Andrew D. Pitkin

Review article: glucose measurement in the operating room: more complicated than it seems.

Abnormalities of blood glucose are common in patients undergoing surgery, and in recent years there has been considerable interest in tight control of glucose in the perioperative period. Implementation of any regime of close glycemic control requires more frequent measurement of blood glucose, a function for which small, inexpensive, and rapidly responding point-of-care devices might seem highly suitable. However, what is not well understood by many anesthesiologists and other staff caring for patients in the perioperative period is the lack of accuracy of home glucose meters that were designed for self-monitoring of blood glucose by patients. These devices have been remarketed to hospitals without appropriate additional testing and without an appropriate regulatory framework. Clinicians who are accustomed to the high level of accuracy of glucose measurement by a central laboratory device or by an automated blood gas analyzer may be unaware of the potential for harmful clinical errors that are caused by the inaccuracy exhibited by many self-monitoring of blood glucose devices, especially in the hypoglycemic range. Knowledge of the limitations of these meters is essential for the perioperative physician to minimize the possibility of a harmful measurement error. In this article, we will highlight these areas of interest and review the indications, technology, accuracy, and regulation of glucose measurement devices used in the perioperative setting.

Challenges to Glycemic Measurement in the Perioperative and Critically Ill Patient: A Review

Accurate monitoring of glucose in the perioperative environment has become increasingly important over the last few years. Because of increased cost, turnaround time, and sample volume, the use of central laboratory devices for glucose measurement has been somewhat supplanted by point-of-care (POC) glucose devices. The trade-off in moving to these POC systems has been a reduction in accuracy, especially in the hypoglycemic range. Furthermore, many of these POC devices were originally developed, marketed, and received Food and Drug Administration regulatory clearance as home use devices for patients with diabetes. Without further review, many of these POC glucose measurement devices have found their way into the hospital environment and are used frequently for measurement during intense insulin therapy, where accurate measurements are critical. This review covers the technology behind glucose measurement and the evidence questioning the use of many POC devices for perioperative glucose management.

An ontology-enabled user interface for simulation model construction and visualization

The purpose of an ontology is to structurally define knowledge about a topic. For the practice of simulation, ontologies have been demonstrated to be useful across a variety of techniques ranging from formally defining the components of dynamic models and capturing key simulation domain constraints to interrelating dynamic model components and geometry in order to visualize a phenomenon. We have created a methodology that requires domain ontologies to be rendered in the human-interface layer in support of the construction of dynamic models and their corresponding visualizations. We hypothesize that this methodology will provide a novel and accessible way to author visualizations and a framework for creating new teaching tools that merge concrete and abstract knowledge. A case study of our methodology is performed by applying our software prototype to simulation and visualization in the domain of healthcare, specifically cardiovascular physiology

Perioperative Management of a Patient With Failed Fontan Physiology

Andrew D. Pitkin, MBBS, MRCP, FRCA, is a cardiac anesthesiologist at the University of Florida. His interests include pediatric cardiac anesthesia, single ventricle physiology, and medical education. Mark C. Wesley, MD, is an assistant professor in cardiac anesthesia at Boston Children’s Hospital. He is board certified in pediatrics and anesthesiology. His clinical interests include pediatric anesthesia and cardiac anesthesia for children and adults with congenital heart disease. Kristine J. Guleserian, MD, is an associate professor of pediatric cardiothoracic surgery and the surgical director of Pediatric Cardiac Transplantation and Adult Congenital Heart Surgery at Children’s Medical Center Dallas/University of Texas Southwestern Medical Center. Her research interest, among others, includes clinical applications of endothelial progenitor cells. Victor C. Baum, MD, is Frederic A. Berry Professor of Pediatric Anesthesiology and director of cardiac anesthesia at the University of Virginia. In addition to anesthesiology, he is board certified in pediatric cardiology. Thomas M. Burch, MD, is an assistant professor in cardiac anesthesia at Boston Children’s Hospital and is board certified in anesthesiology. His interests include adult and pediatric cardiothoracic anesthesiology and echocardiography as well as e-learning for board review.

Point of care devices should not be relied upon for perioperative glucose measurement.

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Left Atrial Appendage Aneurysm Characterized by Multimodal Imaging

We present a four-year-old female with an incidental finding of a congenital left atrial appendage aneurysm who underwent surgical resection with excellent results. This case highlights the importance of multimodal imaging in the diagnosis and characterization of this rare condition.

Post Mitral Valve Replacement: Paravalvular Leak or Unroofed Coronary Sinus?

Graphical abstract