Clinical Focus

  • Anesthesia
  • Critical Care Medicine
  • Cardiac and Thoracic Anesthesia

Academic Appointments

Professional Education

  • Board Certification: American Board of Anesthesiology, Critical Care Medicine (2001)
  • Board Certification: American Board of Anesthesiology, Anesthesia (2000)
  • Fellowship: Stanford University Anesthesiology Fellowships (2000) CA
  • Residency: Stanford University Anesthesiology Residency (1999) CA
  • Internship: Santa Clara Valley Medical Center Internal Medicine Residency (1996) CA
  • Medical Education: University of Maryland School of Medicine (1995) MD
  • MD, University of Maryland, Medicine (1995)
  • PhD, University of Maryland, Physiology (1993)

Community and International Work

  • Anesthesia outreach in developing countries, Mexico



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

I. Medical Emergency Teams
Medical Emergency Teams (or METs for short) are groups that perform rapid assessment and stabilization of patients in response to signs of clinical deterioration. They have arisen in response to data demonstrating that many opportunities to reverse clinical decline are not acted upon in a time frame that would prevent further deterioration, or progression to cardiac arrest. I have implemented a MET at the VA Palo Alto and am looking at the clinical impact of this intervention; I have also developed programs for team training and technical skill development applicable to MET operation.

Work in the field has led the development of "patient deterioration" as an almost separate filed in resuscitation. In such, the following questions are areas of active investigation:

1. What are the best methods to detect patients who are deteriorating and how can we optimize the sensitivity and specificity of such methods?

2. Does earlier attention by critical care personnel really alter the course of patients with deteriorating conditions?

3. Either way, who really benefits from ICU care?

4. Where can/ should septic patients be managed?

5. What monitoring schemes, including complex analytic methods should be
employed on regular hospital wards?

6. How should ward nurses be trained to detect deteriorating patients?

II. Critical Care Education

One of my interests centers on the use of patient simulation as an educational and training tool in critical care. Human patient simulation offers an ever-changing laboratory for developing and testing educational methods as well as participating in our current strength - critical care team training. Earlier projects led to the development of a performance assessment tool to evaluate teams managing septic shock and use of this methodology to evaluate whether classroom instruction improved the management of management of simulated patient emergencies.
The VA simulation center has moved around a bit in the past few years, and now has a permanent home, so I am excited to expand the use of simulation for critical care skill development and team training.

2023-24 Courses

Graduate and Fellowship Programs

All Publications

  • Lactate Predicts Both Short- and Long-Term Mortality in Patients With and Without Sepsis. Infectious diseases Villar, J., Short, J. H., Lighthall, G. 2019; 12: 1178633719862776


    Objective: To measure the relationship between lactate and mortality in hospital inpatients. Main outcomes of interest were 3-day, 30-day, and 1-year all-cause mortality.Design: Retrospective cohort study, October 2011 to September 2013.Setting: University-affiliated US Veterans Affairs Hospital.Patients: All inpatients with lactate level measured during the study period.Measurements: Analysis of peak lactate level (mmol/L) during the most recent admission for patients who died, and peak lactate level during an admission for surviving patients. Covariates including sepsis, ICU admission, code blue and rapid response calls, medical vs surgical ward, liver disease, kidney disease, and hospice status were recorded.Results: In total, 3325 inpatients were included; 564 patients had sepsis. Median lactate 1.7 mmol/L (interquartile range [IQR] 1.2-2.6). The 3-day, 30-day, and 1-year mortality were 2.5%, 10%, and 24%, respectively. A lactate level cutoff of ⩾4 mmol/L had best test characteristics (sensitivity 52.4%, specificity 91.4%) to predict increased 3-day mortality. Unadjusted risk ratio of death in 3 days for lactate ⩾4 was 10.3 (95% confidence interval [CI] 6.8-15.7). Patients with sepsis had a consistently higher risk of death compared with patients without sepsis for any given level of lactate. Adjusted odds ratio (OR) of 3-day mortality for lactate ⩾4 was 7.6 (95% CI 4.6-12.5); 30-day mortality was 2.6 (95% CI 1.9-3.6); and 1-year mortality was 1.8 (95% CI 1.4-2.6). Lactates in the normal range (<1.7) were also independently associated with 30-day and 1-year mortality.Conclusions: Lactate predicts risk of death in all patients, although patients with sepsis have a higher mortality for any given lactate level. We report the novel finding that serum lactate, including normal values, is associated with long-term mortality.

    View details for DOI 10.1177/1178633719862776

    View details for PubMedID 31431799

  • The association of clinical frailty with outcomes of patients reviewed by rapid response teams: an international prospective observational cohort study CRITICAL CARE So, R. L., Bannard-Smith, J., Subbe, C. P., Jones, D. A., van Rosmalen, J., Lighthall, G. K., METHOD Study Investigators 2018; 22: 227


    Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event and is strongly associated with adverse outcomes. Therefore, the assessment of frailty may be an essential part of evaluation in any healthcare encounter that might result in an escalation of care. The purpose of the study was to assess the frequency and association of frailty with clinical outcomes in patients subject to rapid response team (RRT) review.In this multi-national prospective observational cohort study, centres with existing RRTs collected data over a 7-day period, with follow up of all patients at 24 h following their RRT call and at hospital discharge or 30 days following the event trigger (whichever came sooner). Investigators also collected data on the triggers and interventions provided and a bedside assessment on the level of patients' frailty using a clinical frailty scale.Amongst 1133 patients, 40% were screened as frail, which was associated with older age (p < 0.001), admission under a medical speciality (p < 0.001), increased severity of illness at the time of the RRT review (p = 0.0047), and substantially higher frequency of limitations of care (p < 0.001). Importantly, 72% of patients screened as frail were either dead or dependent on hospital care by 30 days (p < 0.001). In the multivariable analysis, the significant risk factors for the composite endpoint "poor recovery" (died or were hospital-dependent by 30 days) were age (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.03-1.05; p < 0.001), frailty level (p < 0.001), existing limitation of care (OR, 2.0; 95% CI, 1.3-3.0; p < 0.001), and the quick sequential organ failure assessment (qSOFA) score (p < 0.001).Higher frailty scores were associated with increased mortality and dependence on health care at 30 days. Our results indicate that frailty has an influence on the clinical trajectory of deteriorating patients and that such assessment should be included in discussion of goals and expectations of care.Netherlands Trial Registry, NTR5535 . Registered on 23 December 2015.

    View details for PubMedID 30241490

    View details for PubMedCentralID PMC6151016

  • Perioperative Surgical Home Reduces Rapid Response Calls to a Postoperative Surgical Ward: How Anesthesiologists Are Improving the Inpatient Safety Net. Seminars in cardiothoracic and vascular anesthesia Walters, T. L., Kim, T. E., Mariano, E. R., Lighthall, G. K. 2018: 1089253218761813


    The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients.This retrospective study was performed at an academic Veterans Affairs hospital with a PSH. Data from both medical and surgical cohorts admitted to a single ward were analyzed for the Pre-PSH (July 2006 to October 2010) and Post-PSH (November 2011 to May 2015) epochs. The primary outcome was incidence of rapid response team (RRT) activations per 1000 bed-days.Surgical patients had 5.8 RRT activations per 1000 bed-days Pre-PSH versus 3.7/1000 bed-days Post-PSH ( P = .006). There was no difference in RRT activations per 1000 bed-days for medical patients before and after PSH implementation. Pre-PSH was an independent predictor of mortality in the multivariable model (odds ratio = 1.7; P = .010).PSH is associated with decreased RRT activations among surgical inpatients only.

