A Practical Guide for Anesthesia Providers on the Management of Coronavirus Disease 2019 Patients in the Acute Care Hospital.

The coronavirus disease 2019 (COVID-19) pandemic has infected millions of individuals and posed unprecedented challenges to health care systems. Acute care hospitals have been forced to expand hospital and intensive care capacity and deal with shortages in personal protective equipment. This guide will review 2 areas where the anesthesiologists will be caring for COVID-19 patients: the operating room and on airway teams. General principles for COVID-19 preparation and hospital procedures will be reviewed to serve as a resource for anesthesia departments to manage COVID-19 or future pandemics.

A randomized-controlled trial of sugammadex versus neostigmine: impact on early postoperative strength.

BACKGROUND: Residual neuromuscular blockade after surgery is associated with airway obstruction, hypoxia, and respiratory complications. Compared with neostigmine, sugammadex reverses neuromuscular blockade to a train-of-four ratio > 0.9 more rapidly. It is unknown, however, whether the superior reversal profile of sugammadex improves clinically relevant measures of strength in the early postoperative period. METHODS: Patients undergoing general, gynecological, or urologic surgery were randomized to receive either neostigmine (70 µg·kg-1, maximum 5 mg) or sugammadex (2 or 4 mg·kg-1) to reverse neuromuscular blockade. The primary outcome was the ability to breathe deeply measured by incentive spirometry at 30, 60, and 120 min after reversal. RESULTS: We randomized 62 patients to either a neostigmine (n = 31) or sugammadex (n = 31) group. The incentive spirometry volume recovery trajectory was not different between the two groups (P = 0.35). Median spirometry volumes at baseline, 30, 60, and 120 min postoperatively were 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, and 1800 vs 1950 mL for the sugammadex and neostigmine groups, respectively. Postoperative incentive spirometry decrease from baseline was not different between the two groups. Hand grip strength, the ability to sit unaided, train-of-four ratio on postanesthesia care unit (PACU) admission, time to extubation, time to PACU discharge readiness, and Quality of Recovery-15 scores were also not different between the groups. CONCLUSIONS: Measures of postoperative strength, such as incentive spirometry, hand group strength, and the ability to sit up in the early postoperative period were not different in patients who received neostigmine or sugammadex for the reversal of neuromuscular blockade. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02909439); registered: 21 September, 2016.

RéSUMé: CONTEXTE: Les blocs neuromusculaires résiduels après une chirurgie sont associés à l'obstruction des voies aériennes, à l'hypoxie et à des complications respiratoires. Par rapport à la néostigmine, le sugammadex neutralise le bloc neuromusculaire à un ratio de train-de-quatre (TOF) > 0,9 plus rapidement. Nous ne savons toutefois pas si le profil de neutralisation supérieur du sugammadex améliore les mesures pertinentes d'un point de vue clinique de la force en période postopératoire initiale. MéTHODE: Nous avons randomisé des patients subissant une chirurgie générale, gynécologique ou urologique à recevoir de la néostigmine (70 µg·kg-1, maximum 5 mg) ou du sugammadex (2 ou 4 mg·kg-1) pour neutraliser le bloc neuromusculaire. Le critère d'évaluation principal était la capacité des patients à respirer profondément telle que mesurée par spirométrie incitative à 30, 60 et 120 min après la neutralisation. RéSULTATS: Au total, 62 patients ont été randomisés dans les groupes néostigmine (n = 31) ou sugammadex (n = 31). Aucune différence dans la trajectoire de récupération de volume de spirométrie incitative n'a été observée entre les deux groupes (P = 0,35). Les volumes médians de spirométrie préopératoire et à 30, 60 et 120 min postopératoires étaient de 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, et 1800 vs 1950 mL pour les groupes sugammadex et néostigmine, respectivement. La diminution postopératoire de la spirométrie incitative par rapport aux valeurs de base était similaire dans les deux groupes. La force de préhension, la capacité à s'asseoir sans assistance, le ratio de train-de-quatre à l'admission à la salle de réveil, le délai jusqu'à l'extubation, le délai jusqu'à l'obtention des critères de congé de la salle de réveil et les scores de QoR-15 (mesurant la qualité de récupération) ne différaient pas non plus entre les groupes. CONCLUSION: Les mesures de la force postopératoire, telles que la spirométrie incitative, la force de préhension et la capacité de s'asseoir en période postopératoire initiale, ne différaient pas entre les patients ayant reçu de la néostigmine ou du sugammadex pour neutraliser le bloc neuromusculaire. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02909439); enregistrée le 21 septembre 2016.

A ten-year retrospective study of post-dural puncture headache in 32,655 obstetric patients.

