Sustainability of the Subspecialty of Anesthesiology Critical Care: An Expert Consensus and Review of the Literature.

While considerable literature exists with respect to clinical aspects of critical care anesthesiology (CCA) practice, few publications have focused on how anesthesiology-based critical care practices are organized and the challenges associated with the administration and management of anesthesiology critical care units. Currently, numerous challenges are affecting the sustainability of CCA practice, including decreased applications to fellowship positions and decreased reimbursement for critical care work. This review describes what is known about the subspecialty of CCA and leverages the experience of administrative leaders in adult critical care anesthesiologists in the United States to describe potential solutions.

Trauma Patients and Acute Compartment Syndrome: Is There an Ariadne's Thread That Can Safely Guide the Anesthesiologist/Emergency Physician Out of the Labyrinth?

Trauma patients in the emergency department experience severe pain that is not always easy to manage. The risk of acute compartment syndrome further complicates the analgesic approach. The purpose of this review is to discuss relevant bibliography and highlight current guidelines and recommendations for the safe practice of peripheral nerve blocks in this special group of patients. According to the recent bibliography, peripheral nerve blocks are not contraindicated in patients at risk of acute compartment syndrome, as long as there is surveillance and certain recommendations are followed.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists.

The Earth's mean surface temperature is already approximately 1.1°C higher than pre-industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three-stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high-, middle- and low-income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists' education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re-evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references.

Rabbit training model for establishing an emergency front of neck airway in children.

BACKGROUND: A 'cannot intubate, cannot oxygenate' (CICO) situation is rare in paediatric anaesthesia, but can always occur in children under certain emergency situations. There is a paucity of literature on specific procedures for securing an emergency invasive airway in children younger than 6 yr. A modified emergency front of neck access (eFONA) technique using a rabbit cadaver model was developed to teach invasive airway protection in a CICO situation in children. METHODS: After watching an instructional video of our eFONA technique (tracheotomy, intubation with Frova catheter over which a tracheal tube is inserted), 29 anaesthesiologists performed two separate attempts on rabbit cadavers. The primary outcome was the success rate and the performance time overall and in subgroups of trained and untrained participants. RESULTS: The overall success rate across 58 tracheotomies was 95% and the median performance time was 67 s (95% confidence interval [CI], 56-76). Performance time decreased from the first to the second attempt from 72 s (95% CI, 57-81) to 61 s (95% CI, 50-81). Performance time was 59 s (95% CI, 49-79) for untrained participants and 72 s (95% CI, 62-81) for trained participants. Clinical experience and age of the participants was not correlated with performance time, whereas the length of the tracheotomy incision showed a significant correlation (P=0.006). CONCLUSION: This eFONA training model for children facilitates rapid skill acquisition under realistic anatomical conditions to perform an emergency invasive airway in children younger than 2 yr.

Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade.

