Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients.

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.

The Other Aortic Syndrome-Intramural Hematoma and Neurological Deficit: Case Report.

Introduction: Acute thoracic aortic syndromes are among the most concerning presentations in emergency medicine and are associated with significant morbidity and mortality. Thoracic aortic dissection is most common, followed by penetrating aortic ulcer and, least commonly, intramural hematoma. Case Report: A 67-year-old woman presented to the emergency department with chest and back pain, and sudden onset of paraparesis. Aortic intramural hematoma was diagnosed, and she underwent spinal drain placement with blood pressure control to optimize spinal cord perfusion. Discussion: When neurological deficits are present, rapid diagnosis of spinal ischemia and blood pressure optimization is vital. Spinal drains may be considered as an adjunctive treatment.

Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization.

This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.

Perioperative outcomes of patients with restless legs syndrome: a single-center retrospective review.

STUDY OBJECTIVES: There are multiple stressors in the perioperative period for patients with restless legs syndrome (RLS) that may be implicated in the worsening of symptoms. Our primary objective was to compare the perioperative course of patients with RLS to patients without the diagnosis. METHODS: This was a single-center, matched-cohort, retrospective chart review of patients with RLS undergoing inpatient procedures from 2015-2019 matched 1:1 with patients without the diagnosis. RESULTS: Patients with RLS had a higher comorbidity burden; specifically, pulmonary, renal, diabetes mellitus, and congestive heart failure. The perioperative course was notable for higher maximum pain scores for patients with RLS in the postanesthesia care unit (odds ratio, 1.29; 95% confidence interval, 1.19-1.40; P < .001). Postoperative patients with RLS also had higher maximum pain scores on postoperative days 0, 1, and 2. The odds of rapid-response calls were higher in patients with RLS (odds ratio, 1.43; 95% confidence interval, 1.18-1.73; P < .001). There were no other significant differences in postoperative complications. The odds of using RLS-triggering medications were lower in the RLS group (odds ratio, 0.85; 95% confidence interval, 0.78-0.92; P < .001). CONCLUSIONS: Our single-center retrospective review found that patients with RLS had higher pain scores in the postanesthesia care unit and on the first few postoperative days. Rapid-response team calls were more common in patients with RLS. RLS-triggering medications were significantly less likely to be used in patients with RLS. There were no significant differences in other postoperative events. CITATION: Gali B, Silber MH, Hanson AC, Portner E, Gay P. Perioperative outcomes of patients with restless legs syndrome: a single-center retrospective review. J Clin Sleep Med. 2022:18(7):1841-1846.

Intraoperative Ventilatory Pressures During Robotic Assisted vs Open Radical Cystectomy.

OBJECTIVE: To investigate whether Robotic assisted radical cystectomy (RARC) is associated with increased postoperative pulmonary complications compared to open radical cystectomy (ORC). RARC poses challenges for ventilation with positioning and abdominal insufflation. Conventionally protective mechanical ventilation may be challenging, especially in patients with obesity or pulmonary comorbidities. Given the proven benefits of RARC compared to ORC, the risk of postoperative pulmonary complications merits further investigation. MATERIALS AND METHODS: Adult patients consented for research who underwent RARC and ORC for invasive bladder cancer from 2013-2018 were identified for retrospective chart review. Perioperative and patient variables were looked at along with postoperative course and outcomes. RESULTS: 328 patients who underwent ORC and 108 patients who underwent RARC were identified. Despite findings of higher peak airway pressures throughout surgery, patients who underwent RARC did not have a higher rate of pulmonary complications than patients who underwent ORC. Patients with obstructive sleep apnea (OSA) who underwent ORC had a higher rate of postoperative pulmonary complications. Patients who underwent RARC had a less intraoperative fluid administration, fewer ICU admissions, and decreased length of hospital stay. CONCLUSION: Despite mechanical ventilation challenges, RARC was not associated with increased post-operative pulmonary complications compared to ORC. This was also found in patients with BMI>30 or with diagnosis or high suspicion of OSA. These findings suggest ventilation at higher pressures does not increase risk for ventilator induced lung injury in patients undergoing RARC, even in conventionally higher risk patients.

