Decreased Electroencephalographic Alpha Power During Anesthesia Induction Is Associated With EEG Discontinuity in Human Infants.

BACKGROUND: Electroencephalogram (EEG) discontinuity can occur at high concentrations of anesthetic drugs, reflecting suppression of electrocortical activity. This EEG pattern has been reported in children and reflects a deep state of anesthesia. Isoelectric events on the EEG, a more extreme degree of voltage suppression, have been shown to be associated with worse long-term neurologic outcomes in neonates undergoing cardiac surgery. However, the clinical significance of EEG discontinuities during pediatric anesthesia for noncardiac surgery is not yet known and merits further research. In this study, we assessed the incidence of EEG discontinuity during anesthesia induction in neurologically normal infants and the clinical factors associated with its development. We hypothesized that EEG discontinuity would be associated with sevoflurane-induced alpha (8-12 Hz) power during the period of anesthesia induction in infants. METHODS: We prospectively recorded 26 channels of EEG during anesthesia induction in an observational cohort of 54 infants (median age, 7.6 months; interquartile range [IQR] [4.9-9.8 months]). We identified EEG discontinuity, defined as voltage amplitude <25 microvolts for >2 seconds, and assessed its association with sevoflurane-induced alpha power using spectral analysis and multivariable logistic regression adjusting for clinically important variables. RESULTS: EEG discontinuity was observed in 20 of 54 subjects (37%), with a total of 25 discrete events. Sevoflurane-induced alpha power in the posterior regions of the head (eg, parietal or occipital regions) was significantly lower in the EEG discontinuity group (midline parietal channel on the electroencephalogram, International 10-20 System [Pz]; 8.3 vs 11.2 decibels [dBs]; P = .004), and this association remained after multivariable adjustment (adjusted odds ratio [aOR] = 0.51 per dB increase in alpha power [95% CI, 0.30-0.89]; P = .02). There were no differences in the baseline (unanesthetized) EEG between groups in alpha power or power in any other frequency band. CONCLUSIONS: We demonstrate that EEG discontinuity is common during anesthesia induction and is related to the level of sevoflurane-induced posterior alpha power, a putative marker of cortical-thalamic circuit development in the first year of life. This association persisted even after adjusting for age and propofol coadministration. The fact that this difference was only observed during anesthesia and not in the baseline EEG suggests that otherwise hidden brain circuit properties are unmasked by general anesthesia. These neurophysiologic markers observed during anesthesia may be useful in identifying patients who may have a greater chance of developing discontinuity.

Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned.

The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.

Anesthesiology Training in the Time of COVID-19: Problems and Solutions.

From March to June of 2020, Montefiore Medical Center faced one of the most acute surges in hospital admissions and critical illness ever experienced in the United States due to the severe acute respiratory syndrome coronavirus 2 pandemic. The pandemic had not yet spread to most of the country, and there was a relative deficit of knowledge regarding treatments, prognosis, and prevention of the virus, making this experience relatively unique and challenging. As part of a surge plan, our institution converted nonclinical spaces, such as conference rooms, to inpatient care settings and placed elective surgeries on hold to free up resources. A central deployment office suspended anesthesiology resident rotations and instead assigned them to intensive care settings based on need. For the Montefiore Medical Center Department of Anesthesiology, preserving its academic mission and commitment to Graduate Medical Education was essential. Adaptations included changing the residency rotation structure to biweekly, converting didactics online, ensuring adequate case numbers for graduating residents, actively pursuing wellness interventions, and prioritizing the safety of the residents caring for patients with coronavirus disease 2019 (COVID-19). In this brief report, the authors discuss solutions devised to maintain the quality of anesthesiology resident education and training as much as possible during the COVID-19 surge.

Assessment of Didactic Transesophageal Echocardiography Education During Anesthesia Residency.

BACKGROUND: Transesophageal echocardiography can be a useful monitor during noncardiac surgery, in patients with comorbidities and/or undergoing procedures associated with substantial hemodynamic changes. The goal of this study was to investigate if transesophageal-echocardiography-related knowledge could be acquired during anesthesia residency. METHODS: After institutional review board approval, a prospective observational study was performed in two anesthesiology residency programs. After a 41-week didactic transesophageal-echocardiography-education curriculum residents' exam scores were compared to baseline. The educators' examination was validated against the National Board of Echocardiography's Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography. RESULTS: After the 41-week course, clinical anesthesia (CA)-3 exam scores increased 12% compared to baseline (P = .03), CA-2 scores increased 29% (P = .007), and CA-1 scores increased 25% (P = .002). Pearson correlation coefficient between the educators' exam score and the special competence exam percentile rank was 0.69 (P = .006). Pearson correlation coefficient between the educators' exam score and the special competence exam scaled score was 0.71 (P = .0045). CONCLUSIONS: The 41-week course resulted in significant increases in exam scores in all 3 CA-classes. While didactic knowledge can be learned by anesthesiology residents during training, it requires significant time and effort. It is important to educate residents in echocardiography, to prepare them for board examinations and to care for the increasingly older and sicker patient population. Further work needs to be done to determine optimal methods to provide such education.

