Jorge A. Gálvez

A Review of Analytics and Clinical Informatics in Health Care

Federal investment in health information technology has incentivized the adoption of electronic health record systems by physicians and health care organizations; the result has been a massive rise in the collection of patient data in electronic form (i.e. “Big Data”). Health care systems have leveraged Big Data for quality and performance improvements using analytics—the systematic use of data combined with quantitative as well as qualitative analysis to make decisions. Analytics have been utilized in various aspects of health care including predictive risk assessment, clinical decision support, home health monitoring, finance, and resource allocation. Visual analytics is one example of an analytics technique with an array of health care and research applications that are well described in the literature. The proliferation of Big Data and analytics in health care has spawned a growing demand for clinical informatics professionals who can bridge the gap between the medical and information sciences.

Telemedicine in anesthesia: An update

Purpose of review Advances in health information technology and broadband Internet connections provide novel opportunities for anesthesiologists to extend perioperative consultation services to remote geographic areas. Increasing economic pressures on healthcare delivery systems make initiatives such as telemedicine, which reduce costs while achieving excellent outcomes, an attractive option. Recent findings Initiatives in remote access to anesthesiology services are emerging throughout the world in the areas of preoperative evaluation, intraoperative consultation, postoperative management and critical care as well as simulation and education. Physicians caring for patients in remote areas can benefit from the expertise found in subspecialty centers. In the US a number of states provide reimbursement for telemedicine services offered in several specialties, including anesthesiology. Summary Anesthesiologists have the opportunity to develop telemedicine programs that can improve the delivery of care to patients. Current programs offer services ranging from remote preoperative evaluation to international collaboration for intraoperative management and consultation. Simulation using telemedicine services can provide educational opportunities and test the effectiveness of institutions’ communications systems.

Association Between Ibuprofen Use and Severity of Surgically Managed Posttonsillectomy Hemorrhage.

Importance Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to quantify but may be a more important outcome to measure. Objective To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity. Design, Setting, and Participants This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children’s Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query. Main Outcomes and Measures Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion. Results Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256 female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater. Conclusions and Relevance The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.

A Narrative Review of Meaningful Use and Anesthesia Information Management Systems.

The US federal government has enacted legislation for a federal incentive program for health care providers and hospitals to implement electronic health records. The primary goal of the Meaningful Use (MU) program is to drive adoption of electronic health records nationwide and set the stage to monitor and guide efforts to improve population health and outcomes. The MU program provides incentives for the adoption and use of electronic health record technology and, in some cases, penalties for hospitals or providers not using the technology. The MU program is administrated by the Department of Health and Human Services and is divided into 3 stages that include specific reporting and compliance metrics. The rationale is that increased use of electronic health records will improve the process of delivering care at the individual level by improving the communication and allow for tracking population health and quality improvement metrics at a national level in the long run. The goal of this narrative review is to describe the MU program as it applies to anesthesiologists in the United States. This narrative review will discuss how anesthesiologists can meet the eligible provider reporting criteria of MU by applying anesthesia information management systems (AIMS) in various contexts in the United States. Subsequently, AIMS will be described in the context of MU criteria. This narrative literature review also will evaluate the evidence supporting the electronic health record technology in the operating room, including AIMS, independent of certification requirements for the electronic health record technology under MU in the United States.

Assessment and Planning for a Pediatric Bilateral Hand Transplant Using 3-Dimensional Modeling: Case Report

Children are not typically considered for hand transplantation for various reasons, including the difficulty of finding an appropriate donor. Matching donor-recipient hands and forearms based on size is critically important. If the donors hands are too large, the recipient may not be able to move the fingers effectively. Conversely, if the donors hands are too small, the appearance may not be appropriate. We present an 8-year-old child evaluated for a bilateral hand transplant following bilateral amputation. The recipient forearms and model hands were modeled from computed tomography imaging studies and replicated as anatomic models with a 3-dimensional printer. We modified the scale of the printed hand to produce 3 proportions, 80%, 100% and 120%. The transplant team used the anatomical models during evaluation of a donor for appropriate match based on size. The donors hand size matched the 100%-scale anatomical model hand and the transplant team was activated. In addition to assisting in appropriate donor selection by the transplant team, the 100%-scale anatomical model hand was used to create molds for prosthetic hands for the donor.

Anesthetic management of the first pediatric bilateral hand transplant.

