Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

BACKGROUND: Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. METHODS: Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. RESULTS: A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. CLINICAL RELEVANCE: A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. CONCLUSION: This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

Anesthetic Considerations of Organ Procurement After Brain and Cardiac Death: A Narrative Review.

Organ donation procedures have become more frequent in the US as the need for transplants is increasing. Defining the anesthesiologist's role in organ donations after brain and cardiac death is important, as is understanding its ethics and practical physiologic and perioperative implications. Despite this, there are few papers specifically addressing the anesthetic management of organ donors. This review summarizes the preoperative, intraoperative, and postmortem considerations for the anesthesiologist involved in organ donation after either brain or cardiac death. A search of the published literature was performed using PubMed, Excerpta Medica dataBASE (EMBASE), and Google Scholar in March of 2022 for articles addressing anesthetic considerations of organ procurement surgeries after brain and cardiac death. This review demonstrates that anesthesiologists play a significant role in the organ procurement process. Their role in the perioperative management of the donor may affect the outcomes of organ transplantation. The gap between the number of organs harvested and the number of patients awaiting organ transplantation remains high despite continued efforts to increase the number of available organs. Perioperative management of organ donors aims at counteracting the associated unique physiologic derangements and targets optimization of oxygenation of the organs intended for procurement. Optimizing care after death can help ensure the viability of organs and the best outcomes for recipients. As organ donation after cardiac death (DCD) becomes more frequent in the US, anesthesiologists should be aware of the DCD classifications of donors and emerging novel perfusion techniques.

Predictors of Matching into Anesthesiology and Surgery: Analysis of One Program's Results.

PURPOSE: The objectives of this study were to use a multivariable regression model to determine what application factors made anesthesiology and surgery applicants more or less likely to match into an anesthesiology or surgery residency program. METHODS: Surgery and Anesthesiology applicants listed on the final National Resident Matching Program (NRMP) Rank Order Lists from WMC in the 2020-2021 application cycle were included in analysis. All applicant data were collected through the Electronic Residency Application Service (ERAS). All ERAS and letters of recommendation (LOR) data were deidentified and LOR were subsequently inputted into a linguistics software to analyze the language use in LOR. Descriptive analyses were conducted to compare variables between applicants that matched to a specific residency program and those who matched elsewhere. A multivariable regression model was then used to determine characteristics of anesthesiology and surgery applicants that were indicative of matching to a specific rank of residency program. RESULTS: A total of 116 anesthesiology and 78 surgery applicants were included in final analysis. Analysis of anesthesiology applicants yielded four significant application characteristics that influenced matching to a higher or lower ranked residency program: USMLE Step 2 CK scores, medical school attended, insight category words in LOR, and anger category words in LOR. Similarly, analysis of surgery applicants yielded four significant characteristics: Race, USMLE Step 1 scores, insight category words, and see category words. CONCLUSION: Our results demonstrated that specialties of anesthesiology and surgery considered different metrics regarding the residency application process. Among the many factors that were analyzed, USMLE scores and language in LOR were considered significant in both specialties. As the application process continues to evolve, we may see a shift in what application factors are considered more important than others.

The Utility of Grip Strength as a Simplified Measure of Frailty in the Older Adult in the Preoperative Clinic.

Objective  The aim of this study was to compare the measure of grip strength against other validated methods of measuring frailty. Materials and methods This was a single-center, cross-sectional study that took place at the Westchester Medical Center Pre-Procedural Testing Clinic. The patient population included n = 73 patients ≥65 years of age evaluated for elective surgery. During the study, patients' grip strength, CFS-I (Clinical Frailty Score of Investigator), CFS-P (Clinical Frailty Score of Participant), and FRAIL (Fatigue, Resistance, Aerobic capacity, Illnesses, and Loss of weight) scores were measured. Results Grip strength correlated negatively with the CFS-I, CFS-P, and FRAIL scores for females. Reduced grip strength in females correlated with higher frailty scores and vice versa. Male grip strength showed no significant relationship with the frailty scales. In addition, multivariate linear regression analysis revealed that the independent measure that demonstrated a significant inverse association with grip strength was age (ß= -0.43, p = <0.001). Conclusions  There exists a difference in the utility of grip strength as a measure of frailty between males and females.

Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis.

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees. Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice. Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students. Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.

Anesthetic Selection for an Awake Craniotomy for a Glioma With Wernicke's Aphasia: A Case Report.

