A Prospective Cohort Study on the Respiratory Effect on Modified Mallampati Scoring.

Background: Mallampati scoring is a common exam method for evaluating the oropharynx as a part of the airway assessment and for anticipation of difficult intubation. It partitions the oropharynx into 4 categories with scores of 1, 2, 3, and 4. Even though its reliability is known to be limited by confounding factors such as patient positioning, patient phonation, tongue protrusion, and examiner variability, the effect of respiration, i.e., inspiration and expiration, has not yet been formally studied. Methods: Mallampati scores were collected from 100 surgical patients during both inspiration and expiration and later compared to the score obtained in the medical record, determined by a board certified anesthesiologist. Results: Score deviations from the medical record reference were compared for both inspiration and expiration showing that respiration affects Mallampati scores; for some patients, the scores improved (i.e., decreased), while in others they worsened (i.e., increased). The respiratory change effect was quantified and visualized by plotting the area under the curve of the histogram of the deviations. 42% of the patients had a worsening of scores by 1 or 2 points with inspiration while 36% of the patients had a worsening of scores by 1 or 2 points with expiration. Conclusions: Mallampati scoring is commonly used in evaluating the oropharynx as a part of the airway assessment and as a screening tool for difficult intubations. However, as this study points out, the respiratory cycle substantially affects the Mallampati scoring system, with significant deviations of 1 or 2 points. In a scoring system of 4 score categories, these deviations are remarkable.

Near-miss hypoglycemia-reflections on perioperative glucose management guidelines in diabetics.

BACKGROUND: The American Society of Anesthesiologists (ASA) has an impressive array of professional perioperative guidelines but has not issued a guideline specific to perioperative blood glucose management and does not delve into the topic in their other guidelines. CASE REPORT: We experienced a perioperative case that highlights the potential difficulty of glucose management in this setting. During anesthetic induction for an orthopedic foot surgery, as the medication was infusing, an IDDM 1 (insulin dependent diabetes mellitus type 1) patient expressed feeling that her blood sugar level was low. Her finger stick after induction showed severe hypoglycemia with a blood glucose of 34 mg/dL. The hypoglycemia was treated with intravenous glucose and further closely monitored. CONCLUSIONS: This case led us to revisit the different perioperative guidelines and recommendations for diabetic patients and this manuscript aims to highlight the similarities and discrepancies among the different published recommendations. This case highlights the value of utilizing insulin pump infusions in the perioperative setting when available.

Protecting the Airway and the Physician: Lessons from 214 Cases of Endotracheal Intubation Litigation.

Objective: Medicolegal examination of an intervention as common as endotracheal intubation may be valuable to physicians in many specialties. Our objectives were to comprehensively detail the factors raised in litigation to better educate physicians on strategies for minimizing liability and augmenting patient safety. Methods: Publicly available court records were searched for pertinent litigation. Ultimately, 214 jury verdict and settlement reports were examined for various factors, including outcome, award, geographic location, defendant specialty, setting in which an injury occurred, patient demographics, and other causes of malpractice. Results: Ninety-two cases (43.0%) were resolved in the defendant's favor, with the remaining cases resulting in out-of-court settlement or a plaintiff's verdict. Payments from these cases were considerable, averaging $2.5 M. The most frequent physician defendants were anesthesiologists (59.8%) and emergency-physicians (19.2%), although other specialties were well represented. The most common setting of injury was the operating room (45.3%). Common factors included sustaining permanent deficits (89.2%), death (50.5%), and anoxic brain injury (37.4%). Injuries occurring in labor and delivery mostly involved newborns and had among the highest awards. Conclusions: Litigation involves injuries sustained in numerous settings. The most common factors present included sustaining permanent deficits, including anoxic brain injury. The presence of this latter injury increased the likelihood of a case being resolved with payment. Finally, deficits in informed consent were noted in numerous cases, stressing the importance of a clear process in which the physician explains specific risks (such as those detailed in this analysis), benefits, and alternatives.

Assessing the Readability of Anesthesia-Related Patient Education Materials from Major Anesthesiology Organizations.

