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Dragan KE, Nemergut EC. Sleep and Fatigue: And Miles to Go Before We Sleep. Anesth Analg 2023; 136:699-700. [PMID: 36928156 DOI: 10.1213/ane.0000000000006265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- Kristen E Dragan
- From the Department of Anesthesiology, West Virginia University, Morgantown, West Virginia
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Dunn LK, Pham E, Kabil E, Kleiman AM, Hilton EJ, Lyons GR, Ma JZ, Nemergut EC, Forkin KT. The Impact of Physician Race and Sex on Patient Ranking of Physician Competence and Perception of Leadership Ability. Cureus 2023; 15:e34778. [PMID: 36909083 PMCID: PMC10005834 DOI: 10.7759/cureus.34778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/10/2023] Open
Abstract
Background Biases affect patient perceptions of their physician and influence the physician-patient relationship. While racial disparities in care and inequities in the healthcare workforce are well-documented, the impact of physician race on patient perceptions remains unclear. We aimed to investigate the association of physician race and sex on patient perceptions during simulated preoperative encounters. Methods Three hundred patients recruited consecutively in the Preanesthesia Evaluation and Testing Center viewed pictures of 4 anesthesiologists (black male, white male, black female, white female) in random order while listening to a set of paired audio recordings describing general anesthesia. Participants ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member, and chose the one anesthesiologist most like a leader. Results Compared to white anesthesiologists, black anesthesiologists had greater odds of being ranked more confident (OR, 1.45; 95% CI, 1.10 to 1.89; P=0.008) and being considered a leader (OR, 2.06; 95% CI, 1.50 to 2.84; P<0.0001). Among white participants, black anesthesiologists had greater odds of being ranked more intelligent (OR, 2.08; 95% CI, 1.54 to 2.81; P<0.0001) and were more likely to be chosen to care for a family member (OR, 2.26; 95% CI, 1.66 to 3.08; P<0.0001). Female anesthesiologists had greater odds of being ranked more intelligent (OR, 1.36; 95% CI, 1.08 to 1.71; P=0.009) and were more likely to be chosen to care for a family member (OR, 1.58; 95% CI, 1.27 to 1.97; P<0.001) compared with male anesthesiologists. Conclusions Contrary to our hypothesis, patients ranked black physicians more highly on multiple competence and leadership quality metrics. Our data likely highlight the role social desirability bias may play in studies of racial disparities within medicine.
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Affiliation(s)
- Lauren K Dunn
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Elizabeth Pham
- Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Emmad Kabil
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Amanda M Kleiman
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Ebony J Hilton
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Genevieve R Lyons
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, USA
| | - Jennie Z Ma
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, USA
| | - Edward C Nemergut
- Anesthesiology, West Virginia University School of Medicine, Morgantown, USA
| | - Katherine T Forkin
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
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Sun H, Chen D, Warner DO, Zhou Y, Nemergut EC, Macario A, Keegan MT. Anesthesiology Residents' Experiences and Perspectives of Residency Training. Anesth Analg 2021; 132:1120-1128. [PMID: 33438965 DOI: 10.1213/ane.0000000000005316] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Anesthesiology residents' experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice. METHODS Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study-3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1-3), 2 surveys for the 2015 cohort (clinical anesthesia years 1-2), and 1 survey for the 2016 cohort (clinical anesthesia year 1). RESULTS The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as "very unimportant" and 5 as "very important," quality of clinical experience (4.7-4.8 among the cohorts) and departmental commitment to education (4.3-4.5) were rated as the most important factors in anesthesiologists' choice of residency. Approximately 70% of first- and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4-4.5 on a 5-point scale among cohort-training levels) and their residency programs (4.0-4.1). The residency training experiences mostly met their expectations (3.8-4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1-4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7-4.9) and interpersonal and communication skills (4.6-4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position. CONCLUSIONS Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program.
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Affiliation(s)
- Huaping Sun
- From the American Board of Anesthesiology, Raleigh, North Carolina
| | - Dandan Chen
- From the American Board of Anesthesiology, Raleigh, North Carolina
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester Minnesota
| | - Yan Zhou
- From the American Board of Anesthesiology, Raleigh, North Carolina
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Alex Macario
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Mark T Keegan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester Minnesota
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Forkin KT, Dunn LK, Kotha NC, Bechtel AJ, Kleiman AM, Huffmyer JL, Collins SR, Lyons GR, Ma JZ, Nemergut EC. Anesthesiologist Age and Sex Influence Patient Perceptions of Physician Competence. Anesthesiology 2021; 134:103-110. [PMID: 33108442 PMCID: PMC7725924 DOI: 10.1097/aln.0000000000003595] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncovering patients' biases toward characteristics of anesthesiologists may inform ways to improve the patient-anesthesiologist relationship. The authors previously demonstrated that patients prefer anesthesiologists displaying confident body language, but did not detect a sex bias. The effect of anesthesiologists' age on patient perceptions has not been studied. In this follow-up study, it was hypothesized that patients would prefer older-appearing anesthesiologists over younger-appearing anesthesiologists and male over female anesthesiologists. METHODS Three hundred adult, English-speaking patients were recruited in the Preanesthesia Evaluation and Testing Center. Patients were randomized (150 per group) to view a set of four videos in random order. Each 90-s video featured an older female, older male, younger female, or younger male anesthesiologist reciting the same script describing general anesthesia. Patients ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member. Patients also chose the one anesthesiologist who seemed most like a leader. RESULTS Three hundred patients watched the videos and completed the questionnaire. Among patients younger than age 65 yr, the older anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.92; 95% CI, 1.41 to 2.64; P < 0.001) and more intelligent (odds ratio, 2.24; 95% CI, 1.62 to 3.11; P < 0.001), and had greater odds of being considered a leader (odds ratio, 2.62; 95% CI, 1.72 to 4.00; P < 0.001) when compared with younger anesthesiologists. The preference for older anesthesiologists was not observed in patients age 65 and older. Female anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.46; 95% CI, 1.13 to 1.87; P = 0.003) and more likely to be chosen to care for one's family member (odds ratio, 1.80; 95% CI, 1.40 to 2.31; P < 0.001) compared with male anesthesiologists. The ranking preference for female anesthesiologists on these two measures was observed among white patients and not among nonwhite patients. CONCLUSIONS Patients preferred older anesthesiologists on the measures of confidence, intelligence, and leadership. Patients also preferred female anesthesiologists on the measures of confidence and likelihood of choosing the anesthesiologist to care for one's family member. EDITOR’S PERSPECTIVE
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Affiliation(s)
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Naveen C. Kotha
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Allison J. Bechtel
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Amanda M. Kleiman
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Julie L. Huffmyer
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Stephen R. Collins
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Genevieve R. Lyons
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Edward C. Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
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Dunn LK, Chen CJ, Taylor DG, Esfahani K, Brenner B, Luo C, Buell TJ, Spangler SN, Buchholz AL, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Naik BI. Postoperative Low-Dose Tranexamic Acid After Major Spine Surgery: A Matched Cohort Analysis. Neurospine 2020; 17:888-895. [PMID: 33401867 PMCID: PMC7788407 DOI: 10.14245/ns.2040114.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/08/2020] [Indexed: 01/04/2023] Open
Abstract
Objective This was a retrospective, cohort study investigating the efficacy and safety of continuous low-dose postoperative tranexamic acid (PTXA) on drain output and transfusion requirements following adult spinal deformity surgery.
