Anesthesiology Resident Knowledge of Transfusion Medicine: Results From the Anesthesiology Transfusion Education Study.

BACKGROUND: Transfusion of blood products is a common practice in anesthesiology. Inadequate transfusion medicine knowledge may lead to inappropriate transfusion practices and patient risk. Using a validated assessment tool modified for anesthesiology, we conducted a survey of anesthesiology residents in the United States to assess transfusion medicine knowledge. METHODS: A validated transfusion medicine examination and accompanying survey were forwarded by program directors to residents for anonymous completion on May 5 and closed on June 30, 2021. The outcome of interest was the mean examination score. Secondary areas of interest were performance by year of training and previous educational experience in transfusion reported by the trainees. Rasch analysis was performed on the examination quality and individual question performance. Kruskal-Wallis H tests were used to identify differences between mean scores. Post hoc comparisons were used to assess specific pairwise differences between mean test scores by survey variable. RESULTS: Four hundred twenty-three anesthesiology residents in 37 programs completed the examination. The mean score was 45.5% ± 12.6%. There was a significant difference in mean cumulative examination scores between different resident training levels (P < 0.001). There was a significant difference in scores between clinical anesthesia (CA)-1 and CA-2 residents (P = 0.011) and CA-1 and CA-3 residents (P = 0.012). No significant difference in examination scores was observed between CA-2 and CA-3 residents (P = 0.95). All these subgroups scored below 50% on the examination. Significant differences between the residency training programs and cumulative scores were identified (P < 0.001). CONCLUSIONS: This examination highlights gaps in transfusion medicine knowledge within US anesthesiology residents. Targeted education may improve knowledge in this area and patient care.

Improving Tolerance to Snorkel Mask Use as Alternative Personal Protective Equipment.

Snorkel masks have become an option for personal protective equipment (PPE) due to the shortage of air filtration at least 95% of airborne particle (N95) masks as a result of the coronavirus disease 2019 (COVID-19) pandemic. We developed a 3D design of a triheaded adapter that connects a snorkel mask to 3 different National Institute for Occupational Safety and Health (NIOSH)-approved air filtration at least 99% of airborne particles (N99) filters with the aim of improving wearer comfort. We measured the resistance of the new triheaded adapter to be one-third the resistance of the single adapter. Interdepartmental survey of anesthesiologists showed an improvement in perceived comfort when using the triheaded adapter as compared to the single adapter.

Heart rate response to a caudal block in children anesthetized with sevoflurane after ultrasound confirmation of placement.

INTRODUCTION: Previous studies identified decreasing heart rate (HR) as a predictor of successful caudal placement in children using halothane and isoflurane. No changes were found in HR in the one study using sevoflurane. We documented HR changes in children following a caudal block during sevoflurane anesthesia utilizing ultrasound to confirm successful caudal placement. METHODS: Seventy-one children (1-82 months) were anesthetized with sevoflurane. A caudal block was placed with confirmation by ultrasound. Four aliquots of bupivacaine 0.2% with epinephrine 5 µg · cc(-1) were administered for a total volume of 1 cc · kg(-1) with HR recorded for 4 min. The outcomes measured were HR changes from the initial baseline and during each 1-min interval. The age-related differences in HR were also analyzed. RESULTS: Heart rate change from the initial baseline after placing the caudal needle and allowing for equilibration ranged from -10.2% to +8.9% and the HR change from the baseline at the start of each aliquot injection ranged from -9.5% to +8.9%. Most participants (n = 60, 84.5%) experienced at least one HR reduction over the observation period. For patients < 36 months, the HR change ranged from -11 to +12 b · min(-1) (mean -0.3); for patients aged ≥ 36 months, the HR change ranged from -10 to +6 b · min(-1) (mean -1.1). CONCLUSIONS: Heart rate changes following a caudal block in children ≤ 82 months of age anesthetized with sevoflurane is not a reliable indicator of a successful block. Despite 100% caudal success, many children had no decrease in HR, and in those that did, the decline was of a magnitude indeterminate from beat-to-beat variability.

Use of ultrasound-guided cryotherapy for the management of chronic pain states.