BACKGROUND: Although the package insert clearly states that "the safety and efficacy of sugammadex in pediatric patients have not been established," we hypothesized that sugammadex is used widely in pediatric anesthetic practice supplanting neostigmine as the primary drug for antagonizing neuromuscular blockade (NMB). Additionally, we sought to identify the determinants by which pediatric anesthesiologists choose reversal agents and if and how they assess NMB in their practice. Finally, because of sugammadex's effects on hormonal contraception, we sought to determine whether pediatric anesthesiologists counseled postmenarchal patients on the need for additional or alternative forms of contraception and the risk of unintended pregnancy in the perioperative period. METHODS: We e-mailed a questionnaire to all 3245 members of the Society of Pediatric Anesthesia (SPA) requesting demographic data and attitudes regarding use of NMB agents, monitoring, and antagonism practices. To address low initial response rates and quantify nonresponse bias, we sent a shortened follow-up survey to a randomly selected subsample (n = 75) of SPA members who did not initially respond. Response differences between the 2 cohorts were determined. RESULTS: Initial questionnaire response rate was 13% (419 of 3245). Overall, 163 respondents (38.9%; 95% confidence interval [CI], 34.2-43.8) used sugammadex as their primary reversal agent, and 106 (25.2%; 95% CI, 21.2-30.0) used it exclusively. Respondents with ≤5 years of practice used sugammadex as their primary reversal agent more often than those with ≥6 years of practice (odds ratio [OR]: 2.08; 95% CI, 1.31-3.31; P = .001). This increased utilization remained after controlling for institutional restriction and practice type (adjusted OR [aOR]: 2.20; 95% CI, 1.38-3.54; P = .001). Only 40% of practitioners always assess NMB (train-of-four), and use was inversely correlated with years of practice (Spearman ρ = -0.11, P = .04). Anesthesiologists who primarily used sugammadex assess NMB less routinely (OR: 0.56; 95% CI, 0.34-0.90; P = .01). A slim majority (52.8%) used sugammadex for pediatric postmenarchal girls; those with less experience used it more commonly (P < .001). Thirty-eight percent did not discuss its effects on hormonal contraception with the patient and/or family, independent of anesthesiologist experience (P = .33) and practice location (P = .38). No significant differences were seen in demographics or practice responses between initial and follow-up survey respondents. CONCLUSIONS: Sugammadex is commonly used in pediatric anesthesia, particularly among anesthesiologists with fewer years of practice. Failure to warn postmenarchal adolescents of its consequences may result in unintended pregnancies. Finally, pediatric anesthesia training programs should emphasize objective monitoring of NMB, particularly with sugammadex use.

Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines.

BACKGROUND: Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap. METHODS: Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018. RESULTS: Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria. CONCLUSIONS: The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.

The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States.

BACKGROUND: Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition. METHODS: We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey. RESULTS: Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again. CONCLUSIONS: The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting.

BACKGROUND: Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies. METHODS: Over a 4-year period, data were obtained from 49,386 procedures and 109 attendings. Cases were restricted to patients aged 18 years or older requiring general anesthesia that lasted at least 60 minutes. We defined protective lung ventilation as a TV of 6-8 mL/kg ideal body weight and a PEEP of ≥4 cm H2O. There was a baseline period followed by 4 behavioral interventions: education, near real-time feedback, individualized post hoc feedback, and enhanced multidimensional decision support. Segmented logistic regression using generalized estimating equations was performed in order to assess temporal trends and effects of interventions on adherence to LPV strategies. RESULTS: Consistent with improvement in adherence with LPV strategies during the baseline period, the predicted probability of adherence with LPV at the end of baseline was 0.452 (95% confidence interval [CI], 0.422-0.483). The improvements observed for each phase were relative to the preceding phase. Education alone was associated with an 8.7% improvement (P < .01) in adherence to lung-protective protocols and was associated with a 16% increase in odds of adherence (odds ratio [OR] = 1.16; 95% CI, 1.01-1.33; P = .04). Near real-time, on-screen feedback was associated with an estimated 15.5% improvement in adherence (P < .01) with a 69% increase in odds of adherence (OR = 1.69; 95% CI, 1.46-1.96; P < .01) over education alone. The addition of an individualized dashboard with personal adherence and peer comparison was associated with a significant improvement over near real-time feedback (P < .01). Near real-time feedback and dashboard feedback systems were enhanced based on feedback from the in-room attendings, and this combination was associated with an 18.1% (P < .01) increase in adherence with a 2-fold increase in the odds of adherence (OR = 2.23; 95% CI, 1.85-2.69; P < .0001) between the end of the previous on-screen feedback phase and the start of the individualized post hoc dashboard reporting phase. The adherence with lung-protective strategies using the multidimensional approach has been sustained for over 24 months. The difference between the end of the previous phase and the start of this last enhanced multidimensional decision support phase was not significant (OR = 1.08; 95% CI, 0.86-1.34; P = .48). CONCLUSIONS: Consistent with the literature, near real-time and post hoc reporting are associated with positive and sustained behavioral changes aimed at adopting evidence-based clinical strategies. Many decision support systems have demonstrated impact to behavior, but the effect is often transient. The implementation of near real-time feedback and individualized post hoc decision support tools has resulted in clinically relevant improvements in adherence with LPV strategies that have been sustained for over 24 months, a common limitation of decision support solutions.

