Pro-Con Debate: Perioperative Research Should Be Color-Blind.

Profound racial and ethnic disparities have been documented in health and health care outcomes in recent decades. Some researchers have erroneously ascribed these inequities to biological variations, prompting debate as to how, or even if, race and ethnicity should be included as an outcome variable. Color blindness is a racial ideology with roots in constitutional law that posits that equality is best achieved by disregarding the racial and ethnic characteristics of the individual. Color consciousness, in contrast, approaches disparities with the knowledge that experiences related to one's race and ethnicity influence an individual's health and well-being. In this Pro-Con commentary article, we discuss the concept of color blindness and debate its use as an approach in medicine and research.

The Management of Pregnant Trauma Patients: A Narrative Review.

Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.

The Anesthesiology Physician-Scientist Pipeline: Current Status and Recommendations for Future Growth-An Initiative of the Anesthesia Research Council.

The limited number and diversity of resident physicians pursuing careers as physician-scientists in medicine has been a concern for many decades. The Anesthesia Research Council aimed to address the status of the anesthesiology physician-scientist pipeline, benchmarked against other medical specialties, and to develop strategic recommendations to sustain and expand the number and diversity of anesthesiology physician-scientists. The working group analyzed data from the Association of American Medical Colleges and the National Resident Matching Program to characterize the diversity and number of research-oriented residents from US and international allopathic medical schools entering 11 medical specialties from 2009 to 2019. Two surveys were developed to assess the research culture of anesthesiology departments. National Institutes of Health (NIH) funding information awarded to anesthesiology physician-scientists and departments was collected from NIH RePORTER and the Blue Ridge Medical Institute. Anesthesiology ranked eighth to tenth place of 11 medical specialties in the percent of "research-oriented" entering residents, defined as those with advanced degrees (Master's or PhDs) in addition to the MD degree or having published at least 3 research publications before residency. Anesthesiology ranked eighth of 11 specialties in the percent of entering residents who were women but ranked fourth of 11 specialties in the percent of entering residents who self-identified as belonging to an underrepresented group in medicine. There has been a 72% increase in both the total NIH funding awarded to anesthesiology departments and the number of NIH K-series mentored training grants (eg, K08 and K23) awarded to anesthesiology physician-scientists between 2015 and 2020. Recommendations for expanding the size and diversity of the anesthesiology physician-scientist pipeline included (1) developing strategies to increase the number of research intensive anesthesiology departments; (2) unifying the diverse programs among academic anesthesiology foundations and societies that seek to grow research in the specialty; (3) adjusting American Society of Anesthesiologists metrics of success to include the number of anesthesiology physician-scientists with extramural research support; (4) increasing the number of mentored awards from Foundation of Anesthesia Education and Research (FAER) and International Anesthesia Research Society (IARS); (5) supporting an organized and concerted effort to inform research-oriented medical students of the diverse research opportunities within anesthesiology should include the specialty being represented at the annual meetings of Medical Scientist Training Program (MSTP) students and the American Physician Scientist Association, as well as in institutional MSTP programs. The medical specialty of anesthesiology is defined by new discoveries and contributions to perioperative medicine which will only be sustained by a robust pipeline of anesthesiology physician-scientists.

A Century of Progress and Collaboration Between Obstetric Anesthesiologists, Anesthesia & Analgesia, and the International Anesthesia Research Society.

The past century has seen significant advances in the practice of obstetric anesthesiology. This article will review the role of Anesthesia & Analgesia and the International Anesthesia Research Society in contributing to fundamental paradigm shifts in our understanding of obstetric anesthesiology.

Readability, Content, and Quality of Online Patient Education Materials on Anesthesia and Neurotoxicity in the Pediatric Population.

OBJECTIVE: Internet-based patient education materials (PEMs) are often above the recommended sixth grade reading level recommended by the U.S. Department of Health and Human Services. In 2016 the U.S. Food and Drug Administration (FDA) released a warning statement against use of general anesthetic drugs in children and pregnant women due to concerns about neurotoxicity. The aim of this study is to evaluate readability, content, and quality of Internet-based PEMs on anesthesia in the pediatric population and neurotoxicity. STUDY DESIGN: The websites of U.S. medical centers with pediatric anesthesiology fellowship programs were searched for PEMs pertaining to pediatric anesthesia and neurotoxicity. Readability was assessed. PEM content was evaluated using matrices specific to pediatric anesthesia and neurotoxicity. PEM quality was assessed with the Patient Education Material Assessment Tool for Print. A one-sample t-test was used to compare the readability of the PEMs to the recommended sixth grade reading level. RESULTS: We identified 27 PEMs pertaining to pediatric anesthesia and eight to neurotoxicity. Mean readability of all PEMs was greater than a sixth grade reading (p <0.001). While only 13% of PEMs on anesthesia for pediatric patient mentioned the FDA warning, 100% of the neurotoxicity materials did. PEMs had good understandability (83%) and poor actionability (60%). CONCLUSION: The readability, content, and quality of PEMs are poor and should be improved to help parents and guardians make informed decisions about their children's health care. KEY POINTS: · The FDA issued a warning statement against the use of general anesthetic drugs in children and pregnant women.. · Readability, content, and quality of Internet-based patient education materials on the topic of neurotoxicity are poor.. · Improving the readability, content, and quality of PEMs could aid parents in making important health care decisions..

