Pro-Con Debate: Electroencephalography-Guided Anesthesia for Reducing Postoperative Delirium.

Postoperative delirium (POD) has significant implications on morbidity, mortality, and health care expenditures. Monitoring electroencephalography (EEG) to adjust anesthetic management has gained interest as a strategy to mitigate POD. In this Pro-Con commentary article, the pro side supports the use of EEG to reduce POD, citing an empiric reduction in POD with processed EEG (pEEG)-guided general anesthesia found in several studies and recent meta-analysis. The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) trial is the exception to this, and issues with methods and achieved depths are discussed. Meanwhile, the Con side advocates that the use of EEG to reduce POD is not yet certain, citing that there is a lack of evidence that associations between anesthetic depth and POD represent causal relationships. The Con side also contends that the ideal EEG signatures to guide anesthetic titration are currently unknown, and the potential benefits of reduced anesthesia levels may be outweighed by the risks of potentially insufficient anesthetic administration. As the public health burden of POD increases, anesthesia clinicians will be tasked to consider interventions to mitigate risk such as EEG. This Pro-Con debate will provide 2 perspectives on the evidence and rationales for using EEG to mitigate POD.

Measuring deliberate reflection in residents: validation and psychometric properties of a measurement tool.

PURPOSE: Reflective capacity is "the ability to understand critical analysis of knowledge and experience to achieve deeper meaning." In medicine, there is little provision for post-graduate medical education to teach deliberate reflection. The feasibility, scoring characteristics, reliability, validation, and adaptability of a modified previously validated instrument was examined for its usefulness assessing reflective capacity in residents as a step toward developing interventions for improvement. METHODS: Third-year residents and fellows from four anesthesia training programs were administered a slightly modified version of the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) in a prospective, observational study at the end of the 2019 academic year. Six written vignettes of imperfect anesthesia situations were created. Subjects recorded their perspectives on two randomly assigned vignettes. Responses were scored using a 5-element rubric; average scores were analyzed for psychometric properties. An independent self-report assessment method, the Cognitive Behavior Survey: Residency Level (rCBS) was used to examine construct validity. Internal consistency (ICR, Cronbach's alpha) and interrater reliability (weighted kappa) were examined. Pearson correlations were used between the two measures of reflective capacity. RESULTS: 46/136 invited subjects completed 2/6 randomly assigned vignettes. Interrater agreement was high (k = 0.85). The overall average REFLECT score was 1.8 (1-4 scale) with good distribution across the range of scores. ICR for both the REFLECT score (mean 1.8, sd 0.5; α = 0.92) and the reflection scale of the rCBS (mean 4.5, sd 1.1; α = 0.94) were excellent. There was a significant correlation between REFLECT score and the rCBS reflection scale (r = .44, p < 0.01). CONCLUSIONS: This study demonstrates feasibility, reliability, and sufficiently robust psychometric properties of a modified REFLECT rubric to assess graduate medical trainees' reflective capacity and established construct/convergent validity to an independent measure. The instrument has the potential to assess the effectiveness of interventions intended to improve reflective capacity.

Catatonia in the ICU: an important and underdiagnosed cause of altered mental status. a case series and review of the literature*.

OBJECTIVE: Catatonia is a neuropsychiatric syndrome with motor and behavioral symptoms occurring in patients with or without a history of psychiatric illness. Although it is associated with significant morbidity and mortality, the prevalence of catatonia in the ICU setting is unknown. The diagnosis and management of catatonia in the critically ill patient raises unique challenges. Furthermore, the diagnosis and management are not included in most critical care curricula. The objective of this retrospective study is to increase the awareness of this clinically important condition among critical care providers. DESIGN: Retrospective case series study. SETTING: Multiple critical care units at a university-affiliated tertiary care hospital. PATIENTS: Five critically ill patients with catatonia, aged 17 to 78. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All notes, laboratory data, imaging results, other diagnostic studies, therapeutic interventions, and responses to treatment were reviewed for five critically ill patients with catatonia. No unifying cause of catatonia or predisposing conditions were identified for these patients. Currently available diagnostic criteria for catatonia were found to be nonspecific in the ICU setting. New diagnostic criteria for catatonia specific to the critically ill patient are proposed. CONCLUSIONS: Catatonia can occur in a wide variety of critical care settings, with or without precedent psychiatric illness, and it may be exacerbated or induced by common intensive care practices. Psychomotor findings are imperative in examination of critically ill patients with altered mental status in order to diagnose catatonia.

Application of process improvement principles to increase the frequency of complete airway management documentation.