Impact of Mentorship, by Gender, on Career Trajectory in an Academic Anesthesiology Department: A Survey Study.

INTRODUCTION: Mentorship has been identified as a key component of success in business and in academic medicine. METHODS: After institutional review board approval of the study, an email survey was sent to anesthesiologists in one anesthesiology department to assess mentorship status. A survey link was sent to nonrespondents at 2 weeks and 4 weeks. All participants were deidentified. The identification of a mentor was compared by gender, academic rank, and years of practice. RESULTS: Among 233 anesthesiologists, 103 (44.2%) responded to the survey. More than 90% of survey respondents agreed or strongly agreed that having a mentor is important to career success. Of the 103 respondents, 31 (30%) indicated they had a mentor. Overall, 84% of the identified mentors were men; however, this percentage differed significantly between men and women respondents (95% versus 60%; P = .03). Characteristics associated with having a mentor included younger age (P = .007), fewer years since finishing training (P = .004), and working full time (P = .02). For respondent age and years since finishing training, there was some evidence that the association was dependent on the gender of the respondent (age-by-gender interaction, P = .08; experience-by-gender interaction, P = .08). DISCUSSION: Anesthesiologists in this department believed that mentorship led to more academic success. Few women mentors were reported, and women were unlikely to identify a mentor once advanced past an assistant professor rank. Most respondents believed that mentorship was important for overall career success, but only approximately one-third identified a mentor at the time of the survey.

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

BACKGROUND: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine. METHODS: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data. RESULTS: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia. CONCLUSIONS: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.

Integrating Sleep Knowledge Into the Anesthesiology Curriculum.

There is common ground between the specialties of anesthesiology and sleep medicine. Traditional sleep medicine curriculum for anesthesiology trainees has revolved around the discussion of obstructive sleep apnea (OSA) and its perioperative management. However, it is time to include a broader scope of sleep medicine-related topics that overlap these specialties into the core anesthesia residency curriculum. Five main core competency domains are proposed, including SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness (SLEEP WELL). The range of topics include not only the basics of the physiology of sleep and sleep-disordered breathing (eg, OSA and central sleep apnea) but also insomnia, sleep-related movement disorders (eg, restless legs syndrome), and disorders of daytime hypersomnolence (eg, narcolepsy) in the perioperative and chronic pain settings. Awareness of these topics is relevant to the scope of knowledge of anesthesiologists as perioperative physicians as well as to optimal sleep health and physician wellness and increase consideration among current anesthesiology trainees for the value of dual credentialing in both these specialties.

Closing the Mentorship Gap: Implementation of Speed Mentoring Events for Women Faculty and Trainees in Anesthesiology.

Introduction: Mentorship is a key component to success in academic medicine. Women are under-represented in leadership positions within medicine. Women are less likely to identify mentors than men. Speed mentoring is an innovative strategy to facilitate mentorship in academic medicine. Materials and Methods: A speed mentoring event for women faculty members in an academic anesthesiology department was held, followed by a second event for trainees. Attendees completed surveys about mentorship experiences at baseline and in follow-up. Questions were rated on a 7-point Likert scale with 1 = strongly disagree and 7 = strongly agree with values reported as median (1st, 3rd quartile). Results: Baseline surveys indicated poor satisfaction with mentoring in the prior 6 months as 4.5 (3, 5.25). Twelve months later, mentees reported increased satisfaction with mentoring 6 (6, 6). Mentors and mentees felt their time was well spent during both events. There was an increase in the number of mentors identified after the events by both groups. Conclusions: Our results suggest speed mentoring is well received and impactful with minimal time and monetary investment. The attendees of the events identified an increased number of mentors after speed mentoring events, and this effect was maintained at 6-12 months. Speed mentoring may be one path to providing support for women to advance their careers in academic medicine. More research is warranted to better evaluate effectiveness of formats such as speed mentoring to facilitate improved mentorship for women in academic anesthesiology.

