Author: Kris

Grew up in a small Texas town. Heavily involved in extracurricular activities: piano, violin, dance (ballet/jazz/tap), tennis, horseback riding (english/western), taekwondo, basketball, soccer, volleyball, percussion, drumline, orchestra, band, mascot, pageants. I had the typical Tiger Mom upbringing. Went to college, medical school, residency, and fellowship. Amidst the ups and downs of life, allow me to share with you my journey...as an "ordinary" person who happens to be an MD.

22ff02 — From Anesthesiology: April 2016

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References

Cerebral oximetry. BJA Education, Volume 16, Issue 12, December 2016, Pages 417–421.

Cerebral oximetry in cardiac anesthesia. J Thorac Dis. 2014 Mar; 6(Suppl 1): S60–S69.

Cerebral oximetry and its role in adult cardiac, non-cardiac surgery and resuscitation from cardiac arrest. Anaesthesia, Volume72, IssueS1 Special Issue: Monitoring in the peri‐operative period; January 2017, Pages 48-57.

Year Round School

We are currently looking at ideas to help our school system move to year round school. The reason for the push is that we have 2 parents working in the family. The benefits are highlighted that kids possibly retain their learned topics better. I definitely think it would help with summer planning as well as enable us the ability to take OFF season vacationing throughout the year. I think kids could be better focused for a shorter time period. I think it promotes a sense of routine that may be better tolerated by kids as well as families.

VeryWell: Pros & Cons of Year Round School, updated

Education Next

EdWeek.Org 2015

EdWeek.org 2020: Is it time to reconsider year round schooling?

CDE.CA.GOV Year Round Guide

Year Round Education Calendar

Public School Review: Pros & Cons

School of Education Online: Pros and Cons of Year Round School

Red Apple Reading Blog: Traditional vs Year Round School 2012

The Edvocate 2017: How to Implement Year Round School System

The Edvoate, 2017: Year-round schooling: 10 things to know

Chaotically Yours

Ed Policy in CA 1987

1991 Guidelines for Implementation to Year Round School

Diabetes Consensus

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2022;45(11):2753–2786.

From Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). *Diabetes Care* 2022;45(11):2753–2786.

Consensus Recommendations

All people with type 2 diabetes should be offered access to ongoing DSMES programs.
Providers and health care systems should prioritize the delivery of person-centered care.
Optimizing medication adherence should be specifically considered when selecting glucose-lowering medications.
MNT focused on identifying healthy dietary habits that are feasible and sustainable is recommended in support of reaching metabolic and weight goals.
Physical activity improves glycemic control and should be an essential component of type 2 diabetes management.
Adults with type 2 diabetes should engage in physical activity regularly (>150 min/week of moderate- to vigorous-intensity aerobic activity) and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks.
Aerobic activity should be supplemented with two to three resistance, flexibility, and/or balance training sessions/week. Balance training sessions are particularly encouraged for older individuals or those with limited mobility/poor physical function.
Metabolic surgery should be considered as a treatment option in adults with type 2 diabetes who are appropriate surgical candidates with a BMI ≥40.0 kg/m² (BMI ≥37.5 kg/m² in people of Asian ancestry) or a BMI of 35.0–39.9 kg/m² (32.5–37.4 kg/m² in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods.
In people with established CVD, a GLP-1 RA with proven benefit should be used to reduce MACE, or an SGLT2i with proven benefit should be used to reduce MACE and HF and improve kidney outcomes.
In people with CKD and an eGFR ≥20 ml/min per 1.73 m² and a UACR >3.0 mg/mmol (>30 mg/g), an SGLT2i with proven benefit should be initiated to reduce MACE and HF and improve kidney outcomes. Indications and eGFR thresholds may vary by region. If such treatment is not tolerated or is contraindicated, a GLP-1 RA with proven cardiovascular outcome benefit could be considered to reduce MACE and should be continued until kidney replacement therapy is indicated.
In people with HF, SGLT2i should be used because they improve HF and kidney outcomes.
In individuals without established CVD but with multiple cardiovascular risk factors (such as age ≥55 years, obesity, hypertension, smoking, dyslipidemia, or albuminuria), a GLP-1 RA with proven benefit could be used to reduce MACE, or an SGLT2i with proven benefit could be used to reduce MACE and HF and improve kidney outcomes.
In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin.
SGLT2i and GLP-1 RA reduce MACE, which is likely to be independent of baseline HbA_1c. In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or an SGLT2i with proven benefit should be independent of baseline HbA_1c.
In general, selection of medications to improve cardiovascular and kidney outcomes should not differ for older people.
In younger people with diabetes (<40 years), consider early combination therapy.
In women with reproductive potential, counseling regarding contraception and taking care to avoid exposure to medications that may adversely affect a fetus are important.

