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Introduction: In austere environments, the safe administration of anesthesia becomes challenging because of unreliable electrical sources, limited amounts of compressed gas, and insufficient machine maintenance capabilities. Such austere environments exist in battlefield medicine, in low- and middle-income countries (LMICs), and in areas struck by natural disasters. Whether in military operations or civilian settings, the Universal Anesthesia Machine (UAM) (Gradian Health Systems, New York, New York) is a draw-over device capable of providing safe and effective general anesthesia when external oxygen supplies or reliable electrical sources are limited. This brief report discusses a proof-of-concept observational study demonstrating the clinical utility of the UAM in a resource-limited area.Materials and Methods: This observational study of 20 patients in Haiti who underwent general anesthesia using the UAM highlights the device's capability to deliver anesthesia intraoperatively in a resource-limited LMIC clinical setting. Preoxygenation was achieved with the UAM's draw-over oxygen supply. Patients received acetaminophen for analgesia, dexmedetomidine for preinduction anesthesia, and succinylcholine for paralysis. After induction, the UAM provided a mixture of oxygen and isoflurane for maintenance of anesthesia. Manual ventilation was performed using draw-over bellows until spontaneous ventilation recurred, when clinically appropriate, artificial airways were removed. Intraoperative medication was administered at the anesthesiologist's discretion. The institutional review board at the U.S. anesthesiologists' affiliated institution and the Haitian hospital approved this study; patients were consented in their native language.Results: Two anesthesiologists used the UAM to deliver general anesthesia to 20 patients in a Haitian hospital without access to an external oxygen supply, reliable power grid, or opioids. The patients' average age was ~40 years, and 90% of them were male. Most of the cases were herniorrhaphy (50%) and hydrocelectomy (25%) surgeries. The median American Society of Anesthesiologists (ASA) score was 2; 45% of the patients had an ASA score of 1, and none had an ASA score >3. Of the 20 cases, 55% of patients received an endotracheal tube, and 40% received a laryngeal mask airway; for one patient, only a masked airway was used. Every patient was discharged on the day of the surgery. No complications occurred in the perioperative or 1-month follow-up period.Conclusion: The UAM can be used where a lack of resources and training exist because of its simple design, built-in oxygen concentrator, and capacity to revert from continuous-flow to draw-over anesthesia in the event of a power failure or if external oxygen supplies are unavailable. We believe the UAM addresses some of the shortcomings of modern anesthesia machines and has the potential to improve the delivery of safe general anesthesia in combat and austere scenarios. Further studies could consider different types of surgeries than those reported here and involve more complex patients. Studies involving alternative anesthetic agents and non-anesthesiologist personnel are also needed. Overall, this brief report detailing the use of the UAM following a natural disaster in a LMIC is proof of concept that the machine can provide reliable anesthesia for surgical procedures in austere and resource-limited environments, including disaster areas and modern combat zones. [ABSTRACT FROM AUTHOR]

Background: Current literature is insufficient to support specific guidelines for estimating nutrition needs during extracorporeal membrane oxygenation (ECMO). The purpose of this single-center observational study was to investigate protein catabolism during venovenous (VV) ECMO support and assess whether current nutrition recommendations were adequate.Methods: All patients admitted to the Lung Rescue Unit between November 2016 and June 2017 were screened for eligibility. Patients with a documented nitrogen balance (NB) study were included in the data set. NB results were excluded for a change in blood urea nitrogen ≥10 mg/dL during the urine collection or unquantified nitrogen losses. Demographics, ECMO-specific data, NB, nutrition prescription, and infusion were recorded in a prospective, observational manner.Results: After exclusions, 25 NB results in 16 patients were included for analysis. Nonobese (body mass index [BMI] ˂ 30 kg/m2 ) and obese (BMI ≥ 30 kg/m2 ) patients received 85% and 84% of their prescribed protein, respectively. Nonobese patients had a mean NB of -1.7 ± 5.7, whereas obese patients had a mean NB of -11.5 ± 9.6. Obese patients displayed significantly higher urine urea nitrogen (26.7 ± 7.7 vs 13.5 ± 4.3; P = .00004).Conclusions: These preliminary findings suggest that current guidelines for estimating protein needs in critically ill patients may be adequate for nonobese patients receiving VV ECMO. However, current protein recommendations for critically ill obese patients may not be adequate during VV ECMO support, possibly related to significantly higher rates of catabolism. Future studies with a larger cohort of patients are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Background: The nutrition needs of patients requiring extracorporeal membrane oxygenation (ECMO) have not been established in the literature. The purpose of this study is to investigate if current protein recommendations are adequate to achieve nitrogen equilibrium in patients on venovenous ECMO (VV ECMO).Methods: Patients aged ≥18 years on VV ECMO admitted November 2016 through January 2018 with a documented nitrogen balance (NB) study were included. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m2 ) and nonobese (BMI < 30 kg/m2 ) categories for analysis.Results: After exclusions, 55 NB studies in 29 patients were analyzed. Twelve nonobese patients received a median of 2.1 g protein/kg actual body weight (ABW) (interquartile range [IQR]: 1.7-2.5), and median NB was -2.2 g/d (IQR: -7.4 to 2.8). In 17 obese patients, median protein delivery of 2 g protein/kg ideal body weight (IBW) (IQR: 1.7-2.5) achieved a median NB of -7.3 g/d (IQR: -12.6 to -2.8). Obese patients exhibited greater urinary urea nitrogen excretion than nonobese patients did (24.6 vs 17.6 g/d, P < 0.0001).Conclusions: Obese and nonobese patients undergoing VV ECMO may require more protein than is currently recommended for critical illness. Monitoring nutrition delivery and serial NB to assess prescription adequacy should be incorporated into routine patient care. Further research is needed to confirm these findings and create specific guidelines for patients on VV ECMO. [ABSTRACT FROM AUTHOR]