The virtual pediatric perioperative home, experience at a major metropolitan safety net hospital.

INTRODUCTION: Successes from anesthesiologist-led perioperative surgical homes in the adult patient population have inspired similar initiatives by pediatric hospitals. Typically the care coordination for these perioperative homes is run through hospital-funded, on-site, preanesthesia clinics. Preliminary data from pediatric perioperative homes have shown promising results in improved patient outcomes and decreased length of hospital stay. The majority of pediatric surgeries within the country are performed in nonpediatric hospitals. Such centers may not have the infrastructure or financial resources for a freestanding pediatric preanesthesia clinic. Faced with this situation at the largest safety net hospital in New England, the authors present their experience designing and implementing a "Virtual Pediatric Perioperative Home," a telemedicine-based triage and preanesthetic optimization for pediatric patients at Boston Medical Center, Boston, MA. METHODS: A retrospective chart review of all pediatric anesthesia cases at Boston Medical Center from February 1, 2019, to January 31, 2020, as well as the number of pediatric cases canceled or postponed on the day of surgery for any reason during the same time period was conducted. RESULTS: From February 1, 2019, to January 31, 2020, 1546 anesthetics were performed in children 18 years and under. Of those, 63 were designated as emergent and hence excluded from our analysis. 153 of the total 1483 (9.4%) of nonemergent bookings were canceled or postponed on the day of surgery. This represented a marked decline from our previous year's 13.7% same-day cancellation rate for pediatric patients. The most common reason for case cancellations (41.8%) was acute illness. Cancellation rates varied from month to month, with the highest cancellation rate of the year in September 2019 (18.8%). The departments of Podiatry and Gastroenterology represented the highest cancellation rates as a denominator of their case volumes, 15.4% and 15.2%, respectively. Younger children had 2.4 times the odds (95% CI: 1.720, 3.4) of cancellation compared to older children. DISCUSSION: The virtual pediatric perioperative home (VPPH) may benefit quality of care while decreasing costs to pediatric patients, families, and hospital systems. While direct financial gains may be difficult to demonstrate, the VPPH has the potential to reduce OR delays and same day cancellations related to questions of medical optimization. In the context of a socioeconomically disadvantaged patient population, our VPPH's team of subspecialists created inroads for at risk children to establish or reestablish care for their comorbidities, while collaboration with the Department of Children and Families further streamlined communication and consent for pediatric patients in foster care. CONCLUSIONS: The authors describe the design and successful implementation of a telemedicine-based pediatric preanesthesia triage and medical optimization service at a large safety net hospital. By creating a communication network of pediatric subspecialists, the anesthesiologists were able to, at minimal institutional cost, coordinate care for children with a variety of comorbidities leading up to the day of surgery. This yielded a 9.4% same day cancellation rate in a complex, socioeconomically disadvantaged pediatric patient population at a general hospital.

No Thromboembolic Complications After Facial Feminization Surgery in Transgender Patients Utilizing Estrogen Therapy: A Retrospective Cohort Study.

Purpose: Estrogen therapy is associated with an increased risk of venous thromboembolism (VTE). A large proportion of transfeminine patients use estrogen therapy before undergoing gender-affirming surgery. Many surgeons implement the discontinuation of hormone therapy before surgery. This study sought to evaluate the perioperative risk of VTE in transfeminine patients undergoing the procedure of facial feminization. Methods: Retrospective chart reviews were performed of all patients who underwent facial feminization by a single surgeon at an urban academic institution from 2014 to 2020. Patient characteristics including comorbidities, Caprini score, VTE chemoprophylaxis, and perioperative hormone therapy management were reviewed. The incidences of VTE during perioperative hospital stay and within 1 week and 6 months after the surgical procedure were examined. Results: There were 296 facial feminization procedures performed on 282 distinct patients who met criteria for inclusion in the study. Hormone therapy was prescribed to 83.6% of patients, 69.5% of whom reported that they held these medications before the procedure. Of those holding, 84.1% of patients reported they discontinued these medications between 2 and 4 weeks. No patients received VTE chemoprophylaxis. There were 0 VTE incidents during the patients' perioperative period up to 6 months postprocedure. Conclusion: Our findings support that transfeminine patients who use estrogen hormone therapy are at a minimal risk to experience VTE when undergoing facial feminization procedures. Future directions include evaluating the psychologic effect of discontinuing hormone therapy to help guide perioperative decision making.