Mastering Diabetes

Glucose Goddess

Huberman Lab: Controlling Sugar Cravings & Metabolism with Science-Based Tools

The PlantPower Meal Planner: code $10 off RRHealth

Prothrombin Complex Concentrate

PCC – StatPearls, Dec 2022.

PCC – Hosp Pharm. 2013 Dec; 48(11): 951–957.

PCC Dosing – Medscape

K Centra dosing calculator

Use of PCC – 2014? PCC Dosing – year?

Comparison of 4-Factor Prothrombin Complex Concentrate With Frozen Plasma for Management of Hemorrhage During and After Cardiac Surgery A Randomized Pilot Trial. JAMA Netw Open. 2021;4(4):e213936.

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients. Anaesthesia, 76: 381-392. https://doi.org/10.1111/anae.15181

In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg^-1. This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available.
In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg^-1) should be considered.
A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. The Lancet, Volume 385, Issue 9982, 2015, Pages 2077-2087,ISSN 0140-6736,https://doi.org/10.1016/S0140-6736(14)61685-8.

From Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. The Lancet, Volume 385, Issue 9982, 2015, Pages 2077-2087,ISSN 0140-6736,https://doi.org/10.1016/S0140-6736(14)61685-8.

In summary:
For the endpoint of rapid INR reduction, the results from our trial are consistent with previously published (mainly observational) data and demonstrate that 4F-PCC is non-inferior and superior to plasma for rapid INR reduction in patients on VKA therapy.
Furthermore, we noted that 4F-PCC could be given more rapidly than plasma, which is in agreement with previously published (retrospectively collected) data.²⁴
For the endpoint of clinical efficacy, we found no other adequately powered trial examining reversal of VKA therapy in patients needing urgent surgical procedures, and this trial therefore offers new insights into their treatment. We noted that 4F-PCC was superior to plasma for haemostatic efficacy.
Although our study was not powered to assess safety, we did not detect any between-treatment differences for the occurrence of thromboembolic events or deaths, a finding in agreement with the existing scientific literature.11, 17, 25, 26 Additionally, although these data guide clinicians on how best to achieve urgent VKA reversal, the scientific literature concerning which patients should be urgently reversed before surgical or invasive interventions continues to evolve; for example, findings from a recent trial showed the safety of pacemaker placement without interruption of anticoagulation.²⁹

Efficacy and safety of a four-factor prothrombin complex concentrate (4F-PCC) in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation, 128 (2013), pp. 1234-1243.

From Efficacy and safety of a four-factor prothrombin complex concentrate (4F-PCC) in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation, 128 (2013), pp. 1234-1243.

Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest, 133 (2008), pp. 160S-198S

Among the key recommendations in this article are the following:
For dosing of VKAs, we recommend the initiation of oral anticoagulation therapy, with doses between 5 mg and 10 mg for the first 1 or 2 days for most individuals, with subsequent dosing based on the international normalized ratio (INR) response (Grade 1B); we suggest against pharmacogenetic-based dosing until randomized data indicate that it is beneficial (Grade 2C); and in elderly and other patient subgroups who are debilitated or malnourished, we recommend a starting dose of ≤ 5 mg (Grade 1C). The article also includes several specific recommendations for the management of patients with nontherapeutic INRs, with INRs above the therapeutic range, and with bleeding whether the INR is therapeutic or elevated.
For the use of vitamin K to reverse a mildly elevated INR, we recommend oral rather than subcutaneous administration (Grade 1A).
For patients with life-threatening bleeding or intracranial hemorrhage, we recommend the use of prothrombin complex concentrates or recombinant factor VIIa to immediately reverse the INR (Grade 1C).
For most patients who have a lupus inhibitor, we recommend a therapeutic target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A].
We recommend that physicians who manage oral anticoagulation therapy do so in a systematic and coordinated fashion, incorporating patient education, systematic INR testing, tracking, follow-up, and good patient communication of results and dose adjustments [Grade 1B].
In patients who are suitably selected and trained, patient self-testing or patient self-management of dosing are effective alternative treatment models that result in improved quality of anticoagulation management, with greater time in the therapeutic range and fewer adverse events. Patient self-monitoring or self-management, however, is a choice made by patients and physicians that depends on many factors. We suggest that such therapeutic management be implemented where suitable (Grade 2B).

Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study). Critical Care volume 18, Article number: R81 (2014).

In patients on VKA therapy presenting with severe hemorrhage, international guidelines recommend, as soon as the diagnosis is confirmed, the administration of PCC (≥20 UI/kg) and vitamin K (≥5 mg) to normalize coagulation (post-reversal INR ≤1.5).
A guideline-concordant administration dose of PCC and vitamin K administrated in the first eight hours was associated with a two-fold decrease in seven-day mortality overall and with a three-fold decrease in the ICH subgroup
The guideline-concordant reversal was performed in 38% of the patients within eight hours after admission
Whereas pre-reversal INR is not absolutely necessary, post-reversal INR is essential to evaluate treatment efficacy
The post-reversal INR target must be performed systematically and immediately after PCC administration

Retirement Info

Physician Reviewment Plans: Overview Of 401k’s

SCPMG Charles Schwab Keogh Retirement Plan at Kaiser Permanente

Kaiser Permanente SCPMG Keogh Plan

80% Savings Rates

ETF’s For Retirement Investing

March 2019 Income

When Your Job Doesn’t Offer You a Retirement Plan

Nothing more than a 401k

Required Minimum Distributions – Rich Person Problems

Vesting and Pensions

The Value Of My Pension Plan

Benefit Structures For Physicians

Northwest Kaiser Permanente Cash Balance Plan

Pension Calculator

PaulMerriman.com

Pulmonary Hypertension

The case: Patient came in for laparoscopic colectomy. She had a history of severe COPD, newly diagnosed adenocarcinoma of colon, anemia (Hb 9), newly diagnosed ANCA vasculitis, h/o mitral stenosis s/p robotic mitral valve replacement, pulmonary HTN, severe TR, systemic HTN, normal EF. Patient had recent exacerbations of CHF with BNP in 1200s. Recent (within the last 3 months) history of coding on induction requiring chest compressions during robotic MVR (50mg propofol). On a steroid taper.

BPs 180-200s/90-110s; PAPs 40-60s/20-40s. 50kg.

Plan: aline, swan, R2, slow induction

Induction: fentanyl 50mcg, propofol 20mg, lidocaine 100mg, etomidate 10mg, roc 50mg. Gtt: epinephrine @ 0.02mcg/kg/min, norepinephrine @ 0.04mcg/kg/min. Milrinone arrived to OR after induction. Able to titrate off epinephrine to Milrinone 0.3mcg/kg/min even with insufflation of abdomen. Did not need to decrease insufflation pressures as hemodynamics were relatively stable.

Extubated safely at the end of the case. Received 100mcg fentanyl, 20mg ketamine, Exparel TAP block, pre-op PO Tylenol 1000mg for pain control. She’s doing well and pleased with her anesthetic management.

