Identifying Relevant Topics for Inclusion in an Ethics Curriculum for Anesthesiology Trainees: A Survey of Practitioners in the Field.

Anesthesiology training programs are tasked with equipping trainees with the skills to become medically and ethically competent in the practice of anesthesia and to be prepared to obtain board certification, yet there is currently no standardized ethics curriculum within anesthesia training programs in the United States. To bridge this gap, and to provide a validated ethics curriculum to meet the aforementioned needs, in July 2021, a survey was sent to anesthesia scholars in the field of biomedical ethics to identify key areas that should be included in such an ethics curriculum. The responses were rated on a Likert scale and ranked. This paper identifies the top ten topics identified as high priority for inclusion in an anesthesiology training program and consequently deemed most relevant to meet the educational needs of graduates of an anesthesiology residency: (1) capacity to consent; (2) capacity to refuse elective versus lifesaving treatment; (3) application of surrogate decisionmaking; (4) approach to do not resuscitate (DNR) status in the operating room; (5) patient autonomy and advance directives; (6) navigating patient beliefs that may impair care; (7) "futility" in end-of-life care: when to withdraw life support; (8) disclosure of medical errors; (9) clinical criteria for "brain death" and consequences of this definition; and (10) the impaired anesthesiologist.

Factors Associated With a Discharge Against Medical Advice From an Emergency Department in Adult Patients With Appendicitis.

BACKGROUND: Delays in care can lead to worsened outcomes with acute appendicitis. To get timely treatment, patients must consent. OBJECTIVE: To determine if there are racial and socioeconomic differences in discharge against medical advice (DAMA) rates from an emergency department after the diagnosis of acute appendicitis. METHODS: Patients were identified retrospectively from the 2019 National Emergency Department Sample. The inclusion criteria were patients 18 years of age or older with acute appendicitis. Rates were compared using chi-square or Fisher's exact test. Odds ratios were determined using multiple logistic regression. A p value of 0.05 was used to determine statistical significance. RESULTS: The overall rate of DAMA was low (0.37%). Black patients had the highest rate, and White patients had the lowest (0.72% and 0.28%, respectively, p < 0.001). When controlling for covariates, Black patients also had a higher odds ratio (OR) for DAMA (OR 1.96, 95% confidence interval [CI] 1.29-2.97). Male patients had a higher unadjusted rate (0.47% vs. 0.26% in females, p < 0.001) and were at increased risk (OR 1.78, 95% CI 1.32-2.41). Patients between 30 and 65 years old had an increased risk (OR 1.48, 95% CI 1.10-2.0). Patients with government insurance or no insurance had higher rates than private insurance (0.57% and 0.56% vs. 0.23% respectively, p < 0.001). CONCLUSION: Race, insurance status, age, and male sex were all associated with increase in DAMA. Risk stratifying patients can help to determine how to best employ mitigations strategies. Reducing DAMA may be the next area for improving reducing disparities in appendicitis care.

Factors affecting providers' comfort and fear during intubations of patients with COVID-19.

BACKGROUND: Providers performing endotracheal intubation are at high risk of contracting SARS-CoV-2. The objective was to assess various demographic, exposure and institutional preparedness factors affecting intubators' comfort and fear level during COVID-19 intubations. METHODS: We conducted a cross-sectional, survey-based study during the COVID-19 pandemic from September 2020 to January 2021 at a single academic medical centre in Washington, DC, USA. Inclusion criteria were healthcare providers who had an experience in intubating patients confirmed with or suspected of COVID-19. The survey assessed various factors related to the providers' comfort with intubation and fear during COVID-19 intubations. RESULTS: A total of 329 surveys from 55 hospitals were analysed. Of the respondents, 173 (52.6%) were from emergency medicine providers. Factors that were associated with a higher comfort level of intubating patients with COVID-19 included attending physician position (adjusted OR (aOR)=2.6, 95% CI 1.4 to 4.8; p=0.003), performing more than 20 COVID-19 intubations (aOR=3.3, 95% CI 1.5 to 6.6; p=0.002), participation in an intubation team (aOR=1.6, 95% CI 1.1 to 2.7; p=0.031) and adequate levels of personal protective equipment (PPE) (aOR=4.3, 95% CI 2.0 to 8.8; p<0.0005). Compared with emergency physicians, anaesthesiology providers had higher fear levels of contracting SARS-CoV-2 during both first and subsequent SARS-CoV-2 intubations (first: OR=1.7, 95% CI 1.1 to 2.6, p=0.006; subsequent: OR=2.0, 95% CI 1.4 to3.2, p<0.0005). CONCLUSION: A higher degree of comfort in intubating patients suspected of or confirmed with COVID-19 was demonstrated in more senior physicians, members of intubation teams, providers who performed a higher number of intubations and providers who reported adequate PPE. These findings highlight potential targets for improving the experience of providers in this setting.

