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Article ; Online: Reducing Volatile Anesthetic Waste Using a Commercial Electronic Health Record Clinical Decision Support Tool to Lower Fresh Gas Flows.

Olmos, Andrea V / Robinowitz, David / Feiner, John R / Chen, Catherine L / Gandhi, Seema

2022 Volume 136, Issue 2, Page(s) 327–337

Abstract: Background: Volatile anesthetic consumption can be reduced by minimizing excessive fresh gas flows (FGFs). Currently, it is unknown whether decision support tools embedded within commercial electronic health record systems can be successfully adopted to ...

Abstract	Background: Volatile anesthetic consumption can be reduced by minimizing excessive fresh gas flows (FGFs). Currently, it is unknown whether decision support tools embedded within commercial electronic health record systems can be successfully adopted to achieve long-term reductions in FGF rates. The authors describe the implementation of an electronic health record-based clinical decision support tool aimed at reducing FGF and evaluate the effectiveness of this intervention in achieving sustained reductions in FGF rates and volatile anesthetic consumption. Methods: On August 29, 2018, we implemented a decision support tool within the Epic Anesthesia Information Management System (AIMS) to alert providers of high FGF (>0.7 L/min for desflurane and >1 L/min for sevoflurane) during maintenance of anesthesia. July 22, 2015, to July 10, 2018, served as our baseline period before the intervention. The intervention period spanned from August 29, 2018, to December 31, 2019. Our primary outcomes were mean FGF (L/min) and volatile agent consumption (mL/MAC-h). Because a simple comparison of 2 time periods may result in false conclusions due to underlying trends independent of the intervention, we performed segmented regression of the interrupted time series to assess the change in level at the start of the intervention and the differences in slopes before and after the intervention. The analysis was also adjusted for potential confounding variables. Data included 44,899 cases using sevoflurane preintervention with 26,911 cases postintervention, and 17,472 cases using desflurane with 1185 cases postintervention. Results: Segmented regression of the interrupted times series demonstrated a decrease in mean FGF by 0.6 L/min (95% CI, 0.6-0.6 L/min; P < .0001) for sevoflurane and 0.2 L/min (95% CI, 0.2-0.3 L/min; P < .0001) for desflurane immediately after implementation of the intervention. For sevoflurane, mL/MAC-h decreased by 3.8 mL/MAC-h (95% CI, 3.6-4.1 mL/MAC-h; P < .0001) after implementation of the intervention and decreased by 4.1 mL/MAC-h (95% CI, 2.6-5.6 mL/MAC-h; P < .0001) for desflurane. Slopes for both FGF and mL/MAC-h in the postintervention period were statistically less negative than the preintervention slopes (P < .0001 for sevoflurane and P < .01 for desflurane). Conclusions: A commercial AIMS-based decision support tool can be adopted to change provider FGF management patterns and reduce volatile anesthetic consumption in a sustainable fashion.
MeSH term(s)	Sevoflurane ; Desflurane ; Anesthetics, Inhalation ; Isoflurane ; Methyl Ethers ; Electronic Health Records ; Decision Support Systems, Clinical ; Anesthesia, Inhalation
Chemical Substances	Sevoflurane (38LVP0K73A) ; Desflurane (CRS35BZ94Q) ; Anesthetics, Inhalation ; Isoflurane (CYS9AKD70P) ; Methyl Ethers
Language	English
Publishing date	2022-11-04
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't
ZDB-ID	80032-6
ISSN	1526-7598 ; 0003-2999
ISSN (online)	1526-7598
ISSN	0003-2999
DOI	10.1213/ANE.0000000000006242
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Article ; Online: Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study.

Gudelunas, M Koa / Lipnick, Michael / Hendrickson, Carolyn / Vanderburg, Sky / Okunlola, Bunmi / Auchus, Isabella / Feiner, John R / Bickler, Philip E

Anesthesia and analgesia

2023 Volume 138, Issue 3, Page(s) 552–561

Abstract: Background: Retrospective clinical trials of pulse oximeter accuracy report more frequent missed diagnoses of hypoxemia in hospitalized Black patients than White patients, differences that may contribute to racial disparities in health and health care. ... ...

