Perioperative do-not-resuscitate orders: Trainee experiential learning in preserving patient autonomy and knowledge of professional guidelines.

ABSTRACT: Anesthesiologists and surgeons have demonstrated a lack of familiarity with professional guidelines when providing care for surgical patients with a do-not-resuscitate (DNR) order. This substantially infringes on patient's self-autonomy; therefore, leading to substandard care particularly for palliative surgical procedures. The interventional nature of surgical procedures may create a different mentality of surgical "buy-in," that may unintentionally prioritize survivability over maintaining patient self-autonomy. While previous literature has demonstrated gains in communication skills with simulation training, no specific educational curriculum has been proposed to specifically address perioperative code status discussions. We designed a simulated standardized patient actor (SPA) encounter at the beginning of post-graduate year (PGY) 2, corresponding to the initiation of anesthesiology specific training, allowing residents to focus on the perioperative discussion in relation to the SPA's DNR order.Forty four anesthesiology residents volunteered to participate in the study. PGY-2 group (n = 17) completed an immediate post-intervention assessment, while PGY-3 group (n = 13) completed the assessment approximately 1 year after the educational initiative to ascertain retention. PGY-4 residents (n = 14) did not undergo any specific educational intervention on the topic, but were given the same assessment. The assessment consisted of an anonymized survey that examined familiarity with professional guidelines and hospital policies in relation to perioperative DNR orders. Subsequently, survey responses were compared between classes.Study participants that had not participated in the educational intervention reported a lack of prior formalized instruction on caring for intraoperative DNR patients. Second and third year residents outperformed senior residents in being aware of the professional guidelines that detail perioperative code status decision-making (47%, 62% vs 21%, P = .004). PGY-3 residents outperformed PGY-4 residents in correctly identifying a commonly held misconception that institutional policies allow for automatic perioperative DNR suspensions (85% vs 43%; P = .02). Residents from the PGY-3 class, who were 1 year removed the educational intervention while gaining 1 additional year of clinical anesthesiology training, consistently outperformed more senior residents who never received the intervention.Our training model for code-status training with anesthesiology residents showed significant gains. The best results were achieved when combining clinical experience with focused educational training.

Continuous Erector Spinae Plane Block for Analgesia after Thoracotomy for Lung Transplantation in an Anticoagulated Patient.

Lung transplant recipients are at particular high risk for postoperative respiratory failure as a result of poorly controlled pain, inadequate graft expansion, decreased cough, and reliance on systemic opioid therapy. Thoracic epidural and paravertebral blocks have been employed with the goal of improving postoperative pain control, improving pulmonary mechanics, and limiting the need for narcotic administration. These approaches require a needle position in proximity to the neuraxis and may cause significant hypotension that is poorly tolerated in transplant patients. Additionally, the use of anticoagulation or underlying clotting disorder limits the use of these regional blocks because of the concern of hematoma and subsequent neurologic injury. Ultrasound-guided continuous erector spinae plane (ESP) block has been shown to be efficacious for pain control following thoracotomy but has had minimal investigations following lung transplantation. In this study, we describe the effective use of a continuous erector spinae plane block to provide analgesia in a postoperative lung transplant recipient receiving systemic anticoagulation. The use of an ESP block with a more superficial needle tract that is further removed from the neuraxis allowed for a greater safety profile while providing efficacious pain control, decreased reliance on systemic narcotics, and improved oxygen saturation. The ESP block was effective in this case and thus may be a valuable alternative following lung transplantation for patients who are not candidates for thoracic epidural or paravertebral approaches.

A prospective observational cohort study to evaluate patients' experience during sequential cataract surgery under monitored anesthesia care and topical anesthesia.

Cataract surgery is the most common ambulatory surgery at our outpatient surgery center. Several studies have shown that patients with bilateral cataracts may experience different levels of anxiety, pain, and awareness during the first and second cataract extraction.A prospective observational cohort study was conducted at The Ohio State University Wexner Medical Center Eye and Ear Institute in order to compare anxiety, general comfort, awareness, and pain levels in patients undergoing sequential cataract surgeries. Likert and numerical rating scale were used to assess the outcomes. Patients receiving monitored anesthesia care and topical anesthesia were included.A total of 198 patients were enrolled in this study, 116 patients (59%) were female and 157 patients (78%) were Caucasians with a median age of 67 years among participants. Patients with rating "no anxiety" or feeling "somewhat anxious" were significantly higher during surgery 2 (P =< .001). Most of the patients felt "extremely comfortable" during surgery 1 when compared to surgery 2 (54% vs 42.9%; P = .08). No significant differences were found between surgeries regarding intraoperative awareness (P = .16). Overall, patients experienced mild pain during both procedures (92.4% in surgery 1 compared to 90.4% in surgery 2; P = .55). During the postoperative visit, 54% of the patients associated surgery 2 with less anxiety levels, 53% with no differences in general comfort, 60% felt more aware, and 59% had no differences in pain levels.Previous exposure to surgery could have been associated with a significant reduction in anxiety levels reported during surgery 2. Non-pharmacological strategies aiming to reduce perioperative anxiety may be considered an alternative or additional approach to premedication in patients undergoing consecutive cataract surgeries.

Elastomeric pump malfunction resulting in over-infusion of local anesthetic.

A 70 year-old female patient presented for a right humeral head replacement. Preoperatively an interscalene catheter was placed and postoperatively connected to an elastomeric pump for continuous infusion at 8 mL/h of Ropivacaine 0.2% with an additional 5 mL patient activated bolus available every 30 min. About 17 h after the elastomeric pump was connected to the catheter, the 550 mL reservoir was found to be empty, indicating the pump's infusion rate was more than 32 mL/h despite the pump still being set at an infusion rate of 8 mL/h with a possible 5 mL bolus every 30 min. There was no visible damage or leak in the pump system, and the insertion site was dry. The patient denied any changes to the pump settings. She was alert and oriented and denied any signs of local anesthetic toxicity. The catheter was immediately pulled and the manufacturer notified. The manufacturer found a red tab broken inside the patient-controlled bolus remote resulting in the over-infusion. Despite the dependability of elastomeric pumps, healthcare providers must be aware of their possible complications and malfunctions.