Five actions for five people: emergency cesarean section protocol.

OBJECTIVE: The scope of this work is to evaluate an operative protocol for emergency C-section to improve teamwork and reduce surgical setup time. METHODS: Sixty-six health care operators working together in the delivery ward (gynecologists, midwives, anesthesiologists) simulated an emergency scenario applying a "five actions for each operator" protocol. For each simulation, the decision to delivery interval was considered and the perception of each operator as a team worker was analyzed with specific tests. RESULTS: The "five actions for five people" protocol significantly reduces the decision to delivery interval (p < 0.001) for emergency C-section. At the same time, a simple and codified scheme improves communication among team members, avoids overlapping roles. Indeed, all the operators become more aware of being helpful to the team (p < 0.001). CONCLUSION: The use of a standardized, simple, and immediately usable protocol improves the performance of the delivery room team in terms of the urgency and quality of the operator's participation in the event. Procedures of this type should be favored within emergency obstetric settings. TRIAL REGISTRATION NUMBER: CEAVNO 19-01-23. Local ethical Committee (COMITATO ETICO REGIONALE PER LA SPERIMENTAZIONE CLINICA - Sezione autonoma Area Vasta Nord Ovest -CEAVNO) approved this study as simulation training study. All the operators participated voluntary during their working time.

Biventricular repair as an alternative to single-ventricle palliation in a child with hypoplastic left heart structures: What the anesthesiologist should know.

Enhanced techniques for single-ventricle palliation (SVP), in which the Fontan procedure is the final phase, have improved the survival and quality of life in patients not eligible for biventricular repair (BiVR). However, Fontan physiology also is associated with predictable long-term consequences that ultimately affect quality of life and freedom from adverse events. Given this harsh reality, the advances in ventricular rehabilitation strategies and the conversion from SVP increasingly are being used to achieve biventricular circulation in patients with left-heart hypoplasia who previously were considered to be marginal or unacceptable candidates for BiVR. The techniques for ventricular recruitment include restriction of the atrial septal defect (ASD), atrioventricular valve repair, repair of left ventricular outflow obstruction, endocardial fibroelastosis resection, an augmented pulmonary blood flow, and catheter-based interventions. In addition, reverse double-switch surgery has been used as an option for patients with a left ventricle of insufficient size and function to support the systemic circulation, who would otherwise require a Fontan surgery. Despite improved management and surgical technique, the outcomes after biventricular staging repair and conversion remain variable, and the complications ultimately may exclude patients from future single-ventricle palliation or transplant. The anesthesiologist should have a basic understanding of the anatomy and physiology of this growing patient population in order to develop adequate perioperative management options.

Opportunities Beyond the Anesthesiology Department: Broader Impact Through Broader Thinking.

Ensuring a productive clinical and research workforce requires bringing together physicians and communities to improve health, by strategic targeting of initiatives with clear and significant public health relevance. Within anesthesiology, the traditional perspective of the field's health impact has focused on providing safe and effective intraoperative care, managing critical illness, and treating acute and chronic pain. However, there are limitations to such a framework for anesthesiology's public health impact, including the transient nature of acute care episodes such as the intraoperative period and critical illness, and a historical focus on analgesia alone-rather than the complex psychosocial milieu-for pain management. Due to the often episodic nature of anesthesiologists' interactions with patients, it remains challenging for anesthesiologists to achieve their full potential for broad impact and leadership within increasingly integrated health systems. To unlock this potential, anesthesiologists should cultivate new clinical, research, and administrative roles within the health system-transcending traditional missions, seeking interdepartmental collaborations, and taking measures to elevate anesthesiologists as dynamic and trusted leaders. This special article examines 3 core themes for how anesthesiologists can enhance their impact within the health care system and pursue new collaborative health missions with nonanesthesiologist clinicians, researchers, and administrative leaders. These themes include (1) reframing of traditional anesthesiologist missions toward a broader health system-wide context; (2) leveraging departmental and institutional support for professional career development; and (3) strategically prioritizing leadership attributes to enhance system-wide anesthesiologist contributions to improving overall patient health.

Effects of a training program in medical hypnosis on burnout in anesthesiologists and other healthcare providers: A survey study.

