Effect of a non-reactive absorbent with or without environmentally oriented electronic feedback on anesthesia provider's fresh gas flow rates: A greening initiative.

STUDY OBJECTIVE: To examine the effects of a non-reactive carbon dioxide absorbent (AMSORB® Plus) versus a traditional carbon dioxide absorbent (Medisorb™) on the FGF used by anesthesia providers and an electronic educational feedback intervention using Carestation™ Insights (GE HealthCare) on provider-specific change in FGF. DESIGN: Prospective, single-center cohort study set in a greening initiative. SETTING: Operating room. PARTICIPANTS: 157 anesthesia providers (i.e., anesthesiology trainees, certified registered nurse anesthetists, and solo anesthesiologists). INTERVENTIONS: Intervention #1 was the introduction of AMSORB® Plus into 8 Aisys CS2, Carestation™ Insights-enabled anesthesia machines (GE HealthCare) at the study site. At the end of week 6, anesthesia providers were educated and given an environmentally oriented electronic feedback strategy for the next 12 weeks of the study (Intervention #2) using Carestation™ Insights data. MEASUREMENTS: The dual primary outcomes were the difference in average daily FGF during maintenance anesthesia between machines assigned to AMSORB® Plus versus Medisorb™ and the provider-specific change in average fresh gas flows after 12 weeks of feedback and education compared to the historical data. MAIN RESULTS: Over the 18-week period, there were 1577 inhaled anesthetics performed in the 8 operating rooms (528 for intervention 1, 1049 for intervention 2). There were 1001 provider days using Aisys CS2 machines and 7452 provider days of historical data from the preceding year. Overall, AMSORB® Plus was not associated with significantly less FGF (mean - 80 ml/min, 97.5% confidence interval - 206 to 46, P = .15). The environmentally oriented electronic feedback intervention was not associated with a significant decrease in provider-specific mean FGF (-112 ml/min, 97.5% confidence interval - 244 to 21, P = .059). CONCLUSIONS: This study showed that introducing a non-reactive absorbent did not significantly alter FGF. Using environmentally oriented electronic feedback relying on data analytics did not result in significantly reduced provider-specific FGF.

AcumenTM hypotension prediction index guidance for prevention and treatment of hypotension in noncardiac surgery: a prospective, single-arm, multicenter trial.

BACKGROUND: Intraoperative hypotension is common during noncardiac surgery and is associated with postoperative myocardial infarction, acute kidney injury, stroke, and severe infection. The Hypotension Prediction Index software is an algorithm based on arterial waveform analysis that alerts clinicians of the patient's likelihood of experiencing a future hypotensive event, defined as mean arterial pressure < 65 mmHg for at least 1 min. METHODS: Two analyses included (1) a prospective, single-arm trial, with continuous blood pressure measurements from study monitors, compared to a historical comparison cohort. (2) A post hoc analysis of a subset of trial participants versus a propensity score-weighted contemporaneous comparison group, using external data from the Multicenter Perioperative Outcomes Group (MPOG). The trial included 485 subjects in 11 sites; 406 were in the final effectiveness analysis. The post hoc analysis included 457 trial participants and 15,796 comparison patients. Patients were eligible if aged 18 years or older, American Society of Anesthesiologists (ASA) physical status 3 or 4, and scheduled for moderate- to high-risk noncardiac surgery expected to last at least 3 h. MEASUREMENTS: minutes of mean arterial pressure (MAP) below 65 mmHg and area under MAP < 65 mmHg. RESULTS: Analysis 1: Trial subjects (n = 406) experienced a mean of 9 ± 13 min of MAP below 65 mmHg, compared with the MPOG historical control mean of 25 ± 41 min, a 65% reduction (p < 0.001). Subjects with at least one episode of hypotension (n = 293) had a mean of 12 ± 14 min of MAP below 65 mmHg compared with the MPOG historical control mean of 28 ± 43 min, a 58% reduction (p< 0.001). Analysis 2: In the post hoc inverse probability treatment weighting model, patients in the trial demonstrated a 35% reduction in minutes of hypotension compared to a contemporaneous comparison group [exponentiated coefficient: - 0.35 (95%CI - 0.43, - 0.27); p < 0.001]. CONCLUSIONS: The use of prediction software for blood pressure management was associated with a clinically meaningful reduction in the duration of intraoperative hypotension. Further studies must investigate whether predictive algorithms to prevent hypotension can reduce adverse outcomes. TRIAL REGISTRATION: Clinical trial number: NCT03805217. Registry URL: https://clinicaltrials.gov/ct2/show/NCT03805217 . Principal investigator: Xiaodong Bao, MD, PhD. Date of registration: January 15, 2019.

