Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study.

BACKGROUND: Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS: We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS: The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group. CONCLUSIONS: In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.

Training Anesthesiology Residents to Care for the Traumatically Injured in the United States.

Training and education for trauma anesthesiology have been predicated on 2 primary pathways: learning through peripheral "complex, massive transfusion cases"-an assumption that is flawed due to the unique demands, skills, and knowledge of trauma anesthesiology-or learning through experiential education, which is also incomplete due to its unpredictable and variable exposure. Residents may receive training from senior physicians who may not maintain a trauma-focused continuing medical education. Further compounding the issue is the lack of fellowship-trained clinicians and standardized curricula. The American Board of Anesthesiology (ABA) provides a section for trauma education in its Initial Certification in Anesthesiology Content Outline. However, many trauma-related topics also fall under other subspecialties, and the outline excludes "nontechnical" skills. This article focuses on the training of anesthesiology residents and proposes a tier-based approach to teaching the ABA outline by including lectures, simulation, problem-based learning discussions, and case-based discussions that are proctored in conducive environments by knowledgeable facilitators.

A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

Alternative blood products in trauma.

PURPOSE OF REVIEW: Hemorrhage and trauma-induced coagulopathy cause significant morbidity and mortality in trauma patients. Although blood products are the cornerstone of resuscitation, these resources are scarce, necessitating alternatives. This review examines the use of alternative blood products in trauma as well as the literature supporting their use. RECENT FINDINGS: There is no single true blood product alternative. In recent years, there has been great progress in understanding trauma-induced pathophysiology and blood component alternatives. Products such as tranexamic acid and prothrombin complex concentrate have become well established and are frequently utilized in trauma centers, and many more alternatives are still undergoing further research and development. SUMMARY: Stabilization of hemorrhage and resuscitation is priority in trauma-induced coagulopathy treatment. Alternative products such as tranexamic acid, recombinant factors, prothrombic complex concentrate, fibrinogen concentrates, and desmopressin may also be considered based on the clinical context. Viscoelastic hemostatic assays such as rotational thromboelastometry and thromboelastography can help guide these efforts. Following initial stabilization, additional interventions such as iron supplementation, erythropoietin stimulating agents, and vitamin D may help with chronic sequela.

Traumatic brain injury and RSI is rocuronium or succinylcholine preferred?

PURPOSE OF REVIEW: Traumatic brain injury is widespread and has significant morbidity and mortality. Patients with severe traumatic brain injury often necessitate intubation. The paralytic for rapid sequence induction and intubation for the patient with traumatic brain injury has not been standardized. RECENT FINDINGS: Rapid sequence induction is the standard of care for patients with traumatic brain injury. Historically, succinylcholine has been the agent of choice due to its fast onset and short duration of action, but it has numerous adverse effects such as increased intracranial pressure and hyperkalemia. Rocuronium, when dosed appropriately, provides neuromuscular blockade as quickly and effectively as succinylcholine but was previously avoided due to its prolonged duration of action which precluded neurologic examination. However, with the widespread availability of sugammadex, rocuronium is able to be reversed in a timely manner. SUMMARY: In patients with traumatic brain injury necessitating intubation, rocuronium appears to be safer than succinylcholine.

The Obese Patient: Facts, Fables, and Best Practices.

The prevalence of obesity continues to rise worldwide, and anesthesiologists must be aware of current best practices in the perioperative management of the patient with obesity. Obesity alters anatomy and physiology, which complicates the evaluation and management of obese patients in the perioperative setting. Gastric point-of-care ultrasound (PoCUS) is a noninvasive tool that can be used to assess aspiration risk in the obese patient by evaluating the quantity and quality of gastric contents. An important perioperative goal is adequate end-organ perfusion. Standard noninvasive blood pressure (NIBP) is our best available routine surrogate measurement, but is vulnerable to greater inaccuracy in patients with obesity compared to the nonobese population. Current NIBP methodologies are discussed. Obese patients are at risk for wound and surgical site infections, but few studies conclusively guide the exact dosing of intraoperative prophylactic antibiotics for them. We review evidence for low-molecular-weight heparins and weight-based versus nonweight-based administration of vasoactive medications. Finally, intubation and extubation of the patient with obesity can be complicated, and evidence-based strategies are discussed to mitigate danger during intubation and extubation.