Current status of point of care ultrasonography for the perioperative care of trauma patients.

PURPOSE OF REVIEW: The incorporation of point of care ultrasound into the field of anesthesiology and perioperative medicine is growing at rapid pace. The benefits of this modality align with the acuity of patient care and decision-making in anesthetic care of a trauma patient. RECENT FINDINGS: Cardiac ultrasound can be used to diagnose cardiac tamponade or investigate the inferior vena cava to assess volume status in patients who may suffer from hemorrhagic shock. Thoracic ultrasound may be used to rapidly identify pneumothorax or hemothorax in a patient suffering chest wall trauma. In addition, investigators are exploring the utility of ultrasonography in traumatic airway management and elevated intracranial pressure. In addition, the utility of gastric ultrasound on trauma patients is briefly discussed. SUMMARY: Incorporation of point of care ultrasound techniques into the practice of trauma anesthesiology is important for noninvasive, mobile and expeditious assessment of trauma patients. In addition, further large-scale studies are needed to investigate how point of care ultrasound impacts outcomes in trauma patients.

Utilization of submandibular ultrasound in assessing upper airway changes following the administration of propofol.

Background and Aims: Our study aimed to use submandibular ultrasound to measure upper airway parameters before and after induction dose of propofol in order to further understand upper airway changes that occur during induction of anesthesia. Measuring the changes that occur in airway anatomy due to the hypotonic effects of induction agents will allow for a deeper understanding of airway management. Material and Methods: We enrolled 39 patients between November 2021 and January 2022. Submandibular ultrasound was used to measure tongue thickness, geniohyoid muscle thickness, the distance between the lingual arteries (DLA), lateral pharyngeal wall thickness, and hyomental distance before and after administration of induction doses of the commonly used, sedative-hypnotic agent, propofol. Results: The mean DLA increased significantly after propofol administration, from 3.62 ± 0.63 cm to 3.79 ± 0.56 cm (P < 0.001). The mean tongue thickness was 4.89 ± 0.51 cm and decreased significantly to a mean of 4.62 ± 0.50 cm after propofol administration (P < 0.001). The change in DLA measurements after propofol administration decreased significantly as STOP-BANG score increased (r = -0.344, P = 0.037). However, DLA measurements when patients were awake increased significantly with an increase in the STOP-BANG score (r = 0.351, P = 0.031). Conclusion: These findings suggest that propofol widens and flattens the tongue, which are changes that may contribute to difficult airway management. Given the quick and non-invasive nature of ultrasound, further studies should evaluate the role of submandibular ultrasound for understanding the upper airway and airway management in various populations.

Sugammadex and blood loss during cervical spine fusion surgery.

Background and Aims: Sugammadex (SUG) has been associated with changes in coagulation studies. Most reports have concluded a lack of clinical significance based on surgical blood loss with SUG use at the end of surgery. Previous reports have not measured its use intraoperatively during ongoing blood loss. Our hypothesis was that the use of SUG intraoperatively may increase bleeding. Material and Methods: This was a single site retrospective study. Inclusion criteria were patients undergoing a primary posterior cervical spine fusion, aged over 18 years, between July 2015 and June 2021. The primary outcomes compared were intraoperative estimated blood loss (EBL) and postoperative drain output (PDO) between patients receiving SUG, neostigmine (NEO) and no NMB reversal agent. The objective was to determine if there was a difference in primary endpoints between patients administered SUG, NEO or no paralytic reversal agent. Primary endpoints were compared using analysis of variance with a P value of 0.05 used to determine statistical significance. Groups were compared using the Chi-squared test, rank sum or student's t test. A logistic regression model was constructed to account for differences between the groups. Results: There was no difference in median EBL or PDO between groups. The use of SUG was not associated with an increase in odds for >500 milliliters (ml) of EBL. Increasing duration of surgery and chronic kidney disease were both associated with an increased risk for EBL >500 ml. Conclusion: Intraoperative use of SUG was not associated with increased bleeding. Any coagulation laboratory abnormalities previously noted did not appear to have an associated clinical significance.

