Faculty retention at a young medical school in crisis times and beyond: prospects, challenges and propositions from a mixed-methods study.

BACKGROUND: Retention of faculty constitutes a significant challenge for higher education institutions, especially in times of crisis. Lebanon has been experiencing economic recession since the end of its civil war in 1990 until its complete collapse in 2019. This resulted in a massive faculty exodus, escaping the daily struggle with the sinking economy. PURPOSE: The purpose of this study was to empirically investigate the factors that precipitate faculty attrition and the measures that foster long-term commitment to the institution in a time of unprecedented crisis. METHODS: An online anonymous survey, using a Likert scale, gathered responses from 92 faculty members. Quantitative findings were complemented by a qualitative exploration of emergent themes in comments. A team of three certified researchers conducted the analysis. Inductive analysis identified recurring themes, with steps like intercoder reliability checks and member-checking enhancing data validity. The researchers ensured methodological rigour, subject expertise, and overall reliability and validity of the thematic analysis. RESULTS: A total of 78 faculty participated in the survey (84.8%), with 79.5% reporting overall satisfaction, but a varying degree of satisfaction was noted across items. Faculty satisfaction was highest in areas such as respectful interactions (91.0%), belonging to the workplace (85.9%), communication from the Dean's office (85.9%), supportive environment and medical school leadership's commitment to retaining faculty (82.1%). Financial assistance, support for research and professional assistance were identified as important retention measures. Effective, transparent communication from leadership was highlighted as a critical factor during times of crisis. CONCLUSION: This study provides strategies for faculty retention in times of crisis that include ensuring timely salary payments, supporting research and professional development, fostering a positive work environment and implementing bonding programmes. Transparent communication from leadership is vital for faculty satisfaction and retention. These findings can aid medical schools and other institutions facing faculty attrition during crises.

Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study.

BACKGROUND: Dexmedetomidine provides smooth and hemodynamically stable emergence at the expense of hypotension, delayed recovery, and sedation. We investigated the optimal dose of dexmedetomidine for prevention of cough, agitation, hypertension, tachycardia, and shivering, with minimal side effects. METHODS: In this prospective, randomized, double-blind trial, 216 adult patients were randomly assigned to dexmedetomidine 1 µg/kg (D 1), 0.5 µg/kg (D 0.5), 0.25 µg/kg (D 0.25), or control (C). During emergence, cough, agitation, hemodynamic parameters, shivering, time to extubation, and sedation scores were recorded. RESULTS: A total of 190 patients were analyzed. The respective incidences for the groups D 1, D 0.5, and D 0.25 versus group C were 48%, 64%, and 64% vs 84% for cough-corrected P < .003 between groups D 1 and C; 33%, 34%, and 33% vs 72% for agitation-corrected P < .003 between group C and each of the study groups; and 4%, 2%, and 7% vs 22% for shivering-corrected P = .03 and corrected P = .009 between groups D 1 and D 0.5 versus group C, respectively. The percent increase from baseline blood pressure on extubation for the 3 treatment groups was significantly lower than group C. Percent increase in heart rate was lower than control in groups D 1 and D 0.5 but not in group D 0.25. Time to extubation and sedation scores were comparable. However, more hypotension was recorded during the emergence phase in the 3 treatment groups versus group C. CONCLUSIONS: D 1 at the end of surgery provides the best quality of emergence from general anesthesia including the control of cough, agitation, hypertension, tachycardia, and shivering. D 0.5 also controls emergence phenomena but is less effective in controlling cough. The 3 doses do not delay extubation. However, they cause dose-dependent hypotension.

Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation / Relaxantes musculares não despolarizantes melhoram a visibilidade em laringoscopia direta sem efeito sobre a ventilação via máscara facial

Abstract Background: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. Methods: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. Results: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p = 0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. Conclusion: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