OBJECTIVE: To determine whether the participation to a medical hypnosis training program reduces the levels of burnout in healthcare providers. DESIGN: Survey study. SETTINGS: Study conducted from 2014 to 2018 using the MBI-HSS questionnaire assessing three dimensions of burnout: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). PARTICIPANTS: Healthcare providers in particular anesthesiologists participating to a one-year medical hypnosis training program. INTERVENTION: All participants were asked to fill the MBI-HSS on the first day before the training program had begun, then on the last day of the program once the entire training was completed. PRIMARY AND SECONDARY OUTCOME MEASURES: The EE, DP and PA scores and their grade (high, average and low) were compared before and after training and between physicians and caregivers. RESULTS: In total, 1850 persons participated to the training sessions, with 1366 participants enrolled before the first session (74%) and 1407 (76%) after the fourth. On the 1366 persons enrolled before training, 1139 (83%) completed the survey and on the 1407 enrolled after training, 1194 (85%) completed the survey. The scores were significantly smaller after training for EE and DP and significantly greater for PA. Before training, EE was significantly greater in physicians than in caregivers as well as DP, with no difference for PA. After training, DP was significantly greater in physicians than in caregivers and PA was smaller, with no difference for EE. Before training, there was high rates of burnout in both healthcare providers but there was a significant trend to smaller rates of burnout after training. CONCLUSIONS: This study shows that healthcare providers who participated to a medical hypnosis training program presented improvements in the three dimensions of burnout. Further study is required to investigate and recommend this type of continuous medical education to improve professional satisfaction and wellbeing in healthcare providers.

Recent Updates in Spinal Anesthesia-A Narrative Review.

Spinal anesthesia is a commonly performed regional technique by a majority of the anesthesiologists worldwide. This technique is learnt early during training and relatively easy to master. Despite being the oldest regional anesthesia technique, it continues to evolve and develop in various aspects. This review attempts to highlight the recent advances in this 〞almost-perfect〞 technique with respect to indications, procedure, drugs, and strategies to minimize side effects. Understanding the finer aspects and knowledge gaps will help postgraduates and practicing anesthesiologists in designing patient specific techniques and interventions.

Unanticipated Consequences of Switching to Sugammadex: Anesthesia Provider Survey on the Hormone Contraceptive Drug Interaction.

BACKGROUND: Sugammadex binds progesterone with high affinity and may interfere with hormonal contraceptive effectiveness. The clinical, economical, and ethical implications of unintended pregnancy should prompt anesthesiologists to actively consider and manage this pharmacologic interaction. We surveyed anesthesiology providers at our institution about knowledge of this potential adverse drug interaction, how they manage it clinically, and the extent to which they involve patients in shared decision-making regarding choice of neuromuscular blocker antagonist. METHODS: A survey instrument was distributed to anesthesiology providers at a large, tertiary-care medical center. The survey explored prior experience using neostigmine and sugammadex, knowledge about potential sugammadex interference with hormonal contraception, pre-/postoperative counseling practices, clinical management, and shared decision-making regarding potential use of neostigmine in lieu of sugammadex to avoid this drug-drug interaction. RESULTS: Of 259 surveys distributed, 155 were fully completed, and 10 were partially completed. Overall response rate was 60% (residents 85%, student nurse anesthetists 53%, certified registered nurse anesthetists 58%, attendings 48%). All but 1 respondent recognized the potential for sugammadex interference with oral hormonal contraception. Far fewer accurately identified potential interference with hormonal intrauterine devices (44%) and hormonal contraceptive implants (55%). The manufacturer's recommended 7-day duration of alternative contraception was correctly identified by 72% of respondents; others (22%) reported longer durations (range 10-30 days). Most (78% overall) agreed/strongly agreed that potential interference with contraceptive effectiveness should be discussed with patients preoperatively. Despite the majority (86% overall) that endorsed shared decision-making and inviting patient input regarding choice between sugammadex and neostigmine, many respondents reported "rarely/never" having discussed this drug interaction with patients in actual clinical practice, either preoperatively (67%) or postoperatively (80%). Furthermore, most respondents (79%) reported "rarely/never" administering neostigmine to intentionally avoid this drug interaction. CONCLUSIONS: Two years after designating sugammadex as antagonist of choice, physician and nurse anesthesia providers reported seldom inquiring about contraceptive use among women of childbearing potential and rarely discussing potential risk of contraceptive failure from sugammadex exposure. Most lack accurate knowledge of sugammadex interference with hormonal intrauterine and subcutaneous contraceptive devices. Although most endorse preoperative counseling and support patient autonomy or shared decision-making regarding choice of reversal agent, the same respondents report rarely, if ever, actualizing these positions in clinical practice. These conflicting findings highlight the need for education regarding residual neuromuscular block versus adverse drug interactions, collaboration among providers involved in patient counseling, and intentional mindfulness of reproductive justice when caring for women of childbearing potential.

