Educating for success: ambulatory anesthesia training.

PURPOSE OF REVIEW: This article explores the unique intersection of the challenges confronting ambulatory anesthesiology education and charts a trajectory forward. The proportion of ambulatory, nonoperating room (NORA), and office-based surgical cases continues to rise; however, the requirements for trainees in these settings have remained static. The rapid evolution of the field combined with a limited workforce also makes continuing education essential, and we discuss the current and future states of ambulatory anesthesia education. RECENT FINDINGS: Although numerous resources are available across an array of platforms to foster both trainee education and continuing education for practicing anesthesiologists, there is a paucity of current literature evaluating the impact of new curricula developed specifically for ambulatory, NORA, or office-based anesthesiology (OBA). SUMMARY: We begin with an appraisal of the current state of ambulatory anesthesiology training and evaluate the gap between current graduate medical education and trends in ambulatory surgery. We then develop a vision for an ideal state of future ambulatory education for residents as well as anesthesiologists in practice and highlight the priorities necessary to reach this vision.

Level of Evidence of Guidelines for Perioperative Management of Patients With Obstructive Sleep Apnea: An Evaluation Using the Appraisal of Guidelines for Research and Evaluation II Tool.

Currently, the quality of guidelines for the perioperative management of patients with obstructive sleep apnea (OSA) is unknown, leaving anesthesiologists to make perioperative management decisions with some degree of uncertainty. This study evaluated the quality of clinical practice guidelines regarding the perioperative management of patients with OSA. This study was reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of the MedlineALL (Ovid) database was conducted from inception to February 26, 2021, for clinical practice guidelines in the English language. Quality appraisal of guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. Descriptive statistical analysis of each of the 6 domains was expressed as a percentage using the formula: (obtained score - minimum possible score)/(maximum possible score - minimum possible score). Of 192 articles identified in the search, 41 full texts were assessed for eligibility, and 10 articles were included in this review. Intraclass correlation coefficients of the AGREE II scores across the 7 evaluators for each guideline were each >0.9, suggesting that the consistency of the scores among evaluators was high. Sixty percent of recommendations were based on evidence using validated methods to grade medical literature, while the remainder were consensus based. The median and range scores of each domain were: (1) scope and purpose, 88% (60%-95%); (2) stakeholder involvement, 52% (30%-82%); (3) rigor of development, 67% (40%-90%); (4) clarity of presentation, 74% (57%-88%); (5) applicability, 46% (20%-73%); and (6) editorial independence, 67% (19%-83%). Only 4 guidelines achieved an overall score of >70%. This critical appraisal showed that many clinical practice guidelines for perioperative management of patients with OSA used validated methods to grade medical literature, such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Oxford classification, with lower scores for stakeholder involvement due to lack of engagement of patient partners and applicability domain due to lack of focus on the complete perioperative period such as postdischarge counseling. Future efforts should be directed toward establishing higher focus on the quality of evidence, stakeholder involvement, and applicability to the wider perioperative patient experience.

Quality indicators and outcomes in ambulatory surgery.

PURPOSE OF REVIEW: Quality indicators are used to monitor the quality and safety of care in ambulatory surgery, a specialty in which major morbidity and mortality remain low. As the demand for safe and cost-effective ambulatory surgical care continues to increase, quality indicators and metrics are becoming critical tools used to provide optimal care for these patients. RECENT FINDINGS: Quality indicators are tools used by both regulatory agencies and surgical centers to improve safety and quality of ambulatory surgical and anesthetic care. These metrics are also being used to develop value-based payment models that focus on efficient, safe, and effective patient care. Patient reported outcome measures are a growing method of collecting data on the satisfaction and postoperative recovery period for ambulatory surgical patients. Monitoring of perioperative efficiency and utilization using quality metrics are important to the financial health of ambulatory surgical centers. SUMMARY: Quality indicators will continue to play a growing role in the monitoring of quality and safety in ambulatory surgery, especially with the trend towards value-based reimbursement models and efficient, cost-effective surgical care. Additionally, quality indicators are useful tools to monitor postoperative patient outcomes and recovery pathways and the efficiency of operating room utilization and scheduling.

