Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective.

BACKGROUND: The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations. METHODS: Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%). RESULTS: Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance. CONCLUSIONS: This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care.

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Complications Associated With Anesthesia Services in Endoscopic Procedures Among Patients With Cirrhosis.

BACKGROUND AND AIMS: Anesthesia services for endoscopic procedures have proliferated with the promise of increased comfort and safety. Cirrhosis patients are higher risk for sedation, yet limited data are available describing anesthesia complications in this population. APPROACH AND RESULTS: This cross-sectional study utilized the National Anesthesia Clinical Outcomes Registry, a multicenter quality-improvement database from 2010 to 2015. Patients with cirrhosis undergoing an endoscopy were identified by International Classification of Diseases, Ninth Revision (ICD-9)/Current Procedures Terminology (CPT) codes. The outcome of interest was serious anesthesia-related complication defined as cardiovascular, respiratory, neurological, drug related, patient injury, death, or unexpected admission. A mixed-effects multivariate logistic regression model determined odds ratios (ORs) between variables and serious complications, adjusting for potential confounders. In total, 9,007 endoscopic procedures were performed among patients with cirrhosis; 92% were esophagogastroduodenoscopies. The majority (81%) were American Society of Anesthesiologists (ASA) class ≥3, and 72% had a history of hepatic encephalopathy, ascites, varices, hepatorenal syndrome, or spontaneous bacterial peritonitis identified by ICD-9/CPT codes. In total, 87 complications were reported, 33 of which were serious. Frequency of serious complications was 0.4% or 378.6 per 100,000 procedures (95% confidence interval [CI], 260.8, 531.3). The majority of serious complications were cardiovascular (21 of 33), including 15 cardiac arrests. Serious complications were significantly associated with ASA 4/5 (OR, 3.84; 95% CI, 1.09, 13.57) and general anesthesia (OR, 4.71; 95% CI, 1.20, 18.50), adjusting for age, sex, ASA class, anesthesia type, inpatient status, portal hypertension history, and variable complication reporting practices. CONCLUSIONS: Anesthesia complications among endoscopic procedures in cirrhosis are rare overall. Serious complications were predominantly cardiac and associated with sicker patients undergoing general anesthesia. The complexity of end-stage liver disease may warrant more intensive care during endoscopic procedures, including anesthesia monitoring.

Nitrous oxide anesthetic versus total intravenous anesthesia for functional endoscopic sinus surgery.

BACKGROUND: Functional endoscopic sinus surgery is a common procedure for sinonasal disease, frequently performed in the outpatient setting. General anesthesia maintained with total intravenous anesthesia (TIVA) with propofol has been shown to give superior surgical conditions compared to inhaled anesthetics. This study evaluated the effects of TIVA versus a predominantly nitrous oxide (N2 O)-based anesthetic with a low-dose propofol and remifentanil infusion on sinus surgery. METHODS: Patients were randomized to either a N2 O-based (nitrous oxide with propofol and remifentanil) or TIVA (propofol and remifentanil without nitrous oxide) group. The surgeon was blinded to the anesthetic technique. Surgical field grading was performed in real time by the otolaryngologist every 15 minutes with the Boezaart grading system. RESULTS: There were no statistically significant differences between the Boezaart scores, duration of surgery, or estimated blood loss between the two anesthetic techniques. However, the use of N2 O provided a statistically significant, 38% reduction in time from surgery end to extubation. The TIVA group had significantly decreased mean and median pain scores in the post-anesthesia care unit (PACU). There was no difference in the rate of postoperative nausea and vomiting between the two groups. CONCLUSION: A N2 O-based anesthetic for functional endoscopic sinus surgery provides similar intraoperative and postoperative conditions when compared to TIVA, while being superior in terms of time to extubation. Although the TIVA group had significantly decreased pain scores, this did not lead to a decrease in pain medicine received in the PACU, and there was no difference between groups in time to discharge. LEVEL OF EVIDENCE: 1b Laryngoscope, 130:E299-E304, 2020.

Complications of Anesthesia Services in Gastrointestinal Endoscopic Procedures.

BACKGROUND & AIMS: Despite the increased use of anesthesia services for endoscopic procedures in the United States, the risks of anesthesia-directed sedation (ADS) are unclear. We analyzed national data from multiple centers to determine patterns of use of anesthesia services and risk factors for serious complications. METHODS: We performed a cross-sectional study using the National Anesthesia Clinical Outcomes Registry, a national quality improvement database. Univariable and bivariate analyses investigated frequencies and relationships between predefined variables and serious complications of anesthesia (cardiovascular, respiratory, neurologic, drug-related, patient injury, death, or unexpected admission). A multivariable mixed-effects model determined the odds ratios between these variables and serious complications, adjusting for confounders and varying reporting practices. RESULTS: In total, 428,947 endoscopic procedures of adults were performed using ADS from 2010 to 2015. The population was 54.9% female with a mean age of 59.1 years, and predominantly American Society of Anesthesiologists classes 2 and 3 (74.4%). More than half of the procedures were colonoscopies (51.4%); 37.4% were esophagogastroduodenoscopies and 6.5% were endoscopic retrograde cholangiopancreatographies. A total of 4441 complications (1.09%) were reported; 1349 were serious complications (0.34%). In multivariable analysis, older age, American Society of Anesthesiologists classes 4 and 5, esophagogastroduodenoscopy, general anesthesia, cases performed on an overnight shift, and longer cases were associated independently and significantly with serious complications. CONCLUSIONS: In an analysis of data from the National Anesthesia Clinical Outcomes Registry, we found ADS during endoscopy to be safe, with few serious complications (<1% of procedures). Risk of ADS complications increased with older age, more severe disease, procedure type, and case complexity.