Propofol Inhibits Glioma Stem Cell Growth and Migration and Their Interaction with Microglia via BDNF-AS and Extracellular Vesicles.

Glioblastoma (GBM) is the most common and aggressive primary brain tumor. GBM contains a small subpopulation of glioma stem cells (GSCs) that are implicated in treatment resistance, tumor infiltration, and recurrence, and are thereby considered important therapeutic targets. Recent clinical studies have suggested that the choice of general anesthetic (GA), particularly propofol, during tumor resection, affects subsequent tumor response to treatments and patient prognosis. In this study, we investigated the molecular mechanisms underlying propofol's anti-tumor effects on GSCs and their interaction with microglia cells. Propofol exerted a dose-dependent inhibitory effect on the self-renewal, expression of mesenchymal markers, and migration of GSCs and sensitized them to both temozolomide (TMZ) and radiation. At higher concentrations, propofol induced a large degree of cell death, as demonstrated using microfluid chip technology. Propofol increased the expression of the lncRNA BDNF-AS, which acts as a tumor suppressor in GBM, and silencing of this lncRNA partially abrogated propofol's effects. Propofol also inhibited the pro-tumorigenic GSC-microglia crosstalk via extracellular vesicles (EVs) and delivery of BDNF-AS. In conclusion, propofol exerted anti-tumor effects on GSCs, sensitized these cells to radiation and TMZ, and inhibited their pro-tumorigenic interactions with microglia via transfer of BDNF-AS by EVs.

Prone Vs. Supine Position Ventilation in Intubated COVID-19 Patients: A Systematic Review and Meta-Analysis.

Whether prone positioning of patients undergoing mechanical ventilation for COVID-19 pneumonia has benefits over supine positioning is not clear. We conducted a systematic review with meta-analysis to determine whether prone versus supine positioning during ventilation resulted in different outcomes for patients with COVID-19 pneumonia. We searched Ovid Medline, Embase, and Web of Science for prospective and retrospective studies up through April 2023. We included studies that compared outcomes of patients with COVID-19 after ventilation in prone and supine positions. The primary outcomes were three mortality measures: hospital, overall, and intensive care unit (ICU). Secondary outcomes were mechanical ventilation days, intensive care unit (ICU) length of stay, and hospital length of stay. We conducted risk of bias analysis and used meta-analysis software to analyze results. Mean difference (MD) was used for continuous data, and odds ratio (OR) was used for dichotomous data, both with 95% CIs. Significant heterogeneity (I2) was considered if I2 was >50%. A statistically significant result was considered if the p-value was <0.05. Of 1787 articles identified, 93 were retrieved, and seven retrospective cohort studies encompassing 5216 patients with COVID-19 were analyzed. ICU mortality was significantly higher in the prone group (OR 2.22, 95% CI 1.43-3.43; p=0.0004). No statistically significant difference was observed between prone and supine groups for hospital mortality (OR, 0.95; 95% CI, 0.66-1.37; p=0.78) or overall mortality (OR, 1.08; 95% CI, 0.72-1.64; p=0.71). Studies that analyzed primary outcomes had significant heterogeneity. Hospital length of stay was significantly higher in the prone than in the supine group (MD, 6.06; 95 % CI, 3.15-8.97; p<0.0001). ICU length of stay and days of mechanical ventilation did not differ between the two groups. In conclusion, mechanical ventilation with prone positioning for all patients with COVID-19 pneumonia may not provide a mortality benefit over supine positioning.

Effect of Cocaine on Potassium-Evoked Release of Glutamate From Fetal Rat Brain Synaptosomes.

