Diversity and Inclusion in Anesthesiology.

In today's world, departments of anesthesiology and professional organizations are rightfully expected to have racial, ethnic, and gender diversity. Diversity and inclusiveness are considered important contributors to an effective and collaborative work environment by promoting excellence in patient care, education, and research. This has been re-emphasized in the racial reckoning in the summer of 2020, and the ongoing health care disparities manifested by the global coronavirus disease 2019 (COVID-19) pandemic. Moreover, the negative consequences of a lack of diversity and inclusion in health care have been shown to impact recruitment, retention, and the economic well-being of academic departments. In the present article, we review the current state of diversity in anesthesiology departments and professional organizations in the United States. We discuss strategies and important approaches to further enhance diversity to promote an inclusive perioperative work environment.

Acute post-operative airway complications following anterior cervical spine surgery and the role for cricothyrotomy.

Anterior cervical spine surgery (ACSS) is a common procedure, but not without its own risks and complications. Complications that can cause airway compromise occur infrequently, but can rapidly lead to respiratory arrest, leading to severe morbidity or death. Knowing emergent post-operative airway management including surgical airway placement is critical. We aim to review the different etiologies of post-operative airway compromise following ACSS, the predictable timeline in which they occur, and the most appropriate treatment and management for each. We place special emphasis on the timing and proper surgical technique for an emergent cricothyrotomy. Angioedema is seen the earliest as a cause of post-operative airway compromise, typically within 6-12 hours. Retropharyngeal hematomas can be seen between 6-24 hours, most commonly within 12 hours. Pharyngolaryngeal edema is seen within 24-72 hours. After 72 hours, retropharyngeal abscess is the most likely etiology. Several studies have utilized delayed extubation protocols following ACSS based on patient risk factors and found reduced postoperative airway complications and reintubation rates. The administration of perioperative corticosteroids continues to be controversial with high-level studies recommending both for and against their use. Animal studies showed that after cardiac arrest, the brain can recover if oxygenation is restored within 5 minutes, but this time is likely shorter with asphyxia prior to cardiac arrest. Experience and training are essential to reduce the time for successful cricothyrotomy placement. Physicians must be prepared to diagnose and treat acute postoperative airway complications following ACSS to prevent anoxic brain injury or death. If emergent intubation cannot be accomplished on the first attempt, physicians should not delay placement of a surgical airway such as cricothyrotomy.

A 25-year retrospective analysis of the American Society of Anesthesiologists physical status classification: did we "up-code" young obese patients when obesity was not yet considered a disease?

PURPOSE: The influence of obesity on anesthetic risk remains controversial, and obesity has only recently been specifically identified as a criterion by which a patient can be given a higher American Society of Anesthesiologists-physical status (ASA-PS) score. Nevertheless, we hypothesized that clinicians had assigned obese patients a greater ASA-PS score before obesity became an "official" criterion in 2015. METHODS: Basic demographic and physical details were collected on patients receiving anesthetics in the Virginia Commonwealth University Health System between 1986 and 2010. The risk ratio (RR) of "up-coding" ASA-PS classification assignments was calculated for patients of varying body mass index (BMI). We specifically focused on the subset of patients aged 20-29 yr in whom the medical sequelae of obesity would not yet likely be manifest. RESULTS: Among a total of 194,698 patients, the percentage who were obese increased from 20% to 39% between 1986 and 2010. Obese patients of all ages were more likely than non-obese patients to be classified as ASA-PS II-IV rather than ASA-PS I. The RR and ratio of RR analyses indicated a consistent pattern of up-coding patients with greater BMI (contingency table Chi-square: P < 0.001). Most notably, relative to patients with a normal BMI, young obese patients aged 20-29 yr had an increased likelihood of up-coding in ASA-PS compared with obese patients in the older cohorts. CONCLUSIONS: These findings suggest a consistent and temporally stable practice of up-coding obese patients despite this lack of explicit guidance. The ASA House of Delegates' recent decision to specifically mention obesity reinforces long-existing practices regarding ASA-PS coding and will likely not degrade the validity of data sets collected before the change.

CME Article: Perceptions of Acupuncture and Acupressure by Anesthesia Providers: A Quantitative Descriptive Study.

Background: Randomized controlled trials show that acupuncture and acupressure support anesthesia management by decreasing anxiety, opioid requirements, and treating post-operative nausea and vomiting. Acupuncture and acupressure have demonstrated clinical usefulness but have not yet diffused into mainstream anesthesia practice. To determine why, this study assessed U.S. anesthesia provider's perceptions of acupuncture and acupressure. Methods: After institutional review board approval, 96 anesthesiology departments stratified by geographic region (Northeast, South, West, and Midwest) and institution type (university medical centers, community hospitals, children's hospitals, and veterans affairs hospitals) were selected for participation in an anonymous, pretested, online survey. The target sample was 1728 providers, of whom 292 (54% anesthesiologists, 44% certified registered nurse anesthetists, 2% anesthesiologist assistants) responded, yielding an overall 17% response rate. Results: Spearman correlation coefficient revealed a statistically significant correlation between acupuncture and geographic region, with the West having the highest predisposition toward acupuncture use (rs = 0.159, p = 0.007). Women are more likely to use acupuncture than men (rs = -0.188; p = 0.002). A strong effect size exists between acupuncture and country of pre-anesthesia training (rs = 1.00; 95% CI = 1.08, 1.16). Some providers have used acupuncture (27%) and acupressure (18%) with positive outcomes; however, the majority have not used these modalities, but would consider using them (54%, SD = 1.44 ; acupressure: 60%, SD = 1.32). Seventy-six percent of respondents would like acupuncture education and 74% would like acupressure education (SDs of 0.43 and 0.44, respectively). Conclusions: While most of the U.S. anesthesia providers in this survey have not used these modalities, they nevertheless report a favorable perception of acupuncture/acupressure's role as part of an anesthetic. This study adds to the body of acupuncture and acupressure research by providing insight into anesthesia providers' perceptions of these alternative medicine modalities.