Cases of acute coronary syndrome and presumed cardiac death prior to arrival at an urban tertiary care hospital in Pakistan during the COVID-19 pandemic.

BACKGROUND: A reduction in overall acute coronary syndrome (ACS) cases, increases in the severity of ACS presentation, and increased rates of out-of-hospital cardiac arrest (OHCA) have been reported from multiple countries during the COVID-19 pandemic. The attributed factors include COVID-19 infection, fear of COVID-19 and resultant avoidance of health care facilities, and restrictions on mobility. Pakistan, a country with a high burden of cardiovascular disease (CVD) and challenges related to health care access, will be expected to demonstrate these same findings. Therefore, we compared ACS hospitalization, ACS severity, and patients who have already died (dead on arrival, or DOA) due to presumed OHCA at a tertiary cardiac hospital during pre-pandemic and intra-pandemic periods in Pakistan. METHODS: Standardized data elements were extracted from the charts of patients with ACS, and telephonic verbal autopsies (VA) using a validated tool were conducted for patients who were arrived DOA. As a comparison, cases during the same months prior to the COVID-19 were analyzed for respective waves. Events were counted, and proportions and frequencies are reported for each time period. RESULTS: A total of 4,480 ACS cases were reviewed; 1,216 cases during March-July 2019, 804 cases in the same months of 2020 (33.8% decrease); 1,304 cases in August 2019-January 2020 and 1,157 in the corresponding months of 2020 and 2021 (11.2% decrease). There was no observed change in the baseline characteristics of patients with ACS or their symptom-to-door time, and in-hospital mortality was unchanged across all time periods. There were 218 DOA cases in pre-pandemic months and 360 cases during the pandemic. The pre-pandemic rate of DOA was 12/1000 emergency patients (95% CI 10-13) compared to 22/1000 (95% CI 22-27) during the pandemic (30/1000in the 1st wave and 17/1000 during 2nd wave). On VA, CVD was found to be the major cause of death during both time periods. CONCLUSION: At a cardiac hospital in Pakistan, the COVID-19 pandemic was associated with a reduction in ACS hospitalization and an increased DOA rate.

Intraoperative prediction of postanaesthesia care unit hypotension.

BACKGROUND: Postoperative hypotension is associated with adverse outcomes, but intraoperative prediction of postanaesthesia care unit (PACU) hypotension is not routine in anaesthesiology workflow. Although machine learning models may support clinician prediction of PACU hypotension, clinician acceptance of prediction models is poorly understood. METHODS: We developed a clinically informed gradient boosting machine learning model using preoperative and intraoperative data from 88 446 surgical patients from 2015 to 2019. Nine anaesthesiologists each made 192 predictions of PACU hypotension using a web-based visualisation tool with and without input from the machine learning model. Questionnaires and interviews were analysed using thematic content analysis for model acceptance by anaesthesiologists. RESULTS: The model predicted PACU hypotension in 17 029 patients (area under the receiver operating characteristic [AUROC] 0.82 [95% confidence interval {CI}: 0.81-0.83] and average precision 0.40 [95% CI: 0.38-0.42]). On a random representative subset of 192 cases, anaesthesiologist performance improved from AUROC 0.67 (95% CI: 0.60-0.73) to AUROC 0.74 (95% CI: 0.68-0.79) with model predictions and information on risk factors. Anaesthesiologists perceived more value and expressed trust in the prediction model for prospective planning, informing PACU handoffs, and drawing attention to unexpected cases of PACU hypotension, but they doubted the model when predictions and associated features were not aligned with clinical judgement. Anaesthesiologists expressed interest in patient-specific thresholds for defining and treating postoperative hypotension. CONCLUSIONS: The ability of anaesthesiologists to predict PACU hypotension was improved by exposure to machine learning model predictions. Clinicians acknowledged value and trust in machine learning technology. Increasing familiarity with clinical use of model predictions is needed for effective integration into perioperative workflows.

Development and Pilot Testing of Entrustable Professional Activities for US Anesthesiology Residency Training.