Introduction Cocaine use during pregnancy can affect fetal brain development. A fetal brain injury could happen from the direct effect of cocaine on the developing brain or from the reduction of placental perfusion from vasoconstriction, which may lead to hypoxia-ischemia. A potential mechanism for brain injury could be due to a neurotransmitter imbalance within the brain, especially glutamate. In an immature rat brain synaptosome model, we explored the additive effect of cocaine alone on glutamate release and the effect of cocaine combined with simulated hypoxic depolarization using potassium as a surrogate. Method Rat pups' brains were dissected and placed on a chilled petri dish. They then entered the experimental protocol. The suspended synaptosomes were divided equally into four experimental groups (control, high potassium "surrogate to hypoxic stimulation," cocaine, and cocaine + high K). Reversed-phase high-performance liquid chromatography analyzed glutamate with fluorescent detection Results The glutamate level was lowest in the cocaine-only group, with a level of 1.96 × 104, compared to the control and high potassium group. However, combining cocaine with high potassium seemed to generate a synergistic effect, achieving the highest glutamate level of all groups with a value of 5.31 × 104. Post hoc Conover's test for multiple pairwise-comparison between groups was done. In comparing various solutions to control, we did not find a statistically significant difference with the cocaine-only solution with a p-value of 0.074. Also, on comparing various other solutions to each other, there was no statistically significant difference between cocaine vs. cocaine + high potassium a p-value of 0.074. Conclusion Our data support the conclusion that cocaine alone does not induce glutamate release from fetal rat brain synaptosomes. Exposure to high potassium does lead to glutamate release. However, cocaine greatly enhances glutamate release in the presence of high potassium levels. This could explain how cocaine affects brain maturation during pregnancy with a low oxygen tension environment in the placenta. This hypothesis should be tested in vivo.

Sequential Organ Failure Assessment (SOFA) Score and Mortality Prediction in Patients With Severe Respiratory Distress Secondary to COVID-19.

Background This study looks at the validity of the sequential organ failure assessment score (SOFA) in detecting mortality in patients with Coronavirus disease of 2019 (COVID-19) pneumonia. Also, it is looking to determine the optimal SOFA score that will discriminate between mortality and survival. Methods It is a retrospective chart review of the patients admitted to Henry Ford Hospital from March 2020 to December 2020 with COVID-19 pneumonia who developed severe respiratory distress. We collected the following information; patient demographics (age, sex, body mass index), co-morbidities (history of diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, coronary artery disease, or cancer), SOFA scores (the ratio of arterial oxygen tension (PaO2) to the fraction of inspired oxygen, Glasgow Coma Scale (GCS) score, mean arterial pressure, serum creatinine level, bilirubin level, and platelet count) as well as inpatient mortality. Results There were 320 patients; out of these, 111 were intubated. The receiver operating characteristic (ROC) curve for SOFA at the moment of inclusion in the study had an area under the curve of 0.883. The optimal point for discrimination between mortality and survival is SOFA of 5. A SOFA score of less than two is associated with 100% survival, while a score of more than 11 is associated with 100% mortality. Conclusions SOFA score in COVID-19 patients with severe respiratory distress strongly correlates with the initial SOFA score. It is a valuable tool for predicting mortality in COVID-19 patients.

The Burnout Epidemic Within A Viral Pandemic: Impact of a Wellness Initiative.

Background: Anesthesiologists are at high risk of developing burnout, a condition which can lead to many deleterious effects for the physician, and far-reaching effects on their patients and hospital systems. The COVID-19 pandemic has presented new challenges that have further exacerbated the risk of burnout in anesthesiologists. It is critical to develop effective strategies to promote well-being and decrease burnout for physicians in this specialty. The purpose of this observational study was to evaluate the impact of a Physician Well-Being Initiative on distress and well-being in anesthesiologists. It was hypothesized that the wellness intervention would promote an improvement in well-being scores. Methods: The Physician Well-Being Initiative was launched in August 2019 in the Department of Anesthesiology, Pain Management and Perioperative Medicine at Henry Ford Hospital in Detroit, Michigan. The Physician Well-Being Initiative was designed to address several of the key factors that improve physician wellness, including 1) a sense of autonomy; 2) positive view of leadership; and 3) flexible schedule opportunities. To assess the impact of the Physician Well-Being Initiative on the well-being and distress scores of participating anesthesiologists, the physicians were emailed the validated Well-Being Index survey at baseline and 3, 6 and 12 months. The Well-Being Index evaluates multiple items of distress in the healthcare setting. The sample size was limited to the 54 anesthesiologists at Henry Ford Hospital. Results: Forty-four of the 54 anesthesiologists completed the baseline questionnaire. A total of 44 physicians answered the questionnaire at baseline, with more male than female physicians (35 males and 7 females) and the majority (17/44) in practice for 5-10 years. Thirty-two physicians completed the survey at 3 and 6 months, and 31 physicians at 12 months after the launch of the Physician Well-Being Initiative. Twenty-one physicians completed the questionnaire at all 4 time points. Although the COVID-19 pandemic started shortly after the 6-month surveys were submitted, results indicated that there was a 0.05 decrease in the Well-Being Index sum score for every 1-month of time (coefficient -0.05, 95% CI -0.01, -0.08, P = 0.013). This study shows that, with the wellness initiative in place, the department was able to maintain and potentially even reduce physician distress despite the concurrent onset of the pandemic. Conclusions: Following the launch of a sustained wellness initiative, this study demonstrates that physician wellness improved with time. This suggests that it takes time for a wellness initiative to have an effect on well-being and distress in anesthesiologists.

