Misinterpretation of USP 797 Continues No abstract available

Decoupling Complexity in Perioperative Systems No abstract available

In Response No abstract available

Intraoperative Awareness With Recall: A Descriptive, Survey-Based, Cohort Study BACKGROUND: Unintended intraoperative awareness with recall (AWR) is a potential complication of general anesthesia. Patients typically report recollections of (1) hearing sounds or conversations, (2) being unable to breathe or move, (3), feeling pain, and/or (4) experiencing emotional distress. The purpose of the current study was to identify and further characterize AWR experiences identified through postoperative surveys of a large unselected adult surgical cohort. METHODS: This is a substudy of a prospective registry study, which surveys patients on their health and well-being after surgery. Responses to 4 questions focusing on AWR were analyzed. Patients who reported AWR with pain, paralysis, and/or distress were contacted by telephone to obtain more information about their AWR experience. The interview results for patients who received general anesthesia were sent to 3 anesthesiologists, who adjudicated the reported AWR episodes. RESULTS: Of 48,151 surveys sent, 17,875 patient responses were received. Of these respondents, 622 reported a specific memory from the period between going to sleep and waking up from perceived general anesthesia and 282 of these reported related pain, paralysis, and/or distress. An attempt was made to contact these 282 patients, and 149 participated in a telephone survey. Among the 149 participants, 87 endorsed their prior report of AWR. However, only 22 of these patients had received general anesthesia, while 51 received only sedation and 14 received regional anesthesia. Three anesthesiologists independently adjudicated the survey results of the 22 general anesthesia cases and assigned 6 as definite AWR, 8 as possible AWR, and 8 as not AWR episodes. Of the 65 patients who confirmed their report of AWR after regional or sedation anesthesia, 37 (31 with sedation and 6 with regional anesthesia) had not expected to be conscious during surgery. CONCLUSIONS: The complication of AWR continues to occur during intended general anesthesia. Many reports of AWR episodes occur in patients receiving sedation or regional anesthesia and relate to incorrect expectations regarding anesthetic techniques and conscious experiences, representing a potential target for intervention. Accepted for publication June 24, 2019. Funding: The study was supported by departmental resources (to Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys [SATISFY-SOS]) and a Barnes-Jewish Hospital Foundation (BJHF) grant 7937–77 from the Barnes-Jewish Hospital Foundation, St Louis, Missouri (to M.S.A.). Conflicts of Interest: See Disclosures at the end of the article. The study was presented, in part, at the annual meeting of the International Anesthesia Research Society, May 18, 2019, Montreal, Quebec, Canada. Reprints will not be available from the authors. Address correspondence to Anna Maria Bombardieri, MD, PhD, Department of Anesthesiology, Washington University School of Medicine in St Louis, 660 S Euclid Ave, Campus Box 8054, St Louis, MO 63110. Address e-mail to annamariabombardieri@wustl.edu. © 2019 International Anesthesia Research Society

Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study BACKGROUND: District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs. METHODS: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision. RESULTS: Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment. CONCLUSIONS: Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists—measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies—are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA. Accepted for publication July 1, 2019. Funding: The Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project is funded by the European Union Horizon 2020 Programme for Research and Innovation, under grant agreement No. 733391. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Jakub Gajewski, PhD, Institute of Global Surgery, Royal College of Surgeons in Ireland, Lower Mercer St, Dublin 2, Ireland. Address e-mail to jakubgajewski@rcsi.ie. © 2019 International Anesthesia Research Society