YouTube to Teach Central Lines, The Expert vs Learner Perspective.

PURPOSE: Instructional videos of medical procedures can be a useful guide for learners, demonstrating proper and safe technique. Open publishing sites such as YouTube are readily accessible, however the content is not peer reviewed and quality of videos vary greatly. Our aim was to evaluate a learner's ability to interpret the quality of openly published content by comparing their rating of the most popular central line insertion videos on YouTube to expert evaluations. METHOD: YouTube search results for "central line placement" sorted by views or relevance compiled a list of the four most common videos. A fifth gold standard video, published by the New England Journal, was included, however was not found in the top results. Eleven expert practitioners from varying medical specialties (Critical Care, Surgery, Anesthesia, & Emergency Medicine) evaluated the 5 videos, utilizing a 22-item Likert scaled questionnaire emphasizing: preparation, sterility, anatomy, technique, & complications. Videos were compared as a composite average of the individual items on the survey. The highest, lowest, and 3rd ranked videos were evaluated by 45 residents ("learners") in varying specialties (Internal Medicine, Emergency Medicine, Surgery, Anesthesia) and post graduate year (PGY). Learners assessed the videos using the same scale. A Welch T-test assessed statistical significance between the two groups. Subgroup analysis compared experts against different PGY and specialty cohorts. RESULTS: The lowest scored video among the experts and learners was the most popular on YouTube, with 858,933 views at the time of inclusion. Though lowest in rank, this video was judged higher by learners than the experts (2.63/5 vs 2.18/5, P = 0.0029). The 3rd ranked video by experts with 249,746 views on YouTube, was also rated higher by learners (3.77/5 vs 3.45/5, P = 0.0084). The gold standard video by NEJM had 320,580 views and was rated highest by both the experts and learners (4.37/5 vs 4.28/5, P = 0.518). Subgroup analysis showed similar results with learners rating the videos overall better than experts, this was particularly true in the PGY-1 subgroup. CONCLUSION: The most popular central line insertion video was the worst rated by both experts and learners. Learners rated all the videos better than the expert. YouTube videos demonstrating medical procedures including central line insertion should come from peer reviewed sources if they are to be incorporated into educational curriculum.

Identifying Frailty Using Point-of-Care Ultrasonography: Image Acquisition and Assessment.

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital stays, unplanned readmissions, stroke, delirium, and death. However, accessible tools for screening in clinical settings are limited. Computed tomography of the psoas muscle is the current standard imaging device for measuring frailty, but it is expensive, time-consuming, and exposes the patient to ionizing radiation. Recently, the use of point-of-care ultrasound (POCUS) has emerged as a potential tool to determine the presence of frailty and has been shown to accurately predict frailty and postoperative outcomes. In this article, we will describe the image acquisition of the quadriceps muscles and explain how they can be used to determine frailty and predict postoperative adverse events. We will present information on probe selection, patient positioning, and troubleshooting. Images from a demonstration will be used to present the POCUS technique and example results. The article will culminate in a discussion of the use of these images in medical decision-making and potential limitations.

Factors associated with unintended perianesthesia hypothermia.

Background: Our hypothesis was that total intravenous anesthesia (TIVA) is associated with an increase in hypothermia. Methods: Inclusion criteria were patients from the National Anesthesia Clinical Outcomes Registry undergoing a general anesthetic during 2019. Data collected included patient age, sex, American Society of Anesthesiologists physical status classification system score (ASAPS), duration of anesthetic, use of TIVA, type of procedure, and hypothermia. Continuous variables were compared using Student's t test or Mann Whitney rank sum as appropriate. Mixed effects multiple logistic regression was performed to determine the association between independent variables and hypothermia. Results: There was a low incidence of hypothermia (1.2%). Patients who became hypothermic were older, had a higher median ASAPS, and had a higher rate of TIVA. TIVA patients had a significantly increased odds for hypothermia when controlling for covariates. Patients undergoing obstetrical, thoracic, or radiological procedures had increased odds for hypothermia. In a matched cohort subset, TIVA was associated with a greater rate and increased odds for hypothermia. Conclusions: The novel and noteworthy finding was the association between TIVA and perianesthesia hypothermia. Thoracic, radiologic, and obstetrical procedures were associated with greater rates of and odds for hypothermia. Other identified factors can help to stratify patients for risk for hypothermia.