The Origins, Evolution, and Spread of Anesthesia Monitoring Standards: From Boston to Across the World.

In the mid-1980s, the anesthesia departments at hospitals affiliated with Harvard Medical School were faced with a challenge: mounting medical malpractice costs. Malpractice insurance was provided by the Controlled Risk Insurance Company (CRICO), a patient safety and medical malpractice insurance company owned by and providing service to the Harvard medical community. CRICO spearheaded an effort to reduce these costs and ultimately found a way to decrease the risks associated with anesthesia. Here, we chronicle events that led to the dramatic changes in medical practice that resulted from the activities of a small group of concerned anesthesiologists at Harvard-affiliated hospitals. We place these events in a historical perspective and explore how other specialties followed this example, and end with current strategies that minimize the risk associated with anesthesia. We conducted interviews with principals who formulated original standards of patient monitoring. In addition, we consulted documents in the public domain and primary source material. Efforts of these pioneers resulted in the establishment of the seminal Harvard-based anesthesia monitoring standards for minimal monitoring. What followed was an unprecedented transformation of the entire field. After the implementation of these standards at Harvard-affiliated hospitals, the American Society of Anesthesiologists (ASA) adopted "Standards for Basic Anesthetic Monitoring" for use during the administration of all anesthetics in the United States. Other nations have since adopted similar guidelines and these practices have resulted in significant improvements in patient safety. Currently, we estimate mortality due to anesthesia in healthy patients to be 1:400,000-perhaps as much as 10 times lower since the early 1980s. What began as an attempt to lower medical malpractice costs in a group of university hospitals became a worldwide effort that resulted in improvements in patient safety. Other specialties have adopted similar measures. Currently, an attitude and appreciation of safety are exemplified by several practices that include among others-the adherence to these patient safety guidelines, simulator training, the promulgation of standards and guidelines by ASA, and the use of a safety checklist before induction of anesthesia.

A Systems Theoretic Process Analysis of the Medication Use Process in the Operating Room.

BACKGROUND: While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room. METHODS: The authors completed a systems theoretic process analysis for the medication use process in the operating room at their institution. First, the authors defined medication-related accidents (adverse medication events) and hazards and created a hierarchical control structure (a schematic representation of the operating room medication use system). Then the authors analyzed this structure for unsafe control actions and causal scenarios that could lead to medication errors, incorporating input from surgeons, anesthesiologists, and pharmacists. The authors studied the entire medication use process, including requesting medications, dispensing, preparing, administering, documenting, and monitoring patients for the effects. Results were reported using descriptive statistics. RESULTS: The hierarchical control structure involved three tiers of controllers: perioperative leadership; management of patient care by the attending anesthesiologist, surgeon, and pharmacist; and execution of patient care by the anesthesia clinician in the operating room. The authors identified 66 unsafe control actions linked to 342 causal scenarios that could lead to medication errors. Eighty-two (24.0%) scenarios came from perioperative leadership, 103 (30.1%) from management of patient care, and 157 (45.9%) from execution of patient care. CONCLUSIONS: In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives.

The Most Influential Publications in Obstetric Anesthesiology, 1998-2017: Utilizing the Delphi Method for Expert Consensus.

BACKGROUND: There have been many advances in obstetric anesthesiology in the past 2 decades. We sought to create a list of highly influential publications in the field using the Delphi method among a group of obstetric anesthesiology experts to create an important educational, clinical, and research resource. METHODS: Experts in the field, defined as obstetric anesthesiologists selected to present the Gerard W. Ostheimer Lecture at the Society for Obstetric Anesthesia and Perinatology (SOAP) annual meeting within the past 20 years, were recruited to participate. The Delphi technique was used by administering 3 rounds of surveys. Participants were initially asked to identify the highly influential publications from the year they presented the Ostheimer lecture, in addition to the most influential publications from the time period overall. Highly influential publications were defined as those that changed traditional views, invoked meaningful practices, catalyzed additional research, and fostered ideas or practices that had durability over time. After each round of surveys, responses were collected and used as choices for subsequent surveys with the goal of obtaining group consensus. RESULTS: We determined expert consensus on 22 highly influential publications from 1998 to 2017. The focus of these publications ranged from disease entities, interventions, treatment methodologies, and complications. CONCLUSIONS: Key themes in the publications chosen included the reduction of maternal morbidity and mortality and refinements in the analgesic and anesthetic management of labor and delivery.

