Perioperative N-acetylcysteine: evidence and indications.

Nonopioid analgesics serve to improve analgesia and limit side effects and risks of perioperative opioids. N-acetylcysteine (NAC), the primary treatment of acetaminophen toxicity, may have perioperative indications, including analgesia. NAC impacts glutathione synthesis, oxidant scavenging, glutamate receptor modulation and neuroinflammation. Potential perioperative benefits include arrhythmia prevention after cardiac surgery, decreased contrast-induced nephropathy, improved post-transplant liver function and superior pulmonary outcomes with general anesthesia. NAC may improve perioperative analgesia, with some studies displaying a reduction in postoperative opioid use. NAC is generally well tolerated with an established safety profile. NAC administration may predispose to gastrointestinal effects, while parenteral administration may carry a risk of anaphylactoid reactions, including bronchospasm. Larger randomized trials may clarify the impact of NAC on perioperative analgesic outcomes.

Nonopioid mediations are important to help pain control after surgery and may decrease risks of opioids. N-acetylcysteine (NAC), the treatment of acetaminophen overdose, decreased inflammation and has other positive effects on the body that may help pain after surgery. Thus, NAC has been studied to prevent abnormal heart rhythms with heart surgery, help kidneys after surgery, improve the liver after liver transplant or other live surgeries and improve breathing after anesthesia. NAC may also decrease pain and the amount of pain medications needed after surgery. While NAC is generally well tolerated and considered safe, stomach upset can occur as can itching or asthma like reactions in certain patients. This review describes how NAC may improve pain, summarizes the other ways NAC may help a patient undergoing surgery, and describes potential side effects when NAC is given.

The impact of intraoperative N-acetylcysteine on opioid consumption following spine surgery: a randomized pilot trial.

Aim: N-acetylcysteine (NAC) decreases inflammation and could augment perioperative analgesia. Materials & methods: This prospective pilot trial examined postoperative opioid consumption at 12 h following intraoperative NAC. In phase I, 20 adults scheduled for posterior spine surgery were randomized to NAC (0, 50, 100 and 150 mg/kg) to determine the optimal dose. In phase II, 30 patients were randomized to placebo or NAC (150 mg/kg). Opioid consumption, pain ratings and time to opioid rescue were recorded. Results: Postoperative opioid consumption was reduced in the NAC group 19.3% at 12 h and 20% at 18 and 36 h. Opioid consumption was reduced 22-24% in the NAC group at all times after adjusting for intraoperative opioid administration. NAC subjects reported lower pain scores relative to placebo. Conclusion: Subjects randomized to NAC consumed less postoperative opioids and reported less pain versus placebo. Larger randomized controlled trials are needed to further evaluate NAC for analgesia. Clinical Trial Registration: NCT04562597 (ClinicalTrials.gov).

N-acetylcysteine (NAC) is a powerful anti-inflammatory drug used to treat some types of poisoning. It could help pain for patients after surgery. This study looked at how much pain medicine patients needed after back surgery when they received NAC or no drug (placebo). In the first 20 patients, people randomly received placebo or a small, medium or large dose of NAC (0, 50, 100, and 150 mg/kg) with five patients in each group. Since there were only a small number of patients, it was difficult to see any definite differences, and the next 30 patient patients randomly received placebo or the large dose of NAC (150 mg/kg). Patients that were given NAC received 16­22% less opioids in the first 2 days after surgery compared with those that were given placebo. NAC patients also took longer to request pain medications after surgery and reported lower pain scores in the first 2 days after surgery relative to placebo.

Particulate Gastric Contents in Patients Prescribed Glucagon-Like Peptide 1 Receptor Agonists After Appropriate Perioperative Fasting: A Report of 2 Cases.

Glucagon-like peptide 1 (GLP-1) receptor agonists have surged in popularity for the treatment of both diabetes mellitus and obesity. While GLP-1 reduces proximal gastrointestinal motility and delays gastric emptying, the impact of these medications on adequate fasting before surgery is not clear. We present 2 cases of particulate gastric contents after following appropriate presurgical fasting in diabetic patients taking GLP-1 receptor agonists and review current literature regarding perioperative implications of these drugs.

