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BACKGROUND: Precise anesthesia delivery helps ensure amnesia, analgesia, and immobility. Conventionally, the end-tidal anesthetic concentration is maintained through manual adjustment of the fresh gas flow and anesthetic vaporizer output. Some anesthesia delivery systems can deliver and maintain clinician-selected end-tidal anesthetic agent (EtAA) concentration using a modified closed-loop system. We evaluated the performance of an End-tidal Control (EtC) system on the Aisys CS2 anesthesia machine (GE HealthCare). We hypothesized EtC anesthetic delivery would be noninferior to manually controlled anesthetic delivery. METHODS: The Multi-site Anesthesia randomized controlled STudy of End-tidal control compared to conventional Results (MASTER) Trial evaluated anesthetic delivery in 210 adult patients receiving inhaled anesthesia. Patients were randomized to either EtC or manual control (MC) anesthetic delivery. The primary objective was to determine whether, compared to conventional anesthesia practice, EtC achieves and maintains clinician-specified EtAA and end-tidal oxygen (Eto2) concentrations within defined noninferiority limits. Noninferiority was concluded if the lower limit of the 95% confidence interval (CI) of the difference between the percent duration within the acceptable range (5% of steady state or a margin of ~10% of each agent's minimum alveolar concentration) for EtC and MC was ≥ -5% for both EtAA and Eto2. Secondary objectives included performance measures: response time: time required to attain 90% of the first desired EtAA, overshoot: amount the controller (or vaporizer delivery) exceeded the desired EtAA, and accuracy: average deviation from the desired EtAA. RESULTS: EtC achieved and sustained targeted EtAA and Eto2 concentrations within the noninferiority threshold. The EtAA was within 5% of the desired value 98% ± 2.05% of the time with EtC compared to 45.7% ± 31.7% of the time with MC (difference 52.3% [95% CI, 45.9%-58.6%], P < .0001). For Eto2, EtC was within the noninferiority limit 86.3% ± 22.8% of the time compared with MC at 41% ± 33.3% (P < .0001, difference 45.3% [95% CI, 36.1%-54.5%]). The median response time for achieving 90% of the initial EtAA desired value was 75 seconds with EtC and 158 seconds with MC (P = .0013). EtC exhibited a median overshoot of 6.64% of the selected EtAA concentration, whereas MC often failed to reach the clinician's desired value. The difference in median percent deviation from desired EtAA value was 15.7% ([95% CI, 13.5%-19.0%], P < 0001). CONCLUSIONS: EtC achieves and maintains the EtAA and Eto2 concentration in a manner that is noninferior to manually controlled anesthesia delivery.
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BACKGROUND: Patient outcomes are improved with physician-patient gender, racial, and ethnic concordance. However, female, Black, Hispanic or Latino, Native Hawaiian-Pacific Islander (NH-PI), and American Indian-Native Alaskan (AI-AN) physicians are underrepresented in anesthesiology. The American Association of Medical Colleges 2018 Diversity in Medicine Report revealed that women comprise only 35% of anesthesiologists yet nearly half of medical school graduates are women. More than 77% of anesthesiologists are White or Asian. Anesthesiology applicant and match trends may provide insights needed to address underrepresentation within anesthesiology. We hypothesized that proportionally fewer women and racially and ethnically minoritized applicants apply and match into anesthesiology. METHODS: This retrospective observational study identified 47,117 anesthesiology applicants among the 546,298 residency applicants in the Electronic Residency Application Service (ERAS) system between 2011 and 2022 and stratified applicants by self-reported gender, race, and ethnicity. The demographics of anesthesiology trainees reported in the 2014 to 2015, 2018 to 2019, and 2022 to 2023 Accreditation Counsel of Graduate Medical Education (ACGME) Data Resource Books were used as surrogates for matched applicants as demographics are not reported by the National Residency Match Program. To facilitate comparisons, ERAS applicants were grouped into 4-year epochs to align with consolidated ACGME reports corresponding to the application years. Odds ratios (OR); 95% confidence interval of applying to and matching into anesthesiology were analyzed. RESULTS: Women had lower odds of applying to anesthesiology compared to men overall (OR, 0.55; 95% CI, 0.54-0.56, P < .0001) and maintained significantly lowered odds of applying within each epoch. Women had similar odds of matching into anesthesiology residency compared to men (OR, 1.10; 95% CI, 1.06-1.14, P < .0001). Black, Hispanic or Latino, Asian and NH-PI, and AI-AN applicants had similar odds to White applicants of applying to anesthesiology but odds of matching were significantly lower overall (P < .0001) for Asian and NH-PI (OR, 0.66; 95% CI, 0.63-0.70), Black (OR, 0.49; 95% CI, 0.45-0.53), Hispanic or Latino (OR, 0.50; 95% CI, 0.46-0.54), and AI-AN (OR, 0.20; 95% CI, 0.15-0.28) applicants. The odds of matching among some minoritized applicants increased in the ACGME 2022 to 2023 report year. CONCLUSIONS: From 2011 to 2022, women had lower odds of applying to anesthesiology residency than men yet had similar odds of matching. Racial and ethnic minoritized groups had significantly lower odds of matching compared to White applicants despite similar odds of applying. These findings highlight disparities in the anesthesiology match and may help identify opportunities to promote workforce diversity within the field. More detailed reporting of gender, race, and ethnicity in annual match data may better define barriers to entry and identify opportunities for improvement.