    View details for PubMedID 29514558

  • Survival After Long-Term Residence in an Intensive Care Unit. Federal practitioner : for the health care professionals of the VA, DoD, and PHS Lighthall, G., Verduzco, L. 2016; 33 (6): 18–27


    A higher mortality trend correlated with increased age and length of stay for medical and surgical patients in the intensive care unit.

    View details for PubMedID 30766180

  • Evaluating the Impact of Classroom Education on the Management of Septic Shock Using Human Patient Simulation. Simulation in healthcare Lighthall, G. K., Bahmani, D., Gaba, D. 2016; 11 (1): 19-24


    Classroom lectures are the mainstay of imparting knowledge in a structured manner and have the additional goals of stimulating critical thinking, lifelong learning, and improvements in patient care. The impact of lectures on patient care is difficult to examine in critical care because of the heterogeneity in patient conditions and personnel as well as confounders such as time pressure, interruptions, fatigue, and nonstandardized observation methods.The critical care environment was recreated in a simulation laboratory using a high-fidelity mannequin simulator, where a mannequin simulator with a standardized script for septic shock was presented to trainees. The reproducibility of this patient and associated conditions allowed the evaluation of "clinical performance" in the management of septic shock. In a previous study, we developed and validated tools for the quantitative analysis of house staff managing septic shock simulations. In the present analysis, we examined whether measures of clinical performance were improved in those cases where a lecture on the management of shock preceded a simulated exercise on the management of septic shock. The administration of the septic shock simulations allowed for performance measurements to be calculated for both medical interns and for subsequent management by a larger resident-led team.The analysis revealed that receiving a lecture on shock before managing a simulated patient with septic shock did not produce scores higher than for those who did not receive the previous lecture. This result was similar for both interns managing the patient and for subsequent management by a resident-led team.We failed to find an immediate impact on clinical performance in simulations of septic shock after a lecture on the management of this syndrome. Lectures are likely not a reliable sole method for improving clinical performance in the management of complex disease processes.

    View details for DOI 10.1097/SIH.0000000000000126

    View details for PubMedID 26836464

  • Understanding Decision Making in Critical Care. Clinical medicine & research Lighthall, G. K., Vazquez-Guillamet, C. 2015; 13 (3-4): 156-168


    Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action.There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature.This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.

    View details for DOI 10.3121/cmr.2015.1289

    View details for PubMedID 26387708

    View details for PubMedCentralID PMC4720506

  • Routine postoperative care of patients undergoing coronary artery bypass grafting on cardiopulmonary bypass. Seminars in cardiothoracic and vascular anesthesia Lighthall, G. K., Olejniczak, M. 2015; 19 (2): 78-86


    The postoperative course of a patient undergoing cardiac surgery (CS) is dictated by a largely predictable set of interactions between disease-specific and therapeutic factors. ICU personnel need to quickly develop a detailed understanding of the patient's current status and how critical care resources can be used to promote further recovery and eventual independence from external support. The goal of this article is to describe a typical operative and postoperative course, with emphasis on the latter, and the diagnostic and therapeutic options necessary for the proper care of these patients. This paper will focus on coronary artery bypass grafting as a model for understanding the course of CS patients; however, many of the principles discussed are applicable to most cardiac surgery patients.

    View details for DOI 10.1177/1089253215584993

    View details for PubMedID 25975592

  • Perioperative Maintenance of Tissue Perfusion and Cardiac Output in Cardiac Surgery Patients. Seminars in cardiothoracic and vascular anesthesia Lighthall, G. K., Singh, S. 2014; 18 (2): 117-136

    View details for DOI 10.1177/1089253214534781

    View details for PubMedID 24876228

  • Videos in clinical medicine: Laryngeal mask airway in medical emergencies. New England journal of medicine Lighthall, G., Harrison, T. K., Chu, L. F. 2013; 369 (20)


    This video demonstrates the placement of a laryngeal mask airway, an alternative airway device that is both efficacious and easy to place. The laryngeal mask airway is routinely used for patients receiving general anesthesia and, increasingly, in patient resuscitation.

    View details for DOI 10.1056/NEJMvcm0909669

    View details for PubMedID 24224639

  • An institution-wide approach to redesigning management of cardiopulmonary arrests The joint commission journal of patient safety Lighthall, G., Mayette M, Harrison TK 2013; 39 (4): 157-166
  • Abnormal vital signs are associated with an increased risk for critical events in US veteran inpatients (vol 80, pg 1264, 2011) RESUSCITATION Lighthall, G. K., Markar, S., Hsiung, R. 2012; 83 (7): E153
  • Introduction of a Rapid Response System at a United States Veterans Affairs Hospital Reduced Cardiac Arrests ANESTHESIA AND ANALGESIA Lighthall, G. K., Parast, L. M., Rapoport, L., Wagner, T. H. 2010; 111 (3): 679-686


    We sought to determine the impact of a rapid response system on cardiac arrest rates and mortality in a United States veteran population.We describe a prospective analysis of cardiac arrests in 9 months before and 27 months after institution of a rapid response system, and retrospective analysis of mortality 3.5 years before the intervention and 27 months after the intervention. The study included all inpatients from a university-affiliated United States Veterans Affairs Medical Center, before and after implementation of a rapid response system, including an educational program, patient calling criteria, and a physician-led medical emergency team. Primary end points were hospital-wide cardiac arrests and mortality rates normalized to hospital discharges. Comparisons of event rates between various time points during the implementation process were made by analysis of variance.Three hundred seventy-eight calls were made to the medical emergency team in the time period studied. Compared with preintervention time points, cardiac arrests were reduced by 57%, amounting to a reduction of 5.6 cardiac arrests per 1000 hospital discharges (P < 0.01). Mortality was reduced during the intervention, but this was attributable to a natural decrease occurring over all phases of the study.A significant reduction in the rate of cardiac arrests was realized with this intervention, as well as a trend toward lower mortality. We estimate that 51 arrests were prevented in the timeframe studied. Our results suggest that further reductions in morbidity can be realized by expansion of rapid response systems throughout the Veterans Affairs network.

