Women in Anesthesiology and the Mid-Career Stall: Why They Are Not Advancing Into Senior Leadership.

Women anesthesiologists face many challenges when trying to advance their careers and find balance in personal and professional endeavors. In this article, we introduce the reader to several concepts central to understanding the challenges faced by mid-career women anesthesiologists and highlight why these challenges become particularly pronounced when women enter the mid-career stage. We describe how lack of constructive actionable feedback combined with lack of mentorship and sponsorship negatively affects women in the workplace. We also outline barriers and bias that mid-career women anesthesiologists face in high-level leadership roles along with the disproportionally high burden of nonpromotable work. We present a discussion of mistreatment and burnout, which are compounded by concurrent demands of parenthood and a professional career. We conclude with the impact that these barriers have on mid-career women anesthesiologists and recommendations for mitigating these challenges. They include a systematic increase in mentorship and sponsorship, an individualized professional development strategy, and an improved and comprehensive approach to promotion.

The Women in Cardiothoracic Anesthesiology Special Interest Group: What Can the Lessons of One Anesthesiology Affinity Group Tell Us About How to Build Impactful Professional Communities?

The Women In Cardiothoracic Anesthesiology (WICTA), a special interest group of the Society of Cardiovascular Anesthesiologists, has been highly successful in mobilizing WICTA, a historically underrepresented and marginalized group in the subspecialty, and in supporting real and meaningful change in the professional community. The experience of WICTA as a professional affinity group in impacting a professional organization to diversify, evolve, and become more responsive to a wider professional audience has important lessons for other professional organizations. This article discusses the recent history of affinity organizations in anesthesiology, the benefits they offer professional organizations, and the strategies that have been used to effectively motivate change in professional communities. These strategies include engaging a strong advisory board, identifying the need of constituents, creating additional opportunities for networking and membership, addressing gaps in professional development, and aligning goals with those of the larger national organization. WICTA is just one example of the potential opportunities that affinity groups offer to professional societies and organizations for expanding their reach, enhancing their impact on physicians in their target audience, and achieving organizational missions.

Two Tales of Cardiomyopathy: Underscore for One Health Initiative.

Hypertrophic cardiomyopathy, a common cause of sudden cardiac death, results from mutations in the cardiac sarcomere. Although there has been much scientific exploration regarding this disease, there is still much to be elucidated. This E-challenge highlights two cases of cardiomyopathy and underscores the need for future multidisciplinary collaboration as outlined by the One Health Initiative.

The Convergent Procedure: A Unique Multidisciplinary Hybrid Treatment of Atrial Fibrillation.

The convergent procedure is a hybrid ablation treatment for atrial fibrillation. It is increasingly considered as a management option for patients with persistent and long-standing atrial fibrillation. It consists of surgical ablation of the posterior left atrium through a minimally invasive closed-chest approach followed by endocardial catheter ablation. It is increasingly performed with concurrent epicardial occlusion of the left atrial appendage with a video-assisted thoracoscopic technique to physically and electrically isolate the left atrial appendage. This article provides an overview of a multidisciplinary approach to the convergent procedure, with concurrent thoracoscopic closure of the left atrial appendage, with an emphasis on perioperative management at a single institution. It provides a literature review of procedural outcomes, current data limitations, and future considerations.

Improving accuracy of American Society of Anesthesiologists Physical Status using audit and feedback and artificial intelligence: a time-series analysis.

