Assessing Practice Variation of Anesthetic Management for Endovascular Thrombectomy in Acute Ischemic Stroke: A Comprehensive Multicenter Survey.

OBJECTIVE: This study explored the current global landscape of periprocedural care of acute ischemic stroke patients undergoing endovascular thrombectomy (EVT). METHODS: An anonymous, 54-question electronic survey was sent to 354 recipients in hospitals worldwide. The responses were stratified by World Bank country income level into high-income (HICs) and low/middle-income (LMICs) countries. RESULTS: A total of 354 survey invitations were issued. Two hundred twenty-three respondents started the survey, and 87 fully completed surveys were obtained from centers in which anesthesiologists were routinely involved in EVT care (38 in HICs; 49 in LMICs). Respondents from 35 (92.1%) HICs and 14 (28.6%) LMICs reported that their centers performed >50 EVTs annually. Respondents from both HICs and LMICs reported low rates of anesthesiologist involvement in pre-EVT care, though a communication system was in place in 100% of HIC centers and 85.7% of LMIC centers to inform anesthesiologists about potential EVTs. Respondents from 71.1% of HIC centers and 51% of LMIC centers reported following a published guideline during EVT management, though the use of cognitive aids was low in both (28.9% and 24.5% in HICs and LMICs, respectively). Variability in multiple areas of practice, including choice of anesthetic techniques, monitoring and management of physiological variables during EVT, and monitoring during intrahospital transport, were reported. Quality metrics were rarely tracked or reported to the anesthesiology teams. CONCLUSIONS: This study demonstrated variability in anesthesiology involvement and in clinical care during and after EVT. Centers may consider routinely involving anesthesiologists in pre-EVT care, using evidence-based recommendations for EVT management, and tracking adherence to published guidelines and other quality metrics.

The impact of an anesthesia residency teaching service on anesthesia-controlled time and postsurgical patient outcomes: a retrospective observational study on 15,084 surgical cases.

BACKGROUND: Limited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality. METHODS: This retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes. RESULTS: A total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7-32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7-29.5]), and attending-only surgical cases (21.0 [17.9-25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients. CONCLUSION: Anesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants.

T2-weighted Imaging Hyperintensity and Transcranial Motor-evoked Potentials During Cervical Spine Surgery: Effects of Sevoflurane in 150 Consecutive Cases.

BACKGROUND: There is debate on the impact of inhalational esthetic agents on transcranial motor evoked potentials (TcMEPs) during intraoperative neuromonitoring. Current guidelines advise their avoidance, which contrasts with common clinical practice. METHODS: This retrospective cohort study of 150 consecutive cervical spine surgeries at a single institution compared stimulation voltages and TcMEP amplitudes in patients who did and did not receive sevoflurane as part of a balanced anesthetic technique. Patients were divided into 3 groups stratified by the presence or absence of increased signal intensity within the cervical spinal cord on T2-weighted magnetic resonance imaging (indicative or myelopathy/spinal cord injury [SCI]) and sevoflurane use. RESULTS: Patients with no magnetic resonance imaging evidence of myelopathy/SCI that received sevoflurane (n=80) had the lowest stimulation voltages and largest TcMEP amplitude responses in the lower extremities compared with those with no magnetic resonance imaging evidence of myelopathy/SCI (n=30). In patients with evidence of myelopathy/SCI who did not receive sevoflurane (n=19), lower extremity TcMEP amplitudes were similar to patients with a myelopathy/SCI that received sevoflurane. Six of these 19 patients had initial low-dose sevoflurane discontinued because of concerns of low/absent baseline TcMEP amplitudes. CONCLUSIONS: Balanced anesthesia with 0.5 MAC sevoflurane in patients with and without radiological evidence of myelopathy/SCI allows reliable TcMEP monitoring. However, in communication with surgical and neuromonitoring teams, it may be advisable in a subset of patients to avoid or discontinue sevoflurane in favor of a propofol/opioid-based anesthetic to ensure adequate and reproducible TcMEPs.