Abstract	Background: Retrospective clinical trials of pulse oximeter accuracy report more frequent missed diagnoses of hypoxemia in hospitalized Black patients than White patients, differences that may contribute to racial disparities in health and health care. Retrospective studies have limitations including mistiming of blood samples and oximeter readings, inconsistent use of functional versus fractional saturation, and self-reported race used as a surrogate for skin color. Our objective was to prospectively measure the contributions of skin pigmentation, perfusion index (PI), sex, and age on pulse oximeter errors in a laboratory setting. Methods: We enrolled 146 healthy subjects, including 25 with light skin (Fitzpatrick class I and II), 78 with medium (class III and IV), and 43 with dark (class V and VI) skin. We studied 2 pulse oximeters (Nellcor N-595 and Masimo Radical 7) in prevalent clinical use. We analyzed 9763 matched pulse oximeter readings (pulse oximeter measured functional saturation [Sp o2 ]) and arterial oxygen saturation (hemoximetry arterial functional oxygen saturation [Sa o2 ]) during stable hypoxemia (Sa o2 68%-100%). PI was measured as percent infrared light modulation by the pulse detected by the pulse oximeter probe, with low perfusion categorized as PI < 1%. The primary analysis was to assess the relationship between pulse oximeter bias (difference between Sa o2 and Sp o2 ) by skin pigment category in a multivariable mixed-effects model incorporating repeated-measures and different levels of Sa o2 and perfusion. Results: Skin pigment, PI, and degree of hypoxemia significantly contributed to errors (bias) in both pulse oximeters. For PI values of 1.0% to 1.5%, 0.5% to 1.0%, and <0.5%, the P value of the relationship to mean bias or median absolute bias was <.00001. In lightly pigmented subjects, only PI was associated with positive bias, whereas in medium and dark subjects bias increased with both low perfusion and degree of hypoxemia. Sex and age was not related to pulse oximeter bias. The combined frequency of missed diagnosis of hypoxemia (pulse oximeter readings 92%-96% when arterial oxygen saturation was <88%) in low perfusion conditions was 1.1% for light, 8.2% for medium, and 21.1% for dark skin. Conclusions: Low peripheral perfusion combined with darker skin pigmentation leads to clinically significant high-reading pulse oximeter errors and missed diagnoses of hypoxemia. Darkly pigmented skin and low perfusion states are likely the cause of racial differences in pulse oximeter performance in retrospective studies.
MeSH term(s)	Humans ; Prospective Studies ; Missed Diagnosis ; Retrospective Studies ; Oximetry ; Hypoxia/diagnosis ; Oxygen ; Perfusion
Chemical Substances	Oxygen (S88TT14065)
Language	English
Publishing date	2023-12-18
Publishing country	United States
Document type	Journal Article
ZDB-ID	80032-6
ISSN	1526-7598 ; 0003-2999
ISSN (online)	1526-7598
ISSN	0003-2999
DOI	10.1213/ANE.0000000000006755
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Article ; Online: Evaluating Pulmonary Function: An Assessment of PaO2/FIO2.

Feiner, John R / Weiskopf, Richard B

Critical care medicine

2017 Volume 45, Issue 1, Page(s) e40–e48

Abstract: Objectives: PaO2/FIO2 is used commonly for diagnosis of lung injury (acute respiratory distress syndrome and transfusion-related acute lung injury), for assessment of pulmonary disease course and therapy, and in pulmonary transplantation for evaluation ... ...