Impaired motor cortical plasticity associated with cannabis use disorder in young adults.

Maladaptive cortical plasticity has been described in individuals with heroin and methamphetamine addiction and may mediate other substance abuse disorders. It is unknown whether cannabis dependence in humans alters the capacity for induction of cortical plasticity. The aim of this study was to non-invasively investigate cortical plasticity with transcranial magnetic stimulation in young adults who meet DSM-5 criteria for cannabis use disorder (CUD). Thirty men (ages 20- 30) who used cannabis daily over the previous 6 months (15 diagnosed of CUD) and 15 demographically matched non-users were enrolled in this study. All participants underwent two sessions of theta burst stimulation (TBS) in which either continuous TBS (cTBS; 600 pulses, 80% active motor threshold) or intermittent TBS (iTBS; 2-s train of cTBS repeated every 10 s for a total of 190 s, 600 pulses) was applied over the primary motor cortex. The effects of these protocols were assessed by analysing the contralateral motor evoked potentials (MEPs). The relationships between cortical plasticity and problematic cannabis use, degree of dependence, and nicotine addiction were also investigated. Significant MEP inhibition after cTBS was observed in both cannabis users without CUD and non-users, while this inhibition was not seen in cannabis users with CUD. Strikingly, less motor cortical plasticity was observed in subjects with severe problematic cannabis use. No significant differences between users and non-users were found in the iTBS-induced cortical plasticity measures. Our study provides the first evidence of maladaptive cortical plasticity associated with cannabis use disorder and problematic cannabis use in humans.

Prophylactic Intrathecal Morphine and Prevention of Post-Dural Puncture Headache: A Randomized Double-blind Trial.

BACKGROUND: Prophylactic epidural morphine administration after unintentional dural puncture with a large-bore needle has been shown to decrease the incidence of post-dural puncture headache. The authors hypothesized that prophylactic administration of intrathecal morphine would decrease the incidence of post-dural puncture headache and/or need for epidural blood patch after unintentional dural puncture. METHODS: Parturients with an intrathecal catheter in situ after unintentional dural puncture with a 17-g Tuohy needle during intended epidural catheter placement for labor analgesia were enrolled in this randomized, double-blind trial. After delivery, subjects were randomized to receive intrathecal morphine 150 µg or normal saline. The primary outcome was the incidence of post-dural puncture headache. Secondary outcomes included onset, duration, and severity of post-dural puncture headache, the presence of cranial nerve symptoms and the type of treatment the patient received. RESULTS: Sixty-one women were included in the study. The incidence of post-dural puncture headache was 21 of 27 (78%) in the intrathecal morphine group and 27 of 34 (79%) in the intrathecal saline group (difference, -1%; 95% CI, -25% to 24%). There were no differences between groups in the onset, duration, or severity of headache, or presence of cranial nerve symptoms. Epidural blood patch was administered to 10 of 27 (37%) of subjects in the intrathecal morphine and 11 of 21 (52%) of the intrathecal saline group (difference 15%; 95% CI, -18% to 48%). CONCLUSIONS: The present findings suggest that a single prophylactic intrathecal morphine dose of 150 µg administered shortly after delivery does not decrease the incidence or severity of post-dural puncture headache after unintentional dural puncture. This study does not support the clinical usefulness of prophylactic intrathecal morphine after an unintentional dural puncture.

Resident Competency and Proficiency in Combined Spinal-Epidural Catheter Placement Is Improved Using a Computer-Enhanced Visual Learning Program: A Randomized Controlled Trial.