Managing COVID-19 from the epicenter: adaptations and suggestions based on experience.

In March 2020, the New York City metropolitan area became the epicenter of the United States' SARS-CoV-2 pandemic and the surge of new cases threatened to overwhelm the area's hospital systems. This article describes how an anesthesiology department at a large urban academic hospital rapidly adapted and deployed to meet the threat head-on. Topics included are preparatory efforts, development of a team-based staffing model, and a new strategy for resource management. While still maintaining a fully functioning operating theater, discrete teams were deployed to both COVID-19 and non-COVID-19 intensive care units, rapid response/airway management team, the difficult airway response team, and labor and delivery. Additional topics include the creation of a temporary 'pop-up' anesthesiology-run COVID-19 intensive care unit utilizing anesthesia machines for monitoring and ventilatory support as well as the development of a simulation and innovation team that was instrumental in the rapid prototyping of a controlled split-ventilation system and conversion of readily available BIPAP units into emergency ventilators. As the course of the disease is uncertain, the goal of this article is to assist others in preparation for what may come next with COVID-19 as well as potential future pandemics.

Olanzapine for the Prevention of Postdischarge Nausea and Vomiting after Ambulatory Surgery: A Randomized Controlled Trial.

BACKGROUND: Postdischarge nausea and vomiting after ambulatory surgery is a common problem that is not adequately addressed in current practice. This prospective, randomized, double-blind, parallel-group, placebo-controlled study was designed to test the hypothesis that oral olanzapine is superior to placebo at preventing postdischarge nausea and vomiting. METHODS: In a single-center, double-blind, randomized, placebo-controlled trial, the authors compared a single preoperative dose of olanzapine 10 mg to placebo, in adult female patients 50 years old or less, undergoing ambulatory gynecologic or plastic surgery with general anesthesia. All patients received standard antiemetic prophylaxis with dexamethasone and ondansetron. The primary composite outcome was nausea and/or vomiting in the 24 h after discharge. Secondary outcomes included severe nausea, vomiting, and side effects. RESULTS: A total of 140 patients were randomized and evaluable. The primary outcome occurred in 26 of 69 patients (38%) in the placebo group and in 10 of 71 patients (14%) in the olanzapine group (relative risk, 0.37; 95% CI, 0.20 to 0.72; P = 0.003). Severe nausea occurred in 14 patients (20%) in the placebo group and 4 patients (6%) in the olanzapine group (relative risk, 0.28; 95% CI, 0.10 to 0.80). Vomiting occurred in eight patients (12%) in the placebo group and two patients (3%) in the olanzapine group (relative risk, 0.24; 95% CI, 0.05 to 1.10). The median score for sedation (scale 0 to 10, with 10 being highest) in the 24 h after discharge was 4 (interquartile range, 2 to 7) in the placebo group and 6 (interquartile range, 3 to 8) in the olanzapine group (P = 0.023). CONCLUSIONS: When combined with ondansetron and dexamethasone, the addition of olanzapine relative to placebo decreased the risk of nausea and/or vomiting in the 24 hafter discharge from ambulatory surgery by about 60% with a slight increase in reported sedation.

Retrospective Analysis of Obstetric Intensive Care Unit Admissions Reveals Differences in Etiology for Admission Based on Mode of Conception.

BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage. METHODS: In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005-2016 at Mount Sinai Hospital, New York, NY, and 2005-2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non-in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non-in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage. RESULTS: During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non-in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model. CONCLUSIONS: Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.

