopathy as compared to females (100% vs. 0 to 43%, p = 0.0072). A higher proportion of low somatomedin C levels was found in females than males (57% vs. 31%); however, the difference was not statistically significant (p = 0.251). Conclusions The screening tool used in this pilot study accurately predicted low total testosterone in all men and reasonably predicted low somatomedin C in a majority of women. However, the ability of the tool to predict low total testosterone in women and low somatomedin C in men is less certain. A gender-specific screening tool might be necessary to predict hormonal deficiencies.
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http://dx.doi.org/10.7759/cureus.15298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237911PMC
May 2021

Regional anesthesia educational material utilization varies by World Bank income category: A mobile health application data study.

PLoS One 2021 1;16(2):e0244860. Epub 2021 Feb 1.

Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, United States of America.

Introduction: Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level.

Methods: We retrospectively analyzed data collected from the free Android app "Anesthesiologist" from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block).

Results: Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic.

Conclusion: The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244860PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850494PMC
February 2021

Impact of COVID-19 response on global surgical volumes: an ongoing observational study.

Bull World Health Organ 2020 Oct 3;98(10):671-682. Epub 2020 Sep 3.

Department of Anesthesiology, Emory University School of Medicine, Atlanta, USA.

Objective: To determine whether location-linked anaesthesiology calculator mobile application (app) data can serve as a qualitative proxy for global surgical case volumes and therefore monitor the impact of the coronavirus disease 2019 (COVID-19) pandemic.

Methods: We collected data provided by users of the mobile app "Anesthesiologist" during 1 October 2018-30 June 2020. We analysed these using RStudio and generated 7-day moving-average app use plots. We calculated country-level reductions in app use as a percentage of baseline. We obtained data on COVID-19 case counts from the European Centre for Disease Prevention and Control. We plotted changing app use and COVID-19 case counts for several countries and regions.

Findings: A total of 100 099 app users within 214 countries and territories provided data. We observed that app use was reduced during holidays, weekends and at night, correlating with expected fluctuations in surgical volume. We observed that the onset of the pandemic prompted substantial reductions in app use. We noted strong cross-correlation between COVID-19 case count and reductions in app use in low- and middle-income countries, but not in high-income countries. Of the 112 countries and territories with non-zero app use during baseline and during the pandemic, we calculated a median reduction in app use to 73.6% of baseline.

Conclusion: App data provide a proxy for surgical case volumes, and can therefore be used as a real-time monitor of the impact of COVID-19 on surgical capacity. We have created a dashboard for ongoing visualization of these data, allowing policy-makers to direct resources to areas of greatest need.
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http://dx.doi.org/10.2471/BLT.20.264044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652560PMC
October 2020

Erector Spinae Regional Anesthesia for Robotic Coronary Artery Bypass Surgery Is Not Associated With Reduced Postoperative Opioid Use: A Retrospective Observational Study.

J Cardiothorac Vasc Anesth 2021 Jul 20;35(7):2034-2042. Epub 2020 Sep 20.

Department of Anesthesiology, Division of Pain Medicine, Stanford University School of Medicine, Stanford, CA.

Objective: Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB).

Design: This was a retrospective observational study of routinely recorded data.

Setting: The study was performed at a single healthcare system.

Participants: All patients underwent robotic MIDCAB.

Intervention: Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS.

Measurements And Main Results: In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC.

Conclusions: These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB.
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http://dx.doi.org/10.1053/j.jvca.2020.09.112DOI Listing
July 2021

Building regional anesthesia capacity in limited-resource settings: a pilot study evaluating a 4-week curriculum.

Pain Manag 2021 Jan 19;11(1):29-37. Epub 2020 Oct 19.

Department of Anesthesiology, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia.

