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In this case study, we describe a 25-year-old male who was admitted due to a severe traumatic brain injury, requiring invasive intracranial pressure monitoring. At 48 hours posttrauma, he developed intracranial hypertension refractory to medical treatment without tomographic changes in the brain. Subsequently, intra-abdominal hypertension and tomographic signs of abdominal surgical pathology were observed. An exploratory laparotomy was performed with an intraoperative diagnosis of acute mesenteric ischemia. After surgical intervention for the abdominal pathology, intracranial pressure was restored to physiological values with a favorable recovery of the patient. In this report, the relationship between intracranial pressure and intra-abdominal pressure is discussed, highlighting the delicate association between the brain, abdomen, and thorax. Measures should be taken to avoid increases in intra-abdominal pressure in neurocritical patients. When treating intracranial hypertension refractory to conventional measures, abdominal causes and multiple compartment syndrome must be considered. The cranial compartment has physiological interdependence with other body compartments, where one can be modified by variations from another, giving rise to the concept of multiple compartment syndrome. Understanding this relationship is fundamental for a comprehensive approach of the neurocritical patient. To the best of our knowledge, this is the first report of a comatose patient post-traumatic brain injury, who developed medically unresponsive intracranial hypertension secondary to acute mesenteric ischemia, in which surgical resolution of intra-abdominal pathology resulted in intracranial pressure normalization and restitutio ad integrum of neurological status.

Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.

Purpose of review The prevalence of procedures performed outside of the operating room is steadily growing around the world, especially in the United States. This review aims to discuss the risks and safety of anesthesia performed in remote locations based on an up-to-date literature review, with a focus on the results from closed claims and other database analyses. Recent findings The published literature in the last decade shows that there is an increase in nonoperating room anesthesia cases and that the highest number of these cases are in gastroenterology endoscopy suites. There are safety concerns in nonoperating room cases that involve both anesthesia and nonanesthesia providers. Specific complications found in closed claims analyses include airway compromise, aspiration pneumonia, and dental injuries. Summary The current literature demonstrates that procedures performed in the endoscopy suite make up the largest number of nonoperating room closed claims anesthesia cases. Oversedation and subsequent inadequate oxygenation/ventilation account for the majority of malpractice claims. Conclusions from the current literature emphasize the importance of complying with monitoring standards and having well prepared providers to improve patient outcomes in nonoperating room locations.

Neuropathic pain is a challenge for physicians to treat and often requires a multimodal approach with both pharmacologic and lifestyle interventions. Mirogabalin, a potent, selective ligand of the α2δ-1 and α2δ-2 subunits of voltage-gated calcium channels (VGCCs), provides analgesia by inhibiting neurotransmitter release at the presynaptic end of the neuron. Mirogabalin offers more sustained analgesia than its gabapentinoid counterparts in addition to a wider safety margin for adverse events. Recent clinical trials of mirogabalin have demonstrated both efficacy and tolerability of the drug for the treatment of diabetic peripheral neuropathic pain and postherpetic neuralgia, leading to its approval in Japan. While still not yet FDA approved, mirogabalin is still in its infancy and offers potential into the treatment of neuropathic pain and its associated comorbidities.

Purpose of review Although both cost and patient preference tend to favor the office-based setting, one must consider the hidden costs in managing complications and readmissions. The purpose of this review is to provide an update on safety outcomes of office-based procedures, as well as to identify common patient-specific factors that influence the decision for office-based surgery or impact patient outcomes. Recent findings Office-based anesthesia (OBA) success rates from the latest publications of orthopedic, plastic, endovascular, and otolaryngologic continue to improve. A common thread among these studies is the ability to predict which patients will benefit from going home the same day, as well as identifying comorbid factors that would lead to failure to discharge or readmission after surgery. Specifically, patients with active infection, cardiovascular disease, coagulopathy, insulin-dependent diabetes, obesity, obstructive sleep apnea, poorly controlled hypertension, and thromboembolic disease are presumed to be poor candidates for outpatient office procedures. Summary Overall, anesthesia and surgery in the office is becoming increasingly safe. Recent data suggest that the improved safety in the office-based setting is attributable to proper patient selection. Anesthesiologists play a critical role in prescreening eligible patients to ensure a safe and productive process. Patients treated in the office seem to be selected based on their low risk for complications, and our review reflects this position.