Modern readmission rates after head trauma.

Background: A report on head trauma using the 2014 National Readmission Database described a significant readmission rate of 8.9%. This study was undertaken to reevaluate the rate based on more granular ICD10 codes and to identify any factors associated with readmission that may be targeted to reduce readmission. Methods: Patients were identified from the 2019 National Readmission Database with an ICD10 code for head trauma. Readmission was defined as occurring within 30 days of initial hospital admission. Comparisons were made using chi square, Mann Whitney rank sum, or multivariable logistic regression. Results: The readmission rate was 5.0%. The rate was higher among men (5.6% vs 4.3%, P < 0.001) and patients ≥65 years of age (5.8% vs 3.9%, P < 0.001). Multiple injuries, discharge against medical advice, and government insurance were associated with higher rates. The mortality rate among those readmitted was 4.34%. Among patients readmitted, the most common primary nontrauma diagnoses were seizure disorder (7.7%) and cerebrovascular disease (3.4%). Younger patients had a higher rate of readmission for seizures (10.3% vs 6.1%, P < 0.001) and a lower rate of cerebrovascular disease (2.3% vs 6.4%, P = 0.004). Discussion: The readmission rate was lower than previously described. Quality metrics used by hospitals should use the revised numbers. Based on the data, we suggest possible interventions to reduce readmission, including a trial among younger men of empirical antiepileptic medications and of prophylactic or continued antibiotics among elderly patients. These interventions should be evaluated to determine if they could reduce readmission, particularly among patients who leave against medical advice.

Gastric Point of Care Ultrasound in Adults: Image Acquisition and Interpretation.

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical inquiries related to gastric content. One emerging concern pertains to patients about to undergo sedation and/or endotracheal intubation: the elevated risk of aspiration from the patient's stomach contents. Aspiration of gastric contents into the lungs poses a serious and potentially life-threatening complication. This occurs more frequently when the stomach is considered "full" and can be affected by the techniques employed for airway management, making it potentially preventable. To mitigate the risk of peri-procedural aspiration, two distinct medical specialties (anesthesiology and critical care medicine) have independently developed techniques to utilize ultrasonography for identifying patients requiring "full stomach" precautions. Due to these separate specialties, the work of each group remains relatively unfamiliar outside its respective field. This article presents descriptions of both techniques for gastric ultrasound. Furthermore, it explains how these approaches can complement each other when one of them falls short. Regarding image acquisition, the article covers the following topics: indications and contraindications, selection of the appropriate probe, patient positioning, and troubleshooting. The article also delves into image interpretation, complete with example images. Additionally, it demonstrates how one of the two techniques can be employed to estimate gastric fluid volume. Lastly, the article briefly discusses medical decision-making based on the findings of this examination.

Point-of-Care Ultrasound for the Trauma Anesthesiologist.

Purpose of Review: With advances in technology and availability of handheld ultrasound probes, studies are focusing on the perioperative care of patients, but a limited number specifically on trauma patients. This review highlights recent findings from studies using point of care ultrasound (POCUS) to improve the care of trauma patients. Recent Findings: Major findings include the use of POCUS to assess volume status of trauma patients upon arrival to measure the major vasculature. Additionally, several studies have advanced the use of POCUS to identify pneumothorax in trauma patients. Finally, the ASA POCUS certification and ASRA expert guidelines are examples of international organizations establishing guidelines for utilization and training of anesthesiologists in the field of POCUS, which will be discussed. Summary: Despite the COVID-19 pandemic, and considerable resources being diverted to fight this global healthcare crisis, advances are being made in utilization of POCUS to aid the care of trauma patients.

Utilization of submandibular ultrasound to measure oral cavity changes with interventions in routine airway management.

