Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy BACKGROUND: In patients presenting for pyloromyotomy, most practitioners prioritize rapid securement of the airway due to concern for aspiration. However, there is a lack of consensus and limited evidence on the choice between rapid sequence induction (RSI) and modified RSI (mRSI). METHODS: The medical records of all patients presenting for pyloromyotomy from May 2012 to December 2018 were reviewed. The risk of hypoxemia (peripheral oxygen saturation [SpO2], <90%) during induction was compared between RSI and mRSI cohorts for all patients identified as well as in the neonate subgroup by univariate and multivariable logistic regression analysis. Complications (aspiration, intensive care unit admission, bradycardia, postoperative stridor, and hypotension) and initial intubation success for both cohorts were also compared. RESULTS: A total of 296 patients were identified: 181 in the RSI and 115 in the mRSI cohorts. RSI was associated with significantly higher rates of hypoxemia than mRSI (RSI, 30% [23%–37%]; mRSI, 17% [10%–24%]; P = .016). In multivariable logistic regression analysis of all patients, the adjusted odds ratio (OR) of hypoxemia for RSI versus mRSI was 2.8 (95% confidence interval [CI], 1.5–5.3; P = .003) and the OR of hypoxemia for multiple versus a single intubation attempt was 11.4 (95% CI, 5.8–22.5; P < .001). In multivariable logistic regression analysis of neonatal subgroup, the OR of hypoxemia for RSI versus mRSI was 6.5 (95% CI, 2.0–22.2; P < .001) and the OR of hypoxemia for multiple intubation versus single intubation attempts was 18.1 (95% CI, 4.7–40; P < .001). There were no induction-related complications in either the RSI and mRSI cohorts, and the initial intubation success rate was identical for both cohorts (78%). CONCLUSIONS: In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients. Accepted for publication June 17, 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 Raymond S. Park, MD, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Bader 3, Boston, MA 02115. Address e-mail to raymond.park@childrens.harvard.edu. © 2019 International Anesthesia Research Society

Monitoring of High- and Intermediate-Risk Surgical Patients No abstract available

Global and Regional Respiratory Mechanics During Robotic-Assisted Laparoscopic Surgery: A Randomized Study BACKGROUND: Pneumoperitoneum and nonphysiological positioning required for robotic surgery increase cardiopulmonary risk because of the use of larger airway pressures (Paws) to maintain tidal volume (VT). However, the quantitative partitioning of respiratory mechanics and transpulmonary pressure (PL) during robotic surgery is not well described. We tested the following hypothesis: (1) the components of driving pressure (transpulmonary and chest wall components) increase in a parallel fashion at robotic surgical stages (Trendelenburg and robot docking); and (2) deep, when compared to routine (moderate), neuromuscular blockade modifies those changes in PLs as well as in regional respiratory mechanics. METHODS: We studied 35 American Society of Anesthesiologists (ASA) I-II patients undergoing elective robotic surgery. Airway and esophageal balloon pressures and respiratory flows were measured to calculate respiratory mechanics. Regional lung aeration and ventilation was assessed with electrical impedance tomography and level of neuromuscular blockade with acceleromyography. During robotic surgical stages, 2 crossover randomized groups (conditions) of neuromuscular relaxation were studied: Moderate (1 twitch in the train-of-four stimulation) and Deep (1–2 twitches in the posttetanic count). RESULTS: Pneumoperitoneum was associated with increases in driving pressure, tidal changes in PL, and esophageal pressure (Pes). Steep Trendelenburg position during robot docking was associated with further worsening of the respiratory mechanics. The fraction of driving pressures that partitioned to the lungs decreased from baseline (63% ± 15%) to Trendelenburg position (49% ± 14%, P < .001), due to a larger increase in chest wall elastance (Ecw; 12.7 ± 7.6 cm H2O·L−1) than in lung elastance (EL; 4.3 ± 5.0 cm H2O·L−1, P < .001). Consequently, from baseline to Trendelenburg, the component of Paw affecting the chest wall increased by 6.6 ± 3.1 cm H2O, while PLs increased by only 3.4 ± 3.1 cm H2O (P < .001). PL and driving pressures were larger at surgery end than at baseline and were accompanied by dorsal aeration loss. Deep neuromuscular blockade did not change respiratory mechanics, regional aeration and ventilation, and hemodynamics. CONCLUSIONS: In robotic surgery with pneumoperitoneum, changes in ventilatory driving pressures during Trendelenburg and robot docking are distributed less to the lungs than to the chest wall as compared to routine mechanical ventilation for supine patients. This effect of robotic surgery derives from substantially larger increases in Ecw than ELs and reduces the risk of excessive PLs. Deep neuromuscular blockade does not meaningfully change global or regional lung mechanics. Accepted for publication April 4, 2019. Funding: This work was funded by Merck & Co. 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). J. C. Brandão and M. A. Lessa contributed equally to this work and share first authorship. Clinical Trials Number: NCT02025075. URL: https://clinicaltrials.gov/ct2/show/NCT02025075. Reprints will not be available from the authors. Address correspondence to Marcos A. Lessa, MD, PhD, Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Fiocruz Foundation, Avenida Brasil 4365, Rio de Janeiro, Brazil 21045-900. Address e-mail to malessa@ioc.fiocruz.br. © 2019 International Anesthesia Research Society