A Novel 3-Dimensional Approach for the Echocardiographic Evaluation of Mitral Valve Area After Repair for Degenerative Disease BACKGROUND: Currently available 2-dimensional (2D) echocardiographic methods for accurately assessing the mitral valve orifice area (MVA) after mitral valve repair (MVr) are limited due to its complex 3-dimensional (3D) geometry. We compared repaired MVAs obtained with commonly used 2D and 3D echocardiographic methods to a 3D orifice area (3DOA), which is a novel echocardiographic measurement and independent of geometric assumptions. METHODS: Intraoperative 2D and 3D transesophageal echocardiography (TEE) images from 20 adult cardiac surgery patients who underwent MVr for mitral regurgitation obtained immediately after repair were retrospectively reviewed. MVAs obtained by pressure half-time (PHT), 2D planimetry (2DP), and 3D planimetry (3DP) were compared to those derived by 3DOA. RESULTS: MVAs (mean value ± standard deviation [SD]) after MVr were obtained by PHT (3 ± 0.6 cm2), 2DP (3.58 ± 0.75 cm2), 3D planimetry (3DP; 2.78 ± 0.74 cm2), and 3DOA (2.32 ± 0.76 cm2). MVAs obtained by the 3DOA method were significantly smaller compared to those obtained by PHT (mean difference, 0.68 cm2; P = .0003), 2DP (mean difference, 1.26 cm2; P < .0001), and 3DP (mean difference, 0.46 cm2; P = .003). In addition, MVA defined as an area ≤1.5 cm2 was identified by 3DOA in 2 patients and by 3DP in 1 patient. CONCLUSIONS: Post-MVr MVAs obtained using the novel 3DOA method were significantly smaller than those obtained by conventional echocardiographic methods and may be consistent with a higher incidence of MVA reduction when compared to 2D techniques. Further studies are still needed to establish the clinical significance of 3D echocardiographic techniques used to measure MVA after MVr. Accepted for publication July 11, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Sergey Karamnov, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115. Address e-mail to skaramnov@bwh.harvard.edu. © 2019 International Anesthesia Research Society

How Do Common Comorbidities Modify the Association of Frailty With Survival After Elective Noncardiac Surgery? A Population-Based Cohort Study BACKGROUND: Older people with frailty have decreased postoperative survival. Understanding how comorbidities modify the association between frailty and survival could improve risk stratification and guide development of interventions. Therefore, we evaluated whether the concurrent presence of common and high-risk comorbidities (dementia, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes mellitus, heart failure [HF]) in conjunction with frailty might be associated with a larger decrease in postoperative survival after major elective surgery than would be expected based on the presence of the comorbidity and frailty on their own. METHODS: This cohort study used linked administrative data from Ontario, Canada to identify adults >65 years having elective noncardiac surgery from 2010 to 2015. Frailty was identified using a validated index; comorbidities were identified with validated codes. We evaluated the presence of effect modification (also called interaction) between frailty and each comorbidity on (1) the relative (or multiplicative) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was different than the product of the risks associated with each condition; and (2) the absolute risk difference (or additive) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was greater than the sum of the risks associated with each condition. RESULTS: 11,150 (9.7%) people with frailty died versus 7826 (2.8%) without frailty. After adjustment, frailty was associated with decreased survival (adjusted hazard ratio [HR] = 2.42; 95% confidence interval [CI], 2.31–2.54). On the relative (multiplicative) scale, only diabetes mellitus demonstrated significant effect modification (P value for interaction .03; reduced risk together). On the absolute risk difference (additive) scale, all comorbidities except for coronary disease demonstrated effect modification of the association of frailty with survival. Co-occurrence of dementia with frailty carried the greatest excess risk (Synergy Index [S; the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation] = 2.29; 95% CI, 1.32–10.80, the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation). CONCLUSIONS: Common comorbidities modify the association of frailty with postoperative survival; however, this effect was only apparent when analyses accounted for effect modification on the absolute risk difference, as opposed to relative scale. While the relative scale is more commonly used in biomedical research, smaller effects may be easier to detect on the risk difference scale. The concurrent presence of dementia, COPD, and HF with frailty were all associated with excess mortality on the absolute risk difference scale. Accepted for publication July 16, 2019. Funding: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. These data sets were held securely in a linked, deidentified form and analyzed at the Institute for Clinical Evaluative Sciences. This study used the Johns Hopkins ACG System v10. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Daniel I. McIsaac, MD, MPH, FRCPC, Department of Anesthesiology, The Ottawa Hospital, Room B311, Civic Campus, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada. Address e-mail to dmcisaac@toh.ca. © 2019 International Anesthesia Research Society

