The Reliability of a Grading System for Digital Subtraction Imaging Quality During Cervical Transforaminal Epidural Steroid Injection.

OBJECTIVE: Digital subtraction imaging (DSI) decreases the risk of intravascular injection during cervical transforaminal epidural steroid injection (CTFESI); however, sequence acquisition and interpretation are operator-dependent skills. This study tests the reliability of a grading system to determine adequate DSI during CTFESI. SETTING: Academic tertiary medical center. METHODS: A grading scheme for adequate DSI quality during CTFESI was created by the study authors based on patient positioning, mask image, and volume of contrast injected. The inter-rater and intrarater reliability values of this grading scheme were tested using 50 DSI images evaluated by three raters during two distinct sessions separated by four weeks. Based on a power analysis, a sample of 50 scans was sufficient to detect significant correlations. Inter-rater reliability was determined by percent agreement between graders for dichotomized categories of "quality of DSI is adequate for safe C-TFESI" vs "quality of DSI is inadequate for safe C-TFESI." The percentage of agreement was reported, along with Gwet's agreement coefficient (AC). The intrarater (pre/post) correlation was assessed using Yule's Q statistics. RESULTS: Correlation coefficients were interpreted as follows: 0.00-0.19 "very weak," 0.20-0.39 "weak," 0.40-0.59 "moderate," 0.60-0.79 "strong," and 0.80-1.00 "very strong." Inter-rater reliability analyses demonstrated that the patient position category had "very strong" agreement, contrast volume had "strong" agreement, and mask image had "moderate" agreement. The overall inter-rater reliability was "moderate." All of the raters demonstrated "very strong" intrarater reliability. CONCLUSIONS: The proposed grading system for adequate-quality DSI during CTFESI showed overall "moderate" and "very strong" inter- and intrarater reliability, respectively. This scheme provides an objective measure of DSI quality for CTFESI. Refinement is needed to improve the reliability of this scheme.

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines.

SETTING: Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk, cessation may precipitate serious thromboembolic events. The Spine Intervention Society (SIS) and American Society of Regional Anesthesia and Pain Medicine (ASRA) put forth guidelines that dissent with regard to management of hemostatically active agents during commonly performed spinal injections. OBJECTIVE: To validate an antiplatelet/anticoagulant management table based on modifications of the SIS 2013 and ASRA 2015 guidelines. DESIGN: Prospective descriptive study. SUBJECTS: Patients undergoing interventional spine injections from a interventional physiatrist's practice. METHODS: A Modified SIS 2013-ASRA 2015 Antiplatelet & Anticoagulant (MSAAA) guideline table was devised and adopted. Patients undergoing interventional spine procedures were monitored for bleeding events. RESULTS: Of 4,253 injection sites, 197 (4.6%) were performed in 74 patients on antiplatelet/anticoagulants. No clinically evident bleeding events were observed in patients on antiplatelet/anticoagulant medications for lumbar transforaminal epidural (N = 90), posterior-approach facet joint (N = 62), lumbar intradiscal (N = 11), lumbar sympathetic (N = 3), and sacroiliac (N = 5) injections or in 26 radiofrequency neurotomy procedures. One in 2,026 (0.05%, 95% confidence interval = 0.00-0.31%) interlaminar epidural injections (cervical, thoracic, lumbar, and caudal) suffered epidural hematoma. This patient was not on an antiplatelet/anticoagulant drug. No patient in 191 cervicothoracic and 723 lumbar transforaminal injections experienced bleeding complications. CONCLUSIONS: Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.

Surgical Apgar score is associated with myocardial injury after noncardiac surgery.

STUDY OBJECTIVE: To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery. DESIGN: Single-center retrospective cohort study of surgical patients from 2007 to 2012. SETTING: Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center. PATIENTS: A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available. MEASUREMENTS: The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL. MAIN RESULTS: Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate >100 beats/min for >59 minutes), and prolonged hypotension (mean arterial pressure <40 mm Hg for >2 minutes) were independently associated with cTn leak and perioperative MI. CONCLUSIONS: Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.

Prolonged patient emergence time among clinical anesthesia resident trainees.

BACKGROUND AND AIMS: Emergence time, or the duration between incision closure and extubation, is costly nonoperative time. Efforts to improve operating room efficiency and identify trainee progress make such time intervals of interest. We sought to calculate the incidence of prolonged emergence (i.e., >15 min) for patients under the care of clinical anesthesia (CA) residents. We also sought to identify factors from resident training, medical history, anesthetic use, and anesthesia staffing, which affect emergence. MATERIAL AND METHODS: In this single-center, historical cohort study, perioperative information management systems provided data for surgical cases under resident care at a tertiary care center in the United States from 2006 to 2008. Using multiple logistic regression, the effects of variables on emergence was analyzed. RESULTS: Of 7687 cases under the care of 27 residents, the incidence of prolonged emergence was 13.9%. Emergence prolongation decreased by month in training for 1st-year (CA-1) residents (r2 = 0.7, P < 0.001), but not for CA-2 and CA-3 residents. Mean patient emergence time differed among 27 residents (P < 0.01 for 58.4% or 205/351 paired comparisons). In a model restricted to 1st-year residents, patient male gender, American Society of Anesthesiologists (ASA) physical status >II, emergency surgical case, operative duration ≥2 h, and paralytic agent use were associated with higher frequency of prolonged emergence, while sevoflurane or desflurane use was associated with lower frequency. Attending anesthesiologist handoff was not associated with longer emergence. CONCLUSION: Incidence of prolonged emergence from general anesthesia differed significantly among trainees, by resident training duration, and for patients with ASA >II.