Feasibility of a Modified Strategy for 2-Rescuer Cardiopulmonary Resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) requires effective chest compressions and ventilations to circulate and oxygenate blood. It has been established that a 2-handed mask seal is superior when providing bag-valve-mask (BVM) ventilations. However a 1-handed technique remains the standard with which health care providers are trained to perform 2-rescuer CPR. OBJECTIVES: We sought to determine if a modified 2-rescuer CPR technique that incorporates a 2-handed mask seal during ventilations can be accomplished without compromising chest compression quality during a simulated cardiac arrest. METHODS: Medical student volunteers were divided into an "intervention" arm, with 1 rescuer creating a 2-handed mask seal and the second rescuer performing chest compressions followed by that second rescuer squeezing the BVM bag to deliver ventilations during compression pauses, and a "control" arm, in which standard 2-rescuer CPR was performed. Both arms received a brief CPR refresher following a standard script. The 2 rescuer teams then performed 2 rounds of CPR on a manikin while being video recorded. Data were collected from real-time evaluation and post hoc video analysis. RESULTS: Forty-seven pairs of students enrolled in the study. There were no statistically significant differences between the intervention and control arms for median (interquartile range [IQR]) compression fraction (72% [69.5-75.7%] vs. 73.2% [69.1-76.1%]; p = 1.0), median time to complete 2 rounds of CPR (207.8 s [198.5-222.9 s] vs. 214.7 s [201.3-219.5 s]; p = 0.625), median hands-off time (49.8 s [46.2-63.0 s] vs. 55.4 s [50.4-65.2 s]; p = 0.278), or median time for 30 compressions (15.2 s [14.3-15.9 s] vs. 15.4 s [14.6-16.3 s]; p = 0.452). CONCLUSION: Two-rescuer CPR incorporating a 2-handed face mask seal can be performed effectively without impacting chest compression quality during simulated cardiac arrest.

Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Analysis.

BACKGROUND: Anesthesiologists have studied adverse events during anesthesia dating back to the original critical incident studies of the 1970s. Despite improvements, adverse events continue to occur. The purpose of this study was to characterize anesthesia-related adverse events within a single large tertiary care institution and to distinguish preventable adverse events from those that are not preventable. METHODS: A retrospective review of all cases referred to the Performance Improvement (PI) Committee at a large academic medical center from 2007 to 2015 was performed. The primary adverse event and underlying cause of the event were determined using a two-reviewer system for each case. Univariate analysis was performed to determine overall characteristics of cases, the underlying causes of adverse events, and whether the event was preventable; p < 0.05 was considered significant. RESULTS: A total of 1,424 records were referred to the PI Committee during the study period. After exclusions, 747 cases were included in the final analysis. Respiratory complications (n = 245) were the most frequently reported adverse event type. The most common respiratory events included unplanned reintubations, aspirations, and respiratory arrests. A large proportion of the adverse events (42.8%) may have been preventable. In particular, respiratory, trauma, and medication adverse events were often preventable. CONCLUSION: Anesthesia-related adverse events continue to occur even though the field is considered at the forefront of patient safety. Respiratory, trauma, and medication events were often preventable, and these represent areas to allocate resources to improve patient safety and perioperative outcomes.

A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation.

BACKGROUND: Awake intubation is the standard of care for management of the anticipated difficult airway. The performance of awake intubation may be perceived as complex and time-consuming, potentially leading clinicians to avoid this technique of airway management. This retrospective review of awake intubations at a large academic medical center was performed to determine the average time taken to perform awake intubation, its effects on hemodynamics, and the incidence and characteristics of complications and failure. METHODS: Anesthetic records from 2007 to 2014 were queried for the performance of an awake intubation. Of the 1,085 awake intubations included for analysis, 1,055 involved the use of a flexible bronchoscope. Each awake intubation case was propensity matched with two controls (1:2 ratio), with similar comorbidities and intubations performed after the induction of anesthesia (n = 2,170). The time from entry into the operating room until intubation was compared between groups. The anesthetic records of all patients undergoing awake intubation were also reviewed for failure and complications. RESULTS: The median time to intubation for patients intubated post induction was 16.0 min (interquartile range: 13 to 22) from entrance into the operating room. The median time to intubation for awake patients was 24.0 min (interquartile range: 19 to 31). The complication rate was 1.6% (17 of 1,085 cases). The most frequent complications observed were mucous plug, endotracheal tube cuff leak, and inadvertent extubation. The failure rate for attempted awake intubation was 1% (n = 10). CONCLUSIONS: Awake intubations have a high rate of success and low rate of serious complications and failure. Awake intubations can be performed safely and rapidly.

The influence of positive end-expiratory pressure on surgical field conditions during functional endoscopic sinus surgery.