Ultrasound-guided superior laryngeal nerve block -A description of the technique / Bloqueo de nervio laríngeo superior guiado por ecografia. Descripción de la técnica

Abstract Complications in airway management remain a common cause of anesthesia-associated mortality. When a patient is considered with anticipated difficult airway, the management depends on several variables, however, at present, the standard of management continues to be the patient awake approach. In scenarios of acute upper airway obstruction, the only way to guarantee adequate ventilation is to obtain a translaryngeal or transtracheal access, for which, it is necessary to use local anesthesia and grade I / II sedation, avoiding loss of spontaneous ventilation. For this purpose, we propose ultrasound-guided superior laryngeal nerve block, in order to standardize an ultrasound landmark that is reproduceable, with a high success rate, which allows limiting complications related to regional anatomic techniques and thus facilitating the securing of the airway in these patients.

Resumen Las complicaciones en el manejo de la vía aérea siguen siendo una causa frecuente de mortalidad relacionada con anestesia. Cuando un paciente se considera con vía aérea difícil anticipada, el manejo depende de diversas variables, sin embargo, en la actualidad, el estándar de manejo sigue siendo el abordaje con paciente despierto. En escenarios de obstrucción aguda de la vía aérea superior, la única forma de garantizar una adecuada ventilación es obtener un acceso translaríngeo o transtraqueal, para lo cual, es necesario el uso de anestesia local y de sedación grado I/II evitando la pérdida de ventilación espontánea. Con este propósito, planteamos el bloqueo del nervio laríngeo superior guiado por ultrasonografía, con el fin de estandarizar una referencia ecográfica reproducible, con alto índice de éxito, la cual permita limitar complicaciones relacionadas con las técnicas regionales anatómicas y así facilitar el aseguramiento de la vía aérea en estos pacientes.

In-House Anesthesia and Interventional Radiology Technologist Support Optimize Mechanical Thrombectomy Workflow after Hours.

BACKGROUND AND PURPOSE: Prior literature suggests after-hours delay leads to poor functional outcomes in stroke patients undergoing thrombectomy. We aimed to evaluate the impact of time of presentation on mechanical thrombectomy (MT) metrics and its association with long-term functional outcome in an Interventional Radiology (IR) suite equipped operating room (OR) setting. METHODS: Retrospective review of prospectively maintained database on all stroke patients undergoing mechanical thrombectomy between January 2015 and December 2018 at our CSC. Work hours were defined by official OR work hours (Monday-Friday 7 AM and 5 PM) and after-hours as between 5 PM and 7 AM during weekdays and weekends as well as official hospital holidays. Primary outcome was 90-day modified Rankin Scale (mRS). Secondary outcomes included door to groin puncture time and procedural complications. RESULTS: A total of 315 patients were included in the analyses. 209 (66.4%) received mechanical thrombectomy after hours and 106 (33.6%) during work hours. There was no difference in the shift distribution of functional outcome on the mRS at 90 days (OR: 1.14, CI: 0.72-1.78, p=0.58) and the percentage of patients achieving functional independence (mRS 0-2) at 90 days (43.1% vs. 41.3%; p=0.83) between the after hour and work hour groups respectively. Similarly, there was no difference in median door to groin times and procedural complications among both groups, with significant year on year improvement in overall time metrics. CONCLUSIONS: Our study showed that undergoing MT during off-hours had similar functional outcomes when compared to MT during working hours in an OR setting. The after-hours deleterious effect might disappear when MT is performed in a system with 24-hours in-house Anesthesia and IR tech services.

A Last Resort When There is No Blood: Experiences and Perceptions of Intraoperative Autotransfusion Among Medical Doctors Deployed to Resource-Limited Settings.

