Toward physician well-being and the mitigation of burnout.

PURPOSE OF REVIEW: Healthcare provider burnout is a real phenomenon. The rates of burnout are on the rise. Burnout-associated suicide amongst physicians represents a real "public health crisis." This article discusses the drivers of burnout and offers some strategies to mitigate burnout and improve well-being. RECENT FINDINGS: Measures of burnout such as stress, micro, and macro-aggression in the workplace have a psychological impact on staff. Additionally, a measurable economic price is exacted when an organization fails to address the lack of well-being burnout represents. SUMMARY: As healthcare providers struggle to survive and deal with the complex new set of problems and obstacles that the COVID-19 pandemic, the National economic crisis, and the increasing regulatory obligations have summoned forth, professional burnout rates have risen drastically. With good leadership, developing comprehensive programs to identify, track, and treat burnout symptoms and improve well-being in the work environment can result in greater work satisfaction and save resources.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. METHODS: This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. RESULTS: There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). CONCLUSIONS: The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Systemic ropivacaine toxicity from a peripheral nerve infusion in a medically complex patient.

This is a case of systemic ropivacaine toxicity from a sciatic nerve catheter. A 20-year-old patient after heart transplant with poor systemic perfusion on hemodialysis and multiple medications experienced local anesthetic systemic toxicity 72 hours after placement of a peripheral nerve catheter. The case demonstrates the potentially significant impact of medical comorbidities on system absorption of local anesthetics and reinforces that existing dose guidelines are not evidence based, and literature to guide local anesthetic bolus supplementation of continuous infusions is scant.

A comparison of the effects of desflurane versus propofol on transcranial motor-evoked potentials in pediatric patients.

PURPOSE: The aim was to compare the effects of propofol and desflurane anesthesia on transcranial motor evoked potentials (MEPs) from pediatric patients undergoing surgery for spinal deformities. METHODS: Desflurane and propofol cohorts (25 patients each) were obtained retrospectively and matched for patient characteristics and surgical approach. MEPs from the thenar eminence and abductor hallucis were compared during maintenance anesthesia on desflurane (0.6-0.8 MAC) or propofol infusion (150-300 µg/kg/min). MEP amplitudes and durations were obtained for successive 30-min intervals for 150 min, beginning 60 min after maintenance anesthesia. RESULTS: Mean peak to peak amplitudes of MEPs under desflurane anesthesia from the thenar eminence (419 µV) and abductor hallucis (386 µv) were not significantly different from those under propofol (608 µV, 343 µV, thenar, and abductor hallucis, respectively). Stimulation was greater by 42 V and 136 mA, and trains were slightly longer in the desflurane compared to the propofol group (p < 0.05). Most MEP amplitudes for the desflurane and propofol cohorts remained the same or increased (71 % of cases) when those after 150 min were compared to those in the first 30-min interval. CONCLUSIONS: MEPs with good amplitudes were obtained under desflurane only anesthesia that were comparable to propofol only anesthesia in pediatric patients during surgery for spinal deformities. There was no evidence for anesthetic fade over the time period examined. When used by itself, desflurane can be considered a viable alternative to propofol anesthesia.

Fever following an Epidural Blood Patch in a Child.

There is increasing evidence that children suffer from the consequences of spontaneous or iatrogenic intracranial hypotension. Pediatric epidural blood patch is gaining popularity because of its ability to alter cerebrospinal fluid dynamics and to alleviate headaches attributed to low cerebrospinal fluid pressure. There is, however, still not enough data to document the safety profile of an epidural blood patch. Here we describe a case of a fever in a child temporally related to the administration of an epidural blood patch. This case depicts the dilemmas in making the diagnosis and instituting treatment for complications of this procedure in the pediatric population.

Complications in postacute care are associated with persistent delirium.

OBJECTIVES: To investigate whether complications in postacute care (PAC) are associated with delirium persistence 30 days after PAC admission. DESIGN: Observational cohort study. SETTING: Eight Boston-area PAC facilities. PARTICIPANTS: Three hundred fifty individuals with delirium at PAC admission. MEASUREMENTS: Participants were interviewed at PAC admission and 30 days later. Delirium presence was determined using the Confusion Assessment Method. Medical record reviews were performed to ascertain new cardiac, noncardiac, and geriatric syndrome complications in PAC. Complication status was also determined 30 days after admission or at PAC discharge, whichever came first. RESULTS: Participants (mean age 83.6, 66% female) experienced the following incidence of PAC complications: cardiac complications (7%), noncardiac complications (21%), and geriatric syndrome complications (39%). Delirium persisted in 56% of participants 1 month after PAC admission. Neither cardiac nor noncardiac complications were associated with delirium persistence. Delirium persistence at 1 month was significantly greater in participants, with more geriatric syndrome complications (no complications, 51%; one complication 61%; ≥ 2 complications, 100%, adjusted P = .048). There was also a trend toward greater delirium persistence in participants with unresolved geriatric syndrome complications (no complications, 51%; resolved complication, 61%; unresolved complication, 68%; adjusted P = .10). CONCLUSION: Geriatric syndrome complications are common in individuals admitted to PAC with delirium and are associated with persistence of delirium 1 month later. Proactively addressing risk factors for geriatric syndromes may improve outcomes of vulnerable individuals in PAC.

Recognition of an incidental abscess and a hematoma during ultrasound-guided femoral nerve block.

Ultrasound guidance for femoral nerve blockade allows visualization of normal and abnormal anatomy. Two cases of femoral nerve blockade under ultrasound guidance are presented where a major perineural pathologic lesion was incidentally revealed. These pathologic lesions, an abscess and a hematoma, resulted in significant adaptations in clinical care and have not been reported previously. We review and discuss incidental pathologic lesions that can be found in the femoral region. Identification of these 2 pathologic lesions facilitated our perioperative management strategies in two separate cases.