Characterization of the clinical and economic impact of opioid-related adverse drug events (ORADEs) after total knee arthroplasty (TKA) may guide provider and hospital system approach to managing postoperative pain after TKA. Our analysis quantifies the rate of potential ORADEs after TKA, the impact of potential ORADEs on length of stay (LOS) and hospital revenue, as well as their association with specific patient risk factors and comorbid clinical conditions. We conducted a retrospective study using the Centers for Medicare and Medicaid Services administrative database to analyze Medicare discharges involving two knee replacement surgery diagnosis-related groups (DRGs) in order to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed. The potential ORADE rate in patients who underwent TKA was 25,523 out of 316,858 records analyzed (8.0%). The mean LOS for patients who experienced a potential ORADE was 1.04 days longer than those without an ORADE. The mean hospital revenue per day with a potential ORADE was $1334 (USD) less than without an ORADE. Potential ORADEs were significantly associated with poor patient outcomes such as pneumonia, septicemia, and shock. Potential ORADEs in TKA are associated with longer hospitalizations, decreased hospital revenue, and poor patient outcomes. Certain risk factors may predispose patients to experiencing an ORADE, and thus perioperative pain management strategies that reduce the frequency of ORADEs particularly in at-risk patients can improve patient satisfaction and increase hospital revenue following TKAs.

This study aimed to assess the impact of data-driven didactic sessions on metrics including fund of knowledge, resident confidence in clinical topics, and stress in addition to American Board of Anesthesiology In-Training Examination (ITE) percentiles.Observational mixed-methods study.Classroom, video-recorded e-learning.Anesthesiology residents from two academic medical centers.Residents were offered a data-driven didactic session, focused on lifelong learning regarding frequently asked/missed topics based on publicly-available data.Residents were surveyed regarding their confidence on exam topics, organization of study plan, willingness to educate others, and stress levels. Residents at one institution were interviewed post-ITE. The level and trend in ITE percentiles were compared before and after the start of this initiative using segmented regression analysis.Ninety-four residents participated in the survey. A comparison of pre-post responses showed an increased mean level of confidence (4.5 ± 1.6 vs. 6.2 ± 1.4; difference in means 95% CI:1.7[1.5,1.9]), sense of study organization (3.8 ± 1.6 vs. 6.7 ± 1.3;95% CI:2.8[2.5,3.1]), willingness to educate colleagues (4.0 ± 1.7 vs. 5.7 ± 1.9;95% CI:1.7[1.4,2.0]), and reduced stress levels (5.9 ± 1.9 vs. 5.2 ± 1.7;95% CI:-0.7[-1.0,-0.4]) (all p 0.001). Thirty-one residents from one institution participated in the interviews. Interviews exhibited qualitative themes associated with increased fund of knowledge, accessibility of high-yield resources, and domains from the Kirkpatrick Classification of an educational intervention. In an assessment of 292 residents from 2012 to 2020 at one institution, there was a positive change in mean ITE percentile (adjusted intercept shift [95% CI] 11.0[3.6,18.5];p = 0.004) and trajectory over time after the introduction of data-driven didactics.Data-driven didactics was associated with improved resident confidence, stress, and factors related to wellness. It was also associated with a change from a negative to positive trend in ITE percentiles over time. Future assessment of data-driven didactics and impact on resident outcomes are needed.

