COVID-19 in the Cancer Patient.

The novel coronavirus disease 2019 (COVID-19) was first reported in China in December 2019. Since then, it has spread across the world to become one of the most serious life-threatening pandemics since the influenza pandemic of 1918. This review article will focus on the specific risks and nuanced considerations of COVID-19 in the cancer patient. Important perioperative management recommendations during this outbreak are emphasized, in addition to discussion of current treatment techniques and strategies available in the battle against COVID-19.

Institution of Monthly Anesthesia Quality Reports Does Not Reduce Postoperative Complications despite Improved Metric Compliance.

While quality programs have been shown to improve provider compliance, few have demonstrated conclusive improvements in patient outcomes. We hypothesized that there would be increased metric compliance and decreased postoperative complications after initiation of an anesthesiology quality improvement program at our institution. We performed a retrospective study of all adult inpatients having anesthesia for a twelve-month period that spanned six months before and after program implementation. The primary outcome was the rate of complications in the post-implementation period. Secondary outcomes included the change in proportion of complications and compliance with quality metrics. We studied a total of 9620 adult inpatient cases, subdivided into pre- and post-implementation groups (4832 vs 4788.) After multivariate model adjustment, the rate of any complication (our primary outcome) was not significantly changed (32% to 31%; adjusted P = 0.410.) Of the individual complications, only wound infection (2.0% to 1.5%; adjusted P = 0.020) showed a statistically significant decrease. Statistically and clinically significant increases in compliance were seen for the BP-02 Avoiding Monitoring Gaps metric (81% to 93%, P < 0.001), both neuromuscular blockade metrics (NMB-01 76% to 91%, P < 0.001; NMB-02 95% to 97%, P = 0.006), both tidal volume metrics (PUL-01 84% to 93%, P < 0.001; PUL-02 30% to 45%, P < 0.001), and the TEMP-02 Core Temperature Measurement metric (88% to 94%, P < 0.001). Implementation of a comprehensive quality feedback program improved metric compliance but was not associated with a change in postoperative complications.

Discharge prescribing of enteral opioids in opioid naïve patients following non-surgical intensive care: A retrospective cohort study.

PURPOSE: To estimate the incidence of new prescription of enteral opioids on hospital discharge in opioid naïve, non-surgical, critically ill patients and evaluate the risk factors associated with such occurrence. METHODS: Using hospital-wide and ICU databases, we retrospectively identified all patients (≥ 18 years old) who were admitted to the 20-bed adult ICU of Memorial Sloan Kettering Cancer Center (MSKCC) between July 1, 2015 and April 20, 2020. Patients' electronic medical records (EMR) were retrieved and patient demographics, peri-ICU admission data were captured and analyzed. RESULTS: During the study period, a total of 3755 opioid naïve patients were admitted to the ICU and 848 patients met the inclusion criteria. Among these, 346 (40.8%) patients were discharged with a new opioid prescription. Age at ICU admission, preadmission use of benzodiazepine, and antidepressants, a diagnosis of sepsis, and use of mechanical ventilation, antidepressants or, opioid infusion for greater than 4 h during the ICU stay, hospital length of stay (LOS), and days between ICU discharge and hospital discharge were independently associated with increased odds of a new opioid prescription. CONCLUSIONS: A significant proportion of opioid naïve non-surgical ICU survivors receive a new opioid prescription on hospital discharge.

Perioperative corneal injury: An unseen casualty of COVID-19.

Introduction: This study is the first to reveal an increased incidence in perioperative corneal injuries during the COVID era and should alert clinicians to this observation. This study could inform investigations into practice or patient factors that changed as a result of the COVID pandemic. We were aware of several adverse corneal injury reports during COVID and as a result did a formal IRB approved retrospective review to see if corneal injuries were more common during that period. Methods: This is a retrospective cross-sectional observational study based on the hospital reporting of corneal injuries in the peri-operative time-period during the COVID pandemic. Comparison to known incidence of corneal injuries from the same institution in the pre COVID era were made. The objective was to examine if there were increased peri-operative corneal injuries during the COVID pandemic compared to other time points at our institution. Results: All corneal injury event reports were aggregated for the time period including January 1, 2015 through April 30, 2021. Data include all patients who underwent anesthesia for any procedure at all sites within the hospital system. Corneal injury rates (in lieu of total number of events) were utilized to account for variation in perioperative volume. Using Poisson regression, corneal injury rates were significantly higher after March 2020 compared to the other time points. Alternatively, RISQ reporting rates were significantly lower after March 2020 compared to other time points. Conclusions: This study reveals an increased incidence in perioperative corneal injuries during the COVID era and should alert clinicians to this observation. This study may inform investigations and may ultimately drive processes that could mitigate preventable causes of perioperative corneal injury.