Methods One hundred forty-seven patients undergoing posterior instrumented thoracolumbar fusion of ≥ 3 vertebral levels at a single institution who received low-dose PTXA infusion (0.5–1 mg/kg/hr) for 24 hours were compared to 292 control patients who did not receive PTXA. The cohorts were propensity matched based on age, sex, American Society of Anesthesiologist physical status classification, body mass index, number of surgical levels, revision surgery, operative duration, and total intraoperative TXA dose (n = 106 in each group). Primary outcome was 72-hour postoperative drain output. Secondary outcomes were number of allogeneic blood transfusions.
Results There was no significant difference in postoperative drain output in the PTXA group compared to control (660 ±420 mL vs. 710 ±490 mL, p = 0.46). The PTXA group received significantly more crystalloid (6,100 ±3,100 mL vs. 4,600 ±2,400 mL, p < 0.001) and red blood cell transfusions postoperatively (median [interquartile range]: 1 [0–2] units vs. 0 [0–1] units; incidence rate ratio [95% confidence interval], 1.6 [1.2–2.2]; p = 0.001). Rates of adverse events were comparable between groups.
Conclusion Continuous low-dose PTXA infusion was not associated with reduced drain output after spinal deformity surgery. No difference in thromboembolic incidence was observed. A prospective dose escalation study is warranted to investigate the efficacy of higher dose PTXA.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Brian Brenner
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Charles Luo
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Sarah N Spangler
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Christopher I Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
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Forkin KT, Chiao SS, Naik BI, Patrie JT, Durieux ME, Nemergut EC. Individualized Quality Data Feedback Improves Anesthesiology Residents' Documentation of Depth of Neuromuscular Blockade Before Extubation. Anesth Analg 2020; 130:e49-e53. [PMID: 31136324 DOI: 10.1213/ane.0000000000004222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Reversal of neuromuscular blockade is an important anesthesia quality measure, and anesthesiologists should strive to improve both documentation and practice of this measure. We hypothesized that the use of an electronic quality database to give individualized resident anesthesiologist feedback would increase the percentage of cases that residents successfully documented quantitative depth of neuromuscular blockade before extubation. The mean baseline success rate among anesthesiology residents was 80% (95% confidence interval [CI], 78-81) and increased by 14% (95% CI, 11-17; P < .001) after the residents were given their individualized quality data. Practice patterns improved quickly but were not sustained over 6 months.
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Affiliation(s)
- Katherine T Forkin
- From the Departments of *Anesthesiology †Neurosurgery ‡Public Health Sciences, University of Virginia, Charlottesville, Virginia
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Gui JL, Nemergut EC, Forkin KT. Distraction in the operating room: A narrative review of environmental and self-initiated distractions and their effect on anesthesia providers. J Clin Anesth 2020; 68:110110. [PMID: 33075633 DOI: 10.1016/j.jclinane.2020.110110] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/28/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
The operating room (OR) is a busy environment with multiple opportunities for distraction. A well-trained anesthesiologist or certified registered nurse anesthetist (CRNA) should remain focused on providing excellent patient care despite these potential distractions. The purpose of this narrative review is to present the multiple types of OR distractions and evaluate each for their level of distraction and their likely impact on patient safety. Distractions in the OR are common and numerous types of distractions exist. Loud OR background noise can lead to miscommunication within the OR team. In several studies, OR noise has been shown to decrease vigilance and possibly delay recognition of non-routine events. The most commonly observed distracting events are "small talk" and staff entering and exiting the OR and most intense distracting events are faulty or unavailable equipment. Phone and pager use can be particularly distracting. Self-initiated distractions can be seen as unprofessional and can negatively impact patient safety. The impact of OR distractions on patient outcomes deserves more vigorous investigation. We must provide anesthesia trainees with the skills to remain vigilant despite numerous and varied OR distractions while also attempting to reduce such OR distractions to improve patient safety. Further research is needed to inform the institution of policies to lessen unnecessary OR distractions.
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Affiliation(s)
- Jane L Gui
- Department of Anesthesiology, Mount Sinai West-St. Luke's Hospital, 1000 Tenth Avenue, New York, NY 10019, USA.
| | - Edward C Nemergut
- Department of Anesthesiology, Department of Neurosurgery, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
| | - Katherine T Forkin
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
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Huffmyer JL, Nemergut EC. In Response. Anesth Analg 2020; 131:e80-e81. [DOI: 10.1213/ane.0000000000004875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Salajegheh R, Nemergut EC, Rice TM, Joseph R, Tsang S, Sarosiek BM, Muthusubramanian CP, Hipwell KM, Horton KB, Naik BI. Impact of a perioperative oral opioid substitution protocol during the nationwide intravenous opioid shortage: A single center, interrupted time series with segmented regression analysis. PLoS One 2020; 15:e0234199. [PMID: 32497141 PMCID: PMC7272091 DOI: 10.1371/journal.pone.0234199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/20/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION To mitigate the recent nationwide shortage of intravenous opioids, we developed a standardized perioperative oral opioid guideline anchored with appropriate use of nonopioid analgesia, neuraxial and loco-regional techniques. We hypothesize that adoption of this new guideline was associated with: 1) equivalent patient reported pain scores in the post-anesthesia care unit (PACU); and 2) equivalent total opioid use (oral and parenteral) during the perioperative period. METHODS Cases performed from July 1, 2017 to May 31, 2019 were screened. All opioids administered were converted to intravenous morphine milligram equivalents. Segmented regression analyses of interrupted time series were performed examining the change in opioid use, PACU pain scores and number of non-opioid analgesic medications used before and after the protocol implementation in April 2018. RESULTS After exclusions, 29, 621 cases were included in the analysis. No significant differences in demographic, ASA status, case length and surgical procedure type were present in the pre and post-intervention period. A significant decrease in total (Estimate: -39.9 mg, SE: 6.9 mg, p < 0.001) and parenteral (Estimate: -51.6 mg, SE: 7.1 mg, p < 0.001) opioid use with a significant increase in oral opioid use (Estimate: 9.4 mg, SE: 1.1 mg, p < 0.001) was noted after the intervention. Pain scores were not significantly different between the pre- and post-intervention period (Estimate: 0.05, SE: 0.13, p = 0.69). CONCLUSION We report our experience with a primary perioperative oral based opioid regimen that is associated with decreased total opioid consumption and equivalent patient reported pain scores.