Postoperative outcomes in patients with treatment-emergent central sleep apnea: a case series.

PURPOSE: Treatment-emergent central sleep apnea (TECSA) is a central sleep-related breathing disorder, characterized by either the persistence or emergence of central sleep apnea during the initiation of positive airway pressure therapy for obstructive sleep apnea. The purpose of this study was to review the perioperative course of patients diagnosed with TECSA. METHODS: We reviewed medical records of patients with TECSA who had a procedure or surgery with general anesthesia between January 1, 2009 and May 1, 2018. We describe postoperative outcomes including respiratory complications, unplanned intensive care unit (ICU) admissions, and other postoperative outcomes. RESULTS: We identified 150 (116 male, 34 female) patients with TECSA. Of these, 39 (26%) had their anesthesia recovery associated with moderate to profound sedation, 22 (14.7%) required unplanned transfer to ICU (8 for hypoxemia). Compared to patients without ICU admissions, patients with unplanned ICU admissions had higher rates of cardiovascular disease, Charlson comorbid scores, and perioperative benzodiazepines. Within the first 30 postoperative days there were 23 (16%) hospital re-admissions, and 7 (4.6%) deaths. CONCLUSION: Patients with TECSA have high rates of postoperative complications, characterized by an increased rate of unplanned intensive care admissions and both high 30-day readmission and mortality rates. When dealing with these patients perioperative physicians should implement an increased level of respiratory monitoring, and early postoperative use of their home prescribed non-invasive ventilation devices.

Postoperative Outcomes of Patients With Obstructive Sleep Apnea Undergoing Cardiac Surgery.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications in noncardiac surgery, with limited literature on cardiac surgical patients. Perioperative outcomes of patients with OSA were compared with outcomes of those without OSA undergoing cardiac surgery. METHODS: This was a retrospective single-center cohort study of adults who underwent cardiac surgery from January 2010 to April 2017. Outcomes of patients with OSA were compared with those without OSA, including length of stay, readmissions, hospital death, and short-term outcomes. RESULTS: OSA was present in 2636 of 8612 patients (30.6%) identified during the study period with OSA. Patients with OSA had a longer median length of stay (6 vs 5 days, P < .001), longer incidence of prolonged (>7 days) length of stay (26.3% vs 23.0%, P < .001), and were less likely to be discharged to home (78.2% vs 84.4%, P < .001). OSA patients also had a higher 30-day readmission rate (14.7% vs 10.4%, P < .001). Acute kidney injury was more common in OSA patients (25.2% vs 19.9%, P < .001). Our multivariable model found postoperative atrial fibrillation was associated with older age and not OSA status (age <50 years compared with >75 years; odds ratio, 4.10; 95% confidence interval, 3.39-4.96). CONCLUSIONS: OSA patients had a longer mean length of stay, were more likely to have a prolonged length of stay, more likely to be discharged to a location other than home, and had a higher 30-day readmission rate. This suggests higher resource utilization is required to care for OSA patients after cardiac surgery.

Speaker Gender Representation for Anesthesiology Grand Rounds at a Large Academic Medical Center.

BACKGROUND: Invited speakerships, such as speaking at grand rounds, are part of the pathway to promotion in academic medicine. This project sought to evaluate if the gender of invited grand rounds speakers at a major academic institution were distributed as expected based on the specialty workforce. MATERIALS AND METHODS: Archived lists of speakers for grand rounds for the Mayo Clinic Department of Anesthesiology were obtained from 2007 through 2018. The Cochran-Armitage test and logistic regression models were used to analyze the change in proportion of invited women speakers over time. One-sample proportion tests were conducted to compare the proportion of women speakers to the expected percentage of available women speakers based on gender data from national organizations. RESULTS: Of the 122 invited external speakers, 28 (23%) were women. Men invited 104/122 (85.2%) of all the speakers, of which 21 (20.2%) were women speakers. There was not significant evidence the proportion of women speakers increased over time (P = .29). Women speakers comprised a lower proportion of external invited speakers compared to the proportion of women in the academic anesthesia workforce; however, this association was not statistically significant (P = .07). The percentage of new residents that were female increased over this time period (P = .001). DISCUSSION: The percentage of women invited to be grand rounds speakers did not increase over the study period. Intentional measures should be instituted to increase the proportion of women grand rounds speakers.