Intrathecal Fentanyl With a Paracervical Block Is Safe and Effective for Elective Termination of Pregnancy in a Patient With Primary Pulmonary Hypertension.

Pulmonary hypertension (PH) in pregnancy, irrespective of etiology, is associated with significant maternal morbidity and mortality. This case describes a novel approach to providing anesthesia for a hemodynamically fragile patient. It demonstrates the careful planning and weighted decision-making that is required when approaching a parturient with severe pulmonary hypertension. The patient's previous pulmonary artery catheterization showed right ventricular systolic pressure of 78 mmHg and pulmonary artery pressure of 78/20 mmHg. The patient presented with worsening dyspnea and a decision was made to proceed with the termination of pregnancy via dilatation and curettage (D&C). Anesthesia was conducted with combined intrathecal fentanyl with a paracervical block using lidocaine 2%. The patient had a complication of post-procedure hemorrhage secondary to uterine atony that required careful monitoring and judicious use of uterotonic medications. A decision was made to use oxytocin due to its favorable effect profile compared to other uterotonic medications. We hope this anesthesia technique will aid in the future management of these challenging cases.

Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies.

Introduction One of the most challenging scenarios an anesthesia provider can face is treating a can't intubate can't ventilate (CICV) patient. The incidence of CICV is estimated to be around one in 10,000 cases. According to the American Society of Anesthesiology Closed Claims Study, adverse respiratory events are the most common type of injury, with difficult intubation and ventilation contributing to the majority of these cases. The objective of this non-interventional quality improvement project was to evaluate the prior training, exposure, and self-reported confidence in handling the CICV scenario among anesthesia providers at Henry Ford Hospital in Detroit, MI. Methods An online questionnaire was distributed via email to all residents, certified registered nurse anesthetists (CRNAs), and attending anesthesiologists in March 2021. The email contained a link to an online questionnaire via Microsoft Forms (Microsoft Corporation, Redmond, WA). Univariate group comparisons were carried out between the respondents' role (attending, CRNA, or resident), as well as between the number of years that the respondents were in practice (< 5 years, 5-10 years, > 10 years). Results Out of the total 170 anesthesia providers, 119 participated in the study where 54 (45%) were attendings, 44 (37%) were residents, and 21 (18%) were CRNAs. The majority (75%) did not know the surgical airway kit location, and 87% had not performed the surgical airway procedure before. The vast majority (96.7%) recommended simulation training compared to online training or lecture series, and just over 50% recommended annual training frequency. When looking at the differences in responses based on years of experience as an anesthesia provider, the majority of those with > 10 years in practice knew how to perform the surgical airway technique while respondents with < 5 years did not know how to perform the technique, and 50% of those with five to 10 years experience knew how to perform the surgical airway procedure for a CICV scenario. Conclusion Although there were many significant differences observed between the various provider roles and years in practice, surprisingly, the responses revealed both a lack of experience and confidence in performing the surgical airway procedure in all provider roles. These findings highlight a need for better emergency airway teaching and training. These findings will be used to guide the design and implementation of improved surgical airway training for residents, CRNAs, and attending anesthesiologists with the goal of better preparedness for handling a CICV scenario.

Characteristics of Organ Donors Who Died From Suicide by Hanging in Australia and New Zealand: A Retrospective Study.

Background and objective The annual incidence of suicide by hanging in Australia and New Zealand has increased in the past decade, and a significant number of these individuals are becoming organ donors. The rates of organ donation following deaths from hanging is unknown and the characteristics of this cohort of donors have not been described in the literature. In light of this, we aimed to examine the trends in organ donation from individuals who had died from hanging, based on the solid organ donor data from the Australia and New Zealand Organ Donation (ANZOD) Registry. Methods We conducted a retrospective study that analyzed the ANZOD Registry donor data (2006-2015) to describe the characteristics of solid organ donors who had died by hanging (post-hanging group); these characteristics were compared to those of individuals who died by all other causes (non-hanging group). Results During the study period, the number and proportion of donors who died by suicide from hanging increased. Of the 4,024 consented organ donors, 226 had died by hanging and 3,798 had died from other causes. The probability that an individual who died by hanging would become an organ donor increased from 0.5 to 3%. Compared to donors who died by all other causes, post-hanging donors were younger (median age of 30 vs. 50 years), with fewer comorbidities, and a higher incidence of smoking. There was no significant difference in the proportion of those who indicated a prior intent to donate organs between post-hanging (34%) and non-hanging donors (38%). A higher proportion of post-hanging donors donated via the donation after the circulatory death pathway (36.3%) than non-hanging donors (24.2%). Individuals in the post-hanging cohort donated an average of 4.19 organs compared to 3.62 in the non-hanging cohort. Conclusion We believe the findings of this retrospective analysis will help inform clinical decision-making regarding organ donation, including the best approaches to obtaining donation consent. Our findings will help physicians provide care to patients and to families of individuals in this challenging group, where organ donation potential is high. Further investigations are required to determine which aspects of healthcare influence the donation rates in individuals who have died by hanging and the outcomes related to transplanted organs.