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Affiliation(s)
- Reza Salajegheh
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Terran M Rice
- Department of Pharmacy, University of Virginia, Charlottesville, Virginia, United States of America
| | - Roy Joseph
- Department of Pharmacy, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Pharmacy, Rady Children's Hospital-San Diego, San Diego, California, United States of America
| | - Siny Tsang
- Department of Nutrition and Exercise Physiology, Washington State University, Spokane, Washington, United States of America
| | - Bethany M Sarosiek
- Department of Perioperative Services, University of Virginia, Charlottesville, Virginia, United States of America
| | - C Paige Muthusubramanian
- Department of Perioperative Services, University of Virginia, Charlottesville, Virginia, United States of America
| | - Katelyn M Hipwell
- Department of Pharmacy, University of Virginia, Charlottesville, Virginia, United States of America
| | - Kate B Horton
- Department of Pharmacy, University of Virginia, Charlottesville, Virginia, United States of America
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
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Dunn LK, Thiele RH, Lin MC, Nemergut EC, Durieux ME, Tsang S, Shaffrey ME, Smith JS, Shaffrey CI, Naik BI. The Impact of Alvimopan on Return of Bowel Function After Major Spine Surgery - A Prospective, Randomized, Double-Blind Study. Neurosurgery 2020; 85:E233-E239. [PMID: 30951602 DOI: 10.1093/neuros/nyz005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/22/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pain management following major spine surgery requires high doses of opioids and is associated with a risk of opioid-induced constipation. Peripheral mu-receptor antagonists decrease the gastrointestinal complications of perioperative systemic opioid administration without antagonizing the analgesic benefits of these drugs. OBJECTIVE To investigate the impact of alvimopan in opioid-naive patients undergoing major spine surgery. METHODS Patients undergoing >3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective, randomized, double-blind study to receive either alvimopan or placebo prior to and following surgery. Opioid consumption; pain scores; and time of first oral intake, flatus, and bowel movement were recorded. RESULTS A total of 24 patients were assigned to the active group and 25 were assigned to the placebo group. There was no significant difference in demographics between the groups. Postoperatively, the alvimopan group reported earlier time to first solid intake [median (range): alvimopan: 15 h (3-25) vs placebo: 17 h (3-46), P < .001], passing of flatus [median (range): alvimopan: 22 h (7-63) vs placebo: 28 h (10-58), P < .001], and first bowel movement [median (range): alvimopan: 50 h (22-80) vs placebo: 64 h (40-114), P < .001]. The alvimopan group had higher pain scores (maximum, minimum, and median); however, there was no significant difference between the groups with postoperative opioid use. CONCLUSION This study shows that the perioperative use of alvimopan significantly reduced the time to return of bowel function with no increase in postoperative opioid use despite a slight increase in pain scores.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia
| | - Michelle C Lin
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Nutrition and Exercise Physiology, Washington State University, Pullman, Washington
| | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Dunn LK, Taylor DG, Chen CJ, Singla P, Fernández L, Wiedle CH, Hanak MF, Tsang S, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Blank RS, Naik BI. Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery. Anesth Analg 2020; 130:100-110. [DOI: 10.1213/ane.0000000000004322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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14
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Affiliation(s)
- Katherine T Forkin
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, Department of Anesthesiology, Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Dunn LK, Yerra S, Fang S, Hanak MF, Leibowitz MK, Tsang S, Durieux ME, Nemergut EC, Naik BI. Incidence and Risk Factors for Chronic Postoperative Opioid Use After Major Spine Surgery: A Cross-Sectional Study With Longitudinal Outcome. Anesth Analg 2019; 127:247-254. [PMID: 29570151 DOI: 10.1213/ane.0000000000003338] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic opioid use is a significant public health concern. Surgery is a risk factor for developing chronic opioid use. Patients undergoing major spine surgery frequently are prescribed opioids preoperatively and may be at risk for chronic opioid use postoperatively. The aim of this study was to investigate the incidence of and perioperative risk factors associated with chronic opioid use after major spine surgery. METHODS The records of patients who underwent elective major spine surgery at the University of Virginia between March 2011 and February 2016 were retrospectively reviewed. The primary outcome was chronic opioid use through 12 months postoperatively. Demographic data, medical comorbidities, preoperative pain scores, and medication use including daily morphine-equivalent (ME) dose, intraoperative use of lidocaine and ketamine, estimated blood loss, postoperative pain scores and medication use, and postoperative opioid use were collected. Logistic regression models were used to examine factors associated with chronic opioid use. RESULTS Of 1477 patient records reviewed, 412 patients (27.9%) were opioid naive and 1065 patients (72.3%) used opioids before surgery. Opioid data were available for 1325 patients, while 152 patients were lost to 12-month follow-up and were excluded. Of 958 preoperative opioid users, 498 (52.0%) remained chronic users through 12 months. There was a decrease in opioid dosage (mg ME) from preoperative to 12 months postoperatively with a mean difference of -14.7 mg ME (standard deviation, 1.57; 95% confidence interval [CI], -17.8 to -11.7). Among 367 previously opioid-naive patients, 67 (18.3%) became chronic opioid users. Factors associated with chronic opioid use were examined using logistic regression models. Preoperative opioid users were nearly 4 times more likely to be chronic opioid users through 12 months than were opioid-naive patients (odds ratio, 3.95; 95% CI, 2.51-6.33; P < .001). Mean postoperative pain score (0-10) was associated with increased odds of chronic opioid use (odds ratio for a 1 unit increase in pain score 1.25, 95% CI, 1.13-1.38; P < .001). Use of intravenous ketamine or lidocaine was not associated with chronic opioid use through 12 months. CONCLUSIONS Greater than 70% of patients presenting for major spine surgery used opioids preoperatively. Preoperative opioid use and higher postoperative pain scores were associated with chronic opioid use through 12 months. Use of ketamine and lidocaine did not decrease the risk for chronic opioid use. Surveillance of patients for these factors may identify those at highest risk for chronic opioid use and target them for intervention and reduction strategies.
