A Call to Action: Why Anesthesiologists Must Train, Prepare, and Be at the Forefront of Disaster Response for Mass Casualty Incidents.

Disasters, both natural and man-made, continue to increase. In Spring 2023, a 3-hour workshop on mass casualty incidents was conducted at the Society for Pediatric Anesthesia-American Academy of Pediatrics Annual conference. The workshop used multiple instructional strategies to maximize knowledge transfer and learner engagement including minididactic sessions, problem-based learning discussions in 3 tabletop exercises, and 2 30-minute disaster scenarios with actors in a simulated hospital environment. Three themes became evident: (1) disasters will continue to impact hospitals and preparation is imperative, (2) anesthesiologists are extensively and comprehensively trained and their value is often underestimated as mass casualty incident responders, and (3) a need exists for longitudinal disaster preparedness education and training over the course of a career. In this special article, we have sought to further define the problem and evidence, the capacity of anesthesiologists as leaders in disaster preparedness, and the rationale for preparation with current best practices to guide how best to move forward.

Anesthetic Management for Ventricular Tachycardia Ablation: A National Anesthesia Clinical Outcomes Registry Analysis.

OBJECTIVES: The authors analyzed anesthetic management trends during ventricular tachycardia (VT) ablation, hypothesizing that (1) monitored anesthesia care (MAC) is more commonly used than general anesthesia (GA); (2) MAC uses significantly increased after release of the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias; and (3) anesthetic approach varies based on patient and hospital characteristics. DESIGN: Retrospective study. SETTING: National Anesthesia Clinical Outcomes Registry data. PARTICIPANTS: Patients 18 years or older who underwent elective VT ablation between 2013 and 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Covariates were selected a priori within multivariate models, and interrupted time-series analysis was performed. Of the 15,505 patients who underwent VT ablation between 2013 and 2021, 9,790 (63.1%) received GA. After the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias supported avoidance of GA in idiopathic VT, no statistically significant increase in MAC was evident (immediate change in intercept post-consensus statement release adjusted odds ratio 1.41, p = 0.1629; change in slope post-consensus statement release adjusted odds ratio 1.06 per quarter, p = 0.1591). Multivariate analysis demonstrated that sex, American Society of Anesthesiologists physical status, age, and geographic location were statistically significantly associated with the anesthetic approach. CONCLUSIONS: GA has remained the primary anesthetic type for VT ablation despite the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias suggested its avoidance in idiopathic VT. Achieving widespread clinical practice change is an ongoing challenge in medicine, emphasizing the importance of developing effective implementation strategies to facilitate awareness of guideline release and subsequent adherence to and adoption of recommendations.

Anesthetic Choice for Cardiovascular Implantable Electronic Device Placement and Lead Removal: A National Anesthesia Clinical Outcomes Registry Analysis.

OBJECTIVE: The authors evaluated the anesthetic approach for cardiovascular implantable electronic device (CIED) placement and transvenous lead removal, hypothesizing that monitored anesthesia care is used more frequently than general anesthesia. DESIGN: A retrospective study. SETTING: National Anesthesia Clinical Outcomes Registry data. PARTICIPANTS: Adult patients who underwent CIED (permanent cardiac pacemaker or implantable cardioverter-defibrillator [ICD]) placement or transvenous lead removal between 2010 and 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Covariates were selected a priori within multivariate models to assess predictors of anesthetic type. A total of 87,530 patients underwent pacemaker placement, 76,140 had ICD placement, 2,568 had pacemaker transvenous lead removal, and 4,861 had ICD transvenous lead extraction; 51.2%, 45.64%, 16.82%, and 45.64% received monitored anesthesia care, respectively. A 2%, 1% (both p < 0.0001), and 2% (p = 0.0003) increase in monitored anesthesia care occurred for each 1-year increase in age for pacemaker placement, ICD placement, and pacemaker transvenous lead removal, respectively. American Society of Anesthesiologists (ASA) physical status ≤III for pacemaker placement, ASA ≥IV for ICD placement, and ASA ≤III for pacemaker transvenous lead removal were 7% (p = 0.0013), 5% (p = 0.0144), and 27% (p = 0.0247) more likely to receive monitored anesthesia care, respectively. Patients treated in the Northeast were more likely to receive monitored anesthesia care than in the West for all groups analyzed (p < 0.0024). Male patients were 24% less likely to receive monitored anesthesia care for pacemaker transvenous lead removal (p = 0.0378). For every additional 10 pacemaker or ICD lead removals performed in a year, a 2% decrease in monitored anesthesia care was evident (p = 0.0271, p < 0.0001, respectively). CONCLUSIONS: General anesthesia still has a strong presence in the anesthetic management of both CIED placement and transvenous lead removal. Anesthetic choice, however, varies with patient demographics, hospital characteristics, and geographic region.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation.