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Heightened sympathetic input to the myocardium potentiates cardiac electrical instability and may herald an electrical storm. An electrical storm is characterized by 3 or more episodes of ventricular tachycardia, ventricular fibrillation, or appropriate internal cardiac defibrillator shocks within 24 hours. Management of electrical storms is resource-intensive and inevitably requires careful coordination between multiple subspecialties. Anesthesiologists have an important role in acute, subacute, and long-term management. Identifying the phase of an electrical storm and understanding the characteristics of each morphology may help the anesthesiologist anticipate the management approach. In the acute phase, management of an electrical storm is aimed at providing advanced cardiac life support and identifying reversible causes. After initial stabilization, subacute management focuses on dampening the sympathetic surge with sedation, thoracic epidural, or stellate ganglion blockade. Definitive long-term management with surgical sympathectomy or catheter ablation also may be warranted. Our objective is to provide an overview of electrical storms and the anesthesiologist's role in management.
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Ablação por Cateter , Desfibriladores Implantáveis , Taquicardia Ventricular , Humanos , Fibrilação Ventricular/etiologia , Arritmias Cardíacas , Taquicardia Ventricular/cirurgia , Desfibriladores Implantáveis/efeitos adversos , Coração , Ablação por Cateter/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE: Point-of-care ultrasound (POCUS) is ultrasound brought to the patient's bedside and performed in 'real time' by the healthcare provider. The utility of POCUS to facilitate management of the acutely ill patient has been demonstrated for multiple pathologies. However, the integration of ultrasonography and echocardiography training into residency curriculum varies across the acute care specialties. STUDY DESIGN: After an institutional review board approval, anaesthesiology, emergency medicine, family medicine, internal medicine, paediatrics and general surgery programme directors (PDs) were surveyed. The survey consisted of 11 questions evaluating the primary bedside assessment tool for common acute care situations, POCUS topics that the PDs were comfortable practising and topics that the PDs felt were useful for their specialty. Barriers to POCUS use, certification and documentation were also surveyed. RESULTS: Overall, 270 PD surveys were completed. The preferred primary assessment tool for common acute care situations varied with specialty; emergency medicine PDs consistently responded that POCUS was the diagnostic modality of choice (p<0.0001). The majority of the PDs reported lack of educational opportunities as the primary barrier to learning POCUS (64%). Most PDs indicated that POCUS examinations should be documented (95.7%), and 39% reported that departmental certification would be sufficient. CONCLUSIONS: This study is the first to evaluate differences in the preferred initial bedside assessment tool between the acute care specialties. Although POCUS is a superior tool for evaluating acute pathologies, disconnect between education and utilisation remains. This study highlights the need to incorporate POCUS into the acute care specialty curriculum.
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Anestesiologia , Sistemas Automatizados de Assistência Junto ao Leito , Humanos , Criança , Testes Imediatos , Inquéritos e Questionários , Ultrassonografia , CurrículoRESUMO
Since the initial reports surfaced of a novel coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe, infecting millions and leaving hundreds and thousands dead. As hospitals cope with the influx of patients with COVID-19, new challenges have arisen as health-care systems care for patients with COVID-19 while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that patients with COVID-19 are at increased risk of thromboembolic complications including strokes. In this article, we detail our experience caring for acute stroke patients and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era.
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Fibrilação Atrial , Neoplasias Cardíacas , Insuficiência da Valva Mitral , Mixoma , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Mixoma/diagnóstico por imagem , Mixoma/cirurgia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgiaRESUMO
OBJECTIVES: The primary aim of this study was to use speckle-tracking strain imaging to evaluate the effect of general anesthesia (GA) and positive-pressure ventilation (PPV) on left atrial (LA) mechanics. The authors hypothesized that GA and PPV would be associated with a decrease in LA strain. The secondary aims were to investigate the effects of GA and PPV on traditional Doppler-derived measures of LA function and Doppler echocardiographic grade of diastolic function. DESIGN: A prospective observational study. SETTING: A university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery. INTERVENTIONS: Transthoracic echocardiography was performed at baseline and under GA with PPV. MEASUREMENTS AND MAIN RESULTS: Changes in LA function associated with GA and PPV were assessed using LA speckle-tracking strain imaging. A reduction was observed in LA peak longitudinal strain (24% v 18%, p<0.001) and preatrial contraction strain (13% v 8%, p<0.001). No difference was seen in LA contraction strain or atrial ejection fraction. Indexed LA volume and Doppler diastolic indices also were reduced significantly, and 39% of patients had a change in measured diastolic grade under GA with PPV. CONCLUSIONS: Speckle-tracking strain imaging of the left atrium demonstrated that GA and PPV had a significant impact on LA mechanics by decreasing strain measures of LA preload, with a lesser effect on LA contractility.