Comparison of Macintosh Laryngoscopy in Bed-up-Head–Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial BACKGROUND: Approximately half of all difficult tracheal intubations (DTIs) are unanticipated; hence, proper positioning during intubation is critical to increase the likelihood of success. The bed-up-head–elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apneic time during intubation. In this study, we sought to determine whether the BUHE intubation position is noninferior to Glidescope (GLSC)-assisted intubation with regard to laryngeal exposure. METHODS: A total of 138 American Society of Anesthesiologists (ASA) I to III patients were randomly assigned into 2 groups and underwent baseline laryngoscopy in the sniffing position. Group BUHE patients (n = 69) were then intubated in the BUHE position, while group GLSC patients (n = 69) were intubated using GLSC laryngoscopy. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score and Cormack–Lehane (CL) grading, and noninferiority will be declared if the difference in mean POGO scores between both groups do not exceed −15% at the lower limit of a 98% confidence interval (CI). Secondary outcomes measured included time required for intubation (TRI), number of intubation attempts, use of airway adjuncts, effort during laryngoscopy, and complications during intubation. RESULTS: Mean POGO score in group BUHE was 80.14% ± 22.03%, while in group GLSC it was 86.45% ± 18.83%, with a mean difference of −6.3% (98% CI, −13.2% to 0.6%). In both groups, there was a significant improvement in mean POGO scores when compared to baseline laryngoscopy in the sniffing position (group BUHE, 25.8% ± 4.7%; group GLSC, 30.7% ± 6.8%) (P < .0001). The mean TRI was 36.23 ± 14.41 seconds in group BUHE, while group GLSC had a mean TRI of 44.33 ± 11.53 seconds (P < .0001). In patients with baseline CL 3 grading, there was no significant difference between mean POGO scores in both groups (group BUHE, 49.2% ± 19.6% versus group GLSC, 70.5% ± 29.7%; P = .054). CONCLUSIONS: In the general population, BUHE intubation position provides a noninferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population. Accepted for publication June 24, 2019. Funding: This study was funded by the Malaysian Society of Anaesthesiologists K. Inbasegaran fund. The authors declare no conflicts of interest. Clinical trial registry: ClinicalTrials.gov (Registration identifier: NCT03357679). Reprints will not be available from the authors. Address correspondence to Samuel E. H. Tsan, MD, BMedSc, Department of Anaesthesiology, Faculty of Medicine and Health Sciences, University of Malaysia Sarawak, Jalan Datuk Mohammad Musa, 94300 Kota Samarahan, Sarawak, Malaysia. Address e-mail to tehsamuel@unimas.my. © 2019 International Anesthesia Research Society

National Institutes of Health–Funded Anesthesiology Research and Anesthesiology Physician-Scientists: Trends, Promises, and Concerns With a difficult National Institutes of Health (NIH) funding climate, the pipeline of physician-scientists in Anesthesiology is continuing to get smaller with fewer new entrants. This article studies current NIH funding trends and offers potential solutions to continue the historical trend of academic innovation and research that has characterized academic Anesthesiology. Using publicly available data, specifically the NIH REPORTeR and Blue Ridge Institute for Medical Research, we examined NIH trends in funding in academic Anesthesiology departments that have Anesthesiology residency training programs. When adjusted for inflation, median NIH funding of departments of Anesthesiology declined approximately 15% between 2008 and 2017. The majority (55%) of NIH funding to academic Anesthesiology departments, including R01 and K-series grants, went to 10 departments in the United States. This trend has remained relatively constant for the 9-year period we studied (2009–2017). There is an inequitable distribution of NIH funding to Anesthesiology departments. Arguably, this may be a case of the “rich get richer,” but the implications for those who are trying to become or remain NIH-funded investigators are that success may depend, in part, on securing a faculty position in one of these well-funded departments. Accepted for publication June 13, 2019. Funding: This work was supported by National Institutes of Health (Bethesda, MD) grants EY010343, EY028690, and EY027477 to S.R. 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 Arvind Chandrakantan, MD, MBA, FAAP, FASA, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, 6621 Fannin St, Suite #A3300, Houston, TX 77030. Address e-mail to axchand2@texaschildrens.org. © 2019 International Anesthesia Research Society