    View details for DOI 10.1213/ANE.0b013e3181e9c3f3

    View details for Web of Science ID 000281150100015

    View details for PubMedID 20624835

  • Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Joint Commission journal on quality and patient safety / Joint Commission Resources Lighthall, G. K., Poon, T., Harrison, T. K. 2010; 36 (5): 209-216


    There is widespread recognition that the conduct of cardiac resuscitation is problematic. In situ simulation has been used to train and evaluate cardiac arrest teams' performance in the hospital setting, but in work at a university-affiliated, tertiary care facility, the simulated cardiac arrests were used to understand how well health care providers and their environment function during arrests, with the goal of a rapid intervention to correct problem areas. Latent conditions--innate, mostly hidden, workplace factors--can have a large detrimental impact on resuscitation efforts.Observations from a series of unannounced simulated cardiac arrests undertaken at diverse locations within a university-affiliated, tertiary care hospital were a component of an ongoing initiative to improve performance of emergency cardiovascular care.Fourteen cardiac arrest simulations revealed 24 hazardous findings, approximately two thirds of which had a high likelihood of compromising patient survival if they had occurred during an actual cardiac arrest. Categories of problems included active errors by teams and individuals and systemic or latent errors of the environment. Because the simulations were designed with the goal of discovering and documenting errors, most errors led to further actions, policies, and procedures that were rapidly adopted by the medical center to prevent their recurrence.In situ simulation of cardiac arrests elicits lifelike behaviors and allows engagement of all personnel and resources applicable to real arrests. This method allowed for remedial plans to be developed before further harm could occur. Accordingly, in situ simulation of high-risk events may be a useful, efficient technique that complements existing quality assurance processes in hospitals.

    View details for PubMedID 20480753

  • Abnormal vital signs are associated with an increased risk for critical events in US veteran inpatients RESUSCITATION Lighthall, G. K., Markar, S., Hsiung, R. 2009; 80 (11): 1264-1269


    Establish the frequency of abnormal vital signs in medical and surgical ward patients; study their association with "critical events," which for the purposes of this study, were mortality, cardiac arrests and unplanned ICU transfers.Four-month prospective, observational cohort study; University-affiliated US Veteran's hospital. Vital signs from all regular ward medical and surgical inpatients were recorded over the study period and compared with records of cardiac arrests, mortality and ICU admissions.Using the Hospital's Medical Emergency Team criteria to define normal/abnormal thresholds for vital signs, abnormal vital signs (VS(MET)) were found in 16% of patients; of these; 35% experienced a critical event vs. 2.5% in the patients with normal vital signs (OR 21, 95% CI 12-35, p<0.001). The sensitivity of VS(MET) to predict a critical event was 0.72 and the positive predictive value was 0.35; sensitivity decreased to 0.28 and positive predictive value increased to 0.78 for patients that had two different VS(MET). Survival was significantly lower in both medical and surgical patients with VS(MET) at both 30 days and at 1 year following discharge (p<0.02). Both medical and surgical patients with VS(MET) had twice the length of stay of patients with normal vitals (3 vs. 7 days; p<0.001).Even single recordings of VS(MET) signaled increased risk for critical events in hospital ward patients. Use of vital signs as criteria for additional patient assessment and possible ICU admission appears justified. Development of abnormal vitals during hospitalization may signify impaired physiologic reserve that places a patient at higher risk for mortality after discharge.

    View details for DOI 10.1016/j.resuscitation.2009.08.012

    View details for Web of Science ID 000272009600011

    View details for PubMedID 19744762

  • Evaluating the management of septic shock using patient simulation CRITICAL CARE MEDICINE Ottestad, E., Boulet, J. R., Lighthall, G. K. 2007; 35 (3): 769-775


    Develop a scoring system that can assess the management of septic shock by individuals and teams.Retrospective review of videotapes of critical care house staff managing a standardized simulation of septic shock.Academic medical center; videotapes were made in a recreated intensive care unit environment using a high-fidelity patient simulator.Residents in medicine, surgery, and anesthesiology who had participated in the intensive care unit rotation.The septic patient was managed by the intensive care unit team in a graded manner with interns present for the first 10 mins and more senior-level help arriving after 10 mins. The intern was graded separately for the first 10 mins, and the team was graded for the entire 35-min performance.Both technical and nontechnical scoring systems were developed to rate the management of septic shock. Technical scores are based on guidelines and principles of managing septic shock. Team leadership, communication, contingency planning, and resource utilization were addressed by the nontechnical rating. Technical scores were calculated for both interns and teams; nontechnical scores applied only to the team. Of 16 technical checklist items, interns completed a mean of 7 with a range of 1.5-11. Team technical ratings had a mean of 9.3 with a range of 3.3-13. Nontechnical scores showed similar intergroup variability with a mean of 26 and a range of 10-35. Technical and nontechnical scores showed a modest correlation (r = .40, p = .05). Interrater reliabilities for intern and team technical scores were both r = .96 and for nontechnical scores r = .88.Objective measures of both knowledge-based and behavioral skills pertinent to the management of septic shock were made. Scores identified both adequate and poor levels of performance. Such assessments can be used to benchmark clinical skills of individuals and groups over time and may allow the identification of interventions that improve clinical effectiveness in sepsis management.

    View details for DOI 10.1097/01.CCM.0000256849.75799.20

    View details for Web of Science ID 000244470800011

    View details for PubMedID 17235260

  • Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents CRITICAL CARE MEDICINE Lighthall, G. K., Barr, J., Howard, S. K., Gellar, E., Sowb, Y., Bertacini, E., Gaba, D. 2003; 31 (10): 2437-2443
  • Variations in Code Team Composition During Different Times of Day and Week and by Level of Hospital Complexity JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Li, Y., Lighthall, G. K. 2022; 48 (11): 564-571


    Previous data demonstrated lower survival rates of in-hospital cardiac arrests during nights and weekends compared to weekday daytime. This study aimed to evaluate variations of personnel attending to codes based on day/night/weekend conditions within the US Veterans Affairs (VA) system, as well as variations of personnel responsible for intubations during codes.Hospital leaders were surveyed regarding code team membership, leadership, and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime, and weekend nighttime).Surveys were completed for 93 of 123 eligible VA hospitals (response rate of 75.6%). Code teams were significantly smaller during "off-hours." Membership in code teams during regular vs. off-hours was significantly greater for ICU physicians (44.1% vs. 7.5%-15.0%, p < 0.001), anesthesiologists (34.4% vs. 12.9%, p < 0.001), and pharmacists (46.2% vs. 23.7%-26.9%, p < 0.01). Significant differences were found for codes led by ICU attendings (20.4% vs. 5.4%-7.5%, p < 0.05) and intubations performed by ICU attendings (21.5% vs. 6.5%-10.8%, p < 0.05). ICU-based physicians were team leaders more often in high-complexity hospitals (19.7%-50.0% vs. 0%-14.8%), while hospitalists led the majority in the low-complexity hospitals (28.8%-39.4% vs. 63.0%-70.4%). ICU physicians had significantly less involvement in code intubations in low-complexity hospitals (6.1%-22.7% vs. 3.7%-18.5%), while respiratory therapists took on most of this responsibility in low-complexity hospitals and particularly at night.This study found significant differences in code team composition, leadership, and intubation responsibilities between regular and off-hours. Low-complexity hospitals, which are generally rural, had team compositions and responsibilities that were visibly different from higher-complexity hospitals.

