The Daily Dose • Saturday, May 18

A Tribute to Excellence

By Adaora M. Chima, MBBS, MPH, from the IARS, AUA and SOCCA 2019 Annual Meetings*

The SOCCA Young Investigator Award is a celebration of anesthesia investigators whose research exemplify the mission of the society to foster the education, knowledge and practice of critical care medicine by anesthesiologists. Dr. Robert Stevens, chair of the SOCCA Research Committee, opened the 2019 award ceremony along with his colleagues from the SOCCA Education Committee Drs. Sheela Pai Cole (Chair), Peter Von Homeyer, Ashish Khanna, and Kunal Karamchandani.

Awardees were selected through a rigorous peer review process of 216 abstract submissions and a short synopsis was offered for each project during the ceremony.

The first place winner was Domagoj Mladinov, MD, PhD, Assistant Professor at University of Alabama at Birmingham, for his submission titled, “Effects of Incubating Packed Red Blood Cells with Common Infusion Crystalloids and Medications on Red Blood Cell Lysis, Aggregation and Deformability.” Hospital policies regarding the use of a dedicated intravenous catheter for the administration of packed red blood cells (PRBCs) are driven by recommendations from organizations such as the American Association of Blood Banks and their international counterparts. Due to this policy, additional resources and procedures often come into play when additional intravenous access is required in order to maintain compliance. In critically ill patients on multiple intravenous medications, it could necessitate the insertion of a central line, a procedure associated with significant complications. Available literature does not reveal evidence supporting this recommendation. Thus, Dr. Mladinov and his colleagues went back to the bench to assess the effect of common crystalloid and medication infusions on PRBCs.

Human PRBCs were incubated in different crystalloid solutions (5% dextrose water (D5W), lactated Ringer’s, normal saline) and medications (epinephrine, norepinephrine, dopamine and propofol) for 5 minutes, at room temperature. The samples were examined for clotting, hemolysis, deformability, aggregation and heme degradation products.

The results were significant for signs of hemolysis and decreased deformability with D5W, attributable to its hypotonicity relative to plasma. Propofol showed a statistically insignificant increase in hemolysis and aggregation compared to other medications.

All solutions except lactated Ringer’s (LR) showed decreased aggregation. The calcium content in LR is likely responsible for this phenomenon. In summary, the most common crystalloid solutions in use appear to be compatible with PRBC, without deleterious effects. Hypotonic solutions increase hemolysis and should be avoided.

The results of this study have the potential to inform liberation of the guidelines regarding PRBC administration, optimize resource utilization, reduce procedure-related complications and improve patient comfort in the administration of blood products.

The first runner-up, Ming Ann Sim, MBBS, is an anesthesia resident at the National University of Singapore. She received this award for her submission titled, “Sustaining the Gains: A 6-year Follow Through of the Impact of a Hospital-Wide Patient Safety Strategy on Global and Anesthetic Patient Safety Outcomes.” This longitudinal program aimed to reduce the incidence of hospital-wide adverse events, 50% of which were deemed to be preventable, based on the literature. Previous initiatives, rolled out with a top down approach (from hospital administration to front line workers), had proved to be unsustainable and this program aimed to identify and address hospital-wide and anesthesia-specific adverse events, with a bottom up approach.

Hospital-wide goals targeted patient safety culture, developing patient safety plans and crisis readiness. Anesthesia specific programs identified three “never events,” from a retrospective audit of medical records: wrong blood administration, wrong drug administration, injection of medication in wrong site (intrathecal). Interventions included two-person verification of blood products, red alert labels for intrathecal catheters, and color-coded patient allergy wrist tags. Anesthesia crisis interventions targeted difficult airway scenarios using airway refresher courses, and crisis management simulation exercises amongst others.

Over the course of the program, hospital-wide patient safety surveys have shown an increase in the patient safety grade among hospital staff. The incidence of intubation events such as dental trauma and unplanned reintubation have also declined. The buy-in and feedback loop between the hospital administration and the anesthesia team provided multiple avenues for promotion and oversight of patient safety initiatives resulting in effective and sustainable programs at departmental and hospital levels.

The second runner-up, Thomas Bunning, BS, is an MD Candidate at Duke University for his abstract titled, “The INTUIT Study: Investigating Neuroinflammation Underlying Postoperative Neurocognitive Dysfunction and Delirium in Older Adults.” He has been involved in INTUIT, an acronym for Investigating Neuroinflammation Underlying Postoperative Brain Connectivity Changes. This translational research study is focused on postoperative cognitive dysfunction (POCD) and delirium in older adults. Although the etiology is multifactorial, his team’s interests revolve around the role of neuroinflammation, which has been found to be causative in animal models. In these models, an influx of monocytes into the hippocampus was associated with memory deficits, and depletion of monocytes was found to reduce these deficits. POCD was also found to be associated with changes in the default mode network (DMN) connectivity. Similar changes have been found in the presence of neuroinflammation.

Given these findings, the investigators sought to determine if an increase in biomarkers of neuroinflammation, monocytes and Monocyte Chemoattractant Protein-1 (MCP-1), is associated with POCD and/or changes in DMN connectivity.

In order to do this, neuroinflammatory markers are measured in enrolled patients (eligible candidates scheduled for surgery). This involves four lumbar puncture procedures, blood tests, neurocognitive tests, and functional MRI over the course of a year.

In preliminary results, the team has found an increase in CSF monocyte to lymphocyte ratio and lower MCP-1 receptor expression in POCD patients compared to non-POCD patients. This exciting 4-year study is ongoing and continues to enroll patients. The preliminary findings are promising for understanding approaches/interventions to mitigate POCD.

*Coverage from the SOCCA Young Investigator Presentations: Award-Winning Research during the SOCCA 2019 Annual Meeting