Difference between revisions of "OHSU Research Ideas"

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=Ideas=
 
=Ideas=
 +
 +
==QI==
 +
* What is the optimal number of evals for residents and attending to fill out? Would having fewer result in higher quality? How often do residents and attendings look at their medhub evals? Does anyone find them useful? If they are not useful, lets stop doing them, or tweak it (to be less frequent)
 +
* Having anesthesia residents/attendings assigned some complex cases 1 month in advance and then have them do the pre-anesthetic eval and interim optimization for that patient. Perhaps even a post-op follow-up call or visit.
 +
* [[Low-flow anesthesia]] real-time decision support built into EPIC (or laminated card reminder placed on workstations). See Baby Miller pg. 877.
 +
* Is there anyway to educate providers on how (or if) anesthetic management decisions affect the bill the patient sees?
 +
* Recycling and waste sortage in the OR. Also, getting rid of ProVu!
 +
 
==Good==
 
==Good==
−
* Does change in PPV/CO after SCD activation predict fluid responsiveness and how does it compare to SLR?
+
* [[SCD Fluid Bolus|Does change in PPV/CO after SCD activation predict fluid responsiveness and how does it compare to SLR?]]
 +
* Alpha band dropout and gamma band increase as [[Objective Measurement of Pain|objective measurement of pain]].
 
* Does sugammadex interfere with HRT in post-menopausal and/or lactating women? (0 articles mentioning both Sugammadex and Menopause)
 
* Does sugammadex interfere with HRT in post-menopausal and/or lactating women? (0 articles mentioning both Sugammadex and Menopause)
−
* Fentanyl patch instead of remifentanil infusion? What other anesthetics could you deliver via patch? Could you do a patch induction for Peds?
 
 
* EEG/MEP/SSEP patterns in monkeys/humans taking THC vs controls
 
* EEG/MEP/SSEP patterns in monkeys/humans taking THC vs controls
−
* Quantification of Hgb mass loss vs. qBL in C-section.
+
* Buprenorphine for induction or acute pain treatment in perioperative setting
 +
* Surgical TAP block vs US guided
 +
* [[Choice of anesthetic for cancer resection]]. Is TIVA superior to inhaled anesthesia for recurrence free survival in cancer surgery?
 +
* [[Xenon recycling]] (7 relevant papers)
 +
* Yohimbine for precedex reversal
 +
* [[Estimating VO2|Can the difference between FiO2 and ETO2 be used to estimate VO2?]]
 +
* Does normocytic hemodilution reduce RBC transfusion?
 +
* What do we know about the very low frequency EEG power bands? i.e. the stuff that is less than 0.2 Hz and is usually filtered out. Analogous to looking at the tides when everyone else is looking at the waves.
 +
* [[Young blood transfusions]]
 +
* Why does albumin not stay intravascular? Why can't you replete hypoalbuminemia via TPN?
  
 
==Very Ambitious, But Still Cool==
 
==Very Ambitious, But Still Cool==
 
* NIBP monitoring from head/neck
 
* NIBP monitoring from head/neck
 +
* Can you [[Bohr Effect Modulation|modulate the strength of the Bohr effect]]?
 
* Better way of determining fluid status
 
* Better way of determining fluid status
 
* Novel reversal agents (e.g. volatile anesthetics, propofol, precedex)
 
* Novel reversal agents (e.g. volatile anesthetics, propofol, precedex)
−
* Reversible chemical/optical/electromagnetic knockdown/inhibition/interference of pain nuclei/DRG/dorsal column/STT activity in rodents/primates
+
* Permanently inhibit a nerve to prevent phantom pain after amputation.
 +
* Reversible chemical/optical/electromagnetic knockdown/inhibition/interference of pain nuclei/DRG/dorsal column/STT activity in rodents/primates. https://onlinelibrary.wiley.com/doi/pdf/10.1002/ejp.1136
 +
* Fentanyl patch instead of remifentanil infusion? What other anesthetics could you deliver via patch? Could you do a patch induction for Peds? There is no remifentanil or sufentanil patch.
 +
* What is the MoA of APAP?
 +
* [[Transfusion thresholds]]
  
 
==Already Done==
 
==Already Done==
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* Which findings on the preop note predict pressors use during the case?
 
* Which findings on the preop note predict pressors use during the case?
 
* EPIC timeline builder
 
* EPIC timeline builder
 +
* Does setting realistic pain expectations in pre-op decrease self-reported pain scores in PACU?
 
* Ultrasound vs blind A-line first attempt success rate and complications?
 