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Affiliation(s)
- Lauren K Dunn
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Sandeep Yerra
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Shenghao Fang
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Mark F Hanak
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Maren K Leibowitz
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Epidemiology, Columbia University, New York, New York
| | - Marcel E Durieux
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Bhiken I Naik
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Chiao SS, Colquhoun DA, Naik BI, Ma JZ, Nemergut EC, Durieux ME, Blank RS, Forkin KT. Changing Default Ventilator Settings on Anesthesia Machines Improves Adherence to Lung-Protective Ventilation Measures. Anesth Analg 2019; 126:1219-1222. [PMID: 29200060 DOI: 10.1213/ane.0000000000002575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative lung-protective ventilation (LPV) can reduce perioperative pulmonary morbidity. We hypothesized that modifying default anesthesia machine ventilator settings would increase the use of intraoperative LPV. Default tidal volume settings on our anesthesia machines were decreased from 600 to 400 mL, and default positive end-expiratory pressure was increased from 0 to 5 cm H2O. This modification increased mean positive end-expiratory pressure from 3.1 to 5.0 cm H2O and decreased mean tidal volume from 8.2 to 6.7 mL/kg predicted body weight. Notably, increased adherence to LPV from 1.6% to 23.0% occurred quickly with the rate of increase more than doubling from 1.8% to 3.9% per year.
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Affiliation(s)
- Sunny S Chiao
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | | | - Bhiken I Naik
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Departments of Neurosurgery
| | - Jennie Z Ma
- Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Departments of Neurosurgery
| | - Marcel E Durieux
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Departments of Neurosurgery
| | - Randal S Blank
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Katherine T Forkin
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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17
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Potter JF, Kleiman AM, Myers EG, Herberg TJ, Bechtel AJ, Forkin KT, Dunn LK, Collins SR, Huffmyer JL, Shilling AM, Nemergut EC. Generative Retrieval Does Not Improve Long-Term Retention of Regional Anesthesia Ultrasound Anatomy in Unengaged Learners. J Educ Perioper Med 2019; 21:E623. [PMID: 31988984 PMCID: PMC6972972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Ultrasound-guided regional anesthesia is increasingly used in the perioperative period but performance requires a mastery of regional ultrasound anatomy. We aimed to study whether the use of generative retrieval to learn ultrasound anatomy would improve long-term recall. METHODS Fourth-year medical students without prior training in ultrasound techniques were randomized into standard practice (SP) and generative retrieval (GR) groups. An initial pre-test consisted of 74 regional anesthesia ultrasound images testing common anatomic structures. During the study/learning session, GR participants were required to verbally identify an unlabeled anatomical structure within 10 seconds of the ultrasound image appearing on the screen. A labeled image of the structure was then shown to the GR participant for 5 seconds. SP participants viewed the same ultrasound images labeled with the correct anatomical structure for 15 seconds. Retention was tested at 1 week and 1 month following the study session. Participants completed a satisfaction survey after each session. RESULTS Forty-five medical students were enrolled with forty included in the analysis. There was no statistically significant difference in baseline scores (GR = 11.5 ± 4.9; SP = 11.2 ± 6.2; P = 0.84). There was no difference in scores at both the 1-week (SP = 54.5 ± 13.3; GR = 53.9 ± 10.5; P = 0.88) and 1-month (SP = 54.0 ± 14.5; GR = 50.7 ± 11.1; P = 0.42) time points. There was no statistically significant difference in learner satisfaction metrics between the groups. CONCLUSIONS The use of generative retrieval practice to learn regional anesthesia ultrasound anatomy did not yield significant differences in learning and retention compared with standard learning.
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18
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Kleiman AM, Potter JF, Bechtel AJ, Forkin KT, Dunn LK, Collins SR, Lyons G, Nemergut EC, Huffmyer JL. Generative retrieval results in positive academic emotions and long-term retention of cardiovascular anatomy using transthoracic echocardiography. Adv Physiol Educ 2019; 43:47-54. [PMID: 30615478 DOI: 10.1152/advan.00047.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
With increasing medical knowledge, procedural, and diagnostic skills to learn, it is vital for educators to make the limited amount of teaching time available to students effective and efficient. Generative retrieval is an effective and efficient learning tool, improving long-term retention through the practice of retrieval from memory. Forty medical students were randomized to learn normal cardiovascular anatomy using transthoracic echocardiography video clips in a generative retrieval (GR) or standard practice (SP) group. GR participants were required to verbally identify each unlabeled cardiovascular structure after viewing the video. After answering, participants viewed the correctly labeled video. SP participants viewed the same video clips labeled with the correct cardiovascular structure for the same amount of total time without verbally generating an answer. All participants were tested for intermediate (1-wk), late (1-mo), and long-term (6- to 9-mo) retention of cardiovascular anatomy. Additionally, a three-question survey was incorporated to assess perceptions of the learning method. There was no difference in pretest scores. The GR group demonstrated a trend toward improvement in recall at 1 wk [GR = 74.3 (SD 12.3); SP = 65.4 (SD 16.7); P = 0.10] and 1 mo [GR = 69.9 (SD15.6); SP = 64.3 (SD 15.4); P = 0.33]. At the 6- to 9-mo time point, there was a statistically significant difference in scores [GR = 74.3 (SD 9.9); SP = 65.0 (SD 14.1); P = 0.042]. At nearly every time point, learners had a statistically significantly higher perception of effectiveness, enjoyment, and satisfaction with GR. In addition to improved recall, GR is associated with increased perceptions of effectiveness, enjoyment, and satisfaction, which may lead to increased engagement, time spent studying, and improved retention.
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Affiliation(s)
- Amanda M Kleiman
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Jennifer F Potter
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Allison J Bechtel
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Katherine T Forkin
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Lauren K Dunn
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Stephen R Collins
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Genevieve Lyons
- Department of Public Health Sciences, University of Virginia , Charlottesville, Virginia
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
- Department of Neurosurgery, University of Virginia , Charlottesville, Virginia
| | - Julie L Huffmyer
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
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19
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Powlovich LG, Nemergut EC, Collins SR. Barash’s Clinical Anesthesia, 8th ed. Anesth Analg 2018. [DOI: 10.1213/ane.0000000000003548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Dunn LK, Yerra S, Fang S, Hanak MF, Leibowitz MK, Alpert SB, Tsang S, Durieux ME, Nemergut EC, Naik BI. Safety profile of intraoperative methadone for analgesia after major spine surgery: An observational study of 1,478 patients. J Opioid Manag 2018; 14:83-87. [PMID: 29733094 DOI: 10.5055/jom.2018.0435] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the incidence of perioperative adverse events in patients receiving intravenous methadone for major spine surgery. DESIGN Retrospective review of perioperative records from March 2011 and February 2016. SETTING University of Virginia Healthsystem. PATIENTS Adult patients undergoing elective spinal fusion of two or more levels. MAIN OUTCOME MEASURES Incidence of respiratory depression, time to extubation, hypotension, hypoxemia, reintubation, cardiac complications, and death. RESULTS Reviewed 1,478 patient records. Mean intraoperative methadone dose was 0.14 ± 0.07 mg/kg. A total of 1,142 patients (77.4 percent) were extubated in the operating room, 543 (36.8 percent) experienced respiratory depression, 1,180 (79.8 percent) hypoxemia, and 22 (1.5 percent) required reintubation. Cardiac complications included arrhythmias (289 patients, 29.9 percent), QTc prolongation (568 patients, 58.8 percent), and myocardial infarction (16 patients, 1.1 percent). Two in hospital deaths occurred (0.14 percent). CONCLUSIONS Mild-moderate respiratory depression is observed following a one-time dose of intraoperative methadone, and monitoring in an appropriate postoperative setting is recommended.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Sandeep Yerra
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Shenghao Fang
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Mark F Hanak
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Maren K Leibowitz
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Salome B Alpert
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Epidemiology, Columbia University, New York, New York
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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21
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McNeil JS, Kleiman AM, Nemergut EC, Huffmyer JL. Thromboatheromatous coarctation of the aorta diagnosed with intraoperative TOE during emergent open aneurysm clipping. BMJ Case Rep 2018; 2018:bcr-2017-224081. [PMID: 29804072 DOI: 10.1136/bcr-2017-224081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A woman in her 50s presenting for emergent intracranial surgery was discovered to have a large incongruity in blood pressure between her right arm and her other extremities. Intraoperative rescue transoesophageal echocardiography (TOE) revealed a large thromboatheromatous burden in her descending aorta resulting in a functional coarctation. Usually diagnosed via CT imaging, we present what we believe to be the first published case diagnosed intraoperatively using TOE. After the diagnosis was made, blood pressure goals were adjusted to provide sufficient perfusion distally and her surgery was completed otherwise uneventfully.