Ultrasound is a quick, noninvasive, inexpensive tool that can provide an accurate airway assessment. Tongue thickness, oral cavity height, and their relationship were measured using submandibular ultrasonography with and without oral airway interventions during intubation in 26 patients. The mean tongue thickness to oral cavity height ratio was 0.83 ± 0.03. The percent change of tongue thickness to oral cavity height decreased significantly by 36.47% with an oral airway and by 43.49% with laryngoscope interventions (P < 0.01). This study demonstrates how ultrasound-measured oral cavity ratios change with the placement of airway equipment, and application of these findings may advance our understanding of advanced airway management among diverse patient populations.

Role of Submandibular Ultrasound in Airway Management of a Patient With Angioedema.

Angioedema is one of several life-threatening clinical scenarios that lacks clarity on when a patient requires intubation. We present a case of angiotensin-converting enzyme-inhibitor-induced angioedema with peri-oral swelling and normal airway measurements on ultrasound, who was intubated with an abundance of caution and extubated successfully. Current tests for intubation and extubation, such as traditional bedside assessments and the cuff leak test, vary in reliability for angioedema and similar urgent situations. Submandibular ultrasound is a quick, low-cost, non-invasive method for determining quantitative criteria for and assessing when intubation and extubation is indicated, which may lead to improved quality of care and patient safety.

Usefulness of preoperative point-of-care ultrasound measurement of the lateral parapharyngeal wall to predict difficulty in mask ventilation.

Measurement of the lateral parapharyngeal wall has been shown to correlate with severity of obstructive sleep apnea, which is believed to increase risk of difficulty in mask ventilation (MV). This study aimed to assess the efficacy of using ultrasound to measure the lateral parapharyngeal wall thickness (LPWT) to predict the difficulty of MV. The LPWT was measured as the distance between the inferior border of the carotid artery and the lateral wall of the pharynx. Difficulty of MV was assessed according to an MV scale. A total of 92 patients were enrolled. Measurements of the LPWT ranged from 1.52 to 4.43 cm. There was a significant correlation between LPWT and difficulty of MV (P = 0.004). Every increase in 1 cm of LPWT was associated with an odds of increase in MV score of 3.17 (P < 0.05). With a cutoff of 3.5 cm, the area under the curve for LPWT was 0.67. The negative predictive value was 0.89, and the positive predictive value was 0.57. Use of point-of-care ultrasound to measure the LPWT shows promise in its ability to aid in airway management planning. Ultrasonic measurements of the LPWT have reasonable accuracy for predicting difficulty of MV.

Image Acquisition using Portable Sonography for Emergency Airway Management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities. Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed. Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US.

BACKGROUND: Catheter associated urinary tract infections (CAUTIs) have become a focus for reducing healthcare costs. Reimbursement may be reduced to hospitals with higher rates. The implementation of bundles or other efforts to reduce infection numbers may not be as robust at hospitals caring for more diverse patient populations. This may lead to a disparity in hospital-associated infections rates that may lead to lower reimbursement and a downward spiral of quality of care and racial disparities. METHODS: We analyzed patients in the National Trauma Data Bank from 2016 to 2017. The final analysis included patients 65 years or older with one or more day of mechanical ventilation. This was the population had the highest rate of CAUTI. We compared white patients to non-whites using students t test, Mann Whitney U test, or chi-square as appropriate. Logistic regression with odds ratios (ORs) and 95% confidence intervals (CI) was computed to identify risk factors for of CAUTI. RESULTS: Risk factors for developing a CAUTI were race (OR 1.44, 95% confidence interval (95%CI) 1.23-1.71), injury severity score (OR 1.10 per increase of one, 95% CI 1.01-1.02), care at a teaching hospital (OR 1.17, 95%CI 1.02-1.35), private insurance (OR 1.28, 95%CI 1.09-1.51), hypertension (OR 1.18, 95%CI 1.02-1.37), female gender (OR 1.54, 95%CI 1.33-1.77). Non-white patients received care at teaching hospitals more often and had a higher rate of government insurance or no insurance. DISCUSSION: The Center for Medicare and Medicaid Services (CMS) has put in place a reimbursement modification 87 plan based on the rates of hospital-associated infections including CAUTIs. We have demonstrated non-white 88 patients have higher odds for developing a CAUTI. CONCLUSION: CMS may potentially worsen the racial disparity by further cutting reimbursement to hospitals who care for higher proportions of non-whites.