Awake craniotomies for tumor resections allow for the preservation of eloquent cortex; however, they are high-risk surgeries that require careful patient selection and meticulous anesthetic management. Patients with significant preoperative language deficits may be unable to participate in intraoperative language mapping, increasing the risk of a failed surgery. Furthermore, anesthetic agents given for sedation and analgesia during the initial portion of the surgery may exacerbate existing language deficits. We present a case of an asleep-awake-asleep craniotomy for a left temporal lobe glioma using intraoperative neuronavigation, 5-aminolevulinic acid fluorescence, and awake speech mapping for a patient with a significant preoperative language deficit, for whom sedation had to be meticulously titrated to optimize intraoperative language testing. Anesthetic titration was aided by bispectral index monitoring, ultimately allowing successful awake speech mapping and tumor resection.

Thomas Drysdale Buchanan, MD, and the Birth of Academic Anesthesiology.

Thomas Drysdale Buchanan, MD (1876-1940), founding president of the American Board of Anesthesiology, was the first person in the United States to hold the title "Professor of Anesthesiology" in a medical school faculty position dedicated exclusively to the specialty. An 1897 graduate of New York Medical College, Dr Buchanan joined the faculty of his alma mater in 1902 in response to demands by medical students and recent graduates for a dedicated instructor in anesthesia. Within a decade, the instructorship had become a professorship, and Dr Buchanan was on his way to distinction as one of the founders of academic anesthesiology. This chapter in Dr Buchanan's early career illustrates how anesthesiology took shape as a distinct body of knowledge during the formative decades of modern medical education at the turn of the century, laying the groundwork for its recognition 30 years later as a specialty in its own right.

Gender Differences in the Language of LORs Written for Anesthesiology Medical Student Applicants: Analysis of One Program's Recruitment Cycle.

BACKGROUND: Prior studies have demonstrated gender differences in language used in letters of recommendation (LOR) for residency applicants. No previous studies have investigated linguistic gender differences in LOR specifically in the field of anesthesiology. The objective of this study is to determine whether there are potential gender biases in the language of LOR written for anesthesiology residency applicants. METHODS: Letters sent through the Electronic Residency Application Service in application for a single training program in the Northeast in 2019-2020 were divided into self-identified male and female groups. The letters were deidentified, converted to machine-readable text, and input into software to analyze differences in language use. Differences in language use and word count between the 2 groups were compared. RESULTS: Included in this analysis were 316 applicants (113 female applicants and 203 male applicants) who submitted a total of 1132 letters, 409 of which were letters written for females and 723 were written for males. Analysis of 4 document characteristics and 19 psychological construct word categories showed that males had a higher frequency of tentative notations (P < .0110), while females had a higher frequency of ability notations (P < .0449). No other meaningful differences were found. CONCLUSIONS: While our results demonstrated 2 differences in language use between male and female anesthesiology residency applicants for LOR, it is reassuring that LOR are relatively free of linguistic bias. Future research should focus on identifying other areas of the specialty's recruitment process in order to recognize and mitigate gender differences in anesthesiology.

Attitudes towards and impact of letters of recommendation for anesthesiology residency applicants.

Background: This survey aims to identify the relative value and the critical components of anesthesiology letters of recommendation(LORs) from the perspective of Program Directors (PDs) and Associate/Assistant Program Directors (APDs). Knowledge and insights originating from this survey might add to the understanding of the anesthesiology residency selection process and mitigate unintended linguistic biases.Methodology: Anonymous online surveys were sent to anesthesiology PDs/APDs from the Accreditation Council for Graduate Medical Education (ACGME) accredited anesthesiology residency Programs in the USA (US), as listed on the ACGME website and the American Medical Association Fellowship and Residency Electronic Interactive Database (AMA FREIDA) Residency Program Database. The survey authors were blinded to the identity of the respondents.Results: 62 out of 183 (33.8%) invited anesthesiology PDs/APDs completed the survey anonymously. In our survey, LORs are reported as more important in granting an interview than in making the rank list. 64% of respondents prefer narrative LORs. 77.4% of respondents look for specific keywords in LORs. Keywords such as 'top % of students' and 'we are recruiting this candidate' indicate a strong letter of recommendation while keywords such as 'I recommend to your program' or non-superlative descriptions indicate a weak letter of recommendation. Other key components of LORs include the specialty of the letter-writer, according to 84% of respondents, with anesthesiology as the most valuable specialty. Although narrative LORs are preferred, 55.1% of respondents are not satisfied with the content of narrative LORs.Conclusion: LORs containing specific keywords play an important role in the application to anesthesiology residency, particularly when submitted by an anesthesiologist. While narrative LORs are still the preferred format, most of our respondents feel they need improvements. The authors suggest specific LOR improvements including creating formalized LOR training, adding a style guide, and applying comparative scales, with standardized vocabulary in the narrative LOR.

