OHSU Research Ideas

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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

  • Does change in PPV/CO after SCD activation predict fluid responsiveness and how does it compare to SLR?
  • Does sugammadex interfere with HRT in post-menopausal and/or lactating women? (0 articles mentioning both Sugammadex and Menopause)
  • EEG/MEP/SSEP patterns in monkeys/humans taking THC vs controls
  • 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
  • Can ET O2 and FiO2 gradient be used to calculate 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.

Very Ambitious, But Still Cool

  • NIBP monitoring from head/neck
  • Can you modulate the strength of the Bohr effect to extract more hemoglobin from oxygen (thus prolonging apnea time before desaturation)? Humpback whales (and very small animals) have a much stronger Bohr effect, presumably from hemoglobin mutations. One approach would be non-immunogenic artificial hemoglobin proteins (made with CRISPR and perhaps packaged into empty RBCs?), another option would be some drug that modulates the Bohr effect on human Hgb.
  • 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?
  • Find a better trigger for transfusion threshold. Hgb mass loss vs. qBL vs. EBL are all various ways of getting at how much blood was lost, but why do we even care? Is that even useful information? How much Hgb do you need? Is Hgb concentration even the right thing to measure for a transfusion threshold? What you really want to know is whether they lost so much blood that they require a transfusion to provide adequate tissue oxygenation. Are there other reasons to care? Is there an early marker of tissue hypoxia that would make a better laboratory marker for determining need for blood transfusion?
    • Hgb mass loss (HML) takes the concentration of Hgb in the suction canister (including irrigation) and multiplies it by the volume to yield the total hemoglobin mass in the canister. This could then be divided by the starting Hgb concentration to determine the volume of blood lost.
    • Assuming the blood is lost acutely, there initially should be no change in the Hgb concentration. Over a sub-acute time frame two dilutional factors kick in, volume resuscitation with crystalloid and fluid shifts from the interstitial to the intravascular compartment.
    • Assuming 100% stayed intravascular and there were no fluid shifts between compartments to compensate, could you predict the new Hgb concentration after fluid administration based on how much volume was given? Probably not, given that you know C1 but not V1, and you are trying to solve for C2 but don't know V2. You do know the volume lost and the volume given back with concentration of 0, but I'm not sure if that is helpful. Assuming a standard blood volume based on patient averages may not be accurate because patients will come to surgery with unpredictable confounders like bleeding/dehydration. The starting blood volume could be measured (e.g. with nuclear medicine assay), but even then you won't know how much of the resuscitation fluid will stay intravascular or how much fluid is shifting between compartments. If you knew the starting blood volume, you could at least say what fraction of total Hgb was lost.

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

SCD hemodynamic effects

Caption text
Reference Population Intervention Comparator Outcome
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.
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.
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
Helmi et al Future Cardiology 2013 Example Example Example Example
Kiefer et al Anesthesiology 2011 Example Example Example Example
Kwak et al J of Neurosurgical Anesthesiology 2011 Example Example Example Example
Kwak et al Arthroscopy 2010 Example Example Example Example
Fanelli et al J of Clin Anesthesia 2008 Example Example Example Example
Sohn et al Circulation J 2008 Example Example Example Example
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