BACKGROUND: Four and a half million people die globally every year due to traumatic injuries. One major cause of preventable death is bleeding. Blood for transfusion is often unavailable in resource-limited settings, where a majority of trauma deaths occur. Intraoperative autotransfusion (IAT) has been proposed as a safe and feasible lifesaving alternative to allogeneic blood transfusion. However, there is limited knowledge regarding its use among doctors working for international non-governmental organisations (INGOs) in resource-limited settings. The aim of this study was to explore the experiences and perceptions of IAT among INGO-affiliated medical doctors with clinical experience in resource-limited settings. METHODS: We conducted semi-structured interviews via telephone or Skype with 12 purposefully sampled surgeons and anaesthesiologists. The interviews were recorded, transcribed verbatim, and analysed using content analysis. RESULTS: We identified three main themes relating to IAT and bottlenecks preventing the scale-up of its use: variation in techniques and systems, contextual factors, and individual medical doctor factors. The participants gave detailed reports of missed opportunities for usage of IAT in resource-limited settings. Bottlenecks included the lack of simple and cost-effective products, limited availability of protocols in the field, and insufficient knowledge and experience of IAT. CONCLUSIONS: The participants found that simple IAT is under-utilised in resource-limited settings. Missed opportunities to use IAT were mainly associated with armed conflict settings and obstetrical emergencies. In order to meet the need for IAT in resource-limited settings, we suggest further consideration of the identified bottlenecks.

Evaluation of an enhanced pulse oximeter auditory display: a simulaion study.

BACKGROUND: We compared anaesthetists' ability to identify haemoglobin oxygen saturation (SpO2) levels using two auditory displays: one based on a standard pulse oximeter display (varying pitch plus alarm) and the other enhanced with additional sound properties (varying pitch plus tremolo and acoustic brightness) to differentiate SpO2 ranges. METHODS: In a counter-balanced crossover study in a simulator, 20 experienced anaesthetists supervised a junior colleague (an actor) managing two airway surgery scenarios: once while using the enhanced auditory display and once while using a standard auditory display. Participants were distracted with other tasks such as paperwork and workplace interruptions, but were required to identify when SpO2 transitioned between pre-set ranges (target, low, critical) and when other vital signs transitioned out of a target range. They also identified the range once a transition had occurred. Visual displays were available for all monitored vital signs, but the numerical value for SpO2 was excluded. RESULTS: Participants were more accurate and faster at detecting transitions to and from the target SpO2 range when using the enhanced display (100.0%, 3.3 s) than when using the standard display plus alarm (73.2%, 27.4 s) (P<0.001 and P=0.004, respectively). They were also more accurate at identifying the SpO2 range once a transition had occurred when using the enhanced display (100.0%) than when using the standard display plus alarm (57.1%; P<0.001). CONCLUSIONS: The enhanced auditory display helps anaesthetists judge SpO2 levels more effectively than current auditory displays and may facilitate 'eyes-free' monitoring.

[Pilot study on subjectively and objectively measurable stress reduction in the daily routine of a university anesthesia department by an intervention program according to mindfulness-based stress reduction]. / Pilotstudie zu subjektiv und objektiv messbarer Stressreduktion im Alltag einer universitären Anästhesieabteilung durch ein Interventionsprogramm nach Mindfulness-Based Stress Reduction (MBSR).

BACKGROUND: Chronic stress and high workload in physicians can lead to loss of interest, emotional exhaustion and finally in burnout syndrome. This can cause serious consequences not only for the physicians personally and their own health by developing extensive health impairments, e.g. depression, suicide, substance abuse and poor self-care but also for patient care, reflected in an increase of medical errors, longer recovery times, lower care quality and consequently lower patient satisfaction. Additionally, it can also have negative effects on the healthcare system by reduced productivity, increased physician turnover and thereby higher costs. OBJECTIVE: This pilot study investigated brief interventions inspired by mindfulness-based stress reduction (MBSR) combined with short daily meditation exercises in the everyday work of anesthetists at a university hospital. Secondly, whether this program increases the development of coping mechanisms for stress and improves participants' resilience and health status. MATERIAL AND METHODS: The pilot study was designed as a monocenter prospective interventional study with four different points of measurement. Subjective and objective stress parameters were measured directly before (t0) and after (t1) the intervention as well as 3 (t2) and 6 (t3) months after end of the intervention. Measurements took place during work time and at the workplace. The intervention was based on the classical MBSR including short daily exercises and lasted for 6 weeks with sessions lasting 1- 1.5 h and an additional 20 min of daily mediation exercises. The subjective parameters were based on validated questionnaires, such as the World Health Organization (WHO) well-being index (WHO-5), resilience scale (RS-11), Maslach burnout inventory (MBI-22) and perceived stress scale (PSS-10). For objective parameters heart rate variability (HRV) was evaluated during rest and after exposure to physical exercise and hair cortisol concentrations (HCC) in a 1.5 cm length of a hair, which represents the equivalent of a 6-week period. RESULTS: Data from 27 subjects could be analyzed. Between t3 and t0 a significant improvement of resilience was detected as a positive personality trait measured by RS-11 with a large effect size (p = 0.013; r = 0.59) as well as a significant reduction of burnout symptoms (MBI-22) also with a large effect size (p = 0.019; r = 0.57). Furthermore, a significant decrease was found in well-being (WHO-5) between t2 and t0 (p = 0.003, r = 0.67) and between t1 and t0 (p = 0.001, r = 0.71). The objective parameters did not show any significant differences between the examinations. CONCLUSION: An MBSR-based intervention in combination with short exercises during and after work can be implemented in daily work of anesthetists at a university hospital. Furthermore, there was clear evidence that the intervention program increased resilience and reduced burnout symptoms for up to 6 months. These findings are in line with the literature that MBSR reduces risk of burnout symptoms. The decrease in well-being might be biased by a high amount of socially accepted answers at the beginning of the study (t0).