PurposeThe purpose of this case report is to describe the anesthetic and case management of the first vascularized composite allograft pediatric bilateral hand transplant.Clinical detailsOur patient was an eight-year-old male with a medical history of Staphylococcus aureus sepsis at one year of age that resulted in end-stage renal disease as well as bilateral upper and lower extremity amputations. After referral for bilateral hand transplantation, the transplantation team, with expertise in all aspects of perioperative care (surgery, anesthesiology, nephrology, renal transplantation, pediatric intensive care, and therapeutic pharmacy), was consulted to help develop anesthetic and other perioperative protocols for surgery. Prior to activation of the transplantation team, the lead surgeon evaluated potential donors by comparing a three-dimensional printed model of the recipient’s forearm with the donor’s upper extremities to ensure an adequate match. The anesthesia team inserted bilateral ultrasound-guided infraclavicular catheters to provide a sympathetic block to facilitate blood flow to the upper extremities and to provide both intraoperative and postoperative pain control. The patient remained in the operating room for 13 hr 37 min for a surgical time of ten hours 39 min. He remained in the hospital for 34 days after the procedure and was then transferred to an inpatient rehabilitation facility for a further 15 days. The patient is currently doing well in a postoperative rehabilitation program. He has demonstrated motor power to the hands using the forearm muscles but is not expected to reach his maximum sensory function for at least one to two years.ConclusionThis report describes the anesthetic management of the first pediatric bilateral hand transplant. This procedure required considerable preoperative planning and communication between various teams to ensure all resources needed to deliver the care for this complex and novel transplant surgery were readily available.RésuméObjectifL’objectif de cette présentation de cas est de décrire la prise en charge anesthésique et la gestion du cas de la première greffe bilatérale des mains chez un enfant à partir d’une allogreffe de tissu composite.Détails cliniquesNotre patient était un garçon de huit ans présentant des antécédents médicaux de sepsis dû à un staphylocoque doré contracté à l’âge d’un an, qui a entraîné une insuffisance rénale terminale ainsi que l’amputation bilatérale des membres supérieurs et inférieurs. Après son aiguillage pour une greffe bilatérale des mains, l’équipe de transplantation, forte d’une vaste expertise en soins périopératoires (chirurgie, anesthésiologie, néphrologie, transplantation rénale, soins intensifs pédiatriques et pharmacie thérapeutique), a été consultée afin de mettre au point des protocoles anesthésiques et périopératoires pour la chirurgie. Avant de réunir l’équipe de transplantation, le chirurgien responsable a évalué les donneurs potentiels en comparant un modèle imprimé en trois dimensions de l’avant-bras du récipiendaire aux membres supérieurs du donneur afin de garantir une bonne correspondance. L’équipe anesthésique a inséré des sondes infraclaviculaires bilatérales par échoguidage afin de réaliser un bloc sympathique qui faciliterait l’apport sanguin aux membres supérieurs et contrôlerait la douleur pendant et après l’opération. Le patient est resté en salle d’opération pendant 13 h 37 min, et la chirurgie a duré 10 h 39 min. Il est resté à l’hôpital 34 jours après l’intervention, puis a été transféré à un centre de réadaptation pour patients hospitalisés pour 15 jours supplémentaires. Le patient se porte actuellement bien et participe à un programme de réadaptation postopératoire. Il a démontré un pouvoir moteur aux mains en utilisant les muscles des avant-bras, mais on ne s’attend pas à ce qu’il atteigne sa fonction sensorielle maximale avant au moins un ou deux ans.ConclusionCe compte rendu décrit la prise en charge anesthésique de la première greffe bilatérale des mains chez un enfant. Cette intervention a nécessité une planification et une communication préopératoires importantes entre diverses équipes afin de s’assurer que toutes les ressources nécessaires à prodiguer les soins optimaux pour cette chirurgie de greffe complexe et innovante soient immédiatement disponibles.

Fatal intraoperative cardiac thrombosis in a patient with renal cell carcinoma.