Systems safety in nonoperating room anesthesia locations.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) care is an area of rapid growth over the last decade. However, literature describing safety systems in NORA is limited. This review evaluates historical safety models described by Donabedian and Reason, assesses the NORA environment and safety concerns that may contribute to adverse events, and provides potential solutions via a human-centered systems safety design. RECENT FINDINGS: Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 provides a framework for quality and patient safety improvement. Although the previous SEIPS 2.0 model has been used to evaluate NORA environments with focus on the case volume, high productivity pressure, and significant physical constraints common to NORA sites, literature describing SEIPS 3.0 in relation to NORA care is sparse. Given the rate of malpractice claims for death in NORA settings, solutions that address the multifactorial nature of adverse events are needed. SUMMARY: The SEIPS 3.0 model may be applied to NORA care. Changes should focus on staffing ratios, staff/patient education, checklist utilization, burnout prevention, scheduling efficiency, anesthesia workstation standardization, communication improvements, room layout, medication and supply availability and storage, and the global managerial approach. Team members must demonstrate flexibility and a willingness to adapt to successfully implement change.

Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review.

Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting ( N -methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.

3D Model of the Early Melanoma Microenvironment Captures Macrophage Transition into a Tumor-Promoting Phenotype.

Tumor immune response is shaped by the tumor microenvironment (TME), which often evolves to be immunosuppressive, promoting disease progression and metastasis. An important example is melanoma tumors, which display high numbers of tumor-associated macrophages (TAMs) that are immunosuppressive but also have the potential to restore anti-tumor activity. However, to therapeutically target TAMs, there is a need to understand the early events that shape their tumor-promoting profile. To address this, we built and optimized 3D in vitro co-culture systems, composed of a collagen-I matrix scaffolding murine bone-marrow-derived macrophages (BMDMs), YUMM1.7 melanoma cells, and fibroblasts to recreate the early melanoma TME and study how interactions with fibroblasts and tumor cells modulate macrophage immune activity. We monitored BMDM behavior and interactions through time-lapse imaging and characterized their activation and secretion. We found that stromal cells induced a rapid functional activation, with increased motility and response from BMDMs. Over the course of seven days, BMDMs acquired a phenotype and secretion profile that resembled melanoma TAMs in established tumors. Overall, the direct cell-cell interactions with the stromal components in a 3D environment shape BMDM transition to a TAM-like immunosuppressive state. Our systems will enable future studies of changes in macrophage-stromal cross-talk in the melanoma TME.

Telemedicine for Anesthesiologists.

Telemedicine represents an area of rapid growth in anesthesiology. Remote preoperative evaluation is associated with high patient and physician satisfaction scores, reduced patient travel and wait times, and similar procedure cancellation rates compared with in-person clinic evaluation. Preoperative tele-evaluation has facilitated a return to normal function during the coronavirus disease 2019 (COVID-19) pandemic. Intraoperatively, remote vital sign monitoring and telecommunications technology combined with a care team model allows provision of expert care in areas experiencing a shortage of anesthesiologists. Virtual intensive care units provide overflow capability for postoperative patients, whereas patient smartphones can reduce the need for in-person evaluation.

Positive or Negative? Implementation Processes and Pitfalls of Preoperative SARS-CoV-2 Testing at a Single Academic Institution.

BACKGROUND: Preoperative screening and testing for SARS-CoV-2 are important aspects of reopening perioperative and procedural sites to elective cases after the initial wave of the novel coronavirus pandemic. However, given that modern healthcare has never experienced a pandemic of this magnitude, rapid operationalization of mass testing presents unique challenges. We aim to highlight our experiences and challenges for preoperative SARS-CoV-2 testing. METHODS: We describe implementation of widespread screening tools and preoperative polymerase chain reaction (PCR) testing in a single, academic medical center. RESULTS: As of August 2020, we have been able to achieve an over 90% success rate in preoperative SARS-CoV-2 PCR testing for both outpatient and inpatient procedures. However, there are certain challenges in obtaining high levels of compliance both on individual and institutional levels. CONCLUSIONS: Instituting preoperative SARS-CoV-2 testing and maintaining high levels of compliance is possible in the midst of a fluctuating pandemic.

To Infinity and Beyond: The Past, Present, and Future of Tele-Anesthesia.

Because the scope of anesthesia practice continues to expand, especially within the perioperative domain, our specialty must continually examine technological services that allow us to provide care in innovative ways. Telemedicine has facilitated the remote provision of medical services across many different specialties, but it remains somewhat unclear whether the use of telemedicine would fit within the practice of anesthesiology on a consistent basis. There have been several reports on the successful use of telemedicine within the preoperative and intraoperative realm. However, patient selection, patient and provider satisfaction, case cancellation rates, equipment reliability, and security of protected health information are just some of the issues that require further examination. This article seeks to review comprehensively the available literature related to the use of telemedicine within the preoperative, intraoperative, and postoperative phases of anesthetic care as well as analyze the major hurdles often encountered when implementing a teleconsultation service. Security of connection, data storage and encryption, federal and state medical licensure compliance, as well as overall cost/savings analysis are a few of the issues that warrant further exploration and research. As telemedicine programs develop within the perioperative arena, it is imperative for institutions to share knowledge, successes, and pitfalls to improve the delivery of care in today's technology-driven medical landscape.