STUDY OBJECTIVE: To report the use of ultrasound for cyroablation of purely sensory nerves for long-term relief of pain because the use of ultrasound enhances accuracy while minimizing injury to surrounding structures. DESIGN: Case series of three patients with positive long-term outcomes. SETTING: Outpatient Pain Management Clinic associated with a large, university affiliated, tertiary-care community hospital. PATIENTS: 3 ASA physical status 2 and 3 patients who were treated for intercostal neuralgia secondary to surgical incision or vertebral fractures. INTERVENTIONS: These patients had failed various medical therapies but had positive responses to diagnostic intercostal nerve blocks. They underwent lesioning of the culprit nerves (with the use of ultrasound). MEASUREMENTS AND MAIN RESULTS: Pain scores were recorded using a numeric rating scale (NRS), and were solicited preprocedurally and postprocedurally, and once again after longterm follow-up (> 2 mos). Longterm (> 2 mos) relief of symptoms from established, chronic pain conditions was achieved with cryotherapy with ultrasound guidance. CONCLUSIONS: Neuro-ablative procedures using cryotherapy have been well reported. The use of ultrasound with cryotherapy facilitates direct visualization of the anatomy and aids in avoidance of vital vascular and pleural structures.

Technical communication: inhaled anesthetic agent-vaporizer mismatch: management in settings with limited resources: don't try this at home.

Agent-specific vaporizers minimize opportunities for error and evidence our specialty's commitment to patient safety as a general principle. End-tidal anesthetic gas concentration monitoring is a useful adjunct whenever inhaled anesthetics are used in operating rooms. Due to their expense and required maintenance, end-tidal anesthetic gas monitors are not commonly used in developing nations. Unfortunately, in resource-constrained environments, situations may arise in which inhaled anesthetic agent-vaporizer mismatch may be necessary in the absence of end-tidal anesthetic gas monitoring. Rather than merely censure such practice as a threat to safety, we believe that certain anesthetic agent-vaporizer mismatch situations can be safely managed providing patients with predictable inspired anesthetic gas concentrations while minimizing errors. We present an approach based on mathematical models and tested in an artificial lung model. Mismatching of inhaled agent and vaporizer is a dangerous practice and should not be performed unless it is absolutely necessary. Such situations may arise in remote locations where neither end-tidal anesthetic gas monitoring nor vaporizer-specific agent is available. We hope our article provides guidance in such situations.

Unwarranted variability in antibiotic prophylaxis for cesarean section delivery: a national survey of anesthesiologists.

BACKGROUND: Current guidelines from the American College of Obstetricians and Gynecologists recommend antibiotic prophylaxis for cesarean delivery immediately before incision. The purpose of this study was to measure and describe correlates of adherence to these guidelines in a sample of United States anesthesiologists. METHODS: We invited a random sample of the membership of the American Society of Anesthesiologists (n = 10,000) to complete an online survey. RESULTS: Of 1052 respondents (10.5%) with complete information for analysis, 63.5% (95% confidence interval 60.6%, 66.3%, n = 668) reported preincision prophylaxis as the standard of care for scheduled cesarean delivery. Twenty-eight percent (n = 299) agreed that the anesthesiologist should take primary responsibility for prophylaxis timing. In a multivariable model, significant variability in preincision prophylaxis was noted for hospital type (community versus teaching, 62% vs 70%, P = 0.004), region (West versus Southeast, 70% vs 59%, P = 0.01; West versus Southwest, 70% vs 58%, P = 0.02), and respondents' belief in appropriate preincision timing (those endorsing routine preincision administration [80%], routine after cord clamp administration [17%], at the discretion of the obstetrician [47%], and the belief that more information was needed [43%]) (P < 0.001 all comparisons). Respondents' belief about appropriate preincision timing was the strongest discriminator in the model (change in area under the receiver operating characteristic curve = 0.13 vs ≤0.02 for all others). CONCLUSION: Adherence with current prophylactic antibiotic administration guidelines for cesarean delivery is not uniform. Education initiatives, regulatory maneuvers, and process improvement should be targeted at sites where anesthesiologists do not comply with current guidelines.

Addition of epinephrine to epidural bupivacaine infusions following initiation of labor analgesia with epidural fentanyl.

