Continuous Catheter Techniques.

Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.

Unique Medical Considerations for the Athlete Undergoing Anesthesia.

Athletes are among a unique group such that they may possess a serious underlying pathologic condition that may often go unnoticed given their high caliber of physical fitness. However, several considerations should be investigated, especially in the perioperative period, in order to minimize morbidity and mortality. Namely, cardiac pathologic condition can result in sudden death, and pulmonary pathologic condition may affect airway and respiratory management. Moreover, patients undergoing orthopedic surgery are at the highest risk for venous thromboembolism. Regardless of the condition, it is crucial to be vigilant and explore the unique medical considerations for the athlete undergoing anesthesia.

Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder.

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

Unique Medical Considerations for the Athlete Undergoing Anesthesia.

Athletes are among a unique group such that they may possess a serious underlying pathologic condition that may often go unnoticed given their high caliber of physical fitness. However, several considerations should be investigated, especially in the perioperative period, in order to minimize morbidity and mortality. Namely, cardiac pathologic condition can result in sudden death, and pulmonary pathologic condition may affect airway and respiratory management. Moreover, patients undergoing orthopedic surgery are at the highest risk for venous thromboembolism. Regardless of the condition, it is crucial to be vigilant and explore the unique medical considerations for the athlete undergoing anesthesia.

Continuous Catheter Techniques.

Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management.

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

A Surgeon Badge or Text Message Sign-in Intervention Improves Operating Room Start Efficiency.

BACKGROUND: Operating room (OR) efficiency, often measured by first case on-time start (FCOTS) percentage, is an important driver of perioperative team morale and the financial success of a hospital. MATERIALS AND METHODS: In this quasi-experimental study of elective surgical procedures at a single tertiary academic hospital, an intervention requiring attending surgeon attestation of availability via SMS text message or identification badge swipe was implemented. Key measures of OR efficiency were compared before and after the change. RESULTS: FCOTS percentage increased from 61.6% to 66.9% after the intervention (P = 0.01). After adjusting for patient and procedural characteristics, postintervention period remained associated with an increased odds of an on-time start (odds ratio 1.29, P = 0.01). Additionally, procedural start times from the pre- to postintervention period were significantly improved (-0.08 min/day, P = 0.009). CONCLUSIONS: Implementation of an attending surgeon text or badge sign-in process was associated with improved FCOTS percentage and earlier procedure start times.

Patient and personnel factors affect operating room start times.

BACKGROUND: Perioperative efficiency has been studied, although little is known about patient and personnel factors associated with a timely operating room start. We hypothesize that patient, personnel factors, and induction-order decisions are associated with anesthesia induction time. METHODS: An institutional database was used to identify the anesthesia induction time of adults undergoing first-start, elective operations from January 2014 to May 2017 at an academic quaternary care center. Data included patient demographics; surgeon and anesthesiologist, as well as their seniority (years since initial board certification); certified registered nurse anesthetist versus anesthesia resident staffing; and use of neuraxial anesthesia. Times were measured as minutes from scheduled start to induction. Univariate and multivariate analyses were performed to identify factors associated with induction time. RESULTS: We identified 15,823 cases. Predictors of later induction included add-on cases (1,224 cases were add-ons, 7.73%), American Society of Anesthesiologists classification ≥ 3, neuraxial anesthesia, and certified registered nurse anesthetist staffing. Surgeon seniority-but not gender-affected induction time. In 11,093 cases (70.1%), the anesthesiologist was scheduled for multiple first starts with a choice of which patient to induce first. Surgeon gender was predictive of induction order, with cases of male surgeons induced first more frequently than female surgeons' (47.0% vs 44.1%, P = .02). Cases staffed by anesthesiology residents were more likely to be induced first compared with those staffed by certified registered nurse anesthetists (52.1% vs 41.5%, P < .01). CONCLUSION: Patient and personnel factors affect the order of case induction, but induction time is most dependent on patient factors. Hospitals should focus on improving preparedness and limiting bias to create a more equitable and efficient perioperative process.

Generative Retrieval Does Not Improve Long-Term Retention of Regional Anesthesia Ultrasound Anatomy in Unengaged Learners.

BACKGROUND: Ultrasound-guided regional anesthesia is increasingly used in the perioperative period but performance requires a mastery of regional ultrasound anatomy. We aimed to study whether the use of generative retrieval to learn ultrasound anatomy would improve long-term recall. METHODS: Fourth-year medical students without prior training in ultrasound techniques were randomized into standard practice (SP) and generative retrieval (GR) groups. An initial pre-test consisted of 74 regional anesthesia ultrasound images testing common anatomic structures. During the study/learning session, GR participants were required to verbally identify an unlabeled anatomical structure within 10 seconds of the ultrasound image appearing on the screen. A labeled image of the structure was then shown to the GR participant for 5 seconds. SP participants viewed the same ultrasound images labeled with the correct anatomical structure for 15 seconds. Retention was tested at 1 week and 1 month following the study session. Participants completed a satisfaction survey after each session. RESULTS: Forty-five medical students were enrolled with forty included in the analysis. There was no statistically significant difference in baseline scores (GR = 11.5 ± 4.9; SP = 11.2 ± 6.2; P = 0.84). There was no difference in scores at both the 1-week (SP = 54.5 ± 13.3; GR = 53.9 ± 10.5; P = 0.88) and 1-month (SP = 54.0 ± 14.5; GR = 50.7 ± 11.1; P = 0.42) time points. There was no statistically significant difference in learner satisfaction metrics between the groups. CONCLUSIONS: The use of generative retrieval practice to learn regional anesthesia ultrasound anatomy did not yield significant differences in learning and retention compared with standard learning.