BACKGROUND: Modern medical education requires frequent competency assessment. The Accreditation Council for Graduate Medical Education (ACGME) provides a descriptive framework of competencies and milestones but does not provide standardized instruments to assess and track trainee competency over time. Entrustable professional activities (EPAs) represent a workplace-based method to assess the achievement of competency milestones at the point-of-care that can be applied to anesthesiology training in the United States. METHODS: Experts in education and competency assessment were recruited to participate in a 6-step process using a modified Delphi method with iterative rounds to reach consensus on an entrustment scale, a list of EPAs and procedural skills, detailed definitions for each EPA, a mapping of the EPAs to the ACGME milestones, and a target level of entrustment for graduating US anesthesiology residents for each EPA and procedural skill. The defined EPAs and procedural skills were implemented using a website and mobile app. The assessment system was piloted at 7 anesthesiology residency programs. After 2 months, faculty were surveyed on their attitudes on usability and utility of the assessment system. The number of evaluations submitted per month was collected for 1 year. RESULTS: Participants in EPA development included 18 education experts from 11 different programs. The Delphi rounds produced a final list of 20 EPAs, each differentiated as simple or complex, a defined entrustment scale, mapping of the EPAs to milestones, and graduation entrustment targets. A list of 159 procedural skills was similarly developed. Results of the faculty survey demonstrated favorable ratings on all questions regarding app usability as well as the utility of the app and EPA assessments. Over the 2-month pilot period, 1636 EPA and 1427 procedure assessments were submitted. All programs continued to use the app for the remainder of the academic year resulting in 12,641 submitted assessments. CONCLUSIONS: A list of 20 anesthesiology EPAs and 159 procedural skills assessments were developed using a rigorous methodology to reach consensus among education experts. The assessments were pilot tested at 7 US anesthesiology residency programs demonstrating the feasibility of implementation using a mobile app and the ability to collect assessment data. Adoption at the pilot sites was variable; however, the use of the system was not mandatory for faculty or trainees at any site.

Impact of COVID-19 response on global surgical volumes: an ongoing observational study.

OBJECTIVE: To determine whether location-linked anaesthesiology calculator mobile application (app) data can serve as a qualitative proxy for global surgical case volumes and therefore monitor the impact of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We collected data provided by users of the mobile app "Anesthesiologist" during 1 October 2018-30 June 2020. We analysed these using RStudio and generated 7-day moving-average app use plots. We calculated country-level reductions in app use as a percentage of baseline. We obtained data on COVID-19 case counts from the European Centre for Disease Prevention and Control. We plotted changing app use and COVID-19 case counts for several countries and regions. FINDINGS: A total of 100 099 app users within 214 countries and territories provided data. We observed that app use was reduced during holidays, weekends and at night, correlating with expected fluctuations in surgical volume. We observed that the onset of the pandemic prompted substantial reductions in app use. We noted strong cross-correlation between COVID-19 case count and reductions in app use in low- and middle-income countries, but not in high-income countries. Of the 112 countries and territories with non-zero app use during baseline and during the pandemic, we calculated a median reduction in app use to 73.6% of baseline. CONCLUSION: App data provide a proxy for surgical case volumes, and can therefore be used as a real-time monitor of the impact of COVID-19 on surgical capacity. We have created a dashboard for ongoing visualization of these data, allowing policy-makers to direct resources to areas of greatest need.

Estimation of US Children's Educational Attainment and Years of Life Lost Associated With Primary School Closures During the Coronavirus Disease 2019 Pandemic.

Importance: United States primary school closures during the 2020 coronavirus disease 2019 (COVID-19) pandemic affected millions of children, with little understanding of the potential health outcomes associated with educational disruption. Objective: To estimate the potential years of life lost (YLL) associated with the COVID-19 pandemic conditioned on primary schools being closed or remaining open. Design, Setting, and Participants: This decision analytical model estimated the association between school closures and reduced educational attainment and the association between reduced educational attainment and life expectancy using publicly available data sources, including data for 2020 from the US Centers for Disease Control and Prevention, the US Social Security Administration, and the US Census Bureau. Direct COVID-19 mortality and potential increases in mortality that might have resulted if school opening led to increased transmission of COVID-19 were also estimated. Main Outcomes and Measures: Years of life lost. Results: A total of 24.2 million children aged 5 to 11 years attended public schools that were closed during the 2020 pandemic, losing a median of 54 (interquartile range, 48-62.5) days of instruction. Missed instruction was associated with a mean loss of 0.31 (95% credible interval [CI], 0.10-0.65) years of final educational attainment for boys and 0.21 (95% CI, 0.06-0.46) years for girls. Summed across the population, an estimated 5.53 million (95% CI, 1.88-10.80) YLL may be associated with school closures. The Centers for Disease Control and Prevention reported a total of 88 241 US deaths from COVID-19 through the end of May 2020, with an estimated 1.50 million (95% CI, 1.23-1.85 million) YLL as a result. Had schools remained open, 1.47 million (95% credible interval, 0.45-2.59) additional YLL could have been expected as a result, based on results of studies associating school closure with decreased pandemic spread. Comparing the full distributions of estimated YLL under both "schools open" and "schools closed" conditions, the analysis observed a 98.1% probability that school opening would have been associated with a lower total YLL than school closure. Conclusions and Relevance: In this decision analytical model of years of life potentially lost under differing conditions of school closure, the analysis favored schools remaining open. Future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children's health.