Introduction Preoperative anemia is associated with increased morbidity, mortality, and healthcare costs. As a result of the increased incidence of chronic blood loss and iron deficiency anemia in abdominal surgery patients and its impact on patient outcomes, we systematically evaluated the quality of evidence for preoperative intravenous (IV) administration of iron to patients with anemia undergoing major abdominal surgery with the focus on clinical outcomes. Methods In this systematic review, PubMed, Cochrane, The Cumulative Index to Nursing and Allied Health Literature, Web Of Science, and Excerpta Medica Database databases were searched up to 2019 using specific keywords. Inclusion criteria were patients that were over 18 years of age, underwent abdominal surgery, and received an IV iron treatment in the preoperative setting. Results The nine studies included in the final systematic review do not provide consistent evidence of a reduced incidence of allogeneic blood transfusions with preoperative IV iron administration. However, IV iron administration did consistently cause a significant increase in hemoglobin levels relative to oral iron therapy or no iron. Conclusion Overall, these findings are consistent in that IV iron administration is highly effective at rapidly increasing hemoglobin levels in patients with iron deficiency anemia undergoing major abdominal surgery. Unfortunately, there is currently no evidence of reduced incidence of allogeneic blood transfusions or other enhanced outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01628-7.

To identify patient risk factors for nonhome discharge (NHD) for home-dwelling older patients undergoing surgery, we performed a retrospective cohort study of patients aged ≥65 years undergoing elective surgery between 2014 and 2016 using the geriatric research file from the National Surgical Quality Improvement Program (NSQIP). Multivariable logistic regression examined the association between preoperative demographics, comorbidities, and functional status and NHD to determine which factors are most strongly predictive of NHD. Risk of NHD was higher among those of age >85 years, age 75 to 85 years, Black race, with body mass index (BMI) >30, dyspnea with exertion or at rest, partially or totally dependent in activities of daily living (ADLs), preoperative steroid use, preoperative wound infection, use of a mobility aid, fall within 3 months, or living alone at home without support. NHDs were statistically more likely among orthopedic, neurosurgery, or cardiac surgery interventions. Understanding individual patient’s risks and setting expectations for likely postoperative course is integral to appropriate preoperative counseling and preoperative optimization.

Therapeutic duration of traditional local anesthetics when used in peripheral nerve blocks is normally limited. This article describes novel approaches to extend the duration of peripheral nerve blocks currently available or in development. Three newer approaches on extending the duration of peripheral nerve blocks include site-1 sodium channel blockers, novel local anesthetics delivery systems, and novel adjuvants of local anesthetics. Compared with plain amide-based and ester-based local anesthetics, alternative approaches show significant promise in decreasing postoperative pain, rescue opioid requirement, hospital length-of-stay, and overall health care cost, without compromising the established safety profile of traditional local anesthetics.

Understanding the risk factors and clinical outcomes associated with acute kidney injury (AKI) after craniotomy may help clinicians identify perioperative patients at risk for AKI and lead clinicians to institute preventive measures. The objective of this study was to identify risk factors associated with AKI after craniotomy and understand whether patients who develop AKI after craniotomy have worse clinical outcomes.We performed a retrospective, propensity score matched cohort study consisting of 344 patients who developed an AKI or required renal dialysis post-operatively versus those who did not. An AKI was defined using a composite of two NSQIP variables: progressive renal insufficiency and acute renal failure. All data were derived from the American College of Surgeons National Safety Quality Improvement Program (ACS-NSQIP) between 2009-2017.Of the 50,691 patients who underwent a craniotomy, 202 developed post-operative AKI or required post-operative renal dialysis. Male gender, black race, age 65 and older, and a body mass index 30 or greater were associated with AKI. Patients with hypertension (OR [95 % CI] 4.41 [3.21-6.06]; p 0.001), diabetes (OR [95 % CI] 3.5 [2.62-4.69]; p 0.001), chronic obstructive pulmonary disease (OR [95 % CI] 2.27 [1.4-3.69]; p = 0.001), congestive heart failure (OR [95 % CI] 8.17 [4.29-15.58]; p 0.001), chronic kidney disease (OR [95 % CI] 10.59 [6.09-18.41]; p 0.001), bleeding disorder (OR [95 % CI] 3.83 [2.59-5.65]; p 0.001), those who developed sepsis (OR [95 % CI] 4.63 [3.33-6.45]; p 0.001), and emergent craniotomy (OR [95 % CI] 5.35 [4.05-7.06); p 0.00) were more likely to develop AKI. The largest association between AKI after surgery was found in patients whose preoperative functional status was totally dependent in activities of daily living (OR [95 % CI] 5.93 [3.53-9.95]; p 0.001). AKI was associated with a higher number of complications experienced by each patient (OR [95 % CI] 1.79 [1.4-2.3; p 0.001]. Patients with higher ASA physical status were more likely to develop AKI, and mortality was significantly higher in the AKI cohort. There was a significant increase in the rates of returning to the operating room, failure to wean from the ventilator, unplanned intubations, number of complications, and length of stay between the two groups. AKI was also associated with a higher rate of perioperative pneumonia, venous thromboembolism, urinary tract infection, and sepsis.AKI is associated with significantly worse clinical outcomes after craniotomy. Perioperative strategies for prevention, management and supportive care of AKI for patients undergoing craniotomy may improve clinical outcomes.

