Jason Brainard

Circadian Rhythms in Anesthesia and Critical Care Medicine Potential Importance of Circadian Disruptions

The rotation of the earth and associated alternating cycles of light and dark—the basis of our circadian rhythms—are fundamental to human biology and culture. However, it was not until 1971 that researchers first began to describe the molecular mechanisms for the circadian system. During the past few years, groundbreaking research has revealed a multitude of circadian genes affecting a variety of clinical diseases, including diabetes, obesity, sepsis, cardiac ischemia, and sudden cardiac death. Anesthesiologists, in the operating room and intensive care units, manage these diseases on a daily basis as they significantly affect patient outcomes. Intriguingly, sedatives, anesthetics, and the intensive care unit environment have all been shown to disrupt the circadian system in patients. In the current review, we will discuss how newly acquired knowledge of circadian rhythms could lead to changes in clinical practice and new therapeutic concepts.

Health implications of disrupted circadian rhythms and the potential for daylight as therapy.

For many thousands of years, the sun was our only source of light, and human behavior followed a natural day-night cycle. This milieu began to change approximately 150 years ago with the invention of incandescent lighting. Electric lighting disrupted our behavioral dependence on the day-night cycles of the sun, and facilitated alterations in our circadian sleep-wake cycles. Recent research has begun to identify the physiologic consequences of unnatural light exposure and subsequently altered circadian rhythms.1 In this paper, we review the molecular basis of circadian rhythms and discuss the established connection between disrupted circadian rhythms and clinical disease. We also explore the concept of daylight as therapy to restore disrupted circadian rhythms and improve clinical outcomes.

Heated humidified high-flow nasal cannula oxygen after thoracic surgery — A randomized prospective clinical pilot trial

Background Thoracic surgery patients are at high‐risk for adverse pulmonary outcomes. Heated humidified high‐flow nasal cannula oxygen (HHFNC O2) may decrease such events. We hypothesized that patients randomized to prophylactic HHFNC O2 would develop fewer pulmonary complications compared to conventional O2 therapy. Methods and patients Fifty‐one patients were randomized to HHFNC O2 vs. conventional O2. The primary outcome was a composite of postoperative pulmonary complications. Secondary outcomes included oxygenation and length of stay. Continuous variables were compared with t‐test or Mann‐Whitney‐U test, categorical variables with Fishers Exact test. Results There were no differences in postoperative pulmonary complications based on intention to treat [two in HHFNC O2 (n = 25), two in control (n = 26), p = 0.680], and after exclusion of patients who discontinued HHFNC O2 early [one in HHFNC O2 (n = 18), two in control (n = 26), p = 0.638]. Discomfort from HHFNC O2 occurred in 11/25 (44%); 7/25 (28%) discontinued treatment. Conclusions Pulmonary complications were rare after thoracic surgery. Although HHFNC O2 did not convey significant benefits, these results need to be interpreted with caution, as our study was likely underpowered to detect a reduction in pulmonary complications. High rates of patient‐reported discomfort with HHFNC O2 need to be considered in clinical practice and future trials. HighlightsPulmonary complications were rare after thoracic surgery.Patient‐reported discomfort was more frequent with the use of HHFNC O2.This pilot study did not indicate a beneficial effect of prophylactic HHFNC O2.Larger samples are necessary to definitively ascertain benefits of HHFNC O2.

360: DEVELOPMENT OF A CONTENT OUTLINE FOR UME CRITICAL CARE EDUCATION USING A MODIFIED DELPHI METHOD

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: The AAMC states that physicians entering residency should be competent in recognizing and initiating the management of a deteriorating patient who requires emergent care. One opportunity to learn such knowledge is by caring for critically-ill patients. There is currently no consensus on what medical students should learn regarding critical care. This lack of consensus is in contrast to other specialties. Other specialties have utilized the Delphi method to develop consensus content outlines. The aim of this research is to develop a national critical care content outline through a multidisciplinary expert consensus process. Methods: We used a modified Delphi process to reach consensus on the core skills and knowledge that should be learned during a UME critical care experience. The Delphi panel included 3 expert groups: 1) UME critical care educators identified through SCCM; 2) residency program directors of multiple specialties nominated by their national organizations; 3) residents nominated by program directors to represent their specialties. Over three, iterative rounds, the Delphi panel reached consensus on the critical care skills and knowledge expected of graduating medical students. Results: The Delphi panel included 28 experts, including 17 experts with sub-specialty training in critical care. Experts represented anesthesia, emergency medicine, internal medicine, OB/ GYN, pediatrics and surgery. Consensus content recommendations were grouped into five subjects: 1) circulatory failure 2) respiratory failure 3) electrolyte derangement 4) altered mental status 5) arrhythmias. Bag-mask ventilation was the only consensus procedure recommended. Conclusions: This Delphi provides a national, consensus UME content outline for critical care. By including experts from multiple specialties, our content outline is meaningful for graduating students, independent of their intended specialty. The content outline represents a first step in the development of local and national UME critical care curriculums.

Animal experimental research design in critical care

BackgroundLimited translational success in critical care medicine is thought to be in part due to inadequate methodology, study design, and reporting in preclinical studies. The purpose of this study was to compare reporting of core features of experimental rigor: blinding, randomization, and power calculations in critical care medicine animal experimental research. We hypothesized that these study design characteristics were more frequently reported in 2015 versus 2005.MethodsWe performed an observational bibliometric study to grade manuscripts on blinding, randomization, and power calculations. Chi-square tests and logistic regression were used for analysis. Inter-rater agreement was assessed using kappa and Gwet’s AC1.ResultsA total of 825 articles from seven journals were included. In 2005, power estimations were reported in 2%, randomization in 35%, and blinding in 20% (n = 482). In 2015, these metrics were included in 9, 47, and 36% of articles (n = 343). The increase in proportion for the metrics tested was statistically significant (p < 0.001, p = 0.002, and p < 0.001).ConclusionsOnly a minority of published manuscripts in critical care medicine journals reported on recommended study design steps to increase rigor. Routine justification for the presence or absence of blinding, randomization, and power calculations should be considered to better enable readers to assess potential sources of bias.

130: CLINICAL IMPACT OF AN EDUCATIONAL COURSE FOR HOSPITAL RAPID RESPONSE TEAMS

Introduction: Throughout the country, patients are increasingly likely to require critical care intervention. Numerous studies have shown that early recognition and intervention can improve outcomes in hospitalized patients. Many hospitals are utilizing rapid response teams (RRTs) to help identify a