To pilot a 4-week regional anesthesia curriculum for limited-resource settings. A baseline needs assessment and knowledge test were deployed. The curriculum included lectures and hands-on teaching, followed by knowledge attainment tests. Scores on the knowledge test improved from a mean of 37.1% (SD 14.7%) to 50.9% (SD 18.6%) (p = 0.017) at 4 weeks and 49% at 24 months. An average of 1.7 extremity blocks per month was performed in 3 months prior to the curriculum, compared with an average of 4.1 per month in 8 months following. This collaborative curriculum appeared to have a positive impact on the knowledge and utilization of regional anesthesia.
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http://dx.doi.org/10.2217/pmt-2020-0044DOI Listing
January 2021

Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial.

Anesth Analg 2020 10;131(4):1012-1024

Trident Anesthesia Group, LLC, Charleston, South Carolina.

Background: Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring.

Methods: PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping.

Results: One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring.

Conclusions: A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
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http://dx.doi.org/10.1213/ANE.0000000000004788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467153PMC
October 2020

A Guide to Performance Evaluation for the Intensivist: Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation in the ICU.

Crit Care Med 2020 10;48(10):1521-1527

Emory Critical Care Center, Atlanta, GA.

Objectives: In 2008, The Joint Commission implemented a new standard mandating a detailed evaluation of a provider's performance. The Ongoing Professional Practice Evaluation was designed to provide ongoing performance evaluation as opposed to periodic evaluation. The Focused Professional Practice Evaluation was designed to evaluate the performance of providers new to the medical staff or providers who are requesting new privileges. To date, we are unable to find critical care specific literature on the implementation of Ongoing Professional Practice Evaluation/Focused Professional Practice Evaluation. The purpose of this concise definitive review is to familiarize the reader with The Joint Commission standards and their application to Ongoing Professional Practice Evaluation/Focused Professional Practice Evaluation design and implementation, literature review in the noncritical care setting, and future process optimization and automation.

Data Sources: Studies were identified through MEDLINE search using a variety of search phrases related to Ongoing Professional Practice Evaluation, Focused Professional Practice Evaluation, critical care medicine, healthcare quality, and The Joint Commission. Additional articles were identified through a review of the reference lists of identified articles.

Study Selection: Original articles, review articles, and systematic reviews were considered.

Data Extraction: Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles.

Data Synthesis: There is limited data for the process of Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation implementation in critical care medicine. Key recommendations exist from The Joint Commission but leave it up to healthcare institutions to realize these. The process and metrics can be tailored to specific institutions and departments.

Conclusions: Currently, there is no standard process to develop Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation processes in critical care medicine. Departments and institutions can tailor metrics and processes but it might be useful to standardize some metrics to assure the overall quality of care. In the future utilization of newer technologies like applications might make this process less time-intensive.
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http://dx.doi.org/10.1097/CCM.0000000000004441DOI Listing
October 2020

Platelet Dysfunction Diseases and Conditions: Clinical Implications and Considerations.

Adv Ther 2020 09 29;37(9):3707-3722. Epub 2020 Jul 29.

Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.

Introduction: Platelet diseases and dysfunction are taught early in medical school to all future physicians. Understanding of the coagulation cascade and hemostatic mechanisms has allowed for targeted pharmacological therapies that have been significantly impactful in clinical practice. Platelets are an early participant in hemostasis physiologically and under pathophysiological states.

Methods: A review of literature involving platelet disfunction.

Results: Various presentations of platelet diseases and dysfunction challenge clinicians and require a firm understanding of normal platelet function, drugs that mediate or modulate platelet effectiveness, and nonpharmacologic etiologies of platelet diseases and dysfunction with corresponding best practice treatment approaches.

Conclusion: This review summarizes normal and abnormal states associated with platelets and treatment strategies.
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http://dx.doi.org/10.1007/s12325-020-01453-4DOI Listing
September 2020

Real-time assessment of COVID-19 impact on global surgical case volumes.

medRxiv 2020 May 8. Epub 2020 May 8.

Importance: The COVID-19 pandemic has disrupted global surgical capacity. The impact of the pandemic in low and middle income countries has the potential to worsen already strained access to surgical care. Timely assessment of surgical volumes in these countries remains challenging.