Two-Week Multimodal Prehabilitation Program Improves Perioperative Functional Capability in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial BACKGROUND: Patients with lung cancer often experience reduced functional capacity and quality of life after surgery. The current study investigated the impact of a short-term, home-based, multimodal prehabilitation program on perioperative functional capacity in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for nonsmall cell lung cancer (NSCLC). METHODS: A randomized controlled trial was conducted with 73 patients. Patients in the prehabilitation group (n = 37) received a 2-week multimodal intervention program before surgery, including aerobic and resistance exercises, respiratory training, nutrition counseling with whey protein supplementation, and psychological guidance. Patients in the control group (n = 36) received the usual clinical care. The assessors were blinded to the patient allocation. The primary outcome was perioperative functional capacity measured as the 6-minute walk distance (6MWD), which was assessed at 1 day before and 30 days after surgery. A linear mixed-effects model was built to analyze the perioperative 6MWD. Other outcomes included lung function, disability and psychometric evaluations, length of stay (LOS), short-term recovery quality, postoperative complications, and mortality. RESULTS: The median duration of prehabilitation was 15 days. The average 6MWD was 60.9 m higher perioperatively in the prehabilitation group compared to the control group (95% confidence interval [CI], 32.4–89.5; P < .001). There were no differences in lung function, disability and psychological assessment, LOS, short-term recovery quality, postoperative complications, and mortality, except for forced vital capacity (FVC; 0.35 L higher in the prehabilitation group, 95% CI, 0.05–0.66; P = .021). CONCLUSIONS: A 2-week, home-based, multimodal prehabilitation program could produce clinically relevant improvements in perioperative functional capacity in patients undergoing VATS lobectomy for lung cancer. Accepted for publication June 14, 2019. Funding: None. 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). ClinicalTrials.gov registration: NCT03068507. Reprints will not be available from the authors. Address correspondence to Yuguang Huang, MD, Department of Anesthesiology, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China. Address e-mail to garypumch@163.com. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 International Anesthesia Research Society

A Mixed-Method Design Evaluation of the SAFE Obstetric Anaesthesia Course at 4 and 12–18 Months After Training in the Republic of Congo and Madagascar BACKGROUND: Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12–18 months after SAFE-OB courses in Madagascar and the Republic of Congo. METHODS: We used a concurrent embedded mixed-methods design based on the Kirkpatrick model for evaluating educational training courses. The primary outcome was qualitative determination of personal and organizational change at 4 months and 12–18 months. Secondary outcomes were quantitative evaluations of knowledge and skill retention over time. From 2014 to 2016, 213 participants participated in 5 SAFE-OB courses in 2 countries. Semistructured interviews were conducted at 4 and 12–18 months using purposive sampling and analyzed using thematic content analysis. Participants underwent baseline knowledge and skill assessment, with 1 cohort reevaluated using repeat knowledge and skills tests at 4 months and another at 12–18 months. RESULTS: At 4 months, 2 themes of practice change (Kirkpatrick level 3) emerged that were not present at 12–18 months: neonatal resuscitation and airway management. At 12–18 months, 4 themes emerged: management of obstetric hemorrhage, management of eclampsia, using a structured approach to assessing a pregnant woman, and management of spinal anesthesia. With respect to organizational culture change (Kirkpatrick level 4), the same 3 themes emerged at both 4 and 12–18 months: improved teamwork, communication, and preparation. Resistance from peers, lack of senior support, and lack of resources were cited as barriers to change at 4 months, but at 12–18 months, very few interviewees mentioned lack of resources. Identified catalysts for change were self-motivation, credibility, peer support, and senior support. Knowledge and skills tests both showed an immediate improvement after the course that was sustained. This supports the qualitative responses suggesting personal and organizational change. CONCLUSIONS: Participation at a SAFE-OB course in the Republic of Congo and in Madagascar was associated with personal and organizational changes in practice and sustained improvements in knowledge and skill at 12–18 months. Accepted for publication June 5, 2019. Funding: The Association of Anaesthetists partially funded some of the international flights for course instructors to teach on some of the SAFE Obstetric Anaesthesia courses described in this study. These were funded by private individual arrangement and not via Mercy Ships or any of the authors. 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 Michelle C. White, MBChB, Department of Paediatric Anaesthesia, Great Ormond Street Hospital, London WC1N 3JH, United Kingdom. Address e-mail to doctormcw@gmail.com. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 International Anesthesia Research Society