Postoperative Facial Nerve Palsy in a Pediatric Patient.

Peripheral nerve injury is a well-recognized complication of surgery and anesthesia. However, overall incidence is less than 1% [1,2]. Most commonly affected nerves include the ulnar nerve, brachial plexus, and lumbosacral nerve root [2]. Postoperative facial nerve palsy as a complication of surgery and anesthesia has been documented in the literature, but it is a rare event [3]. The occurrence of any type of nerve injury as a postoperative complication is even less common in the pediatric population [2,3]. In this report, we describe a case of postoperative facial nerve palsy in a pediatric patient after a thoracotomy..

Unusual Cause of Intraoperative Asystole During Thoracotomy: A Case Report.

Thoracotomies are classified as moderate to high-risk surgeries due to the preponderance of complex anatomic structures, cardiac dysrhythmias, and respiratory insufficiency. The right vagus nerve innervates the sinoatrial node and controls the heart rate. The parasympathetic activation of the sinoatrial node can lead to bradyarrhythmias. The anatomic aortopulmonary window contains lymph nodes and the left vagus nerve. The occurrence of sudden asystole due to left vagus nerve stimulation is extremely rare. We report an unusual case of intraoperative asystole related to electrosurgical stimulation of the left vagus nerve that required cardiopulmonary resuscitation and cardiac massage.

Anesthetic management of a patient with Stiff-Person Syndrome and endometrial cancer for robotic surgery: A case report.

Stiff-person syndrome (SPS) is a rare disorder of the nervous system, characterized by muscle stiffness, rigidity, and painful spasms involving truncal and limb musculature that may severely limit mobility. Our case documents a 53-year-old patient with SPS and endometrial cancer who was positive for anti-GAD and paraneoplastic antibodies, who presented to our institution for robotic surgery. These patients are at high risk for prolonged hypotonia and mechanical ventilation. Our patient underwent general anesthesia without complications despite multiple comorbidities.

Challenges of Going Green in the Operating Room.

The environmental debate continues to expand in the realm of healthcare, resulting in increased scrutiny of the impact of material waste and gas emissions in the operating room (OR). In a single day, ORs can contribute up to 2000 tons of medical waste, mostly in the form of disposable medical supplies. We review the major challenges associated with "going green" in the OR.

Simple Green Changes for Anesthesia Practices to Make a Difference.

The environmental debate on going green in the operating room (OR) has been a controversial topic for many years. Challengers of greening efforts cite various obstacles and arguments against these initiatives. However, ORs in the United States continue to generate a staggering amount of waste daily. In this article, we review major barriers to going green and highlight simple, yet effective greening strategies that anesthesia practices could adopt to reduce our carbon footprint.

Considerations for Transgender Patients Perioperatively.

With a shift in the cultural, political, and social climate surrounding gender and gender identity, an increase in the acceptance and visibility of transgender individuals is expected. Anesthesiologists are thus more likely to encounter transgender and gender nonconforming patients in the perioperative setting. Anesthesiologists need to acquire an in-depth understanding of the transgender patient's medical and psychosocial needs. A thoughtful approach throughout the entirety of the perioperative period is key to the successful management of the transgender patient. This review provides anesthesiologists with a culturally relevant and evidence-based approach to transgender patients during the preoperative, intraoperative, and postoperative periods.

Focused Transesophageal Echocardiography for Bedside Diagnosis of Iatrogenic Cardiac Perforation: A Case Report.