High Incidence of Postoperative Nausea and Vomiting in Transgender Women Undergoing Facial Feminization Procedures.

Background: Postoperative nausea and vomiting (PONV) is a significant concern due to its impact on patient comfort, recovery time, and extended hospital stay. Previous research links higher PONV rates in women during their periovulatory phase to estrogen. This study investigates the PONV risk in transgender women after facial feminization surgery. Methods: Retrospective chart reviews of transgender women aged older than 18 undergoing facial feminization from 2014 to 2020 were undertaken. Data included demographics, hormone use history, comorbidities, and PONV history. PONV was classified as any nausea/vomiting episode before discharge. Anesthesia records were examined, and PACU notes were analyzed for PONV indicators. A cis-gender male and female cohort undergoing rhinoplasty served as controls. Results: Of the 282 transgender women receiving facial feminization surgery, 104 experienced PONV, marking a 37% PONV rate. Compared with the 11% PONV rate among cis-gender rhinoplasty patients, this was notably higher. Hormone therapy discontinuation showed no influence on PONV incidence. Conclusions: Transgender women undergoing facial feminization surgery have a 38% PONV rate, surpassing the 11% rate in cis-gender rhinoplasty patients and the general 20%-30% rate for all procedures, including the 25% for oral and maxillofacial surgery. This suggests a heightened PONV risk for transgender women after facial feminization procedures.

Perception of Web-Based Didactic Activities During the COVID-19 Pandemic Among Anesthesia Residents: Pilot Questionnaire Study.

BACKGROUND: Physical and social distancing recommendations aimed at limiting exposure during the COVID-19 pandemic have forced residency programs to increasingly rely on videoconferencing and web-based resources. OBJECTIVE: In this pilot study, we aimed to explore the effects of the COVID-19 pandemic on residency training experience, and to delineate the perceived barriers to the successful implementation of web-based medical education. METHODS: A 19-item survey was compiled and distributed electronically using Qualtrics. This anonymous survey included information on the training level of each resident, their participation in formal didactics before and during the pandemic, and their perception of the ease and limitations of virtual didactics. The resident's opinions on specific educational resources were assessed, and the effectiveness of new delivery methods on resident engagement and learning was examined. RESULTS: Thirty anesthesiology residents were surveyed, 19 of whom agreed to participate in the pilot study. One participant with incomplete responses was excluded, yielding a final cohort of 18 respondents. Most residents (56%, 10/18) reported that the COVID-19 pandemic negatively affected their residency training. The time spent on didactic training and independent studies was, nevertheless, not affected by the pandemic for 90% (16/18) of respondents. Nonetheless, 72% (13/18) of residents were less engaged during virtual lectures in comparison to in-person didactics. Important limitations included distraction from the physical environment (67%, 12/18), internet instability (67%, 12/18), less obligation to participate (44%, 8/18), technical difficulty and unmuted microphones (33%, 6/18, each), and people speaking over each other (28%, 5/18). Despite these limitations, most residents stated that they would like to keep a combination of virtual didactics including live Zoom lectures (56%, 10/18), prerecorded web didactics (56%, 10/18), and virtual ground rounds via Zoom (50%, 9/18) as the "new normal." CONCLUSIONS: Despite important limitations listed in this report, anesthesia residents would like to keep a combination of virtual lectures and presentations as the new normal after the COVID-19 pandemic.

Persistent coagulopathy after gunshot traumatic brain injury: the importance of INR and the SPIN score.

