Comprehensive Dynamic 3-Dimensional Analysis of the Tricuspid Valve in Functional Tricuspid Regurgitation: Implications for Prophylactic Tricuspid Valve Intervention

OBJECTIVES

To track and measure changes in the tricuspid annulus (TA) using 3-dimensional (3D) echocardiography during a complete cardiac cycle in patients with functional tricuspid regurgitation (TR) compared to patients without TR, and to compare tricuspid annular plane systolic excursion (TAPSE) derived from 2-dimensional (2D) and 3D coordinates as a measure of right ventricular (RV) function to the standard method of 2D fractional area change (FAC).

DESIGN

Intraoperative 3D echocardiography data were collected prospectively, followed by postprocessing software analysis to track and reconstruct changes throughout the cardiac cycle.

SETTING

Data were collected from 108 patients undergoing left-sided heart surgery at 2 large academic centers-Beth Israel Deaconess Medical Center in Boston, MA and Rhode Island Hospital, Providence, RI-between November 2018 and April 2020.

PARTICIPANTS

The final dataset (n = 92) included 2 groups: the no significant functional TR (NTR) group (n = 74), defined as ≤ mild TR and TA <35 mm, and the significant functional TR (FTR) group (n = 18), defined as ≥ moderate TR.

INTERVENTIONS

3D TEE datasets were analyzed, and the motion of TA coordinates was tracked during complete cardiac cycle in 2D and 3D planes using postprocessing and software analysis. Computational modeling of TA motion was performed using computer-aided design. In further analysis, reconstructed and 3D printed models of TV were developed for the 2 groups.

MEASUREMENTS AND MAIN RESULTS

`Patients in FTR group had larger TA size during the cardiac cycle, with less overall excursion and reduced annular dynamism. The 3D motion of TA for lateral, anterolateral, and posterolateral coordinates was lower in the FTR group compared to the NTR group [18 ± 6.8 vs 13.6 ± 8.5( p = 0.02); 15.2 ± 5.5 vs 11.3 ± 6.0 (p = 0.009); and 17.6 ± 6.6 vs 12.3 ± 5.2 (p = 0.002), respectively]. TAPSE derived from 3D planes was more accurate for RV function assessment when comapred with 2D FAC (area under the curve [AUC], 0.704; p = 0.011) than 2D TAPSE (AUC, 0.625; p = 0.129). Finally, in the FTR group, the anteroseptal-posterolateral diameter was consistently larger during all phases of the cardiac cycle compared to the conventionally measured septolateral diameter.

CONCLUSIONS

3D echocardiographic assessment of TA helps better understand its geometry and dynamism in functional TR and is more accurate than 2D measurements for RV function assessment.

Virtual Reality Training for Central Venous Catheter Placement: An Interventional Feasibility Study Incorporating Virtual Reality Into a Standard Training Curriculum of Novice Trainees

OBJECTIVES

This study assess the feasibility of integrating virtual reality (VR) simulation into the central venous catheter (CVC) placement training curriculum.

DESIGN

The study consists of 3 parts: (1) Evaluating current manikin-based training for CVC placement through surveys for senior first-year anesthesia residents and cardiac anesthesia faculty who supervise resident performing the procedure; (2) Interventional study training novice trainees with VR simulator and assessing their reaction satisfaction; and (3) pilot study integrating VR training sessions into CVC training curriculum for first-year anesthesia residents.

SETTING

Conducted at a single academic-affiliated medical center from December 2022 to August 2023.

PARTICIPANTS

Junior first-year anesthesia residents.

INTERVENTIONS

VR training sessions for CVC placements using the Vantari VR system.

MEASUREMENTS AND MAIN RESULTS

Primary outcome: novice trainees' satisfaction with VR training for CVC procedure. Satisfaction of resident and faculty with standard manikin-based training was also collected. Faculty expressed concerns about residents' confidence and perceived knowledge in performing CVC placement independently. Novice trainees showed high satisfaction and perceived usefulness with VR training, particularly in understanding procedural steps and developing spatial awareness. Pilot integration of VR training into the curriculum demonstrated comparable training times and emphasized structured stepwise training modules to ensure completion of vital procedural steps.