Peripheral electrical stimulation reduces postoperative hypoxemia in patients at risk for obstructive sleep apnea: a randomized-controlled trial.

PURPOSE: Severity of hypoxemic events resulting from obstructive sleep apnea (OSA) is correlated with increased risk of complications and sudden death. We studied the use of a peripheral transcutaneous electrical stimulus (TES) on the magnitude and duration of sleep apnea associated hypoxemia in postoperative patients at high risk for OSA. METHODS: In this randomized, double-blind, controlled, single-centre trial, 106 adult patients undergoing elective surgery who were at medium to high risk for OSA (sleep apnea clinical scores of 18-35) were randomized to either TES (active stimulus group, n = 53) or control (non-stimulus group, n = 53) during their stay in the postanesthesia care unit. Transcutaneous electrical stimuli were delivered at threshold oxygen saturation measurements (SpO2) ≤ 93%. The primary endpoint was the SpO2 area under the curve (AUC) < 90%. Secondary endpoints included the percentage of patients with SpO2 < 90%, duration SpO2 < 90%, lowest SpO2 in the first hour, and adverse events associated with TES. RESULTS: Compared with controls (n = 45), those in the active group (n = 34) showed a decreased SpO2 AUC < 90% (median 0.0 vs 15.2 % sec, respectively; P = 0.009), a smaller percentage of subjects with SpO2 < 90% (47% active vs 71% control; P = 0.03), a shorter duration of SpO2 < 90% (median 0.0 vs 19.1 sec, respectively; P = 0.01), and a higher nadir of SpO2 recorded during the first hour (median 90.5% vs 87.9%, respectively; P = 0.04). Among patients with at least one SpO2 < 93%, there were fewer with SpO2 < 90% in the active group (55% vs 84%, respectively; P = 0.009). No adverse events related to TES were reported. CONCLUSION: In postoperative surgical patients at risk for OSA, peripheral transcutaneous electrical stimulation applied during apneic episodes decreased the duration and magnitude of hypoxemia. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT02554110); registered 18 September, 2015.

Respiratory Depression Following Ambulatory Urogynecologic Procedures: A Retrospective Analysis.

OBJECTIVE: To assess the rate of postanesthesia respiratory depression (RD) and test for potential associations with clinical characteristics of patients undergoing urogynecologic procedures at ambulatory surgical centers (ASCs). Postanesthesia RD is poorly characterized for patients undergoing urogynecologic procedures in ASCs. PATIENTS AND METHODS: Health records of adult patients undergoing urogynecologic procedures at an ASC from July 1, 2010, through December 31, 2015, were abstracted. Cases complicated by RD were identified, and analyses of risk factors were performed with generalized estimating equations (GEE). RESULTS: During the study time frame, 9105 patients underwent 9141 procedures, of which RD complicated 221 cases (mean [95% confidence interval (CI)] complication rate per 100 cases, 2.4 [2.1-2.8]). Risk increased with advancing age, male sex, obstructive sleep apnea (OSA), morbid obesity, and use of volatile anesthetics and airway secured. Patients with RD had longer anesthesia recovery (median [interquartile range], 135 [110-166] vs 105 [80-138] minutes; P<.001). Within 48 postprocedural hours, 290 ED visits or hospitalizations occurred, but this risk was not increased by RD (adjusted odds ratio [95% CI], 0.62 [0.30-1.26]; P=.12). CONCLUSION: Postanesthesia RD after ambulatory urogynecologic procedures delay anesthesia recovery but are not associated with later complications. Patients with OSA or having other conditions related to OSA, or both, are at higher risk for RD.