BACKGROUND: Process improvement in healthcare delivery settings can be difficult, even when there is consensus among clinicians about a clinical practice or desired outcome. Airway management is a medical intervention fundamental to the delivery of anesthesia care. Like other medical interventions, a detailed description of the management methods should be documented. Despite this expectation, airway documentation is often insufficient. The authors hypothesized that formal adoption of process improvement methods could be used to increase the rate of "complete" airway management documentation. METHODS: The authors defined a set of criteria as a local practice standard of "complete" airway management documentation. The authors then employed selected process improvement methodologies over 13 months in three iterative and escalating phases to increase the percentage of records with complete documentation. The criteria were applied retrospectively to determine the baseline frequency of complete records, and prospectively to measure the impact of process improvements efforts over the three phases of implementation. RESULTS: Immediately before the initial intervention, a retrospective review of 23,011 general anesthesia cases over 6 months showed that 13.2% of patient records included complete documentation. At the conclusion of the 13-month improvement effort, documentation improved to a completion rate of 91.6% (P<0.0001). During the subsequent 21 months, the completion rate was sustained at an average of 90.7% (SD, 0.9%) across 82,571 general anesthetic records. CONCLUSION: Systematic application of process improvement methodologies can improve airway documentation and may be similarly effective in improving other areas of anesthesia clinical practice.

Identification, Characterization, and Ranking of Candidate Metrics for Selection to Anesthesiology Residency: An Iterative Survey of Program Directors.

Background: The primary aim of this study was to identify and stratify candidate metrics used by anesthesiology residency program directors (PDs) to develop their residency rank lists through the National Resident Matching Program. Methods: Sixteen PDs comprised the participants, selected for diversity in geography and program size. We used a 3-round iterative survey to identify and stratify candidate metrics. In the first round, participants listed metrics they planned to use to evaluate candidates. In the second round, metrics from the first round were ranked by importance, and criteria were solicited to define an exceptional, strong, average, marginal, and uncompetitive candidate for each metric. In the third round, aggregated results were presented and participants refined their rankings. Results: Of the 16 PDs selected, 15 participated in the first and second survey rounds, and 10 in the third. Eighteen candidate metrics were indicated by 8 or more PDs for residency selection. All 10 PDs from the final round identified passing Step 1 of the United States Medical Licensing Exam (USMLE) and the absence of "red flags" like a failed rotation as key selection metrics, both averaging an importance score of 4.9 out of 5. Other metrics identified by all PDs included clerkship evaluation comments, USMLE Step 2 scores, class rank, letters of recommendation, personal statement, and program and geographical signals. Conclusions: The study reveals key metrics anesthesiology residency PDs use for candidate ranking, which may offer candidates insights into their competitiveness for anesthesiology residency.

Left-Sided Double-Lumen Tube vs EZ-Blocker for One-Lung Ventilation in Thoracic Surgery: A Systematic Review and Meta-Analysis.

Background. The EZ-Blocker is the newest generation of bronchial blocker and offers a potential alternative to left-sided double lumen tubes for lung isolation and one-lung ventilation during thoracic surgery. Methods. Databases were searched for randomized controlled trials comparing left-sided double lumen tube to the EZ-Blocker for one-lung ventilation during thoracic surgery. The time for placement, incidence of intraoperative displacement, and surgeons' rating of lung collapse quality were designated as coprimary outcomes. The safety profiles of the two devices, including the incidence of airway trauma and post-extubation discomfort were also examined. Results. Six randomized controlled trials (495 patients) were analyzed. Compared to the EZ-Blocker, the left-sided double lumen tube was faster to place by a weighted mean difference of [95% CI] of -61.24 seconds [-102.48, -20.00] (P = .004) and was much less likely to become displaced during lung isolation with an odds ratio [95% CI] of .56 [.34, .91] (P = .02). The left-sided double lumen tube and the EZ-Blocker provided similar surgeon-rated quality of lung isolation. Although the left-sided double lumen tube caused a greater degree of post-extubation sore throat, there was a similar incidence of carinal trauma and post-extubation hoarseness compared to the EZ-Blocker. Conclusion. Our analysis suggests that the left-sided double lumen tube can be placed more quickly and is less prone to intraoperative displacement compared to the EZ-Blocker; the quality of lung collapse is similar. Thus, evidence appears to support the continued utilization of the left-sided double lumen tube for routine thoracic surgery requiring one-lung ventilation.

A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives.

Although reconstruction is often the primary choice of surgeons after an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study was to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians, and patients with lower extremity trauma completed a Web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by the physicians and the patients highlight the necessity of realistic discussion of outcomes, regardless of the management methods.

Doing More With Written Feedback: Improving Learner Satisfaction and Reflection With the LEAF (Learner-Engaged Analysis of Feedback) Method.