Smooth Extubation and Smooth Emergence Techniques: A Narrative Review.

There is a paucity of literature on extubation technique and a lack of consensus regarding the definition of smooth extubation. This narrative review paper defines an ideal extubation, otherwise known as a "smooth extubation," reviews perioperative criteria for extubation and risks and adverse events related to extubation, and explores various perioperative techniques that can be used to achieve a smooth extubation while caring for an uncomplicated patient without significant risk factors for extubation failure. In light of the evolving practice during the SARS CoV2 (COVID-19) pandemic to minimize aerosol generation and infection transmission, smooth extubation is particularly important.

Use of Disposable Clear Plastic Elastic Band-Rimmed Bag to Limit Infectious Aerosol during Airway Instrumentation.

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the need for appropriate protective measures for health care providers, particularly for those involved in aerosol-generating procedures. We report the use of the banded bag for extubation to contain infectious aerosols. The banded bag is a clear and disposable shower-cap style image intensifier cover which is commonly used as a sterile cover for mobile X-ray systems. With the addition of a filtered suction, safe air exchange rates can be obtained. We anticipate that the banded bag, which is economical, convenient, and highly practical, can be used as a safety-enhancing device for COVID-19 extubations.

Endovascular thrombectomy in acute ischemic stroke: new treatment guide.

PURPOSE OF REVIEW: Recent randomized clinical trials (RCTs) have demonstrated strong efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions (LVO). SIESTA, AnSTROKE, GOLIATH showed no deleterious effects of general anesthesia on patient outcome after EVT compared with conscious sedation. DAWN and DEFUSE 3 are extending the time window for EVT up to 24 h in carefully selected patients. This review discusses the current literature on the rapidly expanding subject of endovascular stroke therapy and optimal anesthetic management. RECENT FINDINGS: Recent retrospective studies of RCT data sets show that general anesthesia is associated with negative clinical outcome in AIS patients undergoing EVT when compared with sedation. Two of the possible mechanisms of this finding are systolic hypotension and hypocapnia. SIESTA, AnSTROKE, GOLIATH showed no difference in short-term clinical outcome between EVT patients treated with general anesthesia versus conscious sedation. DAWN and DEFUSE 3 demonstrated improved functional outcomes after EVT in those treated up to 24 h after selection with perfusion imaging, increasing the number of patients eligible for EVT. SUMMARY: Effective reperfusion with stent retriever technology, careful patient selection using perfusion imaging, and careful use of anesthetic technique affect outcome.

Role of anesthesia in endovascular stroke therapy.

PURPOSE OF REVIEW: Recent randomized clinical trials have demonstrated strong efficacy of endovascular therapy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions; in the USA alone, tens of thousands of patients annually may benefit. The impact of the type of anesthesia used during mechanical thrombectomy on patient outcomes remains controversial. This review discusses the current literature on the effects of anesthesia type on patient outcome following endovascular stroke therapy. RECENT FINDINGS: EVT is the standard of treatment for intracranial large vessel occlusions. Recent studies show that general anesthesia is associated with negative clinical outcome in AIS patients undergoing EVT. Two of the possible mechanisms of this finding are systolic hypotension and hypocapnia. However, the only published randomized controlled studies to date, sedation vs. intubation for endovascular stroke treatment and anesthesia during stroke showed no difference in short-term clinical outcome between EVT patients treated with general anesthesia and conscious sedation and improved longer-term outcome in the general anesthesia group. SUMMARY: Retrospective reports, and the 2015 American Heart Association/American Stroke Association Guideline (focused update of the 2013 guidelines for the early management of patients with AIS regarding endovascular treatment) based on these reports, are in favor of sedation (conscious sedation) over general anesthesia for endovascular stroke thrombectomy. However, the two randomized controlled prospective studies published provide inconclusive evidence as to the best anesthetic practice for endovascular stroke therapy. More randomized clinical trials are needed to optimize anesthetic patient care in AIS.

Surgical and Teaching Mission to Mongolia: Experience and Lessons.