Real-time assessment of COVID-19 impact on global surgical case volumes.

Importance: The COVID-19 pandemic has disrupted global surgical capacity. The impact of the pandemic in low and middle income countries has the potential to worsen already strained access to surgical care. Timely assessment of surgical volumes in these countries remains challenging. Objective: To determine whether usage data from a globally used anesthesiology calculator mobile application can serve as a proxy for global surgical case volume and contribute to monitoring of the impact of the COVID-19 pandemic, particularly in World Bank low income countries where official data collection is not currently practical. Design: Subset of data from an ongoing observational cohort study of users of the application collected from October 1, 2018 to April 18, 2020. Setting: The mobile application is available from public sources; users download and use the application per their own clinical needs on personal mobile devices. Participants: No user data was excluded from the study. Exposures: Events with impacts on surgical case volumes, including weekends, holidays, and the COVID-19 pandemic. Main Outcomes and Measures: It was previously noted that application usage was decreased on weekends and during winter holidays. We subsequently hypothesized that more detailed analysis would reveal impacts of country-specific or region-specific holidays on the volume of app use. Results: 4,300,975 data points from 92,878 unique users were analyzed. Physicians and other anesthesia providers comprised 85.8% of the study population. Application use was reduced on holidays and weekends and correlated with fluctuations in surgical volume. The COVID-19 pandemic was associated with substantial reductions in app use globally and regionally. There was strong cross correlation between COVID-19 case count and reductions in app use. By country, there was a median global reduction in app use to 58% of baseline (interquartile range, 46%-75%). Application use in low-income continues to decline but in high-income countries has stabilized. Conclusions and Relevance: Application usage metadata provides a real-time indicator of surgical volume. This data may be used to identify impacted regions where disruptions to surgical care are disproportionate or prolonged. A dashboard for continuous visualization of these data has been deployed.

Cannabis use is associated with a small increase in the risk of postoperative nausea and vomiting: a retrospective machine-learning causal analysis.

BACKGROUND: Cannabis legalization may contribute to an increased frequency of chronic use among patients presenting for surgery. At present, it is unknown whether chronic cannabis use modifies the risk of postoperative nausea and vomiting (PONV). METHODS: This study was a retrospective cohort study conducted at 2 academic medical centers. Twenty-seven thousand three hundred eighty-eight adult ASA 1-3 patients having general anesthesia for non-obstetric, non-cardiac procedures and receiving postoperative care in the Post Anesthesia Care Unit (PACU) were analyzed in the main dataset, and 16,245 patients in the external validation dataset. The main predictor was patient reported use of cannabis in any form collected during pre-anesthesia evaluation and recorded in the chart. The primary outcome was documented PONV of any severity prior to PACU discharge, including administration of rescue medications in PACU. Relevant clinical covariates (risk factors for PONV, surgical characteristics, administered prophylactic antiemetic drugs) were also recorded. RESULTS: 10.0% of patients in the analytic dataset endorsed chronic cannabis use. Using Bayesian Additive Regression Trees (BART), we estimated that the relative risk for PONV associated with daily cannabis use was 1.19 (95 CI% 1.00-1.45). The absolute marginal increase in risk of PONV associated with daily cannabis use was 3.3% (95% CI 0.4-6.4%). We observed a lesser association between current, non-daily use of cannabis (RR 1.07, 95% CI 0.94-1.21). An internal validation analysis conducted using propensity score adjustment and Bayesian logistic modeling indicated a similar size and magnitude of the association between cannabis use and PONV (OR 1.15, 90% CI 0.98-1.33). As an external validation, we used data from another hospital in our care system to create an independent model that demonstrated essentially identical associations between cannabis use and PONV. CONCLUSIONS: Cannabis use is associated with an increased relative risk and a small increase in the marginal probability of PONV.

Neuraxial Labor Analgesia Utilization, Incidence of Postdural Puncture Headache, and Epidural Blood Patch Placement for Privately Insured Parturients in the United States (2008-2015).