    View details for DOI 10.1016/j.jcjq.2022.07.003

    View details for Web of Science ID 000877714500003

    View details for PubMedID 36155176

  • Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation. Critical care explorations Mitchell, O. J., Dewan, M., Wolfe, H. A., Roberts, K. J., Neefe, S., Lighthall, G., Sands, N. A., Weissman, G., Ginestra, J., Shashaty, M. G., Schweickert, W. D., Abella, B. S. 2022; 4 (4): e0677


    OBJECTIVES: Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated.DESIGN: We utilized a three-phase, modified electronic Delphi (eDelphi) process, followed by a discussion round to generate consensus on the definition of physiological decompensation and on criteria to identify decompensation. We then validated the criteria using a retrospective cohort study of adult patients admitted to the Hospital of the University of Pennsylvania.SETTING: Quaternary academic medical center.PATIENTS: Adult patients admitted to the Hospital of the University of Pennsylvania who had triggered a rapid response team (RRT) response between January 1, 2019, and December 31, 2020.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Sixty-nine experts participated in the eDelphi. Participation was high across the three survey rounds (first round: 93%, second round: 94%, and third round: 98%). The expert panel arrived at a consensus definition of physiological decompensation, "An acute worsening of a patient's clinical status that poses a substantial increase to an individual's short-term risk of death or serious harm." Consensus was also reached on criteria for physiological decompensation. Invasive mechanical ventilation, severe hypoxemia, and use of vasopressor or inotrope medication were bundled as criteria for our novel decompensation metric: the adult inpatient decompensation event (AIDE). Patients who met greater than one AIDE criteria within 24 hours of an RRT call had increased adjusted odds of 7-day mortality (adjusted odds ratio [aOR], 4.1 [95% CI, 2.5-6.7]) and intensive care unit transfer (aOR, 20.6 [95% CI, 14.2-30.0]).CONCLUSIONS: Through the eDelphi process, we have reached a consensus definition of physiological decompensation and proposed clinical criteria with which to identify patients who have decompensated using data easily available from the electronic medical record, the AIDE criteria.

    View details for DOI 10.1097/CCE.0000000000000677

    View details for PubMedID 35392439

  • Mortality of Patients Requiring Escalation to Intensive Care within 24 Hours of Admission in a Mixed Medical-Surgical Population. Clinical medicine & research Leong, J. n., Madhok, J. n., Lighthall, G. K. 2020


    Delayed intensive care unit admissions are associated with increased mortality. We present a retrospective study looking at whether indirect admissions to the ICU within 24 hours of hospital admission were associated with increased mortality.Retrospective cohort study SETTING: Mixed medical-surgical ICU at a large tertiary United States Veterans Affairs (VA) Hospital System POPULATION: The patients were a mix of medical and surgical patients. Patients included both those directly admitted from the operating room as well as those escalated to the ICU after initial admission to the ward (indirect admission).All admissions to a medical-surgical ICU from 2008 to 2013 were included in the study. The database was queried for time and location where the admission originated. Separate lists were created for patients with severe sepsis, patients who transferred to the ICU within the first 24 hours, and patients who had rapid response or code team activations. Analysis was applied to the whole group and to medical and surgical subpopulations.A total of 3,862 ICU admissions were studied. Univariate analysis indicated an impact of delayed admission on whole group and surgical patients, however multivariate analysis indicated a significant effect of delayed admission on 1-year surgical mortality. Multivariate analysis also showed a consistent effect of age, ICU length of stay and cardiac arrest on mortality of both medical and surgical ICU patients.In a large retrospective study, surgical patients had increased 1-year mortality if they required escalation to the ICU within 24 hours of hospital admission. This result was not replicated in medical patients, possibly related to a burden of illness that could not be altered by earlier care.

    View details for DOI 10.3121/cmr.2019.1497

    View details for PubMedID 31959671

  • Differences in identification of patients' deterioration may hamper the success of clinical escalation protocols QJM-AN INTERNATIONAL JOURNAL OF MEDICINE De Bie, A. R., Subbe, C. P., Bezemer, R., Cooksley, T., Kellett, J. G., Holland, M., Bouwman, R. A., Bindels, A. H., Korsten, H. M., Barach, P., Beaugrand, H., Breen, D., Byrne, D., Chalmers, C., Cleaver, H., Croke, E., Davis, E., Donnelly, P., Dunne, E., Durham, L., Ellis, B., Goel, R., Hancock, C., Hartin, J., Hinge, D., Hueske-Kraus, D., Kennelly, S., Lighthall, G., Lunn, R., Mueller, M., O'Dwyer, C., O'Mahony, K., Paice, N., Roberts, L., Savijn, T., Thomas, D., Walsh, R., Weber, F., Welch, J., Woodworth, S., Brabrand, M., Crisis Checklist Collaborative 2019; 112 (7): 497–504


    Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards.To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it.An international survey.Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis.A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to.This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required.

    View details for DOI 10.1093/qjmed/hcz052

    View details for Web of Science ID 000482130600004

    View details for PubMedID 30828732

  • Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems. Resuscitation Subbe, C. P., Bannard-Smith, J. n., Bunch, J. n., Champunot, R. n., DeVita, M. A., Durham, L. n., Edelson, D. P., Gonzalez, I. n., Hancock, C. n., Haniffa, R. n., Hartin, J. n., Haskell, H. n., Hogan, H. n., Jones, D. A., Kalkman, C. J., Lighthall, G. K., Malycha, J. n., Ni, M. Z., Phillips, A. V., Rubulotta, F. n., So, R. K., Welch, J. n. 2019; 141: 1–12


    Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS.We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools.Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area.A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development.

    View details for DOI 10.1016/j.resuscitation.2019.05.012

    View details for PubMedID 31129229

  • Corrigendum to "Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems" [Resuscitation 141 (2019) 1-12]. Resuscitation Subbe, C. P., Bannard-Smith, J. n., Bunch, J. n., Champunot, R. n., DeVita, M. A., Durham, L. n., Edelson, D. P., Gonzalez, I. n., Hancock, C. n., Haniffa, R. n., Hartin, J. n., Haskell, H. n., Hogan, H. n., Jones, D. A., Kalkman, C. J., Lighthall, G. K., Malycha, J. n., Ni, M. Z., Phillips, A. V., Rubulotta, F. n., So, R. K., Welch, J. n. 2019; 145: 93–94
  • A Novel Bedside-Focused Ward Surveillance and Response System JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Sebat, F., Vandegrift, M., Childers, S., Lighthall, G. K. 2018; 44 (2): 94–100


    Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated.A prospective five-year before-and-after comparison of adult ward patient outcomes was conducted at a community regional medical center. The key intervention was expanded administrative oversight of the system, which led to (1) restructuring the content and depth of ward nurse education regarding early recognition of at-risk patients; (2) system changes empowering prompt mobilization of the RRT; (3) development of RRT treatment protocols; and (4) a more frequent and comprehensive data collection and analysis for system compliance and performance improvement.Some 28,914 patients were observed in the 24-month control period, and 39,802 patients were observed in the 33-month intervention period. RRT activations increased from 10.2 to 48.8/1,000 discharges (p <0.001), ward cardiac arrest decreased from 3.1 to. 2.4/1000 discharges (p = 0.04), hospital mortality decreased from 3.8% to 3.2% (p <0.001), and the observed-to-expected ratio decreased from 1.5 to 1.0 (p <0.001).Expanded administrative involvement of an existing RRS that focused on early recognition of patient deterioration by the bedside nurse led to improved performance of the system, with a significant increase in number of RRTs and decreases in cardiac arrests and hospital mortality.