From Mayo Clinic: Pulmonary Hypertension

What is Pulmonary Hypertension?

Medscape: Perioperative Pulmonary Hypertension

Cardiovascular and Ventilatory Consequences of Laparoscopic Surgery. Circulation; Vol 135, no. 7. Feb 2017.

The Physiologic Effects of Pneumoperitoneum in the Morbidly Obese. Ann Surg. 2005 Feb; 241(2): 219–226.

Impairment of Cardiac Performance by Laparoscopy in Patients Receiving Positive End-Expiratory Pressure. Arch Surg. 1999;134(1):76-80.

The effect of pulmonary hypertension on inpatient outcomes of laparoscopic procedures. Updates Surg. 2018 Dec; 70(4):521-528.

Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. BJA; Volume 126, Issue 4, April 2021, Pages 774-790. PDF

From Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. BJA; Volume 126, Issue 4, April 2021, Pages 774-790.

Laparoscopic Cholecystectomy with Pulmonary Hypertension: Anaesthetic Challenges – A Case Report. Indian Journal of Anaesthesia 52(2):p 217-220, Mar–Apr 2008.

Anesthesia for a Patient with Severe Pulmonary Hypertension Undergoing Laparoscopic Cholecystectomy: A Case Report. Zhou et al., J Pulm Respir Med 2017, 7:2

Blocks for Shoulders

80 something year old male came for reverse total shoulder replacement. He had severe COPD as well as an EF 20% with CHF. He had been appropriately optimized. Preoperatively, we performed an anterior approach suprascapular block (10ml, 0.25% bupi) combined with an infraclavicular block (20ml, 0.25% bupi). In retrospect, we could have used 5ml for suprascapular block and 15ml for infraclavicular block.

Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: A meta-analysis of clinical control trials. International Journal of Surgery, Volume 45, September 2017, Pages 85-91.

Supraclavicular block could provide similar analgesic efficacy compared with interscalene block.
Ultrasound-guided supraclavicular block was associated with a low incidence of hoarseness and Horner syndrome.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis. European Journal of Anaesthesiology 36(6):p 427-435, June 2019

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology July 2018, Vol. 129, 47–57.

From Anesthesiology July 2018, Vol. 129, 47–57.

A Randomized Comparison Between Interscalene and Small-Volume Supraclavicular Blocks for Arthroscopic Shoulder Surgery. Regional Anesthesia & Pain Medicine 2018;43:590-595.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series. Acta Anaesthesiol Scand. 2021; 65: 674– 680.

Suprascapular nerve block is a clinically attractive alternative to interscalene nerve block during arthroscopic shoulder surgery: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research volume 16, Article number: 376 (2021).

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review. Osteology 2022, 2(1), 52-61.

YouTube: Anterior suprascapular nerve block and literature 11:43 for procedure

YouTube: Suprascapular and axillary nerve block

New Beginnings

I made the very difficult decision to change jobs. I was with Anesthesia Service Medical Group (ASMG) from 2011-2022. My time at Scripps Memorial Hospital in La Jolla was incredible. There are wonderful and competent surgeons, stellar nurses, fabulous anesthesia techs, dedicated ancillary staff, and collegial anesthesia partners. The reason for my departure: work-life balance. For me, work-life balance is being able to spend time with my family. The way our call structure is designed is to constantly be available to the hospital for add-ons without knowing a time that you are done with work. This often leads to 2-3x/week of not knowing when I can give my husband and kids a set time when I will be home. My kids are 4.5 and 3.5 years old. I want to be more available to them for school activities, dinner, and bed times. My husband and I both have very demanding jobs and I could see the toll my current job was taking on him as well as the kids.

This led me to look at other models that may be more receptive to a working mother who wants to work hard as well as be a present-mom with less mom guilt. This is a personal decision.