* Ultrasound vs blind A-line first attempt success rate and complications?
−
* How do epidurals affect gastric emptying in labor?
+
* [[Epidural Effect on Gastric Emptying|How do epidurals affect gastric emptying?]]
−
When did the ASA make their guideline for fasting? Which studies were cited? Which studies was the ASA (presumably) aware of? Ultimately, the clinical implications of answering this question would hinge on whether the results would change the ASA guidelines. If new information is unlikely to change guidance, then pursuing this question would be less relevant. Fasting for a few hours post-epidural is very low risk compared to the admittedly rare event of clinically significant aspiration. If you show that epidurals increase gastric emptying that would suggest that they also decrease risk of aspiration. However, if you then let patients with epidurals eat, they have a full stomach and their risk of aspiration is heightened despite any protective effect of an epidural. In other words, the lowest risk category of patients, assuming my hypothesis is true, remains fasted patients with epidurals.
 
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{| class="wikitable"
 
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−
! Reference !! Population !! Intervention !! Comparator !! Outcome
 
−
|-
 
−
| [https://dx.doi.org/10.1097/EJA.0000000000001514 Weiniger et al Eur J of Anaes 2022] || 80 non-fasted pregnant women, age 18+, GA 37+ weeks, singleton, cephalad, dilated <= 5 cm, 63 had empty stomachs and 17 had full stomachs at baseline || Double-blind single center RCT with women randomized to low-dose (50) or high-dose (100) epidural fentanyl.  || Stomach antrum cross-sectional area (CSA) was measured with gastric US before and 2 hrs after fentanyl administration || No differences between low-dose and high-dose fentanyl groups.
 
−
|-
 
−
| [https://dx.doi.org/10.1097/ALN.0000000000004133 Chassard et al Anes 2022] || 40 women || Prospective cohort study. Gastric ultrasound (gUS) was used to verify an empty stomach, then participants ate 125 g of yogurt within 5 min. For the epidural group, the meal was consumed within one hour of epidural placement. || 10 parturients with labor epidural were compared with 10 pregnant women at term, 10 non-pregnant women, and 10 parturiants with no labor epidural. Serial gUS was performed at 15, 60, 90, and 120 minutes after a light meal and fraction of gastric emptying was calculated as [Area_Antral_90 / Area_Antral_15 - 1]*100. || Gastric emptying fraction (higher is better) was 52% (non-pregnant), 45% (pregnant), 7% (parturiants w/o epidural), and 31% (parturiants w/ epidural). Parturiants had delayed gastric emptying compared to non-parturiants, and epidural analgesia actually sped up gastric emptying.
 
−
|-
 
−
| [https://dx.doi.org/10.1093/bja/aet435 Bonnet et al BJA 2014] || 60 spontaneously laboring parturients with ropivacaine/sufentanil PCEA analgesia || CSA measured with binary outcome of "full" or "not full" based on cutoff CSA value of >320 determined in small pilot study of 6 pregnant women. || gUS compared CSA when the anesthesiologist was called for epidural placement  (beginning of labor) and at full cervical dilation. || 50% had full stomachs at epidural placement compared to 13% at full cervical dilation.
 
−
|-
 
−
| [https://dx.doi.org/10.1007/s00540-008-0692-5 Inada et al J of Anes 2009] || 16 ASA 1-2 term parturients undergoing elective cesarean delivery || CSE w/ 10 mg Bupivacaine and 10 mcg Fentanyl || Four channel electrogastrography was performed for 10 min at 5 interval time points. || Frequency of gastric contractions increased after spinal anesthetic, during the surgery, and returned to the (presumed) non-pregnant normal values by POD7.
 
−
|-
 
−
| [https://ovidsp.dc2.ovid.com/ovid-new-b/ovidweb.cgi?&S=EGCFFPEMIIEBOLIHJPKJIFDGCBGDAA00&PDFLink=B%7cS.sh.20%7c9&WebLinkReturn=Titles%3dS.sh.20%7c9%7c50%26FORMAT%3dtitle%26FIELDS%3dTITLES&Counter5=SS_as_pdf%7c17717235%7cmedall%7cmedline%7cmed6 Avram et al Anes and Analg 2007] || 10 obese (pre-pregnancy BMI > 35), pregnant, term, non-laboring, fasted women || gUS measurement of CSA and acetaminophen absorption test was used to measure gastric emptying || 1.5g APAP was taken with 50 or 300 ml of water (cross-over design randomly assigned and separated by 2+ days) before measurement/calculation of CSA, gastric emptying half-time, APAP AUC, and C(max) T(max) for APAP concentration. || There were no differences in CSA, gastric 1/2 time, AUC, C(max), or T(max) between the 50 and 300 ml tests.
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/10455830/ O'Sullivan et al Anes 1999] || 94 women in labor || Women were randomised to light diet or water only || CSA and metabolic profiles were compared, as well as length of labor and labor outcome || Blood glucose and insulin were higher and plasma betahydroxybutyrate and non-esterified fatty acids were lower in the diet group. There were no differences in labor course, labor outcomes (e.g. mode of delivery, umbilical artery/vein samples, and APGAR scores). CSA was higher in the diet group as was emesis volume.
 
