Near-miss hypoglycemia-reflections on perioperative glucose management guidelines in diabetics.

BACKGROUND: The American Society of Anesthesiologists (ASA) has an impressive array of professional perioperative guidelines but has not issued a guideline specific to perioperative blood glucose management and does not delve into the topic in their other guidelines. CASE REPORT: We experienced a perioperative case that highlights the potential difficulty of glucose management in this setting. During anesthetic induction for an orthopedic foot surgery, as the medication was infusing, an IDDM 1 (insulin dependent diabetes mellitus type 1) patient expressed feeling that her blood sugar level was low. Her finger stick after induction showed severe hypoglycemia with a blood glucose of 34 mg/dL. The hypoglycemia was treated with intravenous glucose and further closely monitored. CONCLUSIONS: This case led us to revisit the different perioperative guidelines and recommendations for diabetic patients and this manuscript aims to highlight the similarities and discrepancies among the different published recommendations. This case highlights the value of utilizing insulin pump infusions in the perioperative setting when available.

Acetaldehyde Excitation of Lateral Habenular Neurons via Multiple Cellular Mechanisms.

Acetaldehyde (ACD), the first metabolite of ethanol, is implicated in several of ethanol's actions, including the reinforcing and aversive effects. The neuronal mechanisms underlying ACD's aversive effect, however, are poorly understood. The lateral habenula (LHb), a regulator of midbrain monoaminergic centers, is activated by negative valence events. Although the LHb has been linked to the aversive responses of several abused drugs, including ethanol, little is known about ACD. We, therefore, assessed ACD's action on LHb neurons in rats. The results showed that intraperitoneal injection of ACD increased cFos protein expression within the LHb and that intra-LHb infusion of ACD induced conditioned place aversion in male rats. Furthermore, electrophysiological recording in brain slices of male and female rats showed that bath application of ACD facilitated spontaneous firing and glutamatergic transmission. This effect of ACD was potentiated by an aldehyde dehydrogenase (ALDH) inhibitor, disulfiram (DS), but attenuated by the antagonists of dopamine (DA) receptor (DAR) subtype 1 (SCH23390) and subtype 2 (raclopride), and partly abolished by the pretreatment of DA or DA reuptake blocker (GBR12935; GBR). Moreover, application of ACD initiated a depolarizing inward current (IACD) and enhanced the hyperpolarizing-activated currents in LHb neurons. Bath application of Rp-cAMPs, a selective cAMP-PKA inhibitor, attenuated ACD-induced potentiation of EPSCs and IACD Finally, bath application of ZD7288, a selective blocker of hyperpolarization-activated cyclic nucleotide-gated channels, attenuated ACD-induced potentiation of firing, EPSCs, and IACD These results show that ACD exerts its aversive property by exciting LHb neurons via multiple cellular mechanisms, and new treatments targeting the LHb may be beneficial for alcoholism.SIGNIFICANCE STATEMENT Acetaldehyde (ACD) has been considered aversive peripherally and rewarding centrally. However, whether ACD has a central aversive property is unclear. Here, we report that ACD excites the lateral habenula (LHb), a brain region associated with aversion and negative valence, through multiple cellular and molecular mechanisms. Intra-LHb ACD produces significant conditioned place aversion. These results suggest that ACD's actions on the LHb neurons might contribute to its central aversive property and new treatments targeting the LHb may be beneficial for alcoholism.

Outcomes and Disposition of Patients After Case Cancellation on Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective Cohort Analysis.

BACKGROUND: Many day-of-surgery cancellations are avoidable, and different strategies are used to prevent these costly adverse events. Despite these past analyses and evaluations of positive interventions, studies have not examined the final disposition of patients whose cases were canceled in this late manner. This study sought to determine whether surgical procedures canceled for medical or anesthetic reasons were ultimately rescheduled, and the time elapsed between cancellation and completion. In addition, the resolution of the underlying issue leading to cancellation was examined. METHODS: Two years of surgical case data were reviewed in the electronic health record to isolate all procedures canceled on the intended operative date. These cases were then filtered by the documented reason for cancellation into 2 categories: 1 for cases related to medical or anesthetic care and 1 for unrelated cases. Medical- or anesthetic-related cases were further categorized to better elucidate the underlying reason for cancellation. Cases were then traced to determine if and when the procedure was ultimately completed. If a case was rescheduled, the record was reviewed to determine whether the underlying reason for cancellation was resolved. RESULTS: A total of 4472 cases were canceled in the study period with only 20% associated with medical or anesthetic causes. Of these, 72% were rescheduled and 83% of all rescheduled cases resolved the underlying issue before the rescheduled procedure. Nearly half of all cases (47.8%) canceled on the day of surgery for reasons linked to medical and/or anesthetic care were due to acute conditions. CONCLUSIONS: Nearly a fifth of cases that are canceled on the date of surgery are never rescheduled and, if they are rescheduled, the delay can be substantial. Although the majority of patients whose procedure are canceled for reasons related to medical or anesthetic care have resolved the underlying issue that led to initial postponement, a significant portion of patients have no change in their status before the ultimate completion of their surgical procedure.