Elective intubation.

Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The most common intubation technique in the perioperative environment is direct laryngoscopy with orotracheal tube insertion. Infrequently, difficulties that require an alternative intubation technique are encountered due to patient anatomy, equipment limitations, or patient pathophysiology. Careful patient evaluation, advanced planning, equipment preparation, system redundancy, use of checklists, familiarity with airway algorithms, and availability of additional help when needed during OR intubations have resulted in exceptional success and safety. Airway difficulties during intubation outside the controlled environment of the OR are more frequent and more serious. Translating the intubation processes practiced in the OR to intubations outside the perioperative setting should improve patient safety. This paper considers each step in the OR intubation process in detail and proposes ways of incorporating perioperative procedures into intubations outside the OR. Management of the physiologic impact of intubation, lack of readily available specialized equipment and experienced help, and planning for transfer of care following intubation are all challenges during these intubations.

Recreating simulation scenarios for interprofessional education: an example of educational interprofessional practice.

High-fidelity simulation has proliferated in healthcare education. Once a novelty, simulation is now a mainstay of many curricula and even required by some accrediting bodies. Interprofessional behaviors, manifested through interprofessional education and practice are believed to improve patients' lives. The exciting potential of simulation-interprofessional education (SIM-IPE) is now being explored. This report details a SIM-IPE experience from a university medical simulation center and Schools of Nursing and Medicine. Circumstances required an existing scenario to be "retrofitted" for interprofessional education. Key decision points, challenges and practices are highlighted in the hope that they may be of use to other simulation educators.

High-fidelity simulation is superior to case-based discussion in teaching the management of shock.

BACKGROUND: Case-based discussion (CBD) is an established method for active learning in medical education. High-fidelity simulation has emerged as an important new educational technology. There is limited data from direct comparisons of these modalities. AIMS: The primary purpose of this study was to compare the effectiveness of high-fidelity medical simulation with CBD in an undergraduate medical curriculum for shock. METHODS: The subjects were 85 third-year medical students in their required surgery rotation. Scheduling circumstances created two equal groups. One group managed a case of septic shock in simulation and discussed a case of cardiogenic shock, the other group discussed septic shock and experienced cardiogenic shock through simulation. Student comprehension of the assessment and management of shock was then evaluated by oral examination (OE). RESULTS: Examination scores were superior in all comparisons for the type of shock experienced through simulation. This was true regardless of the shock type. Scores associated with patient evaluation and invasive monitoring, however, showed no difference between groups or in crossover comparison. CONCLUSIONS: In this study, students demonstrated better understanding of shock following simulation than after CBD. The secondary finding was the effectiveness of an OE with just-in-time deployment in curriculum assessment.

Diabetes, hyperglycemia, and infections.

Postoperative infection is not only a major source of morbidity and mortality in patients undergoing surgery, but also an important cause of increased hospital stay and resource utilization. Diabetes has been shown in multiple studies to increase the risk of post-surgical infection. More recently, hyperglycemia has been investigated as an independent risk factor for postoperative infection. This paper will review the effects of intra-operative, postoperative, and long-term glycemic control on postoperative infection rates. The mechanisms by which surgery causes hyperglycemia will be reviewed, as well as the immunologic and humeral effects of hyperglycemia.

A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis.

BACKGROUND: A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular surgical patient population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR). METHODS: Medline (1966 to August 2005), MD Consult (1966 to August 2005), BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were searched. Randomized and quasi randomized studies comparing GA and neuraxial (spinal or epidural) block for elective THR were included in this analysis. RESULTS: Ten independent trials, involving 330 patients under GA and 348 patients under neuraxial block, were identified and analyzed. Pooled results from five trials showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio (OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI) 0.17-0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12-0.56. Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.3-11.9 min) and intraoperative blood loss by 275 mL/case (95% CI 180-371 mL). Data from three trials showed that patients under neuraxial block for THR were less likely to require blood transfusion than were patients under GA (21/177 = 12% vs 62/188 = 33% of patients transfused, P < 0.001 by z-test). The OR for this comparison was 0.26. However, the CIs were wide and compatible with both no effect and a nine-tenths reduction (95% CI 0.06-1.05). CONCLUSIONS: Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA.

Pharmacologic modulation of operative risk in patients who have cardiac disease.

Cardiac complications continue to compose a major proportion of serious postoperative morbidity and mortality, and it is appropriate, therefore, that this area has received a lot of attention in the search for pharmacologic modulation of surgical outcomes. Despite numerous studies, conclusive data does not exist, making it difficult to recommend a course of action. beta-blockade has not only made it into national protocols, but is even considered as a quality assessment measure. However, the data are not quite as conclusive as it may sometimes appear. There have been few studies, with a small number of negative outcomes, and, at times, significant methodological concerns. The positive outcomes of meta-analyses rest essentially on a single trial in a highly selected patient population. Although use of beta-blockers in patients who have documented coronary artery disease and are undergoing major vascular procedures appears supported, it is premature to recommend beta-blockade for all patients with cardiac risk. Because these drugs are not without risks, it might be advisable to be restrained in their use until the results of the large-scale randomized POISE trial are available. For clonidine and statins, the data are even more tenuous, and largely based on retrospective reviews (with the exception of postprocedure use of statins, which is well supported). Here again, the results of large-scale prospective trials must become available before recommendations can be made. Finally, promising data indicate that it might be possible to modulate by pharmacologic means the neurocognitive decline that is frequently associated with cardiac surgery, and which is often considered by patients to be the most troublesome complication of the intervention.