Tissue oximetry during cardiac surgery and in the cardiac intensive care unit: A prospective observational trial.

BACKGROUND: Cerebral oximetry using near-infrared spectroscopy (NIRS) has well-documented benefits during cardiac surgery. The authors tested the hypothesis that NIRS technology can be used at other sites as a tissue oximeter during cardiac surgery and in the Intensive Care Unit (ICU). AIMS: To establish feasibility of monitoring tissue oximetry during and after cardiac surgery, to examine the correlations between tissue oximetry values and cerebral oximetry values, and to examine correlations between oximetry values and mean arterial pressure (MAP) in order to test whether cerebral oximetry can be used as an index organ. SETTINGS AND DESIGNS: A large, single-center tertiary care university hospital prospective observational trial of 31 patients undergoing cardiac surgery with cardiopulmonary bypass was conducted. MATERIALS AND METHODS: Oximetry stickers were applied to both sides of the forehead, the nonarterial line forearm, and the skin above one paraspinal muscle. Data were collected from before anesthesia induction until extubation or for at least 24 h in patients who remained intubated. STATISTICAL ANALYSIS: Categorical variables were evaluated with Chi-square or Fisher's exact tests, while Wilcoxon rank-sum tests or student's t-tests were used for continuous variables. RESULTS: The correlation between cerebral oximetry values and back oximetry values ranged from r = 0.37 to 0.40. The correlation between cerebral oximetry values and forearm oximetry values ranged from r = 0.11 to 0.13. None of the sites correlated with MAP. CONCLUSIONS: Tissue oximetry at the paraspinal muscle correlates with cerebral oximetry values while at the arm does not. Further research is needed to evaluate the role of tissue oximetry on outcomes such as acute renal failure, prolonged need for mechanical ventilation, stroke, vascular ischemic complications, prolonged ICU and hospital length of stay, and mortality in cardiac surgery.

Robotic-assisted thoracoscopic lung surgery: anesthetic impact and perioperative experience.

Anesthesiologists and the perioperative team have a tremendous impact upon clinical outcomes in robotic-assisted thoracoscopic surgery. As anesthesiology is developing its role outside the operating room, the patient population benefits from an expanded focus on perioperative critical care and pain management. This article focuses upon the preoperative optimization, unique intraoperative considerations for surgeons and anesthesiologists, and postoperative management of patients undergoing robotic-assisted thoracoscopic surgery.

Simulated Mortality-We Can Do More.

High-fidelity simulation (HFS) is a relatively new teaching modality, which is gaining widespread acceptance in medical education. To date, dozens of studies have proven the usefulness of HFS in improving student, resident, and attending physician performance, with similar results in the allied health fields. Although many studies have analyzed the utility of simulation, few have investigated why it works. A recent study illustrated that permissive failure, leading to simulated mortality, is one HFS method that can improve long-term performance. Critics maintain, however, that the use of simulated death is troubling and excessive. Given the controversy regarding simulated death, we consider the data about the educational value and the emotional harms associated with them, expecting that evidence could be useful in resolving the question. The goal of this narrative review is to explore the argument against simulated mortality and provide educators with an imperative as to why it can be safely utilized.

Can we reduce anesthesia exposure? Neonatal brain MRI: Swaddling vs. sedation, a national survey.

STUDY OBJECTIVE: Neonatal magnetic resonance imaging (MRI) is a diagnostic modality that requires minimal motion to acquire quality images. Sedation or even general anesthesia may be necessary to achieve acceptable scans. There is a growing body of literature, especially in animal studies, that links neurotoxicity with anesthetic exposure to the developing brain. There is no study outlining strategies used by neonatal intensive care units (NICU) to achieve quality MRI images with limited exposure to medications identified as possibly harmful to the developing brain. DESIGN: A 15-question survey was sent to all NICU programs in the United States (US) with fellowship programs. SETTING: MRI suite. PATIENTS: Neonates. INTERVENTIONS: None. MEASUREMENTS: The programs were queried regarding their preferred method for obtaining MRIs of the brain and how successful they were in obtaining quality images. MAIN RESULTS: Of the 96 programs surveyed, 58 responded (response rate of 60%). To obtain brain MRIs, 64%(n=37) used feed and swaddle; 32% (n=19) use sedation; and 3% (n=2) used general anesthesia (GA). Success rate of obtaining quality MRI images varied by technique. In the feed and swaddle group, 81% reported that a failure to obtain useful images occurred <25%; 11% reported that it occurred 25-75%; and 5% reported that it occurred >75%. In the sedation and GA group, 100% reported failure to obtain useful images occurred rarely. CONCLUSIONS: The majority of NICUs in the US that responded to the survey utilized feed and swaddle as their primary technique for obtaining MRIs of the brain and reported a high success rate. Given the growing concern over the possible neurotoxic effects of anesthetic drugs on the developing brain, more centers should consider this technique as a first line method to obtain brain MRIs, with sedation and GA reserved for failed feed and swaddle attempts and special circumstances.