INTRODUCTION: Penetrating ballistic brain injury (gunshot traumatic brain injury or GTBI) is associated with a high mortality. Admission Glascow Coma Scale (GCS), injury severity score and neurological findings, cardiopulmonary instability, coagulopathy and radiological finding such as bullet trajectory and mass effect are shown to predict survival after GTBI. We aimed to examine the dynamics of the observed coagulopathy and its association with outcome. METHODS: In this single-centered retrospective cohort study, we examined 88 patients with GTBI between 2015 and 2021. Variables analyzed include patient age; temperature, hemodynamic and respiratory variables, admission Glasgow Coma Scale (GCS); injury severity score (ISS); head abbreviated injury scale (AIS); Marshall, Rotterdam, SPIN and Baylor scores, and laboratory data including PTT, INR and platelet count. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. RESULTS: The average age of our sample was 28.5 years and a majority were male subjects (92%). Fifty-four (62%) of the patients survived to discharge. The GCS score, as well as the motor, verbal, and eye-opening sub-scores were higher in survivors (P < 0.001). As was expected, radiologic findings including the Marshall and Rotterdam Scores were also associated with survival (P < 0.001). Although the ISS and Head AIS scores were higher (P < 0.001), extracranial injuries were not more prevalent in non-survivors (P= 0.567). Non-survivors had lower platelet counts and elevated PTT and INR (P < 0.001) on admission. PTT normalized within 24 h but INR continued to increase in non-survivors. SPIN score, which includes INR, was a better predictor for mortality than Rotterdam, Marshall, and Baylor etc. CONCLUSION: Progressively increasing INR after GTBI is associated with poor outcome and may indicate consumption coagulopathy from activation of the extrinsic pathway of coagulation and metabolic derangements that are triggered and sustained by the brain injury. The SPIN score, which incorporates INR as a major survival score component, outperforms other available prediction models for predicting outcome after GTBI.

Oxygen desaturation in a transgender man: initial concerns and recommendations regarding the practice of chest binding: a case report.

BACKGROUND: Over 1.4 million US adults identify as transgender when gender identity differs from the sex assigned at birth [1]. Although transgender patients face adverse health outcomes, they remain an understudied population [2]. A 2017 study surveyed 411 practicing clinicians and found that 80% had been involved in treating a transgender patient, but 80.6% had never received training on transgender care [3]. The purpose of this report is to describe prolonged desaturation in one case of a transgender patient who wore a chest binder intraoperatively owing to a lack of preoperative recognition. CASE PRESENTATION: A 19-year-old transgender male of African-American descent with anxiety and class 3 obesity presented for an esophagogastroduodenoscopy to evaluate a 2-year history of upper abdominal pain unresponsive to proton pump inhibitor therapy, with a plan for monitored anesthesia care. His medications included sertraline, pantoprazole, zolpidem, ergocalciferol, leuprolide, and testosterone cypionate. Preoperatively, the patient was instructed to remove all clothing and to don a patient gown while in the bathroom. The attending anesthesiologist then conducted the interview and examination in the preoperative holding area. The patient was induced with 250 mg of propofol, and reassuring respirations were noted by capnography. Respirations and oxygen saturation remained stable upon insertion of the endoscope. Four minutes later, the patient's oxygen saturation rapidly decreased to 50% and end-tidal capnography was lost. The endoscope was removed, and the patient was given 200 mg of propofol and 20 mg succinylcholine. His oxygen saturation recovered to 80% and 100% after 2 and 5 minutes, respectively, of ventilation with 100% inspired oxygen. No further oxygen desaturation was noted throughout the procedure, and the patient was closely monitored for signs of respiratory difficulty during an uneventful postoperative course. After full emergence, it was revealed that the patient had been wearing a chest binder throughout the operative procedure. The patient was counseled on the necessity to communicate the presence of this accessory prior to all future procedures. CONCLUSION: In the clinical narrative, a healthy patient was observed to have prolonged oxygen desaturation after induction of anesthesia. Laryngospasm was suspected clinically owing to the sudden absence of end-tidal carbon dioxide. Prolonged oxygen desaturation despite appropriate interventions suggests the contribution of additional factors. We speculate that the presence of a chest binder intraoperatively predisposed the patient to more rapid oxygen desaturation less responsive to typical therapy. A chest binder would introduce mechanical restriction to the patient's breathing owing to its inherent design to compress. Although the patient was asked to remove all clothing, specific instructions were not provided regarding the removal of a chest binder. The presence of chest binding was also absent in the electronic health record, despite the documented presence of the patient's preferred gender, hormonal therapy regimen, and medical history. Ultimately, this case reflects the gap between practitioner knowledge and hospital guidelines and the practices of transgender patients. In reviewing existing literature and the potential for atelectasis with external compression, we would consider that patients refrain from chest binding for 12-24 hours before surgical procedures, resume no sooner than 24 hours after ambulation, and participate in diagnostic incentive spirometry pre- and postoperatively.

High-Dose Inhaled Nitric Oxide for the Treatment of Spontaneously Breathing Pregnant Patients With Severe Coronavirus Disease 2019 (COVID-19) Pneumonia.