Advantages of the New Tao Mask for Bag Mask Ventilation: a randomized crossover trial.

BACKGROUND AND AIMS: Manual bag mask ventilation is a life saving skill. An investigation was made to compare two different facemasks used in bag mask ventilation, the standard and the novel Tao face mask, and evaluate the ability of novices to achieve adequate tidal volume. METHODS: The study design was a crossover trial, which randomized forty medical students with no previous airway experience to learn bag mask ventilation with the standard mask and the Tao face mask. Primary outcome measures were mean and median tidal volume per mask, and secondary measures were hand area, age, gender, and order of mask usage. RESULTS: Medical students who used the Tao mask first achieved significantly more tidal volume than those who used the standard mask first (p = 0.002). However, when comparing face masks that were used second, the tidal volume did not differ significantly between the two masks (p = 1.000). Greater tidal volume was achieved on the second attempt relative to the first attempt with each mask. There was significantly more tidal volume achieved with greater hand size with the standard mask, whether it was used first or second (p < 0.001 and p = 0.012 respectively). Greater hand size was associated with greater tidal volume in the Tao mask also, but only when used first (p < 0.001). When first attempting bag mask ventilation, inexperienced students achieved greater tidal volume with the Tao Mask. The results also suggest that hand size matters less when using the Tao Mask. CONCLUSION: When first attempting bag mask ventilation inexperienced students achieved greater tidal volume with the Tao Mask. The results also suggest that hand size matters less when using the Tao mask.

Acute Coronary Artery Thrombus After Tranexamic Acid During Total Shoulder Arthroplasty in a Patient With Coronary Stents: A Case Report.

Tranexamic acid (TXA), an antifibrinolytic, is routinely used to decrease transfusion rates in total joint replacement surgery. While recent publications have indicated a low risk of TXA-associated thromboembolic events in this orthopedic population, few studies specifically address the safety of TXA administration in high-risk patients. We present a case of acute coronary thrombus requiring emergent intervention in a patient with indwelling coronary stents who underwent shoulder arthroplasty with TXA administration.

Safety and Effectiveness of a Novel Facemask for Positive Pressure Ventilation.

BACKGROUND: Manual positive pressure ventilation is an essential skill in a variety of clinical situations. The C&E technique is commonly used with standard facemasks to provide effective ventilation. The Tao mask is a novel design that allows a more ergonomic grip. A seal between the mask and face is made with downward pressure of the palm, centered on the mask, and jaw lift is achieved with 4 fingers centered under the mandible. The purpose of this study was to evaluate the safety and effectiveness of the Tao mask compared to a standard mask before and after the administration of neuromuscular blockade (NMB) using 2 previously established ventilation scales. METHODS: One hundred fifty-two patients >18 years of age who were scheduled for general anesthesia were recruited. All care team members were shown a brief instructional video on the use of the Tao mask. After induction of general anesthesia with a standardized protocol, each patient was ventilated with both the standard (Vital Signs #082510) and Tao masks and effectiveness was measured using the Han and Warters scales. This process was repeated after NMB. The sequence of masks was determined with a random-number generator. RESULTS: Tao mask ventilation scores were significantly better than standard mask scores on both the Han scale and the Warters scale before the administration of NMB (P < .001 for both). Tao mask scores were also significantly better than standard mask scores on the Warters scale after the administration of NMB (P < .001). However, there was no significant difference on the Han scale between the 2 mask types after NMB (P = .180). On the Warters scale, there were significantly fewer patients who were difficult to ventilate with the Tao mask than the standard mask before NMB (18 vs 40; P < .001) and after NMB (8 vs 17; P = .005). No adverse events were reported with either mask. CONCLUSIONS: Our results indicate that the Tao mask demonstrated equivalent safety and superior effectiveness compared to a standard mask. The study design favored the standard mask because all participating practitioners had multiple years of experience with the standard mask and no prior experience with the Tao mask. Since the incidence of inadequate mask ventilation goes up significantly with inexperienced operators, the improved effectiveness of the Tao mask could be even more profound with novice operators.

Effect of a cognitive aid on adherence to perioperative assessment and management guidelines for the cardiac evaluation of noncardiac surgical patients.

BACKGROUND: The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. METHODS: Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. RESULTS: All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). CONCLUSIONS: Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.