Objective: To determine whether usage data from a globally used anesthesiology calculator mobile application can serve as a proxy for global surgical case volume and contribute to monitoring of the impact of the COVID-19 pandemic, particularly in World Bank low income countries where official data collection is not currently practical.

Design: Subset of data from an ongoing observational cohort study of users of the application collected from October 1, 2018 to April 18, 2020.

Setting: The mobile application is available from public sources; users download and use the application per their own clinical needs on personal mobile devices.

Participants: No user data was excluded from the study. Exposure(s): Events with impacts on surgical case volumes, including weekends, holidays, and the COVID-19 pandemic. Main Outcome(s) and Measure(s): It was previously noted that application usage was decreased on weekends and during winter holidays. We subsequently hypothesized that more detailed analysis would reveal impacts of country-specific or region-specific holidays on the volume of app use.

Results: 4,300,975 data points from 92,878 unique users were analyzed. Physicians and other anesthesia providers comprised 85.8% of the study population. Application use was reduced on holidays and weekends and correlated with fluctuations in surgical volume. The COVID-19 pandemic was associated with substantial reductions in app use globally and regionally. There was strong cross correlation between COVID-19 case count and reductions in app use. By country, there was a median global reduction in app use to 58% of baseline (interquartile range, 46%-75%). Application use in low-income continues to decline but in high-income countries has stabilized.

Conclusions And Relevance: Application usage metadata provides a real-time indicator of surgical volume. This data may be used to identify impacted regions where disruptions to surgical care are disproportionate or prolonged. A dashboard for continuous visualization of these data has been deployed.
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http://dx.doi.org/10.1101/2020.05.03.20086819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273300PMC
May 2020

Recent technological advancements in regional anesthesia.

Best Pract Res Clin Anaesthesiol 2019 Dec 25;33(4):499-505. Epub 2019 Jul 25.

Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA. Electronic address:

Just two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and largely improved outcomes. Ultrasound (US) technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment. The US technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage and effective treatments and providing timelier interventions. In recent years, several different strategies to help improve and ease US-guided needle identification and placement have been developed, including magnetically guided needle US technology. Three-dimensional (3D) and four-dimensional (4D) US use is another potential way to help improve first-pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under US has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during US-guided procedures. To reduce variability and to reduce the anesthesiologist's workload, the use of robots in regional anesthesia has been assessed in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.
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http://dx.doi.org/10.1016/j.bpa.2019.07.002DOI Listing
December 2019

Liposomal bupivacaine and novel local anesthetic formulations.

Best Pract Res Clin Anaesthesiol 2019 Dec 19;33(4):425-432. Epub 2019 Jul 19.

Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA. Electronic address:

Novel preparations allowing for the extended duration of action of local anesthetics have many clinically relevant benefits. With regard to this, the development of liposomal bupivacaine has the potential to significantly impact patient care by improving perioperative pain control. The unique liposomal bilayer that encapsulates bupivacaine allows for a sustained release of local anesthetic for up to 72 h after a single use and can significantly decrease postoperative opioid consumption. SABER-bupivacaine is another depot formulation that helps in sustained release of bupivacaine from an encapsulated bupivacaine in a biodegradable sucrose acetate isobutyrate biolayer. HTX-011 is an investigational extended-release local anesthetic formulation currently undergoing Phase 3 clinical trials. HTX-011 is composed of a bioerodible polymer with bupivacaine and low-dose meloxicam in which the polymer undergoes hydrolysis and allows for sustained release of bupivacaine and meloxicam for 3 days. The present investigation reviews pharmacologic considerations related to the formulation of liposomal bupivacaine, current FDA-approved indications for its use, and future extended-release local anesthetic formulations currently under investigation.
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http://dx.doi.org/10.1016/j.bpa.2019.07.012DOI Listing
December 2019

Adjuvants in clinical regional anesthesia practice: A comprehensive review.

Best Pract Res Clin Anaesthesiol 2019 Dec 2;33(4):415-423. Epub 2019 Jul 2.