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Affiliation(s)
- John S McNeil
- Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Amanda M Kleiman
- Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Edward C Nemergut
- Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Julie L Huffmyer
- Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
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22
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Elmore BJ, Nemergut EC. Oxford Textbook of Anaesthesia, 1st ed. Anesth Analg 2018. [DOI: 10.1213/ane.0000000000002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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Affiliation(s)
- Lauren K Dunn
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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24
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Forkin KT, Colquhoun DA, Nemergut EC, Huffmyer JL. The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management. Anesth Analg 2018; 126:46-61. [PMID: 28795966 DOI: 10.1213/ane.0000000000002394] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease.
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Affiliation(s)
- Katherine T Forkin
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | | | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Julie L Huffmyer
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Affiliation(s)
- Bhiken I Naik
- University of Virginia, Charlottesville, Virginia (B.I.N.).
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Dunn LK, Durieux ME, Fernández LG, Tsang S, Smith-Straesser EE, Jhaveri HF, Spanos SP, Thames MR, Spencer CD, Lloyd A, Stuart R, Ye F, Bray JP, Nemergut EC, Naik BI. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine 2017; 28:119-126. [PMID: 29125426 DOI: 10.3171/2017.5.spine1734] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.
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Affiliation(s)
| | - Marcel E Durieux
- Departments of1Anesthesiology and.,2Neurosurgery, University of Virginia, Charlottesville, Virginia; and
| | | | - Siny Tsang
- 3Department of Epidemiology, Columbia University, New York, New York
| | | | | | | | | | | | | | | | - Fan Ye
- Departments of1Anesthesiology and
| | | | - Edward C Nemergut
- Departments of1Anesthesiology and.,2Neurosurgery, University of Virginia, Charlottesville, Virginia; and
| | - Bhiken I Naik
- Departments of1Anesthesiology and.,2Neurosurgery, University of Virginia, Charlottesville, Virginia; and
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Kleiman AM, Forkin KT, Bechtel AJ, Collins SR, Ma JZ, Nemergut EC, Huffmyer JL. Generative Retrieval Improves Learning and Retention of Cardiac Anatomy Using Transesophageal Echocardiography. Anesth Analg 2017; 124:1440-1444. [PMID: 28431420 DOI: 10.1213/ane.0000000000002004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is a valuable monitor for patients undergoing cardiac and noncardiac surgery as it allows for evaluation of cardiovascular compromise in the perioperative period. It is challenging for anesthesiology residents and medical students to learn to use and interpret TEE in the clinical environment. A critical component of learning to use and interpret TEE is a strong grasp of normal cardiovascular ultrasound anatomy. METHODS Fifteen fourth-year medical students and 15 post-graduate year (PGY) 1 and 2 anesthesiology residents without prior training in cardiac anesthesia or TEE viewed normal cardiovascular anatomy TEE video clips; participants were randomized to learning cardiac anatomy in generative retrieval (GR) and standard practice (SP) groups. GR participants were required to verbally identify each unlabeled cardiac anatomical structure within 10 seconds of the TEE video appearing on the screen. Then a correctly labeled TEE video clip was shown to the GR participant for 5 more seconds. SP participants viewed the same TEE video clips as GR but there was no requirement for SP participants to generate an answer; for the SP group, each TEE video image was labeled with the correctly identified anatomical structure for the 15 second period. All participants were tested for intermediate (1 week) and late (1 month) retention of normal TEE cardiovascular anatomy. Improvement of intermediate and late retention of TEE cardiovascular anatomy was evaluated using a linear mixed effects model with random intercepts and random slopes. RESULTS There was no statistically significant difference in baseline score between GR (49% ± 11) and SP (50% ± 12), with mean difference (95% CI) -1.1% (-9.5, 7.3%). At 1 week following the educational intervention, GR (90% ± 5) performed significantly better than SP (82% ± 11), with mean difference (95% CI) 8.1% (1.9, 14.2%); P = .012. This significant increase in scores persisted in the late posttest session at one month (GR: 83% ± 12; SP: 72% ± 12), with mean difference (95% CI) 10.2% (1.3 to 19.1%); P = .026. Mixed effects analysis showed significant improvements in TEE cardiovascular anatomy over time, at 5.9% and 3.5% per week for GR and SP groups respectively (P = .0003), and GR improved marginally faster than SP (P = .065). CONCLUSIONS Medical students and anesthesiology residents inexperienced in the use of TEE showed both improved learning and retention of basic cardiovascular ultrasound anatomy with the incorporation of GR into the educational experience.
