The Impact of COVID-19 on Racial and Ethnic Disparities in Cardiac Procedural Care.

OBJECTIVE: The primary objective of this study was to evaluate whether the COVID-19 pandemic altered the racial and ethnic composition of patients receiving cardiac procedural care. DESIGN: This was a retrospective observational study. SETTING: This study was conducted at a single tertiary-care university hospital. PARTICIPANTS: A total of 1,704 adult patients undergoing transcatheter aortic valve replacement (TAVR) (n = 413), coronary artery bypass grafting (CABG) (n = 506), or atrial fibrillation (AF) ablation (n = 785) from March 2019 through March 2022 were included in this study. INTERVENTIONS: No interventions were performed as this was a retrospective observational study. MEASUREMENTS AND MAIN RESULTS: Patients were grouped based on the date of their procedure: pre-COVID (March 2019 to February 2020), COVID Year 1 (March 2020 to February 2021), and COVID Year 2 (March 2021 to March 2022). Population-adjusted procedural incidence rates during each period were examined and stratified based on race and ethnicity. The procedural incidence rate was higher for White patients versus Black, and non-Hispanic patients versus Hispanic patients for every procedure and every period. For TAVR, the difference in procedural rates between White patients versus Black patients decreased between the pre-COVID and COVID Year 1 (12.05-6.34 per 1,000,000 persons). For CABG, the difference in procedural rates between White patients versus Black, and non-Hispanic patients versus Hispanic patients did not change significantly. For AF ablations, the difference in procedural rates between White patients versus Black patients increased over time (13.06 to 21.55 to 29.64 per 1,000,000 persons in the pre-COVID, COVID Year 1, and COVID Year 2, respectively). CONCLUSION: Racial and ethnic disparities in access to cardiac procedural care were present throughout all study time periods at the authors' institution. Their findings reinforce the continuing need for initiatives to reduce racial and ethnic disparities in healthcare. Further studies are needed to fully elucidate the effects of the COVID-19 pandemic on healthcare access and delivery.

The Penn Classification Predicts Hospital Mortality in Acute Stanford Type A and Type B Aortic Dissections.

OBJECTIVES: Mortality in acute aortic dissection varies depending on anatomic location, extent, and associated complications. The Stanford classification guides surgical versus medical management. The Penn classification stratifies mortality risk in patients with Stanford type A aortic dissections undergoing surgery. The objective of the present study was to determine whether the Penn classification can predict hospital mortality in patients with acute Stanford type A and type B aortic dissections undergoing surgical or medical management. DESIGN: Retrospective, observational study. SETTING: Tertiary care, university hospital. PARTICIPANTS: Patients with acute aortic dissection between January 2008 and December 2017. INTERVENTIONS: Examination of hospital mortality after surgical or medical management. MEASUREMENTS AND MAIN RESULTS: Three hundred fifty-two patients had confirmed dissections (186 type A, 166 type B). The overall mortality was 18.8% for type A and 13.3% for type B. Penn class A patients with type A or type B dissections undergoing surgical repair had the lowest mortality (both 3.1%). Penn class B, C, or B+C patients with type A dissections and Penn class B+C patients with type B dissections undergoing medical management had the greatest incidence of mortality (50.0%-57.1%). All others had intermediate mortality (6.7%-39.3%). Logistic regression analysis demonstrated that Penn class B, C, and B+C patients had a greater odds of mortality and predicted mortality than did Penn class A patients. CONCLUSIONS: The Penn classification predicts hospital mortality in patients with acute Stanford type A or type B aortic dissections undergoing surgical or medical management. Early endovascular repair may confer lower risk of mortality in patients with type B dissections presenting without ischemia.

Anesthetic Outcomes of Children With Arthrogryposis Syndromes: No Evidence of Hyperthermia.

