Liberal Administration Research Articles

Postoperative nausea and vomiting at Landspitali: A prospective study.

In the last decade, anaesthesia practice has changed at Landspitali, where the majority of patients now receive antiemetic prophylaxis, and the use of total intravenous anaesthesia is the dominant mode for maintenance of anaesthesia. The aim of this study was to assess the incidence of postoperative nausea and vomiting (PONV) in a prospective way, the use of PONV prophylaxis, and clinical risk factors associated with PONV during this era. A prospective cohort study using a convenience sample of 438 patients ≥18 years old admitted to the postoperative care unit (PACU) after elective or emergency operations in May-July 2022 at Landspitali University Hospital in Iceland. Patients answered questionnaires in the PACU and 24 h after discharge from PACU. The incidence of self-reported moderate/severe nausea (5/10 or higher on NRS) in PACU was 4% and 3% on postoperative day 1. A total of 91% of delivered anaesthetics were with intravenous medications only, and 82% of patients received at least one prophylactic medication for PONV. When asked to rate the worst nausea experienced, this was described as moderate/severe by 7% in PACU and 17% on postoperative day 1. Risk factors associated with PONV were female gender (OR 1.90, 95% CI 1.04-3.53) and a history of motion sickness or PONV (2.74, 1.51-4.94), but increasing age was protective (0.83 per decade, 0.71-0.98). Despite a more liberal administration of antiemetics, patients with more risk factors per Apfel PONV risk classification had a higher incidence of PONV. The incidence of PONV is generally low in this diverse surgical population where anaesthesia is mostly maintained with total intravenous anaesthesia and PONV prophylaxis is common. PONV remains a predictable complication following anaesthesia, suggesting further improvement in its prevention is possible.

An Overview Regarding the U.S domestic Economic Strategies: Role of Think Tanks

Even though federal government of U.S play the primary role in managing the nations various systems such as fiscal policy, healthcare, defense and welfare, the existence of different political ideologies plays a part in national and international stability[1] , in sense that each ideology strategy in managing economic issues reach a different conclusion, proved by the numerous economical tragedies such as the greater recession , implements the bases of each ideologies perspective on government's role in reducing economic inequality, addressing job displacement due to technological change, and striking a balance between free market principles and government intervention during economic crises.1 To discuss the economical view of each side, one must fully understand in clarity the differences between two ideologies, in simplest form liberalism is described by the government's sole responsibly in preserving freedom protections its citizens individual liberty while also minimizing its intervention in its citizens lives, on the other hand, conservatism allows the government vast influence thus to conserve the established norms and institutions such as the cultural and religious traditions of its nation. While this is nearly the correct definition of what each ideology stands for, such political movements do tend to abuse power through the ideological privileges they stand for. Furthermore, the existence of the federal government is crucial in interfering with conservative or liberal administrations when their policies threaten economic stability. Federal governments’ regulatory agencies such as federal reserves and the Environmental protection agencies exist to act as checks on extreme economic policies. Under a conservative administration that Favors deregulation and reduced taxes, the federal government may intervene to prevent excessive corporate power or environmental harm that could arise from such policies.[2] Conversely, in a liberal administration pushing for expansive social programs or aggressive tax hikes, the federal government’s budgetary and constitutional frameworks can limit excessive spending or prevent overreach that may stifle economic growth.[3] Thus, regardless of the political ideology in power, the federal government ensures a balanced approach to economic management by safeguarding essential public interests while keeping national economic stability.

Canada's Lobbying Industry: Business and Public Interest Advocacy from Harper to Trudeau

AbstractThis article provides an empirical overview of federal lobbying in Canada, examining lobbying contacts by field and sector from 2011 to 2022. We track shifts in lobbying representation over this period, including across Harper Conservative and Trudeau Liberal administrations. The study reveals the dominance of business interests in lobbying in Canada and a high level of lobbying concentration. By sector, export-oriented industries with high environmental and climatic impacts—namely, agriculture, fossil fuel and manufacturing industries—predominate. With the transition to Trudeau, we find a significant increase in overall rates of lobbying and a modest increase in the ratio of public interest representation. Overall, the lobbying industry is characterized by greater access but unequal voice.