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Affiliation(s)
- Amanda M Kleiman
- From the Departments of *Anesthesiology, and †Public Health Sciences, University of Virginia, Charlottesville, Virginia
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Nemergut EC, Durieux ME. Teaching Children to Resuscitate. Anesth Analg 2017; 124:1039-1040. [DOI: 10.1213/ane.0000000000001889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Naik BI, Durieux ME, Knisely A, Sharma J, Bui-Huynh VC, Yalamuru B, Terkawi AS, Nemergut EC. SEER Sonorheometry Versus Rotational Thromboelastometry in Large Volume Blood Loss Spine Surgery. Anesth Analg 2016; 123:1380-1389. [DOI: 10.1213/ane.0000000000001509] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Naik BI, Nemergut EC, Kazemi A, Fernández L, Cederholm SK, McMurry TL, Durieux ME. The Effect of Dexmedetomidine on Postoperative Opioid Consumption and Pain After Major Spine Surgery. Anesth Analg 2016; 122:1646-53. [PMID: 27003917 DOI: 10.1213/ane.0000000000001226] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adult deformity correction spine surgery can be associated with significant perioperative pain because of inflammatory, muscular, neuropathic, and postsurgical pain. α-2 Agonists have intrinsic antinociceptive and antihyperalgesic properties that can potentially reduce both postoperative opioid consumption and pain. We hypothesized that intraoperative dexmedetomidine would reduce postoperative opioid consumption and improve pain scores in deformity correction spine surgery. METHODS Patients undergoing >3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective randomized double-blind study to receive either dexmedetomidine (1 μg/kg load followed by a continuous infusion of 0.5 μg/kg/h) or saline. Both groups received a single dose of 0.2 mg/kg (ideal body weight) of methadone at the start of surgery. Intraoperative fentanyl was administered based on the clinical and hemodynamic signs suggestive of increased nociception. Postoperative analgesia was provided with a hydromorphone patient-controlled analgesia pump. Opioid consumption and pain scores were recorded at 24, 48, and 72 hours after surgery. RESULTS One hundred forty-two participants were enrolled with 131 completing the study. There was no significant difference in demographics (age, sex, weight, and ASA physical status), percentage of participants with preoperative opioid use, and daily median opioid consumption between the groups. The study was terminated early after interim analysis. Intraoperative opioid use was reduced in the dexmedetomidine arm (placebo versus dexmedetomidine, median [25%-75% interquartile range]: 7 [3-15] vs 3.5 [0-11] mg morphine equivalents, P = 0.04) but not at 24 hours: 49 (30-78) vs 61 (34-77) mg morphine equivalents, P = 0.65, or 48 hours: 41 (28-68) vs 40 (23-64) mg morphine equivalents, P = 0.60, or 72 hours: 29 (15-59) vs 30 (14-46) mg morphine equivalents, P = 0.58. The Wilcoxon-Mann-Whitney odds are 1.11 with 97.06% confidence interval (0.71-1.76) for opioid consumption. No difference in pain score, as measured by the 11-point visual analog scale, was seen at 24 hours (placebo versus dexmedetomidine, median [25%-75% interquartile range]: 7 [5-7] vs 6 [4-7], P = 0.12) and 48 hours (5 [3-7] vs 5 [3-6], P = 0.65). There was an increased incidence of bradycardia (placebo: 37% vs dexmedetomidine: 59% P = 0.02) and phenylephrine use in the dexmedetomidine group (placebo: 59% versus dexmedetomidine: 78%, P = 0.03). CONCLUSIONS Intraoperative dexmedetomidine does not reduce postoperative opioid consumption or improve pain scores after multilevel deformity correction spine surgery.
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Affiliation(s)
- Bhiken I Naik
- From the Departments of *Anesthesiology, †Neurosurgery, and ‡Public Health Sciences, University of Virginia, Charlottesville, Virginia
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Abstract
Patients undergoing surgery for pituitary tumors represent a heterogeneous population each with unique clinical, biochemical, radiologic, pathologic, neurologic, and/or ophthalmologic considerations. The postoperative management of patients following pituitary surgery often occurs in the context of a dynamic state of the hypothalamic-pituitary-end organ axis. Consequently, a significant component of the postoperative care of these patients focuses on vigilant screening and observation for neuroendocrinologic perturbations such as varying degrees of hypopituitarism and disorders of water balance (diabetes insipidus and the syndrome of inappropriate antidiuretic hormone). Additionally, one must be cognizant of other potential complications specific to the transsphenoidal approach for tumor removal including cerebrospinal fluid leakage and meningitis. This review addresses the postoperative management of patients undergoing pituitary surgery with an emphasis on careful screening and recognition of complications.
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Affiliation(s)
- Aaron S Dumont
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, 22908, USA
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Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: Novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30:79-89. [DOI: 10.1016/j.bpa.2015.11.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/27/2015] [Accepted: 11/16/2015] [Indexed: 01/07/2023]
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Thiele RH, Hucklenbruch C, Ma JZ, Colquhoun D, Zuo Z, Nemergut EC, Raphael J. Admission hyperglycemia is associated with poor outcome after emergent coronary bypass grafting surgery. J Crit Care 2015; 30:1210-6. [PMID: 26428075 DOI: 10.1016/j.jcrc.2015.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE Hyperglycemia during or after cardiac surgery is a common finding that is associated with poor outcome. Very few data, however, are available regarding a correlation between admission blood glucose and outcomes after coronary artery bypass grafting (CABG). Thus, the goal of the current study was to examine the relationship between admission blood glucose and outcome after emergency CABG surgery. MATERIALS AND METHODS A retrospective analysis to evaluate whether admission hyperglycemia associated with increased morbidity or mortality was performed in patients after emergency CABG surgery. The records of all the patients undergoing emergency CABG surgery between January 1999 and December 2010 at the University of Virginia Health System were reviewed. Postoperative in-hospital mortality and complications were considered as study end points. RESULTS A total of 240 patients met the final inclusion criteria. Overall mortality was 14.1%. The median admission blood glucose in patients who died 7.4 (interquartile range, 5.9-10.1) mmol/L was significantly higher compared with survivors 6.1 (interquartile range, 5.4-7.2; P<.01). Furthermore, 59% of the patients who died had admission blood glucose levels higher than 6.6 mmol/L, whereas only 35% of the patients who survived had similar blood glucose levels (P=.01). On multivariable analysis, admission blood glucose was identified as an independent risk factor for death after emergency CABG (P=.01; odds ratio, 1.16; 95% confidence interval, 1.04-1.29). Admission blood glucose was further identified as independently associated with increased risk for a composite outcome of death, postoperative renal failure or stroke (P=.01; odds ratio, 1.14; 95% confidence interval, 1.03-1.27). CONCLUSIONS Our study shows for the first time that admission blood glucose is correlated with increased morbidity and mortality among patients undergoing emergency CABG surgery.
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Affiliation(s)
- Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA
| | - Christoph Hucklenbruch
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA; Department of Anesthesiology, University of Muenster, Muenster, Germany
| | - Jennie Z Ma
- Department of Biostatistics and Epidemiology, University of Virginia Health System, Charlottesville, VA
| | - Douglas Colquhoun
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA
| | - Jacob Raphael
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA.
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Naik BI, Pajewski TN, Bogdonoff DI, Zuo Z, Clark P, Terkawi AS, Durieux ME, Shaffrey CI, Nemergut EC. Rotational thromboelastometry–guided blood product management in major spine surgery. J Neurosurg Spine 2015; 23:239-49. [DOI: 10.3171/2014.12.spine14620] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Major spinal surgery in adult patients is often associated with significant intraoperative blood loss. Rotational thromboelastometry (ROTEM) is a functional viscoelastometric method for real-time hemostasis testing. In this study, the authors sought to characterize the coagulation abnormalities encountered in spine surgery and determine whether a ROTEM-guided, protocol-based approach to transfusion reduced blood loss and blood product use and cost.