Effect of Intubation Timing on the Outcome of Patients With Severe Respiratory Distress Secondary to COVID-19 Pneumonia.

Background The optimal timing of intubation for critically ill patients with severe respiratory illness remains controversial among healthcare providers. The coronavirus disease 2019 (COVID-19) pandemic has raised even more questions about when to implement this life-saving therapy. While one group of providers prefers early intubation for patients with respiratory distress because these patients may deteriorate rapidly without it, other providers believe that intubation should be delayed or avoided because of its associated risks including worse outcomes. Research question Our objective was to assess whether the timing of intubation in patients with severe COVID-19 pneumonia was associated with differences in mortality or other outcomes. Study design and methods This was a single-center retrospective observational cohort study. We analyzed outcomes of patients who were intubated secondary to COVID-19 pneumonia between March 13, 2020, and December 12, 2020, at Henry Ford Hospital in Detroit, Michigan. Patients were categorized into two groups: early intubated (intubated within 24 hours of the onset of severe respiratory distress) and late intubated (intubated after 24 hours of the onset of severe respiratory distress). Demographics, comorbidities, respiratory rate oxygenation (ROX) index, sequential organ failure assessment (SOFA) score, and treatment received were compared between groups. The primary outcome was mortality. Secondary outcomes were ventilation time, intensive care unit stay, hospital length of stay, and discharge disposition. Post hoc and Kaplan-Meier survival analyses were performed. Results A total of 110 patients were included: 55 early intubated and 55 late intubated. We did not observe a significant difference in overall mortality between the early intubated (43%) and the late intubated groups (53%) (p = 0.34). There was no statistically significant difference in patients' baseline characteristics including SOFA scores (the early intubation group had a mean score of 7.5 compared to 6.7 in the late intubation group). Based on the ROX index, the early intubation group had significantly more patients with a reduced risk of intubation (45%) than the late group (27%) (p = 0.029). The early intubation group was treated with a high-flow nasal cannula at a significantly lower rate (47%) than the late intubation group (83%) (p < 0.001). Significant differences in patient baseline characteristics, treatment received, and other outcomes were not observed. Post hoc analysis adjusting for SOFA score between 0 and 9 revealed significantly higher mortality in the late intubation group (49%) than in the early intubation group (26%) (p = 0.03). Patients in the 0 to 9 SOFA group who were intubated later had 2.7 times the odds of dying during hospital admission compared to patients who were intubated early (CI, 1.09-6.67). Interpretation The timing of intubation for patients with severe COVID-19 pneumonia was not significantly associated with overall mortality or other patient outcomes. However, within the subgroup of patients with SOFA scores of 9 or lower at the time of intubation, patients intubated after 24 hours of the onset of respiratory distress had a higher risk of death than those who were intubated within 24 hours of respiratory distress. Thus, patients with COVID-19 pneumonia who are not at a high level of organ dysfunction may benefit from early mechanical ventilation.

Neuron-Glia Crosstalk Plays a Major Role in the Neurotoxic Effects of Ketamine via Extracellular Vesicles.