−
|-
 
−
| [https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2044.1997.238-az0373.x?sid=Ovid%3Amedline Reynolds et al Anes 1997] || 56 women in labor, >36 weeks gestation, singleton, cephalad, no systemic opioids || Women had epidurals placed and were given 1.5g of paracetamol, then had serum levels measured at 0, 15, 30, 45, 60, and 90 minute timepoints. || Women were randomly assigned to either 0.125% bupivacaine solution or 0.0625% bupivacaine with 2.5 mcg/ml fentanyl, with continuous infusion rate titrated to effect. Rescue boluses of 5 ml 0.25% bupivacaine were given as needed. In study A, 28 women received paracetamol after 30 ml (75 mcg of fentanyl), while in study B it was after 40-50 ml (100-125 mcg of fentanyl). || No significant differences in AUC, peak concentration, or time to peak concentration in study A. In study B, the time to max concentration was delayed in the fentanyl group.
 
−
|-
 
−
| [https://ovidsp.dc2.ovid.com/ovid-new-b/ovidweb.cgi?WebLinkFrameset=1&S=EGLNFPLEIIEBMLKBIPKJOFPFCBGDAA00&returnUrl=ovidweb.cgi%3f%26Titles%3dS.sh.20%257c13%257c50%26FORMAT%3dtitle%26FIELDS%3dTITLES%26S%3dEGLNFPLEIIEBMLKBIPKJOFPFCBGDAA00&fromjumpstart=0&directlink=https%3a%2f%2fovidsp.dc2.ovid.com%2fovftpdfs%2fFPEBIPPFOFKBII00%2ffs047%2fovft%2flive%2fgv024%2f00000539%2f00000539-199710000-00022.pdf&filename=A+Comparison+of+the+Effect+of+Intrathecal+and+Extradural+Fentanyl+on+Gastric+Emptying+in+Laboring+Women.&navigation_links=NavLinks.S.sh.20.13&PDFIdLinkField=%2ffs047%2fovft%2flive%2fgv024%2f00000539%2f00000539-199710000-00022&link_from=S.sh.20%7c13&pdf_key=B&pdf_index=S.sh.20&D=medall Mirakhur et al Anes and Analg 1997] || 105 parturiants || APAP absorption assay was done in women getting neuraxial labor analgesia || Neuraxial analgesia was administered with bupivacaine and 25 mcg intrathecal fentanyl (S), 50 mcg epidural fentanyl (E), or no opioid (C). APAP CMax, TMax, and AUC were measured at 60 and 120 min || Median (range) TMax values were 120 (15-180), 82.5 (15-180), and 90 (15-180) min in Groups S, E, and C, respectively (P < 0.05). Mean ± SD CMax was 13.4 ± 8.82, 17.9 ± 8.06, and 15.0 ± 6.22 µg/mL in Groups S, E, and C, respectively (P < 0.05). Mean ± SD AUC90 and AUC120 were also significantly smaller in Group S than in the other two groups (430 ± 616, 736 ± 504, and 672 ± 453; and 649 ± 592, 1063 ± 627, and 1053 ± 616 µg/ml/min in Groups S, E, and C, respectively).
 
−
|}
 
  
 
=Resources=
 
=Resources=
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* Jeff Davis
 
* Jeff Davis
 
* Brandon Togioka
 
* Brandon Togioka
−
 
−
=SCD hemodynamic effects=
 
−
{| class="wikitable"
 
