Electroconvulsive Therapy Considerations for Transgendered Patients.

As the transgender patient population continues to grow, health care providers will need to become aware of elements unique to the transgender community in order to provide the highest quality of care. Neuromuscular blockade with succinylcholine is routinely administered to patients undergoing electroconvulsive therapy (ECT). Decreased amounts or activity of pseudocholinesterase in serum can lead to prolonged duration of muscle paralysis. Causes of reduced action by pseudocholinesterase include genetically abnormal enzymes, reduced hepatic production, pregnancy, and various drug interactions. Estrogen supplementation taken by transitioning patients may affect the duration of neuromuscular blockade.This is a case of a 32-year-old male-to-female transgender patient with prolonged apnea following ECT treatment for severe, refractory depression. Further investigation revealed the patient was on estrogen therapy as a part of her transition and laboratory testing demonstrated reduced serum pseudocholinesterase activity. Further laboratory testing demonstrated reduced serum pseudocholinesterase activity. Succinylcholine dosing was titrated to an appropriate level to avoid prolonged apnea in subsequent ECT treatments. Physicians and other health care providers are faced with a unique population in the transgender community and must be aware of distinctive circumstances when providing care to this group. Of specific interest, many transitioning and transitioned patients can be on chronic estrogen supplementation. Neuromuscular blockade in those patients require attention from the anesthesiology care team as estrogen compounds may decrease pseudocholinesterase levels and lead to prolonged muscle paralysis from succinylcholine.

Analysis to Establish Differences in Efficiency Metrics Between Operating Room and Non-Operating Room Anesthesia Cases.

While a number of studies have examined efficiency metrics in the operating rooms (ORs), there are few studies addressing non-operating room anesthesia (NORA) metrics. The standards established in the realm of OR studies may not apply to ongoing investigations of NORA efficiency. We hypothesize that there are significant differences in these commonly used metrics. Using retrospective data from a single tertiary care hospital in the 2015 calendar year, we measured turnover times, cancellation rates, first case start delays, and scheduling error (actual time minus scheduled time) for the OR and NORA settings. On average, TOTs for NORA cases were approximately 50% shorter than OR cases (16.21 min vs. 37.18 min), but had a larger variation (11.02 min vs. 8.12 min). NORA cases were 64% as likely to be cancelled compared to OR cases. In contrast, NORA cases had an average first case start delay that was two times greater than that of OR cases (24.45 min vs. 10.58 min), along with over double the standard deviation (11.97 min vs. 5.90 min). Case times for NORA settings tended to be overestimated (-4.07 min versus -2.12 min), but showed less variation (8.61 min vs. 17.92 min). In short, there are significant differences in common efficiency metrics between OR and NORA cases. Future studies should elucidate and validate appropriate efficiency benchmarks for the NORA setting.