Introduction: The National Institutes of Health (NIH), American Medical Association (AMA), and the US Department of Health and Human Services (USDHHS) recommend that patient education materials (PEMs) be written between the 4th to 6th grade reading level to ensure readability by the average American. In this study, we examine the reading levels of online patient education materials from major anesthesiology organizations. Methods: Readability analysis of PEMs found on the websites of anesthesiology organizations was performed using the Flesch Reading Ease score, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Gunning Frequency of Gobbledygook, New Dale-Chall test, Coleman-Liau Index, New Fog Count, Raygor Readability Estimate, the FORCAST test, and the Fry Score. Results: Most patient educational materials from the websites of the anesthesiology organizations evaluated were written at or above the 10th grade reading level. Conclusions: Online patient education materials from the major anesthesiology societies are written at levels higher than an average American adult reading skill level and higher than recommended by National Institute of Health, American Medical Association, and US Department of Health and Human Services. Online resources should be revised to improve readability. Simplifying text, using shorter sentences and terms are strategies online resources can implement to improve readability. Future studies should incorporate comprehensibility, user-friendliness, and linguistic ease to further understand the implications on overall healthcare.

Deviation from Clinical Routines Can Reveal Sources of Device Design Vulnerability.

The ability to adequately ventilate a patient is critical and sometimes a challenge in the emergency, intensive care, and anesthesiology settings. Commonly, initial ventilation is achieved through the use of a face mask in conjunction with a bag that is manually squeezed by the clinician to generate positive pressure and flow of air or oxygen through the patient's airway. Large or small erroneous openings in the breathing circuit can lead to leaks that compromise ventilation ability. Standard procedure in anesthesiology is to check the circuit apparatus and oxygen delivery system prior to every case. Because the face mask itself is not a piece of equipment that is associated with a source of leak, some common anesthesia machine designs are constructed such that the circuit is tested without the mask component. We present an example of a leak that resulted from complete failure of the face mask due to a tiny tear in its cuff by the patient's sharp teeth edges. This subsequently prevented formation of a seal between the face mask and the patient's face and rendered the device incapable of generating the positive pressure it is designed to deliver. This instance depicts the broader lesson that deviation from clinical routines can reveal unappreciated sources of vulnerability in device design.

Case report and review of literature of a rare congenital disorder: Adams-Oliver syndrome.

BACKGROUND: Adams-Oliver syndrome is characterized by the combination of congenital scalp defects and terminal transverse limb defects. In some instances, cardiovascular malformations and orofacial malformations have been observed. Little is written with regards to the anesthetic management and airway concerns of patients with Adams-Oliver syndrome. CASE PRESENTATION: A five-year-old female with Adams-Oliver syndrome presented for repeat lower extremity surgery. Airway exam was significant for dysmorphic features, such as hypertelorism, deviated jaw, and retrognathia. Video laryngoscope was utilized for intubation due to the patients retrognathic jaw, cranial deformities, and facial dysmorphism. A vein finder with ultrasound guidance was needed to place the peripheral intravenous line due to her history of difficult intravenous access. The patient was successfully intubated with slight cricoid pressure applied to direct the endotracheal tube smoothly. Surgery and recovery were both unremarkable. CONCLUSIONS: Due to varying presentations of Adams-Oliver syndrome, anesthetic and airway management considerations should be carefully assessed prior to surgery. Anesthesiologists must take into consideration possible orofacial abnormalities that may make intubation difficult. Amniotic band syndrome and other limb defects could potentially impact intravenous access as well.

Dose Comparison of Dexmedetomidine Sedation following Spinal Anesthesia: Parturient versus Nonpregnant Women-A Randomized Trial.

BACKGROUND: This study was designed to investigate and compare the effective doses of dexmedetomidine for sedation in parturient patients who underwent Cesarean section (CS) and nonpregnant women who underwent elective gynecologic surgery. METHODS: The study comprised 60 females aged between 25 and 35. They were divided into two groups. The parturient group received a bolus dose of dexmedetomidine over 15 min after the delivery of the fetus and placenta. In the nonpregnant women group, a bolus of dexmedetomidine was administered intravenously upon the completion of spinal anesthesia. The subsequent dose required by patients in each group was then determined through a modified two-stage Dixon up-and-down sequential method. Probit analysis was used to calculate the ED50 and the ED95 of dexmedetomidine for adequate sedation. RESULTS: The ED50 of dexmedetomidine for adequate sedation in parturient patients was 1.58 µg/kg (1.51-1.66 µg/kg); in nonpregnant women, it was 0.96 µg/kg (0.91-1.01 µg/kg) (95% CI). The ED95 of dexmedetomidine in parturients was 1.80 µg/kg (1.70-2.16) µg/kg and that of nonpregnant women was 1.10 µg/kg (1.04-1.30 µg/kg) (95% CI). The ED50 in parturients was significantly higher than that in nonpregnant women (P < 0.05). CONCLUSION: The ED50 of dexmedetomidine for target sedation in parturients who received spinal anesthesia for CS is greater than 1.5 times that in nonpregnant women who received spinal anesthesia for lower abdominal gynecologic surgery. This study postulates that the dose of dexmedetomidine required to achieve optimal sedation following spinal anesthesia is much higher in parturients than in nonpregnant women undergoing gynecologic surgeries. This trial is registered with NCT02111421.

