A Case Report of Acute Onset and Rapid Resolution of Atrioventricular Block After Sugammadex: Is the Autonomic System Involved?

Administering sugammadex to reverse neuromuscular blockade can cause marked bradycardia and rarely asystole. In this case, a rapid onset, biphasic heart rate response; slowing then speeding, after administering sugammadex was noted while at steady state, 1.3% end-tidal sevoflurane. On review of the electrocardiogram (ECG), the heart rate slowing coincided with the onset of a second-degree, Mobitz type I block that lasted 45 seconds. No other events, drugs, or stimuli coincided with the event. The acute onset and transient nature of the atrioventricular block without evidence of ischemia implies a brief parasympathetic effect on the atrioventricular node after sugammadex administration.

Perception of Burnout and Its Impact on Academic Hospitalists During COVID-19 and Institutional Strategies to Combat Burnout and Improve Wellness.

INTRODUCTION: Physician burnout has been alarmingly high, particularly among general internal medicine, which displays some of the highest rates. A recent study of academic hospitalists reported a higher level of burnout (62%) than the rates found in similar studies, but with agreement about factors leading to burnout, consequences of burnout, and importance of steps to prevent burnout. This study seeks to expand upon these results by investigating the impact of COVID-19 on burnout among hospitalists and uncovering the perspectives of frontline clinicians to formulate effective mitigation strategies. METHODS: Academic hospitalists were recruited to participate in a series of focus group interviews. The questions focused on contributors to burnout, the impact of COVID-19, and strategies to improve wellness and reduce burnout. The focus groups were audio-recorded, transcribed, and coded for emergent themes using Taguette, an open-source qualitative data analysis software. RESULTS: Burnout-inducing themes included workload, bureaucratic hurdles, and lack of control. COVID-19-specific themes included fear of exposing family and social isolation. The most common mitigation strategy was to increase social interactions to foster a sense of community. Additional solutions included adhering to a census cap of patients, streamlining clinical work, and providing avenues for two-way communication between leadership and clinicians to share concerns and elicit feedback. CONCLUSIONS: Streamlining clinical work allows more time for patient care. Enhancing community and fostering collaboration in decision-making allows clinicians to feel more empowered. A crucial first step to combat burnout is to encourage a work environment that values clinician well-being and proactively works to increase job satisfaction.

Muslims, Islam, and Organ Donation: Righting Social Narratives and Designing Ethically Balanced Educational Interventions.

The popular narrative about Muslims and organ donation, especially about Muslims in the diaspora, is that Muslims have unfavorable sentiments about organ donation. Furthermore, this skepticism is associated with Islam in the sense that pious Muslims are regarded to be more averse to organ donation, and Islamic edicts that judge organ donation to be religiously forbidden are thought to be erroneous. Based on this narrative, public health leaders encourage organ donation by teaching Muslims about the social advantages of organ donation and linking these advantages to religious edicts that consider organ donation to be lawful. We examined the factual and moral foundations of this narrative of Muslims, Islam, and organ donation. Our analysis demonstrated that the narrative is undermined by methodological flaws in existing empirical research and misconceptions of Islamic normativity. We contend that Muslim concerns about organ donation extend beyond whether it is religiously allowed and that contextual circumstances produce diverse and equally acceptable Islamic viewpoints on organ donation. As a result, we advocate that educational initiatives aid informed decision-making by debunking misunderstandings about organ donation and promoting plurality of Islamic ethicolegal positions on the practice.

Characterizing the Heart Rate Effects From Administration of Sugammadex to Reverse Neuromuscular Blockade: An Observational Study in Patients.

BACKGROUND: Reversal of neuromuscular blockade (NMB) with sugammadex can cause marked bradycardia and asystole. Administration of sugammadex typically occurs in a dynamic period when anesthetic adjuvants and gas concentrations are being titrated to achieve emergence. This evaluation examined the heart rate (HR) responses to sugammadex to reverse moderate to deep NMB during a steady-state period and sought mechanisms for HR changes. METHODS: Patients with normal sinus rhythm, who were undergoing elective surgery that included rocuronium for NMB, were evaluated. After surgery, while at steady-state surgical depth anesthesia with sevoflurane and mechanical ventilation, patients received either placebo or 2 or 4 mg/kg of sugammadex to reverse moderate to deep NMB. Study personnel involved in data analysis were blinded to treatment. Continuous electrocardiogram (ECG) was recorded from the 5 minutes before and 5 minutes after sugammadex/placebo administration. R-R intervals were converted to HR and averaged in 1-minute increments. The maximum prolongation of an R-R interval after sugammadex was converted to an instantaneous HR. RESULTS: A total of 63 patients were evaluated: 8 received placebo, and 38 and 17 received 2 and 4 mg/kg sugammadex. Age, body mass index, and patient factors were similar in groups. Placebo did not elicit HR changes, whereas sugammadex caused maximum instantaneous HR slowing (calculated from the longest R-R interval), ranging from 2 to 19 beats/min. There were 7 patients with maximum HR slowing >10 beats/min. The average HR change and 95% confidence interval (CI) during the 5 minutes after 2 mg/kg sugammadex were 3.1 (CI, 2.3-4.1) beats/min, and this was not different from the 4 mg/kg sugammadex group (4.1 beats/min [CI, 2.5-5.6]). HR variability derived from the standard deviation of consecutive R-R intervals increased after sugammadex. CONCLUSIONS: Sugammadex to reverse moderate and deep NMB resulted in a fast onset and variable magnitude of HR slowing in patients. A difference in HR slowing as a function of dose did not achieve statistical significance. The observational nature of the investigation prevented a full understanding of the mechanism(s) of the HR slowing.