Background: Continuous noninvasive arterial pressure monitoring devices are available for bedside use, but the accuracy and precision of these devices have not been evaluated in a systematic review and meta-analysis.Methods: The authors performed a systematic review and meta-analysis of studies comparing continuous noninvasive arterial pressure monitoring with invasive arterial pressure monitoring. Random-effects pooled bias and SD of bias for systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure were calculated. Continuous noninvasive arterial pressure monitoring was considered acceptable if pooled estimates of bias and SD were not greater than 5 and 8 mmHg, respectively, as recommended by the Association for the Advancement of Medical Instrumentation.Results: Twenty-eight studies (919 patients) were included. The overall random-effect pooled bias and SD were −1.6 ± 12.2 mmHg (95% limits of agreement −25.5 to 22.2 mmHg) for systolic arterial pressure, 5.3 ± 8.3 mmHg (−11.0 to 21.6 mmHg) for diastolic arterial pressure, and 3.2 ± 8.4 mmHg (−13.4 to 19.7 mmHg) for mean arterial pressure. In 14 studies focusing on currently commercially available devices, bias and SD were −1.8 ± 12.4 mmHg (−26.2 to 22.5 mmHg) for systolic arterial pressure, 6.0 ± 8.6 mmHg (−10.9 to 22.9 mmHg) for diastolic arterial pressure, and 3.9 ± 8.7 mmHg (−13.1 to 21.0 mmHg) for mean arterial pressure.Conclusions: The results from this meta-analysis found that inaccuracy and imprecision of continuous noninvasive arterial pressure monitoring devices are larger than what was defined as acceptable. This may have implications for clinical situations where continuous noninvasive arterial pressure is being used for patient care decisions.

This prospective, randomized, double-blinded, crossover trial compared the accuracy of detecting bronchial intubation between point-of-care ultrasound and auscultation in 42 adult subjects. The point-of-care ultrasound was a reliable technique to detect bronchial intubation by demonstrating absent contralateral pleural lung sliding on the unintubated side. Supplemental Digital Content is available in the text. Background: Unrecognized malposition of the endotracheal tube (ETT) can lead to severe complications in patients under general anesthesia. The focus of this double-blinded randomized study was to assess the accuracy of point-of-care ultrasound in verifying the correct position of the ETT and to compare it with the accuracy of auscultation. Methods: Forty-two adult patients requiring general anesthesia with ETT were consented. Patients were randomized to right main bronchus, left main bronchus, or tracheal intubation. After randomization, the ETT was placed via fiber-optic visualization. Next, the location of the ETT was assessed using auscultation by a separate blinded anesthesiologist, followed by an ultrasound performed by a third blinded anesthesiologist. Ultrasound examination included assessment of tracheal dilation via cuff inflation with air and evaluation of pleural lung sliding. Statistical analysis included sensitivity, specificity, positive predictive value, negative predictive value, and interobserver agreement for the ultrasound examination (95% CI). Results: In differentiating tracheal versus bronchial intubations, auscultation showed a sensitivity of 66% (0.39 to 0.87) and a specificity of 59% (0.39 to 0.77), whereas ultrasound showed a sensitivity of 93% (0.66 to 0.99) and specificity of 96% (0.79 to 1). Identification of tracheal versus bronchial intubation was 62% (26 of 42) in the auscultation group and 95% (40 of 42) in the ultrasound group (P = 0.0005) (CI for difference, 0.15 to 0.52), and the McNemar comparison showed statistically significant improvement with ultrasound (P < 0.0001). Interobserver agreement of ultrasound findings was 100%. Conclusion: Assessment of trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the location of ETT.

This study highlights that a novel “whole-body” point-of-care ultrasound examination (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) can be taught to anesthesiology residents using a model/simulation-guided curriculum, and with this appropriate training, one can impact clinical management of patients in the perioperative setting. Supplemental Digital Content is available in the text. Background: The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training. Methods: For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data. Results: Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%. Conclusions: Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.

Variation in clinical practice in the perioperative environment and intensive care unit is a major challenge facing modern medicine. The objective of the present study was to analyse intraoperative crystalloid administration practices at two academic medical centres in the USA. We extracted clinical data from patients undergoing intra-abdominal procedures performed at UC Irvine (UCI) and Vanderbilt University (VU) Medical Centres. Limiting data to uncomplicated elective surgery with minimal blood loss, we quantified variability in fluid administration within individual providers, between providers, and between types of procedures using a corrected coefficient of variation (cCOV). Regression was performed using a general linear model to determine factors most predictive of fluid administration. For provider analysis and model building, 1327 UCI and 4585 VU patients were used. The average corrected crystalloid infusion rate across all providers at both institutions was 7.1 (sd 4.9) ml kg⁻¹ h⁻¹, an overall cCOV of 70%. Individual providers ranged from 2.3 (sd 3.7) to 14 (sd 10) ml kg⁻¹ h⁻¹. The final regression model strongly favoured personnel as predictors over other patient predictors. Wide variability in crystalloid administration was observed both within and between individual anaesthesia providers, which might contribute to variability in surgical outcomes.

Dynamic variables are the best predictors of fluid responsiveness in patients under general anesthesia and mechanical ventilation; namely, respiratory variations in pulse pressure and in the plethysmographic waveform. However, these variables have potential limitations. Our aim was to evaluate their intraoperative applicability. We extracted clinical data from all anesthesia procedures performed at our institution in 2009 and identified the number of cases that presented predetermined conditions of application. Among the 12,308 procedures, 39% met the criteria for the noninvasive monitoring of variations in the plethysmographic waveform of which 23% had arterial lines and met the criteria for the invasive monitoring of variations in pulse pressure.

Noninvasive hemoglobin (Hb) monitoring devices are available in the clinical setting, but their accuracy and precision against central laboratory Hb measurements have not been evaluated in a systematic review and meta-analysis. We conducted a comprehensive search of the literature (2005 to August 2013) with PubMed, Web of Science and the Cochrane Library, reviewed references of retrieved articles, and contacted manufactures to identify studies assessing the accuracy of noninvasive Hb monitoring against central laboratory Hb measurements. Two independent reviewers assessed the quality of studies using recommendations for reporting guidelines and quality criteria for method comparison studies. Pooled mean difference and standard deviation (SD) (95% limits of agreement) across studies were calculated using the random-effects model. Heterogeneity was assessed using the I2 statistic. A total of 32 studies (4425 subjects, median sample size of 44, ranged from 10 to 569 patients per study) were included in this meta-analysis. The overall pooled random-effects mean difference (noninvasive—central laboratory) and SD were 0.10 ± 1.37 g/dL (−2.59 to 2.80 g/dL, I2 = 95.9% for mean difference and 95.0% for SD). In subgroup analysis, pooled mean difference and SD were 0.39 ± 1.32 g/dL (−2.21 to 2.98 g/dL, I2 = 93.0%, 71.4%) in 13 studies conducted in the perioperative setting and were −0.51 ± 1.59 g/dL (−3.63 to 2.62 g/dL, I2 = 83.7%, 96.4%) in 5 studies performed in the intensive care unit setting. Although the mean difference between noninvasive Hb and central laboratory measurements was small, the wide limits of agreement mean clinicians should be cautious when making clinical decisions based on these devices.