Administrator Political Orientations and Views on Federal Encroachment

Does a public administrator’s political orientation color how they perceive the actions and activities of the federal government? Using a long-running national survey, I measure the impact of state administrators’ party identification and ideology on several measures of federal encroachment. I find that self-identified Democratic and liberal administrators are less likely to believe that the federal government is encroaching on state actions and hold more positive evaluations of encroachment when it occurs. Additionally, I find that these beliefs are conditioned on the composition of the federal government, with the largest differences occurring under a Democratic-controlled White House and Congress.

Die Verfassungsgerichtsbarkeit in Österreich 1919–1939

Constitutional jurisdiction in Austria between the two World Wars can be divided into four periods: (I) From 1919 to 1920, under the provisional constitution, the Constitutional Court was the successor of the Imperial Court of the monarchy, continuing its jurisdiction. (II) Under the new federal constitution of 1920, it developed into an important political actor in the 1920s, making confident use of its competences. Hans Kelsen shaped the jurisprudence and set the lines: the Court acted as a neutral arbiter between the federal and state governments, as a guardian of democracy and as a patron of minorities. In the ideologically charged conflict over the Sever marriages, it took sides with the liberal administration and against the conservative ordinary courts. (III) After its reorganisation by the 1929 constitutional amendment, the Constitutional Court was re‐staffed. Henceforth, it no longer supported parliament in hard cases, but the government. Ludwig Adamovich exercised the strongest influence within the Court between 1930 and 1933. (IV) The authoritarian constitution of 1934 no longer provided for a Constitutional Court, but only a Senate for Constitutional Questions within the Federal Court, the highest administrative court. In practice, it played a minor role.

The politics of post-developmentalist expertise: progressive movements, strategic localism, and urban governance in Seoul

ABSTRACT This article interrogates emergent forms of progressive ‘post-developmentalist’ urban expertise in Seoul, South Korea. We argue that a critical understanding of the nexus between political and civil society forged by pro-democratic activism is necessary to understand the politics of this expertise and the dilemmas it has encountered in creating alternatives to the legacy of developmentalist urbanization and promoting a more inclusive and emancipatory vision of urban politics. To illustrate our argument, we examine two cases: the first involves the incorporation of progressive labour, intellectual, and civil society activists to create urban-level institutions of social dialogue to upgrade labour relations. The second explores a community-empowerment movement, called Maulmandeulgi, initiated by local activists and later institutionalized in Seoul and other cities to establish a participatory model of community building. These cases detail how these actors have promoted progressive policies through engaging in strategic forms of localism, but also how their activity has risked becoming a policy fix for reconfigured neoliberal and developmentalist policy agendas. This risk is most apparent, we argue, as the political context at the national level has shifted between conservative and liberal administrations and the knowledge practices developed by these experts encouraged to move between places and across scale.

Fluid restriction versus conventional fluid administration in acute lung injury patients (Comparative study between different strategies of fluid administration in acute lung injury patients)

Abstract Background Acute lung injury and ARDS are major causes of morbidity and mortality all over the world. Major steps of understanding the pathophysiology, causes, diagnosis and treatment of this syndrome were taken in last twenty year. Diagnosis of this condition remains underestimated by physicians particularly mild form of this syndrome specially in developing world in which presence of investigations and well trained physicians is not adequate. Objective To compare between the outcomes of fluid administration strategies in the form of restricted or conventional fluid administration that affect oxygenation, weaning of mechanical ventilation and free days of icu admission in acute lung injury patients and its severe form ARDS. To detect the optimal strategy of fluid administration which decrease morbidity and mortality. Patients and Methods Type of Study: Prospective study. Study Setting: The study will be conducted in the ICU units at Ain-Shams University Hospitals and Ahmed Maher Teaching Hospital. Study Period: Four months from date of approval of the protocol. 90 adult patients- divided into three groups each group include 30 patients- (fulfilling inclusion criteria) admitted in the ICU units at Ain Shams University Hospitals and Ahmed Maher Teaching Hospital were included. Results Based on more than one point of view; underlying cause of ARDS palys major role in predicting these unpredictable results of this study in haemodynamically unstable patients. There are many factors, rather than hypoxemia, that affect organ outcomes (including respiratory system itself) in haemodynamically unstable patients which may caused by septic shock and other types of shock. Conclusion This small trial evoked new questions more than answering traditional ones about fluid management of acute lung injury and ARDS. Firstly; the accurate method to assess and guide fluid therapy in ARDS should be on top of searching priorities. Although using central venous pressure to guide fluid therapy could theoretically results in outcome improvement, but according to its many limitations and poor relation to volume status, its using in that issue is questionable. Secondly; establishing one fluid management strategy to all patients with ARDS seems to be not accurate. Unpredictable results on outcomes in ARDS patients receiving fluids particularly in those were haemodynamically unstable drive us to seek for new classification of ARDS patients based on underlying cause, haemodynamic stability and other elements that responsible for organ failure rather than volume status. However; this small trial suggests conservative fluid strategy in acute lung injury patients which are haemodynamically stable. And using of both conservative and liberal fluid administration strategies wisely in those patients which are haemodynamically unstable to reach the optimal intravascular volume– pressure with the best risk–benefit ratio.