A 61-YR-OLD man with renal cell carcinoma and inferior vena cava thrombus presented for nephrectomy with thrombectomy. Preoperative echocardiography was normal and excluded a patent foramen ovale. During inferior vena cava dissection, the patient developed an acute decrease of end-tidal carbon dioxide and a loss of arterial pressure with waveform nonresponsive to cardiopulmonary resuscitation. Emergency transesophageal echocardiographic examination revealed extensive thrombosis of the right heart chambers (right atrium [RA], right ventricle [RV]) and, unexpectedly, significant left ventricular (LV) and left atrial (LA) thrombus (fig. A). Figure B provides for comparison a normal transesophageal echocardiography four-chamber view from a different patient. The extensive thrombus observed in all four heart chambers explained the ineffectiveness of cardiopulmonary resuscitation efforts and excluded cardiopulmonary bypass as a viable alternative. Renal cell carcinoma is associated with a hypercoagulable state, which results in inferior vena cava thrombosis in 4–10% of cases. The etiology of this devastating intracardiac thrombosis involving left heart chambers remains elusive. Potential causes include a generalized thrombotic event secondary to a massive pulmonary embolism with a resultant low flow state in a hypercoagulable patient, or a right-to-left heart thrombus migration through a previously occult patent foramen ovale under the condition of increased right atrial pressures. As illustrated, resection of renal cell carcinoma with inferior vena cava thrombosis can be complicated by tumor or thrombus dislodgment and cardiovascular collapse. Transesophageal echocardiography is indicated in such cases for confirming the diagnosis, allowing detection of thrombus migration, monitoring the effectiveness of resuscitation, and assisting surgical management.

Visual analytical tool for evaluation of 10-year perioperative transfusion practice at a children's hospital

Children are a vulnerable population in the operating room, and are particularly at risk of complications from unanticipated hemorrhage. The decision to prepare blood products prior to surgery varies depending on the personal experience of the clinician caring for the patient. We present the first application of a data visualization technique to study large datasets in the context of blood product transfusions at a tertiary pediatric hospital. The visual analytical interface allows real-time interaction with datasets from 230 000 procedure records. Clinicians can use the visual analytical interface to analyze blood product usage based on procedure- and patient-specific factors, and then use that information to guide policies for ordering blood products.

The efficacy of GlideScope ® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: An analysis from the paediatric difficult intubation registry

Background We analysed data from the Paediatric Difficult Intubation Registry examining the use of direct laryngoscopy and GlideScope® videolaryngoscopy. Methods Data collected by a multicentre, paediatric difficult intubation registry from 1295 patients were analysed. Rates of success and complications between direct laryngoscopy and GlideScope videolaryngoscopy were analysed. Results Initial (464/877 = 53% vs 33/828 = 4%, Z-test = 22.2, P < 0.001) and eventual (720/877 = 82% vs. 174/828 = 21%, Z-test = 25.2, P < 0.001) success rates for GlideScope were significantly higher than direct laryngoscopy. Children weighing <10 kg had lower success rates with the GlideScope than the group as a whole. There were no differences in complication rates per attempt between direct laryngoscopy and GlideScope. The direct laryngoscopy group had more complications associated with the greater number of attempts needed to intubate. There were no increased risks of hypoxia or trauma with GlideScope use. Each additional attempt at intubation with either device resulted in a two-fold increase in complications (odds ratio: 2.0, 95% confidence interval: 1.5-2.5, P < 0.001). Conclusions During difficult tracheal intubation in children, direct laryngoscopy is an overly used technique with a low chance of success. GlideScope use was associated with a higher chance of success with no increased risk of complications. GlideScope use in children with difficult tracheal intubation has a lower success rate than in adults with difficult tracheal intubation. Children weighing less than 10 kilograms had lower success rates with either device. Attempts should be minimized with either device to decrease complications.

Interactive pediatric emergency checklists to the palm of your hand - How the Pedi Crisis App traveled around the world

Cognitive aids help clinicians manage critical events and have been shown to improve outcomes by providing critical information at the point of care. Critical event guidelines, such as the Society of Pediatric Anesthesias Critical Events Checklists described in this article, can be distributed globally via interactive smartphone apps. From October 1, 2013 to January 1, 2014, we performed an observational study to determine the global distribution and utilization patterns of the Pedi Crisis cognitive aid app that the Society for Pediatric Anesthesia developed. We analyzed distribution and utilization metrics of individuals using Pedi Crisis on iOS (Apple Inc., Cupertino, CA) devices worldwide. We used Google Analytics software (Google Inc., Mountain View, CA) to monitor users’ app activity (eg, screen views, user sessions).