BACKGROUND: For decades, the disparity in medical care across the world along with the fundamental essence of medicine as service has laid the foundation for the global medical mission. Mongolia, a country often overlooked as an area in need of medical aid, harbors a fertile environment for long-term change. In the last 15-20 years, after the fall of the Union of Soviet Socialist Republics, Mongolia has turned to a free-market healthcare model and has been struggling with the transition from the formally state-run system. These changes have slowed the original progress noted among surgical specialties, namely neurosurgery, in Mongolia. A lack of resources, a desire for international interaction, and a need for technical mentorship remain a real struggle for local neurosurgeons. METHODS: Under the auspices of the Virtue Foundation (www.virtuefoundation.org), we report on our 3-year experiences during our surgical and teaching mission to Mongolia and look towards long-term improvements in Mongolian neurosurgery. RESULTS: A total of 15 operations were performed and more than 50 patients seen in clinic during the 3-year experience. Patients ranged from 1 to 77 years of age. No patients encountered any significant peri- or postoperative complications. CONCLUSIONS: In our experience with the surgical and teaching mission to Mongolia, when directed appropriately, medical missions can serve as the perfect medium in fostering that environment, providing local healthcare professionals with the knowledge, skills, and motivation to create self-sustaining improvement in their own country, hence promoting intellectual and technological advancement and raising the standard of care.

General Anesthesia During Endovascular Stroke Therapy Does Not Negatively Impact Outcome.

OBJECTIVE: Recent randomized trials have demonstrated that endovascular therapy improves outcomes in patients with an acute ischemic stroke from a large vessel occlusion. Subgroup analysis of the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) study found that patients undergoing general anesthesia (GA) for the procedure did worse than those with nongeneral anesthesia (non-GA). Current guidelines now suggest that we consider non-GA over GA, without large, randomized trials specifically designed to address this issue. We sought to review our experience and outcomes in a program where we routinely use GA in patients undergoing mechanical thrombectomy with similar techniques. METHODS: Patients with anterior circulation strokes who received intravenous tissue plasminogen activator (IV-tPA) and endovascular stroke therapy were included in the analysis. The National Institutes of Health Stroke Scale (NIHSS) on admission and discharge and modified Rankin scale scores at discharge were recorded and compared with the outcome measurements of MR CLEAN. RESULTS: Sixty patients were identified: 39 males and 21 females with a mean age of 62 (range of 29-88). Forty-seven patients were transferred from outside primary stroke centers, while 13 patients presented directly to our institution. Median NIHSS on admission was 15. The median time of symptom onset to endovascular therapy was 265 minutes, with an interquartile range of 81 minutes. Using the thrombolysis in cerebral infarction (TICI) scale, recanalization of TICI 2b-3 was achieved in 76.4% of recorded patients (42/55 recorded). At discharge, mortality was 16.7% (10/60), median NIHSS was 5, and 38.3% (23/60) of patients had a modified Rankin Scale score of 0-2. CONCLUSIONS: General anesthesia does not worsen outcome in patients undergoing mechanical thrombectomy when compared to historical subgroups. Despite a longer time from symptom onset to treatment, our outcomes for patients receiving GA compare favorably to the GA and non-GA groups in MR CLEAN.

O-arm failure traps patient prone on a Jackson table.

The O-arm Surgical Imaging System (Medtronic Sofamor Danek, Memphis, TN, USA) is an increasingly popular tool for spinal surgical procedures that allows for intraoperative acquisition of multi-dimensional spinal imaging that can be used either to confirm placement of spinal instrumentation or to guide spinal screw placement in conjunction with a navigation system. The machine is typically placed open from the side of the patient positioned prone on the Jackson spinal table (Mizuho OSI, Union City, CA, USA) and then closed to complete a ring around the patient to acquire images. A failure of the O-arm opening mechanism can lead to a patient becoming effectively trapped within the device with limited physician access to the patient's body, a situation that may be remedied by using a manual opening procedure. This report highlights a patient safety issue encountered when a mechanical failure of the O-arm occurred and one of the two tools required for its manual opening was missing. We describe the improvised method employed to successfully open the device.

Air embolism during operative hysteroscopy: TEE-guided resuscitation.

During hysteroscopic surgery there are concerns about potential complications such as venous air and gas embolism. The incidence of subclinical air emboli events during operative hysteroscopy is significantly underestimated. The manifestations of this complication may range from an unnoticeable decrease in P(ET)CO(2) to the need for resuscitation. Three cases of air embolism with variable outcomes occurring during general anesthesia for operative hysteroscopy in otherwise healthy patients are presented.