49 Effect of enhanced recovery protocol in urogynecologic surgery

Enhanced Recovery After Surgery (ERAS) protocols are evidence-based, multidisciplinary and outcome-driven measures developed to provide best practice guidelines for surgical care. Limited data exists to support conventional perioperative interventions of caloric restriction, prolonged immobilization, and liberal administration of fluids and opioids. ERAS protocols for urogynecologic populations are being adopted with limited population and procedure-specific outcome data. Our primary aim was to compare opioid use by patients undergoing major pelvic organ prolapse (POP) surgery before and after implementation of an ERAS protocol. Secondary aims included comparing length of stay and 30-day follow-up characteristics. This ambispective cohort study included a retrospective, pre-ERAS cohort of consecutive patients who underwent major POP surgery starting January 2016. A comprehensive ERAS protocol was implemented in October 2019 (Table 1). A prospective, ERAS cohort consisted of consecutive patients undergoing POP surgery starting in January 2020, 3 months after full implementation of the ERAS protocol. ERAS patients were screened for eligibility and enrolled on the day of surgery. Major POP surgery was defined as including an apical procedure. Demographic and clinical data were abstracted. Descriptive statistics were used for demographic variables. Opioid use was converted to morphine milligram equivalents (MME) and compared between cohorts using the t-test. Other outcomes were compared between groups using t-test or Chi-Square as appropriate. Participants (33 pre-ERAS, 32 ERAS) were similar between cohorts and had mean (SD) age 62.4 (9.7) years, body-mass index 28.9 (4.8) kg/m2, and median (IQR) parity 3 (2-4). Similarly, medical co-morbidities and type of apical POP procedure did not differ between groups. Following ERAS implementation, mean total intra- and post-operative MME decreased (59.4 (31.6) vs 36.6 (20.5), P<0.01). Total discharge prescription MME also decreased (392.3 (88.4) vs 94.6 (61.3), P<0.01). Despite decreased opioid use, post-operative pain scores were not different between groups (Table 2). The ERAS cohort had decreased length of stay and were more likely to be discharged on the day of surgery. Mean number of telephone calls within 30 days of surgery increased (1.0 (1.0) to 2.2 (1.9), P<0.01) while clinic visits, emergency room visits and readmissions did not differ. Implementation of an ERAS protocol in women undergoing major POP surgery resulted in decreased opioid use and length of stay without impacting post-operative pain scores.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Higher Fluid Balance is Associated With Worse Outcome in Critically Ill Traumatic Brain Injury Patients