Abstract	Objectives: PaO2/FIO2 is used commonly for diagnosis of lung injury (acute respiratory distress syndrome and transfusion-related acute lung injury), for assessment of pulmonary disease course and therapy, and in pulmonary transplantation for evaluation of donor lungs and clinical outcome. It was developed for convenience, without formal mathematical and graphic assessment to validate its suitability for these purposes. Design: We examined, mathematically and graphically, the relationship of PaO2/FIO2 to FIO2 at constant normal and several degrees of increased intrapulmonary shunting (QS/QT), assessing the impact of intra- and extrapulmonary factors on the relationship and thus the reliability of PaO2/FIO2. Measurements and main results: The relationship of PaO2/FIO2 varies at all shunt fractions but most with QS/QT from 0.1 to 0.3 with FIO2 approximately greater than 0.4. At higher QS/QT, the relationship is more constant and changes less with FIO2 more than 0.4. Hemoglobin concentration and arterial-venous oxygen content difference have large effects that can confound interpretation of PaO2/FIO2. Barometric pressure has a substantial effect; PCO2, base excess, and respiratory quotient have small effects. Conclusions: At high QS/QT with FIO2 more than 0.4, the relationship of PaO2/FIO2 to FIO2 is relatively constant. However, with QS/QT of 0.1-0.3, PaO2/FIO2 changes substantially with FIO2. Understanding the important effects of nonpulmonary factors (especially hemoglobin concentration and arterial-venous oxygen content difference) should enhance appropriate clinical use, interpretation of PaO2/FIO2, and interpretation of previous publications and future studies (especially those seeking to assess effects of anemia or transfusion on lung function). The ratio of PaO2/FIO2 is a good tool for some, but not many clinical circumstances, and is insufficiently robust for most research applications.
MeSH term(s)	Blood Gas Analysis ; Hemoglobins/analysis ; Humans ; Models, Statistical ; Oxygen/blood ; Pulmonary Gas Exchange/physiology
Chemical Substances	Hemoglobins ; Oxygen (S88TT14065)
Language	English
Publishing date	2017-01
Publishing country	United States
Document type	Journal Article
ZDB-ID	197890-1
ISSN	1530-0293 ; 0090-3493
ISSN (online)	1530-0293
ISSN	0090-3493
DOI	10.1097/CCM.0000000000002017
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Article ; Online: Response to Burtscher re: "Increased Cytokines at High Altitude: Lack of Effect of Ibuprofen on Acute Mountain Sickness, Physiological Variables, or Cytokine Levels".

Bickler, Philip / Feiner, John R / Lundeberg, Jenny

High altitude medicine & biology

2018 Volume 19, Issue 3, Page(s) 304–305

MeSH term(s)	Acute Disease ; Altitude ; Altitude Sickness ; Cytokines ; Humans ; Ibuprofen
Chemical Substances	Cytokines ; Ibuprofen (WK2XYI10QM)
Language	English
Publishing date	2018-09-21
Publishing country	United States
Document type	Letter ; Comment
ZDB-ID	2076262-8
ISSN	1557-8682 ; 1527-0297
ISSN (online)	1557-8682
ISSN	1527-0297
DOI	10.1089/ham.2018.0092
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Article ; Online: "Silent" Presentation of Hypoxemia and Cardiorespiratory Compensation in COVID-19.

Bickler, Philip E / Feiner, John R / Lipnick, Michael S / McKleroy, William

Anesthesiology

2020 Volume 134, Issue 2, Page(s) 262–269

MeSH term(s)	COVID-19/complications ; COVID-19/physiopathology ; Heart/physiopathology ; Humans ; Hypoxia/etiology ; Hypoxia/physiopathology ; Respiratory System/physiopathology ; SARS-CoV-2
Keywords	covid19
Language	English
Publishing date	2020-09-23
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	269-0
ISSN	1528-1175 ; 0003-3022
ISSN (online)	1528-1175
ISSN	0003-3022
DOI	10.1097/ALN.0000000000003578
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Article ; Online: Anesthesia for Maternal-Fetal Interventions: A Survey of Fetal Therapy Centers in the North American Fetal Therapy Network.

Wood, Cristina L / Zuk, Jeannie / Rollins, Mark D / Silveira, Lori J / Feiner, John R / Zaretsky, Michael / Chatterjee, Debnath

Fetal diagnosis and therapy

2021 Volume 48, Issue 5, Page(s) 361–371

Abstract: Introduction: A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques.: Methods: We conducted an online survey of ... ...