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Anestesia Geral/efeitos adversos , Função do Átrio Esquerdo/fisiologia , Ecocardiografia/métodos , Átrios do Coração/diagnóstico por imagem , Respiração com Pressão Positiva/efeitos adversos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Background: The Accreditation Council for Graduate Medical Education (ACGME) case log system for anesthesiology resident training relies on subjective categorization of surgical procedures and lacks clear guidelines for assigning credit roles. Therefore, resident reporting practices likely vary within and between institutions. Our primary aim was to develop a systematic process for generating automated case logs using data elements extracted from the electronic health care record. We hypothesized that automated case log reporting would improve accuracy and reduce reporting variability. Methods: We developed a systematic approach for automating anesthesiology resident case logs from the electronic health care record using a discrete classification system for assigning credit roles and Anesthesia Current Procedure Terminology codes to categorize cases. The median number of cases performed was compared between the automated case log and resident-reported ACGME case log. Results: Case log elements were identified in the electronic health care record and automatically extracted. A total of 42 individual case logs were generated from the extracted data and visualized in an external dashboard. Automated reporting captured a median of 1226.5 (interquartile range: 1097-1366) total anesthetic cases in contrast to 1134.5 (interquartile range: 899-1208) reported to ACGME by residents (P = .0014). Automation also decreased the case count interquartile range and the distribution approached normality, suggesting that automation reduces reporting variability. Conclusions: Automated case log reporting uniformly captures the resident training experience and reduces reporting variability. We hope this work provides a foundation for aggregating graduate medical education data from the electronic health care record and advances adoption of case log automation.
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Percutaneous ventricular assist devices have been used for high-risk ventricular tachycardia ablation when hemodynamic decompensation is expected. Utilizing a case example, we present our experience with development of a coordinated, team-based approach focused on periprocedural management of patients with high-risk ventricular tachycardia. (Level of Difficulty: Advanced.).
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INTRODUCTION: Accuracy of fluoroscopy in predicting septal placement of the right ventricular (RV) leads is poor. This pilot study evaluated the feasibility and impact of real-time transthoracic echocardiogram (TTE) during RV lead placement. METHOD: Consecutive patients undergoing transvenous RV lead placement and had a point of care ultrasound team available for TTE guidance were included in the study. TTE was performed to confirm or refute the septal position of RV lead initially positioned using fluoroscopy; leads were repositioned until a septal position was confirmed on TTE. The primary outcome measured was whether the use of TTE resulted in lead repositioning. RESULT: Among the 26 patients included in the study, real-time TTE during RV lead placement resulted in reposition of the lead to a septal position in 38.5% of patients. CONCLUSION: Use of real-time TTE guidance during fluoroscopic RV lead placement is feasible and can aid in confirming a septal position.
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The fundamental perioperative concern for patients with implantable cardioverter-defibrillators (ICDs) is the potential for electromagnetic interference (EMI) from monopolar electrosurgery. The ICD may interpret electromagnetic signals as a tachyarrhythmia and deliver an inappropriate shock to the patient. Magnet placement is often used to avoid this problem since a magnet will often deactivate an ICD's tachyarrhythmia therapy. We report a case in which magnet placement over an ICD failed to suspend tachyarrhythmia therapy because of imprecise magnet positioning. This case demonstrates the possibility for error when relying on a magnet to suspend tachyarrhythmia therapies.
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Desfibriladores Implantáveis , Imãs , HumanosRESUMO
Early detection of acute myocardial ischemia is critical to prevent permanent myocardial damage. The impact of apical ischemia on global left ventricular (LV) function can be difficult to characterize using traditional volume-based echocardiography measures. Myocardial strain imaging is a sensitive, quantitative marker of myocardial deformation that can measure ventricular function. Recent advances allow layer-specific measurement of endo- and epicardial strain, enhancing the ability to evaluate myocardial ischemia. This study investigates the effects of apical ischemia on LV function using epi- and endocardial strain. We hypothesize that myocardial strain will identify changes in regional and global myocardial function associated with focal apical ischemia as compared to ejection fraction (EF), and that longitudinal strain will be a better indicator of myocardial dysfunction compared to circumferential or radial strain. In a porcine model (n = 9), acute ischemia was induced by left anterior descending coronary artery occlusion. Echocardiograms were performed at baseline, during 15-min ischemia, and after reperfusion. Global longitudinal strain decreased with acute focal ischemia of the left ventricular apical region (baseline: -16.4% vs. ischemia: -12.2%; P = 0.010), with no change observed in global circumferential and radial strain or EF Both endocardial and epicardial longitudinal strain decreased by 68% (P < 0.001) in the ischemic and peri-ischemic zone, while circumferential and radial strain only decreased in endocardium of the ischemic zone. Longitudinal strain was more sensitive to ischemia, being able to detect changes in global LV function and thus may confer clinical diagnostic advantage in the evaluation of acute LV apical ischemia.