Department of Anesthesia, LSUHSC, 1542 Tulane Avenue, Suite 659, New Orleans, LA, 70112, USA. Electronic address:

Adjuvants are medications that work synergistically with local anesthetics to help enhance the duration and quality of analgesia in regional techniques. Regional anesthesia has become more prevalent as evidence continues to show efficacy, enhancement of patient care, increased patient satisfaction, and improved patient safety. Practitioners in the perioperative setting need to not only be familiar with regional techniques but also the medications used for them. Some examples of adjuvant medications for regional techniques include dexamethasone, alpha 2 agonists such as clonidine and dexmedetomidine, midazolam, buprenorphine, NMDA antagonists, including ketamine and magnesium, neostigmine, sodium bicarbonate, epinephrine, and non-steroidal anti-inflammatory drugs. The aim of the present investigation, therefore, is to provide a comprehensive review of the most commonly used non-opioid adjuvants in clinical practice today. Regional adjuvants can improve patient safety, increase patient satisfaction, and enhance clinical efficacy. Future studies and best practice techniques can facilitate standardization of regional anesthesia adjuvant dosing when providing nerve blocks in clinical practice.
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http://dx.doi.org/10.1016/j.bpa.2019.06.001DOI Listing
December 2019

Regional anesthesia considerations for cardiac surgery.

Best Pract Res Clin Anaesthesiol 2019 Dec 17;33(4):387-406. Epub 2019 Jul 17.

Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA. Electronic address:

Pain is a significant consequence of cardiac surgery and newer techniques in cardiac anesthesia have provided an impetus for the development of multimodal techniques to manage acute pain in this setting. In this regard, regional anesthesia techniques have been increasingly used in many cardiac surgical procedures, for the purposes of reducing perioperative consumption of opioid agents and enhanced recovery after surgery. The present investigation focuses on most currently used regional techniques in cardiac surgical procedures. These regional techniques include chest wall blocks (e.g., PECS I and II, SAP, ESB, PVB), sternal blocks (e.g., TTMPB, PSINB), and neuraxial blocks (e.g., TEA, high spinal anesthesia). The present investigation also summarizes indications, technique, complications, and potential clinical benefits of these evolving regional techniques. Cardiac surgery patients may benefit from application of these regional techniques with well controlled indications and careful patient selections.
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http://dx.doi.org/10.1016/j.bpa.2019.07.008DOI Listing
December 2019

Comparison of Multivariate Regression Models Based on Water- and Carbohydrate-Related Spectral Regions in the Near-Infrared for Aqueous Solutions of Glucose.

Molecules 2019 Oct 15;24(20). Epub 2019 Oct 15.

Institute of Analytical Chemistry and Radiochemistry, CCB-Center for Chemistry and Biomedicine, Innrain 80/82, 6020 Innsbruck, Austria.

The predictive power of the two major water bands centered at 6900 cm - 1 and 5200 cm - 1 in the near-infrared (NIR) region was compared to carbohydrate-related spectral areas located in the first overtone (around 6000 cm - 1 ) and combination (around 4500 cm - 1 ) region using glucose in aqueous solutions as a model substance. For the purpose of optimal coverage of stronger as well as weaker absorbing NIR regions, cells with three different declared optical pathlengths were employed. The sample set consisted of multiple separately prepared batches in the range of 50-200 mmol/L. Moreover, the samples were divided into a calibration set for the construction of the partial least squares regression (PLS-R) models and a test set for the validation process with independent samples. The first overtone and combination region showed relative prediction errors between 0.4-1.6% with only one PLS-R factor required. On the other hand, the errors for the water bands were found between 1.6-8.3% and up to three PLS-R factors required. The best PLS-R models resulted from the cell with 1 mm optical pathlength. In general, the results suggested that the carbohydrate-related regions in the first overtone and combination region should be preferred over the regions of the two dominant water bands.
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http://dx.doi.org/10.3390/molecules24203696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832891PMC
October 2019

Severe Hypoxia and Compartment Syndrome in a Patient With Sickle Cell Trait After Redo Aortic Valve Replacement: A Case Report and Review of the Literature.

J Cardiothorac Vasc Anesth 2020 Jan 23;34(1):175-178. Epub 2019 Aug 23.

Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA.

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http://dx.doi.org/10.1053/j.jvca.2019.08.028DOI Listing
January 2020

A Case of Multifactorial Diabetic Ketoacidosis Acquired in the Intensive Care Unit: A Case Report.

Cureus 2019 Jul 12;11(7):e5128. Epub 2019 Jul 12.

Anesthesiology, Emory School of Medicine, Atlanta, USA.

Diabetic ketoacidosis (DKA) is a potentially fatal endocrine emergency resulting from uncontrolled diabetes mellitus (DM). The development of DKA has been linked to a number of precipitating factors such as infectious process, ischemia, medications, and other medical-surgical illnesses. These factors have been found to aggravate or unmask pre-existing glucose dysregulation secondary to absolute or relative insulin deficiency and increased levels of counter-regulatory hormones. We describe the case of a 61-year-old male with a history of insulin dependent DM who develops DKA postoperatively after a three-vessel coronary artery bypass surgery and mitral valve repair while in the intensive care unit (ICU). The patient's postoperative course was complicated by presumed pneumonia and hyperactive delirium. On postoperative day (POD) five, the patient's insulin infusion was held due to non-symptomatic hypoglycemia. Eleven hours later, the insulin infusion was resumed to treat DKA after laboratory findings revealed hyperglycemia, an elevated β-hydroxybutyrate, and anion gap metabolic acidosis. Multiple contributing factors for the development of DKA are suspected and discussed. It is paramount that clinicians are knowledgeable of the multiple factors that can contribute to the development of DKA in the ICU.
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http://dx.doi.org/10.7759/cureus.5128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6741380PMC
July 2019

Successful Use of Octreotide Therapy for Refractory Levofloxacin-Induced Hypoglycemia: A Case Report and Literature Review.

Case Rep Crit Care 2019 9;2019:3560608. Epub 2019 May 9.

Department of Anesthesiology, Emory Center of Critical Care, Emory School of Medicine, Atlanta, Georgia, USA.

Fluoroquinolones are commonly prescribed antimicrobials that have been implicated in alterations of glucose metabolism. We report a case of refractory fluoroquinolone-induced hypoglycemia in a patient with type-2 diabetes mellitus on glipizide that was successfully treated with octreotide. A patient was admitted with hypoglycemia after having been initiated on levofloxacin therapy. Despite treating the hypoglycemia supportively with multiple boluses of 25 g of dextrose, a continuous dextrose infusion, and glucagon, the patient experienced repeated episodes of rebound hypoglycemia. The persistent hypoglycemia was eventually reversed with the administration of subcutaneous octreotide. Clinicians should be cognizant of this adverse effect of fluoroquinolones, as well as predisposing risk factors, and consider octreotide as an adjunctive therapy for refractory hypoglycemia cases.
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http://dx.doi.org/10.1155/2019/3560608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6532307PMC
May 2019

The Lung Point: Early Identification of Pneumothorax on Point of Care Ultrasound.

Anesthesiology 2019 11;131(5):1148

From the Department of Anesthesiology, Division of Critical Care Medicine, Emory University Hospital, Atlanta, Georgia.

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http://dx.doi.org/10.1097/ALN.0000000000002843DOI Listing
November 2019

Highly visible sepsis publications from 2012 to 2017: Analysis and comparison of altmetrics and bibliometrics.

J Crit Care 2018 12 30;48:357-371. Epub 2018 Sep 30.

Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA; Department of Anesthesiology, Children's Healthcare of Atlanta, 1405 Clifton Rd, Atlanta, GA 30329, USA. Electronic address:

Purpose: We sought to delineate highly visible publications related to sepsis. Within these subsets, elements of altmetrics performance, including mentions on Twitter, and the correlation between altmetrics and conventional citation counts were ascertained.

Materials And Methods: Three subsets of sepsis publications from 2012 to 2017 were synthesized by the overall Altmetric.com attention score, number of mentions by unique Twitter users, and conventional citation counts. For these subsets, geolocated Twitter activity was plotted on a choropleth, the lag between publication date and altmetrics mentions was characterized, and correlations were examined between altmetrics performance and normalized conventional citation counts.