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

BACKGROUND: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine. METHODS: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data. RESULTS: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia. CONCLUSIONS: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.

A Positive Cocaine Urine Toxicology Test and the Effect on Intraoperative Hemodynamics Under General Anesthesia.

BACKGROUND: Cocaine has a short biological half-life, but inactive urine metabolites may be detectable for a week following use. It is unclear if patients who test positive for cocaine but have a normal electrocardiogram and vital signs have a greater percentage of hemodynamic events intraoperatively. METHODS: A total of 328 patients with a history of cocaine use who were scheduled for elective noncardiac surgery under general anesthesia were enrolled. Patients were categorized into cocaine-positive versus cocaine-negative groups based on the results of their urine cocaine toxicology test. The primary aim of this study was to evaluate whether asymptomatic cocaine-positive patients had similar percentages of intraoperative hemodynamic events, defined as (1) a mean arterial blood pressure (MAP) of <65 or >105 mm Hg and (2) a heart rate (HR) of <50 or >100 beats per minute (bpm) compared to cocaine-negative patients. The study was powered to assess if the 2 groups had an equivalent mean percent of intraoperative hemodynamic events within specific limits using an equivalence test of means consisting of 2 one-sided tests. RESULTS: The cocaine-positive group had a blood pressure (BP) that was outside the set limits 19.4% (standard deviation [SD] 17.7%) of the time versus 23.1% (SD 17.7%) in the cocaine-negative group (95% confidence interval [CI], 0.5-7.0). The cocaine-positive group had a HR outside the set limits 9.6% (SD 16.2%) of the time versus 8.2% (SD 14.9%) in the cocaine-negative group (95% CI, 4.3-1.5). Adjusted for age, sex, body mass index (BMI), smoking status, and the presence of comorbid hypertension, renal disease, and psychiatric illness, the cocaine-positive and cocaine-negative patients were similar within a 7.5% margin of equivalence for MAP data (ß coefficient = 2%, P = .003, CI, 2-6) and within a 5% margin of equivalence for HR data (ß coefficient = 0.2%, P < .001, CI, 4-3). CONCLUSIONS: Asymptomatic cocaine-positive patients undergoing elective noncardiac surgery under general anesthesia have similar percentages of intraoperative hemodynamic events compared to cocaine-negative patients.

Ketamine Use in the Surgical Patient: a Literature Review.

PURPOSE OF REVIEW: While ketamine is an established anesthetic, its role in the management of acute surgical pain is less certain. Therefore, a literature review is warranted to examine the role of ketamine in acute pain management. RECENT FINDINGS: The use of ketamine appears to be most efficacious in larger procedures that lead to increased systemic inflammation or extensive tissue damage. In addition, ketamine seems to be most successful when administered consistently throughout a procedure, such as by an infusion instead of a single bolus, in order to have adequate dosing for an analgesic effect. Therefore, the focus of research should be on procedures that lead to moderate to severe pain using frequent dosing to determine the most effective role of ketamine. Most importantly, the current literature shows that ketamine can be used as a successful part of multimodal anesthesia with few side effects in patients undergoing major procedures associated with moderate to severe pain.

The influence of morbid obesity on difficult intubation and difficult mask ventilation.