Electroencephalographic Findings and Clinical Behavior During Induction of Anesthesia With Sevoflurane in Human Infants: A Prospective Observational Study Seizures and interictal epileptiform discharges (IEDs) have been described during sevoflurane. We prospectively estimated their incidence in 54 otherwise neurologically healthy infants by obtaining the full-head video electroencephalogram (EEG). No infants had clinical seizures, but 1 had an electrographic seizure; 3 others had focal IEDs (7.4%; 95% confidence interval [CI], 2.1%–17.9%). We detected no differences in demographic or clinical characteristics between normal and abnormal EEG groups. Diffuse slowing was the most common initial EEG change followed by fast (α, β) activity in all head leads. Larger studies with more statistical power are needed to further investigate the hypotheses generated with this research. Accepted for publication July 11, 2019. Funding: The research described was supported by institutional and departmental sources (the Department of Anesthesiology and The Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine) as well as National Institutes of Health (NIH)/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore Clinical and Translational Sciences Award (CTSA) Grant Number UL1TR001073. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Jerry Y. Chao, MD, MSc, Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467. Address e-mail to jechao@montefiore.org. © 2019 International Anesthesia Research Society

The Pediatric Procedural Sedation Handbook No abstract available

Point-of-Care Ultrasound for Obstructive Sleep Apnea Screening: Are We There Yet? A Systematic Review and Meta-analysis BACKGROUND: Perioperative diagnosis of obstructive sleep apnea (OSA) has important resource implications as screening questionnaires are overly sensitive, and sleep studies are expensive and time-consuming. Ultrasound (US) is a portable, noninvasive tool potentially useful for airway evaluation and OSA screening in the perioperative period. The objective of this systematic review was to evaluate the correlation of surface US with OSA diagnosis and to determine whether a point-of-care ultrasound (PoCUS) for OSA screening may help with improved screening in perioperative period. METHODS: A search of all electronic databases including Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from database inception to September 2017. Inclusion criteria were observational cohort studies and randomized controlled trials of known or suspected OSA patients undergoing surface US assessment. Article screening, data extraction, and summarization were conducted by 2 independent reviewers with ability to resolve conflict with supervising authors. Diagnostic properties and association between US parameters (index test) and OSA diagnosis using sleep study (reference standard) were evaluated. The US parameters were divided into airway and nonairway parameters. A random-effects meta-analysis was planned, wherever applicable. RESULTS: Of the initial 3865 screened articles, 21 studies (7 airway and 14 nonairway) evaluating 3339 patients were included. Majority of studies were conducted in the general population (49%), respirology (23%), and sleep clinics (12%). No study evaluated the use of US for OSA in perioperative setting. Majority of included studies had low risk of bias for reference standard and flow and timing. Airway US parameters having moderate–good correlation with moderate–severe OSA were distance between lingual arteries (DLAs > 30 mm; sensitivity, 0.67; specificity, 0.59; 1 study/66 patients); mean resting tongue thickness (>60 mm; sensitivity, 0.85; specificity, 0.59; 1 study/66 patients); tongue base thickness during Muller maneuver (MM; sensitivity, 0.59; specificity, 0.78; 1 study/66 patients); and a combination of neck circumference and retropalatal (RP) diameter shortening during MM (sensitivity, 1.0; specificity, 0.65; 1 study/104 patients). Nonairway US parameters having a low–moderate correlation with moderate–severe OSA were carotid intimal thickness (pooled correlation coefficient, 0.444; 95% confidence interval [CI], 0.320–0.553; P value = .000, 8 studies/727 patients) and plaque presence (sensitivity, 0.24–0.75; specificity, 0.13–1.0; 4 studies/1183 patients). CONCLUSIONS: We found that a number of airway and nonairway parameters were identified with moderate to good correlation with OSA diagnosis in the general population. In future studies, it remains to be seen whether PoCUS screening for a combination of these parameters can address the pitfalls of OSA screening questionnaires. Accepted for publication June 24, 2019. Funding: This work was funded by Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Mandeep Singh, MD, MSc, Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, McL 2-405, Toronto, ON M5T 2S8, Canada. Address e-mail to mandeep.singh@uhn.ca. © 2019 International Anesthesia Research Society