The purpose of this review is to discuss current drugs used for intravenous moderate and deep sedation by nonanesthesiologists in the United States. We also explore training expectations for moderate and deep sedation as they play key roles in anesthetic selection and preprocedural planning.Although opioids and benzodiazepines are considered the standard for moderate sedation, increased interest in propofol, dexmedetomidine, and other sedative-hyptonic drugs require additional attention in terms of training providers and complying with current practice guidelines.Moderate sedation providers should be familiar with titrating benzodiazepines and opioids to achieve targeted sedation. The use of propofol and ketamine is generally reserved for deep sedation by qualified professionals. However, the role of dexmedetomidine in procedural sedation continues to evolve as its use is explored in moderate sedation. Providers of all sedation types should be aware of hypotension, apnea, hypoventilation, and hypoxia that can develop and they should be able to manage the patient under these circumstances. Preprocedural planning is an integral training expectation to minimize patient risks.

Background: Currently, there are only a few retrospective, single-institution studies that have addressed the prevalence and risk factors associated with unplanned admissions to the pediatric intensive care unit (ICU) after surgery. Based on the limited amount of studies, it appears that airway and respiratory complications put a child at increased risk for unplanned ICU admission. A more extensive and diverse analysis of unplanned postoperative admissions to the ICU is needed to address risk factors that have yet to be revealed by the current literature. Aim: To establish a rate of unplanned postoperative ICU admissions in pediatric patients using a large, multi-institution data set and to further characterize the associated risk factors. Methods: Data from the National Anesthesia Clinical Outcomes Registry were analyzed. We recorded the overall risk of unplanned postoperative ICU admission in patients younger than 18 years and performed univariate and multivariate logistic regression analysis to identify the associated patient, surgical, and anesthetic-related characteristics. Results: Of the 324 818 cases analyzed, 211 reported an unexpected ICU admission. There was an increased likelihood of unplanned postoperative ICU in infants (age Conclusion: This study establishes a rate of unplanned ICU admission following surgery in the heterogeneous pediatric population. This is the first study to utilize such a large data set encompassing a wide range of practice environments to identify risk factors leading to unplanned postoperative ICU admissions. Our study revealed that patient, surgical, and anesthetic complexity each contributed to an increased number of unplanned ICU admissions in the pediatric population.

There has been a significant increase in the number and types of procedures performed outside of the operating room with nonanesthesia providers administering sedation. This review describes current recommendations for training nonanesthesiologists involved in administering deep sedation, summarizes best practices and highlights select patient outcomes.There are numerous guidelines and standards related to the administration of deep sedation. However, there are no universally accepted guidelines regarding the necessary educational and skill competencies needed for nonanesthesiologists to provide deep sedation. The American Society of Anesthesiologists has published a position statement and guidelines on these educational requirements, yet the extent to which these are adhered to remains unknown. As evidence-based guidelines continue to evolve, more research is needed to describe how current practices affect patient outcomes.The American Society of Anesthesiologists publishes recommendations regarding the essential educational components for nonanesthesiologist providers who administer deep sedation. The available data support the need for formal educational programmes to prevent adverse events associated with deep sedation. Competencies should include preprocedural evaluation, understanding sedation levels, airway management, documentation, emergency life support skills, teamwork and quality improvement.