Objective validation of YouTube™ educational videos for the instruction of regional anesthesia nerve blocks: a novel approach.

BACKGROUND: YouTube™ ("YouTube") is often used as an educational tool to instruct anesthesia providers on regional anesthesia nerve blocks. However, there is no current objective standard to assess the educational quality of these user-uploaded videos. A new approach was used to objectively validate these videos by comparing them to high quality educational sources for the seven most commonly used nerve blocks. OBJECTIVE: We sought to evaluate the educational quality of user-uploaded videos when compared to the highest quality anesthesia society websites (NYSORA, ACEP, USRA). METHODS: After reviewing the instructional material available for the seven most frequently conducted nerve blocks on high-quality reference websites, we documented the educational characteristics present including such things as indications, volume, anatomy, etc. Next we reviewed the five most popular videos on YouTube for each block (by views) and documented the presence or absence of these educational characteristics. RESULTS: Eighteen educational characteristics were documented in the "high-quality" anesthesia society reference material. Correlation was sought between this material and YouTube videos. Although there were varying degrees of correlation between the high quality sources and the videos, rarely did YouTube videos contain as high a percentage of these educational characteristics as the well-established sources. Some videos contained very few of these important educational characteristics. CONCLUSION: Although YouTube has been used an educational tool, we recommend that only high quality sources be used to teach or illustrate regional anesthesia nerve blocks.

A survey of practice patterns in the use of laryngeal mask by pediatric anesthesiologists.

BACKGROUND: Laryngeal mask is frequently the airway device of choice in routine general anesthesia for many procedures in children. Several studies have described the use of laryngeal masks in unconventional situations. This survey was undertaken to assess how laryngeal masks are being used by pediatric anesthesiologists. METHOD: The 40-question electronic survey using SurveyMonkey™ was sent to 2740 members of the Society for Pediatric Anesthesia (SPA). This survey assessed the age, work environment, types of practice, and training levels, as well as clinical situations in which the practitioners use laryngeal masks across different pediatric age groups. RESULTS: Seven hundred and forty-three (27.1%) responses were obtained. The use of laryngeal mask increased as the patient age increased in nearly every queried situation. The practitioners routinely utilize laryngeal masks in a variety of challenging scenarios, such as in patients with a recent upper respiratory infection, in the difficult airway, remote locations, and long-duration surgeries. A small percentage of pediatric anesthesiologists use laryngeal masks in laparoscopic surgery and prone position procedures. CONCLUSION: Pediatric anesthesiologists are using laryngeal masks in both routine and challenging/unconventional situations. Although many of the uses for laryngeal masks are not explicitly stated in the manufacturer guidelines, literature and current practice support the use of laryngeal masks in several of these scenarios.

Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture.

ABSTRACT: Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

The Risks and Benefits of Physician Practice Acquisition and Consolidation: A Narrative Review of Peer-Reviewed Publications Between 2009 and 2022 in the United States.

The objective of this narrative review was to assess current literature regarding acquisition and consolidation of physician practices in the United States (US). The acquisition and consolidation of physician practices is a trend affecting patient care, quality of services, healthcare economics and the daily practice of physicians. As practices are acquired by fellow physician groups, private equity investors and entities such as hospitals or large healthcare systems, it is important to better understand the underlying forces driving these transactions and their effects. This is a narrative review of peer-reviewed publications to determine what current literature has covered regarding the acquisition and consolidation of physician practices in the US regarding risks and benefits of this trend. Sources included the SCOPUS, Medline- PUBMED and Web of Science databases. Peer reviewed publications from 2009 to 2022 were included for initial review and curation for relevance using the search terms "physician" and "practice" with either "acquisition" or "consolidation". Synthesis conducted after narrowing down of relevant articles did not use quantitative measurements, but instead examined overall trends, as well as risk and benefits of ongoing acquisition and consolidation in a narrative format. Journal articles focused on physician consolidation in the US often reported increases in physician numbers with decreases in numbers of individual practices. Private equity quantitative analyses reported rapidly accelerating acquisitions driven by these investors, and vertical integration scholarly work reported frequent geographic consolidation of nearby practitioners. Risks associated with these transactions included such items as decreased physician autonomy and higher cost of care. Benefits included practice stability, improved negotiation with insurers and improved access to resources.

Intervention for Intraoperative Teaching in Anesthesiology Using Weekly Keyword Program: Development and Usability Study.

