Anesthesiology 2019 Projects

Project Title: A Retrospective Chart Review: Post-Operative Effects of Cuffed vs Un-cuffed ETTs in Infants Undergoing Cardiac Surgery

Faculty Mentor’s Name: Dr. Kevin Sullivan
Phone: 904-654-4427
Email: kevinsullivan@ufl.edu

Student’s Name: Allyson Tragesser
Email: atragesser@ufl.edu

Project Description:

This retrospective chart review is aimed to investigate the differences of endotracheal tubes in cardiac surgeries of high-risk patients who are < 6 mo and < 5 kg. If a significant difference is found, this research shall promote a protocol for pediatric anesthesiologists be installed in order to deliver safer care to their patients. The protocol would dictate what size tube and whether a cuff should be used depending on the patient’s surgical risk, age, and weight. This would be designed in hopes of limiting the administration of epinephrine and steroids, as well as injury to the airway.

Project Title: Blood Cardiac Surgery Utilization Study

Faculty Mentor’s Name: Dr. Kevin Sullivan
Phone: 904-654-4427
Email: kevinsullivan@ufl.edu

Student’s Name: Christian Eskander
Email: c.eskander@ufl.edu

Project Description:

The project consists of both a prospective cohort from April to July 2019, and a retrospective cohort for the past 2 years starting April 2017. In the prospective cohort, we are having the perfusionists, and anesthesiologists in each surgery enter all blood units used and unused, opened and unopened, including not only the blood administered by anesthesia, but also in the cardiopulmonary bypass machine. The retrospective cohort will be looking at similar information, but only for blood administer by anesthesia.

 We will use Epic to view the data entered by the medical team prospectively and retrospectively and collect it with the REDcap tool. We will be looking at multiple parameters and evaluate based not only on the amount of blood used and unused, but also based on what kind of surgery was performed, as different types of surgeries may have different blood usage efficiency rates.

Project Title: Early Extubation in Liver Transplant Patients

Faculty Mentor’s Name: Dr. Rensheng Zhang
Phone:
Email: rzhang@anest.ufl.edu

Student’s Name: Erich Zellmer
Email: ezellmer@ufl.edu

Project Description:

Early extubation has been shown to be beneficial in a selected group of liver transplant recipients and demonstrates benefits such as improved regional blood flow to liver graft from increased venous return, reduced ICU stay (Zeyneloglu et al), and possibly reduced postoperative pulmonary complications. Several studies demonstrated the safety and feasibility of early or immediate extubation in liver transplant patients with good pretransplant conditions and uncomplicated intraoperative course. Despite the data, some anesthesiologists may still be reluctant to extubate any liver transplant patients in the OR due to concerns for encephalopathy, large blood loss, fluid shifts, hemodynamic instability and metabolic derangements. Others who aim to extubate in the OR may base their judgments on experience and clinical gestalts.

Careful patient selection is key to avoiding compromising patient safety from premature extubation. Successful early extubation depends on multiple patient and physiologic factors. In the literature, there have been attempts to identify these preoperative and intraoperative factors that predicts successful early extubation. For example, Skurzak et al (2010) develop the SORELT (Safe Operating Room Extubation after Liver Transplantation) score consisting of 2 major and 3 minor criteria derived from retrospective data from 597 OLT who either were or were not immediately extubated. Major criteria found included 1) <7 units of packed RBCs transfused intraoperatively; 2) end of surgery lactate <3.4 mmol/L. Minor criteria included 1) patient at home pretransplant; 2) duration of surgery <5 hours; 3) vasoactive infusions at end surgery (dopamine <5 μg/kg/min or norepinephrine <0.05 μg/kg/min). Due to heterogeneity of patient population and surgical and anesthetic practice at each institution, these objective scoring systems still require further external validation. Many features from the SORELT score were subsequently reproduced in the study by Lee et al in 2014 in living donor liver transplant recipients who reported major predictors for extubation within 1 hour of surgery end included pRBC transfused <7 units and final intraoperative lactate<=8.2 mmol/L, which is a much higher threshold partly due to graft related factors of living donor LT compared with OLT. The amount of pRBC transfusion also appears to be a consistent major predictor of successful early extubation across many other studies, each study found different cutoff values (12 units in Biancofiore et al; 10 units in Cammu et al; 6 units in Glanemann et al). Perhaps measuring the ml/kg instead of units transfused will help normalize the values across different patient sizes and be more indicative of amount transfused in proportion to individual’s estimated blood volume.