Perioperative Efficiency vs. Quality of Care - Do We Always Have to Choose?

Introduction: ATTEMPTS to enforce optimization practices for operating room (OR) efficiency are often interpreted as a "pressure for production" which threatens patient safety. The aim of this study is to assess if and how improvements in OR efficiency affect patient safety and thus the quality of care. Methods: In an attempt to optimize OR efficiency, a new OR management approach "Integrated Practice Improvement Solutions" (IPIS) was developed at the Weiler Division of Montefiore Medical Center in 2011. IPIS is a flexible managerial system based on elements of multiple practice improvement methodologies incorporated into an open source framework. It was implemented in 2012. The data presented covers the period from 2012 through 2014 when the system was temporarily discontinued due to administrative restructuring. Data from 2011 was used as a baseline. The impact of IPIS on patient safety and quality of care was assessed based on quality improvement and patient safety (QIPS) Committee reports covering the same period of time. Results: IPIS implementation resulted in an increase in surgical workload by an average of 10.7%, an increase in OR and anesthesia revenues by 18.5% and 6.9%, respectively, and decreases in turnover time by 15% and overtime for the anesthesia staff by 26%. Based on QIPS reports, the total number of complications potentially attributable to "production pressure" was 0.25%, 0.2% and 0.16% in 2012, 2013 and 2014, respectively compared to 0.21% in 2011 (p = 0.56). Conclusions: Gradual implementation of a methodologically structured improvement in OR efficiency has no negative impact on patient safety and quality of care.

Reasons for article retraction in anesthesiology: a comprehensive analysis.

BACKGROUND: Increasing awareness of scientific misconduct has prompted various fields of medicine, including orthopedic surgery, neurosurgery, and dentistry to characterize the reasons for article retraction. The purpose of this review was to evaluate the reasons for and the rate of article retraction in the field of anesthesia within the last 30 years. METHODS: Based on a reproducible search strategy, two independent reviewers searched MEDLINE, EMBASE, and the Retraction Watch website to identify retracted anesthesiology articles. Extracted data included: author names, year of publication, year of the retracted article, journal name, journal five-year impact factor, research type (clinical, basic science, or review), reason for article retraction, number of citations, and presence of a watermark indicating article retraction. RESULTS: Three hundred and fifty articles were included for data extraction. Reasons for article retraction could be grouped into six broad categories. The most common reason for retraction was fraud (data fabrication or manipulation), which accounted for nearly half (49.4%) of all retractions, followed by lack of appropriate ethical approval (28%). Other reasons for retraction included publication issues (e.g., duplicate publications), plagiarism, and studies with methodologic or other non-fraud data issues. Four authors were associated with most of the retracted articles (59%). The majority (69%) of publications utilized a watermark on the original article to indicate that the article was retracted. Journal Citation Reports journal impact factors ranged from 0.9 to 48.1 (median [interquartile range (IQR)], 3.6 [2.5-4.0]), and the most cited article was referenced 197 times (median [IQR], 13 [5-26]). Most retracted articles (66%) were cited at least once by other journal articles after having been withdrawn. CONCLUSIONS: Most retracted articles in anesthesiology literature were retracted because of research misconduct. Limited information is available in the retraction notices, unless explicitly stated, so it is challenging to distinguish between an honest error and research misconduct. Therefore, a standardized reporting process with structured retraction notices is desired.

Electroencephalographic Findings and Clinical Behavior During Induction of Anesthesia With Sevoflurane in Human Infants: A Prospective Observational Study.

Seizures and interictal epileptiform discharges (IEDs) have been described during sevoflurane. We prospectively estimated their incidence in 54 otherwise neurologically healthy infants by obtaining the full-head video electroencephalogram (EEG). No infants had clinical seizures, but 1 had an electrographic seizure; 3 others had focal IEDs (7.4%; 95% confidence interval [CI], 2.1%-17.9%). We detected no differences in demographic or clinical characteristics between normal and abnormal EEG groups. Diffuse slowing was the most common initial EEG change followed by fast (α, ß) activity in all head leads. Larger studies with more statistical power are needed to further investigate the hypotheses generated with this research.