BACKGROUND: Functional endoscopic sinus surgery (FESS) is the mainstay of surgical treatment for sinonasal disease. This surgery carries certain risks. Most of these risks relate to the quality of the surgical field. Thus, mechanisms by which the surgical field can be improved are important to study. We sought to determine whether positive end-expiratory pressure (PEEP) had a deleterious effect on the quality of the surgical field in patients undergoing primary FESS. METHODS: Forty-seven patients were randomized to a ventilation strategy using either 5 cm H2O of PEEP or zero added PEEP. The quality of the surgical field was measured every 15 minutes using a validated surgical scoring method. RESULTS: The addition of PEEP did not have any measurable effect on the surgical field scores after onset of surgery (odds ratio [OR] (95% confidence interval [CI]) = 1.06 (0.44-2.58), P = 0.895 for side 1; OR (95% CI) = 0.56 (0.16-1.93), P = 0.356 for side 2). The peak inspiratory pressure did have an effect on surgical grades. Every cm H2O of added pressure over 15 cm H2O total pressure contributing to increased odds of higher surgical field score. For each cm H2O increase in inspiratory pressure above 15cm H2O increased the surgical field score (OR [95% CI] 1.13 [1.04-1.22], P = 0.002). CONCLUSIONS: During FESS surgery if PEEP is added, it is important to keep the mean inspiratory pressure below 15cm H2O to avoid worsening surgical field conditions.

Early observations with an ERAS pathway for thyroid and parathyroid surgery: Moving the goalposts forward.

BACKGROUND: Enhanced recovery after surgery pathways have become the standard of care in various surgical specialties. In this study, we discuss our initial experience with a staged enhanced recovery after surgery pathway in endocrine surgery and assess the impact of this pathway on select perioperative outcomes and unanticipated admissions. METHODS: We collected information regarding all thyroid/parathyroid surgeries performed by endocrine surgeons at our institution before and after the implementation of the multi-intervention enhanced recovery after surgery pathway. We compared relevant outcomes for all cases 1 year before (n = 479) and 1 year after (n = 166) implementation of the pathway. We also compared outcomes between enhanced recovery after surgery patient groups with varying levels of enhanced recovery after surgery compliance. RESULTS: Enhanced recovery after surgery was associated with a significant decrease in total length of stay (9.2 vs 7.5 hours, P < .0001). Whereas there was no significant decrease in all-cause unanticipated postoperative admissions, there was a decrease in patient-initiated admissions in the Enhanced recovery after surgery group. There was also a significant decrease in mean postoperative morphine milligram equivalents (14.4 vs 16.2 vs 24.8, P = .0015), average daily morphine milligram equivalents (25.6 vs 45.6 vs 53, P < .0001), and average daily pain scores (1.89 vs 2.38 vs 2.74, P = .0045) in the Enhanced recovery after surgery group (particularly with increasing Enhanced recovery after surgery compliance). There were no significant differences in the requirement for postoperative antiemetics or in the post-anesthesia care unit length of stay. CONCLUSION: This study demonstrates a significant benefit from Enhanced recovery after surgery pathways for thyroidectomies and parathyroidectomies, even with initial data and a staggered roll-out plan. Further directions include a follow-up study once we reach a higher level of institutional compliance with all components of the Enhanced Recovery After Surgery pathway and a prospective trial to identify the relative significance of different portions of the Enhanced Recovery after Surgery pathway, particularly the superficial cervical plexus block.

Comparison of electronic versus phone-based administration of the Quality of Recovery-40 survey after ambulatory surgery.