Results: Of 57,152 PubMed query results, Altmetric.com data was available for 28,344 (49.6%). The top 50 publications by Altmetric.com attention score and Twitter attention represented a mix of original research and other types of work, garnering attention from Twitter users in 143 countries that was highly contemporaneous with publication. Altmetrics performance and conventional citation counts were poorly correlated.

Conclusions: While unreliable to gauge impact or future citation potential, altmetrics may be valuable for parties who wish to detect and drive public awareness of research findings and may enable researchers to dynamically explore the reach of their work in novel dimensions.
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http://dx.doi.org/10.1016/j.jcrc.2018.09.033DOI Listing
December 2018

Trends in Extracorporeal Membrane Oxygenation Growth in the United States, 2011-2014.

ASAIO J 2019 Sep/Oct;65(7):712-717

From the Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia.

The use of extracorporeal membrane oxygenation (ECMO) has grown rapidly in recent years. We sought to describe the rate of ECMO use in the United States, regional variation in ECMO use, the hospitals performing ECMO, and the primary payers for ECMO patients. Detailed data were obtained using the Healthcare Cost and Utilization Project (HCUPnet) summaries of State Inpatient Databases from 34 participating states for the years 2011-2014. The ECMO rates over time were modeled, overall and within subcategories of age group, bed size, hospital ownership, teaching status, and payer type. During the study period, the overall rate of ECMO use increased from 1.06 (1.01, 1.12) to 1.77 (1.72, 1.82) cases per 100,000 persons per year (p = 0.005). The rate of ECMO use varied significantly by region. Most ECMO patients are cared for at large hospitals, and at private, not-for-profit hospitals with teaching designation. The most common payer was private insurance; a minority of patient were uninsured. The use of ECMO increased significantly during the study period, but regional variation in the rate of ECMO use suggests that this technology is not being uniformly applied. Further research is warranted to determine why differences in ECMO use persist and what impact they have on patient outcomes.
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http://dx.doi.org/10.1097/MAT.0000000000000872DOI Listing
June 2020

Association of Serratus Anterior Plane Block for Minimally Invasive Direct Coronary Artery Bypass Surgery With Higher Opioid Consumption: A Retrospective Observational Study.

J Cardiothorac Vasc Anesth 2018 12 26;32(6):2570-2577. Epub 2018 Apr 26.

Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA.

Objective: The optimal regional technique for minimally invasive direct coronary artery bypass (MIDCAB) has yet to be determined. The aim of this study was to compare the efficacy of ultrasound-guided serratus anterior plane block (SAPB) with paravertebral block (PVB) and no block for controlling acute thoracotomy pain after robotic-assisted coronary artery bypass grafting (CABG).

Design: This is a retrospective study. Multiple variable regression analyses were performed.

Setting: The study was performed as a single institution.

Participants: All patients underwent robotic-assisted CABG.

Intervention: Data were analyzed from 197 patients during a 27-month period. Charts were abstracted manually to ascertain type of nerve block, age, gender, use of home opioids, use of adjuncts for opioid reduction, Society of Thoracic Surgeons predicted long length of stay (LOS), total opioid consumption during the 72 hours after surgery, and postoperative LOS. The authors' primary outcome was total morphine equivalents consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS.

Measurements And Main Results: Patients who received SAPB did not have significantly different opioid consumption than patients who had no block (p = 0.15), but it was increased significantly compared to patients administered PVB (PVB v SAPB catheter, p = 0.049; PVB v SAPB single shot, p = 0.049). There were no significant differences between groups in terms of postoperative LOS.

Conclusion: These findings suggest SAPB might not cover adequately the incisional and tube pain associated with MIDCAB. If validated by prospective studies, these findings suggest that SAPB should be considered only for patients who are not candidates for PVB.
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http://dx.doi.org/10.1053/j.jvca.2018.04.043DOI Listing
December 2018
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