Gabapentin Does Not Appear to Improve Postoperative Pain and Sleep Patterns in Patients Who Concomitantly Receive Regional Anesthesia for Lower Extremity Orthopedic Surgery: A Randomized Control Trial.

In recent years, gabapentin has gained popularity as an adjuvant therapy for the treatment of postoperative pain. Numerous studies have shown a decrease in pain score, even with immediate postoperative activity, which is significant for early post-op ambulation and regaining functionality sooner. However, studies have been in conclusive in patients undergoing lower extremity orthopedic surgery. For this reason, we hoped to study the effect of gabapentin on postoperative pain in patients undergoing total knee arthroplasty, total hip arthroplasty, or a hip fracture repair. This was done in the setting of ensuring adequate postoperative analgesia with regional blocks and opioid PCA, as is protocol at our institution. Given the sedative effects of gabapentin and the potential for improving postoperative sleep patterns, we also studied the drug's effect on this aspect of our patient's postoperative course. We utilized the Pittsburg Sleep Quality Index and Visual Analog Scale for pain to obtain a more objective standardized score amongst our study population. Our results indicate that gabapentin does not offer any additional relief in pain or improve sleep habits in patients who have received either a femoral or lumbar plexus block for lower extremity orthopedic surgery. This trial is registered with NCT01546857.

Fellowships Represent a Logical Target for Cultivating Research in Academic Anesthesiology.

Background: The need for greater emphasis on research contributions in academic anesthesiology has been widely recognized in recent years. Some propose increasing integration of research, including dedicated research time, into ACGME requirements for residency and fellowship training experiences. The h-index, an effective measure of research productivity that takes into account relevance and impact of an author's contributions on discourse within a field, was used to examine whether there are differences in research productivity between non-fellowship and fellowship-trained faculty in academic anesthesiology departments. This bibliometric was further used to examine differences in subspecialties, and other specialties of medicine. Methods: Research productivity, as measured by the h-index, was examined using the Scopus database for 508 academic Anesthesiologists practicing in the various subspecialties. Results: There was no statistical difference in research productivity, as measured by the h-index, between non-fellowship and fellowship-trained academic anesthesiologists (2.98+-0.32 vs. 2.88+-0.31). Critical care anesthesiologists had the highest h-indices (5.78+-1.11), while regional anesthesia and pain medicine practitioners had the lowest values (1.18+-0.32). Unlike in anesthesiology, a sample of physicians from other specialties revealed a statistical difference in h-index between non-fellowship and fellowship-trained physicians. Conclusions: Scholarly productivity, as measured by the h-index was similar for fellowship and non-fellowship trained anesthesiologists.

A comparison of plaintiff and defense expert witness qualifications in malpractice litigation in anesthesiology.

BACKGROUND: Expert witnesses serve a crucial role in the medicolegal system, interpreting evidence so that it can be understood by jurors. Guidelines have been established by both the legal community and professional medical societies detailing the expectations of expert witnesses. The primary objective of this analysis was to evaluate the expertise of anesthesiologists testifying as expert witnesses in malpractice litigation. METHODS: The WestlawNext legal database was searched for cases over the last 5 years in which anesthesiologists served as expert witnesses. Internet searches were used to identify how long each witness had been in practice. Departmental websites, the Scopus database, and state medical licensing boards were used to measure scholarly impact (via the h-index) and determine whether the witness was a full-time faculty member in academia. RESULTS: Anesthesiologists testifying in 295 cases since 2008 averaged over 30 years of experience per person (mean ± SEM, defense, 33.4 ± 0.7, plaintiff, 33.1 ± 0.6, P = 0.76). Individual scholarly impact, as measured by h-index, was found to be lower among plaintiff experts (mean ± SEM, 4.8 ± 0.5) than their defendant counterparts (mean ± SEM, 8.1 ± 0.8; P = 0.02). A greater proportion of defense witnesses were involved in academic practice (65.7% vs 54.8%, P = 0.04). CONCLUSIONS: Anesthesiologists testifying for both sides are very experienced. Defense expert witnesses are more likely to have a higher scholarly impact and to practice in an academic setting. This indicates that defense expert witnesses may have greater expertise than plaintiff expert witnesses.

Gabapentin in acute postoperative pain management.