STUDY OBJECTIVE: Studies that track patient-centered outcomes are better suited to evaluate the relative benefits and harms of an intervention in ambulatory surgery as severe morbidity and mortality have become increasingly rare. This pilot study aimed to assess for differences in response rate and survey scores for phone-based and electronic administration of the Quality of Recovery-40 (QoR-40) survey in patients undergoing general anesthesia for ambulatory surgery. DESIGN: A single-center prospective observational study. SETTING: Yale New Haven Hospital (September 22-November 2, 2021). PATIENTS: 100 consecutive patients undergoing ambulatory surgery under general anesthesia. INTERVENTIONS: Patients were randomized to receive QoR-40 surveys via email or phone. MEASUREMENTS: The QoR-40 survey is a 40-item questionnaire that provides a global score across five dimensions: patient support, comfort, emotions, physical independence, and pain. The primary outcome was the response rate following the administration of the QoR-40 survey on postoperative days 1, 2, and 7. The secondary outcome was the mean QoR-40 score during the study period. MAIN RESULTS: A total of 109 patients consented to participate and 100 patients were randomized in this study. A total of 76%, 72%, and 68% of patients completed the survey on POD 1, 2, and 7, respectively. There were no differences in the response rate of patients who completed the survey between phone (78%) versus electronic (74%) administration (difference 4%, 95% confidence interval (CI): -13%, 21%, respectively) on POD 1, 2 (74% vs 70%, difference 4%, 95% CI -14%, 22%, respectively) or 7 (68% vs 68%, difference 0%, 95% CI -18%, 18%, respectively). The mean (standard deviation) QoR-40 score was 176.2 (18.1), 179.8 (19.4), 187.7 (13.1) on POD 1, 2, and 7, respectively. There were no significant differences in the mean QoR-40 scores between groups at any of the time points. CONCLUSION: The response rate following the electronic administration of the QoR-40 survey did not differ from the phone-based administration during the postoperative period following ambulatory surgery. The use of an electronic version of the survey may allow for larger sample sizes with fewer resources utilized in future interventional studies.

Single-use versus reusable metallic laryngoscopes for non-emergent intubation: A retrospective review of 72,672 intubations.

STUDY OBJECTIVE: Increased regulatory requirements for sterilization in recent years have prompted a widespread transition from reusable to single-use laryngoscopes. The purpose of this study was to determine if the transition from metallic reusable to metallic single-use laryngoscopes impacted the performance of direct laryngoscopy at an academic medical center. DESIGN: Single-site retrospective cohort study. SETTING: General anesthetic cases requiring tracheal intubation. PATIENTS: Adult patients undergoing non-emergent procedures. INTERVENTIONS: Data were collected two years before and two years after a transition from metallic reusable to metallic single-use laryngoscopes. MEASUREMENTS: The primary outcome was need for intubation rescue with an alternate device. Secondary outcomes were difficult laryngeal view (modified Cormack-Lehane grade ≥ 2b) and hypoxemia (SpO2 < 90% for >30 s) during direct laryngoscopy intubations. Subgroup analyses for rapid sequence induction, Macintosh blades, Miller blades, and patients with difficult airway risk factors (Obstructive Sleep Apnea, Mallampati ≥3, Body Mass Index >30 kg/m2) were performed. MAIN RESULTS: In total, 72,672 patients were included: 35,549 (48.9%) in the reusable laryngoscope cohort and 37,123 (51.1%) in the single-use laryngoscope cohort. Compared with reusable laryngoscopes, single-use laryngoscopes were associated with fewer rescue intubations with an alternate device (covariates-adjusted odds ratio [OR] 0.81 95% CI 0.66-0.99). Single-use laryngoscopes were also associated with lower odds of difficult laryngeal view (OR 0.86; 95% CI 0.80-0.93). Single use laryngoscopes were not associated with hypoxemia during the intubation attempt (OR 1.03; 95% CI 0.88-1.20). Similar results were observed for subgroup analyses including rapid sequence induction, Macintosh blades, Miller blades, and patients with difficult airway risk factors. CONCLUSIONS: Metallic single-use laryngoscopes were associated with less need for rescue intubation with alternate devices and lower incidence of poor laryngeal view compared to reusable metallic laryngoscopes.

A Prospective Observational Study of Video Laryngoscopy Use in Difficult Airway Management.