BACKGROUND: While the American Society of Anesthesiologists (ASA) Physical Status (PS) is used to adjust for greater mortality risk with higher ASA PS classification, inaccurate classification can lead to an inaccurate comparison of institutions. OBJECTIVE: The purpose of this study was to assess the effect of audit and feedback with a rule-based artificial intelligence algorithm on the accuracy of ASA PS classification. METHODS: We reviewed 78 121 anesthetic records from 1 January 2017 to 19 February 2020. The first intervention entailed audit and feedback emphasizing accurately documenting ASA PS classification using body mass index (BMI), while the second intervention consisted of implementing a rule-based artificial intelligence algorithm. If a patient with a BMI ≥40 kg/m2 had a documented ASA PS classification of 1 or 2, the provider was alerted to change the ASA PS classification to 3 or above. The primary outcome was the overall proportion of patients with inaccurate ASA PS classification based on BMI per month. Secondary outcomes included the proportion of patients with a BMI ≥40 or a BMI 30-39.9 who had inaccurate ASA PS classification and the proportion of patients documented as having ASA 3-5. Data were analyzed using interrupted time-series analysis. RESULTS: For the primary outcome, the slope for ASA PS classification inaccurately incorporating BMI was unchanging before the first intervention (parameter coefficient 0.002, 95% CI -0.034 to 0.038; P = 0.911). Following the first intervention, there was an immediate level change (parameter coefficient -0.821, 95% CI -1.236 to -0.0406; P < 0.001) without significant change in slope (parameter coefficient -0.048, 95% CI -0.100 to 0.004; P = 0.067). The post-intervention slope was negative (parameter coefficient -0.046, 95% CI -0.083 to -0.009; P = 0.017). Following the second intervention, there was no level change (parameter coefficient 0.203, 95% CI -0.380 to 0.463; P = 0.839) and no significant change in slope (parameter coefficient 0.013, 95% CI -0.043 to 0.043; P = 0.641). The post-intervention slope was not significant (parameter coefficient -0.034, 95% CI -0.078 to 0.010; P = 0.121). The proportion of patients whose ASA PS classification inaccurately incorporated BMI at the first and final timepoint of the study was 2.6% and 0.8%, respectively. CONCLUSIONS: Our quality improvement efforts successfully modified clinician behavior to accurately incorporate BMI into the ASA PS classification. By combining audit and feedback methodology with a rule-based artificial intelligence algorithm, we created a process that resulted in immediate and sustained effects. Improving ASA PS classification accuracy is important because it affects quality metrics, research design, resource allocation and workflow processes.

Implementing structured handoffs to verify operating room blood delivery using a quality academy training program: an interrupted time-series analysis.

BACKGROUND: Blood transfusion is a complex process at risk for error. OBJECTIVE: To implement a structured handoff during the blood transfusion process to improve delivery verification. METHODS: A multidisciplinary team participated in the quality academy training program at an academic medical center and implemented a structured handoff of blood delivery to the operating room (OR) using Plan-Do-Study-Act cycles between 28 October 2019 and 1 December 2019. An interrupted time-series analysis was performed to investigate the proportions of verified deliveries (primary outcome) and of verified deliveries among those without a handoff (secondary outcome). Delivery duration was also assessed. RESULTS: A total of 2606 deliveries occurred from 1 July 2019 to 19 April 2020. The baseline trend for verified deliveries was unchanging [parameter coefficient -0.0004; 95% confidence interval (CI) -0.002 to 0.001; P = 0.623]. Following intervention, there was an immediate level change (parameter coefficient 0.115; 95% CI 0.053 to 0.176; P = 0.001) without slope change (parameter coefficient 0.002; 95% CI -0.004 to 0.007; P = 0.559). For the secondary outcome, there was no immediate level change (parameter coefficient -0.039; 95% CI -0.159 to 0.081; P = 0.503) or slope change (parameter coefficient 0.002; 95% CI -0.022 to 0.025; P = 0.866). The mean (SD) delivery duration during the intervention was 12.4 (2.8) min and during the post-intervention period was 9.6 (1.6) min (mean difference 2.8; 95% CI 0.9 to 4.8; P = 0.008). CONCLUSION: Using the quality academy framework supported the implementation of a structured handoff during blood delivery to the OR, resulting in a significant increase in verified deliveries.

The Mitral/Aortic Flow Velocity Integral Ratio in Mitral Regurgitation.

The development of echocardiography was driven, in part, by a need to diagnose mitral regurgitation in patients undergoing finger fracture commissurotomy in the 1950s. Decades later, color Doppler became the cornerstone for noninvasive evaluation of mitral regurgitation. The authors present 2 cases of calcific mitral stenosis in which reliance on color Doppler in transthoracic echocardiography resulted in erroneous conclusions as to the severity of coexisting mitral regurgitation. The possible application of the Mitral to Aortic Flow Velocity Integral Ratio in such cases as a possible adjunct to grading mitral regurgitation is also discussed.

Effect of a Cognitive Aid on Reducing Sugammadex Use and Associated Costs: A Time Series Analysis.