STUDY OBJECTIVE: To evaluate the analgesic effects of the addition of epinephrine to a bupivacaine epidural infusion in early labor after a fentanyl bolus, following a lidocaine-epinephrine test dose. DESIGN: Randomized, double-blinded study. SETTING: Labor suite of a tertiary care hospital. PATIENTS: 60 ASA physical status 1 and 2, laboring, nulliparous women. INTERVENTIONS: All laboring women received a 3 mL epidural test dose of 1.5% lidocaine with 1:200,000 epinephrine, followed by a fentanyl 100 µg bolus in 10 mL of diluent volume. Patients were randomized to receive one of two continuous epidural infusions: bupivacaine 0.625 mg/mL at 10 mL/hr (control group) or bupivacaine 0.625 mg/mL with epinephrine 5 µg/mL at 10 mL/hr (epinephrine group). MEASUREMENTS: Time to re-dose, pain scores, and side effects were recorded. MAIN RESULTS: The mean duration of satisfactory analgesia prior to re-dose was 159 ± 62 min for the control group and 221 ± 111 min for the epinephrine group (P < 0.02). Pain scores were significantly higher in the control group than the epinephrine group at two time periods: 2.5 hours and 4.5 hours (P < 0.04). CONCLUSIONS: The administration of 0.625 mg/mL bupivacaine with epinephrine 5 µg/mL at 10 mL/hr, compared with plain 0.625 mg/mL bupivacaine at 10 mL/hr, provided a longer time to re-dose, decreased pain scores at two time intervals, and had no significant difference in duration of labor or side effects.

ε-Aminocaproic acid and clinical value in cardiac anesthesia.

OBJECTIVE: The primary aim was to compare the "clinical value" of tranexamic acid (TXA) with ε-aminocaproic acid (EACA) when used for blood conservation during high-risk cardiac surgery. DESIGN: Data previously reported by the Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) study investigators were reanalyzed independently after appropriate statistical adjustment. The authors compared TXA with EACA for important primary and secondary outcomes and applied the "clinical value" equation to this comparison. SETTING: BART, the largest blinded multicenter study on this topic to date, compared all 3 commonly used antifibrinolytics head-to-head in a randomized dose-equivalent fashion during high-risk cardiac surgery. Comparisons of TXA with EACA with application of the clinical value equation was not performed specifically by the BART investigators. PARTICIPANTS: One thousand five hundred fifty patients enrolled in 2 of the 3 arms of the BART study were included in the analysis (TXA, n= 770 and EACA, n = 780, with data reported by the investigators in the New England Journal of Medicine). MAIN RESULTS: The major finding was that there were no significant differences in overall safety and clinically important efficacy between TXA and EACA. CONCLUSIONS: Considering the substantial difference in costs and with the increasing volume of high-risk cardiac surgery, EACA has increased "clinical value" when compared with TXA. EACA should be the antifibrinolytic medication of choice for high-risk cardiac surgery.

Inhaled epoprostenol during one-lung ventilation.

We used inhaled epoprostenol (with intravenous phenylephrine) during one-lung ventilation to improve oxygenation in a patient with severe interstitial lung disease undergoing video-assisted thoracoscopic surgery. The pharmacologic manipulation of pulmonary blood flow remains an underused strategy for the management of hypoxemia during one-lung ventilation.

A surgical site infection cluster: the process and outcome of an investigation--the impact of an alcohol-based surgical antisepsis product and human behavior.

BACKGROUND: The institution of a process used to successfully execute a perioperative antibiotic administration system is but 1 component of preventing postoperative infections. Continued surveillance of infections is an important part of the process of decreasing postoperative infections. We recently experienced an increase in the number of postoperative infections in our patients. Using standard infection control methods of outbreak investigation, we tracked multiple variables to search for a common cause. We describe herein the process by which Quality Improvement methodology was used to investigate and manage this surgical site infection (SSI) cluster. METHODS: As part of routine surveillance for SSI, the infection control division seeks out evidence of postoperative infections. Patients were defined as having an SSI according to National Healthcare Safety Network SSI criteria. SSI data are reviewed monthly and aggregated on a quarterly basis. The SSI rate was above our usual level for 3 consecutive quarters of 2007. This increase in the infection rate led to an internal outbreak investigation, termed a "cluster investigation." This investigation comprised multiple concurrent methods including manual chart review of all cases; review of microbiological data; and inspection of operating rooms, instrument processing facilities, and storage areas. RESULTS: During 3 quarters, a trend emerged in our general surgical population that demonstrated that 4 surgical types had a sustained increase in SSI. The institutional antibiotic protocol was appropriate for prevention of the majority of these SSIs. As part of the investigation, direct observation of hand hygiene and surgical hand antisepsis technique was undertaken. At this time, there were 2 types of surgical hand preparation being used, at the discretion of the clinician: either a "standard" scrub with an antimicrobial soap or the application of a chlorhexidine gluconate and alcohol-based surgical hand antisepsis product. Observers noted improper use of this alcohol-based surgical hand antiseptic. This product was withdrawn from our operating rooms, and the SSI rate markedly decreased in the following 2 quarters. DISCUSSION: In conclusion, we report the results of a quality improvement process that investigated a 3-quarter increase in our SSI rate. An investigation was undertaken, and it was thought that the (mis)use of an alcohol-based hand antiseptic product was associated with the increased infection rate. Removing this product, along with reemphasizing the importance of infection control, was associated with a decrease in the infection rate to a level at or below our historical rate.

Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade.

BACKGROUND AND OBJECTIVE: Dexamethasone has been shown to prolong the duration of postoperative analgesia when given as an adjunct for peripheral nerve blocks. However, it has not been evaluated when given in conjunction with bupivacaine and clonidine to provide blockade of the brachial plexus at the interscalene level. The purpose of this investigation was to determine whether the addition of dexamethasone to interscalene brachial plexus block would prolong the duration of sensory analgesia in a group of patients undergoing outpatient shoulder arthroscopy. METHODS: This prospective, randomized, double-blind investigation was performed on 88 individuals undergoing shoulder arthroscopy. Patients received interscalene brachial plexus block using 20 ml of bupivacaine 5 mg ml(-1) with 1: 200,000 epinephrine and clonidine 75 microg. Patients were randomly assigned to receive either dexamethasone 8 mg or 0.9% NaCl as an adjuvant to the mixture. After discharge, patients recorded pain scores and analgesic consumption in a diary and estimated the time at which they perceived that the sensory block from the interscalene brachial plexus block resolved. This was based on pain, recovery of sensation and strength in the arm. Variables measured included demographics, timed pain intensity measurements, postoperative analgesic consumption, duration of analgesia and patient satisfaction. RESULTS: Dexamethasone prolonged median sensory (1457 vs. 833 min, P < 0.0001) and motor (1374 vs. 827 min, P < 0.0001) blockade compared with the control. At 24 h, the dexamethasone group had lower median verbal analogue scale scores compared with control (3.0 vs. 6.0). At 48 h, the two groups had similar median pain scores (4.0 vs. 5.0, dexamethasone vs. control, respectively). The opioid requirement in oxycodone equivalency was lower in the dexamethasone group than in the control group for the first 24 h, and similar thereafter. Median patient satisfaction scores were not significantly different between the two groups at 48 h (9.5 vs. 8.0, dexamethasone vs. control, respectively). CONCLUSION: The addition of dexamethasone to a bupivacaine-epinephrine-clonidine interscalene block prolongs sensory block and reduces opioid use.

Determining the accuracy of caudal needle placement in children: a comparison of the swoosh test and ultrasonography.

BACKGROUND: The aim of the present study was to compare two confirmatory tests - the 'swoosh' test (auscultation during caudal injection) and real time ultrasound imaging (both transverse 2D imaging and color flow Doppler imaging) in pediatric patients receiving a caudal epidural block. METHODS/MATERIALS: This was a retrospective observational study of caudal injections administered to 83 pediatric patients (0-11 years) presenting for elective surgery over a 4 month time period. While injecting small aliquots of local anesthetic, a standard stethoscope was placed over the lower lumbar spine to auscultate for the 'swoosh' test. An ultrasound machine (Sonosite Titan, Sonosite Inc., Bothell, WA, USA) was then utilized for real-time visualization of caudal injectate. Each test performed during the caudal injection (swoosh, turbulence on 2D imaging, or color flow on Doppler imaging) was recorded as positive, negative or equivocal. RESULTS: Eighty out of 83 patients (96.4%) had a successful caudal block based on minimal or no perioperative narcotic use, minimal or no response to surgical stimulation, the presence of motor blockade and patient comfort in the PACU. Ultrasound was significantly superior to 'swoosh' for sensitivity (96.3% vs 57.5%), negative predictive (40% vs 5.6 value) % and likelihood ratio (2.89 vs 1.73). Specificity and positive predictive value were not different between 'swoosh' and ultrasound. Of the ultrasound tests, turbulence was more sensitive than color flow Doppler (95.0% vs 78.8%). CONCLUSION: Ultrasonography is superior to the 'swoosh' test as an objective confirmatory technique during caudal block placement in children. We found the presence or absence of turbulence during injection within the caudal space to be the best single indicator of caudal success. We think ultrasonography should be used, if available, when teaching this technique.