Abstract	Introduction: A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques. Methods: We conducted an online survey of anesthesiology directors at every FTC within the North American Fetal Therapy Network (NAFTNet). The survey included details of fetal interventions performed in 2018, anesthesia staffing models, anesthetic techniques, fetal monitoring, and postoperative management. Results: There was a 92% response rate. Most FTCs are located within an adult hospital and employ a small team of anesthesiologists. There is heterogeneity when evaluating anesthesiology fellowship training and staffing, indicating there is a multidisciplinary specialty team-based approach even within anesthesiology. Minimally invasive fetal interventions were the most commonly performed. The majority of FTCs also performed ex utero intrapartum treatment (EXIT) and open mid-gestation procedures under general anesthesia (GA). Compared to FTCs only performing minimally invasive procedures, FTCs performing open fetal procedures were more likely to have a pediatric surgeon as director and performed more minimally invasive procedures. Conclusions: There is considerable variability in anesthesia staffing, caseload, and anesthetic techniques among FTCs in NAFTNet. Most FTCs used maternal sedation for minimally invasive procedures and GA for EXIT and open fetal surgeries.
MeSH term(s)	Adult ; Anesthesia ; Anesthesiology ; Child ; Female ; Fetal Diseases/surgery ; Fetal Therapies ; Humans ; North America ; Pregnancy
Language	English
Publishing date	2021-04-07
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	1066460-9
ISSN	1421-9964 ; 1015-3837
ISSN (online)	1421-9964
ISSN	1015-3837
DOI	10.1159/000514897
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Article ; Online: Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study.

Kolodzie, Kerstin / Cakmakkaya, Ozlem S / Boparai, Eshandeep S / Tavakol, Mehdi / Feiner, John R / Kim, Mi-Ok / Newman, Thomas B / Niemann, Claus U

Anesthesiology

2021 Volume 135, Issue 4, Page(s) 621–632

MeSH term(s)	Adult ; Aged ; Cohort Studies ; Delayed Graft Function/chemically induced ; Delayed Graft Function/diagnosis ; Delayed Graft Function/epidemiology ; Female ; Humans ; Kidney Transplantation/adverse effects ; Kidney Transplantation/trends ; Male ; Middle Aged ; Perioperative Care/adverse effects ; Perioperative Care/methods ; Retrospective Studies ; Saline Solution/administration & dosage ; Saline Solution/adverse effects
Chemical Substances	Saline Solution
Language	English
Publishing date	2021-07-15
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	269-0
ISSN	1528-1175 ; 0003-3022
ISSN (online)	1528-1175
ISSN	0003-3022
DOI	10.1097/ALN.0000000000003887
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Article ; Online: Pulse Oximeter Performance, Racial Inequity, and the Work Ahead.

Okunlola, Olubunmi E / Lipnick, Michael S / Batchelder, Paul B / Bernstein, Michael / Feiner, John R / Bickler, Philip E

Respiratory care

2021 Volume 67, Issue 2, Page(s) 252–257

Abstract: It has long been known that many pulse oximeters function less accurately in patients with darker skin. Reasons for this observation are incompletely characterized and potentially enabled by limitations in existing regulatory oversight. Based on decades ... ...

Abstract	It has long been known that many pulse oximeters function less accurately in patients with darker skin. Reasons for this observation are incompletely characterized and potentially enabled by limitations in existing regulatory oversight. Based on decades of experience and unpublished data, we believe it is feasible to fully characterize, in the public domain, the factors that contribute to missing clinically important hypoxemia in patients with darkly pigmented skin. Here we propose 5 priority areas of inquiry for the research community and actionable changes to current regulations that will help improve oximeter accuracy. We propose that leading regulatory agencies should immediately modify standards for measuring accuracy and precision of oximeter performance, analyzing and reporting performance outliers, diversifying study subject pools, thoughtfully defining skin pigmentation, reporting data transparently, and accounting for performance during low-perfusion states. These changes will help reduce bias in pulse oximeter performance and improve access to safe oximeters.
MeSH term(s)	Humans ; Hypoxia/diagnosis ; Hypoxia/etiology ; Oximetry ; Oxygen ; Skin Pigmentation
Chemical Substances	Oxygen (S88TT14065)
Language	English
Publishing date	2021-11-12
Publishing country	United States
Document type	Journal Article
ZDB-ID	603252-7
ISSN	1943-3654 ; 0098-9142 ; 0020-1324
ISSN (online)	1943-3654
ISSN	0098-9142 ; 0020-1324
DOI	10.4187/respcare.09795
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Article ; Online: In Reply.