Resumo Justificativa: A ventilação difícil ou impossível via máscara facial complicada pela intubação traqueal difícil durante a indução da anestesia ocorre em 0,4% dos casos de anestesia em adultos, possivelmente leva a complicações fatais. Devido a tais catástrofes, recomendou-se que a administração de relaxantes musculares seja feita após a confirmação de ventilação adequada via máscara facial, sem uma validação científica sólida dessa conduta. Métodos: Neste estudo observacional, a facilidade de ventilação e os escores de visibilidade em laringoscopia direta antes e após a administração de cisatracúrio foram avaliados em 90 adultos jovens e saudáveis, sem riscos anestésicos e sem intubação difícil prevista, agendados para cirurgias eletivas gerais. Resultados: Antes do relaxamento muscular, 43 pacientes (48%) eram Cormack Grau I, enquanto os 47 (52%) restantes eram ou Cormack Grau II (28, 31%) ou Cormack Grade III (19, 21%). Após o relaxamento muscular com cisatracúrio, o número de pacientes com Cormack Grau I aumentou significativamente de 43 (48%) para 65 (72%) (p = 0,0013). Apenas um paciente (5%) dos 19 melhorou sua classificação de Cormack do Grau III para o Grau I, enquanto 16 dos 19 (84%) melhoraram suas classificações de Cormack do Grau III para o grau II após o uso de cisatracúrio. A qualidade da ventilação via máscara facial não diferiu com ou sem relaxantes musculares em todos os pacientes. Conclusão: O uso de cisatracúrio em adultos jovens saudáveis submetidos a cirurgias eletivas gerais sem intubação traqueal difícil prevista não teve efeito sobre a qualidade da ventilação via máscara facial, mesmo resultando em melhora quantificável da visibilidade da laringe.

[Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation]. / Relaxantes musculares não despolarizantes melhoram a visibilidade em laringoscopia direta sem efeito sobre a ventilação via máscara facial.

BACKGROUND: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. METHODS: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. RESULTS: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p=0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. CONCLUSION: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

Haloperidol Versus Ondansetron for Treatment of Established Nausea and Vomiting Following General Anesthesia: A Randomized Clinical Trial.

BACKGROUND: Haloperidol is an antipsychotic. At low doses, it is a useful agent for the prophylaxis of postoperative nausea and vomiting (PONV). However, its use for treating established PONV has not been well studied. METHODS: This randomized double-blinded trial tested whether haloperidol is noninferior to ondansetron for the early treatment of established PONV in adult patients undergoing general anesthesia. The primary outcome is whether patients were PONV free during the first 4 hours. The noninferiority margin was set at 15%. One hundred twenty patients with PONV received either haloperidol 1 mg intravenously (n = 60) or ondansetron 4 mg intravenously (n = 60). RESULTS: Data from 112 patients (59 in the haloperidol group and 53 in the ondansetron group) were analyzed. Thirty-five patients (52%) in the haloperidol group received 1 or 2 prophylactic antiemetics compared with 42 (79%) in the ondansetron group. Haloperidol was noninferior to ondansetron for the end point of complete response to treatment (defined as the rate of PONV-free patients) for the early (0-4 hour) and the 0- to 24-hour postoperative periods by both the per-protocol and intention-to-treat analyses. In the per-protocol analysis, complete responses in the early period were noted in 35 of 59 patients (59%) and 29 of 53 patients (55%) for the haloperidol and ondansetron groups, respectively (difference 5%; 95% confidence interval [CI]: -13% to 22 %), and in the 0- to 24-hour period in 31 of 59 patients (53%) and 26 of 53 patients (49%) for the haloperidol and ondansetron groups, respectively (difference 4%; 95% CI of the difference: -15% to 21%). In the intention-to-treat analysis, complete responses in the early period were noted in 35 of 60 patients (58%) and 29 of 60 patients (48%) for the haloperidol and ondansetron groups, respectively (difference 10%; 95% CI of difference: -8% to 27%) and in the 0- to 24-hour period in 31 of 60 patients (52%) and 26 of 60 patients (43%) for the haloperidol and ondansetron groups, respectively (difference 8%; 95% CI of the difference: -9% to 25%). All other PONV secondary outcomes were comparable. Twenty-five percent of patients in the haloperidol group were sedated versus 2% in the ondansetron group (P < .001; difference 23%; 95% CI of the difference: 11%-36%). Pain, satisfaction scores, need for analgesics, and changes in QTc intervals were not different between the 2 groups. CONCLUSIONS: Haloperidol is at worst 13% and 8% less effective than ondansetron by per-protocol analysis and by intention-to-treat analysis, respectively. Thus, it is noninferior to ondansetron for the early treatment of established PONV, but is associated with sedation.

A comparison between dexamethasone and methylprednisolone for vomiting prophylaxis after tonsillectomy in inpatient children: a randomized trial.