Knowledge Gaps in the Perioperative Management of Adults With Narcolepsy: A Call for Further Research.

There is increasing awareness that sleep disorders may be associated with increased perioperative risk. The Society of Anesthesia and Sleep Medicine created the Narcolepsy Perioperative Task Force: (1) to investigate the current state of knowledge of the perioperative risk for patients with narcolepsy, (2) to determine the viability of developing perioperative guidelines for the management of patients with narcolepsy, and (3) to delineate future research goals and clinically relevant outcomes. The Narcolepsy Perioperative Task Force established that there is evidence for increased perioperative risk in patients with narcolepsy; however, this evidence is sparse and based on case reviews, case series, and retrospective reviews. Mechanistically, there are a number of potential mechanisms by which patients with narcolepsy could be at increased risk for perioperative complications. These include aggravation of the disease itself, dysautonomia, narcolepsy-related medications, anesthesia interactions, and withdrawal of narcolepsy-related medications. At this time, there is inadequate research to develop an expert consensus or guidelines for the perioperative management of patients with narcolepsy. The paucity of available literature highlights the critical need to determine if patients with narcolepsy are at an increased perioperative risk and to establish appropriate research protocols and clearly delineated patient-centered outcomes. There is a real need for collaborative research among sleep medicine specialists, surgeons, anesthesiologists, and perioperative providers. This future research will become the foundation for the development of guidelines, or at a minimum, a better understanding how to optimize the perioperative care of patients with narcolepsy.

Speaker Gender Representation at the American Society of Anesthesiology Annual Meeting: 2011-2016.

The American Society of Anesthesiologists (ASA) Annual Meeting is the primary venue for anesthesiologists to present research, share innovations, and build networks. Herein, we describe gender representation for physician speakers at the Annual Meeting relative to the specialty overall. Details of ASA Annual Meeting presentations for individuals and panels were abstracted from the ASA archives for 2011-2016. Observed speaker gender composition was compared to expected composition based on the gender distribution of members of the ASA. There were 5167 speaker slots across 2025 presentations and panels. Of the speaker slots, 3874 were assigned to men and 1293 to women. Speaker slot gender composition was relatively consistent between 2011 and 2016 (annual percentage 22.3%-27.7% women, trend test P = .062). ASA membership composition of women increased slightly over the study period (24%-28%). The overall observed number of women in speaker slots over the study period did not differ significantly from what would be expected based on the ASA membership composition (25.0% observed versus 25.9% expected; P = .153). However, the percentage of single speakers who were women was significantly less than would be expected based on the ASA gender distribution (20.2% observed versus 25.9% expected; P < .001). Interestingly, for panels that included 2-5 anesthesiologists, single-gender panels were more common than would be expected by chance, with all-male panels predominating (all P < .01). The gender composition of speakers at the ASA Annual Meeting largely reflected gender composition within the specialty, although women were not overrepresented at any meeting. The predominance of single-gender panels and underrepresentation of women as single speakers is a potential target to improve gender representation.

Preventing Opioid-Induced Respiratory Depression in the Hospitalized Patient With Obstructive Sleep Apnea.

PURPOSE: To enhance the role of nursing interventions in the management of perioperative opioid-induced respiratory depression (OIRD) in patients with obstructive sleep apnea (OSA). DESIGN: Narrative review of the literature. METHODS: Literature reviewed with emphasis on recommendations by professional and accrediting organizations. FINDINGS: Postsurgical OIRD increases hospital stay (55%), cost of care (47%), 30-day readmission (36%), and inpatient mortality (3.4 fold). OSA increases the risk of OIRD and may result in legal claims averaging $2.5 million per legal claim. CONCLUSIONS: Nursing interventions are essential to improving outcome and reduce cost in the management of postsurgical OIRD in OSA patients.