A randomized trial evaluating the safety profile of sugammadex in high surgical risk ASA physical class 3 or 4 participants.

BACKGROUND: The aim of this randomized, double-blind trial was to evaluate the safety and tolerability profile, including cardiac safety, of sugammadex-mediated recovery from neuromuscular block in participants undergoing surgery who met the American Society of Anesthesiologists (ASA) Physical Class 3 or 4 criteria. Specifically, this study assessed the impact of sugammadex on cardiac adverse events (AEs) and other prespecified AEs of clinical interest. METHODS: Participants meeting ASA Class 3 and 4 criteria were stratified by ASA Class and NMBA (rocuronium or vecuronium) then randomized to one of the following: 1) Moderate neuromuscular block, sugammadex 2 mg/kg; 2) Moderate neuromuscular block, neostigmine and glycopyrrolate (neostigmine/glycopyrrolate); 3) Deep neuromuscular block, sugammadex 4 mg/kg; 4) Deep neuromuscular block, sugammadex 16 mg/kg (rocuronium only). Primary endpoints included incidences of treatment-emergent (TE) sinus bradycardia, TE sinus tachycardia and other TE cardiac arrhythmias. RESULTS: Of 344 participants randomized, 331 received treatment (61% male, BMI 28.5 ± 5.3 kg/m2, age 69 ± 11 years). Incidence of TE sinus bradycardia was significantly lower in the sugammadex 2 mg/kg group vs neostigmine/glycopyrrolate. The incidence of TE sinus tachycardia was significantly lower in the sugammadex 2 and 4 mg/kg groups vs neostigmine/glycopyrrolate. No significant differences in other TE cardiac arrythmias were seen between sugammadex groups and neostigmine/glycopyrrolate. There were no cases of adjudicated anaphylaxis or hypersensitivity reactions in this study. CONCLUSIONS: Compared with neostigmine/glycopyrrolate, incidence of TE sinus bradycardia was significantly lower with sugammadex 2 mg/kg and incidence of TE sinus tachycardia was significantly lower with sugammadex 2 mg/kg and 4 mg/kg. These results support the safety of sugammadex for reversing rocuronium- or vecuronium-induced moderate and deep neuromuscular block in ASA Class 3 or 4 participants. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03346057 .

Does anesthesiology residency training result in decreasing intraoperative drug cost from a resident's first to second month's experience in adult cardiac anesthesiology?

BACKGROUND: All physicians bear the responsibility of minimizing cost while providing care that meets or exceeds national quality benchmarks. Intraoperative anesthetic drug costs constitute a small but significant fraction of the total cost in the perioperative period. Previous studies have revealed that anesthesiologists are generally unaware of drug costs. In order to determine if experience and education improve anesthetic drug cost containment, we compared the total anesthetic drug cost per case as residents progressed through their rotations in cardiac anesthesia. METHODS: We considered the total anesthetic drug cost for 202 adult cardiac cases, including coronary artery bypass grafting, mitral valve repair/replacement, and aortic valve repair/replacement. 77 of the cases analyzed were done by residents in their first month of cardiac anesthesia, and 125 were done by residents in their second month of cardiac anesthesia. In the interval between these rotations, residents participate in didactics and other educational activities including a practice management rotation in the CA-3 year where they are exposed to financial topics in healthcare. RESULTS: The average total drug cost per case for residents in their first month was $193.50; SD= $82.00. The average total cost per case for residents in their second month was $223.30; SD=$96.10. With multivariate analysis considering case type, length of procedure and patient age, the resident training level did not impact the cost in a significant way (p=0.062). CONCLUSIONS: In the multivariate analysis considering case type, length of procedure and patient age, more experienced residents did not have a significantly different total drug cost per case. This finding suggests that didactic educational efforts and implicit modeling over time did not reduce drug costs in the operating room during adult cardiac surgery.

Endotracheal tube size does not affect time to extubation in adult cardiac surgery.

Managed care over the last 20 years has brought considerable attention to the impact of clinical variables on time to extubation in adult cardiac surgery. One variable that has not yet been analyzed is the endotracheal tube (ETT) size. Our retrospective electronic database review was performed on adult subjects that had a primary, non-emergent cardiac surgery in the last four years. The records of 936 patients were analyzed to find 193 patients meeting inclusion criteria. Due to the low number of 7.0 ETTs used in the study, this group was eliminated from analysis. The means for times to extubation for the two remaining groups were 7:45 standard deviation (SD) 4:27 (hrs:min) and 7:30 SD 4:48 (hrs:min) for patients managed with 8.0 and 9.0 ETTs respectively, with no statistically significant differences between the tube sizes p=0.2389. Analysis of variance did not demonstrate a statistically significant impact with age (p=0.3199), gender (p=0.5394), body mass index (BMI) (p=0.4060), nor intravenous (IV) anesthetic adjuvants midazolam (p= 0.4815) or opiates (p=0.3617) used in the operating room (OR), but length of time on cardiopulmonary bypass did play a role (p=0.0274). These data suggest that the size of the ETT utilized during cardiovascular surgery in adult patients does not play a role in the length of time of postoperative ventilation.