Background: Fluid therapy is a ubiquitous part of management of critically ill patients with traumatic brain injury (TBI) and may impact on outcome. Our aim was to quantify variability in current fluid therapy in patients with TBI admitted at European and Australian Intensive Care Units (ICUs) and to study the association between fluid therapy and outcome after TBI. Methods: We analyzed data from patients admitted to the ICU with TBI and aged 16 and older included in the observational European CENTER-TBI and Australian OzENTER-TBI studies. The association of net daily fluid balance and -input with outcome (ICU mortality and functional outcome at 6 months) was analyzed at patient level with mixed effects logistic and ordinal regression with a random intercept for centre and adjustment for patient characteristics, and at centre level with centre as instrumental variable. Findings: In total, 2125 patients were included (1005 patients with isolated TBI). Mean daily fluid input ranged from 1·5 to 4·2L per centre. More positive daily mean fluid balance and fluid input were associated with worse outcome in patient-level analyses (fluid balance: ORs per 0·1L increase 1·10 [95%CI:1·07–1·13] and 1·03 [95%CI:1·02–1·05] for ICU mortality and functional outcome respectively; fluid input: ORs 1·05 [95%CI:1·03–1·06] and 1·03 [95%CI:1·02–1·04]). Centre-level analysis showed similar associations for fluid balance (ORs 1·15 [95%CI:1·02-1·29]; and 1·07 [95%CI:1·01-1·12], but not for fluid input (ORs: 0·95 [95%CI: 0·90-1·00]; and 1·01 [95%CI:0·99–1·03]). Interpretation: In critically ill patients with TBI, there is significant variability in fluid management with more positive fluid balances being associated with worse outcomes. Further research is needed to establish whether mitigation of positive fluid balance by less liberal fluid administration contributes to improved outcome. Funding: This research was funded by the European Commission 7th Framework program (602150) and the Australian Health and Medical Research Council (NHMRC 1074181). Declaration of Interests: DJC is an Australian NHMRC Practitioner Fellow and reports grants from the NHMRC and consulting fees to Monash University from PresSura Neuro. AIM declares consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. DKM reports grants from the UK National Institute for Health Research, during the conduct of the study; grants, personal fees, and non-financial support from GlaxoSmithKline; personal fees from Neurotrauma Sciences, Lantmaanen AB, Pressura, and Pfizer, outside of the submitted work. ES reports personal fees from Springer, during the conduct of the study. All other authors declare no competing interests. Ethics Approval Statement: In each recruiting site ethical approval was given.

QTc prolongation among hydroxychloroquine sulphate-treated COVID-19 patients: An observational study.

BackgroundThe liberal administration of hydroxychloroquine‐sulphate (HCQ) to COVID‐19 patients has raised concern regarding the risk of QTc prolongation and cardiac arrhythmias, particularly when prescribed with azithromycin. We evaluated the incidence of QTc prolongation among moderately and severely ill COVID‐19 patients treated with HCQ and of the existence of concomitant alternative causes.MethodsAll COVID‐19 patients treated with HCQ (between Mar 1 and Apr 14, 2020) in a tertiary medical centre were included. Clinical characteristics and relevant risk factors were collected from the electronic medical records. Individual patient QTc intervals were determined before and after treatment with HCQ. The primary outcome measure sought was a composite end point comprised of either an increase ≥60 milliseconds (ms) in the QTc interval compared with pre‐treatment QTc, and/or a maximal QTc interval >500 msResultsNinety patients were included. Median age was 65 years (IQR 55‐75) and 57 (63%) were male. Thirty‐nine patients (43%) were severely or critically ill. Hypertension and obesity were common (n = 23 each, 26%). QTc prolongation evolved in 14 patients (16%). Age >65 years, congestive heart failure, severity of disease, C‐reactive protein level, hypokalaemia and furosemide treatment, were all associated with QTc prolongation. Adjusted analysis showed that QTc prolongation was five times more likely with hypokalaemia [OR 5, (95% CI, 1.3‐20)], and three times more likely with furosemide treatment [OR 3 (95% CI, 1.01‐13.7)].ConclusionIn patients treated with HCQ, QTc prolongation was associated with the presence of traditional risk factors such as hypokalaemia and furosemide treatment.

Effects of Liberal Versus Restrictive Fluid Therapy on Renal Function Indices in Laparoscopic Bariatric Surgery.