Suspected Buprenorphine-Precipitated Opioid Withdrawal following Intercourse: A Case Report.

Buprenorphine, a partial mu-opioid receptor agonist, is a commonly prescribed medication for opioid use disorder (OUD). There is evidence that drugs may enter the male genitourinary tract by an ion-trapping process, based on the lipid solubility and degree of ionization (1). While little is known about the pharmacokinetics of drugs in seminal fluid, pH is thought to play an integral role. Limited evidence exists surrounding cervical absorption of drugs via seminal fluid transmission. This also prompts survey of the frequency of this event and the influence on treatment within this population.

Anesthesia, Blood Pressure, and Socioeconomic Status in Endovascular Thrombectomy for Acute Stroke: A Single Center Retrospective Case Cohort.

INTRODUCTION: Mechanical thrombectomy (MT) is standard for acute ischemic stroke (AIS), with early studies suggesting that general anesthesia (GA) is associated with worse outcomes than monitored anesthesia care (MAC). Socioeconomic deprivation is also a risk factor for worse AIS outcomes. With improvements in MT and blood pressure (BP) management, it remains unclear if GA or socioeconomic deprivation are risk factors for worse outcomes after MT. METHODS: We retrospectively analyzed 125 consecutive AIS patients presenting for MT at a comprehensive stroke center serving patients with high levels of socioeconomic deprivation. The primary objective was impact of GA versus MAC on functional independence at 90 days. Secondary outcomes included procedural BP, and impact of BP and socioeconomic deprivation (assessed by the area of deprivation index) on outcomes. RESULTS: A 90-day outcomes were similar in patients undergoing MT with GA or MAC. The area of deprivation index was similar in GA and MAC groups and in patients with good versus poor 90-day outcomes. There were similar numbers of patients with mean arterial pressure (MAP) <60 mm Hg in the MAC and GA groups (8 vs. 11; P =0.21), but more patients with MAP <70 mm Hg in the GA group (28 vs. 9; P <0.001). Median (interquartile range) duration of MAP <70 mm Hg was 10 (5 to 15) and 20 (10 to 36) minutes in the MAC and GA groups, respectively ( P <0.001); however, these MAPs were not associated with worse 90-day outcomes. CONCLUSION: Anesthesia and MAP did not affect MT outcomes. The cohort is unique based on an area of deprivation index in the higher deciles in the United States. While the area of deprivation index was not associated with worse outcomes, further study is warranted.

Liposomal compared to 0.25% bupivacaine in patients undergoing hemorrhoidectomy: A pre- and post-implementation quality improvement evaluation.

STUDY OBJECTIVE: The efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures. DESIGN: A pre- and post-implementation quality improvement evaluation. SETTING: Operating room and post-anesthesia care unit. PATIENTS: Ninety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020. INTERVENTIONS: A preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration. MEASUREMENTS: The primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery. MAIN RESULTS: PACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0-6] vs. 0 [IQR 0-4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10-23] vs. 15 [IQR 15-25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07). CONCLUSIONS: Liposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups.

A Unique Treatment for Compartment Syndrome After Intravenous Catheter Extravasation: A Case Report.

Intravenous cannulation is performed on nearly every patient presenting for an anesthetic. Complications of the procedure include infiltration and extravasation, which can have a varied impact on the patient. Here, we present a case of severe intravenous (IV) extravasation, resulting in compartment syndrome of the hand. Rather than treating the compartment syndrome with fasciotomies as is standard, we utilized compression therapy via an Esmarch surgical dressing wrapped distal to proximal on the effected limb, which resulted in marked decrease in swelling and return of perfusion to the hand.

Improving intraoperative temperature management in elective repeat cesarean deliveries: a retrospective observational cohort study.