CONCLUSIONS

This study underscores the potential of VR simulation as a complementary training tool for CVC placement rather than a substitution of standard manikin training. VR is offering immersive experiences and addressing limitations of traditional manikin-based training methods. The integration of VR into training curricula warrants further exploration to optimize procedural proficiency and patient safety in clinical practice.

Implementation of Routine In Situ Simulation in Residency Curriculum Targeting Competency in Technical and Decision-Making Skills

OBJECTIVE

To describe the development and implementation of a comprehensive in situ simulation-based curriculum for anesthesia residents.

DESIGN

This is a prospective study.

SETTING

This study was conducted at a university hospital.

PARTICIPANTS

This single-center prospective study included all 53 anesthesia residents enrolled in the anesthesia residency program.

INTERVENTIONS

Introduction of a routine, high-fidelity, in situ simulation program that incorporates short sessions to train residents in the necessary skill sets and decision-making processes required in the operating room.

MEASUREMENTS AND MAIN RESULTS

Our team conducted 182 individual 15-minute simulation sessions over 3 months during regular working hours. All 53 residents in our program actively participated in the simulations. Most residents engaged in at least 3 sessions, with an average participation rate of 3.4 per resident (range, 1-6 sessions). Residents completed an online anonymous survey, with a response rate of 71.7% (38 of 53 residents) over the 3-month period. The survey aimed to assess their overall impression and perceived contribution of this project to their training.

CONCLUSIONS

Our proposed teaching method can bridge the gap in resident training and enhance their critical reasoning to manage diverse clinical situations they may not experience during their residency.

Advancing Precision in 3D Echocardiography: Incorporating 3D Markers to Aid Spatial Orientation

The incorporation of 3D imaging into diagnostic and interventional echocardiography has rapidly expanded in recent years. Applications such as multiplanar reconstruction that were once considered research tools and required off-cart analysis can now readily be performed at the point of image acquisition and in real-time during live image acquisition for procedural guidance. While the application and quality of 3D images have significantly improved in recent years, there remains a noticeable lag in the evolution of artificial intelligence that would further simplify the interpretative processes, both during live sessions and offline analyses. Users are still required to mentally reconstruct sliced images during multiplanar reconstruction based on color-coded planes. While this may be an effortless task for the seasoned echocardiographer, it can be a challenging task for echocardiographers who are less familiar with 3D imaging and multiplanar reconstruction. This article describes the utility of using 3D markers to aid in image interpretation.

Association of Body Surface Area versus Body Mass Index on Outcomes in Peripheral Arterial Disease

BACKGROUND

Numerous studies have indicated that increased obesity in patients with established peripheral artery disease (PAD) is inversely associated with disease prognosis, a phenomenon coined as the "obesity paradox". A major cause of criticism in studies investigating the obesity paradox is the use of body mass index (BMI) as a surrogate marker in defining and quantifying the degree or severity of obesity. We conducted a retrospective review to verify whether the obesity paradox persists in patients with PAD when using body surface area (BSA) as an alternative anthropometric measure.

METHODS

Patients undergoing surgery (open or endovascular) for PAD between January 2009 and March 2020 were identified from the Vascular Quality Initiative (VQI) national database. The association between BSA or BMI and risk of postoperative complications was evaluated using logistic regression and restricted cubic spline analysis, both of which were adjusted for demographic and comorbid risk predictors. When analyzing BSA and BMI as categorical variables, patients were grouped according to BSA quintiles and the World Health Organization (WHO) BMI categories.

RESULTS

A total of 130,428 patients were included based on our eligibility criteria, of which 85,394 (65.5%) were men. Patients were typically hypertensive (87.8%), diabetic (50.4%), and overweight (63.0% over 25 kg/m2). Patients with a high BMI or BSA typically presented at a younger age and with greater preoperative administration of drugs (statin, angiotensin converting enzyme inhibitor, anticoagulant, and beta blocker). Our results indicate that BSA and BMI are inversely associated with postoperative risk of all-cause morbidity, mortality, and cardiac complications. This finding was displayed when analyzing BMI or BSA as a continuous variable or when indexing patients into BMI or BSA groups.