PROBLEM: Written feedback is often overly positive, nonspecific, and difficult to interpret. Learner satisfaction with written feedback is low and obtaining written feedback that encourages self-reflection is challenging. Improving feedback quality is laborious and only modestly effective. APPROACH: The authors developed the LEAF (Learner-Engaged Analysis of Feedback) method to improve learner satisfaction with, and reflection on, existing written feedback. The method pairs a learner and coach to methodically identify themes in the learner's written feedback. Themes occurring more frequently or less frequently than typical offer areas for reflection, as they may identify learners' relative strengths or weaknesses. The method was introduced at the Massachusetts General Hospital in 2017 during program director (PD) meetings with anesthesiology residents. In 2018, resident satisfaction was measured (1 to 5 Likert-type questions, 1 = "not at all satisfied," 5 = "extremely satisfied") for 4 feedback sources, 2 related to the LEAF method (PD meetings, written feedback) and 2 unrelated (verbal feedback, mentor feedback). Residents' comments were qualitatively assessed to explore the impact on self-reflection. OUTCOMES: Residents who had participated in a LEAF session (n = 54), compared with those who had not (n = 11), reported higher satisfaction with written feedback (mean 3.1 versus 2.5, d = 0.53, P = .03) and PD meeting feedback (mean 3.8 versus 2.8, d = 0.80, P = .03). There were no significant differences between groups for satisfaction with feedback unrelated to the LEAF method. Qualitative analysis of comments suggested that residents found the method useful for providing holistic self-assessment, facilitating goal setting, uncovering blind spots, and improving feedback interpretation. NEXT STEPS: Next steps should include studies determining if the association between increased learner satisfaction with written feedback and the LEAF method is causal, and whether this feedback process changes learners' subsequent behaviors.

Establishing Psychological Safety to Obtain Feedback for Training Programs: A Novel Cross-Specialty Focus Group Exchange.

BACKGROUND: Formative feedback from residents is essential to improve residency programs, and focus groups may provide rich information. However, residents may withhold information due to fear of retaliation or speak less candidly to please focus group moderators. OBJECTIVE: We assessed participant perceptions and utility of feedback obtained from a confidential focus group exchange between 2 residency programs. METHODS: Anesthesiology and pediatric programs at the same institution participated in 2017. Residents voluntarily provided program feedback during 1 of 2 confidential focus groups for each program. Each focus group was moderated by the program director (PD) of the other specialty. The PDs used thematic analysis to identify themes for use by the respective programs in improvement efforts. An anonymous survey was distributed after the focus groups to collect participant perceptions (quantitative and narrative) on this approach. RESULTS: Thirteen residents of 140 (9.3%) participated (7 anesthesiology, 6 pediatrics). Thematic feedback from focus groups was largely consistent with known issues, although novel information was also obtained (eg, pediatric interns wanted earlier one-on-one meetings with their PD). Survey data suggest that residents were able to share more meaningful feedback than they would otherwise, and they did not feel that having an external moderator (a PD who may have been unfamiliar with the specialty) was a barrier to discussion. The approach required 6 hours of time for each PD and approximately $200 for dinners. CONCLUSIONS: The focus group exchange required modest resources, was perceived as safe by residents, and generated robust, actionable feedback for the programs.

Faculty Underestimate Resident Desire for Constructive Feedback and Overestimate Retaliation.

BACKGROUND: Constructive feedback from faculty to trainees is essential to promoting trainees' learning yet is rarely provided. Resident physicians want more feedback than they receive but it is unclear whether faculty know this. We explored faculty and resident impressions of constructive feedback and the barriers to giving more. We hypothesized that residents want more constructive feedback; however, faculty believe that residents do not want constructive feedback and would retaliate against faculty who give it. METHODS: Between January and March 2019, we performed a cross-sectional survey study of anesthesiology residents and teaching faculty at two large academic centers. All residents and faculty were eligible to participate. The survey assessed satisfaction with written and in-person feedback and predicted responses to specific examples, in addition to perceived barriers. RESULTS: The survey was distributed to 156 residents and 260 faculty across the two institutions: 116 residents (74% response rate) and 127 faculty (49% response rate) responded. Eighty-eight percent of residents would want to receive feedback similar to the examples, whereas only 60% of faculty responded that they thought residents would want feedback. Ninety-eight percent of residents said they would not retaliate. Barriers to providing feedback included time constraints, insufficient confidence/training, fear of retaliation, and feelings of futility. CONCLUSIONS: Residents were significantly more likely to want to receive constructive feedback than the faculty members had predicted. Further, residents are unlikely to retaliate against faculty who provide feedback. Addressing barriers may help increase the amount of constructive feedback that faculty provide and resident satisfaction with feedback received.