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.

Early trends in ECMO mortality during the first quarters of 2019 and 2020: Could we have predicted the onset of the pandemic?

OBJECTIVE: To compare mortality trends in patients requiring Extracorporeal Membrane Oxygenation (ECMO) support between the first quarters of 2019 and 2020 and determine whether these trends might have predicted the severe acute respiratory syndrome coronavirus-2 (SARS)-Cov-2 pandemic in the United States. METHODS: We analyzed 5% Medicare claims data at aggregate, state, hospital, and encounter levels using MS-DRG (Medicare Severity-Diagnosis Related Group) codes for ECMO, combining state-level data with national census data. Necessity and sufficiency relations associated with change in mortality between the 2 years were modeled using qualitative comparative analysis (QCA). Multilevel, generalized linear modeling was used to evaluate mortality trends. RESULTS: Based on state-level data, there was a 3.36% increase in mortality between 2019 and 2020. Necessity and sufficiency evaluation of aggregate data at state and institutional levels did not identify any association or combinations of risk factors associated with this increase in mortality. However, multilevel and generalized linear models using disaggregated patient-level data to evaluate institution mortality and patient death, identified statistically significant differences between the first (p = .019) and second (p = .02) months of the 2 years, the first and second quarters (p < .001 and p = .042, respectively), and the first 6 months (p < .001) of 2019 and 2020. CONCLUSION: Mortality in ECMO patients increased significantly during the first quarter of 2020 and may have served as an early warning of the SARS-Cov-2 pandemic. Granular data shared in real-time may be used to better predict public health threats.

Incremental effect of complications on mortality and hospital costs in adult ECMO patients.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO. METHODS: Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs. RESULTS: Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529. CONCLUSION: In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis.

OBJECTIVE: The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia. DESIGN: A retrospective study. SETTING: National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States. PARTICIPANTS: Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005). CONCLUSIONS: General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

Contemporary look at extracorporeal membrane oxygenation as a bridge to reoperative lung transplantation in the United States - a retrospective study.

The purpose of this study was to examine the influence of extracorporeal membrane oxygenation (ECMO) as a bridge to reoperative lung transplantation (LT) on outcomes and survival. A total of 1960 LT recipients transplanted a second time between 2005 and 2017 were analyzed using the United Network for Organ Sharing (UNOS) Organ Procurement and Transplantation Network (OPTN). Of these recipients, 99 needed ECMO as a bridge to reoperative LT. Mean age was 50 ± 14 years, 47% were females, and the group with ECMO was younger [42 (30-59) vs. 55 (40-62) years]. In both univariate and multivariable analyses (adjusting for age and gender), the ECMO group had greater incidence of prolonged ventilation >48 h (83% vs. 40%, P < 0.001) and in-hospital dialysis (27% vs. 7%, P < 0.001). There were no differences in incidence of acute rejection (15% vs. 11%, P = 0.205), airway dehiscence (4% vs. 2%, P = 0.083), stroke (3% vs. 2%, P = 0.731), or reintubation (20% vs. 20%, P = 0.998). Kaplan-Meier survival analysis showed the ECMO group had reduced 1-year survival (66.6% vs. 83.0%, P < 0.001). After covariate adjustment, the ECMO group only had increased risk for 1-year mortality in the 2005-2011 era (HR = 2.57, 95% CI = 1.45-4.57, P = 0.001). For patients who require reoperative LT, bridging with ECMO was historically a significant predictor of poor outcome, but may be improving in recent years.

Remifentanil and perioperative glycaemic response in cardiac surgery: an open-label randomised trial.