OBJECTIVES/HYPOTHESIS: Video laryngoscopy has grown tremendously in popularity over the last decade for management of the anticipated difficult airway. The use of video laryngoscopy has not been adequately studied in the head and neck pathology patient population, including those with masses, previous head and neck surgery, or radiation. STUDY DESIGN: Prospective observational study. METHODS: This study included 100 patients with head and neck pathology undergoing awake flexible bronchoscopic intubation for nonemergency surgery requiring general anesthesia. After the performance of awake flexible bronchoscopic intubation and induction of anesthesia, video laryngoscopy was performed with the CMAC D blade and Glidescope AVL. The primary outcome was the modified Cormack-Lehane view obtained on video laryngoscopy. RESULTS: One hundred patients were enrolled in the study. After exclusions, 92 patients underwent video laryngoscopy with both the CMAC D blade and the Glidescope AVL. Thirty-seven patients (40.2%) had a Cormack-Lehane view ≥3 with the CMAC D blade, and 28 patients (30.4%) had a Cormack-Lehane view ≥3 with the Glidescope AVL. There were no complications from awake flexible bronchoscopic intubation or video laryngoscopy. CONCLUSIONS: There is a high incidence of inability to obtain a view of the glottis with video laryngoscopy in patients with head and neck pathology, particularly airway masses. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:82-86, 2021.

Use of Provider Scorecards to Improve Early Postoperative Recovery-Initial Implementation Study.

ABSTRACT: Intraoperative anesthetic technique directly impacts immediate postoperative recovery, yet there are few opportunities for anesthesiologists to receive feedback and no easily available benchmarks, making it difficult to reflect on one's own practice. This initial implementation study used retrospective data from 5,712 ambulatory surgery cases with healthy adult patients undergoing general anesthesia in 2018 at a large tertiary care academic center. It examines variation in practice among anesthesiologists for eight surgical specialties. Scorecards assessing intraoperative and postoperative opioids, antiemetics, nonopioid analgesics, regional blocks, recovery time, and severe postoperative pain compared with peers were given to anesthesiologists with prefeedback and postfeedback surveys assessing their attitudes toward feedback. Before receiving their scorecard, 71% of providers predicted their performance was average, and 29% predicted their performance was above average. After receiving their scorecards, 42% rated their quality of recovery as worse than expected, 42% rated it as expected, and 16% rated it as better than expected. Thirteen percent disagreed, 44% were neutral, and 44% agreed that this feedback will change their practice. Implementing a scorecard of patient-centered measures that shows where an anesthesiologist stands in the distribution of their peers was well-received, provides a benchmark, and has the potential to change practice.

The Mount Sinai Hospital Institute for critical care medicine response to the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of critically ill patients. This was especially true in New York City. We present a roadmap for hospitals and healthcare systems to prepare for a Pandemic. METHODS: This was a retrospective review of how Mount Sinai Hospital (MSH) was able to rapidly prepare to handle the pandemic. MSH, the largest academic hospital within the Mount Sinai Health System, rapidly expanded the intensive care unit (ICU) bed capacity, including creating new ICU beds, expanded the workforce, and created guidelines. RESULTS: MSH a 1,139-bed quaternary care academic referral hospital with 104 ICU beds expanded to 1,453 beds (27.5% increase) with 235 ICU beds (126% increase) during the pandemic peak in the first week of April 2020. From March to June 2020, with follow-up through October 2020, MSH admitted 2,591 COVID-19-positive patients, 614 to ICUs. Most admitted patients received noninvasive support including a non-rebreather mask, high flow nasal cannula, and noninvasive positive pressure ventilation. Among ICU patients, 68.4% (n=420) received mechanical ventilation; among the admitted ICU patients, 42.8% (n=263) died, and 47.8% (n=294) were discharged alive. CONCLUSIONS: Flexible bed management initiatives; teamwork across multiple disciplines; and development and implementation of guidelines were critical accommodating the surge of critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units. This approach to rapidly expand bed availability and staffing across the system helped provide the best care for the patients and saved lives.

Nitrous oxide anesthetic versus total intravenous anesthesia for functional endoscopic sinus surgery.