METHODS
A hospital database was used to identify patients who had undergone adult deformity correction spine surgery with ROTEM-guided therapy. All patients who received ROTEM-guided therapy (ROTEM group) were matched with historical cohorts whose coagulation status had not been evaluated with ROTEM but who were treated using a conventional clinical and point-of-care laboratory approach to transfusion (Conventional group). Both groups were subdivided into 2 groups based on whether they had received intraoperative tranexamic acid (TXA), the only coagulation-modifying medication administered intraoperatively during the study period. In the ROTEM group, 26 patients received TXA (ROTEM-TXA group) and 24 did not (ROTEM-nonTXA group). Demographic, surgical, laboratory, and perioperative transfusion data were recorded. Data were analyzed by rank permutation test, adapted for the 1:2 ROTEM-to-Conventional matching structure, with p < 0.05 considered significant.
RESULTS
Comparison of the 2 groups in which TXA was used showed significantly less fresh-frozen plasma (FFP) use in the ROTEM-TXA group than in the Conventional-TXA group (median 0 units [range 0–4 units] vs 2.5 units [range 0–13 units], p < 0.0002) but significantly more cryoprecipitate use (median 1 unit [range 0–4 units] in the ROTEM-TXA group vs 0 units [range 0–2 units] in the Conventional-TXA group, p < 0.05), with a nonsignificant reduction in blood loss (median 2.6 L [range 0.9–5.4 L] in the ROTEM-TXA group vs 2.9 L [0.7–7.0 L] in the Conventional-TXA group, p = 0.21). In the 2 groups in which TXA was not used, the ROTEM-nonTXA group showed significantly less blood loss than the Conventional-nonTXA group (median 1 L [range 0.2–6.0 L] vs 1.5 L [range 1.0–4.5 L], p = 0.0005), with a trend toward less transfusion of packed red blood cells (pRBC) (median 0 units [range 0–4 units] vs 1 unit [range 0–9 units], p = 0.09]. Cryoprecipitate use was increased and FFP use decreased in response to ROTEM analysis identifying hypofibrinogenemia as a major contributor to ongoing coagulopathy.
CONCLUSIONS
In major spine surgery, ROTEM-guided transfusion allows for standardization of transfusion practices and early identification and treatment of hypofibrinogenemia. Hypofibrinogenemia is an important cause of the coagulopathy encountered during these procedures and aggressive management of this complication is associated with less intraoperative blood loss, reduced transfusion requirements, and decreased transfusion-related cost.
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Affiliation(s)
| | | | | | - Zhiyi Zuo
- Departments of 1Anesthesiology,
- 2Neurosurgery, and
| | - Pamela Clark
- 3Pathology, University of Virginia, Charlottesville, Virginia
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Kiehna EN, Huffmyer JL, Thiele RH, Scalzo DC, Nemergut EC. Use of the intrathoracic pressure regulator to lower intracranial pressure in patients with altered intracranial elastance: a pilot study. J Neurosurg 2013; 119:756-9. [DOI: 10.3171/2013.4.jns122489] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The intrathoracic pressure regulator (ITPR) is a novel noninvasive device designed to increase circulation and blood pressure. By applying negative pressure during the expiratory phase of ventilation it decreases intrathoracic pressure and enhances venous return, which increases cardiac output. It is possible that the ITPR may both decrease intracranial pressure (ICP) and increase cerebral perfusion pressure (CPP) in brain-injured patients by decreasing cerebral venous blood volume and increasing cardiac output. The authors conducted an open-label, “first-in-humans” study of the ITPR in patients with an ICP monitor or external ventricular drain and altered intracranial elastance.
Methods
This prospective randomized trial commenced July 2009. Baseline hemodynamic variables and ICP were recorded prior to inserting one of the two ITPRs into the ventilator circuit based on a randomization scheme. Depending on the device selected, activation provided either −5 or −9 mm Hg endotracheal tube pressure. Hemodynamic and ICP data were recorded sequentially every 2 minutes for 10 minutes. The first device was turned off for 10 minutes, then it was removed and the second device was applied, and then the procedure was repeated for the second device.
Results
Ten patients with elevated ICP secondary to intracranial hemorrhage (n = 4), trauma (n = 2), obstructive hydrocephalus (n = 2), or diffuse cerebral processes (n = 2) were enrolled. Baseline ICP ranged from 12 to 38 mm Hg. With device application, a decrease in ICP was observed in 16 of 20 applications. During treatment with the −5 mm Hg device, there was a mean maximal decrease of 3.3 mm Hg in ICP (21.7 vs 18.4 mm Hg, p = 0.003), which was associated with an increase in CPP of 6.5 mm Hg (58.2 vs 64.7 mm Hg, p = 0.019). During treatment with the −9 mm Hg device, there was a mean maximal decrease of 2.4 mm Hg in ICP (21.1 vs 18.7 mm Hg, p = 0.044), which was associated with an increase in CPP of 6.5 mm Hg (59.2 vs 65.7 mm Hg, p = 0.001).
Conclusions
This pilot study demonstrates that use of the ITPR in patients with altered intracranial elastance is feasible. Although this study was not powered to demonstrate efficacy, these data strongly suggest that the ITPR may be used to rapidly lower ICP and increase CPP without apparent adverse effects. Additional studies will be needed to assess longitudinal changes in ICP when the device is in use and to delineate treatment parameters.
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Affiliation(s)
- Erin N. Kiehna
- 1Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; and
| | - Julie L. Huffmyer
- 2Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Robert H. Thiele
- 2Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - David C. Scalzo
- 2Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Edward C. Nemergut
- 2Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
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Thiele RH, Knipper E, Dunn LK, Nemergut EC. Auditory stimuli as a contributor to consciousness while under general anesthesia. Med Hypotheses 2013; 80:568-72. [DOI: 10.1016/j.mehy.2013.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/16/2013] [Accepted: 01/23/2013] [Indexed: 11/30/2022]
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Abstract
BACKGROUND The incidence of intraoperative awareness under general anesthesia approaches 1% in high-risk patients. Anesthesiologists commonly utilize processed electroencephalograms (EEG) in order to monitor "depth" of anesthesia, the most common of which is the Bispectral Index (BIS). The B-aware and B-Unaware trials, which were designed to test the efficacy of the BIS monitor, noted an auditory component in 16 of 17 confirmed cases of intraoperative awareness. Implicit auditory memory formation has been documented under general anesthesia. Small studies have documented a significant effect of noise on BIS scores during monitored anesthesia care. METHODS Twenty-two patients undergoing general anesthesia received earplugs after the induction of anesthesia. Every ten minutes the earplugs were reinserted or removed. Noise levels were recorded every 0.125 s and both average and maximal BIS scores were recorded every minute. Non-parametric analysis of both populations (with and without earplugs) was performed. A mixed effects model with one degree of freedom (with and without earplugs) was generated to take into account the effect of anesthetic agents on BIS scores. RESULTS 3009 min of data were recorded. The median and range (25-75%) BIS scores were 39 (29-46) and 39 (28-44) with and without earplugs in place, respectively. Earplugs were associated with lower BIS scores (p=0.0183). The mixed effects model confirmed this relationship (p<0.001). Subgroup analysis of BIS scores in which the potential for awareness existed (maximum BIS>60 in any one minute epoch) showed a 32% reduction in the incidence of maximal BIS scores exceeding 60 (p=0.0012). There was no relationship between ambient noise level and average maximal BIS score (R(2)=0.003). CONCLUSIONS Our study suggests that earplugs may reduce the incidence of BIS scores >60 in patients undergoing total intravenous anesthesia and that auditory stimuli may affect EEG interpretation. Because of the low cost and safety of noise reduction, as well as the catastrophic implications of intraoperative awareness, further studies to explore the effects of auditory stimuli on awareness and anesthesia are warranted.