BACKGROUND: Neuraxial analgesia is the gold standard for labor analgesia in the United States, and postdural puncture headache (PDPH) is one of the most common complications. PDPH is frequently treated with an epidural blood patch (EBP), but conservative treatment approaches remain common. Our current understanding of the incidence of PDPH and the frequency of EBP utilization is heavily based on reports from academic medical centers. We studied a private insurance database to provide estimates of neuraxial labor analgesia (NLA) use and PDPH and EBP incidence in the United States. METHODS: Labor and delivery insurance claims from the Truven MarketScan Commercial Claims and Encounters database were analyzed. Mode of delivery, analgesic and/or operative anesthesia information, and EBP placement were identified using Current Procedural Terminology (CPT) codes. PDPH was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. RESULTS: The analytic dataset consisted of 1,752,243 deliveries. Vaginal deliveries (VD) comprised 64.6% of the sample. Of these, 72.9% received NLA, with a PDPH incidence of 0.58% (95% confidence interval [CI], 0.57-0.60). Using VD with NLA as a referent, the risk ratio for PDPH following cesarean delivery (CD) without a prior NLA was 1.1 (95 CI, 1.05-1.15; P = .0001), while the risk ratio for PDPH following CD with a prior NLA was 0.81 (95% CI, 0.76-0.87; P < .0001). EBP placement was documented in 68.4% PDPH cases following VD with NLA, 67.2% of PDPH cases following CD with prior NLA, and 59.7% of PDPH cases following CD without prior NLA. The median number of days between delivery and first and EBP was 3. A second EBP was performed in 8.3% of initially patched patients, and a third in 0.1%. In patients who went on to receive a repeat EBP, the median interval between delivery and the first EBP was 1 day. CONCLUSIONS: This analysis confirms findings of prior studies regarding the present utilization of neuraxial analgesia and the incidence of PDPH. When compared to patients undergoing VD with NLA, patients having CD without NLA had a higher incidence of PDPH, presumably due to intentional dural puncture. Women having CD with a prior NLA had a lower incidence of PDPH, possibly due to avoidance of pushing during the second stage of labor. EBP was a commonly pursued strategy for the treatment of PDPH and was more commonly pursued in patients with a history of NLA. Repeat EBP was rare.

Neuraxial anesthesia for postpartum tubal ligation at an academic medical center.

Background: Use of an in situ epidural catheter has been suggested to be efficient to provide anesthesia for postpartum tubal ligation (PPTL). Reported epidural reactivation success rates vary from 74% to 92%. Predictors for reactivation failure include poor patient satisfaction with labor analgesia, increased delivery-to-reactivation time and the need for top-ups during labor. Some have suggested that this high failure rate precludes leaving the catheter in situ after delivery for subsequent reactivation attempts. In this study, we sought to evaluate the success rate of neuraxial techniques for PPTL and to determine if predictors of failure can be identified. Methods: After obtaining IRB approval, a retrospective chart review of patients undergoing PPTL after vaginal delivery from July 2010 to July 2016 was conducted using CPT codes, yielding 93 records for analysis. Demographic, obstetric and anesthetic data (labor analgesia administration, length of epidural catheter in epidural space, top-up requirements, time of catheter reactivation, final anesthetic technique and corresponding doses for spinal and epidural anesthesia) were obtained. Results: A total of 70 patients received labor neuraxial analgesia. Reactivation was attempted in 33 with a success rate of 66.7%. Patient height, epidural volume of local anesthetic and administered fentanyl dose were lower in the group that failed reactivation. Overall, spinal anesthesia was performed in 60 patients, with a success rate of 80%. Conclusions: Our observed rate of successful postpartum epidural reactivation for tubal ligation was lower than the range reported in the literature. Our success rates for both spinal anesthesia and epidural reactivation for PPTL were lower than the generally accepted rates of successful epidural and spinal anesthesia for cesarean delivery. This gap may reflect a lower level of motivation on behalf of both the patients and anesthesia providers to tolerate "imperfect" neuraxial anesthesia once fetal considerations are removed.

Training anesthesiologists in out-of-operating room anesthesia.

PURPOSE OF REVIEW: The purpose of this review is to describe recent developments and current trends in training anesthesiologists in out-of-operating room anesthesia (OORA). RECENT FINDINGS: In the United States, the Accreditation Council for Graduate Medical Education recently updated its training requirements to include a mandatory 2-week rotation in OORA for anesthesiology residents. This likely reflects the continuing expansion of anesthesia services in the out-of-operating room (OOR) environment as well as the increasing complexity of OOR procedures and medical acuity of patients in these settings. In the United Kingdom, the Royal College of Anaesthetists has rigorous and progressively complex requirements for trainees in 'non-theater' anesthesia experience as they move through the four stages of training. A variety of educational strategies and a well-validated six-step process for curriculum development are described in this review. SUMMARY: This review will provide useful models for training directors needing to design and implement OOR rotations for their trainees.