BACKGROUND: This study investigated whether remifentanil infusion decreased intraoperative hyperglycaemia and insulin resistance compared with intermittent fentanyl administration in patients undergoing elective cardiac surgery. METHODS: This was a randomised, prospective, open-label trial. Patients undergoing elective cardiac surgery (n=116) were randomised to receive either continuous intravenous remifentanil infusion or intermittent fentanyl boluses. Hourly blood glucose values were obtained for 24 h starting from induction of anaesthesia. The difference in percentage of patients with ≥2 intraoperative blood glucose concentrations >10 mM (180 mg dl-1) between the groups was the primary outcome measure. Secondary outcome measures included insulin requirements, select stress hormone and inflammatory cytokine concentrations, and safety events and adverse outcomes. RESULTS: The trial included 106 subjects in the final intention-to-treat analysis. There were fewer patients with ≥2 intraoperative blood glucose values >10 mM (180 mg dl-1) in the remifentanil group (17 [31.5%]) compared with the fentanyl group (33 [63.5%]) (relative risk: 0.50; 95% confidence interval [CI]: 0.32-0.77; P=0.001). The administered intraoperative insulin was a median of 8.1 units (range: 0-46.7) in the fentanyl group and 2.9 units (range: 0-35.1) in the remifentanil group (median difference=5 units; 95% CI: 1-7; P=0.004). Cortisol and adrenocorticotropic hormone were increased less in the remifentanil group (P<0.001), but there was no relative decrease in this group in select inflammatory cytokines. Postoperative measures of glycaemic control and adverse clinical outcomes were not significantly different between groups. CONCLUSIONS: Compared with patients treated with intermittent fentanyl, patients receiving continuous remifentanil infusion had fewer episodes of hyperglycaemia and less need for insulin administration during the intraoperative period of cardiac surgery. CLINICAL TRIAL REGISTRATION: NCT02349152.

Lung transplantation and Affordable Care Act Medicaid expansion in the era of lung allocation score - a retrospective study.

This study evaluated the impact of Medicaid eligibility expansion (ME) on lung transplant (LT) listings and Medicaid coverage. Data on LT candidates aged 18-64 were obtained from the Scientific Registry of Transplant Recipients (N = 9153). The impact of ME was evaluated by comparing LT listings in 2011-2013 with listings in 2014-2016, as well as comparing states that had and had not adopted ME in 2014. LT listings increased by 7.7% nationally post-ME. In ME states, LT listings increased by 15.2%, whereas nonexpansion states decreased by 1.5%. LT candidates with Medicaid increased after ME nationally (8.3% vs. 9.9%, P = 0.006) and in ME states (9.7% vs. 11.5%, P = 0.036), but not in nonexpansion states (6.6% vs. 7.7%, P = 0.170). Following multivariable adjustment, LT listings in ME states had 58% greater odds for Medicaid compared to nonexpansion states (P < 0.001). Expansion of Medicaid provided greater healthcare access and increased LT listings, but only within states that adopted eligibility expansion.

Optimizing Anesthesia-Related Waste Disposal in the Operating Room: A Brief Report.

Misappropriation of noncontaminated waste into regulated medical waste (RMW) containers is a source of added expense to health care facilities. The operating room is a significant contributor to RMW waste production. This study sought to determine whether disposing of anesthesia-related waste in standard waste receptacles before patient entry into the operating room would produce a reduction in RMW. A median of 0.35 kg of waste was collected from 51 cases sampled, with a potential annual reduction of 13,800 kg of RMW to the host institution, and a cost savings of $2200.

Anesthesiologists and Disaster Medicine: A Needs Assessment for Education and Training and Reported Willingness to Respond.

BACKGROUND: Anesthesiologists provide comprehensive health care across the emergency department, operating room, and intensive care unit. To date, anesthesiologists' perspectives regarding disaster medicine and public health preparedness have not been described. METHODS: Anesthesiologists' thoughts and attitudes were assessed via a Web-based survey at 3 major academic institutions. Frequencies, percentages, and odds ratios (ORs) were used to assess self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, employee development, professional obligation, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond (WTR). Three representative disaster scenarios (natural disaster [ND], radiological event [RE], and pandemic influenza [PI]) were investigated. Results are reported as percent or OR (95% confidence interval). RESULTS: Participants included 175 anesthesiology attendings (attendings) and 95 anesthesiology residents (residents) representing a 47% and 51% response rate, respectively. A minority of attendings indicated that their hospital provides adequate pre-event preparation and training (31% [23-38] ND, 14% [9-21] RE, and 40% [31-49] PI). Few residents felt that their residency program provided them with adequate preparation and training (22% [14-33] ND, 16% [8-27] RE, and 17% [9-29] PI). Greater than 85% of attendings (89% [84-94] ND, 88% [81-92] RE, and 87% [80-92] PI) and 70% of residents (81% [71-89] ND, 71% [58-81] RE, and 82% [70-90] PI) believe that their hospital or residency program, respectively, should provide them with preparation and training. Approximately one-half of attendings and residents are confident that they would be safe at work during response to a ND or PI (55% [47-64] and 58% [49-67] of attendings; 59% [48-70] and 48% [35-61] of residents, respectively), whereas approximately one-third responded the same regarding a RE (31% [24-40] of attendings and 28% [18-41] of residents). Fewer than 40% of attendings (34% [26-43]) and residents (38% [27-51]) designated who would take care of their family obligations in the event they were called into work during a disaster. Regardless of severity, 79% (71-85) of attendings and 73% (62-82) of residents indicated WTR to a ND, whereas 81% (73-87) of attendings and 70% (58-81) of residents indicated WTR to PI. Fewer were willing to respond to a RE (63% [55-71] of attendings and 52% [39-64] of residents). In adjusted logistic regression analyses, those anesthesiologists who reported knowing one's role in response to a ND (OR, 15.8 [4.5-55.3]) or feeling psychologically prepared to respond to a ND (OR, 6.9 [2.5-19.0]) were found to be more willing to respond. Similar results were found for RE and PI constructs. Both attendings and residents were willing to respond in whatever capacity needed, not specifically to provide anesthesia. CONCLUSIONS: Few anesthesiologists reported receiving sufficient education and training in disaster medicine and public health preparedness. Providing education and training and enhancing related employee services may further bolster WTR and help to build a more capable and effective medical workforce for disaster response.