BACKGROUND: Physician educators must balance the need for resident procedural education with clinical time pressures as well as patient safety and comfort. Alternative educational strategies, including e-learning tools, may be beneficial to orient novice learners to new procedures and speed proficiency. We created an e-learning tool (computer-enhanced visual learning [CEVL] neuraxial) to enhance trainee proficiency in combined spinal-epidural catheter placement in obstetric patients and performed a randomized controlled 2-center trial to test the hypothesis that use of the tool improved the initial procedure performed by the anesthesiology residents. METHODS: Anesthesiology residents completing their first obstetric anesthesiology rotation were randomized to receive online access to the neuraxial module (CEVL group) or no access (control) 2 weeks before the rotation. On the first day of the rotation, residents completed a neuraxial procedure self-confidence scale and an open-ended medical knowledge test. Blinded raters observed residents performing combined spinal-epidural catheter techniques in laboring parturients using a procedural checklist (0-49 pts); the time required to perform the procedure was recorded. The primary outcome was the duration of the procedure. RESULTS: The CEVL group had significantly shorter mean (±standard deviation) procedure time compared to the control group 22.5 ± 4.9 vs 39.5 ± 7.1 minutes (P < .001) and had higher scores on the overall performance checklist 36.4 ± 6.6 vs 28.8 ± 7.1 (P = .012). The intervention group also had higher scores on the open-ended medical knowledge test (27.83 ± 3.07 vs 22.25 ± 4.67; P = .002), but self-confidence scores were not different between groups (P = .64). CONCLUSIONS: CEVL neuraxial is a novel prerotation teaching tool that may enhance the traditional initial teaching of combined spinal-epidural procedures in obstetric anesthesiology. Future research should examine whether the use of web-based learning tools impacts long-term provider performance or patient outcomes.

Status of Women in Academic Anesthesiology: A 10-Year Update.

BACKGROUND: Gender inequity is still prevalent in today's medical workforce. Previous studies have investigated the status of women in academic anesthesiology. The objective of this study is to provide a current update on the status of women in academic anesthesiology. We hypothesized that while the number of women in academic anesthesiology has increased in the past 10 years, major gender disparities continue to persist, most notably in leadership roles. METHODS: Medical student, resident, and faculty data were obtained from the Association of American Medical Colleges. The number of women in anesthesiology at the resident and faculty level, the distribution of faculty academic rank, and the number of women chairpersons were compared across the period from 2006 to 2016. The gender distribution of major anesthesiology journal editorial boards and data on anesthesiology research grant awards, among other leadership roles, were collected from websites and compared to data from 2005 and 2006. RESULTS: The number (%) of women anesthesiology residents/faculty has increased from 1570 (32%)/1783 (29%) in 2006 to 2145 (35%)/2945 (36%) in 2016 (P = .004 and P < .001, respectively). Since 2006, the odds that an anesthesiology faculty member was a woman increased approximately 2% per year, with an estimated odds ratio of 1.02 (95% confidence interval, 1.014-1.025; P < .001). In 2015, the percentage of women anesthesiology full professors (7.4%) was less than men full professors (17.3%) (difference, -9.9%; 95% confidence interval of the difference, -8.5% to -11.3%; P < .001). The percentage of women anesthesiology department chairs remained unchanged from 2006 to 2016 (12.7% vs 14.0%) (P = .75). To date, neither Anesthesia & Analgesia nor Anesthesiology has had a woman Editor-in-Chief. The percentage of major research grant awards to women has increased significantly from 21.1% in 1997-2007 to 31.5% in 2007-2016 (P = .02). CONCLUSIONS: Gender disparities continue to exist at the upper levels of leadership in academic anesthesiology, most importantly in the roles of full professor, department chair, and journal editors. However, there are some indications that women may be on the path to leadership parity, most notably, the growth of women in anesthesiology residencies and faculty positions and increases in major research grants awarded to women.

Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study.

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.

Postpartum hemorrhage revisited: new challenges and solutions.

PURPOSE OF REVIEW: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the United States, and worldwide. Recognition of PPH is challenging, but once hemorrhage is recognized, management needs to focus on achieving adequate uterine tone and maintaining maternal hemodynamic stability. There have been several advances in the management of postpartum hemorrhage, many of which can be implemented at the labor and delivery unit level. RECENT FINDINGS: There have been many advances in the understanding of at-risk parturients, and the use of hemorrhage protocols and safety bundles have been shown to improve patient outcomes. There are many new advances in transfusion management (e.g. fibrinogen concentrate, prothrombin complex concentrate, tranexamic acid) that can compliment traditional component therapy. Consideration should be given to transferring women at high risk for complications (e.g. invasive placentation) to a higher level facility for delivery. SUMMARY: Although postpartum hemorrhage itself may not be preventable, early identification of blood loss, and mobilization of resources may prevent adverse outcomes. Multidisciplinary planning at the system level, ensuring that hemorrhage protocols exist, as well as for management of high-risk patients is important for improving patient outcomes.

Effect of Epidural Infusion Bolus Delivery Rate on the Duration of Labor Analgesia: A Randomized Clinical Trial.