Impact of the Zika Virus for Anesthesiologists: A Review of Current Literature and Practices.

Zika virus disease is of growing concern to all clinicians. There is a growing concern with regards to the neurologic sequela of the virus, particularly for infants born to women infected while pregnant. The continued spread of this virus throughout North and South America requires all anesthesiologists to maintain vigilance on this issue. This article addresses some of the key issues that pertain to anesthesiologists with regards to the Zika virus including the risks of perioperative management of patients with Zika virus. A discussion of the risks of transfusion and current blood management practices also is included in this review.

Death During Simulation: A Literature Review.

INTRODUCTION: One of the goals of simulation is to teach subjects critical skills and knowledge applicable to live encounters, without the risk of harming actual patients. Although simulation education has surged in medical training over the last two decades, several ethically challenging educational methods have arisen. Simulated death has arisen as one of these challenging issues and currently there is no consensus regarding how to best manage this controversial topic in the simulated environment. The goal of this review is to analyze how simulated mortality has been used and discover whether or not this tool is beneficial to learners. METHODS: In May 2016, the authors performed a literature search on both Pubmed and the Cochrane database using multiple variations of keywords; they then searched bibliographies and related articles. RESULTS: There were 901 articles acquired in the initial search. The authors eliminated articles that were not relevant to the subject matter. After adding articles from bibliographies and related articles, the authors included the 43 articles cited in this article. DISCUSSION: As a result, the authors of this article believe that death, when used appropriately in simulation, can be an effective teaching tool and can be used in a responsible manner.

BILATERAL SUPERFICIAL CERVICAL BLOCKS AS THE PRIMARY ANESTHETIC FOR THE PATIENT UNDERGOING AN EVACUATION OF NECK HEMATOMA AFTER PARATHYROID SURGERY.

This is the case of an 80-year-old female who presented for evacuation of a neck hematoma on POD#3 after a parathyroidectomy. Her medical history included coronary artery disease with a drug-eluding stent, off aspirin for 2 weeks. She had a significant hematoma from the hyoid bone extending down to below the suprasternal notch. She reported hoarseness. The anesthesiology team provided regional anesthesia with bilateral superficial cervical blocks, supplemented with minimal sedation for patient compliance. The surgical team used no adjuvant local anesthetic. A deep exploration was performed and significant clot was evacuated. The patient went home safely from the PACU.

The efficacies of cell-penetrating peptides in accumulating in large unilamellar vesicles depend on their ability to form inverted micelles.

In this study, the direct translocation of cell-penetrating peptides (CPPs) into large unilamellar vesicles (LUVs) was shown to be rapid for all the most commonly used CPPs. This translocation led within a few minutes to intravesicular accumulation up to 0.5 mM, with no need for a transbilayer potential. The accumulation of CPPs inside LUVs was found to depend on CPP sequence, CPP extravesicular concentration and phospholipid (PL) composition, either in binary or ternary mixtures of PLs. More interestingly, the role of anionic phospholipid flip-flopping in the translocation process was ascertained. CPPs enhanced the flipping of PLs, and the intravesicular CPP accumulation directly correlated with the amount of anionic PLs that had been transferred from the external to the internal leaflet of the LUV bilayer, thus demonstrating the transport of peptide/lipid complexes as inverted micelles.

Assessment of liver transplant donor biopsies for steatosis using frozen section: accuracy and possible impact on transplantation.

BACKGROUND: Pre-transplant frozen section evaluation for macrovesicular steatosis has long been used as a guide for donor liver utility, but may not agree with the permanent section evaluation. This study sought to evaluate the accuracy of frozen section in an active transplant service. METHODS: Retrospective review of cases where frozen section analysis was undertaken to assess percent macrovesicular steatosis was performed, comparing the frozen section diagnosis to the final diagnosis. RESULTS: Ninety-six cases were available for review. In 7 of these cases (7%), the difference between the two slides was significant; that is, the difference between the two slides may have contributed to a change in clinical management at a cutoff of 30%. CONCLUSIONS: Clinicians need to be aware that accuracy is satisfactory in experienced hands but some discrepancies may occur. KEYWORDS: Liver; Steatosis; Pathology.