Gabapentin (1-aminomethyl-cyclohexaneacetic acid) is an amino acid that has the structure of the neurotransmitter γ -aminobutyric acid (GABA). It is a novel drug used for the treatment of postoperative pain with antihyperalgesic properties and a unique mechanism of action. Gabapentin and the related, more potent compound pregabalin have been shown to be beneficial in the treatment of neuropathic pain as well as postoperative pain following spinal surgery and hysterectomy. This study reviews five aspects of gabapentin: (1) chemical and structural characteristics; (2) pharmacokinetics and pharmacodynamics; (3) application in acute pain management; (4) adverse effects; and (5) drug safety. Overall, gabapentin has been reported to be a safe and efficacious drug for the treatment of postoperative pain.

Obstructive sleep apnea: strategies for minimizing liability and enhancing patient safety.

OBJECTIVE: To characterize malpractice litigation regarding obstructive sleep apnea (OSA) and educate physicians on frequently cited factors. STUDY DESIGN AND SETTING: Analysis of the Westlaw legal database. METHODS: Jury verdict and settlement reports were examined for outcome, awards, patient demographic factors, defendant specialty, and alleged causes of malpractice. RESULTS: Out of 54 identified cases, 33 (61.1%) cases were resolved in favor of defendants, 12 (22.2%) via settlement, and 9 (16.7%) through jury award. Median settlement and jury awards did not significantly differ ($750,000 vs $550,000, P > .50). Age and gender did not affect outcome. Otolaryngologists and anesthesiologists were the most frequently named defendants. Forty-seven cases (87.1%) stemmed from OSA patients who underwent procedures with resultant perioperative adverse events. Common alleged factors included death (48.1%), permanent deficits (42.6%), intraoperative complications (35.2%), requiring additional surgery (25.9%), anoxic brain injury (24.1%), inadequate informed consent (24.1%), inappropriate medication administration (22.2%), and inadequate monitoring (20.4%). CONCLUSION: Litigation related to OSA is frequently associated with perioperative complications more than nonoperative issues such as a failure to diagnose this disorder. Nonetheless, OSA is considerably underdiagnosed, and special attention should be paid to at-risk patients, including close monitoring of their clinical status and the medications they receive. For patients with diagnosed or suspected OSA with planned operative intervention, whether for OSA or an unrelated issue, a comprehensive informed consent process detailing the factors outlined in this analysis is an effective strategy to increase communication and improve the physician-patient relationship, minimize liability, and ultimately improve patient safety.

In-office balloon dilation and drainage of frontal sinus mucocele.

Treatment of frontal sinus disease represents one of the most challenging aspects of endoscopic sinus surgery. Frontal sinus mucocele drainage may be an exception to the rule because in many instances, the expansion of the mucocele widens the frontal sinus recess and renders surgical drainage technically undemanding. Recently, there has been an increased interest in in-office procedures in otolaryngology because of patient satisfaction and substantial savings of time and cost for both patients and physicians. Similarly, the past few years have witnessed an increased use of balloon dilation devices in sinus surgery. Previously, we have described the in-office use of this device in treating patients who failed prior conventional frontal sinusotomy in the operating room. In this report, we describe our step-by-step in-office experience using this tool for drainage of a large frontal sinus mucocele.

Determination of legal responsibility in iatrogenic tracheal and laryngeal stenosis.

OBJECTIVES/HYPOTHESIS: Laryngotracheal stenosis usually occurs as a result of injury from endotracheal intubation or tracheostomy placement. With an estimated incidence of 1% to 22% after these procedures, chronic sequelae ranging from discomfort to devastating effects on quality of life, and even death, make this complication a potential litigation target. We examined federal and state court records for malpractice regarding laryngotracheal stenosis and examined characteristics influencing determination of liability. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw Next legal database (Thomson Reuters, New York, NY) was searched for pertinent federal and state malpractice cases and examined for several factors including alleged cause of malpractice, complications, case outcome, and specialty of the defendants. RESULTS: Twenty-three pertinent cases over 35 years were identified. Fourteen (60.9%) cases were decided in the physician's favor, with six plaintiff verdicts awarding an average of $922,129 for malpractice, and three out-of-court settlements averaging $441,600. Hospitals were the most frequently named defendants, and anesthesiologists were most commonly named physician defendants. Endotracheal intubations and tracheostomy history were frequent factors in these cases. Laryngeal lesions were more likely to result in payments, trending higher than those stemming from tracheal lesions. CONCLUSIONS: Multiple cases mentioned previous intubation as a potential risk factor that may have led to laryngotracheal stenosis. Location of stenosis and requirement of reparative procedures may also influence outcomes. Cases not decided in the defendant's favor frequently included other extenuating circumstances, including severity of other injuries. Although the majority of cases were defendant decisions, the verdicts decided for the plaintiffs had considerable damages awarded.