CONCLUSIONS

Our data suggests that the obesity paradox persists in patients with PAD when using either BMI or BSA as anthropometric measures. Future studies with a prospective design and utilizing newer anthropometric indices should be conducted to fully verify the presence of this phenomenon.

Misidentification of the True Aortic Annulus With 2-dimensional Echocardiography: A Critical Appraisal Using 3-Dimensional Imaging

OBJECTIVES

This study aimed to evaluate the accuracy of identifying the true aortic valve (AV) annulus using 2-dimensional (2D) echocardiography, with the goal of highlighting potential misidentification issues in clinical practice.

DESIGN

An observational study employing 3-dimensional (3D) datasets to generate 2D images of the AV annulus for analysis.

SETTING

The study was conducted in an academic medical center.

PARTICIPANTS

Three-dimensional transesophageal echocardiography datasets were obtained from 11 patients with normal AV and aortic root anatomies undergoing coronary artery bypass surgery. Attending anesthesiologists certified by the National Board of Echocardiography (NBE) were approached subsequently to participate in this study.

INTERVENTIONS

Two images per patient were generated from 3D datasets, reflecting the mid-esophageal long-axis view of the AV, a true AV annulus image, and an off-axis image. A survey was distributed to NBE-certified perioperative echocardiographers across 12 academic institutions to identify the true AV annulus from these images.

MEASUREMENTS AND MAIN RESULTS

The survey, completed by 45 qualified respondents, revealed a significant misidentification rate of the true AV annulus, with only 36.8% of responses correctly identifying it. The rate of correct identification varied across image sets, with 44.4% of participants unable to correctly identify any true AV annulus image.

CONCLUSIONS

The study highlighted the limitations of 2D echocardiography in accurately identifying the true AV annulus in complex 3D structures like the aortic root. The findings suggest a need for greater reliance on advanced imaging modalities, such as 3D echocardiography, to improve accuracy in clinical practice.

Analyzing the Evolution of Needle and Ultrasound Probe Manipulation Skills of Interventional Radiology Trainees With Time and Experience

PURPOSE

To test the hypothesis that hand motion analysis can measure the progression of needle and ultrasound probe manipulation skills of interventional radiology trainees in central venous line placement.

MATERIALS AND METHODS

An expert cohort of 6 interventional radiologists and 4 anesthesiologists and a trainee cohort of 6 novice trainees (<50 central lines) and 5 experienced trainees (>50 central lines) performed simulated central venous access. Four novices and 1 experienced trainee repeated the task 1 year later. An electromagnetic motion tracking system tracked the needle hand and ultrasound probe. Path length, translational, and rotational movements were calculated separately for the needle hand and probe sensor. These metrics were used to calculate motion metrics based scores on a scale of 0 to 3 for each sensor. Nonparametric statistics were used, and the data are reported as median ± interquartile range.

RESULTS

Comparing novice and experienced trainees, there was a significant difference in probe scores (experienced vs. novice: 1 ± 2 vs. 0 ± 0, P = 0.04) but not in needle-hand scores (1 ± 1.5 vs. 0 ± 1, P = 0.26). Trainees showed a significant increase in probe scores at the 1-year follow-up (baseline vs. follow-up: 0 ± 1 vs. 2.5 ± 1.8, P = 0.003), but no significant difference was observed in the needle manipulation metrics. Experts differed significantly from experienced trainees for all metrics for both sensors (P < 0.05), with the exception of the path length of the probe.

CONCLUSIONS

Acquisition of improved dexterity of the probe may occur before improvement in the dexterity with the needle hand for interventional radiology trainees.