Development and Multidisciplinary Preliminary Validation of a 3-Dimensional-Printed Pediatric Airway Model for Emergency Airway Front-of-Neck Access Procedures.

BACKGROUND: Pediatric-specific difficult airway guidelines include algorithms for 3 scenarios: unanticipated difficult tracheal intubation, difficult mask ventilation, and cannot intubate/cannot ventilate. While rare, these instances may require front-of-neck access (FONA) to secure an airway until a definitive airway can be established. The aim of this study was to develop a pediatric FONA simulator evaluated by both anesthesiology and otolaryngology providers, promoting multidisciplinary airway management. METHODS: A 3-dimensional-printed tracheal model was developed using rescaled, anatomically accurate dimensions from a computerized tomography scan using computer-aided design software. The medical grade silicone model was incorporated into a mannequin to create a low-cost, high-fidelity simulator. A multidisciplinary team of anesthesiology, otolaryngology, and simulation experts refined the model. Experts in airway management were recruited to rate the realism of the model's characteristics and features and their own ability to complete specific FONA-related tasks. RESULTS: Six expert raters (3 anesthesiology and 3 otolaryngology) were identified for multidisciplinary evaluation of model test content validity. Analysis of response data shows null variance within 1 or both specialties for a majority of the content validity tool elements. High and consistent absolute ratings for each domain indicate that the tested experts perceived this trainer as a realistic and highly valuable tool in its current state. CONCLUSIONS: The ability to practice front-of-neck emergency airway procedures safely and subsequently demonstrate proficiency on a child model has great implications regarding both quality of physician training and patient outcomes. This model may be incorporated into curricula to teach needle cricothyroidotomy and other FONA procedures to providers across disciplines.

Current Neurologic Assessment and Neuroprotective Strategies in Cardiac Anesthesia: A Survey to the Membership of the Society of Cardiovascular Anesthesiologists.

BACKGROUND: Neurologic injury and cognitive disorder after cardiac surgery are associated with morbidity and mortality. Variability in the application of neuroprotective strategies likely exists during cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) conducted a survey among its members on common perioperative neuroprotective strategies: assessment of aortic atheromatous burden, management of intraoperative blood pressure, and use of cerebral oximetry. METHODS: A 15-item survey was developed by 3 members of the SCA Continuous Practice Improvement - Cerebral Protection Working Group. The questionnaire was then circulated among all working group members, adapted, and tested for face validity. On March 26, 2018, the survey was sent to members of the SCA via e-mail using the Research Electronic Data Capture system. Responses were recorded until April 16, 2018. RESULTS: Of the 3645 surveys e-mailed, 526 members responded (14.4%). Most responders worked in academic institutions (58.3%), followed by private practices (38.7%). Epiaortic ultrasound for the assessment of aortic atheromatous burden was most commonly utilized at the surgeon's request (46.5%). Cerebral oximetry was most commonly used in patients with increased perioperative risk of cerebral injury (41.4%). Epiaortic ultrasound (1.9%) and cerebral oximetry (5.2%) were rarely part of a standardized monitoring approach. A majority of respondents (52.0%) reported no standardized management strategies for neuroprotection during cardiac surgery at their institution. A total of 55.3% stated that no standardized institutional guidelines were in place for managing a patient's blood pressure intraoperatively or during cardiopulmonary bypass. When asked about patients at risk for postoperative cerebral injury, 41.3% targeted a blood pressure goal >65 mmHg during cardiopulmonary bypass. The majority of responders (60.4%) who had access to institutional rates of postoperative stroke/cerebral injury had standard neuroprotective strategies in place. CONCLUSIONS: Our data indicate that approximately half of the respondents to this SCA survey do not use standardized guidelines/standard operating procedures for perioperative cerebral protection. The lack of standardized neuroprotective strategies during cardiac surgery may impact postoperative neurologic outcomes. Further investigations are warranted and should assess the association of standardized neuroprotective approaches and postoperative neurological outcomes.