BACKGROUND: Arthrogryposis syndromes are a heterogeneous group of disorders characterized by congenital joint contractures often requiring multiple surgeries during childhood to address skeletal and visceral abnormalities. Previous reports suggest that these children have increased perioperative risk, including hypermetabolic events discrete from malignant hyperthermia, difficult airway management, isolated hyperthermia, and difficult IV line placement. We sought to compare children with arthrogryposis multiplex congenita (AMC) versus the less severe, distal arthrogryposis syndromes (DAS) and to evaluate possible intraoperative hyperthermia of patients with AMC. We hypothesized that children with AMC had a greater incidence of intraoperative hyperthermia and more difficulty with airway management and IV access. METHODS: Children aged 0 to 25 years with arthrogryposis syndromes who underwent anesthesia from 1972 to 2013 were identified. The medical records were reviewed for demographics, arthrogryposis type, and anesthetic complications. AMC subjects were compared with DAS subjects. To evaluate the probability of hyperthermia and hypermetabolic responses of patients with AMC, we performed a post hoc case-control analysis. Patients with AMC were matched in a 1:2 ratio to patients without arthrogryposis to evaluate the primary outcome of maximum intraoperative temperature. RESULTS: Forty-five patients with AMC and 16 patients with DAS underwent 264 and 105 unique anesthetics, respectively. There was no significant difference in intraoperative hyperthermia or hypermetabolic events (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.36-2.47; P = .90). Children with AMC were more likely to have difficult IV access (OR, 7.1; 95% CI, 1.81-27.90; P = .005). Additional evidence suggested that difficult airway management (OR, 4.06; 95% CI, 1.01-16.39; P = .049) and hemodynamic instability (OR, 4.22; 95% CI, 1.03-17.26; P = .045) were more likely in children with AMC. From post hoc case-control analysis, there was no significant difference in the mean maximum intraoperative temperature (estimated difference +0.04°C; 95% CI, -0.14 to +0.22; P = .64) or odds of intraoperative hyperthermia (OR, 1.49; 95% CI, 0.78-2.82; P = .223) for patients with AMC compared with control subjects. CONCLUSIONS: Children with arthrogryposis syndromes present challenges to the anesthesia and surgical teams, including greater neuromuscular disease burden and challenging peripheral IV placement, with additional evidence suggesting difficult airway management and intraoperative hemodynamic instability. Although more definitive studies are warranted, we did not find evidence of increased odds of intraoperative hyperthermia or hypermetabolic responses.

A peer-designed selective in anesthesiology, critical care, and perioperative medicine for first- and second-year medical students.

STUDY OBJECTIVE: The objective of this study was to design and implement a preclinical elective (termed selective) in anesthesiology, critical care, and perioperative medicine and to report survey results assessing the impact of the selective on first- and second-year medical students' understanding of basic concepts, comfort with procedural skills, and interest in the specialty. DESIGN: Preinvention and postintervention survey evaluation was used as the design of this study. SETTING: The study was conducted at Mayo Medical School and Mayo Clinic. PARTICIPANTS: The participants in this study are first- and second-year medical students. INTERVENTIONS: A 1-week introductory anesthesiology curriculum was developed to include didactic sessions, shadowing experiences, lunch and dinner panels, mentorship and networking opportunities, and procedural workshops in airway management, ultrasound, and vascular access techniques. MEASUREMENTS: Preselective and postselective surveys using a 10-point scale (1, strongly disagree; 10, strongly agree) were administered 1 week before and after the selective. MAIN RESULTS: A total of 8 students participated in the selective, with a 100% survey response rate. Students reported significant increases for all survey questions regarding basic concepts and skills. The largest increases were reported in comfort with airway management skills, understanding of the perioperative surgical home model, and vascular access skills. All participants indicated a higher likelihood of pursuing anesthesiology as a career and attributed their increased interest in anesthesiology to the selective. CONCLUSIONS: This new selective was successful in giving first- and second-year medical students a comprehensive overview of anesthesiology and increasing medical student interest in the specialty. The success of this selective leads to promising belief that similar peer-designed educational experiences can be developed at other medical schools to improve education and interest in this area of medicine.

A retrospective comparison of programmed intermittent epidural bolus with continuous epidural infusion for maintenance of labor analgesia.

OBJECTIVE: To assess whether maintenance of labor epidural analgesia using programmed intermittent epidural bolus (PIEB) is associated with reduced local anesthetic (LA) consumption, patient-controlled epidural analgesia (PCEA) use, and rescue analgesia requirements compared to continuous epidural infusion (CEI). RESEARCH DESIGN AND METHODS: This is a retrospective study at an academic university medical center. Women receiving epidural labor analgesia from March to July of 2015 were identified and categorized into three groups: 1) CEI 5 mL/hr, 2) PIEB 5 mL/60 minutes, 3) PIEB 3 mL/30 minutes. The LA consisted of bupivacaine 0.125 mg/mL and fentanyl 2 µg/mL. All patients had similar PCEA settings. Data were collected on pattern of LA usage, obstetric outcomes and Bromage scores. MAIN OUTCOME MEASURES: The primary endpoint was total volume of LA consumed per hour. Secondary outcomes included need for clinician boluses, pattern of PCEA use, degree of motor blockade and delivery mode. RESULTS: We included 528 patients (262 had CEI, 162 had PIEB 5 mL/60 minutes, and 104 had PIEB 3 mL/30 minutes). Median LA consumed was 10.3, 9.5, and 9.7 mL/hr, respectively (p = 0.10). There were no differences in PCEA attempts or rescue clinician boluses, but PCEA volume (p = 0.03) and ratio of PCEA attempts/given (p < 0.01) were significantly different among the groups. Patients receiving PIEB 3 mL/30 minutes used lower PCEA volume than patients receiving CEI (p = 0.04). Patients with PIEB 5 mL/60 minutes and PIEB 3 mL/30 minutes had a higher ratio of PCEA attempts/given than CEI patients (p = 0.01 and p < 0.01, respectively). There were no differences in Bromage scores (p = 0.14) or delivery mode (p = 0.55) among the groups. CONCLUSIONS: The epidural maintenance regimen used (CEI vs. PIEB) was not associated with differences in LA consumption, motor blockade or delivery mode. Main limitations of the study include its single center retrospective design and the fact that patients were not randomized to treatment groups.