Hospital-Based Healthcare Worker Perceptions of Personal Risk Related to COVID-19: One Year Follow-Up.

BACKGROUND: The COVID-19 pandemic has significantly impacted health care workers (HCW). Most research focused on the adverse mental health effects during the initial surge of cases; and yet little is known about approximately how workers are faring 1 year into the pandemic. The objective of this study is to examine stress, burnout, and risk perception in an academic medical system, 1 year after the start of the pandemic. METHODS: HCW across care specialties participated in online surveys in Spring 2020 and Spring 2021. The surveys included questions related to workplace stress and risk perception related to COVID-19. Correlates of stress and burnout were explored using multivariable linear regression models. Professional Quality of Life Scale (PROQOL) questions were added to the second survey. RESULTS: While HCW reported significantly fewer concerns about the risk of COVID-19 transmission to themselves and their families during the 2021 survey (compared with 2020), the percentage of workers who reported feeling excess stress at work or considered resigning stayed the same. One year into the pandemic, 57% of study participants met criteria for moderate or high levels of traumatic stress and 75% met criteria for moderate or high levels of burnout. As compared with participants who cared for no COVID-19 deaths, participants who cared for COVID-19 patients who died had significantly higher traumatic stress (1 to 10: Coef. = 2.7, P = .007; >10: Coef. = 6.7, P < .001) and burnout scores (1 to 10: Coef. = 2.7, P = .004; >10: Coef. = 2.6, P = .036). CONCLUSION: While Although perceptions of risk declined over the course of the year, levels of stress still remained high despite high vaccination rates. Those who witnessed more COVID-19 deaths were more likely to report increased burnout and post-traumatic stress. As our nation continues to grapple with the COVID-19 pandemic and new variants emerge it is imperative to focus on recovery strategies for high burnout groups to ensure the wellbeing of our health care workforce.

Socioeconomic Disparities in Method of Anesthesia for Knee Arthroplasties in the US.

INTRODUCTION: Knee arthroplasty (KA) can be performed using general anesthesia (GA), neuraxial anesthesia (NA) or regional anesthesia (RA). We believe proportion of types of anesthetics have changed but that there is a disparity based on socioeconomic factors. METHODS: Unadjusted rates and adjusted odds ratios for the use of RA or PNB were compared between groupings of patients based on socioeconomic status. RESULTS: General anesthesia is the most common (49.7%) while NA (39.4%) and RA (10.9%) were the second and third. University hospitals and patient home ZIP Code median income had the strongest association with RA as a (adjusted odds ratio (AOR) 26.3, 95% confidence interval (95%CI) 22.1-31.3, p<.01 and AOR 7.58, 95% CI 7.20-7.98, p<.01). CONCLUSION: General anesthesia is the most common but the rate of alternative forms of primary anesthesia type have changed over time. Disparities exist in anesthesia care which are associated with income levels.

Impact of COVID-19 specific simulation training in improving intubators' level of comfort during intubations of COVID-19 patients - Results from a USA national survey.

Background: Tracheal intubation is a hazardous aerosolizing procedure with a potential risk of spreading SAR-CoV-2 between patients and physicians. Aim: The purpose of this study was to explore the impact of COVID-19 specific simulation training in improving provider level of comfort during the intubation of COVID-19 patients. Methods: In this cross-sectional national study, an electronic survey was disseminated using a snowball sample approach to intubators from 55 hospitals across the United States. The survey assessed providers' comfort of intubating and fear of contracting the virus during COVID-19 intubations. Results: A total of 329 surveys from 55 hospitals were analyzed. Of 329 providers, 111 providers (33.7%) reported participating in simulation training. Of those, 86 (77.5%) reported that the simulation training helped reduce their fear of intubating COVID-19 patients. Providers in the simulation training group also reported a higher level of comfort level with intubating both general patients (median [range] no-simulation training group 9 [3-10], simulation training group 9 [6-10]; p = 0.015) and COVID-19 patients (no-ST 8 [1-10], ST group 9 [4-10]; p < 0.0005) than providers in the no-simulation training group. Conclusions: Our study suggests that COVID-19 specific intubation simulation training promotes provider comfort. Simulation training may be implemented as part of airway management training during the current and novel pandemic situations.