ASA Monitor Today
Follow this section for practical sound bites from experts in the field of anesthesiology on issues for which controlled data may not exist.
OHSU anesthesiology, critical care teams perform rare AAA surgery on an infant
ASA Monitor staff
Intentional communication was key to success during a first-ever surgery for a baby with an abdominal aortic aneurysm (AAA) at OHSU. This condition is usually seen in men ages 65+. Anesthesiologist Philip Yun shares advice for any physicians in a similar unprecedented situation.
The 11-person team, which included two pediatric surgeons, three vascular surgeons, a pediatric cardiac surgeon, Dr. Yun and an anesthesiology fellow, and three nurses, planned precise surgical methods and medical materials to create a solution for immediate, effective stabilization and resumption of blood flow.
Dr. Yun’s professionalism and honesty didn’t go unnoticed by the parents, who had requested that the team not sugarcoat their daughter’s case. While acknowledging that staff had not seen this condition in the hospital before, Dr. Yun emphasized they had time to prepare, and that Blakely’s youth was on their side.
Despite the chaos of the day, Blakely’s parents reported being encouraged by the hourly text updates from the surgical team during the seven-hour procedure.
While communication with the parents was important, communication with the staff was literally a matter of life or death. Dr. Yun described the pediatric OR at Doernbecher as a tight-knit group, but it was the first time working with many of the vascular surgeons, all of whom primarily had experience working with adult patients.
“Communication is arguably the most important piece, and I felt like there was good communication with everybody treating Blakely that day,” he recalled. “That being said, there were individuals that I was working with for the first time. This required everybody to have to be very intentional with verbal communication.”
Dr. Yun encourages other anesthesiologists to be confident in their skillset, should the need to work on such a complex surgery arise. “With understanding of the hemodynamic changes during adult AAA repair and experience with massive transfusion in an infant, any experienced pediatric anesthesiologist should feel confident in taking care of these patients,” he said.
For more details on this groundbreaking case, read the full article.
Just say no to N20
ASA Monitor staff
Nitrous oxide use for labor is common in much of Europe (Br J Anaesth 2016;117:eLetters Supplement). In the U.S., nitrous oxide has gained some popularity since approval of a self-administering system by the Food and Drug Administration that allows intermittent delivery of a fixed 50% nitrous oxide/50% oxygen mix. These systems utilize high flows, causing a large carbon footprint. For example, during four hours of labor, the system can have a carbon footprint equivalent to driving a car 1,500 km. In comparison, the carbon footprint of an epidural is equivalent to driving a car approximately 6 km (Australasian Anaesthesia 2021:193-202). Scavenging vacuum systems are set up to minimize nitrous oxide concentrations within the indoor laboring room to reduce occupational exposure. All the gas, however, is released into the outdoor atmosphere.
Nitrous oxide analgesia is often inadequate in labor, with around 40%-60% of women converting to epidural analgesia (Ochsner J 2020;20:419-21).
Nitrous oxide has known nonanalgesic effects, like anxiolysis, and self-administration provides patients with a sense of autonomy that can lead to maternal satisfaction (ASA Monitor 2017;81:14-16). Perhaps selectively targeting the administration of nitrous oxide to this group of parturients could limit indiscriminate use and therefore mitigate nitrous oxide greenhouse effects, while still facilitating patient-centered care (Birth 2019;46:97-104).
Read more on the impact of nitrous oxide in environmental conservation in the full article.
Guidelines for mitigating pollution from Waste Anesthetic Gases (WAGs)
ASA Monitor staff
Current recommendations for mitigating WAG pollution include utilizing low fresh gas flows, avoiding desflurane and N2O as much as possible, considering TIVA and regional anesthesia where clinically applicable, decommissioning central piping systems for N2O, and using portable N2O canisters that can be closed off between uses (asamonitor.pub/40kSYby; Br J Anaesth 2020;125:680-92; Anaesthesia 2022;77:1023-9). While these recommendations are the gold standard for minimizing WAG pollution, novel environmental technologies to minimize, treat, or reuse WAGs have also been introduced in recent years. For example, the use of automated control of end-tidal anesthetic gas concentration was shown to decrease the GHG emissions over manual control by 44% (Anaesth Intensive Care 2013;41:95-101). Technology for the destruction of WAGs also exists. In Sweden, hospitals capture and destroy N2O waste on a regular basis (Br J Anaesth 2020;125:680-92). In another prototype study, a photochemical exhaust gas destruction system demonstrated successful destruction of desflurane and sevoflurane, though the feasibility of widespread implementation and its net environmental impact reduction remain to be seen (Anesth Analg 2020;131:288-97).