Background: There is a compelling evidence from animal models that early exposure to clinically relevant general anesthetics (GAs) interferes with brain development, resulting in long-lasting cognitive impairments. Human studies have been inconclusive and are challenging due to numerous confounding factors. Here, we employed primary human neural cells to analyze ketamine neurotoxic effects focusing on the role of glial cells and their activation state. We also explored the roles of astrocyte-derived extracellular vesicles (EVs) and different components of the brain-derived neurotrophic factor (BDNF) pathway. Methods: Ketamine effects on cell death were analyzed using live/dead assay, caspase 3 activity and PARP-1 cleavage. Astrocytic and microglial cell differentiation was determined using RT-PCR, ELISA and phagocytosis assay. The impact of the neuron-glial cell interactions in the neurotoxic effects of ketamine was analyzed using transwell cultures. In addition, the role of isolated and secreted EVs in this cross-talk were studied. The expression and function of different components of the BDNF pathway were analyzed using ELISA, RT-PCR and gene silencing. Results: Ketamine induced neuronal and oligodendrocytic cell apoptosis and promoted pro-inflammatory astrocyte (A1) and microglia (M1) phenotypes. Astrocytes and microglia enhanced the neurotoxic effects of ketamine on neuronal cells, whereas neurons increased oligodendrocyte cell death. Ketamine modulated different components in the BDNF pathway: decreasing BDNF secretion in neurons and astrocytes while increasing the expression of p75 in neurons and that of BDNF-AS and pro-BDNF secretion in both neurons and astrocytes. We demonstrated an important role of EVs secreted by ketamine-treated astrocytes in neuronal cell death and a role for EV-associated BDNF-AS in this effect. Conclusions: Ketamine exerted a neurotoxic effect on neural cells by impacting both neuronal and non-neuronal cells. The BDNF pathway and astrocyte-derived EVs represent important mediators of ketamine effects. These results contribute to a better understanding of ketamine neurotoxic effects in humans and to the development of potential approaches to decrease its neurodevelopmental impact.

Hemodynamic Changes with 1:1000 Epinephrine on Wrung-Out Pledgets Before and During Sinus Surgery.

BACKGROUND: Intranasal topical 1:1000 epinephrine has been used safely and effectively for hemostasis during endoscopic sinus surgery (ESS). Prior studies assessing hemodynamic changes after intranasal topical epinephrine application have only used soaking wet cottonoid pledgets, and have only assessed for hemodynamic changes before any surgery being performed. OBJECTIVE: The purposes of this study were to determine whether intranasal application of topical 1:1000 epinephrine with wrung-out cottonoid pledgets caused significant hemodynamic changes both before and during ESS, and whether it allowed for adequate hemostasis. METHODS: A prospective evaluation of 30 patients with eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP) undergoing complete bilateral ESS was conducted. Heart rate, blood pressure (systolic, diastolic, and mean arterial pressure), and electrocardiography changes were recorded at 0, 1, 2, and 5-minute intervals after placing wrung-out epinephrine-saturated pledgets, both before and at the end of ESS. No submucosal epinephrine injections were performed. Estimated blood loss (EBL) and major intraoperative complications were recorded for all cases. RESULTS: There were no significant hemodynamic changes or electrocardiographic abnormalities after placement of wrung-out epinephrine-soaked pledgets both before and after ESS. After bilateral ESS, there were actually mean decreases in heart rate and blood pressure parameters. Mean EBL was 75.8 ± 32.2 mL, and no major intraoperative complications occurred. CONCLUSION: Intranasal application of topical 1:1000 epinephrine via wrung-out cottonoid pledgets was effective for intraoperative hemostasis, and did not cause clinically significant alterations in hemodynamic parameters or cardiovascular events, either before or during ESS in patients with CRSwNP.Level of Evidence: 4.

Frequency and Analysis of Unplanned Extubation in Coronavirus Disease 2019 Patients.

OBJECTIVES: To determine if patients with coronavirus disease 2019 had a greater number of unplanned extubations resulting in reintubations than in patients without coronavirus disease 2019. DESIGN: Retrospective cohort study comparing the frequency of unplanned extubations resulting in reintubations in a group of coronavirus disease 2019 patients to a historical (noncoronavirus disease 2019) control group. SETTING: This study was conducted at Henry Ford Hospital, an academic medical center in Detroit, MI. The historical noncoronavirus disease 2019 patients were treated in the 68 bed medical ICU. The coronavirus disease 2019 patients were treated in the coronavirus disease ICU, which included the 68 medical ICU beds, 18 neuro-ICU beds, 32 surgical ICU beds, and 40 cardiovascular ICU beds, as the medical ICU was expanded to these units at the peak of the pandemic in Detroit, MI. PATIENTS: The coronavirus disease 2019 cohort included patients diagnosed with coronavirus disease 2019 who were intubated for respiratory failure from March 12, 2020, to April 13, 2020. The historic control (noncoronavirus disease 2019) group consisted of patients who were admitted to the medical ICU in the year spanning from November 1, 2018 to October 31, 2019, with a need for mechanical ventilation that was not related to surgery or a neurologic reason. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To identify how many patients in each cohort had unplanned extubations, an electronic medical records query for patients with two intubations within 30 days was performed, in addition to a review of our institutional quality and safety database of reported self-extubations. Medical charts were manually reviewed by board-certified anesthesiologists to confirm each event was an unplanned extubation followed by a reintubation within 24 hours. There was a significantly greater incidence of unplanned extubations resulting in reintubation events in the coronavirus disease 2019 cohort than in the noncoronavirus disease 2019 cohort (coronavirus disease 2019 cohort: 167 total admissions with 22 events-13.2%; noncoronavirus disease 2019 cohort: 326 total admissions with 14 events-4.3%; p < 0.001). When the rate of unplanned extubations was expressed per 100 intubated days, there was not a significant difference between the groups (0.88 and 0.57, respectively; p = 0.269). CONCLUSIONS: Coronavirus disease 2019 patients have a higher incidence of unplanned extubation that requires reintubation than noncoronavirus disease 2019 patients. Further study is necessary to evaluate the variables that contribute to this higher incidence and clinical strategies that can reduce it.