Whitlock, Elizabeth L / Feiner, John R / Chen, Lee-Lynn

Anesthesiology

2016 Volume 124, Issue 6, Page(s) 1419

Language	English
Publishing date	2016-06
Publishing country	United States
Document type	Journal Article
ZDB-ID	269-0
ISSN	1528-1175 ; 0003-3022
ISSN (online)	1528-1175
ISSN	0003-3022
DOI	10.1097/ALN.0000000000001102
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Article ; Online: Comparison of Transcranial Doppler and Ultrasound-Tagged Near Infrared Spectroscopy for Measuring Relative Changes in Cerebral Blood Flow in Human Subjects.

Lipnick, Michael S / Cahill, Elizabeth A / Feiner, John R / Bickler, Philip E

Anesthesia and analgesia

2017 Volume 126, Issue 2, Page(s) 579–587

Abstract: Background: Currently, no reliable method exists for continuous, noninvasive measurements of absolute cerebral blood flow (CBF). We sought to determine how changes measured by ultrasound-tagged near-infrared spectroscopy (UT-NIRS) compare with changes ... ...

Abstract	Background: Currently, no reliable method exists for continuous, noninvasive measurements of absolute cerebral blood flow (CBF). We sought to determine how changes measured by ultrasound-tagged near-infrared spectroscopy (UT-NIRS) compare with changes in CBF as measured by transcranial Doppler (TCD) in healthy volunteers during profound hypocapnia and hypercapnia. Methods: Ten healthy volunteers were monitored with a combination of TCD, UT-NIRS (c-FLOW, Ornim Medical), as well as heart rate, blood pressure, end-tidal PCO2 (PEtCO2), end-tidal O2, and inspired O2. Inspired CO2 and minute ventilation were controlled to achieve 5 stable plateau goals of EtCO2 at 15-20, 25-30, 35-40, 45-50, and 55-60 mm Hg, for a total of 7 measurements per subject. CBF was assessed at a steady state, with the TCD designated as the reference standard. The primary analysis was a linear mixed-effect model of TCD and UT-NIRS flow with PEtCO2, which accounts for repeated measures. Receiver operating characteristic curves were determined for detection of changes in CBF. Results: Hyperventilation (nadir PEtCO2 17.1 ± 2.4) resulted in significantly decreased mean flow velocity of the middle cerebral artery from baseline (to 79% ± 22%), but not a consistent decrease in UT-NIRS cerebral flow velocity index (n = 10; 101% ± 6% of baseline). Hypercapnia (peak PEtCO2 59.3 ± 3.3) resulted in a significant increase from baseline in both mean flow velocity of the middle cerebral artery (153% ± 25%) and UT-NIRS (119% ± 11%). Comparing slopes versus PEtCO2 as a percent of baseline for the TCD (1.7% [1.5%-2%]) and UT-NIRS (0.4% [0.3%-0.5%]) shows that the UT-NIRS slope is significantly flatter, P < .0001. Area under the receiver operating characteristic curve was significantly higher for the TCD than for UT-NIRS, 0.97 (95% confidence interval, 0.92-0.99) versus 0.75 (95% confidence interval, 0.66-0.82). Conclusions: Our data indicate that UT-NIRS cerebral flow velocity index detects changes in CBF only during hypercarbia but not hypocarbia in healthy subjects and with much less sensitivity than TCD. Additional refinement and validation are needed before widespread clinical utilization of UT-NIRS.
MeSH term(s)	Adult ; Blood Flow Velocity/physiology ; Cerebrovascular Circulation/physiology ; Female ; Humans ; Male ; Monitoring, Intraoperative/methods ; Monitoring, Intraoperative/standards ; Spectroscopy, Near-Infrared/methods ; Spectroscopy, Near-Infrared/standards ; Ultrasonography, Doppler, Transcranial/methods ; Ultrasonography, Doppler, Transcranial/standards
Language	English
Publishing date	2017-11-29
Publishing country	United States
Document type	Comparative Study ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80032-6
ISSN	1526-7598 ; 0003-2999
ISSN (online)	1526-7598
ISSN	0003-2999
DOI	10.1213/ANE.0000000000002590
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