Another method of reducing WAG release has been the implementation of gas capture systems to recycle and reuse volatile anesthetics. While this technology is not as readily available in the U.S., gas capture systems such as CONTRAfluran™ by Zeosys and Baxter and the Deltasorb® and Centralsorb® systems by Blue-Zone Technologies are routinely used across Canada, Europe, and the United Kingdom. The general concept for such systems is the recapture of exhaled gases with specialized filters that are then recycled in the future as ingredients for new anesthetic gases (asamonitor.pub/41ofFw6; asamonitor.pub/40adQSB). Given the relative novelty of gas capture systems, their efficacy in minimizing WAG emissions is uncertain. There is a dearth of studies looking at the efficacy of WAG recapture.
For more discussion on this topic, read the full article here.
Thinking critically in times of supply chain shortages
ASA Monitor staff
The danger to public health and safety posed by supply chain shortages is particularly pertinent for anesthesiologists because the growing list of critical, lifesaving medications in short supply is disproportionate in this field (asamonitor.pub/3zXuAli). This article outlines actions by the federal government, implications for using older “generic” drugs, navigating group purchasing organizations, and more.
Anesthesiologists are particularly well equipped to partner with pharmacy colleagues to develop and implement strategies, ensuring the least amount of patient harm from medication shortages and therapeutic alternatives. The American Society of Health-System Pharmacists (ASHP), a leading resource in managing this persistent problem, released guidelines for any mitigation plan, including:
- Pharmacy validation of the details of the shortage, such as estimated duration, stock on hand, and potential supply of alternative therapies
- Clinician identification of the patient population affected, any need for patient prioritization of the limited medication, and therapeutic alternatives
- An impact analysis developed by an interprofessional team focusing on therapeutic differences between the shortage medication and the alternatives, administrative and logistical changes required, and financial ramifications
- A comprehensive action plan that’s communicated with all affected clinicians on the degree of the shortage, recommended alternatives, and temporary guidelines and procedures
More winning practices can be found in the full article.
Anesthesiologists’ role in the equity equation
ASA Monitor staff
Anesthesiologists would be well served to consider their role in the broader equity equation, as further explained in this article. Anesthesiologists can be instrumental by ensuring and valuing a diverse workforce, using interpreter services appropriately, tackling the inequitable provision of epidurals and pain medication, and addressing the much higher maternal mortality among Black women, for example.
DEI programs also help anesthesiologists recognize inequities that exist in their area of care, including:
- The lower rate of epidural use among Black, Hispanic, and non-English speaking women. It should be our responsibility to ensure that all patients have the same opportunity to gain the appropriate education about the risks and benefits of anesthetic procedures, including epidurals.
- The significantly higher rate of maternal mortality in Black women – often related to postpartum hemorrhage – which is worse than it’s ever been. And it’s not just about access to care. The richest Black women have higher maternal mortality rates than the poorest White women.
- Lower admission to critical care and higher morbidity and mortality rates in critical care units among people of color.
- Lower procedural rates for pain treatment among Black or Hispanic patients at pain clinics.
- Lower rates of the utilization of anti-emetics in minorities after surgery.
ASA’s Be The Solution toolkit (asamonitor.pub/3ybWw4A) includes insights and resources to help you address these inequity issues. It also includes a leave-behind document you can provide your C-suite that shows how anesthesiologists can be leaders and ensure quality care for all patients. The document includes thoughts on:
- Providing high-quality preoperative evaluation, including managing surgical patients with comorbidities such as diabetes and cardiovascular disease, which are more likely to impact minorities. Through this evaluation, anesthesiologists also can identify if these conditions have previously been undetected and untreated and can then collaborate with providers within the system to ensure these patients get the care they need.
- Developing and leading pathways for improving patient care throughout the perioperative process, from the Perioperative Surgical Home to Enhanced Recovery After Surgery.