Postoperative Pulmonary Complications in the Morbidly Obese: The Role of Tidal Volume and Type of Abdominal Surgery.

BACKGROUND: The patient who is morbidly obese is not adequately represented in the evidence recommending intraoperative low tidal volume (VT) ventilation. We aimed to explore the association between VT adjusted for ideal body weight (IBW) and the occurrence of postoperative pulmonary complications in subjects who were morbidly obese and undergoing abdominal surgery, as well as its implications on intraoperative ventilatory variables. METHODS: We included 734 subjects with a body mass index of at least 40 kg/m2, undergoing open or laparoscopic abdominal surgery that lasted for at least 120 min. Clinical variables were obtained to estimate the preoperative pulmonary risk as well as intraoperative ventilator data to perform associations. Outcomes were defined by medical billing code diagnoses and oxygen use. All data were collected electronically by using Structured Query Language. RESULTS: The subjects received a mean VT/IBW of 9.41 mL/kg IBW, and postoperative pulmonary complications occurred in 7.5% of the subjects. The occurrence of complications was correlated with the presence of several preoperative risk factors for postoperative pulmonary complications. VT/IBW was not associated with postoperative pulmonary complications. This finding remained present after separating different levels of VT/IBW. In a multivariate analysis, only laparoscopic surgery was an independent protective factor against postoperative pulmonary complications (odds ratio 0.07, 95% CI 0.01-0.55). CONCLUSIONS: VT/IBW was not associated with the occurrence of postoperative pulmonary complications in subjects who were morbidly obese and undergoing prolonged abdominal surgery. Future prospective studies are indicated to guide the optimum ventilation strategy for patients who are morbidly obese.

Late first-case of the day starts do not cause greater minutes of over-utilized time at an endoscopy suite with 8-hour workdays and late running rooms. A historical cohort study.

STUDY OBJECTIVE: We consider the influence of the tardiness of first-case of the day start times on the minutes that rooms finish late for procedural suites with relatively interchangeable rooms and mean workloads ≅ 7 h per room, thus regularly filling 8-hour of allocated time. DESIGN: Historical cohort of N = 331 workdays of data. SETTING: Gastrointestinal endoscopy suite. MAIN RESULTS: By unadjusted analyses, reductions in the number of first-cases of the day starting ≥5 min late were associated with less minutes that the day's cases ended beyond the allocated 8 h. However, there were no significant relationships in adjusted analyses, controlling for the daily total hours of cases and turnovers ("workload") or the daily caseload of elective cases. There also were no significant relationships in adjusted analyses between the minutes of cases ending beyond the allocated 8 h and either the count of cases starting ≥15 min late or the mean minutes of case tardiness. The differences between unadjusted and adjusted results were explained by slight positive associations between the count of first-cases starting ≥5 min late and both the daily workload and caseload. Days with less hours of cases had significantly fewer cases starting near simultaneously at the beginning of the day; the same was true for days with fewer total cases. CONCLUSIONS: For procedural suites with relatively interchangeable rooms and mean workloads ≅ 7 h per room, reducing tardiness of first-case of the day start times does not result in beneficial reductions in over-utilized time. The focus of improving on-time starts for the first-cases of the day should be on services with mean workloads that exceed the minimum scheduled duration of the workday.

Benefit of systematic selection of pairs of cases matched by surgical specialty for surveillance of bacterial transmission in operating rooms.