Anesthesia preparation time is not affected by the experience level of the resident involved during his/her first month of adult cardiac surgery.

OBJECTIVE: This study was designed to answer the question of whether the experience level of the resident on his/her first month of adult cardiothoracic anesthesiology has an impact on operating room efficiency in a large academic medical center. Traditionally, the resident's 1st month of cardiac anesthesia had been reserved for the clinical anesthesia (CA)-2 year of training. This study analyzed the impact on operating room efficiency of moving the 1st month of cardiac anesthesia into the CA-1 year. The authors hypothesized that there would be no difference in anesthesia preparation times (defined as the interval between "in-room" and "anesthesia-ready" times) between CA-1 and CA-2 residents on their 1st month of cardiac anesthesia. DESIGN: This study was retrospective and used an electronic anesthesia information management system database. SETTING: This study was conducted on care provided at a single 450-bed academic medical center. PARTICIPANTS: This study included 12 residents in their 1st month of cardiac anesthesia. INTERVENTIONS: The anesthesia preparation time (defined as the interval between "in-room" and "anesthesia-ready" times) was measured for cases involving residents on their first month of cardiac anesthesia. MEASUREMENTS AND MAIN RESULTS: Anesthesia preparation times for 6 CA-1 resident months and 6 CA-2 resident months (100 adult cardiac procedures in total) were analyzed (49 for the CA-1 residents and 51 for the CA-2s). There were no differences in preparation time between CA-1 and CA-2 residents as a group (p = 0.8169). The CA-1 residents had an unadjusted mean (±standard error) of 51.1 ± 3.18 minutes, whereas the CA-2 residents' unadjusted mean was 50.2 ± 2.41 minutes. Adjusting for case mix (valves v coronary artery bypass graft surgery), the CA-1 mean was 49.1 ± 5.22 minutes, whereas the CA-2 mean was 49.1 ± 4.54 minutes. CONCLUSIONS: These findings suggest that operating room efficiency as measured by the anesthesia preparation time may not be affected by the level of the resident on his/her 1st month of adult cardiac anesthesia.

The influence of Dr. John Adriani on the American Board of Anesthesiology Oral Examination.

Though Dr. John Adriani was respected worldwide for his contributions in the clinical arena, he has received little acknowledgement for his influence on the American Board of Anesthesiology (ABA) oral exam. His essay, "The oral examination of the American Board of Anesthesiology" was the first work of its kind helping new and experienced examiners approach the examination process. An analysis of the literature investigating the reliability of the ABA oral exam from before and after the release of Dr. Adriani's document reveals that Dr. Adriani's suggestions likely helped improve the examination process.

Intraoperative oxygen administration does not reduce the incidence or severity of nausea or vomiting associated with neuraxial anesthesia for cesarean delivery.

BACKGROUND: Supplemental oxygen may reduce postoperative nausea and vomiting after general anesthesia. We designed this study to evaluate the efficacy of supplemental oxygen administration for reducing nausea and vomiting in women having neuraxial anesthesia for cesarean delivery. METHODS: We conducted a prospective, randomized, double-blind study of women having standardized neuraxial anesthesia and postoperative analgesia for cesarean delivery. After umbilical cord clamp, women were randomized to receive either 70% or 21% oxygen for surgery. Nausea and vomiting were recorded at three time intervals: induction until delivery, delivery until the end of surgery, and at 24 postoperative hours. chi2 and Student's t-tests were used to determine significant differences. RESULTS: The study groups were similar with respect to demographic and procedural variables. There was no significant difference between groups in the overall incidences of nausea and vomiting. The incidence of severe nausea (rated by mothers) in the oxygen group predelivery, postdelivery, and postoperatively was 3%, 7%, and 9%, respectively, and in the medical air group was 3%, 9%, and 7%, respectively. Severe vomiting (>2 episodes) in both the oxygen and medical air groups were 0%, 2%, and 4% at the corresponding time intervals. These differences were not statistically significant. CONCLUSION: Administration of supplemental oxygen during cesarean delivery with neuraxial anesthesia does not decrease the incidence or severity of intraoperative or postoperative nausea or vomiting.

Ochsner Health System Department of Anesthesiology: the first thirty years.

The Department of Anesthesiology at Ochsner Clinic Foundation was founded in 1947 at the original Ochsner Hospital at Camp Plauche in New Orleans. An anesthesiology residency training program was accredited in 1953, making Ochsner one of the early and leading producers of anesthesiologists for the Gulf South region. Staff members over the years have held prominent national leadership positions, including two American Society of Anesthesiology presidents, the founder of the Society of Cardiovascular Anesthesiology, and the president of the Society for Obstetric Anesthesiology and Perinatology.