    View details for DOI 10.1016/j.jcjq.2017.09.002

    View details for Web of Science ID 000432376400006

    View details for PubMedID 29389465

  • Dreamland: The True Tale of America's Opiate Epidemic. Anesthesia and analgesia Lighthall, G. K. 2017

    View details for DOI 10.1213/ANE.0000000000002421

    View details for PubMedID 28857798

  • Clinical outcomes of patients seen by Rapid Response Teams: A template for benchmarking international teams. Resuscitation Bannard-Smith, J., Lighthall, G. K., Subbe, C. P., Durham, L., Welch, J., Bellomo, R., Jones, D. A. 2016; 107: 7-12


    The study was developed to characterize short-term outcomes of deteriorating ward patients triggering a Rapid Response Team (RRT), and describe variability between hospitals or groups thereof.We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February 2014. Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review. Further follow-up at 24h following RRT review focused on patient orientated outcomes including need for admission to critical care, change in limitations of therapy and all cause mortality.We studied 1188 RRT activations. Derangement of vital signs as measured by the National Early Warning Score (NEWS) was more common in non-UK hospitals (p=0.03). Twenty four hour mortality after RRT review was 10.1% (120/1188). Urgent transfer to ICU or the operating theatre occurred in 24% (284/1188) and 3% (40/1188) of events, respectively. Patients in the UK were less likely to be admitted to ICU (31% vs. 22%; p=0.017) and their median (IQR) time to ICU admission was longer [4.4 (2.0-11.8) vs. 1.5 (0.8-4.4)h; p<0.001]. RRT involvement lead to new limitations in care in 28% of the patients not transferring to the ICU; in the UK such limitations were instituted in 21% of patients while this occurred in 40% of non-UK patients (p<0.001).Among patients triggering RRT review, 1 in 10 died within 24h; 1 in 4 required ICU admission, and 1 in 4 had new limitations in therapy implemented. We provide a template for an international comparison of outcomes at RRT level.

    View details for DOI 10.1016/j.resuscitation.2016.07.001

    View details for PubMedID 27417561

  • Postoperative care of cardiac surgery patients . . . Finishing what you started. Seminars in cardiothoracic and vascular anesthesia Lighthall, G. K. 2015; 19 (2): 77

    View details for PubMedID 25975591

  • Safer tracheostomy: a proposal for the routine use of an airway exchange catheter during tracheostomy. A & A case reports Olejniczak, M., Lighthall, G. 2014; 3 (11): 146-148


    In the United States, more than 100,000 tracheostomies are performed annually. Many patients undergoing tracheostomy are critically ill, making them higher risk surgical candidates. Fortunately, the loss of airway during the procedure is rare, but when it occurs, the outcome can be catastrophic. In this report, we describe a technique to minimize the risk of airway loss by using an airway exchange catheter as an airway conduit during endotracheal tube removal. We present 2 clinical cases in which this technique was used successfully and made an important contribution to patient safety.

    View details for DOI 10.1213/XAA.0000000000000092

    View details for PubMedID 25612101

  • Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success. Journal of intensive care medicine Maxwell, B. G., Ganaway, T., Lighthall, G. K. 2014; 29 (2): 110-115


    We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

    View details for DOI 10.1177/0885066613487305

    View details for PubMedID 23753248

  • Laryngeal Mask Airway in Medical Emergencies NEW ENGLAND JOURNAL OF MEDICINE Lighthall, G., Harrison, T. K., Chu, L. F. 2013; 369 (20)


    This video demonstrates the placement of a laryngeal mask airway, an alternative airway device that is both efficacious and easy to place. The laryngeal mask airway is routinely used for patients receiving general anesthesia and, increasingly, in patient resuscitation.

    View details for DOI 10.1056/NEJMvcm0909669

    View details for Web of Science ID 000330468300001

  • The pharmacology of airway management in critical care. Journal of intensive care medicine Consilvio, C., Kuschner, W. G., Lighthall, G. K. 2012; 27 (5): 298-305


    This review provides an update on the pharmacology of airway management, emphasizing medications and management strategies widely used in an intensive care unit setting. Induction agents, muscle relaxants, opioids, sedative-hypnotics, and adjunctive agents are reviewed in the context of emergent airway management. Throughout this review, we emphasize the utility of considering a broad set of pharmacologic agents and approaches for airway management of the critically ill patient.

    View details for DOI 10.1177/0885066611402154

    View details for PubMedID 21436166

  • Generation of early warnings with smart monitors: The future is all about getting back to the basics! CRITICAL CARE MEDICINE Lighthall, G. K. 2012; 40 (8): 2509-2511

    View details for DOI 10.1097/CCM.0b013e31825adc46

    View details for Web of Science ID 000306604900041

    View details for PubMedID 22809927

  • The evolving role of preoperative testing in vascular surgery patients: can a little knowledge be dangerous? Seminars in cardiothoracic and vascular anesthesia Verduzco, L. A., Lighthall, G. K. 2011; 15 (3): 75-84


    It has been traditionally recommended that candidates for vascular surgery receive noninvasive stress perfusion testing risk stratification to help decide which patients may benefit from coronary artery revascularization. Recent clinical trials have contested the efficacy of revascularization in this population as well as the information yield of noninvasive testing. This article reviews a number of these studies that are likely to change our beliefs regarding testing and subsequent interventions as well as evolving role of medical therapy in patients undergoing vascular surgery.

    View details for DOI 10.1177/1089253211416517

    View details for PubMedID 21859808

  • Use of physiologic reasoning to diagnose and manage shock States. Critical care research and practice Lighthall, G. 2011; 2011: 105348-?


    Shock states are defined by stereotypic changes in well-known physiologic parameters. While these well-known changes provide a convenient entry point into further evaluation of patients in shock or at risk for shock, use of such physiologic evaluation is not commonly seen in clinical medicine. A formal description of physiologic reasoning in the diagnosis of shock states is presented in this paper. Included with this conceptual framework is a discussion of key tests or findings that can be used to differentiate between possible diagnoses, and the pairing of treatment strategies to distinct classes of physiologic abnormalities. It is hoped that the methodology presented here will demonstrate the primacy of physiologic reasoning in the diagnosis and treatment of hemodynamic instability. Advantages of this method are speed and accuracy, efficient use of resources, and mitigation against sources of medical errors.

    View details for DOI 10.1155/2011/105348

    View details for PubMedID 21845222

    View details for PubMedCentralID PMC3154489

  • Resident Training and RRSs TEXTBOOK OF RAPID RESPONSE SYSTEMS: CONCEPT AND IMPLEMENTATION Lighthall, G. K., DeVita, M. A., Hillman, K., Bellomo, R. 2011: 347–55
  • Perioperative intravascular fluid assessment and monitoring: a narrative review of established and emerging techniques. Anesthesiology research and practice Singh, S., Kuschner, W. G., Lighthall, G. 2011; 2011: 231493-?


    Accurate assessments of intravascular fluid status are an essential part of perioperative care and necessary in the management of the hemodynamically unstable patient. Goal-directed fluid management can facilitate resuscitation of the hypovolemic patient, reduce the risk of fluid overload, reduce the risk of the injudicious use of vasopressors and inotropes, and improve clinical outcomes. In this paper, we discuss the strengths and limitations of a spectrum of noninvasive and invasive techniques for assessing and monitoring intravascular volume status and fluid responsiveness in the perioperative and critically ill patient.