BACKGROUND: Bacterial transmission within and between successive surgical cases occurs in operating rooms (ORs), often includes anesthesia equipment as a reservoir, and can be monitored by collecting samples and identifying bacteria by genetic testing. We evaluated how to choose cases for active surveillance to quantify the effectiveness of interventions in 2 groups of ORs (eg, rooms with germicidal lighting vs those without). METHODS: Data were from a 7 OR single-specialty gastrointestinal endoscopy suite and from a typical 8 OR multispecialty surgical suite. RESULTS: At the multispecialty hospital, 40.3% (SE 1.2%) of the total number of cases could be used for surveillance (ie, followed by another case of the same specialty and matched with a corresponding pair of cases from the other OR group). Random selection obtained fewer matched pairs than deliberate selection: mean ratio of random/deliberate = 0.64 (0.01) for the single-specialty and 0.51 (0.02) for the multispecialty suite (P <.001). CONCLUSIONS: The efficiency of sampling to obtain pairs of successive surgical cases of the same specialty is impaired markedly by randomly selecting pairs of cases (or using convenience sampling) as compared to choosing pairs deliberately. This is important because the number of cases that can be suitably used for surveillance of bacterial transmission will typically be less than one-half the total case number.

Approximate Weight of 1:1000 Topical Epinephrine on Wrung-Out Epinephrine-Soaked Pledgets.

OBJECTIVE: Topical 1:1000 epinephrine solution is commonly applied intranasally with cottonoid pledgets in endoscopic sinonasal surgery for local vasoconstriction and hemostasis. Pledgets are typically submerged in epinephrine solution and applied without measurement. Hemodynamic complications have been reported when pledgets have been saturated and not wrung out. The amount of epinephrine absorbed per pledget has not been studied methodically. The purpose of this study was to determine the amount of topical 1:1000 epinephrine remaining on a cottonoid pledget after wringing out the pledget, to simulate intraoperative application. STUDY DESIGN: Cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: Sixty 0.5-in × 3-in cottonoid pledgets were submerged in canisters filled with 1:1000 epinephrine solution (1 mg/mL). Weights of the epinephrine-filled canisters were measured before submerging the pledgets and then after removing and wringing out the pledgets. Measurements were recorded for each pledget after being submerged for 0, 1, and 5 minutes and then wrung out. Mean weights were calculated and compared between the submersion durations. RESULTS: The mean overall weight of epinephrine on a wrung-out pledget was 0.931 mg. Mean weights of epinephrine absorbed onto wrung-out pledgets after submersion for 0, 1, and 5 minutes were 0.914, 0.913, and 0.967 mg, respectively. There were no significant differences in weights based on submersion duration (P = .296). CONCLUSION: Approximately 1 mg of epinephrine was absorbed onto 0.5-in × 3-in cottonoid pledgets when pledgets were wrung out after being submerged in 1:1000 epinephrine, whether being removed from solution immediately or after up to 5 minutes.

Ultrasound-guided bilateral transversus abdominis plane blocks in conjunction with intrathecal morphine for postcesarean analgesia.

STUDY OBJECTIVE: To determine whether transversus abdominis plane (TAP) blocks administered in conjunction with intrathecal morphine provided superior analgesia to intrathecal morphine alone. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Operating room of a university hospital. PATIENTS: 51 women undergoing elective Cesarean delivery with a combined spinal-epidural technique that included intrathecal morphine. INTERVENTIONS: Subjects were randomized to receive a bilateral TAP block with 0.5% ropivacaine or 0.9% saline. Postoperative analgesics were administered on request and selected based on pain severity. MEASUREMENTS: Patients were evaluated at 2, 24, and 48 hours after the TAP blocks were performed. Verbal rating scale (VRS) pain scores at rest, with movement, and for colicky pain were recorded, as was analgesic consumption. Patients rated the severity of opioid side effects and their satisfaction with the procedure and analgesia. MAIN RESULTS: 51 subjects received TAP blocks with ropivacaine (n = 26) or saline (n = 25). At two hours, the ropivacaine group reported less pain at rest and with movement (0.5 and 1.9 vs 2.8 and 4.9 in the saline group [VRS scale 0 - 10]; P < 0.001) and had no requests for analgesics; there were several requests for analgesia in the saline group. At 24 hours, there was no difference in pain scores or analgesic consumption. At 48 hours, the ropivacaine group received more analgesics for moderate pain (P = 0.04) and the saline group received more analgesics for severe pain (P = 0.01). CONCLUSIONS: Transversus abdominis plane blocks in conjunction with intrathecal morphine provided superior early postcesarean analgesia to intrathecal morphine alone. By 24 hours there was no difference in pain scores or analgesic consumption.