At our institution from 2000 to 2008, a consistent group of anesthesiologists routinely aimed to extubate in the operating room. Due to the absence of specific guidelines for immediate extubation after liver transplant other than general extubation criteria, most providers presumably made their judgement based on clinical gestalts and experience.

Project Title: Micro SpO2 Changes and Respiration Rate

Faculty Mentor’s Name: Dr. Nikolaus Gravenstein
Phone:
Email: ngravenstein@anest.ufl.edu

Student’s Name: Leila Shafiq
Email: lshafiq@ufl.edu

Project Description:

Traditionally, standard pulse oximeters placed on a patient’s fingertip offer peripheral oxygen saturation (SpO2) readings that are only provided in whole number values. However, with a software connection, SpO2 sensor readings report values to the tenths place. Pulse oximeter probes may be placed on a finger or a nasal ala.

The objective of this project will be accomplished by the following specific aims:

(1) Identify a method to signal process micro SpO2 changes in order to record an output of respiration rate.

(2) Measure the metronome-guided respiration rates of volunteers using a finger and a nasal alar SpO2 sensor as compared to the gold standard of End-Tidal CO2 (EtCO2).

(3) Analyze data obtained to determine if either a finger or a nasal alar SpO2 sensor offers a reliable method of obtaining respiration rate.

Project Title: Optimizing the allocation of blood products used by the UFCHC

Faculty Mentor’s Name: Dr. Kevin Sullivan
Phone: 904-654-4427
Email: kevinsullivan@ufl.edu

Student’s Name: Samuel Armington
Email: samarmington@ufl.edu

Project Description:

Blood transfusion involves the administration of packed red cells, fresh frozen plasma, cryoprecipitate, and platelets which collectively are referred to as blood products. Transfusion of blood products is essential for many surgeries, particularly pediatric cardiac surgery. Unfortunately, blood products are frequently wasted despite their importance. One study found that 25% of the blood products were wasted in a single hospital (Kurup et al.). Due to the hospital wide demand, and the relatively significant waste, it is imperative that ordering physicians and blood banking service work together to more efficiently allocate this precious resource. To do this, various strategies are being developed and employed (Eeles and Baikady; Singh).

Pediatric cardiac surgery is increasing in incidence, and its demand for blood products is higher than that for comparable adult surgeries (Singh; Manno et al.). Notably, an estimated 98% of pediatric patients on cardiopulmonary bypass receive transfusion (Chambers et al.). Together, these factors make pediatric cardiac surgery a major consumer of blood products in the hospital. Consequently, these pediatric anesthesiologists and surgeons bear a particularly high responsibility for stewardship of blood products to ensure their availability for other patients.

We believe that a comprehensive strategy that measures blood utilization and stratifies it by patient age, size, re-operation status, and complexity of surgical lesion will allow us to both estimate and aliquot blood products so that blood banked units can be partitioned for use both in the operating room and for the perioperative period in the intensive care unit. Under the current paradigm, incomplete aliquots of blood units are utilized with the remainder being wasted. We seek to define practices and promote protocols that allow for the complete utilization of this precious and expensive resource.

The specific aims are as follows:

  1. Determine the amount/composition of all blood products ordered for various surgical procedures
  2. Determine the amount of blood products administered versus the amount wasted
  3. Define strategies to promote the return and reallocation of unopened blood product units
  4. Determine the amount of time required to fulfill an order to the blood bank
  5. Develop more accurate estimations for the blood product requirements of specific surgical procedures in patients of different age, size, and reoperation status

Project Title: Safety of Pediatric Scheduling Assignments

Faculty Mentor’s Name: Dr. Kevin Sullivan
Phone: 904-654-4427
Email: kevinsullivan@ufl.edu

Student’s Name: Evan Johns
Email: ejohns@ufl.edu

Project Description:

Modern anesthesia services in academic medical centers are often provided in a model of concurrent care wherein an anesthesia faculty member supervises residents, nurse anesthetists, or anesthesia assistants. The methods employed for assigning multiple operating rooms of pediatric and or adult patients may directly impact the safety of the care provided and is a concern for practicing anesthesiologists.
In this hypothesis generating quality assurance program the medical student will work with the pediatric anesthesia faculty to determine risk factors and interventions that minimize risk and maximize safety for pediatric anesthesia services.

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