BACKGROUND: Functional endoscopic sinus surgery is a common procedure for sinonasal disease, frequently performed in the outpatient setting. General anesthesia maintained with total intravenous anesthesia (TIVA) with propofol has been shown to give superior surgical conditions compared to inhaled anesthetics. This study evaluated the effects of TIVA versus a predominantly nitrous oxide (N2 O)-based anesthetic with a low-dose propofol and remifentanil infusion on sinus surgery. METHODS: Patients were randomized to either a N2 O-based (nitrous oxide with propofol and remifentanil) or TIVA (propofol and remifentanil without nitrous oxide) group. The surgeon was blinded to the anesthetic technique. Surgical field grading was performed in real time by the otolaryngologist every 15 minutes with the Boezaart grading system. RESULTS: There were no statistically significant differences between the Boezaart scores, duration of surgery, or estimated blood loss between the two anesthetic techniques. However, the use of N2 O provided a statistically significant, 38% reduction in time from surgery end to extubation. The TIVA group had significantly decreased mean and median pain scores in the post-anesthesia care unit (PACU). There was no difference in the rate of postoperative nausea and vomiting between the two groups. CONCLUSION: A N2 O-based anesthetic for functional endoscopic sinus surgery provides similar intraoperative and postoperative conditions when compared to TIVA, while being superior in terms of time to extubation. Although the TIVA group had significantly decreased pain scores, this did not lead to a decrease in pain medicine received in the PACU, and there was no difference between groups in time to discharge. LEVEL OF EVIDENCE: 1b Laryngoscope, 130:E299-E304, 2020.

Differences in Outcomes After Anesthesia-Related Adverse Events in Older and Younger Patients.

Because more older adults undergo surgical procedures, it is incumbent on us to learn how to provide them with the safest possible perioperative care. We conducted a retrospective cohort study at a large tertiary care center to determine whether outcomes after anesthesia-related adverse events differed between patients aged 65 years and older versus patients under age 65. One thousand four hundred twenty-four cases were referred to the Performance Improvement committee of the Department of Anesthesiology from the years 2007-2015. After exclusions of cases that were not anesthesia-related, could not be identified, or were duplicates, 747 cases with anesthesia-related adverse events were included in the study. Two hundred eighty-six were aged 65 years and older and 461 were under age 65. Anesthesia-related adverse events occurred more commonly in the postoperative period in older patients relative to younger patients (37.7% vs. 21.9%, p = .001), and older patients had a greater incidence of mortality compared with a propensity-matched group of younger patients (adjusted odds ratio 1.87 [1.14-3.12], p < .05). We concluded that older patients have a greater likelihood of mortality as a result of suffering an anesthesia-related adverse event and may benefit from increased vigilance in the postoperative period.

Timing of Intubation and In-Hospital Mortality in Patients With Coronavirus Disease 2019.

OBJECTIVES: To examine whether increasing time between admission and intubation was associated with mortality in patients with coronavirus disease 2019 who underwent mechanical ventilation. DESIGN: Retrospective cohort study of patients with severe acute respiratory syndrome coronavirus 2 infection who were admitted between January 30, 2020, and April 30, 2020, and underwent intubation and mechanical ventilation prior to May 1, 2020. Patients were followed up through August 15, 2020. SETTING: Five hospitals within the Mount Sinai Health System in New York City, NY. PATIENTS: Adult patients with severe acute respiratory syndrome coronavirus 2 infection who underwent intubation and mechanical ventilation. INTERVENTIONS: Tracheal intubation and mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality. A hospital-stratified time-varying Cox model was used to evaluate the effect of time from admission to intubation on in-hospital death. A total of 755 adult patients out of 5,843 admitted with confirmed severe acute respiratory syndrome coronavirus 2 infection underwent tracheal intubation and mechanical ventilation during the study period. The median age of patients was 65 years (interquartile range, 56-72 yr) and 64% were male. As of the time of follow-up, 121 patients (16%) who were intubated and mechanically ventilated had been discharged home, 512 (68%) had died, 113 (15%) had been discharged to a skilled nursing facility, and 9 (1%) remained in the hospital. The median time from admission to intubation was 2.3 days (interquartile range, 0.6-6.3 d). Each additional day between hospital admission and intubation was significantly associated with higher in-hospital death (adjusted hazard ratio, 1.03; 95% CI, 1.01-1.05). CONCLUSIONS: Among patients with coronavirus disease 2019 who were intubated and mechanically ventilated, intubation earlier in the course of hospital admission may be associated with improved survival.