Anesthetic Choice for Percutaneous Transcatheter Closure of the Left Atrial Appendage: A National Anesthesia Clinical Outcomes Registry Analysis.

CONTEXT: Left atrial appendage closure (LAAC) was developed as a novel stroke prevention alternative for patients with atrial fibrillation, particularly for those not suitable for long-term oral anticoagulant therapy. Traditionally, general anesthesia (GA) has been more commonly used primarily due to the necessity of transesophageal echocardiography. AIMS: Compare trends of monitored anesthesia care (MAC) versus GA for percutaneous transcatheter LAAC with endocardial implant and assess for independent variables associated with primary anesthetic choice. SETTINGS AND DESIGN: Multi-institutional data collected from across the United States using the National Anesthesia Clinical Outcomes Registry. MATERIAL AND METHODS: Retrospective data analysis from 2017-2021. STATISTICAL ANALYSIS USED: Independent-sample t tests or Mann-Whitney U tests were used for continuous variables and Chi-square tests or Fisher's exact test for categorical variables. Multivariate logistic regression was used to assess patient and hospital characteristics. RESULTS: A total of 19,395 patients underwent the procedure, and 352 patients (1.8%) received MAC. MAC usage trended upward from 2017-2021 (P < 0.0001). MAC patients were more likely to have an American Society of Anesthesiologists (ASA) physical status of≥ 4 (33.6% vs 22.89%) and to have been treated at centers in the South (67.7% vs 44.2%), in rural locations (71% vs 39.5%), and with lower median annual percutaneous transcatheter LAAC volume (102 vs 153 procedures) (all P < 0.0001). In multivariate analysis, patients treated in the West had 85% lower odds of receiving MAC compared to those in the Northeast (AOR: 0.15; 95% CI 0.03-0.80, P = 0.0261). CONCLUSIONS: While GA is the most common anesthetic technique for percutaneous transcatheter closure of the left atrial appendage, a small, statistically significant increase in MAC occurred from 2017-2021. Anesthetic management for LAAC varies with geographic location.

Triple Threat: Significant Concomitant Aortic Stenosis, Mitral Stenosis, and Systolic Anterior Motion of the Mitral Valve Causing Left Ventricular Outflow Tract Obstruction in Cardiac Surgical Patients.

Systolic anterior motion (SAM) describes a pathologic condition of the mitral valve in which the anterior leaflet is displaced anteriorly, resulting in a narrowed left ventricular outflow tract (LVOT). The implications of SAM may range in severity from clinically insignificant disease to severe LVOT obstruction resulting in hemodynamic collapse. While SAM is typically observed in patients with hypertrophic cardiomyopathy or following mitral valve repair, it may be seen in any setting in which the anatomy and function of the left ventricle has been altered. Here we discuss two patients who presented for aortic and mitral valve replacements for concomitant aortic and mitral stenosis. These cases were further complicated by the preoperative diagnosis of SAM in addition to the preexisting valvular lesions, further increasing the risk of sudden hemodynamic collapse and cardiac arrest.

Decision-Making Prepandemic: University Curtailment of Academic Operations Closure Processes During the Novel Coronavirus Disease 2019 (COVID-19) Outbreak.

