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A significant role of intensive care unit (ICU) workforce is ongoing communication with and support for families of critically ill patients. The COVID-19 pandemic has created unanticipated challenges to this essential function. Restrictions on visitors to hospitals and unprecedented clinical demands hamper traditional communication between ICU staff and patient families. In response to this challenge, we created a dedicated communications service to provide comprehensive support to families of COVID-19 patients, and to create capacity for our ICU teams to focus on patient care. In this brief report, we describe the development, implementation, and preliminary experience with the service.

To assess anesthesiologists’ familiarity with the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) guidelines on Advance Directives in the perioperative setting. Single-center, 4-question anonymous survey. Urban academic medical center. Up to 34 subjects responded to each question. Familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting ranged from 45% to 100%. There was inadequate familiarity with components of the ASA and ACS guidelines on advance directives in the perioperative setting. Larger studies are required to assess anesthesiologists' familiarity with national society guidelines that directly affect patient care. Future work should investigate best practices for guideline implementation, and consequences of poor adherence to national guidelines.

Background It is unclear when it is safe to discharge patients with a diagnosis of Obstructive Sleep Apnea (OSA) after ambulatory surgical procedures due to concern for postoperative respiratory compromise and hypoxemia. Our OSA patients undergoing ambulatory-type orthopedic procedures are monitored overnight in the PACU, thus we reviewed patient records to determine incidence of complications. Methods Two hundred and six charts of patients with preoperative diagnosis of OSA based on ICD-9 codes were reviewed for outcomes including episodes of hypoxemia. Univariate analysis followed by logistic regression and propensity analysis was performed to determine independent risk factors for hypoxemia and association with adverse outcomes. Results The majority of patients had regional anesthesia (95%). Thirty four percent of patients had hypoxemia in the PACU. Initial risk factors for hypoxemia identified by univariate analysis were BMI ≥ 35, increased age, history of COPD, upper extremity procedure, and use of peripheral nerve block. Independent risk factors identified by logistic regression were history of COPD (OR 3.64 with 95% CI 1.03-12.88) and upper extremity procedure (2.53, 1.36-4.68). After adjustment with propensity scores, adverse events were rare, and unplanned hospital admission after PACU stay was not increased with hypoxemia (11% vs 16%) Conclusions Episodes of postoperative hypoxemia in OSA patients undergoing ambulatory surgery with regional anesthesia are not associated with increased adverse outcomes or unplanned hospital admission.

Purpose Subsartorial saphenous nerve blockade (SSNB) is an effective analgesic alternative to femoral nerve blockade after anterior cruciate ligament (ACL) reconstruction with bone-tendon-bone (BTB) autograft. It was hypothesized that dexamethasone in a SSNB will prolong analgesia, improve pain and satisfaction, and reduce postoperative opioid requirements and side effects. Methods One hundred ninety-five patients undergoing ACL reconstruction with BTB autograft (ages 16–65) were enrolled. Subjects received SSNB with 13 ml of 0.5 % bupivacaine (control group), 1 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group I), or 4 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group II). Subjects received identical perioperative management. On postoperative days 1 and 2, subjects reported perceived block duration, pain scores, satisfaction, opioid use, and side effects. Cox-proportional hazards modelling was used to compare block duration, adjusting for body mass index, age, sex, tourniquet time, American Society of Anesthesiologists classification, and intravenous dexamethasone dose. Results Patient-perceived block duration was significantly increased in treatment group I [hazard ratio (95 % confidence interval [CI]) 0.48 (0.31–0.75); P  = 0.001] and treatment group II (hazard ratio (95 % CI): 0.52 (0.33–0.81); P  = 0.004) compared to control. The block was extended from a median (95 % CI) of 33.1 (28.4–37.3) to 41.2 (32.4–50.9) and 46.5 (35.8–48.9) hours, respectively. Additionally, patients in treatment group II reported increased time that block provided pain relief, higher patient satisfaction, lower pain scores at rest, and decreased drowsiness and confusion. Conclusion The addition of 1 and 4 mg of dexamethasone to the block injectate significantly increased SSNB duration by 8–13 h compared to control. Level of evidence Therapeutic study, level 1.