Assessing the depth of anesthesia and reducing intraoperative awareness has become a focus of much technology development and research in the field of anesthesia. Bispectral index (BIS) is the most widely utilized technology that uses electroencephalogram to provide a measurement of anesthetic depth. There are no definitive guidelines on when BIS should be used. Our aim was to assess actual patterns of intraoperative use of BIS by anesthesia professionals. We retrospectively collected intraoperative data on 55,210 surgical cases at a tertiary care hospital. Variables collected included: age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, anesthesia provider type and level of training, use of inhalational anesthetics versus total intravenous anesthesia (TIVA), utilization of nitrous oxide, utilization of non-depolarizing neuromuscular blockade, emergency status of surgery, airway type, case duration, and surgical subspecialty. A univariate logistic regression model was fitted. Subsequently, a multivariate logistic regression model was applied. Covariates utilized for the model included age, anesthesia provider level, and length of case. Factors associated with BIS use included increased age, greater ASA physical status, extremes of BMI, use of TIVA, use of a long-acting paralytic agent, use of an endotracheal tube (ETT), emergency surgery, increasing length of case, and certain surgical services. BIS use was associated with previously documented risk factors for intraoperative awareness. These factors are also indicators of case complexity, which may be a major factor among providers deciding when to apply BIS monitoring in the operating room.

Operating rooms (ORs) are an important source of hospital revenue, and utilization rate is a key determinant of OR efficiency. Multiple factors contribute to OR underutilization, and OR managers may have biased views about which factors contribute most to OR underutilization. We examined various factors leading to OR underutilization at one academic tertriary care center.Data were collected retrospectively from over a 12-month period. Contribution to OR underutilization was measured in terms of hours of OR underutilization. Statistical significance between categories and days was calculated using an unpaired t test.By comparing means of the various contributors to OR underutilization (patient in the room, turnover time, scheduling gaps, OR holds, closed rooms), we determined that mid/end-of-day gaps and closed rooms contributed the most hours (9.7% and 4.6%, respectively; P < .0001) to OR underutilization, whereas turnover time and "patient in the room" contributed the least (2.0% and 0.8%, respectively; P < .0001).The contributors to OR underutilization are complex, and many OR staff from physicians to nurses and OR administrators may have biased views about which factors contribute most predominantly to inefficiency. Awareness of how various factors contribute to OR underutilization can pave the way for goal-directed changes on a systems-based level to improve efficiency in the OR by decreasing underutilization.

There is a growing body of literature documenting the use of deep neuromuscular block (NMB) during surgery. Traditional definitions of depth of NMB rely on train-of-four assessment, which can be less reliable in retrospective studies. The goal of our study was to investigate the real-world practice pattern of dosing of neuromuscular blocking agents (NMBA), utilizing the amount of NMBA used during the course of a case, adjusted for patient weight and case duration, as a surrogate measure of depth of NMB. We also aimed to identify case factors associated with larger NMBA doses. In this retrospective observational analysis of our anesthesia information management system, we analyzed all general endotracheal anesthesia cases from 2012 to 2015 in which an intermediate-acting NMBA was used. Cases using a long-acting NMBA or only succinylcholine were excluded. The expected duration of the case was calculated based on the cumulative dose of NMB used, normalized to the patient’s ideal body weight and the ED95 of the drug. If the expected duration of the case was greater than the actual case duration documented in the case record, it was classified as higher dosing (HD). If the expected duration was equal to or less than the actual duration, it was considered predicted dosing (PD). Categorical comparisons between HD and PD groups were made for various patient, procedural, and provider factors. 72,684 cases were included in the final analysis, of which 46,358, or 64% of cases, used HD. Cases with patients who were morbidly obese, younger than 65 years, and who were lower ASA Physical Status classification (I or II) used more HD as opposed to PD. Cases that were non-open, used total intravenous anesthesia, emergent cases, or used non-rapid sequence anesthesia induction had higher rates of HD than their matched counterparts. All results were statistically significant. HD was more common in cases that documented train-of-four and used the reversal agent neostigmine. Approximately two-thirds of general endotracheal anesthesia cases using an intermediate-acting NMBA used HD. Cases with higher rates of HD may be those that are traditionally technically complex or emergent, would benefit from greater paralysis, or do not use adjunctive medications for muscle relaxation. Age greater than 65 years was shown to have lower rates of HD, likely due to provider awareness of age-related changes in pharmacokinetics and pharmacodynamics. Intraoperative monitoring and NMB antagonism with neostigmine were used more frequently with HD.