OBJECTIVE: To evaluate whether the use of inhaled nitric oxide (iNO)200 improves respiratory function. METHODS: This retrospective cohort study used data from pregnant patients hospitalized with severe bilateral coronavirus disease 2019 (COVID-19) pneumonia at four teaching hospitals between March 2020 and December 2021. Two cohorts were identified: 1) those receiving standard of care alone (SoC cohort) and 2) those receiving iNO200 for 30 minutes twice daily in addition to standard of care alone (iNO200 cohort). Inhaled nitric oxide, as a novel therapy, was offered only at one hospital. The prespecified primary outcome was days free from any oxygen supplementation at 28 days postadmission. Secondary outcomes were hospital length of stay, rate of intubation, and intensive care unit (ICU) length of stay. The multivariable-adjusted regression analyses accounted for age, body mass index, gestational age, use of steroids, remdesivir, and the study center. RESULTS: Seventy-one pregnant patients were hospitalized for severe bilateral COVID-19 pneumonia: 51 in the SoC cohort and 20 in the iNO200 cohort. Patients receiving iNO200 had more oxygen supplementation-free days (iNO200: median [interquartile range], 24 [23-26] days vs standard of care alone: 22 [14-24] days, P=.01) compared with patients in the SoC cohort. In the multivariable-adjusted analyses, iNO200 was associated with 63.2% (95% CI 36.2-95.4%; P<.001) more days free from oxygen supplementation, 59.7% (95% CI 56.0-63.2%; P<.001) shorter ICU length of stay, and 63.6% (95% CI 55.1-70.8%; P<.001) shorter hospital length of stay. No iNO200-related adverse events were reported. CONCLUSION: In pregnant patients with severe bilateral COVID-19 pneumonia, iNO200 was associated with a reduced need for oxygen supplementation and shorter hospital stay.

Postintubation Decline in Oxygen Saturation Index Predicts Mortality in COVID-19: A Retrospective Pilot Study.

BACKGROUND: Acute respiratory failure from COVID-19 pneumonia is a major cause of death after SARS-CoV-2 infection. We investigated whether PaO2/FiO2, oxygenation index (OI), SpO2/FiO2, and oxygen saturation index (OSI), commonly used to assess the severity of acute respiratory distress syndrome (ARDS), can predict mortality in mechanically ventilated COVID-19 patients. METHODS: In this single-centered retrospective pilot study, we enrolled 68 critically ill mechanically ventilated adult patients with confirmed COVID-19. Physiological variables were recorded on the day of intubation (day 0) and postintubation days 3 and 7. The association between physiological parameters, PaO2/FiO2, OI, SpO2/FiO2, and OSI with mortality was assessed using multiple variable logistic regression analysis. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. RESULTS: The ARDS severity indices were not statistically different on the day of intubation, suggesting similar baseline conditions in nonsurviving and surviving patients. However, these indices were significantly worse in the nonsurviving as compared to surviving patients on postintubation days 3 and 7. On intubation day 3, PaO2/FiO2 was 101.0 (61.4) in nonsurviving patients vs. 140.2 (109.6) in surviving patients, p=0.004, and on day 7 106.3 (94.2) vs. 178.0 (69.3), p < 0.001. OI was 135.0 (129.7) in nonsurviving vs. 84.8 (86.1) in surviving patients (p=0.003) on day 3 and 150.0 (118.4) vs. 61.5 (46.7) (p < 0.001) on day 7. OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7. Similarly, SpO2/FiO2 was 130 (90) vs. 210 (90) (p=0.003) on day 3 and 130 (90) vs. 230 (50) (p < 0.001) on day 7, while OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7 in the nonsurviving and surviving patients, respectively. All measures were independently associated with hospital mortality, with significantly greater odds ratios observed on day 7. The area under the receiver operating characteristic curve (AUC) for mortality prediction was greatest on intubation day 7 (AUC = 0.775, 0.808, and 0.828 for PaO2/FiO2, OI, SpO2/FiO2, and OSI, respectively). CONCLUSIONS: Decline in oxygenation indices after intubation is predictive of mortality in COVID-19 patients. This time window is critical to the outcome of these patients and a possible target for future interventions. Future large-scale studies to confirm the prognostic value of the indices in COVID-19 patients are warranted.