Background Adequate pain control following anterior cruciate ligament reconstruction (ACL) often requires regional nerve block. The femoral nerve block (FNB) has been traditionally employed. Ultrasound application to regional nerve blocks allows for the use of alternatives such as the saphenous nerve block following ACL reconstruction. Questions/Purposes This study evaluated postoperative analgesia provided by the subsartorial saphenous nerve block (SSNB) compared to that provided by the traditional FNB for patients undergoing ACL reconstruction with patellar tendon (bone–tendon–bone (BTB)) autografts. Methods A randomized, blinded, controlled clinical trial was conducted using 80 ASA I–III patients, ages 16–65, undergoing ACL reconstruction with BTB. The individuals assessing all outcome measures were blinded to the treatment group. Postoperatively, all patients received cryotherapy and parenteral hydromorphone to achieve numeric rating scale pain scores less than 4. At discharge, patients were given prescriptions for oral opioid analgesics and a scheduled NSAID. Patients were instructed to complete pain diaries and record oral opioid utilization. Patients were contacted on postoperative days (POD) 1 and 2 to ascertain the level of patient satisfaction with the analgesic regimen. Results No differences between the two groups were found. Patient demographics and postoperative pain scores at rest were not different. In addition, there was no difference in opioid use, as measured in daily oral morphine equivalents between groups. A small but statistically significant report of higher patient satisfaction with the FNB was found on POD 1 but not on POD 2. Conclusion These data support our hypothesis that the SSNB provides similar and adequate postoperative analgesia when compared to the FNB, following arthroscopic ACL reconstruction with patellar tendon autograft.

Criteria to determine which patients with obstructive sleep apnea (OSA) require intensive postoperative monitoring are lacking. Our postoperative OSA patients are all intensively monitored in the PACU and can provide such data. Thus, we reviewed patient records to determine incidence and risk factors for postoperative hypoxemia in OSA patients and subsequent association with postoperative complications. Five hundred twenty-seven charts of patients with OSA based on preoperative ICD-9 codes were reviewed for outcomes including episodes of hypoxemia and hypercarbia. Univariate analysis, logistic regression, and propensity analysis were performed to determine independent risk factors for hypoxemia and association with adverse outcomes. Thirty-three and 11 percent of these patients developed hypoxemia or hypercarbia. Risk factors for hypoxemia were hypercarbia, home bronchodilator use, BMI ≥35, and estimated blood loss ≥250 ml. Patients with hypoxemia had significantly more respiratory interventions and increased intensity of care. Patients with hypoxemia had significantly increased length of stay and risk of wound infections. Severe hypoxemia was associated with significantly more interventions than mild hypoxemia. Propensity analysis confirmed significant association of hypoxemia with adverse outcomes after adjustment for pre-existing risk factors. We conclude that postoperative hypoxemia in OSA patients is associated with adverse outcomes. Risk factors for hypoxemia were identified to guide allocation of monitoring resources to high-risk patients.

THE one hundredth anniversary of the birth of Thomas Chandler Haliburton-- which occurred on December 17, 1896-- is an event which his Canadian admirers cannot permit to pass by without some adequate manifestation of their regard. Haliburton is, by common consent, the greatest literary man yet produced in the Canadian provinces, and by his literary work he established a considerable claim upon the attention of the world.

THE one hundredth anniversary of the birth of Thomas Chandler Haliburton--which occurred on December 17, 1896--is an event which his Canadian admirers cannot permit to pass by without some adequate manifestation of their regard. Haliurton is, by common consent, the greatest literary man yet produced in the Canadian provinces, and by his literary work he established a considerable claim upon...

Although the potential for genomics to contribute to clinical care has long been anticipated, the pace of defining the risks and benefits of incorporating genomic findings into medical practice has been relatively slow. Several institutions have recently begun genomic medicine programs, encountering many of the same obstacles and developing the same solutions, often independently. Recognizing that successful early experiences can inform subsequent efforts, the National Human Genome Research Institute brought together a number of these groups to describe their ongoing projects and challenges, identify common infrastructure and research needs, and outline an implementation framework for investigating and introducing similar programs elsewhere. Chief among the challenges were limited evidence and consensus on which genomic variants were medically relevant; lack of reimbursement for genomically driven interventions; and burden to patients and clinicians of assaying, reporting, intervening, and following up genomic findings. Key infrastructure needs included an openly accessible knowledge base capturing sequence variants and their phenotypic associations and a framework for defining and cataloging clinically actionable variants. Multiple institutions are actively engaged in using genomic information in clinical care. Much of this work is being done in isolation and would benefit from more structured collaboration and sharing of best practices. Genet Med 2013:15(4):258–267