OBJECTIVE: Through in-depth interviews, this study aimed to understand perspectives of key stakeholders regarding the decision to curtail academic operations in the setting of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak before the declaration of a pandemic on March 11, 2020, and how such processes may be optimized in the future to best protect public health and safety. METHODS: Virtual interviews with key stakeholders from 4 academic institutions were conducted from September to December 2020 using a standardized interview question template. The interviews lasted approximately 30-45 minutes and each interview was recorded with permission. The interviews were then transcribed and reviewed for qualitative analysis. RESULTS: The decision to curtail academic operations involved several common themes, such as discussing how institutions would control the outbreak and the process of transitioning to virtual learning and remote work. Universities were monitoring other universities' responses as well as evaluating the prevalence of cases nationally and globally. Risks and challenges identified included housing for international students, financial implications, and loss of academic productivity. CONCLUSIONS: The decision-making process may be optimized in the future by focusing on communication within a smaller committee, prioritizing epidemiology over fiscal implications, and embracing an openness to consider new strategies. Further research regarding this topic should be pursued to best protect public health and safety.

Anesthetic Management of Coronary Artery Bypass Grafting in a Patient with Charcot-Marie-Tooth Disease and Multivessel Coronary Artery Disease.

BACKGROUND The anesthetic management of patients with Charcot-Marie-Tooth disease (CMT) requires special deliberation. Previous literature has suggested that patients with CMT may have increased sensitivity to non-depolarizing neuromuscular blocking agents, and hyperkalemia associated with the administration of succinylcholine has been reported. The potential risk of malignant hyperthermia and underlying cardiopulmonary abnormalities, such as pre-existing arrhythmias, cardiomyopathy, or respiratory muscle weakness, must also be considered in patients with CMT. CASE REPORT We describe a case of a patient with a history of CMT and multivessel coronary artery disease who underwent coronary artery bypass grafting (CABG). Careful consideration was given to the anesthetic plan, which consisted of thorough pre- and perioperative evaluation of cardiac function, total intravenous anesthesia with propofol and remifentanil infusions, the use of a non-depolarizing neuromuscular blocking agent, and utilization of a malignant hyperthermia protocol with avoidance of volatile anesthetics to decrease the possible risk of malignant hyperthermia. Following a 3-vessel CABG, no anesthetic or surgical complications were noted and the patient was discharged on postoperative day 6 after an uneventful hospital course. CONCLUSIONS Exacerbation of underlying cardiac and pulmonary abnormalities associated with the pathophysiology of CMT, as well as patient response to neuromuscular blocking and volatile agents, should be of concern for the anesthesiologist when anesthetizing a patient with CMT. Therefore, CMT patients undergoing surgery require special consideration of their anesthetic management plan in order to ensure patient safety and optimize perioperative outcomes.

Anesthetic choice for arteriovenous access creation: A National Anesthesia Clinical Outcomes Registry analysis.

BACKGROUND: We sought to evaluate differences in primary anesthetic type used in arteriovenous access creation with the hypothesis that administration of regional anesthesia and monitored anesthesia care (MAC) with local anesthesia as the primary anesthetic has increased over time. METHODS: National Anesthesia Clinical Outcomes Registry data were retrospectively evaluated. Covariates were selected a priori within multivariate models to determine predictors of anesthetic type in adults who underwent elective arteriovenous access creation between 2010 and 2018. RESULTS: A total of 144,392 patients met criteria; 90,741 (62.8%) received general anesthesia. The use of regional anesthesia and MAC decreased over time (8.0%-6.8%, 36.8%-27.8%, respectively; both p < 0.0001). Patients who underwent regional anesthesia were more likely to have ASA physical status >III and to reside in rural areas (52.3% and 12.9%, respectively; both p < 0.0001). Patients who underwent MAC were more likely to be older, male, receive care outside the South, and reside in urban areas (median age 65, 56.8%, 68.1%, and 70.8%, respectively; all p < 0.0001). Multivariate analysis revealed that being male, having an ASA physical status >III, and each 5-year increase in age resulted in increased odds of receiving alternatives to general anesthesia (regional anesthesia adjusted odds ratios (AORs) 1.06, 1.12, and 1.26, MAC AORs 1.09, 1.2, and 1.1, respectively; all p < 0.0001). Treatment in the Midwest, South, or West was associated with decreased odds of receiving alternatives to general anesthesia compared to the Northeast (regional anesthesia AORs 0.28, 0.38, and 0.03, all p < 0.0001; MAC 0.76, 0.13, and 0.43, respectively; all p < 0.05). CONCLUSIONS: Use of regional anesthesia and MAC with local anesthesia for arteriovenous access creation has decreased over time with general anesthesia remaining the primary anesthetic type. Anesthetic choice, however, varies with patient characteristics and geography.