Intrathecal Hydromorphone and Morphine for Postcesarean Delivery Analgesia: Determination of the ED90 Using a Sequential Allocation Biased-Coin Method.

BACKGROUND: Intrathecal (IT) morphine is considered the "gold standard" for analgesia after cesarean delivery under spinal anesthesia, most commonly administered at a dose of 100 to 200 µg. There is less experience with IT hydromorphone for postcesarean analgesia and limited information on its optimal analgesic dose. We conducted this study to determine the effective analgesic dose for 90% patients (ED90) of IT hydromorphone that provides effective analgesia for women undergoing elective cesarean delivery and its potency ratio to IT morphine. METHODS: In this dose-finding trial, 80 patients received spinal anesthesia for cesarean delivery. Participants were randomized to receive IT morphine or IT hydromorphone at a dose determined using up-down sequential allocation with a biased-coin design to determine ED90. All patients received standardized multimodal analgesia postoperatively in addition to IT opioid. An effective dose was defined as a numeric response score for pain of ≤3 (scale 0-10) 12 hours after spinal injection. RESULTS: The ED90 was 75 µg (95% confidence interval [CI], 46-93 µg) for IT hydromorphone and 150 µg (95% CI, 145-185 µg) for IT morphine. At these doses, the 95% CI for the percentage of patients with effective analgesia (numeric rating scale ≤3) was 64% to 100% for hydromorphone and 68% to 100% for morphine. Exploratory findings showed that the incidence of nausea and pruritus was not different among the most commonly used doses of IT hydromorphone (P = 0.44 and P = 0.74) or IT morphine (P = 0.67 and P = 0.38, respectively). When administering IT opioids at ED90 doses or higher, 100% (21/21) of IT hydromorphone and 95% (37/39) of IT morphine patients were satisfied with their analgesia. CONCLUSIONS: The ratio of IT morphine to IT hydromorphone for effective postcesarean analgesia is 2:1. Patient satisfaction was high with both medications.

Failure rate and complications associated with the use of spinal catheters for the management of inadvertent dural puncture in the parturient: a retrospective comparison with re-sited epidural catheters.

Objective To report on the failure rate of spinal catheters placed following inadvertent dural puncture (IDP) compared with re-sited epidural catheters in the obstetric population. Research design and methods Patients who experienced IDP during epidural or combined spinal epidural placement with 17 or 18 gauge Tuohy needles for labor analgesia between 2003 and 2014 were identified using our post-dural puncture headache (PDPH) database. Patients were categorized into two groups: those who had spinal catheters inserted and those who had epidural catheters re-sited. Main outcome measure Failure rate associated with spinal or re-sited epidural catheters (defined as need for repeat block or alternative analgesic modality). Secondary outcomes were incidence of PDPH, need for epidural blood patch (EBP), and adverse events. Results A total of 109 patients were included in the final analysis; 79 ultimately had spinal catheters and 30 ultimately had re-sited epidural catheters. There were no differences between spinal catheters and re-sited epidural catheters in failure rate (22% vs. 13%, P = 0.33), incidence of PDPH (73% vs. 60%, P = 0.24), need for EBP (42% vs. 30%, P = 0.28), number of headache days, or maximum headache scores. There was also no difference in the rate of adverse events including high block levels, hypotension, and fetal bradycardia (9% vs. 7%, P = 1.0) between the two groups. Conclusions There were no differences in failure rates, PDPH outcomes, or adverse events between spinal catheters and re-sited epidural catheters following IDP in parturients receiving labor analgesia. Limitations of the study include its single-center retrospective non-randomized design, and the uneven number of patients in the two groups with a relatively small number in the re-sited epidural catheter group.