Nasal Intubation is not Associated with "Smoother" Emergence from General Anesthesia for Carotid Endarterectomy: A Case-Cohort Study.

BACKGROUND: Postoperative hematoma after carotid endarterectomy (CEA) is a devastating complication and may be more likely in patients with uncontrolled hypertension and coughing on emergence from anesthesia. We sought to determine if intubation with a nasal endotracheal tube (ETT)-instead of an oral ETT-is associated with "smoother" (i.e., less hemodynamic instability) emergence from general anesthesia for CEA. METHODS: Patients receiving CEA between December 2015 and September 2021 at a single tertiary academic medical center were included. We examined the electronic anesthesia records for 323 patients who underwent CEA during the 6-year study period and recorded consecutive systolic blood pressure (SBP) values during the 10 minutes before extubation as a surrogate for "smoothness" of the emergence. RESULTS: Intubation with a nasal ETT, when compared with intubation with an oral ETT, was not associated with any difference in maximum, minimum, average, median, or standard deviation of serial SBP values in the 10 minutes before extubation. The average SBP on emergence for patients with an oral ETT was 141 mm Hg and with a nasal ETT was 144 mm Hg (P = 0.562). The maximum SBP for patients with oral and nasal ETTs were 170 mm Hg and 174 mm Hg, respectively (P = 0.491). There were also no differences in the qualitative "smoothness" of emergence or in the percentage of patients who required an intravenous dose of 1 or more antihypertensive medications. The incidence of postoperative complications was similar between the 2 groups. CONCLUSIONS: When SBP is used as a surrogate for smoothness of emergence from general anesthesia for CEA, intubation with a nasal ETT was not associated with better hemodynamic stability compared to intubation with an oral ETT.

Sustained Implementation of an Evidence-Based Extubation Checklist Reduced Extubation Failure in Trauma Patients.

Extubation failure remains a challenge in the perioperative setting. The aim of this intervention was to decrease the rate of perioperative extubation failure through the utilization of an extubation checklist. A five-item evidence-based extubation readiness checklist was implemented at a level I trauma center on all patients who were electively extubated in the operating room (OR). Extubation failure rates before and after implementation of the checklist were compared. Of 26,867 trauma patients extubated in the OR after the intervention, 84 cases (0.31%) failed extubation in the immediate postoperative period. A significant and sustained decrease in extubation failure rate per case performed was observed between the pre- and post-checklist period (OR, 0.33; 95% CI, 0.19, 0.56; P < 0.001). Partial (vs full) checklist completion, higher ASA physical status score, advanced age, and longer case length were independently associated with increased odds of extubation failure in the postintervention period.

Impact of Pandemic Response on Training Experience of Anesthesiology Residents in an Academic Medical Center: A Retrospective Cohort Study.

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic substantially altered operations at hospitals that support graduate medical education. We examined the impact of the pandemic on an anesthesiology training program with respect to overall case volume, subspecialty exposure, procedural skill experience, and approaches to airway management. Methods Data for this single center, retrospective cohort study came from an Institutional Review Board approved repository for clinical data. Date ranges were divided into the following phases in 2020: Pre-Pandemic (PP), Early Pandemic (EP), Recovery 1 (R1), and Recovery 2 (R2). All periods were compared to the same period from 2019 for case volume, anesthesia provider type, trainee exposure to Accreditation Council for Graduate Medical Education (ACGME) index case categories, airway technique, and patient variables. Results 15,087 cases were identified, with 5,598 (37.6%) in the PP phase, 1,570 (10.5%) in the EP phase, 1,451 (9.7%) in the R1 phase, and 6,269 (42.1%) in the R2 phase. There was a significant reduction in case volume during the EP phase compared to the corresponding period in 2019 (-55.3%; P < .001) that improved but did not return to baseline by the R2 phase (-17.6%; P < .001). ACGME required minimum cases were reduced during the EP phase compared to 2019 data for pediatric cases (age < 12 y, -72.1%; P < .001 and age < 3 y, -53.5%; P < .006) and cardiopulmonary bypass cases (52.3%, P < .003). Surgical subspecialty case volumes were significantly reduced in the EP phase except for transplant surgery. By the R2 phase, all subspecialty volumes had recovered except for plastic surgery (14.9 vs. 10.5 cases/week; P < .006) and surgical endoscopy (59.2 vs. 40 cases/week; P < .001). Use of video laryngoscopy (VL) and rapid sequence induction and intubation (RSII) also increased from the PP to the EP phase (24.6 vs. 79.6%; P < .001 and 10.3 vs. 52.3%; P < .001, respectively) and remained elevated into the R2 phase (35.2%; P < 0.001 and 23.1%; P < .001, respectively). Conclusions The COVID-19 pandemic produced significant changes in surgical case exposure for a relatively short period. The impact was short-lived, with sufficient remaining time to meet the annual ACGME program minimum case requirements and procedural experiences. The longer-term impact may be a shift towards the increased use of VL and RSII, which became more prevalent during the early phase of the pandemic.

Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation.

INTRODUCTION: Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors' cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020. METHODS: The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors' institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients' time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium. RESULTS: The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers' satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients. DISCUSSION: The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.

A Retrospective Analysis of Respiratory Complications under General Anesthesia during EBUS-TBNA.

Background: EBUS-TBNA is an established technique for diagnostically sampling intrathoracic masses and lymph nodes. While the procedure is commonly conducted under general anesthesia (GA), little is known regarding the association between anesthetic management and perioperative respiratory complications. Here, we aim to evaluate this association among patients presenting for EBUS-TBNA. Methods: 586 patients receiving GA for EBUS-TBNA between 2012 and 2018 were retrospectively evaluated. The primary endpoint was the occurrence of perioperative respiratory complications and the secondary endpoint was procedure end to OR exit time (minutes). Respiratory complications were defined as episodes of severe (SpO2 <85%) or prolonged (SpO2<90% for >5 min) hypoxemia, bronchospasm, and postoperative ventilation that could not be directly attributed to procedural invasiveness. Results: Among all patients, 79 (13.5%) had respiratory complications. Four patient characteristics were associated with respiratory complications: home oxygen use (OR 2.39; 95% CI 1.26-4.45; P = 0.007), pre-existing respiratory disease (OR 2.01; CI 1.21-3.29; P = 0.005), ASA class (P = 0.03), and albuterol administration intra-operatively (OR 2.22; CI 1.23-3.92; P = 0.007). No anesthetic factors were found to be statistically significant. Procedures with respiratory complications had a longer duration (mean time 88.7 min vs. 111.8 min; P = 0.00009), prolonged time to extubation (mean time 11.9 min vs. 14.2 min; P = 0.039), and stayed in the room longer after extubation (mean time 18.4 min vs. 23.1 min; P = 0.0016). When comparing types of GA, there were no significant differences between volatile anesthetics versus TIVA (12.7% vs. 14.6%, P = 0.54). Conclusions: Pre-existing patient characteristics, as opposed to anesthetic factors, are associated with respiratory complications during EBUS-TBNA.

Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice.

A retained surgical item (RSI) can be a devastating and costly procedural complication. Although the current incidence of RSIs is unknown, perioperative personnel routinely perform surgical counts according to their facility's policies and procedures to prevent this sentinel event. The American College of Surgeons, The Joint Commission, and AORN emphasize the importance of communication and standardized protocols for the counting of surgical items. However, there is a lack of current evidence to support specific recommendations for the counting of items during endovascular procedures. After the occurrence of RSIs during endovascular procedures at our facility, we convened an interdisciplinary workgroup, conducted an analysis of root causes, reviewed the available literature, and revised the existing policy. This article reviews the available literature on RSIs, describes root causes, discusses recommendations from national organizations, and describes the process that we used to create the policy changes at our facility.

Anesthetic Management of Patients After Traumatic Injury With Resuscitative Endovascular Balloon Occlusion of the Aorta.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver for noncompressible torso hemorrhage. To our knowledge, this single-center brief report provides the most extensive anesthetic data published to date on patients who received REBOA. As anticipated, patients were critically ill, exhibiting lactic acidosis, hypotension, hyperglycemia, hypothermia, and coagulopathy. All patients received blood products during their index operations and received less inhaled anesthetic gas than normally required for healthy patients of the same age. This study serves as an important starting point for clinician education and research into anesthetic management of patients undergoing REBOA.

Recreational marijuana use is not associated with worse outcomes after renal transplantation.

As marijuana (MJ) legalization is increasing, kidney transplant programs must develop listing criteria for marijuana users. However, no data exist on the effect of MJ on kidney allograft outcomes, and there is no consensus on whether MJ use should be a contraindication to transplantation. We retrospectively reviewed 1225 kidney recipients from 2008 to 2013. Marijuana use was defined by positive urine toxicology screen and/or self-reported recent use. The primary outcome was death at 1 year or graft failure (defined as GFR<20 mL/min/1.73 m2 ). The secondary outcome was graft function at 1 year. Using logistic regression analyses, we compared these outcomes between MJ users and non-users. Marijuana use was not associated with worse primary outcomes by unadjusted (odds ratio 1.07, 95% CI 0.45-2.57, P=.87) or adjusted (odds ratio 0.79, 95% CI 0.28-2.28, P=.67) analysis. Ninety-two percent of grafts functioned at 1 year. Among these, the mean creatinine (1.52, 95% CI 1.39-1.69 vs 1.46, 95% CI 1.42-1.49; P=.38) and MDRD GFR (50.7, 95% CI 45.6-56.5 vs 49.5, 95% CI 48.3-50.7; P=.65) were similar between groups. Isolated recreational MJ use is not associated with poorer patient or kidney allograft outcomes at 1 year. Therefore, recreational MJ use should not necessarily be considered a contraindication to kidney transplantation.