PURPOSE: Accidental dural puncture and post-dural puncture headache are well-known complications of neuraxial anesthesia in parturients. The primary goal of this study was to identify the rate of post-dural puncture headache and epidural blood patch in all parturients who received a neuraxial anesthetic during a ten-year period at an academic tertiary-care medical centre. A secondary goal was to identify any delay in hospital discharge due to a post-dural puncture headache. METHODS: We conducted a retrospective analysis of all patients who received a neuraxial anesthetic on the labour and delivery unit at Stony Brook Medical Center from 1 January, 2006 to 31 December, 2015. Standardized neuraxial anesthesia equipment was used throughout this period. Chart reviews were conducted on all patients who received a neuraxial anesthetic and had an accidental dural puncture and/or developed a post-dural puncture headache. RESULTS: Of the 32,655 neuraxial anesthetics performed, 298 (0.9%) patients experienced a post- dural puncture headache. Analysis of all patients who developed a post-dural puncture headache showed that 150 (50.3%) patients received one or more epidural blood patches. Overall, 19 (0.06%) patients had a delay in hospital discharge due to a post-dural puncture headache. CONCLUSIONS: We showed a relatively low incidence (< 1%) of post-dural puncture headache following neuraxial anesthesia in parturients at an academic tertiary-care medical centre. Patients that rated their post-dural puncture headache as very severe were more likely to undergo at least one epidural blood patch procedure. Post-dural puncture headache is a well-known complication of neuraxial anesthesia, and may lead to a delay in hospital discharge.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway.

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Patient-Reported Outcomes in an Enhanced Recovery Pathway.

Patient-reported outcomes (PROs) are measures of health status that come directly from the patient. PROs are an underutilized tool in the perioperative setting. Enhanced recovery pathways (ERPs) have primarily focused on traditional measures of health care quality such as complications and hospital length of stay. These measures do not capture postdischarge outcomes that are meaningful to patients such as function or freedom from disability. PROs can be used to facilitate shared decisions between patients and providers before surgery and establish benchmark recovery goals after surgery. PROs can also be utilized in quality improvement initiatives and clinical research studies. An expert panel, the Perioperative Quality Initiative (POQI) workgroup, conducted an extensive literature review to determine best practices for the incorporation of PROs in an ERP. This international group of experienced clinicians from North America and Europe met at Stony Brook, NY, on December 2-3, 2016, to review the evidence supporting the use of PROs in the context of surgical recovery. A modified Delphi method was used to capture the collective expertise of a diverse group to answer clinical questions. During 3 plenary sessions, the POQI PRO subgroup presented clinical questions based on a literature review, presented evidenced-based answers to those questions, and developed recommendations which represented a consensus opinion regarding the use of PROs in the context of an ERP. The POQI workgroup identified key criteria to evaluate patient-reported outcome measures (PROMs) for their incorporation in an ERP. The POQI workgroup agreed on the following recommendations: (1) PROMs in the perioperative setting should be collected in the framework of physical, mental, and social domains. (2) These data should be collected preoperatively at baseline, during the immediate postoperative time period, and after hospital discharge. (3) In the immediate postoperative setting, we recommend using the Quality of Recovery-15 score. After discharge at 30 and 90 days, we recommend the use of the World Health Organization Disability Assessment Scale 2.0, or a tailored use of the Patient-Reported Outcomes Measurement Information System. (4) Future study that consistently applies PROMs in an ERP will define the role these measures will have evaluating quality and guiding clinical care. Consensus guidelines regarding the incorporation of PRO measures in an ERP were created by the POQI workgroup. The inclusion of PROMs with traditional measures of health care quality after surgery provides an opportunity to improve clinical care.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery.

The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.

Intraoperative airway obstruction related to tracheostomy tube malposition in a patient with achondroplasia and Jeune's syndrome.

A 14 year-old adolescent with achondroplasia and Jeune's syndrome (asphyxiating thoracic dystrophy) presented for cervical spine surgery in the prone position. Due to the need for home mechanical ventilation at night, the patient had a tracheostomy in place. With the first surgical procedure, the cuffed tracheostomy tube was left in place during prone positioning. Difficulties encountered with ventilation through the cuffed tracheostomy tube in the prone position necessitated aborting the case. During three subsequent surgeries, the tracheostomy tube was removed and an armored endotracheal tube was placed through the tracheostomy stoma prior to prone positioning. No further difficulties with ventilation were noted with the subsequent cases. There are currently no guidelines in the medical literature regarding perioperative management of patients with a tracheostomy requiring prone positioning for surgery. The management of such patients is reviewed and possible problems with tracheostomy positioning during prone positioning are explored. Given such issues, we would suggest removal of the tracheostomy tube and placement of an armored endotracheal tube through the stoma during surgical procedures in the prone position.