- Participating in efforts to address maternal mortality disparities, including the Alliance for Innovation on Maternal Health, a data-driven quality improvement effort, contributing to updated versions of guidelines, and helping develop – with the American College of Obstetricians and Gynecologists – evidence-based standards to eliminate racial disparities in maternal and infant care.
Anytime anesthesiologists show your value above and beyond your area and specialty, you gain value at your institution. You’re not only delivering high-quality anesthesia care – you’re being a more complete doctor, leader in your organization, and most importantly, a better human being.
The versatility of viscoelastic testing
ASA Monitor staff
Viscoelastic has utility in obstetrics with respect to PPH management and neuraxial block placement.
Viscoelastic testing refers to several types of point-of-care tests that assess whole blood hemostasis from initial clot formation to clot lysis. A graphical representation is created based on these kinetic changes, which can then be interpreted to guide therapy instead of relying on protocolized transfusion guidelines. Furthermore, unlike traditional coagulation studies that test plasma, viscoelastic testing evaluates whole blood. This process provides information that may be more reflective of the true coagulation profile of the patient than static traditional coagulation studies (Front Med 2015;2:62). By providing real-time information, providers can more swiftly diagnose and treat coagulopathy without having to wait for the long processing times of traditional coagulation studies.
Read the full article for the latest information on its use to guide blood product therapy during a postpartum hemorrhage, aid in decision-making regarding neuraxial block placement, or for timing of procedures in a patient on heparin.
Trends in EEG Usage
ASA Monitor staff
The intraoperative electroencephalography (EEG) story is one of many promises and dashed hopes. The massive uptake in EEG usage guided by the seductive simplicity of an index number met skepticism after the publication of several manuscripts (N Engl J Med 2008;358:1097-108; Anesth Analg 2003;97:488-91).
The differences in target populations, study methods, endpoints, and even delirium diagnostic criteria have led to an uninterpretable mess; disparate opinions from thought leaders have further muddied the field.
The Committee on Neuroanesthesiology commissioned a survey of its members and those of the Educational Track Subcommittee on Neuro Anesthesia, all of whom are neuroanesthesiologists, on their intraoperative usage and assessment of the utility of EEG technology. Findings are outlined in the table below. More information is available in the full ASA Monitor article.
ACOG recommendations for high-risk obstetric patients
ASA Monitor staff
The article “High-Risk Obstetric Patients—More Needs to Be Done!” highlights current American College of Obstetricians and Gynecologists (ACOG) recommendations to improve outcomes for high-risk patients.
- Obstetric facilities must have a higher level of resources that need to be readily available.
- Standardization of a regionalized system of perinatal care and risk-appropriate care.
This requires uniform definitions:
- A standardized description of maternity facility capabilities and personnel (anesthesiologists, obstetric staff, neonatologists)
- A framework for integrated systems that address maternal health needs.
Established levels of maternal care include basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). Patients with complex medical conditions should receive care in level II to level IV centers that have more facility capabilities and specialized medical staff available when needed. Risk-assessment systems should be utilized to ensure that patients are at a facility with an appropriate level of care. There should be transportation available in case transfer to a higher level of care is needed.
Read more, including a discussion on anesthesiologist availability and anesthesia care, in the full article.
Maternal early warning system distinguishes the normal physiologic changes of pregnancy from the abnormal
ASA Monitor staff
Maternal morbidity and mortality are rising in the United States due to many factors, including increased maternal age and comorbidities. Identifying patients on the labor floor who are at increased risk of developing complications or severe maternal morbidity (SMM) is an important step in reducing this risk (asamonitor.pub/3FzKZy8).
While traditional scoring systems such as SIRS or qSOFA consistently fail to identify the crashing parturient, other maternal early-warning systems have been developed to distinguish the normal physiologic changes of pregnancy from the abnormal. A high score triggers providers to urgently evaluate patients to improve time to diagnosis and treatment of conditions such as bleeding, infection, and hypertension (Anesth Analg 2019;129:1613-20;Obstet Gynecol 2014;124:782-6;Anaesthesia 2013;68:354-67). These warning systems may also predict the risk of ICU admission and have been integrated into clinical pathway tools to protocolize treatment of the most common obstetric complications with resultant improvement in severe maternal morbidity (SMM) (J Obstet Gynaecol Can 2017;39:728-33.e3;Am J Obstet Gynecol 2016;214:527.e1-6).