    View details for DOI 10.1155/2011/231493

    View details for PubMedID 21785588

    View details for PubMedCentralID PMC3139886

  • "Identifying the hospitalised patient in crisis"-A consensus conference on the afferent limb of Rapid Response Systems RESUSCITATION DeVita, M. A., Smith, G. B., Adam, S. K., Adams-Pizarro, I., Buist, M., Bellomo, R., Bonello, R., Cerchiari, E., Farlow, B., Goldsmith, D., Haskell, H., Hillman, K., Howell, M., Hravnak, M., Hunt, E. A., Hvarfner, A., Kellett, J., Lighthall, G. K., Lippert, A., Lippert, F. K., Mahroof, R., Myers, J. S., Rosen, M., Reynolds, S., Rotondi, A., Rubulotta, F., Winters, B. 2010; 81 (4): 375-382


    Most reports of Rapid Response Systems (RRS) focus on the efferent, response component of the system, although evidence suggests that improved vital sign monitoring and recognition of a clinical crisis may have outcome benefits. There is no consensus regarding how best to detect patient deterioration or a clear description of what constitutes patient monitoring.A consensus conference of international experts in safety, RRS, healthcare technology, education, and risk prediction was convened to review current knowledge and opinion on clinical monitoring. Using established consensus procedures, four topic areas were addressed: (1) To what extent do physiologic abnormalities predict risk for patient deterioration? (2) Do workload changes and their potential stresses on the healthcare environment increase patient risk in a predictable manner? (3) What are the characteristics of an "ideal" monitoring system, and to what extent does currently available technology meet this need? and (4) How can monitoring be categorized to facilitate comparing systems?The major findings include: (1) vital sign aberrations predict risk, (2) monitoring patients more effectively may improve outcome, although some risk is random, (3) the workload implications of monitoring on the clinical workforce have not been explored, but are amenable to study and should be investigated, (4) the characteristics of an ideal monitoring system are identifiable, and it is possible to categorize monitoring modalities. It may also be possible to describe monitoring levels, and a system is proposed.

    View details for DOI 10.1016/j.resuscitation.2009.12.008

    View details for Web of Science ID 000276707200003

    View details for PubMedID 20149516

  • A Controllable Patient Monitor for Classroom Video Projectors SIMULATION IN HEALTHCARE Lighthall, G. K., Harrison, T. K. 2010; 5 (1): 58-60


    Moderate capability simulators such as Laerdal's SimMan allow for the operator to control the vital signs presented on the monitor. However, the presence of the mannequin simulator may not always be needed to achieve specific teaching goals. In this report, we describe the use of the SimMan software to generate, control, and project vital signs on a projector screen, with an appearance identical to that of its normal companion monitor.We connected a laptop computer running Laerdal's SimMan software to a video projection system through a VGA or S-video connection and were able to create a controllable monitor that could be used for tabletop simulation sessions.We were able to create an interactive and dynamic patient monitor that could be projected to a large group to facilitate tabletop simulation utilizing the Laerdal SimMan software and an external projection screen setup.Laerdal SimMan software can be used to create a dynamic and interactive presentation tool for classroom learning.

    View details for DOI 10.1097/SIH.0b013e3181b5c3e6

    View details for Web of Science ID 000276077900012

    View details for PubMedID 20383093

  • The Difficulty of Implementing Clinical Guidelines Unmasked Using Simulation SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE Lighthall, G. 2009; 4 (4): 191–92

    View details for DOI 10.1097/SIH.0b013e3181bf93df

    View details for Web of Science ID 000277050600002

    View details for PubMedID 21330790

  • Using the rapid response system to provide better oversight of patient care processes. Joint Commission journal on quality and patient safety / Joint Commission Resources Moore, M. S., Howard, S. K., Lighthall, G. 2007; 33 (11): 695-?


    The cross-disciplinary nature of patient care and medical emergency teams allows for identification of systemwide problems that might otherwise be perceived as isolated events.

    View details for PubMedID 18074718

  • The use of clinical simulation systems to train critical care physicians. Journal of intensive care medicine Lighthall, G. K., Barr, J. 2007; 22 (5): 257-269


    Intensive care units are complex and dynamic clinical environments in which the delivery of appropriate and timely care to critically ill patients depends on the integrated and efficient actions of providers with specialized training. The use of realistic clinical simulator systems can help to facilitate and standardize the training of critical-care physicians, nurses, respiratory therapists, and pharmacists without having the training process jeopardize the well-being of patients. In this article, we review the current state of the art of patient simulator systems and their applications to critical-care medicine, and we offer some examples and recommendations on how to integrate simulator systems into critical-care training.

    View details for PubMedID 17895484

  • Genetic variants of the P-glycoprotein gene Abcb1b modulate opioid-induced hyperalgesia, tolerance and dependence PHARMACOGENETICS AND GENOMICS Liang, D., Liao, G., Lighthall, G. K., Peltz, G., Clark, D. J. 2006; 16 (11): 825-835


    Opioid-induced hyperalgesia (OIH) is a state of paradoxically increased nociceptive sensitivity seen in both humans and rodents following the resolution of the acute opioid antinociceptive effects or during periods of chronic opioid administration. Using the power of genetic analysis, we hoped to discover novel mechanisms modulating this trait.The degree of opioid-induced hyperalgesia displayed in response to a thermal stimulus applied to the hind paw was measured in 16 strains of inbred mice after 4 days of morphine administration. The degree of thermal sensitization was then used in a recently developed in silico haplotypic mapping algorithm along with a haplotypic map constructed from a database containing 209,000 single nucleotide polymorphisms.Analysis of the data resulted in the identification of several haplotype blocks strongly associated with the thermal opioid-induced hyperalgesia trait. The most strongly associated block was located within the Abcb1b P-glycoprotein drug transporter gene. Experiments using the P-glycoprotein inhibitor cyclosporine A and P-glycoprotein null mutant mice supported the hypothesis that a functional association exists between P-glycoprotein transporters and opioid-induced hyperalgesia. The observation of a correlation between morphine brain concentrations and the development of opioid-induced hyperalgesia was consistent with this hypothesis as well. In addition, P-glycoprotein gene deletion and pharmacological inhibition altered morphine ED50, tolerance and physical dependence.We conclude that the use of haplotypic mapping to identify novel mechanisms controlling complex traits is a viable approach. Variants of the Abcb1b gene may explain some portion of the interstrain differences in OIH and perhaps other consequences of chronic opioid administration.

    View details for Web of Science ID 000241971500008

    View details for PubMedID 17047491

  • Findings of the First Consensus Conference on Medical Emergency Teams CRITICAL CARE MEDICINE DeVita, M. A., Bellomo, R., Hillman, K., Kellum, J., Rotondi, A., Teres, D., Auerbach, A., Chen, W., Duncan, K., Kenward, G., Bell, M., Buist, M., Chen, J., Bion, J., Kirby, A., Lighthall, G., Ovreveit, J., Braithwaite, R. S., Gosbee, J., Milbrandt, E., Peberdy, M., Savitz, L., Young, L., Galhotra, S. 2006; 34 (9): 2463-2478


    Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system.In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experience with one of the three major forms of RRS. After preconference telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists convened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should outcome be measured? Panelists considered whether all hospitals should implement an RRS.Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, "crisis detection" and "response triggering" mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.