Measurement of resident fatigue using rapid number naming.

OBJECTIVE: Sleep deprivation has a negative effect on neurocognitive performance. The King-Devick test (KDT), which tests speed and accuracy of number-reading, requires integrity of saccades, visual processing, and cognition. This study investigated effects of sleep deprivation in on-call residents using KDT. METHODS: A prospective cohort study was conducted among 80 residents. KDT was performed at the beginning and end of an overnight call shift for the residents in the experimental group. A control group was tested at the beginning of 2 consecutive day shifts. Estimates of hours of sleep, Karolinska Sleepiness Scale (KSS)(1 = extremely alert, 9 = extremely sleepy), and time and accuracy of KDT were recorded. RESULTS: 42 residents were tested before and after overnight call shifts and 38 served as controls. Change in test time differed between the groups, with the experimental group performing 0.54(SD = 4.0) seconds slower after their night on call and the control group performing 2.32(SD = 3.0) seconds faster on the second day, p < 0.001. This difference was larger in surgical compared to medical residents. CONCLUSIONS: Sleep deprivation was inversely correlated with neurocognitive performance as measured by KDT, with more effect on surgical than medical residents. Further research could investigate whether this test could help determine fatigue level and ability to continue working after a long shift.

Domino Liver Transplantation from a Child with Propionic Acidemia to a Child with Idiopathic Fulminant Hepatic Failure.

Domino liver transplant has emerged as a viable strategy to increase the number of grafts available for transplantation. In the domino transplant organs explanted from one patient are transplanted into another patient. The first successful domino liver transplant was performed in Portugal in 1995. Since then this innovative concept has been applied to several genetic or biochemical disorders that are treated by liver transplantation. An important consideration during this operation is that such livers can pose a risk of the de novo development of the disease in the recipient. That is why this surgical procedure requires careful planning, proper selection of the patients, and informed consent of both donor and recipient.

A Retrospective Analysis of Clinical Research Misconduct Using FDA-Issued Warning Letters and Clinical Investigator Inspection List From 2010 to 2014.

BACKGROUND: The US Food and Drug Administration (FDA) conducts inspections of clinical investigation sites as a component of clinical trial regulation. The FDA describes the results of these inspections in the Clinical Investigator Inspection List (CLIIL). More serious violations are followed up in FDA warning letters issued to investigators. The primary objective of the current study is to qualitatively and quantitatively describe the CLIIL data and contents of FDA-issued warning letters from 2010 to 2014. METHODS: We retrospectively analyzed the CLIIL and FDA warning letters. For the CLIIL, we quantified the frequency of each violation among other data points. We compared recent data (2010-2014) to the previous 5 years (2005-2009). To analyze FDA warning letters, we developed a coding system to quantify the frequency of violations found. RESULTS: We analyzed 3637 inspections in the CLIIL database and 60 warning letters. Overall, there was a decrease or no change in all violations in the CLIIL database. The largest violation code reported was "failure to follow investigational plan" in both the 2005-2009 and 2010-2014 timeframes. Coding of FDA warning letters shows that the most common violations reported were failing to maintain accurate case histories (10.82%), enrolling ineligible subjects (8.85%), and failing to perform required tests (8.52%). CONCLUSIONS: The overall decrease in violations is encouraging. But, the high proportion of violations related to failure to follow the investigational plan is concerning as the complexity of trials increases. We conclude that more detailed information is necessary to accurately evaluate these violations. The current study provides a model for creating more granular data of violations to better inform clinical investigators and improve clinical trials.

Does the obesity paradox apply to early postoperative complications after hip surgery? A retrospective chart review.