BACKGROUND: Inadvertent perioperative hypothermia (< 36 °C) occurs frequently during elective cesarean delivery and most institutions do employ perioperative active warming. The purpose of this retrospective observational cohort study was to determine if the addition of preoperative forced air warming in conjunction with intraoperative underbody forced air warming improved core temperature and reducing inadvertent perioperative hypothermia during elective repeat elective cesarean delivery with neuraxial anesthesia. METHODS: We evaluated the addition of perioperative active warming to standard passive warming methods (preheated intravenous/irrigation fluids and cotton blankets) in 120 parturients scheduled for repeat elective cesarean delivery (passive warming, n = 60 vs. active + passive warming, n = 60) in a retrospective observational cohort study. The primary outcomes of interest were core temperature at the end of the procedure and a decrease in inadvertent perioperative hypothermia (< 36 °C). Secondary outcomes were surgical site infections and adverse markers of neonatal outcome. RESULTS: The mean temperature at the end of surgery after instituting the active warming protocol was 36.0 ± 0.5 °C (mean ± SD, 95% CI 35.9-36.1) vs. 35.4 ± 0.5 °C (mean ± SD, 95% CI 35.3-35.5) compared to passive warming techniques (p <  0.001) and the incidence of inadvertent perioperative hypothermia at the end of the procedure was less in the active warming group - 68% versus 92% in the control group (p <  0.001). There was no difference in surgical site infections or neonatal outcomes. CONCLUSIONS: Perioperative active warming in combination with passive warming techniques was associated with a higher maternal temperature and lower incidence of inadvertent perioperative hypothermia with no detectable differences in surgical site infections or indicators of adverse neonatal outcomes.

Cognitive Aids for the Diagnosis and Treatment of Neuroanesthetic Emergencies: Consensus Guidelines on Behalf of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Education Committee.

Cognitive aids and evidence-based checklists are frequently utilized in complex situations across many disciplines and sectors. The purpose of such aids is not simply to provide instruction so as to fulfill a task, but rather to ensure that all contingencies related to the emergency are considered and accounted for and that the task at hand is completed fully, despite possible distractions. Furthermore, utilization of a checklist enhances communication to all team members by allowing all stakeholders to know and understand exactly what is occurring, what has been accomplished, and what remains to be done. Here we present a set of evidence-based critical event cognitive aids for neuroanesthesia emergencies developed by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Education Committee.

Comparison of single-injection ultrasound-guided approach versus multilevel landmark-based approach for thoracic paravertebral blockade for breast tumor resection: a retrospective analysis at a tertiary care teaching institution.

BACKGROUND: The role of thoracic paravertebral blockade (TPVB) in decreasing opioid requirements in breast cancer surgery is well documented, and there is mounting evidence that this may improve survival and reduce the rate of malignancy recurrence following cancer-related mastectomy. We compared the two techniques currently in use at our institution, the anatomic landmark-guided (ALG) multilevel versus an ultrasound-guided (USG) single injection, to determine an optimal technique. METHODS: We retrospectively reviewed records of patients who received TPVB from January 2013 to December 2014. Perioperative opioid use, post anesthesia care unit (PACU) pain scores and length of stay, block performance, and complications were compared between the two groups. RESULTS: We found no statistical difference between the two approaches in the studied outcomes. We did find that the number of times attending physicians in the ALG group took over the blocks from residents was significantly greater than that of the USG group (p=0.006) and more local anesthetic was used in the USG group (p=0.04). CONCLUSION: This study compared the ALG approach with the USG approach for patients undergoing mastectomy for breast cancer. Based on our observations, an attending physician is more likely to take over an ALG injection, and more local anesthetic is administered during USG single injection.

Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care.

External ventricular drains and lumbar drains are commonly used to divert cerebrospinal fluid and to measure cerebrospinal fluid pressure. Although commonly encountered in the perioperative setting and critical for the care of neurosurgical patients, there are no guidelines regarding their management in the perioperative period. To address this gap in the literature, The Society for Neuroscience in Anesthesiology & Critical Care tasked an expert group to generate evidence-based guidelines. The document generated targets clinicians involved in perioperative care of patients with indwelling external ventricular and lumbar drains.