Awake Volunteer Pain Scores During Neuromuscular Monitoring BACKGROUND: There is a need for easy to use, reliable neuromuscular monitors (NMMs). This multicenter, prospective, unblinded study compared the discomfort associated with neurostimulation in unmedicated healthy volunteers when using the new electromyography (EMG)-based TetraGraph and acceleromyography (AMG)-based TOF-Watch NMMs. The secondary aim was to compare the repeatability of the train-of-four (TOF) ratios (TOFRs) obtained with the 2 devices. METHODS: The TOF measurements of 135 volunteers from 3 university hospitals were analyzed (age: 38.3 ± 12 years [mean ± standard deviation [SD]]; male/female ratio = 63:72). The left or right ulnar nerve was stimulated at the wrist in TOF mode with 20, 30, 40, and 50 mA stimulating current intensities with both devices in random order. The TOF-Watch used standard electrocardiography (ECG) electrodes (Red Dot; 3M Health Care) for nerve stimulation. The stimulating surface area of 1 ECG electrode is 113 mm2. The piezoelectric probe was attached to the thumb, and a hand adapter was used to ensure consistency of AMG measurements. The TetraGraph uses proprietary surface strip electrodes for nerve stimulation and muscle action potential recording, whose stimulating surface area is roughly twice as big as that of standard ECG electrodes (228.5 mm2). The volunteers were asked to rate the discomfort associated with neurostimulation on a 0–10 verbal numerical rating scale (VNRS) score anchored with 0 (no pain) and 10 (worst pain ever experienced). A linear mixed-effects model was used to evaluate the difference in VNRS scores between devices. P <.05 was accepted as the level of significance. RESULTS: In the linear mixed-effects model, there were no differences in VNRS scores between devices at any of the stimulating current intensities, P = .38. The median (range) VNRS scores obtained with TOF-Watch and TetraGraph devices were 2 (0–7) vs 2 (0–8) at 20 mA, 3 (1–9) vs 3 (1–9) at 30 mA, 5 (1–10) vs 5 (1–10) at 40 mA, and 5 (1–10) vs 6 (1–10) at 50 mA stimulating current intensities. The mean of the 1469 TOFRs obtained with TetraGraph was 100.43% ± 7.74% (standard error = 0.2%). Due to technical difficulties, the repeatability of the TOFRs could not be determined. CONCLUSIONS: Despite the different size and design of the stimulating electrodes, the 2 NMMs caused the same level of discomfort in unmedicated healthy volunteers. Accepted for publication June 4, 2019. Funding: None. The authors declare no conflicts of interest. Clinicaltrials.gov identifier: NCT02912039. Reprints will not be available from the authors. Address correspondence to Réka Nemes, MD, Department of Anesthesiology and Intensive Care, University of Debrecen, 94 Nagyerdei krt, Debrecen 4032, Hungary. Address e-mail to reka.nemes.11@gmail.com. © 2019 International Anesthesia Research Society

Reversal of Vasodilatory Shock: Current Perspectives on Conventional, Rescue, and Emerging Vasoactive Agents for the Treatment of Shock Understanding the different mechanisms of vasoconstrictors is crucial to their optimal application to clinically diverse shock states. We present a comprehensive review of conventional, rescue, and novel vasoactive agents including their pharmacology and evidence supporting their use in vasodilatory shock. The role of each drug in relation to the Surviving Sepsis Guidelines is discussed to provide a context of how each one fits into the algorithm for treating vasodilatory shock. Rescue agents can be utilized when conventional medications fail, although there are varying levels of evidence on their clinical effectiveness. In addition, novel agents for the treatment of vasodilatory shock have recently emerged such as ascorbic acid and angiotensin II. Ascorbic acid has been used with some success in vasoplegia and is currently undergoing a more rigorous evaluation of its utility. Angiotensin II (Ang-2) is the newest available vasopressor for the treatment of vasodilatory shock. In addition to its catecholamine-sparing properties, it has been shown to hold promising mortality benefits in certain subsets of critically ill patients. Accepted for publication June 17, 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 Jonathan H. Chow, MD, Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, 22 S Greene St, Suite S11D20, Baltimore, MD 21201. Address e-mail to jchow@som.umaryland.edu. © 2019 International Anesthesia Research Society

BASIC Essentials: A Comprehensive Review for the Anesthesiology BASIC Exam No abstract available