BACKGROUND: The authors observed increased pharmaceutical costs after the introduction of sugammadex in our institution. After a request to decrease sugammadex use, the authors implemented a cognitive aid to help choose between reversal agents. The purpose of this study was to determine if sugammadex use changed after cognitive aid implementation. The authors' hypothesis was that sugammadex use and associated costs would decrease. METHODS: A cognitive aid suggesting reversal agent doses based on train-of-four count was developed. It was included with each dispensed reversal agent set and in medication dispensing cabinet bins containing reversal agents. An interrupted time series analysis was performed using pharmaceutical invoices and anesthesia records. The primary outcome was the number of sugammadex administrations. Secondary outcomes included total pharmaceutical acquisition costs of neuromuscular blocking drugs and reversal agents, adverse respiratory events, emergence duration, and number of neuromuscular blocking drug administrations. RESULTS: Before cognitive aid implementation, the number of sugammadex administrations was increasing at a monthly rate of 20 per 1,000 general anesthetics (P < 0.001). Afterward, the monthly rate was 4 per 1,000 general anesthetics (P = 0.361). One month after cognitive aid implementation, the number of sugammadex administrations decreased by 281 per 1,000 general anesthetics (95% CI, 228 to 333, P < 0.001). In the final study month, there were 509 fewer sugammadex administrations than predicted per 1,000 general anesthetics (95% CI, 366 to 653; P < 0.0001), and total pharmaceutical acquisition costs per 1,000 general anesthetics were $11,947 less than predicted (95% CI, $4,043 to $19,851; P = 0.003). There was no significant change in adverse respiratory events, emergence duration, or administrations of rocuronium, vecuronium, or atracurium. In the final month, there were 75 more suxamethonium administrations than predicted per 1,000 general anesthetics (95% CI, 32 to 119; P = 0.0008). CONCLUSIONS: Cognitive aid implementation to choose between reversal agents was associated with a decrease in sugammadex use and acquisition costs.

Echocardiographic evaluation of mitral inflow hemodynamics after asymmetric double-orifice repair.

BACKGROUND: A comprehensive transesophageal echocardiographic (TEE) examination is essential for the evaluation of a mitral valve (MV) repair. The edge-to-edge MV repair (i.e., Alfieri stitch) can pose a unique challenge in assessing iatrogenic mitral stenosis, especially when an asymmetric double-orifice is created. The reliability of the simplified Bernoulli equation for evaluating transvalvular pressure gradients across an asymmetric Alfieri MV repair remains controversial. We sought to evaluate the reliability of this principle further by comparing TEE-acquired pressure gradients across each orifice in patients undergoing asymmetric, double-orifice repair. METHODS: Routinely collected intraoperative, 2-dimensional and 3-dimensional TEE datasets acquired from 15 patients undergoing double-orifice MV repair were retrospectively reviewed and analyzed. Planimetered anterior lateral (AL) and posterior medial (PM) orifice areas were acquired from 3-dimensional TEE full volume datasets, by cropping the image to develop a short-axis view at the narrowest diastolic orifice cross-sectional area at the MV leaflet tips. Transmitral Doppler flow velocity values were measured through the AL and PM orifices. Peak and mean pressure gradients were calculated from the simplified Bernoulli equation at both orifices and were compared to each respective orifice for each patient. RESULTS: The mean difference between the AL and PM orifice areas for each patient was statistically significant (0.72 ± 0.40 cm(2), P < 0.0001). The mean differences between the AL and PM parameters were also significant for peak velocity: 0.15 m/s, SD: 0.08, P < 0.0001; peak pressure gradients: 1.76 mm Hg, SD: 1.42, P < 0.0001; and mean pressure gradient: 1.04 mm Hg, SD: 0.93, P < 0.0001. CONCLUSIONS: The echocardiographic assessment of MV dysfunction after an Alfieri repair is important. Although the differences that we demonstrated between orifice areas and maximum velocities across the asymmetric orifices after a double-orifice MV repair are statistically significant, the corresponding difference in mean transorifice pressure gradient is not clinically relevant. Thus, either orifice can be interrogated with Doppler echocardiography for the determination of pressure gradients after double-orifice MV repair.

Iatrogenic Injury During Intraoperative Transesophageal Echocardiography: Implications for Medical Equipment Storage.