BACKGROUND: The frequent incidence of postoperative vomiting in children undergoing tonsillectomy, in addition to the occurrence of severe pain, may delay postoperative oral intake and lead to increased risk of dehydration. Thus, prophylactic therapy is indicated in this high-risk group. Glucocorticoids, such as dexamethasone and methylprednisolone, have anti-inflammatory and antiemetic properties with dexamethasone being frequently used. We hypothesized that methylprednisolone should be noninferior to dexamethasone for the prevention of vomiting in children after tonsillectomy. METHODS: We designed a randomized double-blind trial to compare the efficacy of a single prophylactic dose of 0.5 mg/kg dexamethasone with a dose of 2.5 mg/kg methylprednisolone on the incidence of postoperative vomiting during the first 24 hours (primary outcome) in children undergoing total or partial tonsillectomy with a noninferiority margin set at 9%. One hundred sixty children undergoing total or partial tonsillectomy under general anesthesia were randomly assigned to receive either IV dexamethasone 0.5 mg/kg (n = 79) or methylprednisolone 2.5 mg/kg (n = 81) after induction of anesthesia. Secondary analysis of all studied outcomes was also performed according to the type of surgery. RESULTS: An intention-to-treat analysis showed an overall incidence of vomiting of 30% in the dexamethasone group and of 22% in the methylprednisolone group (difference: 8%, 95% confidence interval [CI]: -5% to 21%). A per protocol analysis showed an incidence of vomiting of 32% and 23%, respectively (difference: 9%, and 95% CI of the difference: -5 to 23%, P(sup) = 0.28). The time and quality of oral intake and the duration of IV hydration, as well as pain and satisfaction scores and the need for analgesics, were similar between the 2 groups. The incidence of vomiting was also similar in patients who had total versus partial tonsillectomy; however, time to first oral intake, duration of IV hydration, and the need for analgesics were less with better satisfaction scores in partial versus total tonsillectomy patients. CONCLUSION: Methylprednisolone is at worst 5% less effective than dexamethasone by the intention-to-treat analysis, and by the per protocol analysis. Thus, it is noninferior to dexamethasone in preventing vomiting after tonsillectomy in children.

The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials.

Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1-9 years. Sevoflurane with remifentanil (1 or 2 µg·kg(-1) ), lidocaine (2 mg·kg(-1) ), or propofol (2 mg·kg(-1) ) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg(-1) ) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 µg·kg(-1) ). No serious adverse events were reported with these combinations.

Effect of vitamin C on morphine use after laparoscopic cholecystectomy: a randomized controlled trial.

PURPOSE: We designed a randomized double-blind placebo-controlled trial to assess the role of a single prophylactic dose of vitamin C (2 g) po in reducing the consumption of opioids postoperatively in patients undergoing laparoscopic cholecystectomy. METHODS: Eighty adult patients were allocated to receive 2 g vitamin C po or placebo approximately one hour prior to induction of anesthesia. Following laparoscopic cholecystectomy, patients received morphine patient-controlled analgesia for 24 hr. The following data were assessed postoperatively in the postanesthesia care unit at two, four, six, 12, and 24 hr: morphine consumption, verbal numerical rating scale scores for incisional pain and nausea/vomiting, and pruritus and sedation scores. The primary outcome measure was 24-hr morphine consumption. Patient satisfaction was assessed before hospital discharge. RESULTS: Morphine consumption was significantly lower in the vitamin C group vs the placebo group [16.2 (10.7) and 22.8 (13.8) mg, respectively; difference = 6.6 mg; 95% confidence interval, 1.1 to 12.1 mg; P = 0.02]. There was no difference in pain scores or side effects between the two groups. Satisfaction scores were similar in both groups. CONCLUSION: Our study showed that supplementation with vitamin C (2 g) po decreased morphine consumption in the postoperative period in patients undergoing laparoscopic cholecystectomy.

Supplementation of retrobulbar block with clonidine in vitreoretinal surgery: effect on postoperative pain.