BackgroundEarlier studies have suggested the liberal administration of fluids in favor of reducing the risk of rhabdomyolysis in obese patients, but the results are conflicting.ObjectivesThe present study aimed at comparing the effects of liberal and restrictive fluid therapy on renal indices in laparoscopic gastric bypass surgery.MethodsIn a double-blinded randomized clinical trial, 72 candidates of bariatric surgery were randomly assigned into two groups of restrictive and liberal fluid therapy. Indices, including BUN, creatinine, creatine kinase, GFR, and urine output were measured before and 24 hours after the surgery. The clinical trial was registered at IRCT.ir under code IRCT20170109031852N3.ResultsThere was no significant difference in BUN, creatinine, creatinine kinase, and GFR indices between the two groups of liberal and restrictive fluid therapy both before and 24 hours after surgery (P > 0.05). Intragroup comparisons before and after surgery revealed that BUN decreased in both groups after the surgery (P < 0.05). Also, creatinine and GFR values improved in patients who received a liberal fluid regimen, whereas these indices remained statistically unchanged in the restrictive group before and 24 hours after the surgery (P > 0.05).ConclusionsTwo methods of liberal and restrictive fluid therapy have comparable effects on traditional renal functional indices in laparoscopic bariatric surgery. The clinical significance of observed differences in outcomes should be investigated in further studies. The use of early biomarkers of acute kidney injury is warranted.

Partisan politics and fiscal policy in the Canadian provinces

AbstractThis article evaluates the impact of partisanship on provincial fiscal policies over business‐ and electoral‐cycles between 1981 and 2016. There were partisan differences between left‐wing governments (the New Democratic Party and the Parti Québécois), on the one hand, and conservative ones, on the other. The evidence is particularly strong for business‐cycles, where left‐wing parties pursued much more countercyclical strategies than conservatives. In contrast, there was little difference between most Liberal administrations and conservative ones. Left‐wing fiscal policies nevertheless lost their distinctiveness during the last third of the study period. The article concludes by discussing possible explanations for this change.

Restricted versus liberal intraoperative benzodiazepine use in cardiac anaesthesia for reducing delirium (B-Free Pilot): a pilot, multicentre, randomised, cluster crossover trial

BackgroundDelirium is common after cardiac surgery and is associated with adverse outcomes. Perioperative benzodiazepine use is associated with delirium and is common during cardiac surgery, which may increase the risk of postoperative delirium. We undertook a pilot study to inform the feasibility of a large randomised cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared with liberal administration) would reduce delirium. MethodsWe conducted a two-centre, pilot, randomised cluster crossover trial with four 4 week crossover periods. Each centre was randomised to a policy of restricted or liberal use, and then alternated between the two policies during the remaining three periods. Our feasibility outcomes were adherence to each policy (goal ≥80%) and outcome assessment (one delirium assessment per day in the ICU in ≥90% of participants). We also evaluated the incidence of intraoperative awareness in one site using serial Brice questionnaires. ResultsOf 800 patients undergoing cardiac surgery during the trial period, 127/800 (15.9%) had delirium. Of these, 355/389 (91.3%) received benzodiazepines during the liberal benzodiazepine periods and 363/411 (88.3%) did not receive benzodiazepines during the restricted benzodiazepine periods. Amongst the 800 patients, 740 (92.5%) had ≥1 postoperative delirium assessment per day in the ICU. Of 521 patients screened for intraoperative awareness, one patient (0.2%), managed during the restricted benzodiazepine period (but who received benzodiazepine), experienced intraoperative awareness. ConclusionsThis pilot study demonstrates the feasibility of a large, multicentre, randomised, cluster crossover trial examining whether an institutional policy of restricted vs liberal benzodiazepine use during cardiac surgery will reduce postoperative delirium. Clinical trial registrationNCT03053869.

Waving Israeli Flags at Right-Wing Christian Rallies in South Korea

ABSTRACT The impeachment of President Park Geun-hye and the ensuing shift to a liberal administration triggered massive far-right rallies in South Korea. The rally participants waved the South Korean flag to invoke their patriotism and the US flag to show their support for the Korean–USA alliance; however, a group of Protestant Christians at the front of pro-Park rallies waved Israeli flags, which was perplexing to non-participants. To explore why the Israeli flag was waved at the rallies, the study reported in this article examined video recordings of the Christian participants carrying Israeli flags. An analysis of the attendees’ spoken language, signs and edited captions reveals that the Israeli flag first symbolises ancient Israel in the Bible, from which stories and metaphors legitimise the Christians’ participation in the right-wing rallies. Second, the Israeli flag symbolises the modern State of Israel that was restored in 1948 together with the Republic of Korea, which supports right-wing ideology regarding the establishment of the first South Korean government. Finally, by waving the Israeli flag with the other two national flags, the flag wavers were attempting to make their Christian group identity salient without harming the right-wing identity of the rallies.