Surmounting Barriers to EM Use in China
ASA Monitor staff
One of the largest reported barriers to EM use during a critical event is a lack of sufficient simulation training programs (asamonitor.pub/3IEWA0T). In China, a simulation training competition was founded by the Zhongshan City Society of Anesthesiology (APSF Newsletter 2017;32:53-4). Finalists from seven hospitals competed in a half-day event that focused on crisis resource management skills using EMs (APSF Newsletter 2017;32:53-4). The event served as a catalyst to encourage facilities to organize simulation training for OR EM implementation. A study completed one year later found that among those who participated in the competition, 85% reported using EMs in at least one OR critical event, a statistically significant increase (Cureus 2018;10:e3188).
An Anesthesia Crisis Resource Management Workshop was organized by the Department of Anesthesiology, Peking University People's Hospital in Beijing, China, in 2017 to demonstrate the utility of EMs as a resource for education and clinical care ( target="_blank"APSF Newsletter 2017;32:53-4). The participants could become qualified teachers to organize and teach simulations at their own institutions (APSF Newsletter 2017;32:53-4).
An EM simulation demonstration was included in a regional anesthesia meeting by the Department of Anesthesia, Xiangyang Central Hospital (APSF Newsletter 2017;32:53-4). Participants found that expert demonstration appears to be similar to simulation participation and was superior to didactics for teaching tenets involving the application of teamwork skills (APSF Newsletter 2017;32:53-4).
“Training a trainer” is an efficient way to spread new medical practices, and having trained individuals at every hospital can eliminate the fees, travel costs, and time-consuming nature of simulation training workshops, which are often multiday events (APSF Newsletter 2018;33:60-1). During a Chinese Association of Anesthesiologists annual meeting, attendees were able to participate in a two-hour EM simulation instructor training course, where they became qualified teachers (APSF Newsletter 2018;33:60-1). Participants engaged in a series of three standardized simulation scenarios (APSF Newsletter 2018;33:60-1). A post-course evaluation survey found that 80% of participants felt that they obtained the basic skills of EM simulation training, and 97% of participants agreed that they would organize EM simulation training at their hospitals (APSF Newsletter 2018;33:60-1).
Clinical Abnormalities Associated with Pompe Disease
ASA Monitor staff
The Anesthesiology Continuing Education (ACE) question in the April issue of ASA Monitor is: The juvenile form of Pompe disease is MOST often associated with which of the following clinical abnormalities?
(B) Hypertrophic cardiomyopathy
Read the article for more details on features of Pompe disease in infantile form and its progression. The answer to the ACE question appears at the bottom.
What anesthesiologists need to know about biologics
ASA Monitor staff
Over the past two decades, treatment strategies for various inflammatory and autoimmune conditions have evolved from the use of small molecule broad-spectrum immunomodulators to that of highly targeted antibody-based immunotherapies.
Previously, glucocorticoids served as a key therapy for most of these conditions. However, this strategy demonstrated diminished benefit as a result of considerable off-target toxicities. Steroid-sparing agents such as methotrexate, azathioprine, and sulfasalazine provided modest benefits, albeit with some significant adverse events. Research in biochemistry and molecular biology allowed greater mechanistic understanding of these disease processes.
Consequently, new targeted immunotherapies that act quickly and directly to interrupt inflammatory processes and tissue destruction have been developed. These new therapies include biologics and small molecules that target several cytokines, cytokine receptors, and other relevant immunologic pathways. In doing so, it was hoped that high response rates could be obtained with reduced toxicity profiles. In this brief update, “In the Know” authors review the most frequently used monoclonal antibodies to treat a variety of conditions.
Bringing Back Whole Blood Resuscitation
ASA Monitor staff
Physicians have long known the potential of whole blood resuscitation. It was standard practice for 100 years and utilized during WWI and WWII, with component therapy becoming more popular around the Vietnam War, when blood banks developed the technical capability to partition blood to give patients specifically the portion of blood they needed.