Since the public demonstration of ether as a novel, viable anesthetic for surgery in 1846, the field of anesthesia has continually sought the ideal anesthetic-rapid onset, potent sedation-hypnosis with a high therapeutic ratio of toxic dose to minimally effective dose, predictable clearance to inactive metabolites, and minimal side effects. This article aims to review current progress of novel induction agent development and provide an update on the most promising drugs poised to enter clinical practice. In addition, the authors describe trends in novel agent development, implications for health care costs, and implications for perioperative care.

Introduction: Opioid-related adverse drug events (ORADEs) are an increasingly recognized complication associated with the common prescription of opioids after orthopedic surgery. In this study, we attempted to understand how potential ORADEs following hip replacement surgery in older patients affected hospital length of stay, hospital revenue, and their association with specific risk factors and clinically relevant diseases occurring during hospitalization. Methods: We conducted a retrospective study using the Centers for Medicare and Medicaid Services Administrative Database to analyze Medicare discharges after hip replacement surgery to identify potential ORADEs. The impact of potential ORADEs on mean hospital length of stay (LOS) and hospital revenue was analyzed. Results: The potential ORADE rate in patients who underwent hip replacement surgery was 8.6%. The mean LOS for discharges with a potential ORADE was 1.41 days longer than that for discharges without an ORADE. The mean hospital revenue per day with a potential ORADE was US$1708 less than without an ORADE. Potential ORADEs were also found to be strongly associated with poor patient outcomes such as pneumonia, septicemia, and shock. Discussion: Potential ORADEs in hip replacement surgery in older patients are associated with longer hospitalizations, decreased hospital revenue per day, certain patient risk factors, and clinically relevant diseases occurring during hospitalizations. Our finding of an association between potential ORADEs and decreased hospital revenue per day may be attributed to the management of these adverse events, as a patient may need to undergo additional testing, may need additional treatment regimens, and may need a higher level of care. Conclusion: By reducing the use of opioids and employing a multimodal analgesic approach, we may improve patient care, decrease hospital lengths of stay, and increase hospital revenue

Objective Transthoracic echocardiography (TTE) is finding increased use in anesthesia and critical care. Efficient options for training anesthesiologists should be explored. Simulator mannequins allow for training of manual acquisition and image recognition skills and may be suitable due to ease of scheduling. The authors tested the hypothesis that training with a simulator would not be inferior to training using a live volunteer. Design Prospective, randomized trial. Setting University hospital. Participants Forty-six anesthesia residents, fellows, and faculty. Interventions After preparation with a written and video tutorial, study subjects received 80 minutes of TTE training using either a simulator or live volunteer. Practical and written tests were completed before and after training to assess improvement in manual image acquisition skills and theoretic knowledge. The written test was repeated 4 weeks later. Measurements and Main Results Performance in the practical image-acquisition test improved significantly after training using both the live volunteer and the simulator, improving by 4.0 and 4.3 points out of 15, respectively. Simulator training was found not to be inferior to live training, with a mean difference of –0.30 points and 95% confidence intervals that did not cross the predefined non-inferiority margin. Performance in the written retention test also improved significantly immediately after training for both groups but declined similarly upon repeat testing 4 weeks later. Conclusions When providing initial TTE training to anesthesiologists, training using a simulator was not inferior to using live volunteers.