The first peasant and his fellow travellers: state control over Greek agricultural institutions under Metaxas

AbstractState control over Greece’s agricultural institutions increased during Metaxas’s authoritarian regime (1936–41). Analysing such state control allows us to address, in the Greek context, two questions with regard to fascist agrarian regimes. First, considering the trajectory of agricultural policy before the emergence of these regimes, how much of what they did was new, and how much was not? Second, how did the cadres of agricultural specialists participate in, or at least accommodate, the new regimes? Our research shows that Metaxas received support from the agronomists who had been active in Greece under previous liberal administrations. Such support did not take the form of laudatory statements or ideology-driven activism. It was rather a discreet acceptance of the new circumstances, combined with defection from one’s previous political camp. Metaxas’s dictatorship inherited most traits that made it a fascist agricultural regime from previous liberal administrations.

Presidential Power, Vetoes, and Public Policy: a Comparative Study between Brazil and the United States

&lt;p&gt;&lt;strong&gt;[Poder presidencial, vetos y política pública: Un estudio comparativo de Brasil y Estados Unidos]&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;ABSTRACT&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Much of the literature on Presidentialism focuses on the argument that bipartisan presidential systems are better able to avoid a conflictive Executive-Legislative relationship by facilitating the formation of coalitions in Congress and partisan ideological identification. From a comparative perspective, this study aims to identify and discuss the ability of the presidents of the United States and Brazil to promote public policy, and to examine the degree of conflict in the drafting of these policies by studying legislative vetoes. In addition, it analyzes the success rate of welfare bills voted in the lower chamber of the two countries and supported by their respective presidents. The period studied here covers 16 years (from 1995 to 2010 in Brazil and in the United States from 1993 to 2008), consisting of eight years of more liberal administrations and eight years of more conservative ones in each country. The presented hypothesis is that there is no significant difference between two-party or multi-party systems in terms of conflict, public policy drafting and presidential success rate. The data are analyzed using multivariate regressions and undergo qualitative treatment for a deeper understanding.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;RESUMEN&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Gran parte de la literatura sobre el presidencialismo se centra en el argumento de que los sistemas presidenciales bipartidistas son más capaces de evitar una relación conflictiva entre ejecutivo y legislativo al facilitar la formación de coaliciones en el Congreso y la identificación ideológica partidista. Desde una perspectiva comparativa, este estudio tiene como objetivo identificar y discutir los poderes de los presidentes de los Estados Unidos y Brasil para promover políticas públicas y verificar el grado de conflicto en la producción de dichas políticas mediante el control de los vetos legislativos. Analiza también la tasa de éxito de los proyectos de leyes de políticas de bienestar votadas en la cámara baja de los dos países y respaldados por sus respectivos presidentes. Abarca un período de 16 años (de 1995 a 2010 en Brasil y en los Estados Unidos de 1993 a 2008), con ocho años de administraciones más liberales y ocho años de gobiernos más conservadores en cada país. La hipótesis es que no hay una diferencia significativa con respecto al conflicto y la producción de políticas públicas en sistemas bipartidistas o multipartidistas y que las tasas de éxito son similares. Los datos se analizan mediante regresiones multivariables y se someten a un tratamiento cualitativo para una comprensión más profunda.&lt;/p&gt;

The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial

BackgroundHemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications.MethodsTen patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters.ResultsApplying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg−1 h−1, p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min−1 m−2, p = 0.005; HIAT: 2.08 vs. 2.56 l min−1 m−2, p = 0.225).ConclusionsAs vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course.Trial registration: ClinicalTrials.gov, Identifier: NCT01425710.

Red Blood Cell Product Transfusion Thresholds and Clinical Outcomes.