BACKGROUND: There is evidence that very obese patients (body mass index [BMI] >40 kg/m(2)) undergoing hip replacement have longer average hospital stays, as well as higher rates of complications and readmission compared with patients with normal BMI. However, there are sparse data describing how overweight and obese patients fare in the period immediately after hip replacement surgery compared with patients with low or normal BMI. In this study, we sought to explore the association of BMI with the rate of early postoperative complications in patients undergoing total hip arthroplasty. METHODS: A proprietary hospital software program, Clinical Looking Glass was used to query the Montefiore Medical Center database and create a list of patients with International Classification of Diseases, Ninth Revision code 81.51 (hip replacement) from the period of January 1, 2010, through December 31, 2012. The medical records of patients with length of stay 5 or more days were reviewed to evaluate the reason for the extended stay. The primary outcome studied was the association between BMI and occurrence of early complications in patients who had undergone total hip replacement surgery. Logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of BMI and early postoperative complications. RESULTS: Of the 802 patients undergoing hip replacement surgery within our time frame, 142 patient medical records were reviewed due to their length of stay of ≥5 days. Overall complication rate in the analyzed patients demonstrated a J-curve distribution pattern, with the highest morbidity being 23.5% in the underweight group, the second highest in the normal-weight group (17.3%), and decreasing to nadir in the overweight (8.0%) and obese class I (10.0%) and then higher again in classes II (14.3%) and III (16.7%). Adjusted ORs demonstrated the same J distribution pattern similar to the pattern observed in the univariate analysis. Of the variables studied, Charlson score (OR, 1.1; 95% CI, 1.1-1.2; P = .03), diagnosis of hip fracture (OR, 5.2; 95% CI, 2.8-9.8; P = .01), normal weight (OR, 1.9; 95% CI, 1.1-3.8; P = .04), and obese class III (OR, 2.5; 95% CI, 1.1-6.3; P = .04) were the factors associated with the highest odds of early complications after hip replacement surgery. CONCLUSIONS: In this retrospective review of hip replacement surgery patients, BMI classification was a predictor of early postoperative complications. Although the exact underlying mechanisms are still not clear, these results are consistent with the obesity paradox, in which obesity or its correlates provide some form of protection.

Integrated Practice Improvement Solutions-Practical Steps to Operating Room Management.

UNLABELLED: Perioperative productivity is a vital concern for surgeons, anesthesiologists, and administrators as the OR is a major source of hospital elective admissions and revenue. Based on elements of existing Practice Improvement Methodologies (PIMs), "Integrated Practice Improvement Solutions" (IPIS) is a practical and simple solution incorporating aspects of multiple management approaches into a single open source framework to increase OR efficiency and productivity by better utilization of existing resources. MATERIALS AND METHODS: OR efficiency was measured both before and after IPIS implementation using the total number of cases versus room utilization, OR/anesthesia revenue and staff overtime (OT) costs. Other parameters of efficiency, such as the first case on-time start and the turnover time (TOT) were measured in parallel. RESULTS: IPIS implementation resulted in increased numbers of surgical procedures performed by an average of 10.7%, and OR and anesthesia revenue increases of 18.5% and 6.9%, respectively, with a simultaneous decrease in TOT (15%) and OT for anesthesia staff (26%). The number of perioperative adverse events was stable during the two-year study period which involved a total of 20,378 patients. CONCLUSION: IPIS, an effective and flexible practice improvement model, was designed to quickly, significantly, and sustainably improve OR efficiency by better utilization of existing resources. Success of its implementation directly correlates with the involvement of and acceptance by the entire OR team and hospital administration.

Opioid-Induced Hyperalgesia: A Diagnostic Dilemma.

Opioids are utilized frequently for the treatment of moderate to severe acute pain in the perioperative setting, as well as in the treatment of cancer-related pain. When prescribing chronic opioid therapy to patients with chronic pain, it is crucial for the practitioner to be aware not only of the issues of tolerance and withdrawal, but also to have knowledge of the possibility for opioid-induced hyperalgesia (OIH). An understanding of the differences between tolerance and OIH when escalating opioid therapy allows the titration of opioid as well as nonopioid analgesics in order to obtain maximum control of both chronic and acute pain. A case study is described to highlight the importance of judicious utilization of opioids in the treatment of cancer-related pain. In this case, high-dose opioid therapy did not improve chronic pain and contributed to a hyperalgesic state in which a young man experienced severe intractable pain postoperatively after two routine thoracotomies, despite aggressive pharmacologic measures to manage his perioperative pain. Furthermore, it illustrates the potential advantages of opioid rotation to methadone when OIH is suspected.

Intraoperative inflation of laryngocele with LMA.

OBJECTIVES: Laryngoceles are pathologic air filled dilations of the laryngeal ventricle. They are most often benign and incidental findings. Resection may be necessary in the setting of infection, airway obstruction, dysphagia, and phonatory disturbances. External laryngoceles are almost universally treated with open resection via a lateral or midline cervical approach. Care must be taken to resect the laryngocele in its entirety to avoid recurrence. In cases of recurrent infection, normal surgical planes are often fibrosed and obscured increasing the risk of neurovascular sacrifice and functional losses. METHODS: We are reporting a case of recurrent infections in a large, palpable external laryngocele. During resection the patient was ventilated using an endotracheal tube (ETT). Additionally, a laryngeal mask airway (LMA) was inserted posterior to the ETT, resting in the hypopharynx and attached to a Jackson Rees circuit. Air was passed through the LMA to inflate the laryngocele and better define its borders. The LMA was also used to identify the root of the laryngocele in the paraglottic space and ensure its airtight closure. RESULTS: The LMA assisted our dissection and helped progress the surgery safely in a fibrosed surgical field. We have not seen this method described previously. The patient continues to be free of recurrence 2 years after surgery. CONCLUSION: While in most cases, with careful surgical technique, even a fibrotic and scarred laryngocele can be excised in its entirety without neurovascular sacrifice. In some cases where this may be difficult with a traditional approach, we offer the intra-operative trumpet maneuver as a viable method of better delineating the borders of a laryngocele.