    View details for DOI 10.1097/01.CCM.0000235743.38172.6E

    View details for Web of Science ID 000240010400027

    View details for PubMedID 16878033

  • The value of simulation training during anesthesia residency ANESTHESIOLOGY Lighthall, G. K. 2006; 105 (2): 433-433

    View details for Web of Science ID 000239411600036

    View details for PubMedID 16871088

  • An interchangeable Mapleson A-E breathing system is practical and cost effective ACTA ANAESTHESIOLOGICA SCANDINAVICA Robinson, M., Lighthall, G. K. 2006; 50 (1): 45-49


    In locations where oxygen and anesthesia gas supplies are limited, and where circle systems are not practical, means to reduce fresh gas flow during maintenance of inhalational anesthesia are of potential value. We investigated whether a common transport breathing apparatus could be modified to allow interchange between Mapleson D (Map-D) and Mapleson A (Map A) configurations.A common Map-D transport system was converted to a Map-A system by switching positions of the exhaust valve and the elbow connector where fresh gas is delivered; these two breathing systems were compared in this study. The key question was whether rebreathing of CO2 could be eliminated at a lower fresh gas flow rate (FGF) with the Map-A design. A structured protocol was followed.A mean decrease in FGF of 2.8 l/min was seen with the Map-A apparatus when compared with the Map-D (P=0.003). With no significant differences in physiologic or anesthetic variables, FGF/V(E) was significantly lower with the Mapleson A configuration than with the Mapleson D system design (1.1 vs. 1.8; P=0.007). The extent to which FGF could be lowered when switching between Mapleson D and A systems correlated strongly with the patients' respiratory rate while under anesthesia (r=0.45, P<0.01).Cost and resource savings can be realized through the use of a breathing system modification that achieves appropriate ventilation at lower fresh gas flows.

    View details for DOI 10.1111/j.1399-6576.2005.00848.x

    View details for Web of Science ID 000235005500007

    View details for PubMedID 16451150

  • Fluid management in hospitalized patients. Comprehensive therapy Meinke, L., Lighthall, G. K. 2005; 31 (3): 209-223


    Intravenous fluid administration is critical to the care of hospitalized patients. Despite the lack of a clear consensus on fluid administration, one may use the principles in this article to develop an organized framework for patient care.

    View details for PubMedID 16110129

  • Alterations in spinal cord gene expression after hindpaw formalin injection JOURNAL OF NEUROSCIENCE RESEARCH Li, X. Q., Lighthall, G., Liang, D. Y., Clark, J. D. 2004; 78 (4): 533-541


    Heme oxygenase type 2 (HO-2) is an enzyme that uses heme as a substrate to produce iron, biliverdin, and carbon monoxide (CO). This enzyme participates in regulation of nociceptive signal transmission in spinal cord tissue. We set out to identify genes undergoing alterations in expression in a model of inflammatory pain and to determine whether HO-2 participates in that regulation. After the hindpaw injection of formalin in mice, we measured changes in expression of immediate early genes including c-fos, c-jun, jun B, nerve growth factor induced genes (NGFI-A and NGFI-B) and activity-related cytoskeletal protein (ARC) using real-time PCR. The mRNA corresponding to these genes increased in abundance in the first hour after formalin injection and then slowly declined. Changes in the abundance of prodynorphin, extracellular signal related kinases (ERK1 and ERK2) and N-methyl-D-aspartate (NMDA) receptor R1 subunit mRNA generally peaked between 8 and 12 hr after formalin injection. In HO-2 null mutant mice, the enhancement of expression was less for all genes studied. We went on to quantify gene expression in superficial dorsal horn tissue using laser capture microdissection followed by RNA amplification and real-time PCR. The results confirmed that the changes in gene expression were occurring in regions of the spinal cord involved in nociceptive processing. We conclude that the hindpaw injection of formalin leads to enhanced early and late expression of many genes in spinal cord dorsal horn tissue, and that this enhancement of expression relies to a degree on the presence of HO-2.

    View details for DOI 10.1002/jnr.20274

    View details for PubMedID 15389827

  • Identification of salt-sensitive genes in the kidneys of Dahl rats JOURNAL OF HYPERTENSION Lighthall, G. L., Hamilton, B. P., Hamlyn, J. M. 2004; 22 (8): 1487-1494


    Inherited differences in renal function underlie the effect of high salt diets on blood pressure in Dahl rats. We probed the kidneys of inbred Dahl SS/Jr and SR/Jr for anonymous and candidate genes whose expression was regulated by dietary sodium.mRNA quantitation of both candidate genes implicated in sodium excretion and anonymous gene products found by differential hybridization in the kidneys of salt-resistant (SR) and salt sensitive (SS) inbred Dahl rats on high and low salt diets for 21 days.Differential screening revealed a cDNA clone (H1) that showed increased dietary salt-dependent expression only in SS rats. Sequencing of the H1 cDNA showed it was the Dahl rat homologue to a perchloric acid soluble protein expressed in liver and kidney. Among candidate genes, transcript levels of arginosuccinate synthetase (AS) and arginosuccinate lyase (AL) were higher in SS on low salt diets, and AS mRNA increased in response to a high salt diet in SR. Renal mRNA for the ANP-A and the vasopressin type II receptors did not differ by strain or dietary conditions.Three new salt-sensitive genes were detected in the kidneys of inbred Dahl rats. Two genes encode enzymes in the biosynthesis of L-arginine. The upregulation of these genes by dietary salt indicates increased demand and biosynthesis of L-arginine in Dahl SS rats. A third gene encodes a small acid-soluble protein thought to influence the transcription/translation of numerous genes. Further studies will be needed to determine the nature of the association of these genes with salt-sensitivity and blood pressure.

    View details for DOI 10.1097/01.hjh.0000133719.94075.e2

    View details for Web of Science ID 000222982600012

    View details for PubMedID 15257170

  • Correction of intraoperative coagulopathy in a patient with neurofibromatosis type I with intravenous desmopressin (DDAVP) INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Lighthall, G. K., Morgan, C., Cohen, S. E. 2004; 13 (3): 174-177


    A patient with the genetic condition neurofibromatosis type I and no known coagulopathy undergoing cesarean delivery, had diffuse uterine and surgical site bleeding that was not correctable by oxytocin, methylergonovine and PGF2 alpha. Despite good uterine tone, hemorrhage continued from the uterus and the surrounding tissues, persisting even after surgical ligation of the uterine arteries. With no change in her condition, which was behaving clinically as a coagulopathy, an infusion of desmopressin acetate (DDAVP) was begun. The patient's bleeding promptly resolved shortly after infusion of this agent. A review of relevant literature suggests that platelet reactivity of patients with neurofibromatosis type 1 is attenuated in some in vitro conditions. Thus, there may be some theoretical basis for using DDAVP in patients with neurofibromatosis type 1 who have bleeding problems with no other known source, such as in the case presented here.