Purpose: GlideScope® videolaryngoscope (GVL, Verathon Medical Inc., Bothell, WA, USA) assisted orotracheal intubation is a useful technique for patients who are difficult to intubate, but who can be mask ventilated. The effect of muscle relaxants on the success of GVL intubation has not been evaluated. The authors conducted a prospective, placebo- controlled study to assess the effectiveness and incidence of complications of GVL-assisted tracheal intubation performed during general anesthesia with and without the use of a muscle relaxant in patients with seemingly normal airway anatomy. Material and Methods: 52 patients who required orotracheal intubation were prospectively included. Anesthesia was induced using midazolam (0.01-0.03 mg/kg), fentanyl (1-3 µg/kg) and propofol (1-3 mg/kg). Patients were randomly assigned to one of two groups to receive rocuronium 0.6 mg/kg (n = 26 for rocuronium group) or saline intravenously (n = 26 for placebo group). GVL-assisted intubation was initiated after 90 s. The number of successful intubations, the number of attempts and their duration were recorded. Events during the procedure, such as airway trauma, blood pressure changes and movements were also recorded. Results: The success rate of GVL intubation was 100% in the placebo group and 100% in the rocuronium group. Patients in both groups received the same number of intubation attempts and the intubation time were alike (53± 15 vs. 55 ± 18 s; p=0.63). The Placebo group experienced a greater incidence of events during intubation (81 vs. 35%; P < 0.001) than patients in the rocuronium group. Conclusions: Omitting muscle relaxants in patients with apparently normal airways is not associated with a higher failure rate, increased intubation attempts or intubation time when performing GVL assisted orotracheal intubation, but is associated with a higher rate of patient movement.

Postoperative delirium is a change in cognition that occurs frequently during the postoperative period, particularly in the elderly. Postoperative delirium is a major public health concern that negatively affects morbidityand mortalityandplacesa largefiscalburdenonthehealthcare system. Although the anesthesiologist’s care of these patients has often ended well before the symptoms of postoperative delirium begin, they can play an important role in the prevention of this disease.

Purpose: Monitoring using transpulmonary thermodilution (TPTD) via a single thermal indicator technique allows measurement of cardiac output, extravascular lung water (EVLW) and volumetric vari- ables. Methods and results: This report describes two cases of sys- temic-venous circulation shunt generating early recirculation of thermal indicator with overestimation of EVLW. Conclusion: In the case of recirculation of thermal indicator, the observed overestimated EVLW in absence of gas exchanges abnormal- ity could be an indicator suggesting the search for a circulatory shunt.

An operating room (OR) environment is challenging and complicated. At any given time, several vital tasks are being performed by skilled individuals, including physicians, nurses, and ancillary staff. There is a potential for multifactorial mistakes; many arise because of communication issues.To evaluate the current state of perceptions of interdisciplinary communication in an OR setting, a survey was developed and administered to four academic residency training departments of anesthesiology in a single U.S. state.The results of this survey show that perceived poor communication within the OR leads to a lack of emphasis on a multidisciplinary approach to patient care in the OR.Survey data can be used internally to identify shortcomings in communication at a facility, to stress the importance of communication, and to serve as a powerful education tool to potentially improve patient care. Through this type of survey, which emphasizes communication in the OR, stakeholders can work more effectively to improve patient care and decrease adverse outcomes in the hospital environment.

Objective The authors’ aim was to assess practice variations in anesthesia for carotid endarterectomies (CEA) and report outcomes. Design A retrospective cohort study. Setting A multi-institutional setting. Participants Patients who underwent CEA. Interventions None. Measurements and Main Results Using the National Anesthesia Clinical Outcomes Registry of the Anesthesia Quality Institute, CEAs performed from 2010 to 2014 were identified, and a logistic regression model was fitted to determine if various patient, intraoperative, and provider characteristics were associated with usage of regional anesthesia (RA) versus general anesthesia (GA) (primary outcome) as the primary anesthetic in CEAs. The majority of CEAs were performed under GA (31,003 GA v 1,968 RA). American Society of Anesthesiologists class III-V patients were more likely to receive RA than class I-II (odds ratio 1.63, 95% confidence interval 1.39-1.91). Also, board certification status was associated with utilization of RA (odds ratio 2.95, 95% confidence interval 2.59-3.36). Among various facility types, community hospitals had the highest rates of RA use for CEAs. Secondary outcomes studied included extended recovery room stay, unexpected intensive care admissions, inadequate pain control, and postoperative nausea/vomiting. The usage of RA over GA was associated only with decreased postoperative nausea/vomiting. Conclusions This study was the first to use the National Anesthesia Clinical Outcomes Registry to evaluate practice trends in the utilization of RA versus GA in CEAs. Patient comorbidities, as well as type of anesthesia provider, were associated with the usage of RA.