BACKGROUND: Learning in the operating room (OR) for residents in anesthesiology is difficult but essential for successful resident education. Numerous approaches have been attempted in the past to varying degrees of success, with efficacy often judged afterward using surveys distributed to participants. The OR presents a particularly complex set of challenges for academic faculty due to the pressures required by concurrent patient care, production pressures, and a noisy environment. Often, educational reviews in ORs are personnel specific, and instruction may or may not take place in this setting, as it is left to the discretion of the parties without regular direction. OBJECTIVE: This study aims to determine if a structured intraoperative keyword training program could be used to implement a curriculum to improve teaching in the OR and to facilitate impactful discussion between residents and faculty. A structured curriculum was chosen to allow for the standardization of the educational material to be studied and reviewed by faculty and trainees. Given the reality that educational reviews in the OR tend to be personnel specific and are often focused on the clinical cases of the day, this initiative sought to increase both the time and efficiency of learning interactions between learners and teachers in the stressful environment of the OR. METHODS: The American Board of Anesthesiology keywords from the Open Anesthesia website were used to construct a weekly intraoperative didactic curriculum, which was distributed by email to all residents and faculty. A weekly worksheet from this curriculum included 5 keywords with associated questions for discussion. The residents and faculty were instructed to complete these questions on a weekly basis. After 2 years, an electronic survey was distributed to the residents to evaluate the efficacy of the keyword program. RESULTS: A total of 19 teaching descriptors were polled for participants prior to and following the use of the intraoperative keyword program to assess the efficacy of the structured curriculum. The survey results showed no improvement in intraoperative teaching based on respondent perception, despite a slight improvement in teaching time, though this was statistically insignificant. The respondents reported some favorable aspects of the program, including the use of a set curriculum, suggesting that greater structure may be beneficial to facilitate more effective intraoperative teaching in anesthesiology. CONCLUSIONS: Although learning is difficult in the OR for residents, the use of a formalized didactic curriculum, centered on daily keywords, does not appear to be a useful solution for residents and faculty. Further efforts are required to improve intraoperative teaching, which is well known to be a difficult endeavor for both teachers and trainees. A structured curriculum may be used to augment other educational modalities to improve the overall intraoperative teaching for anesthesia residents.

Simulated anesthesia consent discussions demonstrate high level of comprehension and education requirements for patients: A pilot study.

Objective: Patient comprehension of informed consent and demonstration of procedural understanding is often lacking in anesthesiology. The purpose of this study was to determine if patient communication in anesthesiology is being conducted effectively, and in a manner that ensures adequate communication between anesthesia professionals and their patients regarding procedures with associated risks and benefits. Methods: Anesthesia professionals were recorded in a simulated setting explaining anesthesia procedures of increasing complexity with one control scenario. Score means were calculated, and statistical comparisons made between discussion of anesthesia procedures and the control scenario. Results: Calculation of means for 6 readability tests demonstrated the grade level required to understand the medical practitioners' verbal communication was high and increased with complexity of the anesthesia procedure described. The control scenario required a statistically significant lower level of comprehension for the recipient of the information. Conclusion: In simulated settings, anesthesia professionals regularly communicate procedural details in a manner that is difficult for the general public to understand. Subjects could communicate in simple terms when discussing a control. Innovation: This pilot study demonstrated effective methodology, using artificial intelligence technology for transcription, to assess patient comprehension of verbal communication.

Use of a Superficial Abdominal Wall Vein in a Gravida Patient for Emergency Vascular Access.

Obtaining vascular access through a superficial vein of the abdominal wall of a gravida patient is an option in an emergency Cesarean surgery when other means fail. Such superficial veins may be mistaken for striae gravidarum on physical exam. A small intravenous (IV) cannula is not ideal but could save valuable time and avoid delaying induction of general anesthesia. Once the airway is secured, a larger bore IV can then be inserted while surgical exposure is undergoing. Analysis of the risks and benefits of inducing general anesthesia with a small gauge IV for a gravida patient should take into consideration risk factors for massive peripartum hemorrhage such as placental disorders (accreta, increta, precreta, abruption, or previa), presence of uterine fibroids, preeclampsia, hemolysis, elevated liver enzymes, low platelet count (HELP syndrome), severe polyhydramnios, history of grand multiparty, and bleeding disorders such as Von Willibrands and hemophilia.

A Prospective Cohort Study on the Respiratory Effect on Modified Mallampati Scoring.