I landed on a model at Kaiser where I will know when I will be done everyday as it is primarily shiftwork. Yes, I will still take call, work weekends/nights/ holidays,etc… but when I am done, I will be done. I am excited knowing that I will be able to tell my kids that I will be home for dinner or home to tuck them in. The littles are growing so quickly. Kindergarten will start for my oldest in 2023 and G will follow in 2024. If I break down their ages in 5 year timeframe… 0-5 is almost complete. Next will be 5-10 and 10-15 and 15-20. The first 5 year time frame went by quickly. Everyone says it goes by so fast. I want to stop and enjoy this time.

I still want to work hard and push myself career-wise, and I do plan on doing that. My goal is to continue evidence-based practice focused on patient care, dive into more ERAS guidelines, bring my private practice experience to the Kaiser model, encourage well-being mentally and physically, and lean into more leadership roles acting as a mentor and role model.

Kaiser Blogs:

The Permanente Journal

Kaiser Health News

Health & Wellness

Thrive Together

Thrive: Center for Healthy Living Latest Blogs

Center for Total Health

Continuous Glucose Monitor

In November 2022, I opted to try a continuous glucose monitor (CGM) to track my blood sugar readings. Granted, I am not diabetic, however my father and my aunt are diabetics and I had gestational diabetes during my 2nd pregnancy. I’m a bit of a data nerd and like to see how my body responds to the things I eat. So, I signed up for a program through Zoe and started following the app and logging my food. After I completed the 14 days, I then stumbled upon Glucose Goddess and want to try another 14 days with the CGM. Here’s the data from the first trial.

I felt that my blood glucose was actually pretty well maintained. My average reading was 94 and I fluctuated from 72-138. That’s pretty much carrying on with my regular lifestyle: protein shake for breakfast, whole food plant based meal for lunch, and regular dinner and a snack before bed. After reading the Glucose Revolution book, I find that I have an even better understanding of what I can do to improve my stability and consistency of my glucose curve. 2nd trial coming soon!

April 2023

I opted to try the CGM again for a two week period. Similar results with the diet/nutrition and knowledge that I had from before. Biggest issue is will power.

Breakfast: ACV water when wake up. Vedge protein shake

Lunch: PBM or balance of veggies to protein w ACV

Snack: Vedge protein shake

Dinner: ACV, balance of veggies and protein

Kept wine/bevies to 1-2 on weekend only. My body just doesn’t like it and I sleep like crap. If I am to have alcohol, it’s better at lunch for me so it doesn’t mess up my sleep.

VO2 Max and Health/Wellness

VO2 max

After listening to the Huberman Lab podcast (and you should too! He’s got nuggets of info on health!), I decided to schedule a Dexa Scan as well as VO2 max test. I want to have a baseline of where I am at my age. This year has been a huge year of change. I’ve committed to my health (yes I’m currently 7 months in with a strength program called Rise; I started 1-2x/wk rowing; MMA 1x/wk). I’m changing jobs. I have cut back or cut out unnecessary or harmful things to my life. I’m participating in a glucose monitoring study. I wish I had done these metrics every decade of my life starting at 10.

What is VO2 max?

How to Improve VO2 max

6 Ways to Improve Your VO2 Max

VO2 Max: The Fitness Metric That Can Help You Run Faster and Workout Harder

Effect of dietary fat on metabolic adjustments to maximal VO2 and endurance in runners. Med Sci Sports Exerc. 1994 Jan;26(1):81-8.

VO2 max test on Concept 2

The more I dig into the world of health and wellness, the more there is to learn. Hormones, gut health, nutrition, supplements, macros/micros, exercise (role for mobility, flexibility, cardio, strength, functional, etc). I wish they taught this stuff in medical school. This is the real foundation of health and wellness.

Cardiorespiratory Coordination in Collegiate Rowing PDF

A New Fitness Test of Estimating VO_2max in Well-Trained Rowing Athletes. Front. Physiol., 02 July 2021. Sec. Exercise Physiology