This article in ASA Monitor details the shift from blood component therapy back to whole blood resuscitation, as outlined by Justin Richards, MD, Associate Professor of Anesthesiology and Critical Care Medicine at the University of Maryland School of Medicine Division of Trauma Anesthesiology, and Associate Medical Director of the Trauma Resuscitation Unit at the R Adams Cowley Shock Trauma Center.
“When patients are bleeding, they're bleeding whole blood. We need to give them back what they're bleeding,” reasoned Dr. Richards.
Anesthesia considerations for a Patient with mpox
ASA Monitor staff
This month’s Anesthesia Incident Reporting System (AIRS) case explores placement of a gastric feeding tube, with a request for anesthesia support. The 35-year-old patient had HIV/AIDS and active mpox (formerly “monkeypox”) infection, with multiple ulcerative lesions of the oral mucosa that made it painful to eat and drink.
While patients with mpox do not commonly require anesthesia, a situation like the one presented in the article illustrates the need to remain current with new threats. Read how the perioperative team, including anesthesiologists who were consulted late in the process, performed an appropriate preoperative assessment (World J Clin Cases 2022;10:9348-53) and proceeded with a general anesthetic and direct control of the airway rather than attempt sedation.
International Delegation Visits Cuba Amidst Anesthesia Supply Shortages
Adriana Paz, MD, Alioth Fernandez Valle, MD, Renan Ferrufino, MD, and Roman Schumann, MD
The 12th Congress of Anesthesia, Resuscitation and Pain and the largest delegation of anesthesiologists from the United States to visit Cuba ever occurred last November. This major Cuban anesthesiology meeting takes place only every 4 years. Twenty-eight medical doctors, faculty, anesthesiologists, and a CRNA travelled from prestigious institutions including Tufts, John Hopkins, University of Michigan, University of Vermont, UCSF, Cedars-Sinai, University of Oklahoma, and Harvard Medical School, along with doctors from Europe and South America, to convene for this occasion.
The most recent meeting at Hotel Nacional de Cuba was the latest in an educational relationship between Tufts, additional academic anesthesiology programs, and The Cuban Society of Anesthesiology. A first-of-its-kind obstetric anesthesia workshop delivered by the obstetric anesthesia team from Beth Israel Deaconess Medical Center in Boston included a visit to Hospital Gonzales-Coro in Havana and the opportunity to assist with surgical deliveries. Dr. de Armendi, a pediatric anesthesiologist from Oklahoma Children’s Hospital, visited William Soler Pediatric Hospital in Havana where he met with the CEO, changed into scrubs, and visited the preop area, several ORs, and the PACU during his tour at the facility. Dr. de Armendi and the visiting teams were most impressed with the extent of services and level of care for patients within the Cuban health care system’s supply crisis.
Many anesthesiologists are familiar with the story of the Cuban health system. In 1962, President John F. Kennedy declared a comprehensive economic embargo, which, 60 years later, remains intact. The humanitarian impact of this embargo was detailed by Dr. Atul Gawande in the 1998 Slate article titled, “The Human Cost of Crippling Castro: Health Care Is Still Pretty Good in Cuba—Unless You Die Waiting for Embargoed Supplies.” Items that anesthesiologists take for granted in the U.S. and the developed world are severely limited or non-existent. For example, Cuban physicians have limited access to sevoflurane, non-depolarizing neuromuscular blockers, dexmedetomidine, and bupivacaine, among other common anesthesia- related medications. The embargo makes acquisition of equipment, from IV catheters to prosthetic heart valves, difficult. The current world political developments and climate change have not helped Cuba. Today, Cuba has patients that have been waiting for pacemakers for several months and, according to Dr. Alioth Fernandez Valle, Vice President of the Cuban SCAR, the country has started to recycle pacemakers. A once vibrant national cardiac surgical service is now crippled and relegated to rationing.
Cuba was one of the first countries to build a heart transplant program. The first heart transplant was performed in 1985 and since then the program has been in economically forced slow decline with the last transplant performed in 2016. Dr. Humberto Sainz Cabrera, the first Cuban Presidential Award Winner of the World Federation of Societies of Anesthesiologists, expressed that the “blockade” of Cuba limits access to essential medical supplies. He states that it is harder today to practice medicine in Cuba than it has ever been, as politics interferes with caring for patients on many different levels.