Intra-ventrolateral preoptic nucleus injection of γ-aminobutyric acid induces sedation in rats.

The ventrolateral preoptic nucleus (VLPO) plays a critical role in regulating and maintaining sleep-awake cycle. It receives both excitatory and inhibitory inputs and regulates the activity of tuberomamillary nucleus and other monoaminergic nuclei, which in turn determines the alternation between wakefulness and non-rapid eye movement sleep. Although a previous study has shown that systematic administration of GABAergic anesthetic agents activated VLPO neurons, which is believed to be responsible for the sedative effects of these agents, it is unknown whether a direct administration of γ-Aminobutyric acid (GABA) into the VLPO can induce sedation. Here we report that rats that received intra-VLPO infusion of GABA demonstrated sustained reduction in locomotion, most significantly during the 10-40th min period after infusion. Conversely, rats that received intra-VLPO infusion of noradrenaline demonstrated a sustained increase in locomotion from 20(th) min after infusion. By contrast, no appreciable change was observed in rats that received intra-VLPO infusion of glycine. This result demonstrates that exogenous GABA may activate sleep-active neurons in the VLPO and promote sedation.

Systemic inflammatory response does not correlate with acute lung injury associated with mechanical ventilation strategies in normal lungs.

BACKGROUND: Mechanical ventilation (MV) can lead to ventilator-induced lung injury secondary to trauma and associated increases in pulmonary inflammatory cytokines. There is controversy regarding the associated systemic inflammatory response. In this report, we demonstrate the effects of MV on systemic inflammation. METHODS: This report is part of a previously published study (Hong et al. Anesth Analg 2010;110:1652-60). Female pigs were randomized into 3 groups. Group H-Vt/3 was ventilated with a tidal volume (Vt) of 15 mL/kg predicted body weight (PBW)/positive end-expiratory pressure (PEEP) of 3 cm H(2)O; group L-Vt/3 with a Vt of 6 mL/kg PBW/PEEP of 3 cm H2O; and group L-Vt/10 with a Vt of 6 mL/kg PBW/PEEP of 10 cm H(2)O, for 8 hours. Each group had 6 subjects (n = 6). Prelung and postlung sera were analyzed for inflammatory markers. Hemodynamics, airway mechanics, and arterial blood gases were monitored. RESULTS: There were no significant differences in systemic cytokines among groups. There were similar trends of serum inflammatory markers in all subjects. This is in contrast to findings previously published demonstrating increases in inflammatory mediators in bronchoalveolar lavage. CONCLUSION: Systemic inflammatory markers did not correlate with lung injury associated with MV.

A prospective controlled study to determine the blood propofol concentration in anesthesiologists exposed to propofol vapor in the expired gases of patients receiving propofol-based intravenous sedation.

STUDY OBJECTIVE: To determine the blood propofol concentration of anesthesiologists who were exposed to the expired gases of patients receiving propofol-based intravenous (IV) sedation. DESIGN: Prospective controlled investigation and laboratory analysis. SETTING: Operating room of a university hospital and an independent technical laboratory. SUBJECTS: 5 anesthesiologists who independently delivered propofol-based IV sedation to patients presenting for first trimester termination of pregnancy. In addition, a patient receiving propofol-based IV sedation was recruited as a positive control. A laboratory technician who never had previous exposure to propofol was recruited as a negative control. INTERVENTIONS: Blood samples were obtained from each anesthesiologist before and after an 8-hour work period of anesthesia care of patients as described above. Blood samples were also obtained from the positive control, following propofol-based IV sedation, and the negative control. MEASUREMENTS: An independent laboratory determined the blood propofol concentrations using a gas-liquid partition chromatograph and verified the results by repeated measurements in order to avoid a laboratory error. The gas-liquid partition chromatograph had an analytic capability that set the detection limit for propofol at 50 ng/mL. MAIN RESULTS: None of the anesthesiologists had detectable blood propofol concentration in either the pre-exposure or post-exposure sample. The positive control and the negative control had detectable and non-detectable blood propofol concentration, respectively. CONCLUSIONS: This experiment did not detect propofol in the blood of anesthesiologists who administered propofol-based IV sedation to patients.