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Affiliation(s)
- Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Abstract
Liver transplantation may be complicated by massive intraoperative bleeding, and red blood cell (RBC) transfusions may be required. The storage duration or age of transfused RBCs has been shown to affect the morbidity and mortality of critically ill, trauma, and cardiac surgery patients. Here we investigate the effect of RBC age on the outcomes of liver transplant patients. Five hundred thirty-one patients underwent orthotopic liver transplantation between January 1, 2000 and August 15, 2010. The patient demographics, the Model for End-Stage Liver Disease-sodium (MELD-Na) score, and the number and age of RBC units were evaluated with univariate and multivariate models of outcomes, which included mortality rates 2 years after transplantation, postoperative infections, and organ rejection. In a univariate analysis, the number of RBC units (but not the RBC age) was associated with increased 2-year mortality, an increased risk of infection, and a decreased risk of organ rejection. Only the number of RBC units was associated with increased 2-year mortality in a multivariate Cox regression model. The mortality risk was decreased by two-thirds for patients who received <10 U of RBCs versus those who received ≥10 U (hazard ratio = 0.33, 95% confidence interval = 0.16-0.69, P = 0.003). The number of transfused RBC units was not associated with the risk of infection or organ rejection in a multivariate logistic regression model. In conclusion, the RBC age is not associated with infection, organ rejection, or death in liver transplant patients. Patients who receive more blood have an increased risk of death. In a multivariate model, the MELD-Na score was not associated with increased mortality, and this is consistent with previous studies demonstrating that the MELD-Na score is a poor predictor of long-term survival after transplantation.
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Affiliation(s)
- Lauren K Dunn
- Departments of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, USA
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Hayhurst CJ, Nemergut EC. Essence of Anesthesia Practice, 3rd ed. Anesth Analg 2012. [DOI: 10.1213/ane.0b013e31822cf1b8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nemergut EC, FIagg PJ, Nemergut EC. Education in anesthesia: then & now. Anesth Analg 2012; 114:5-6. [PMID: 22184609 DOI: 10.1213/ane.0b013e31823b2619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Nemergut EC. The future of clinical research. Best Pract Res Clin Anaesthesiol 2011; 25:vii-viii. [DOI: 10.1016/j.bpa.2011.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022]
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Ellison BJ, Nemergut EC. Handbook of Clinical Anesthesia Procedures of the Massachusetts General Hospital, 8th ed. Anesth Analg 2011. [DOI: 10.1213/ane.0b013e3182071b55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Phenylephrine and methoxamine are direct-acting, predominantly α(1) adrenergic receptor (AR) agonists. To better understand their physiologic effects, we screened 463 articles on the basis of PubMed searches of "methoxamine" and "phenylephrine" (limited to human, randomized studies published in English), as well as citations found therein. Relevant articles, as well as those discovered in the peer-review process, were incorporated into this review. Both methoxamine and phenylephrine increase cardiac afterload via several mechanisms, including increased vascular resistance, decreased vascular compliance, and disadvantageous alterations in the pressure waveforms produced by the pulsatile heart. Although pure α(1) agonists increase arterial blood pressure, neither animal nor human studies have ever shown pure α(1)-agonism to produce a favorable change in myocardial energetics because of the resultant increase in myocardial workload. Furthermore, the cost of increased blood pressure after pure α(1)-agonism is almost invariably decreased cardiac output, likely due to increases in venous resistance. The venous system contains α(1) ARs, and though stimulation of α(1) ARs decreases capacitance and may transiently increase venous return, this gain may be offset by changes in afterload, venous compliance, and venous resistance. Data on the effects of α(1) stimulation in the central nervous system show conflicting changes, while experimental animal data suggest that renal blood flow is reduced by α(1)-agonists, and both animal and human data suggest that gastrointestinal perfusion may be reduced by α(1) tone.
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Affiliation(s)
- Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
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Gottschalk A, Durieux ME, Nemergut EC. Intraoperative Methadone Improves Postoperative Pain Control in Patients Undergoing Complex Spine Surgery. Anesth Analg 2011; 112:218-23. [DOI: 10.1213/ane.0b013e3181d8a095] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Thiele RH, Poiro NC, Scalzo DC, Nemergut EC. Speed, accuracy, and confidence in Google, Ovid, PubMed, and UpToDate: results of a randomised trial. Postgrad Med J 2010; 86:459-65. [PMID: 20709767 DOI: 10.1136/pgmj.2010.098053] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The explosion of biomedical information has led to an 'information paradox'-the volume of biomedical information available has made it increasingly difficult to find relevant information when needed. It is thus increasingly critical for physicians to acquire a working knowledge of biomedical informatics. AIM To evaluate four search tools commonly used to answer clinical questions, in terms of accuracy, speed, and user confidence. METHODS From December 2008 to June 2009, medical students, resident physicians, and attending physicians at the authors' institution were asked to answer a set of four anaesthesia and/or critical care based clinical questions, within 5 min, using Google, Ovid, PubMed, or UpToDate (only one search tool per question). At the end of each search, participants rated their results on a four point confidence scale. One to 3 weeks after answering the initial four questions, users were randomised to one of the four search tools, and asked to answer eight questions, four of which were repeated. The primary outcome was defined as a correct answer with the highest level of confidence. RESULTS Google was the most popular search tool. Users of Google and UpToDate were more likely than users of PubMed to answer questions correctly. Subjects had the most confidence in UpToDate. Searches with Google and UpToDate were faster than searches with PubMed or Ovid. CONCLUSION Non-Medline based search tools are not inferior to Medline based search tools for purposes of answering evidence based anaesthesia and critical care questions.
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Affiliation(s)
- Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908, USA.
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