Helping to organize this successful exchange between this group of Cuban, U.S., and other physicians was a privilege beyond words. We are thrilled to facilitate relationship building and protecting what matters most to us as anesthesia clinicians: caring for patients, regardless of nationality, history, or politics, brings the nations together.
In the future, we hope to further extend this exchange to include POCUS workshops.
Those interested in donating medical equipment for anesthesia or participating in future meetings can contact meeting organizers listed below.
Caring for transgender patients
In the February article, Caring for the Transgender Patient: It Is More Than Using the Right Pronouns!, authors Kara Segna, MD, and Lalitha Sundararaman, MBBS, MD, note that appreciation for the appropriate terminology and avoidance of offensive, outdated terms is paramount for making medical diagnoses and speaking with patients. The authors provide a list of the outdated and current gender terminology to help physicians better communicate with patients.
Optimizing Anesthesia Residency Opportunities
Pedro Tanaka, MD, PhD (Medicine), MACM, PhD (Education), clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University
In the April issue of ASA Monitor, I'll share my journey from a private physician at an academic center in Brazil to Stanford University Department of Anesthesiology, Perioperative and Pain Medicine. The article will highlight variations in medical education and residency requirements in different countries.
In advance of the full article, here are answers to questions common to students exploring a career in anesthesiology.
How does a medical student decide they want to pursue an anesthesia residency, and what makes for a good resident?
Understanding the timeline leading up to a residency program is a key place to start. We can talk about, theoretically, what it is to be an anesthesiologist, and the importance of understanding the concepts of physiology and pharmacology, but does that theoretical understanding make you a good anesthesiologist? The earlier the exposure to the field, the easier it is to understand the expectations in anesthesiology. Most undergraduate students may know that they want to go into medical school, but not yet know in which field they want to specialize. If a student’s initial motive is to become a physician, they can choose to specialize in anesthesiology when they prepare for residency and choose their specialization within anesthesia during their residency. Most students come out of college thinking, ‘I want to help the community,’ ‘I want to do good for humanity,’ ‘I want to be empathic for the underserved community.’ Medical school provides the opportunity for students to explore a variety of departments. By the third year of medical school, students will start to realize if they’d like to apply for anesthesia residency programs, because by then they have been exposed to a variety of clinical clerkships and have been shadowing different departments like family medicine, obstetrics and gynecology, or surgery. By the time you rotate through these, students start to think about what will fit for them as a specialty.
Can you offer any tips for finding solid opportunities throughout medical school?
By the time you rotate through your clinical clerkships, you start to think about what fits for you as a specialty. Some medical students come in their first year and find good mentors in a specialty. In my first year of medical school, I started working with a mentor who used to be a chronic pain physician and so my focus started in that route, because I had this mentor who was an amazing person. There are many context-dependent factors in terms of what you’re exposed to in your medical school student trajectory.
How important is the role of the mentor in the resident’s journey?
During my residency in internal medicine, I had the opportunity to shadow my now wife, who also works in anesthesiology. While shadowing her, I took an interest in the OR and ICU, and the use of critical decision-making and procedural skills. Professors and mentors can influence their residents’ interests. Students and residents may make career decisions based on their experience with a mentor, so it’s important for educators to always be honest when students ask about experiences in the field of anesthesiology.
Staffing ratios & Patient Outcomes
Amr E. Abouleish, MD, MBA, FASA
Amr E. Abouleish, MD, MBA, FASA highlights a study examining anesthesiologists covering overlapping anesthesia cases and the staffing ratio impact on patient outcomes in this retrospective, matched cohort study of major noncardiac inpatient surgical procedures done in 23 U.S. academic and private hospitals (JAMA Surg 2022;157:807-15). In contrast to previous studies on anesthesia outcomes using claims database, this study utilizes a large database that is populated by the EMR that provides more granular and detailed data. Read his insights on how this study provides evidence that this inability to flex staffing to meet “demand matching” leads to worse patient outcomes.
New heart failure guidelines
The American Heart Association and the American College of Cardiology, with the Heart Failure Society of America, recently updated their joint practice guideline for the management of heart failure. Most notable in their top take-home messages is the inclusion of SGLT2i, which are recommended in all classes of heart failure, including the prevention of heart failure in at-risk patients. Read more in the SEE Question of the Month.