To determine whether patients transfused red blood cell (RBC) products according to guideline-specified pretransfusion hemoglobin (Hb) concentrations or for other reasons were more likely to survive their intensive care unit (ICU) stay. An observational study of 375 478 episodes of ICU care, over 5 years, was performed with ICU survival as the primary outcome. Outcomes were analyzed as a function of pretransfusion Hb concentration for groups with distinct transfusion indications while adjusting for potential confounders. This study included all adult patients discharged from 1 of 203 adult ICUs from 32 US health-care systems. The patients were from community hospitals, tertiary, and academic medical centers. Transfusion of allogenic packed RBCs or whole blood was prescribed at the discretion of the treating clinicians. We found that 15% of adult ICU patients are transfused RBC products, and most transfusions for hemodynamically stable patients are administered above the guideline-specified pretransfusion Hb threshold of 7 g/dL. Hemodynamically stable patients transfused below this threshold were significantly more likely to survive their ICU stay than those not transfused (odds ratio [OR] 0.59, 95% confidence interval [CI], 0.43-0.81; P = .001), and patients transfused at thresholds above 9 g/dL were less likely to survive their ICU stay than those not transfused. Patients of the acute blood loss group who were transfused appeared to benefit or were not harmed by transfusion. Conservative RBC product transfusion practices for groups that are targeted by guidelines are justified by outcomes observed in clinical practice. This study provides evidence for the liberal administration of RBC products to critically ill adults with acute blood loss based on association with lower risk of mortality.

Anesthetic Management for Percutaneous Minimally Invasive Fetoscopic Surgery of Spina Bifida Aperta: A Retrospective, Descriptive Report of Clinical Experience

(Anesth Analg. 2017;125(1):219-222) Liberal administration of tocolytic drugs (e.g. indomethacin) and intravenous fluids along with high concentrations of volatile anesthetic gases during fetal surgery are thought to contribute to the development of maternal pulmonary edema. Consequently, during the introduction of the Minimally Invasive Fetoscopic Approach (MIFA) for the closure of fetal spina bifida aperta (SBA), Hering and Kohl identified a general anesthetic technique that reduced concentrations of volatile anesthetic and thus minimized adverse side effects of deep anesthesia (hemodynamic depression, pulmonary edema, and need for vasopressor support). In this retrospective case series, the authors described their own clinical experiences with a modified Hering-Kohl-Protocol in patients undergoing MIFA for SBA. In this modified protocol, vasopressor management is guided by pulse contour analysis (PiCCO) alone and atosiban is the first-line agent for perioperative tocolysis instead of indomethacin.

Benzodiazepine administration during adult cardiac surgery: a survey of current practice among Canadian anesthesiologists working in academic centres.

Benzodiazepines are commonly administered during cardiac surgery because of their limited effect on hemodynamics and presumed role in preventing intraoperative awareness. Recent concerns about an increased risk of delirium with benzodiazepines have resulted in decreased usage in the intensive care unit and in geriatric perioperative practice. Little is known, however, about current benzodiazepine usage in the setting of adult cardiac surgery. We contacted all academic anesthesia departments in Canada to identify practicing attending cardiac anesthesiologists; this group constituted our sampling frame. Information regarding participant demographics, benzodiazepine usage, type, dose, and other administration details were obtained by electronic survey. Responses were analyzed descriptively. The survey was completed by 243/346 (70%) of cardiac anesthesiologists. Eleven percent of respondents do not administer benzodiazepines. Midazolam was the most commonly used benzodiazepine, with a mean (standard deviation) dose of 4.9 (3.8) mg given to an average patient. When respondents were asked the proportion of patients that they gave benzodiazepines, the response was bimodal. The most common considerations that influenced benzodiazepine use were patient age (73%), patient anxiety (63%), history of alcohol/drug/benzodiazepine use (60%), and the presence of risk factors for intraoperative awareness (44%). Benzodiazepine use is common among academic cardiac anesthesiologists in Canada. Nonetheless, heterogeneity exists between individual practices, suggesting clinical equipoise between restrictive and liberal administration of benzodiazepines for cardiac anesthesia. L'administration de benzodiazépines pendant la chirurgie cardiaque chez l'adulte: évaluation de la pratique actuelle des anesthésiologistes canadiens exerçant en milieu universitaire.