    View details for DOI 10.1016/j.ijoa.2004.01.008

    View details for Web of Science ID 000222738700008

    View details for PubMedID 15321397

  • Asystole during successive electroconvulsive therapy sessions: A report of two cases JOURNAL OF CLINICAL ANESTHESIA Robinson, M., Lighthall, G. 2004; 16 (3): 210-213


    Intense vagal discharge often follows stimulus application during electroconvulsive therapy (ECT). Related periods of asystole during ECT have been reported sporadically in psychiatric journals, but to date not in the anesthesia literature. We report here two cases of prolonged asystole that occurred in our facility in spite of the fact that published suggestions for its prevention were followed. With careful monitoring of these patients--including echocardiography for one patient--we document the onset of asystole at the exact time of ECT stimulus application. With these data, we discuss why asystole is likely to result from a direct central pathway rather than via a baroreceptor reflex, and discuss a neuroanatomic pathway potentially responsible for our findings. We also demonstrate that high-dose atropine (0.8 mg) can effectively prevent most cases of asystole in susceptible patients, and that administration of esmolol following cessation of seizures effectively reduces the elevated heart rate without causing asystole or bradycardia.

    View details for DOI 10.1016/j.jclinane.2003.07.009

    View details for Web of Science ID 000222422600010

    View details for PubMedID 15217662

  • Dexmedetomidine fails to cause hyperalgesia after cessation of chronic administration ANESTHESIA AND ANALGESIA Davies, M. F., Haimor, F., Lighthall, G., Clark, J. D. 2003; 96 (1): 195-200


    Hyperalgesia occurring after the cessation of chronic opioid administration occurs in humans and has been modeled in rodents with chronic systemic and intrathecal administration paradigms. It is, however, unclear if this type of postanalgesic hyperalgesia is unique to opioids. The alpha(2)-adrenergic receptor agonist, dexmedetomidine (Dex), is similar to opioids in that it is an analgesic that interacts with cell-surface receptors linked to the inhibition of adenylate cyclase and the modulation of ion channel activity. In these studies, we first constructed antinociceptive dose-response curves for Dex and morphine (MSO4). The 50% effective doses for Dex and MSO4 administered intraperitoneally to C57Bl/6 mice were 75 micro g/kg and 5.2 mg/kg, respectively. Using equally effective doses, we treated separate groups of mice with twice-daily injections of Dex or MSO4 for 5 days. Tolerance to these drugs was documented after this period. In the 16-72 h after cessation of administration, MSO4-treated mice demonstrated both thermal hyperalgesia and mechanical allodynia. However, the Dex-treated mice showed no changes in their thermal or mechanical withdrawal thresholds. We conclude that using this experimental paradigm, opioids but not an alpha(2)-adrenergic agonist, cause hyperalgesia and allodynia after cessation of chronic administration.The cessation of the administration of opioids is associated with hyperalgesia in both humans and other animals. However, antinociceptive dexmedetomidine does not seem to be associated with this type of hyperalgesia syndrome during periods of abstinence.

    View details for DOI 10.1213/01.ANE.0000038086.81696.9C

    View details for PubMedID 12505952

  • Heme oxygenase type 2 modulates molecular changes during chronic behavioral and exposure to morphine NEUROSCIENCE Liang, D., Li, X., Lighthall, G., Clark, J. D. 2003; 121 (4): 999-1005


    The heme oxygenase (HO) enzyme system has been shown to participate in nociceptive signaling in a number of different models of pain. In these experiments we investigated the role of the HO type 2 (HO-2) isozyme in tolerance to the analgesic effects of morphine, and the hyperalgesia and allodynia which are measurable upon cessation of administration. Wild type C57Bl/6 wild type mice or HO-2 null mutants in that background strain were treated with morphine for 5 days. The morphine administration protocol consisted of either twice daily repeated s.c. boluses of 15 mg/kg or s.c. implantation of a morphine pellet. At the end of the treatment period wild type mice treated by either protocol exhibited tolerance, but the HO-2 null mutants did not. The HO-2 null mutants also exhibited less mechanical allodynia following cessation of morphine administration, though only modest differences in thermal hyperalgesia were noted. There was no correlation between the degree of tolerance obtained in the bolus and pellet protocols and the degree of hyperalgesia and allodynia observed after cessation of morphine administration in the wild type mice. Our final experiments analyzed increases in expression of mRNA for nitric oxide synthase type 1, N-methyl-D-aspartate (NMDA) receptor NMDAR1 subunit and prodynorphin in spinal cord tissue. In pellet-treated mice two- to three-fold increases were observed in the abundance of these species, but very little change was observed in the null-mutant mice. Taken together our results indicate that HO-2 participates in the acquisition of opioid tolerance, the expression of mechanical allodynia after cessation of opioid administration and in gene regulation occurring in the setting of treatment with morphine. Furthermore, these studies suggest that the mechanisms underlying analgesic tolerance and opioid-induced hypersensitivity are at least somewhat distinct.

    View details for DOI 10.1016/S0306-4522(03)00483-4

    View details for Web of Science ID 000186469800020

    View details for PubMedID 14580950

  • An improved method for topical cerebral cooling during deep hypothermic circulatory arrest JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Lighthall, G. K., Cartwright, C. R., Haddow, G. R. 2000; 120 (2): 403-404

    View details for Web of Science ID 000088733700028

    View details for PubMedID 10917961

  • A comparison of the onset and clinical duration of high doses of cisatracurium and rocuronium JOURNAL OF CLINICAL ANESTHESIA Lighthall, G. K., Jamieson, M. A., Katolik, J., Brock-Utne, J. G. 1999; 11 (3): 220-225


    To determine the onset and clinical duration of cisatracurium and rocuronium in equipotent doses in balanced opioid/isoflurane anesthesia.Randomized, controlled study.University hospital.40 healthy patients scheduled for elective surgery.Patients underwent anesthesia induction with thiopental or propofol with a cisatracurium intubating dose of either 0.15 or 0.2 mg/kg or a rocuronium dose of either 0.9 or 1.2 mg/kg. These doses correspond to three and four times the ED95 dose.The onset time and time to 25% recovery of baseline first twitch in a train-of-four were determined using an accelerometric sensor. Rocuronium had a faster onset time that cisatracurium at equipotent doses (3 x ED95: 134 vs. 220 sec respectively, and at 4 x ED95: 95 vs. 162 sec). Recovery tended to be faster, but not statistically different for cisatracurium compared to rocuronium.With equipotent intubating doses of rocuronium and cisatracurium, rocuronium produces a more rapid onset of muscle relaxation. The data suggest a tendency toward more rapid clinical recovery of cisatracurium compared to equipotent doses of rocuronium, although these differences were not statistically significant.

    View details for Web of Science ID 000081512700008

    View details for PubMedID 10434218



    Chromosome size polymorphisms occur in Leishmania such that each strain of a given species has a distinctive molecular karyotype. Despite this variability, the chromosomal similarities among closely related strains of Leishmania are sufficiently characteristic to permit classification of unidentified clinical isolates. Mechanisms generating chromosome size polymorphisms are related to chromosomal evolution. In this review, Geoffrey Lighthall and Suzanne Giannini explain that the chromosomal profiles of members of different species may be diverging from a conserved 'consensus' karyotype at different rates, and present a current understanding of the genomic organization of Leishmania with emphasis on chromosomal elements.

    View details for Web of Science ID A1992HW56100005

    View details for PubMedID 15463615