Anesthesiologists' and Intensive Care Providers' Exposure to COVID-19 Infection in a New York City Academic Center: A Prospective Cohort Study Assessing Symptoms and COVID-19 Antibody Testing.

BACKGROUND: Protecting first-line health care providers against work-related coronavirus disease 2019 (COVID-19) infection at the onset of the pandemic has been a crucial challenge in the United States. Anesthesiologists in particular are considered at risk, since aerosol-generating procedures, such as intubation and extubation, have been shown to significantly increase the odds for respiratory infections during severe acute respiratory syndrome (SARS) outbreaks. This study assessed the incidence of COVID-19-like symptoms and the presence of COVID-19 antibodies after work-related COVID-19 exposures, among physicians working in a large academic hospital in New York City (NYC). METHODS: An e-mail survey was addressed to anesthesiologists and affiliated intensive care providers at Columbia University Irving Medical Center on April 15, 2020. The survey assessed 4 domains: (1) demographics and medical history, (2) community exposure to COVID-19 (eg, use of NYC subway), (3) work-related exposure to COVID-19, and (4) development of COVID-19-like symptoms after work exposure. The first 100 survey responders were invited to undergo a blood test to assess antibody status (presence of immunoglobulin M [IgM]/immunoglobulin G [IgG] specific to COVID-19). Work-related exposure was defined as any episode where the provider was not wearing adequate personal protective equipment (airborne or droplet/contact protection depending on the exposure type). Based on the clinical scenario, work exposure was categorized as high risk (eg, exposure during intubation) or low risk (eg, exposure during doffing). RESULTS: Two hundred and five health care providers were contacted and 105 completed the survey (51%); 91 completed the serological test. Sixty-one of the respondents (58%) reported at least 1 work-related exposure and 54% of the exposures were high risk. Among respondents reporting a work-related exposure, 16 (26.2%) reported postexposure COVID-19-like symptoms. The most frequent symptoms were myalgia (9 cases), diarrhea (8 cases), fever (7 cases), and sore throat (7 cases). COVID-19 antibodies were detected in 11 of the 91 tested respondents (12.1%), with no difference between respondents with (11.8%) or without (12.5%) a work-related exposure, including high-risk exposure. Compared with antibody-negative respondents, antibody-positive respondents were more likely to use NYC subway to commute to work and report COVID-19-like symptoms in the past 90 days. CONCLUSIONS: In the epicenter of the United States' pandemic and within 6-8 weeks of the COVID-19 outbreak, a small proportion of anesthesiologists and affiliated intensive care providers reported COVID-19-like symptoms after a work-related exposure and even fewer had detectable COVID-19 antibodies. The presence of COVID-19 antibodies appeared to be associated with community/environmental transmission rather than secondary to work-related exposures involving high-risk procedures.

Association between leniency of anesthesiologists when evaluating certified registered nurse anesthetists and when evaluating didactic lectures.

