Remimazolam is an ultrashort acting intravenous sedative-hypnotic approved for procedural sedation. We report a series of 8 cases of radiographically placed gastrostomy tubes using remimazolam as the sole anesthetic agent. Interventional radiology (IR) gastrostomy tube placement entails anesthetizing often complex patients in a nonoperating room environment. All 8 patients reported here underwent successful gastrostomy tube placement without the need for conversion to general anesthesia. Remimazolam is a feasible option to sedate patients for gastrostomy tube placement in the IR suite.

Introduction: Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy or Broken Heart Syndrome, is a reversible, transient state of myocardial dyskinesis and apical ballooning. Infrequently, TCM may progress to severe life-threatening complications such as cardiogenic shock. Early mechanical circulatory support (MCS) is crucial to myocardial recovery in these cases. We present one of the first cases of TCM successfully treated with the advanced micro-axial minimally invasive Impella 5.5 with SmartAssist MCS device. Case Presentation: A female in her late 70s with a history of hypothyroidism, atrial fibrillation post-ablation, and cholelithiasis was referred to our facility for an elective cholecystectomy. Post-anesthesia induction with propofol 2.1 mg/kg (140 mg bolus), she became bradycardic and hypotensive, eventually leading to asystole, requiring CPR and termination of the procedure. Echocardiography revealed a left ventricular ejection fraction (LVEF) of 24% with mid-ventricular akinesis and apical ballooning with mild mitral regurgitation, suggesting the diagnosis of TCM. Cardiac catheterization showed RA 20 and mean PA 42 mmHg. Lactate was 18.7 mmol/L and LDH 1776 U/L, suggesting progressive shock. Continuous epinephrine 0.1 mcg/kg/min and norepinephrine 0.06 mcg/kg/min were titrated for BP 97/58, and she was initially supported with the Impella CP device. Despite aggressive efforts, rising LDH levels and increased vasopressor needs indicated inadequate organ perfusion, requiring an upgrade to Impella 5.5. Impella 5.5 support for 11 days led to impressive myocardial recovery, leading to reductions, and eventual discontinuation, of inotropes and vasopressors. Post-Impella 5.5 explantation, her LVEF was 59–65% and she was discharged with Mobile Cardiac Outpatient Telemetry (MCOT) monitoring for her arrhythmias and reinitiation of guideline-directed medical therapies (GDMTs) for her comorbidities. Her 2-month follow-up shows sustained LVEF greater than 45% with functional improvements. Conclusions: Early escalation within 24 h of Impella CP to Impella 5.5 provided stabilization of cardiometabolic shock, preventing end-organ damage, allowing recovery of native heart function while maintaining ambulatory status, and allowing for optimizing medical therapy. It presents a safe, minimally invasive, and cost-effective intervention in TCM cases refractory to GDMT or when additional time is needed for decision-making in cases presenting with CS.

Hand hygiene is vital to infection prevention, but sustaining high compliance remains an ongoing challenge. This project aimed to determine if a culturally focused hand hygiene program, leveraging existing resources and context-driven data, could sustain high compliance in an acute care hospital setting. In June 2023, our tertiary acute care hospital implemented a hand hygiene program targeting roots of non-compliance. Light-duty nurses and patient care technicians observed compliance through security cameras, provided real-time feedback, and acted as cultural change agents. Context-specific data were leveraged to create targeted education and recognition programs. Results were analyzed using an interrupted time series analysis, logistic regression, and a decision tree algorithm to assess impact and predictors of compliance. 191,403 observations were collected across 11 inpatient units. Overall post-implementation compliance improved by 11.6% (effect size: 0.34). Improvements were observed across all units, roles, and shifts. Significant predictors of compliance were identified, including staff roles and shifts. Improvements were resilient to the hourly census and showed a 54% reduction in the variance of compliance. Our program sustainably improved and stabilized hand hygiene compliance. The approach offers a practical and scalable model for institutions seeking to overcome common challenges to achieve sustainable compliance.

A 68-year-old with a history of ischemic cardiomyopathy, chronic kidney disease, hypertension, and anxiety was admitted to the intensive care unit (ICU) in cardiogenic shock. After an intubation and several days in the ICU, he expressed hopelessness with further care and was considering a transition to hospice. The treatment team was concerned that clinical depression was influencing his decision. After obtaining consent, depression was treated with 0.5 mg/kg of intravenous ketamine for 3 days, with rapid and significant improvement in his mood. He made an informed choice to pursue a workup for heart transplantation. Besides improving his mood, ketamine led to vivid subjective experiences. This case provides a qualitative account of the patient's experience. It raises crucial questions about the influence of depressive symptoms in decision-making in critically ill patients and the potential role of ketamine in the rapid resolution of depressive symptoms and subsequent changes in care decisions.