Background: Mallampati scoring is a common exam method for evaluating the oropharynx as a part of the airway assessment and for anticipation of difficult intubation. It partitions the oropharynx into 4 categories with scores of 1, 2, 3, and 4. Even though its reliability is known to be limited by confounding factors such as patient positioning, patient phonation, tongue protrusion, and examiner variability, the effect of respiration, i.e., inspiration and expiration, has not yet been formally studied. Methods: Mallampati scores were collected from 100 surgical patients during both inspiration and expiration and later compared to the score obtained in the medical record, determined by a board certified anesthesiologist. Results: Score deviations from the medical record reference were compared for both inspiration and expiration showing that respiration affects Mallampati scores; for some patients, the scores improved (i.e., decreased), while in others they worsened (i.e., increased). The respiratory change effect was quantified and visualized by plotting the area under the curve of the histogram of the deviations. 42% of the patients had a worsening of scores by 1 or 2 points with inspiration while 36% of the patients had a worsening of scores by 1 or 2 points with expiration. Conclusions: Mallampati scoring is commonly used in evaluating the oropharynx as a part of the airway assessment and as a screening tool for difficult intubations. However, as this study points out, the respiratory cycle substantially affects the Mallampati scoring system, with significant deviations of 1 or 2 points. In a scoring system of 4 score categories, these deviations are remarkable.

A Survey-Based Assessment of the Practices Governing Morbidity and Mortality Conferences and the Effects of the COVID-19 Pandemic.

Background: Morbidity and mortality (M&M) conferences are essential components for resident education and provide a valuable tool to improve patient safety and quality of care. M&M conferences help identify important gaps in safety and reduce avoidable events in future patient care. Active methods to improve the utilization of M&M conferences have been shown to enhance their educational value for residents, faculty and multidisciplinary teams in healthcare institutions. Objective: The purpose of this study was to use a survey-based methodology to assess how morbidity and mortality conferences are conducted in residency programs, including characteristics such as frequency, involvement of personnel and the effects of COVID-19. Methods: From February to October 2021, a validated 19 question survey was electronically distributed to residency program directors in anesthesiology, emergency medicine and general surgery, after a search for email addresses in the ACGME database. The survey was created and hosted on Google Forms. Results: A total of 125 of 713 program directors (17.5%) responded to the survey. Eighty-three percent of respondent programs reported mandatory participation for residents, with residents providing most of the presentations. Case presentations utilized various formats including SBAR, adverse event analysis and root cause analysis as the most common modalities. Though most programs reported no change in frequency of M&M conferences due to COVID-19, most respondents reported a shift to a virtual or hybrid platform. Conclusion: M&M conferences are an important educational and quality improvement modality, and many residency directors changed practice to incorporate virtual platforms due to the COVID-19 pandemic to maintain uninterrupted educational sessions. Nonetheless, significant variation still exists in how these conferences are conducted between different institutions.

A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19.

OBJECTIVE: The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients. METHODS: Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients. CONCLUSION: Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing-the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients. LEVEL OF EVIDENCE: NA.

Human life cost in anaesthesiology cost-benefit decisions.

The United States (US) aviation industry provides a potentially useful mental model for dealing with certain cost-benefit decisions in aesthesiology. The Federal Aviation Administration (FAA), the national aviation authority of the United States, quantifies a price for the value of a human life based on the U.S. Department of Transportation's (DOT) value of a statistical life (VSL) unit. The current VSL is around $9.6 million, indexed to grow with consideration given to inflation and wage changes from the 2016 baseline of $9.4 million [1]. To illustrate the concept, if the FAA estimates that 100 people are likely to die in the future given the current practice standards then the monetary cost of this loss will be $940 million. The FAA uses this estimated monetary value as an official reference point in its regulatory decisions, and the agency publishes in detail how it derives the estimated value. When proposing new regulations, the FAA bases its decisions on comparisons of the human life cost associated with the existing regulation versus the alternative cost that the industry stakeholders will incur subsequent to the adoption of the regulation. In this example, if the cost incurred by the industry is more than the $940 million cost then the FAA will not adopt the proposed regulation and hence will not require the industry to undertake this cost.

Under-Reporting of a Critical Perioperative Adverse Event: Intravenous Infiltration and Extravasation.

A critical step in understanding and preventing potentially disastrous complications in the perioperative period is the accurate recording of their occurrence and subsequent analysis. However, the recording of intravenous infiltration and extravasation is likely inaccurate due to several factors: rare serious complications associated with infiltration/extravasation, limitation in ICD-10 codes to describe the injury, reliance on coders to record these events in searchable databases, and limited quality measures in anesthesiology to record these events. Although current literature cites results of studies that found rates of 16% and higher for intravenous infiltration, a limited internal review at University Hospital in Newark, NJ found significantly lower rates with only 14 instances recorded in an 18-month period across the institution. This leads the author to conclude that interventions are required to better track these events including such steps as staff education and more efficient/accessible reporting systems. The accurate recording and analyzing of data related to adverse events, and in particular regarding infiltration and extravasation, require revision and reinterpretation to gain an accurate picture of their rates.