BACKGROUND: Medical equipment failure is an underappreciated source of iatrogenesis. The authors report a successful root cause analysis and action (RCA2) to improve compliance and decrease risks to patients during cardiac anesthesia care. METHODS: A quality and safety team of five content experts performed an RCA2 after an iatrogenic injury with transesophageal echocardiogram (TEE) probe insertion. The team used a fishbone diagram to identify causes and performed a Gemba walk to discuss probability of the different causes with key stakeholders. The team reviewed hospital policies and procedures as well as manufacturer manuals regarding best practices for maintenance and storage of TEE probes. The team created a corrective action plan centered on purchasing larger TEE storage cabinets, education of those who handle TEE probes, and implementing standard operating procedures. Effectiveness of the intervention was evaluated by analyzing frequency of TEE probe maintenance. RESULTS: The study period ranged from July 2016 to June 2021. TEE probes required maintenance 51 times, of which 40 (78.4%) occurred prior to the larger storage cabinet purchase, and 11 (21.6%) afterward. The number of TEE probes requiring maintenance per quarter was 4.4 (standard deviation [SD] 2.5) during the preintervention period and 1.0 (SD 1.0) during the postintervention period (mean difference 3.4, 95% confidence interval 1.0-5.9, p = 0.0006). CONCLUSION: An extensive RCA2 resulting in a corrective action plan centered on compliance with manufacturer recommendations for storage of TEE probes resulted in fewer maintenance requests, which decreased the risk of iatrogenic patient injury from TEE probe failure during cardiac anesthesia care.

Bleb morphology characteristics and effect on positional intraocular pressure variation.

BACKGROUND AND OBJECTIVE: To study bleb morphology and positional intraocular pressure (IOP) change (IOP supine to IOP sitting). PATIENTS AND METHODS: In this observational case series, blebs were graded for height, extent, vascularity, microcysts, and "ring of steel." Positional IOP change was analyzed using the paired t test. Associations between IOP change and bleb morphologies were evaluated by regression adjusting for inter-eye dependency. RESULTS: Ninety-five eyes of 68 subjects were included. Decreased bleb height (P = .05), absence of microcysts (P = .02), and increased bleb vascularity (P = .02) were associated with larger positional IOP change. Twenty patients with a filter in one eye and a medically treated fellow eye had larger positional IOP change in the medically treated eye (6.1 vs 4.6 mm Hg, respectively; P = .01). CONCLUSION: Successful filtration surgery results in both lower IOP and less positional IOP change compared with medically treated eyes. Bleb features associated with smaller positional IOP change include higher elevation, microcysts, and less vascularity.

Late-onset Haemophilus Influenzae endophthalmitis in an immunized child after Baerveldt implant.

Endophthalmitis after a glaucoma drainage implant is uncommon. In a case series of drainage implant-associated endophthalmitis, tube exposure was present in all cases.(1) Among the organisms cultured from these eyes was Haemophilus influenzae. After the introduction of the H. influenzae type b vaccine, infections related to this bacterium dramatically decreased in children. We report a case of late-onset H. influenzae endophthalmitis in an immunized child after bilateral glaucoma drainage implants without evidence of conjunctival erosion or wound dehiscence.

The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment.

UNLABELLED: Pain assessment remains difficult in children with cognitive impairment (CI). In this study, we evaluated the validity and reliability of the Face, Legs, Activity, Cry, Consolability (FLACC) tool for assessing pain in children with CI. Each child's developmental level and ability to self-report pain were evaluated. The child's nurse observed and scored pain with the FLACC tool before and after analgesic administration. Simultaneously, parents scored pain with a visual analog scale, and scores were obtained from children who were able to self-report pain. Observations were videotaped and later viewed by nurses blinded to analgesics and pain scores. One-hundred-forty observations were recorded from 79 children. FLACC scores correlated with parent scores (P < 0.001) and decreased after analgesics (P = 0.001), suggesting good validity. Correlations of total scores (r = 0.5-0.8; P < 0.001) and of each category (r = 0.3-0.8; P < 0.001), as well as measures of exact agreement (kappa = 0.2-0.65), suggest good reliability. Test-retest reliability was supported by excellent correlations (r = 0.8-0.883; P < 0.001) and categorical agreement (r = 0.617-0.935; kappa = 0.400-0.881; P < 0.001). These data suggest that the FLACC tool may be useful as an objective measure of postoperative pain in children with CI. IMPLICATIONS: The FLACC pain assessment tool may facilitate reliable and valid observational pain assessment in children with cognitive impairment who cannot self-report their pain. Objective pain assessment is important to facilitate effective postoperative pain management in these vulnerable children.