Artificial Intelligence for Anesthesiology Board-Style Examination Questions: Role of Large Language Models

New artificial intelligence tools have been developed that have implications for medical usage. Large language models (LLMs), such as the widely used ChatGPT developed by OpenAI, have not been explored in the context of anesthesiology education. Understanding the reliability of various publicly available LLMs for medical specialties could offer insight into their understanding of the physiology, pharmacology, and practical applications of anesthesiology. An exploratory prospective review was conducted using 3 commercially available LLMs--OpenAI's ChatGPT GPT-3.5 version (GPT-3.5), OpenAI's ChatGPT GPT-4 (GPT-4), and Google's Bard--on questions from a widely used anesthesia board examination review book. Of the 884 eligible questions, the overall correct answer rates were 47.9% for GPT-3.5, 69.4% for GPT-4, and 45.2% for Bard. GPT-4 exhibited significantly higher performance than both GPT-3.5 and Bard (p = 0.001 and p < 0.001, respectively). None of the LLMs met the criteria required to secure American Board of Anesthesiology certification, according to the 70% passing score approximation. GPT-4 significantly outperformed GPT-3.5 and Bard in terms of overall performance, but lacked consistency in providing explanations that aligned with scientific and medical consensus. Although GPT-4 shows promise, current LLMs are not sufficiently advanced to answer anesthesiology board examination questions with passing success. Further iterations and domain-specific training may enhance their utility in medical education.

A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study

OBJECTIVES

To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications.

DESIGN

A retrospective before-after study.

SETTING

A tertiary-care academic hospital.

PARTICIPANTS

Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups.

INTERVENTION

The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035).

CONCLUSIONS

Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.

Virtual Reality: The Future of Invasive Procedure Training?

Invasive procedures are associated with adverse events that are both hazardous to patients and expensive to treat. A trainee is expected to perform complex sterile invasive procedures in a dynamic environment under time pressure while maintaining patient safety at the highest standard of care. For mastery in performing an invasive procedure, the automatism of the technical aspects is required, as well as the ability to adapt to patient conditions, anatomic variability, and environmental stressors. Virtual reality (VR) simulation training is an immersive technology with immense potential for medical training, potentially enhancing clinical proficiency and improving patient safety. Virtual reality can project near-realistic environments onto a head-mounted display, allowing users to simulate and interact with various scenarios. Virtual reality has been used extensively for task training in various healthcare-related disciplines and other fields, such as the military. These scenarios often incorporate haptic feedback for the simulation of physical touch and audio and visual stimuli. In this manuscript, the authors have presented a historical review, the current status, and the potential application of VR simulation training for invasive procedures. They specifically explore a VR training module for central venous access as a prototype for invasive procedure training to describe the advantages and limitations of this evolving technology.

Evaluation of Technical Performance of Ultrasound-Guided Procedures through Hand Motion Analysis: an Exploration of Motion Metrics

PURPOSE

To evaluate the ability of hand motion analysis using conventional and new motion metrics to differentiate between operators of varying levels of experience for central venous access (CVA) and liver biopsy (LB).

METHODS

CVA task: 7 Interventional Radiologists (experts), 10 senior trainees, and 5 junior trainees performed ultrasound-guided CVA on a standardized manikin; 5 trainees were retested after one year. LB task: 4 Radiologists (experts) and 7 trainees biopsied a lesion on a manikin. Conventional motion metrics (path length and task time), a refined metric (translational movements), and new metrics (rotational sum, rotational movements), were calculated.

RESULTS

CVA: experts outperformed trainees on all metrics (p ≤ 0.02). Senior trainees required fewer rotational movements (p = 0.02), translational movements (p = 0.045), and time (p = 0.001) than junior trainees. Similarly, on one-year follow-up, trainees had fewer translational (p=0.02) and rotational movements (p=0.003) with less task time (p=0.003). Path length and rotational sum were not different between junior and senior trainees or for trainees on follow-up. Rotational and translational movement had a greater area-under-the-curve (0.91 and 0.86 respectively) compared to rotational sum (0.73) and path length (0.61). LB: experts performed the task with a shorter path length (p=0.04), fewer translational movements (p=0.04), rotational movements (p=0.02), and less time (p<0.001) relative to the trainees.

