A post-COVID syndrome curriculum for continuing medical education (CME): in-person versus livestream.

Background: Nearly 30% of patients with COVID-19 infection develop post-COVID Syndrome. Knowledge of post-COVID Syndrome is evolving, creating the need for adaptable curricula. Flipped classrooms (FC) are flexible and dynamic with demonstrated utility in continuing medical education (CME), yet there has been no research on application of FCs, or comparisons between livestream and in-person learning, in post-COVID CME. Methods: We implemented a novel post-COVID curriculum using FCs for in-person and livestream participants at four Mayo Clinic CME conferences. Outcomes were validated measures of knowledge; perceptions of FCs and CME teacher effectiveness; and learner engagement. Pre-conferences surveys were a post-COVID knowledge test and the Flipped Classroom Perception Inventory (FCPI). Post-conference surveys were a post-COVID knowledge test, the FCPI, the CME Teaching Effectiveness Instrument (CMETE), and the Learner Engagement Inventory (LEI). Pre-post knowledge and FCPI scores were analyzed using linear mixed models. CMETE and LEI were compared for in-person versus livestream participants using the Wilcoxon rank-sum test. Results: Overall, 59 participants completed the pre-test, and 72 participants completed the post-test, surveys. Participants were predominantly female (58%), were in nonacademic group practices (65%), and lacked prior experience with flipped classrooms (83%). Following the presentations, participants showed significant improvements in post-COVID knowledge (47% correct precourse to 54% correct postcourse, p-value = 0.004), and a trend toward improved FCPI scores. Teaching effectiveness, learner engagement, and pre-post change in COVID knowledge did not differ significantly between participants of in-person versus livestream sessions. Conclusion: This post-COVID FC curriculum was feasible and associated with improved knowledge scores among a diverse population of physician learners in CME, without any apparent compromise in learner engagement, or in perceptions of teaching effectiveness and FCs, among livestream versus in-person participants.

Regional cerebral oxygen saturation variability and brain injury in preterm infants.

Objective: To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants. Study design: A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury. Results: The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury. Conclusions: In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.

Associations Between Oversedation and Agitation in Postanesthesia Recovery Room and Subsequent Severe Behavioral Emergencies.

OBJECTIVES: Hospital-based behavioral emergency response teams (BERT) respond to acute behavioral disturbances among hospitalized patients. We aimed to examine associations between altered mental status in postanesthesia care unit (PACU) and behavioral disturbances on surgical wards requiring BERT activation. METHODS: Electronic medical records of patients who underwent general anesthesia and were admitted to the PACU between May 2018-December 2020 were reviewed for episodes of BERT activations on surgical wards. Characteristics of BERT patients were compared with the rest of surgical population during the same period to examine risk factors for BERT. RESULTS: Of 56,275 adult surgical patients, 133 patients had 178 BERT activations (incidence 2.4, 95% confidence interval [CI] 2.0-2.8 per 1000 admissions), with 21 being for physical assault. The risk for BERT activation was increased with each decade over age of 50 as well as younger age (30 versus 50 y), male sex (odds ratio [OR] = 2.48, 95% CI 1.69, 3.62), longer procedures (OR = 1.08 per 30 minutes, 95% CI 1.05, 1.11), and alterations in mental status in PACU, with both moderate/deep sedation (OR = 1.63, 95% CI 1.04, 2.57) and agitation/combative state (OR = 8.47, 95% CI 5.13, 14.01), P < 0.001 for all comparisons. CONCLUSIONS: Early postoperative agitation and oversedation are associated with BERT activation on surgical wards. Altered mental status in PACU should be conveyed to accepting hospital units so healthcare staff can be vigilant for the potential development of behavioral disturbances.

Anesthetic recovery outcomes after 2 methods of nasal mucosal preparation for endoscopic sinus surgery.

PURPOSE: Our institution uses two approaches for nasal mucosal preparation during endoscopic sinus surgery (ESS) to improve surgical field visualization: topical epinephrine (TE) versus topical cocaine with injection of lidocaine containing epinephrine (TCLE). We aimed to compare anesthetic outcomes after ESS using these techniques. METHODS AND MATERIALS: We retrospectively identified adult patients at our institution who underwent ESS from May 2018 through January 2023 under general anesthesia with propofol and remifentanil infusions. Postoperative anesthetic outcomes, including pain and recovery time, were compared between patients who had mucosal preparation with TE versus TCLE using inverse probability of treatment weighting (IPTW) to adjust for potential confounders. RESULTS: Among 1449 patients who underwent ESS, 585 had TE, and 864 had TCLE. Compared with TE, during anesthetic recovery, the TCLE group had fewer episodes of severe pain (numeric pain score ≥ 7) (IPTW-adjusted odds ratio, 0.65; 95 % CI, 0.49-0.85; P = .002), less opioid analgesic administration (IPTW-adjusted odds ratio, 0.55; 95 % CI, 0.44-0.69; P < .001), and shorter recovery room stay (IPTW-adjusted ratio of the geometric mean, 0.90; 95 % CI, 0.85-0.96; P = .002). Postoperative nausea and vomiting and postoperative sedation were similar between groups. CONCLUSIONS: Patients who received preparation of the nasal mucosa with TCLE, compared with TE, were less likely to report severe pain or receive an opioid analgesic in the postanesthesia recovery room and had faster anesthetic recovery. This observation from our large clinical practice indicates that use topical and local anesthetic during endoscopic sinus surgery may have benefit for ambulatory ESS patients.