Cardiogenic Shock in Perioperative and Intraoperative Settings: A Team Approach.

Cardiogenic shock (CS) is a multifactorial disease process with high morbidity and mortality. When it occurs in a peri- or intraoperative setting, factors such as surgery, anesthesia, and post-surgical physiology can negatively affect patient outcomes. Since patient needs often escalate during CS-from medications to mechanical support to palliative care-this disease demands a multidisciplinary approach that encompasses all aspects of medical delivery. Preliminary studies have indicated that a multidisciplinary team approach to CS results in earlier diagnosis and treatment and improves patient outcomes. Here we discuss various management strategies for CS from an anesthesiology, surgery, and critical care perspective.

Regional anaesthesia practice for arteriovenous fistula formation surgery.

We conducted a survey and semi-structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty-five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill-mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as 'regional anaesthesia dominant' or 'local anaesthesia/mixed'; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians' beliefs and preferences, resource considerations and patients' treatment preferences; (4) anaesthetists' preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource-related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.

How to communicate between surgeon and intensivist?

PURPOSE OF REVIEW: Communication and teamwork are essential to enhance the quality of care, especially in operating rooms and ICUs. In these settings, the effective interprofessional collaboration between surgeons and intensivists impacts patients' outcome. This review discusses current opinions and evidence for improving communication strategies and the relationship between surgeons and intensivists/anesthesiologist. RECENT FINDINGS: Effective teamwork has been demonstrated to improve patient outcome and foster healthier relationships between professionals.With the expansion of new medical superspecialist disciplines and the latest medical developments, patient care has been put through a progressive fragmentation, rather than a holistic approach. Operating theaters and ICU are the common fields where surgeons and anesthesiologists/intensivists work. However, communication challenges may frequently arise. Therefore, effective communication, relational coordination, and team situation awareness are considered to affect quality of teamwork in three different phases of the patient-centered care process: preoperatively, intraoperatively, and postoperatively. SUMMARY: Although limited, current evidence suggests to improve communication and teamwork in patient perioperative care. Further research is needed to strengthen the surgeon-intensivist relationship and to deliver high-quality patient care.

Niveles de vitamina D en médicos: ¿son los anestesiólogos el único grupo de riesgo? / Vitamin D levels among anesthesiologists and other physicians

Background Sun exposure is the main source of 25-hydroxy-vitamin D. Since anesthesiologists work inside operating rooms, they are identified as a deficiency risk group. As medical activity in general occurs indoors, added to the work excess and sedentary lifestyle, physicians in general have low sun exposure. Aim To investigate the determinants of vitamin D levels in physicians. Material and Methods Anesthesiologists and physicians not working in operating rooms were included. A survey that comprised working hours, diet, skin color, sunscreen use and outdoor activities was also applied. Measurements of vitamin D and parathormone levels in blood were performed. Results We analyzed samples from 81 volunteers. Median vitamin D values of the whole sample were in the range of insufficiency (25.3 [interquartile range 12.4] ng/ml). Multiple linear regression analysis detected no differences between anesthesiologists and non-anesthesiologists. A higher body mass index was a risk factor for vitamin D deficiency, (p = 0.025). The only protective factor was the intake of a vitamin D supplement (p < 0.01). Conclusions Anesthesiologists and other specialists were both at risk for vitamin D deficiency. Obesity was a risk factor and the use of a vitamin D supplement was the only protective factor.