STUDY OBJECTIVE: To evaluate the effect of clonidine when added to local anesthetics on duration of postoperative analgesia during retrobulbar block. DESIGN: Prospective, randomized controlled trial. SETTING: Operating room and Postanesthesia Care Unit of a university-affiliated hospital. SUBJECTS: 80 ASA physical status 1, 2, and 3 patients undergoing vitreoretinal surgery with or without scleral buckling. INTERVENTIONS: Patients in the control group (n = 40) received a retrobulbar block with 4.5 mL of lidocaine-bupivacaine and 0.5 mL of saline. Clonidine group patients (n = 40) received 4.5 mL of lidocaine-bupivacaine and 0.5 µg/kg of clonidine in a 0.5 mL volume. MEASUREMENTS: The time to first analgesic request, frequency of postoperative pain, and number of postoperative analgesic requests per patient were assessed. MAIN RESULTS: 37 patients in the control group (92.5%) versus 24 patients (60%) in the clonidine group reported pain postoperatively (P = 0.001), with a shorter time to first analgesic request noted in the control group (4.9 ± 3 vs 11.9 ± 5.3 hrs; P < 0.001). The median number of postoperative analgesic requests per patient during the first 24 hours was higher in the control group than the clonidine group [2 (0-3) vs. 1 (0-3); P < 0.001]. CONCLUSIONS: The addition of clonidine 0.5 µg/kg to the local anesthetics of a retrobulbar block for vitreoretinal surgery decreases the frequency of postoperative pain and prolongs the time of analgesia.

A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia.

BACKGROUND: Emergence agitation in children after sevoflurane is common. Different drugs have been used to decrease its occurrence with variable efficacy. The authors compared the incidence and severity of emergence agitation in children who received a single dose of propofol at the end of strabismus surgery versus children who received saline. METHODS: In this prospective, randomized, double-blind study, the authors enrolled 80 healthy children aged 2-6 yr. The children were randomly allocated to the propofol group (n = 41), which received 1 mg/kg propofol at the end of surgery, or to the saline group (n = 39), which received saline. RESULTS: The mean scores on the Pediatric Anesthesia Emergence Delirium scale were significantly lower in the propofol group compared with the saline group (8.6 +/- 3.9 vs. 11.5 +/- 4.5; P = 0.004). Also, the incidence of agitation was significantly lower in the propofol group compared with the saline group (19.5% vs. 47.2%; P = 0.01). A threshold score greater than 10 on the Pediatric Anesthesia Emergence Delirium scale was the best discriminator between presence and absence of emergence agitation. Times to removal of the laryngeal mask airway (10.6 +/- 1.5 vs. 9.4 +/- 1.9 min; P = 0.004) and emergence times (23.4 +/- 5.7 vs. 19.7 +/- 5 min; P = 0.004) were significantly longer in the propofol group. However, discharge times were similar between the two groups (propofol: 34.1 +/- 8.4 min; saline: 34.9 +/- 8.6 min). More parents in the propofol group were satisfied. CONCLUSIONS: In children undergoing strabismus surgery, 1 mg/kg propofol at the end of surgery after discontinuation of sevoflurane decreases the incidence of agitation and improves parents' satisfaction without delaying discharge from the postanesthesia care unit.

Laryngeal mask airway for ventilation during diagnostic and interventional fibreoptic bronchoscopy in children.

BACKGROUND: The use of the flexible fibreoptic bronchoscope in infants and children has expanded to include both interventional and diagnostic bronchoscopy. The present report utilizes the laryngeal mask airway (LMATM) for ventilation and anaesthesia administration in children during fibreoptic bronchoscopy using an adult bronchoscope. METHODS: The technique was used in 10 children; their age ranged between 1.2 and 5 years. Six of these children had a history of foreign body aspiration and underwent interventional bronchoscopy, while four children underwent diagnostic bronchoscopy. Anaesthesia was induced by facemask using sevoflurane 6-8% followed by the insertion of a LMA size 2 or 2.5. A swivel adapter connected the proximal end of the LMA to the T-piece anaesthesia system. Anaesthesia was then maintained with spontaneous breathing of sevoflurane 2-4% in oxygen, delivered via the LMA. A flexible adult fibreoptic bronchoscope (outer diameter 4.9 mm) was inserted via the swivel adapter. RESULTS: The procedure could be accomplished successfully in the 10 patients. However, one child developed laryngospasm that was easily relieved by deepening the level of anaesthesia. In a second child hypoxia and hypercarbia occurred and were relieved by intermittent withdrawal of the fibreoptic bronchoscope. CONCLUSIONS: Laryngeal mask airway is a safe and effective adjunct to fibreoptic bronchoscopy under general anaesthesia in children. Its larger internal diameter compared with a tracheal tube permits the use of relatively large fibreoptic bronchoscope without a significant increase in airway resistance.