BACKGROUND: Programmed intermittent boluses of local anesthetic have been shown to be superior to continuous infusions for maintenance of labor analgesia. High-rate epidural boluses increase delivery pressure at the catheter orifice and may improve drug distribution in the epidural space. We hypothesized that high-rate drug delivery would improve labor analgesia and reduce the requirement for provider-administered supplemental boluses for breakthrough pain. METHODS: Nulliparous women with a singleton pregnancy at a cervical dilation of less than or equal to 5 cm at request for neuraxial analgesia were eligible for this superiority-design, double-blind, randomized controlled trial. Neuraxial analgesia was initiated with intrathecal fentanyl 25 µg. The maintenance epidural solution was bupivacaine 0.625 mg/ml with fentanyl 1.95 µg/ml. Programmed (every 60 min) intermittent boluses (10 ml) and patient controlled bolus (5 ml bolus, lockout interval: 10 min) were administered at a rate of 100 ml/h (low-rate) or 300 ml/h (high-rate). The primary outcome was percentage of patients requiring provider-administered supplemental bolus analgesia. RESULTS: One hundred eight women were randomized to the low- and 102 to the high-rate group. Provider-administered supplemental bolus doses were requested by 44 of 108 (40.7%) in the low- and 37 of 102 (36.3%) in the high-rate group (difference -4.4%; 95% CI of the difference, -18.5 to 9.1%; P = 0.67). Patient requested/delivered epidural bolus ratio and the hourly bupivacaine consumption were not different between groups. No subject had an adverse event. CONCLUSIONS: Labor analgesia quality, assessed by need for provider- and patient-administered supplemental analgesia and hourly bupivacaine consumption was not improved by high-rate epidural bolus administration.

The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants.

Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism-related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies' recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk-benefit discussions with patients and facilitate shared decision making.

Disparities in the Use of Seizure Medications After Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: We investigated potential disparities in the use of prophylactic seizure medications in patients with intracerebral hemorrhage. METHODS: Review of multicenter electronic health record (EHR) data with simultaneous prospective data recording. EHR data were retrieved from HealthLNK, a multicenter EHR repository in Chicago, Illinois, from 2006 to 2012 (multicenter cohort). Additional data were prospectively coded (single-center cohort) from 2007 through 2015. RESULTS: The multicenter cohort comprised 3422 patients from 4 HealthLNK centers. Use of levetiracetam varied by race/ethnicity (P=0.0000008), with whites nearly twice as likely as blacks to be administered levetiracetam (odds ratio: 1.71; 95% confidence interval, 1.43-2.05; P<0.0001). In the single-center cohort (n=450), hematoma location, older age, depressed consciousness, larger hematoma volume, no alcohol abuse, and race/ethnicity were associated with levetiracetam administration (P≤0.04). Whites were nearly twice as likely as blacks to receive levetiracetam (odds ratio: 1.9; 95% confidence interval, 1.25-2.89; P=0.002); however, the association was confounded by history of hypertension, higher blood pressure on admission, and deep hematoma location. Only hematoma location was independently associated with levetiracetam administration (P<0.00001), rendering other variables, including race/ethnicity, nonsignificant. CONCLUSIONS: Although multicenter EHR data showed apparent racial/ethnic disparities in the use of prophylactic seizure medications, a more complete single-center cohort found the apparent disparity to be confounded by the clinical factors of hypertension and hematoma location. Disparities in care after intracerebral hemorrhage are common; however, administrative data may lead to the discovery of disparities that are confounded by detailed clinical data not readily available in EHRs.

Association between Intrapartum Magnesium Administration and the Incidence of Maternal Fever: A Retrospective Cross-sectional Study.

BACKGROUND: Intrapartum maternal fever is associated with several adverse neonatal outcomes. Intrapartum fever can be infectious or inflammatory in etiology. Increases in interleukin 6 and other inflammatory markers are associated with maternal fever. Magnesium has been shown to attenuate interleukin 6-mediated fever in animal models. We hypothesized that parturients exposed to intrapartum magnesium would have a lower incidence of fever than nonexposed parturients. METHODS: In this study, electronic medical record data from all deliveries at Northwestern Memorial Hospital (Chicago, Illinois) between 2007 and 2014 were evaluated. The primary outcome was intrapartum fever (temperature at or higher than 38.0°C). Factors associated with the development of maternal fever were evaluated using a multivariable logistic regression model. Propensity score matching was used to reduce potential bias from nonrandom selection of magnesium administration. RESULTS: Of the 58,541 women who met inclusion criteria, 5,924 (10.1%) developed intrapartum fever. Febrile parturients were more likely to be nulliparous, have used neuraxial analgesia, and have been delivered via cesarean section. The incidence of fever was lower in women exposed to magnesium (6.0%) than those who were not (10.2%). In multivariable logistic regression, women exposed to magnesium were less likely to develop a fever (adjusted odds ratio = 0.42 [95% CI, 0.31 to 0.58]). After propensity matching (N = 959 per group), the odds ratio of developing fever was lower in women who received magnesium therapy (odds ratio = 0.68 [95% CI, 0.48 to 0.98]). CONCLUSIONS: Magnesium may play a protective role against the development of intrapartum fever. Future work should further explore the association between magnesium dosing and the incidence of maternal fever.