Daily evaluations of certified registered nurse anesthetists' (CRNAs') work habits by anesthesiologists should be adjusted for rater leniency. The current study tested the hypothesis that there is a pairwise association by rater between leniencies of evaluations of CRNAs' daily work habits and of didactic lectures. The historical cohorts were anesthesiologists' evaluations over 53 months of CRNAs' daily work habits and 65 months of didactic lectures by visiting professors and faculty. The binary endpoints were the Likert scale scores for all 6 and 10 items, respectively, equaling the maximums of 5 for all items, or not. Mixed effects logistic regression estimated the odds of each ratee performing above or below average adjusted for rater leniency. Bivariate errors in variables least squares linear regression estimated the association between the leniency of the anesthesiologists' evaluations of work habits and didactic lectures. There were 29/107 (27%) raters who were more severe in their evaluations of CRNAs' work habits than other anesthesiologists (two-sided P < 0.01); 34/107 (32%) raters were more lenient. When evaluating lectures, 3/81 (4%) raters were more severe and 8/81 (10%) more lenient. Among the 67 anesthesiologists rating both, leniency (or severity) for work habits was not associated with that for lectures (P = 0.90, unitless slope between logits 0.02, 95% confidence interval -0.34 to 0.30). Rater leniency is of large magnitude when making daily clinical evaluations, even when using a valid and psychometrically reliable instrument. Rater leniency was context dependent, not solely a reflection of raters' personality or rating style.

End-of-life care in patients with a highly transmissible respiratory virus: implications for COVID-19.

Symptom management and end-of-life care are core skills for all physicians, although in ordinary times many anesthesiologists have fewer occasions to use these skills. The current coronavirus disease (COVID-19) pandemic has caused significant mortality over a short time and has necessitated an increase in provision of both critical care and palliative care. For anesthesiologists deployed to units caring for patients with COVID-19, this narrative review provides guidance on conducting goals of care discussions, withdrawing life-sustaining measures, and managing distressing symptoms.

RéSUMé: La prise en charge des symptômes et les soins de fin de vie sont des compétences de base pour tous les médecins, bien qu'en temps ordinaire, de nombreux anesthésiologistes n'ont que peu d'occasions de mettre en pratique ces compétences. La pandémie actuelle de coronavirus 2019 (COVID-19) a provoqué un taux de mortalité significatif dans un court intervalle et a nécessité une augmentation des besoins en soins intensifs et en soins palliatifs. Destiné aux anesthésiologistes déployés dans les unités prenant soin de patients atteints de la COVID-19, ce compte rendu narratif offre des recommandations quant à la façon de mener les discussions à propos des objectifs de soins, du retrait des thérapies de soutien vital, et de la prise en charge de symptômes de détresse.

Anesthesia for Patients Undergoing Anesthesia for Elective Thoracic Surgery During the COVID-19 Pandemic: A Consensus Statement From the Israeli Society of Anesthesiologists.

Anesthesia for thoracic surgery requires specialist intervention to provide adequate operating conditions and one-lung ventilation. The pandemic caused by severe acute respiratory syndrome-associated coronavirus 2 (SARS-CoV-2) is transmitted by aerosol and droplet spread. Because of its virulence, there is a risk of transmission to healthcare workers if appropriate preventive measures are not taken. Coronavirus disease 2019 (COVID-19) patients may show no clinical signs at the early stages of the disease or even remain asymptomatic for the whole course of the disease. Despite the lack of symptoms, they may be able to transfer the virus. Unfortunately, during current COVID-19 testing procedures, about 30% of tests are associated with a false-negative result. For these reasons, standard practice is to assume all patients are COVID-19 positive regardless of swab results. Here, the authors present the recommendations produced by the Israeli Society of Anesthesiologists for use in thoracic anesthesia for elective surgery during the COVID-19 pandemic for both the general population and COVID-19-confirmed patients. The objective of these recommendations is to make changes to some routine techniques in thoracic anesthesia to augment patients' and the medical staff's safety.

Infection Prevention Strategy in Operating Room during Coronavirus Disease 2019 (COVID-19) Outbreak.

A novel coronavirus that emerged in late 2019 rapidly spread around the world. Most severe cases need endotracheal intubation and mechanical ventilation, and some mild cases may need emergent surgery under general anesthesia. The novel coronavirus was reported to transmit via droplets, contact and natural aerosols from human to human. Therefore, aerosol-producing procedures such as endotracheal intubation and airway suction may put the healthcare providers at high risk of nosocomial infection. Based on recently published articles, this review provides detailed feasible recommendations for primary anesthesiologists on infection prevention in operating room during COVID-19 outbreak.