−
|+ Caption text
 
−
|-
 
−
! Reference !! Population !! Intervention !! Comparator !! Outcome
 
−
|-
 
−
| [https://www.ima.org.il/FilesUploadPublic/IMAJ/0/384/192227.pdf Moady et al IMAJ 2019] || Healthy volunteers and HFrEF patients || Pneumatic sleeve (PS) compression devices applied to both legs from toe to thigh and inflated to a pressure of 50 or 80 mmHg. the same method does not exacerbate symptoms and increases CO via an increase in SV, decreases SVR, and has no effect on HR (see ref 17). || Example || In healthy volunteers, there was increased CO, decrease SVR, and have no effect on HR (see ref 16). HFrEF patients who were medically optimized had '''no change in any hemodynamic parameter after 60 minutes of PS application''', and that they tolerated it well without any increase in their BNP.
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/25038262/#:~:text=There%20was%20no%20detrimental%20effect,and%20a%20reduction%20in%20SVR. Bickel et al J of Card Failure 2014] || Patients with HFrEF (mean LVEF 30%) || ISPC devices applied to both legs and cycled every 2 min for 40 min. || Example || Increased CO, SV, and decreased SVR w/o any effect on HR and without causing signs or symptoms of heart failure exacerbation. CVP and atrial size increased during ISPC activation.
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/31578774/ Gibbons et al Experimental Physiology 2019] || 14 healthy university students || Four 3 minute trials of orthostatic maneuvers (stand-to-squat or thigh cuff compression/release) were done in random order with half of the trials involving ISPC (5 cuffs, peristaltic motion, applied over 200 ms, 65 mmHg, timed to local diastolic phase) of the lower extremity timed to counteract orthostatic changes (return to standing or after thigh-cuff release). Hemodynamic parameters (superficial femoral artery, MAP, Doppler ultrasound cardiac output, total peripheral resistance, middle cerebral artery blood velocity (MCAv), and cerebral tissue saturation index) were measured non-invasively before, during, and after || Example || Decreased TPR, heart rate; increased CO (via increased SV), TSI, and MCAv
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/24020667/ Helmi et al Future Cardiology 2013] || Example || Example || Example || Example
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/21307764/ Kiefer et al Anesthesiology 2011] || Example || Example || Example || Example
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/20622680/ Kwak et al J of Neurosurgical Anesthesiology 2011] || Example || Example || Example || Example
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/20511029/ Kwak et al Arthroscopy 2010] || Example || Example || Example || Example
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/18761240/ Fanelli et al J of Clin Anesthesia 2008] || Example || Example || Example || Example
 
−
|-
 
−
| [https://pubmed.ncbi.nlm.nih.gov/18219162/ Sohn et al Circulation J 2008] || Example || Example || Example || Example
 
−
|}
 

Latest revision as of 14:54, 2 October 2024

https://www.mediawiki.org/wiki/Extension:CollapsibleSections

Ideas

QI

  • What is the optimal number of evals for residents and attending to fill out? Would having fewer result in higher quality? How often do residents and attendings look at their medhub evals? Does anyone find them useful? If they are not useful, lets stop doing them, or tweak it (to be less frequent)
  • Having anesthesia residents/attendings assigned some complex cases 1 month in advance and then have them do the pre-anesthetic eval and interim optimization for that patient. Perhaps even a post-op follow-up call or visit.
  • Low-flow anesthesia real-time decision support built into EPIC (or laminated card reminder placed on workstations). See Baby Miller pg. 877.
  • Is there anyway to educate providers on how (or if) anesthetic management decisions affect the bill the patient sees?
  • Recycling and waste sortage in the OR. Also, getting rid of ProVu!

Good

Very Ambitious, But Still Cool

  • NIBP monitoring from head/neck
  • Can you modulate the strength of the Bohr effect?
  • Better way of determining fluid status
  • Novel reversal agents (e.g. volatile anesthetics, propofol, precedex)
  • Permanently inhibit a nerve to prevent phantom pain after amputation.
  • Reversible chemical/optical/electromagnetic knockdown/inhibition/interference of pain nuclei/DRG/dorsal column/STT activity in rodents/primates. https://onlinelibrary.wiley.com/doi/pdf/10.1002/ejp.1136
  • Fentanyl patch instead of remifentanil infusion? What other anesthetics could you deliver via patch? Could you do a patch induction for Peds? There is no remifentanil or sufentanil patch.
  • What is the MoA of APAP?
  • Transfusion thresholds

Already Done

Not Super Exciting/Impactful

  • Which findings on the preop note predict pressors use during the case?
  • EPIC timeline builder
  • Does setting realistic pain expectations in pre-op decrease self-reported pain scores in PACU?
  • Ultrasound vs blind A-line first attempt success rate and complications?
  • How do epidurals affect gastric emptying?

Resources

  • Schnell lab
  • Leimer/Lo lab (THC, NHPs)
  • Saugstad lab (EVs)
  • Schennings (Gas vs. TIVA risk of post-op delirium, assessed via CAM)
  • Schulman (interrogate ICDs for EMI after surgery)
  • Austin Peters
  • Selva Balkan
  • Dale Hodges
  • Liz Moss
  • Jeff Davis
  • Brandon Togioka
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