Postoperative Sedation in General Care Wards: A Retrospective Cohort Study.

BACKGROUND: We hypothesized that deeper sedation in the postanesthesia care unit (PACU) increases the risk of subsequent sedation in general care wards (ward sedation) and that patients with ward sedation have more postoperative adverse events than those without ward sedation. METHODS: We reviewed the health records of adult patients who underwent procedures with general anesthesia at Mayo Clinic from May 5, 2018, through December 31, 2020, and were discharged from the PACU to the general care ward. Patient groups were dichotomized as with ward sedation (Richmond Agitation-Sedation Scale [RASS], ≤-2) and without ward sedation (RASS, ≥-1) within the first 24 hours after PACU discharge. Multivariable logistic regression was used to assess the association between clinical variables and ward sedation. RESULTS: A total of 23,766 patients were included in our analysis, of whom 1131 had ward sedation (incidence, 4.8 [Poisson 95% confidence interval, CI, 4.5-5.0]) per 100 patients after general anesthesia. Half of the ward sedation episodes occurred within 32 minutes after PACU discharge. The risk of ward sedation increased with the depth of PACU sedation. The odds ratios (95% CI) of ward sedation for patients with a PACU RASS score of -1 was 0.98 (0.75-1.27); -2, 1.87 (1.44-2.43); -3, 2.98 (2.26-3.93); and ≤-4, 3.97 (2.91-5.42). Adverse events requiring an emergency intervention occurred more often for patients with ward sedation (n = 92, 8.1%) than for those without ward sedation (n = 326, 1.4%; P < .001). CONCLUSIONS: Among patients who met our criteria for PACU discharge, deeper sedation during anesthesia recovery was associated with an increased risk of ward sedation. Patients who had ward sedation had worse outcomes than those without ward sedation.

Longitudinal Progression of Patients with Long COVID Treated in a Post-COVID Clinic: A Cross-Sectional Survey.

BACKGROUND: In addition to the morbidity and mortality associated with acute infection, COVID-19 has been associated with persistent symptoms (>30 days), often referred to as Long COVID (LC). LC symptoms often cluster into phenotypes, resembling conditions such as fibromyalgia, postural orthostatic tachycardiac syndrome (POTS), and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). LC clinics have been established to best address the needs of LC patients and continuity of care. We developed a cross-sectional survey to assess treatment response through our LC Clinic (LCC). METHODS: A 25-question survey (1-10 Likert scale) was expert- and content-validated by LCC clinicians, patients, and patient advocates. The survey assessed LC symptoms and the helpfulness of different interventions, including medications and supplements. A total of 852 LCC patients were asked to complete the survey, with 536 (62.9%) responding. RESULTS: The mean time from associated COVID-19 infection to survey completion was 23.2 ± 6.4 months. The mean age of responders was 52.3 ± 14.1 (63% females). Self-reported symptoms were all significantly improved (P < .001) from the initial visit to the LCC (baseline) to the time of the follow-up survey. However, only 4.5% (24/536) of patients rated all symptoms low (1-2) at the time of the survey, indicating low levels of full recovery in our cohort. The patients rated numerous interventions as being helpful, including low-dose naltrexone (45/77; 58%), vagal nerve stimulation (18/34; 53%), and fisetin (28/44; 64%). CONCLUSIONS: Patients report general improvements in symptoms following the initial LCC visit, but complete recovery rates remain low at 23.2 ± 6.4 months.

Managing the Lactating Patient Receiving Anesthesia: An Innovative Educational Initiative.

Background: Breastfeeding has numerous health benefits for patients and their infants. There are inconsistencies in how anesthesia providers care for lactating patients undergoing anesthesia. Providers may be cautious and have patients "pump and dump" instead of following current evidence-based recommendations. Video-based education provides a novel reference for health care providers in their fast-paced work environments. This project evaluated the effectiveness of an online video module and resources accessed at the bedside for anesthesia providers caring for lactating patients. Materials and Methods: A preintervention survey was sent to anesthesia providers at a large academic institution to assess baseline knowledge of current recommendations for caring for lactating patients having anesthesia. A quick response code-linked video module and references were created and disseminated to all anesthesia providers. A postsurvey was sent to assess knowledge and satisfaction with the educational approach. Postsurvey data were compared with presurvey data. Results: All who watched the educational video found the education helpful to care for lactating patients undergoing surgery. In the posteducation group, 93% of providers selected the correct recommendation to continue breastfeeding or pumping after general anesthesia or sedation once the patient is awake and alert, compared with 48% in the pre-education group. After education, 92% would recommend preoperative feeding or pumping prior to transport to the operating room, compared with the 50% in the pre-education group. Conclusions: Video-based, just-in-time education is an effective way to deliver updated information to anesthesia providers. This format is conducive to just-in-time delivery, and there may be implications for other patient populations that present infrequently but require population-specific care.

Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia: A Retrospective Cohort Study.

BACKGROUND: Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU). METHODS: We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics. RESULTS: Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 µg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56). CONCLUSIONS: The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.