PURPOSE: To determine the influence of morbid obesity on the incidence of difficult mask ventilation and difficult intubation. METHODS: Over a 6-year period, all tracheal intubations in the operating room of a large tertiary teaching hospital were analyzed. A modified version of the intubation difficulty scale (mIDS) was used to define easy versus difficult intubation, where a score of two or greater was defined as difficult intubation. Difficult mask ventilation was defined as the use of one or more adjuncts to achieve successful mask ventilation. RESULTS: Of 45,447 analyzed cases, 1893 (4.2%) were classified as difficult intubations. Morbidly obese patients were not more likely to have difficult intubation [Odds Ratio (OR) = 1.131, 95% confidence interval (CI): 0.958, 1.334, p = 0.146]. Factors that were associated with difficult intubation included patient age > 46 years, male sex, Mallampati 3-4, thyromental distance < 6 cm, and the presence of intact dentition. Of 37,016 cases in which mask ventilation was attempted, 1069 (2.9%) were difficult. Morbidly obese patients were more likely to have difficult mask ventilation (OR = 3.785, 95% CI: 3.188, 4.493, p < 0.0001). Other factors associated with difficult mask ventilation included patient age > 46 years, male sex, Mallampati 3-4, and a history of obstructive sleep apnea. Having intact dentition decreased the likelihood of difficult mask ventilation. CONCLUSION: Morbidly obese patients do not have a higher incidence of difficult intubation compared to non-morbidly obese patients. However, they have a significantly higher incidence of difficult mask ventilation. Other factors that are predictive of both difficult mask ventilation and difficult intubation include age > 46 years, male sex, and Mallampati 3-4.

Are morbidly obese patients suitable for ambulatory surgery?

PURPOSE OF REVIEW: The incidence of morbid obesity continues to increase worldwide. Associated comorbidities, particularly obstructive sleep apnea, increase the perioperative morbidity for this group of patients. The purpose of this review is to discuss appropriate selection of morbidly obese patients for ambulatory surgery. RECENT FINDINGS: Patients with BMI <40 kg/m can safely undergo ambulatory surgery, provided their comorbidities are optimized before surgery. However, patients who are super obese (BMI ≥ 50 kg/m) have an increased risk of perioperative complications, suggesting that these patients should be selected with caution for ambulatory surgery. The outcomes data for patients with BMI between 40-50 kg/m are limited, and therefore, it is suggested that other factors such as obstructive sleep apnea are taken into consideration. SUMMARY: Recent evidence suggests that carefully selected morbidly obese patients can safely undergo surgery on an ambulatory basis. Individualized evaluations taking into account patient-related factors, surgery-related factors, and anesthesia-related factors should dictate which patients are appropriate for ambulatory surgery.

Preoperative Assessment of a Patient Undergoing Bariatric Surgery.

Over the past few decades, obesity rates in the United States have risen drastically, and with this, there has been a rising demand for bariatric surgery. As such, anesthesiologists need to be familiar with the challenges presented by patients seeking bariatric surgery. Obesity causes pathophysiologic changes which may affect decision-making during the management of these patients. Patients seeking bariatric surgery also have a long, prescribed preoperative course that offers anesthesiologists the opportunity to be involved earlier during the pre-surgical evaluation and optimization process.

A survey of education and confidence level among graduating anesthesia residents with regard to selected peripheral nerve blocks.

BACKGROUND: As peripheral nerve blockade has increased significantly over the past decade, resident education and exposure to peripheral nerve blocks has also increased. This survey assessed the levels of exposure and confidence that graduating residents have with performing selected peripheral nerve blocks. METHODS: All program directors of ACGME-accredited anesthesiology programs in the USA were asked to distribute an online survey to their graduating residents. Information was gathered on the number and types of nerve blocks performed, technique(s) utilized, perceived comfort level in performing nerve blocks, perceived quality of regional anesthesia teaching during residency, and suggested areas for improvement. RESULTS: One hundred and seven residents completed the survey. The majority completed more than 60 nerve blocks. Femoral and interscalene blocks were performed most frequently, with 59% and 41% of residents performing more than 20 of each procedure, respectively. The least-performed block was the lumber plexus block, with just 9% performing 20 or more blocks. Most residents reported feeling "very" to "somewhat" comfortable performing the surveyed blocks, with the exception of the lumber plexus block, where 64% were "not comfortable." Overall, 78% of residents were "mostly" to "very satisfied" with the quality of education received during residency. CONCLUSIONS: Most of the respondents fulfilled the ACGME requirement and expressed satisfaction with the peripheral nerve block education received during residency. However, the ACGME requirement for 40 nerve blocks may not be adequate for some residents to feel comfortable in performing a full range of blocks upon graduation. Many residents felt that curriculums incorporating simulator training and didactic lectures would be the most helpful method of improving the quality of their education pertaining to peripheral nerve blocks.