We describe an extremely rare complication of chest tube placement and focused transesophageal echocardiography (TEE) in the diagnosis of a life-threatening condition. It illustrates the value and utility of point-of-care ultrasound (POCUS) by way of a focused TEE in confirming a diagnosis and contributing toward the expeditious operative management of a life-threatening scenario. POCUS continues to gain traction in the field of anesthesiology. However, incorporation of POCUS training into curriculum of anesthesia residency programs is still in the infancy stages. Our report demonstrates the need for development and standardization of POCUS training for anesthesiologists in the perioperative setting.

Ingestion of Dental Prosthesis of A Patient with an LMA Under General Anesthesia: A case report.

60-year-old male presented for outpatient cystoscopy under General Anesthesia with a Laryngeal Mask Airway (LMA). The patient denied dental prosthesis during assessment. In recovery, a family member noticed a missing dental bridge which prompted a workup that revealed the ingested dental bridge in the stomach. The patient underwent a second anesthetic for upper endoscopy to retrieve the foreign body. This case report highlights the need for vigilance during the entire perioperative period. Early interventions in this setting should include chest and abdominal x-rays and possibly an urgent endoscopy to prevent severe damage to the Gastrointestinal tract.

Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

OBJECTIVE: We determine if Real Time Locating Systems (RTLS) paired with automated notifications have a sustained effect on perioperative efficiency in anesthesiologists over a one-year period from the time of implementation. METHODS: A retrospective chart review of all outpatient and short-stay patients, who received general anesthesia at our ambulatory surgery center between July 1st, 2017 and December 31st, 2018 was performed. Patients included were over 18 years of age who presented for non-urgent cases with ASA classification of 1, 2, and 3. Additionally, only first cases of the day for individual anesthesiologists were included.Time was used as a measure of efficiency between three comparison groups: Anesthesiologists who use RTLS prior to implementation of automated notification pairing for the period of 1 July 2017 to 31 December 2017.Anesthesiologists who use RTLS paired with automated notifications for the period of 1 January 2018 to 30 June 2018.Anesthesiologists who use RTLS paired with automated notifications for the period of 1 July 2018 to 31 December 2018.The primary outcome measure duration (DUR) was collected from patient electronic records.DUR was defined as duration of time, in minutes, from patient arrival to the Operating Room (OR) and initiation of induction by the anesthesiologist (exclusively for first cases of the day). RESULTS: During the initial six months, DUR between time of OR admission and time of induction was significantly reduced to 6.0 minutes (5.0,8.0) post-implementation of automated notification pairing with RTLS. DUR then returned to pre-intervention baseline of 7.0 minutes (5.0, 9.0) during the subsequent six-month study period. CONCLUSION: Initial results indicate that implementation of integrated RTLS technology enabled anesthesiologists at our institution to be more efficient during the perioperative period. However, this perceived benefit was not sustained over a 1-year period as our measure of efficiency DUR ultimately returned to the pre-intervention baseline.

The incidence of intraoperative gastric tube malposition verified by Point-of-Care Ultrasound.

BACKGROUND: Over a million gastric tubes are placed yearly for varying medical reasons including gastric decompression. In the operating room (OR), this is performed blindly, and position is confirmed by auscultation, aspiration, or palpation by a surgeon. Despite the known risks of malpositioned gastric tubes, there is limited data in anesthesia literature about the incidence of intraoperative malpositioned gastric tubes. In this study, we use Point-of-Care ultrasonography (POCUS) to confirm gastric tube placement in the OR. METHODS: Prospective observational study with a total of 149 subjects, all over 18 years of age, undergoing surgery with general endotracheal anesthesia and intraoperative blind placement of a gastric tube by an anesthesia provider. The primary objective of this study is to determine the incidence of malposition of blindly placed gastric tubes. RESULTS: In our analysis, we found that out of 149 patients 110 patients were successfully visualized; the incidence of malposition was 0.14 [95% CI: 0.08-0.21]. We did not find age, Body Mass Index, or sex to be associated with predisposing patients to intraoperative malposition of gastric tube. However, increasing years of experience of anesthesia provider correlated with higher malposition rates. CONCLUSIONS: In summary, we demonstrated that the incidence of malposition of blindly gastric tubes was 14%. Given the attendant risks of malpositioned gastric tubes, this data should inform decision algorithms for the blind placement of gastric tubes.