CONCLUSION

Hand motion analysis using translational and rotational movements was better at differentiating levels of experience and improvement with training, as compared to the conventional metric of path length.

Novel Three-Dimensionally Printed Ultrasound Probe Simulator and Heart Model for Transthoracic Echocardiography Education

Simulation-based training is an essential component in the education of transthoracic echocardiography (TTE). Nevertheless, current TTE teaching methods may be subject to certain limitations. Hence, the authors in this study aimed to invent a novel TTE training system employing three-dimensional (3D) printing technology to teach the basic principles and psychomotor skills of TTE imaging more intuitively and understandably. This training system comprises a 3D-printed ultrasound probe simulator and a sliceable heart model. The probe simulator incorporates a linear laser generator to enable the visualization of the projection of the ultrasound scan plane in a 3D space. By using the probe simulator in conjunction with the sliceable heart model or other commercially available anatomic models, trainees can attain a more comprehensive understanding of probe motion and related scan planes in TTE. Notably, the 3D-printed models are portable and low-cost, suggesting their potential utility in various clinical scenarios, particularly for just-in-time training.

Structural and Electrical Integrity of Transesophageal Echocardiography Probes: Importance and Key Concepts

The clinical utility of transesophageal echocardiography (TEE) is well-established for patients undergoing cardiac surgery. With the increase in percutaneous structural heart disease procedures that rely on TEE for procedural guidance, the use of TEE probes is expanding. Although there are well-established protocols for routine cleaning and decontaminating TEE probes between patient use, there is a lack of awareness and misconceptions about maintaining TEE probes' structural and electrical integrity. The electrical leakage test (ELT) is routinely performed between patient use. From a patient safety standpoint, the ELT is necessary to ensure the longevity of this expensive equipment and prevent disruptions to the workflow in a busy department caused by TEE probes being decommissioned due to probe damage. This technical communication aims to highlight the importance of maintaining TEE probes' structural and electrical integrity. The article also highlights and discusses probe handling techniques between patient use, emphasizing the ELT to ensure patient safety and compliance with national and international standards.

Motion Analysis: An Objective Assessment of Special Operations Forces and Tactical Medics Performing Point-of-Care Ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) is commonly employed to image the heart, lungs, and abdomen. Rapid ultrasound for shock and hypotension (RUSH) exams are a critical component of POCUS employed in austere environments by Special Operations Forces (SOF) and tactical medics for triage and diagnosis. Despite its utility, training for POCUS remains largely unstandardized with respect to feedback and markers of proficiency. We hypothesized that motion analysis could objectively identify improvement in medics' performance of RUSH exams. Furthermore, we predicted that motion metrics would correlate with qualitative ratings administered by attending anesthesiologists.

METHODS

A team of civilian and military attending anesthesiologists trained 24 medics in POCUS during a 5-day course. Each medic performed eight RUSH exams using an ultrasound probe equipped with an electromagnetic motion sensor to track total distance travelled (path length), movements performed (translational motions), degrees rotated (rotational sum), and time. Instructors (experts) observed and rated the exams on the following items: image finding, image fine-tuning, speed, final image accuracy, and global assessment. Motion metrics were used to provide feedback to medics throughout the course. Generalized estimating equations were used to analyze the trends of motion metrics across all trials. Correlations amongst motion metrics and expert ratings were assessed with Pearson correlation coefficients.

RESULTS

Participants exhibited a negative trend in all motion metrics (p < 0.001). Pearson correlation coefficients revealed moderate inverse correlations amongst motion metrics and expert ratings.

CONCLUSION

Motion analysis was able to quantify and describe the performance of medics training in POCUS and correlated with expert ratings.

Regulation of Hypoxic-Adenosinergic Signaling by Estrogen: Implications for Microvascular Injury

Loss of estrogen, as occurs with normal aging, leads to increased inflammation, pathologic angiogenesis, impaired mitochondrial function, and microvascular disease. While the influence of estrogens on purinergic pathways is largely unknown, extracellular adenosine, generated at high levels by CD39 and CD73, is known to be anti-inflammatory in the vasculature. To further define the cellular mechanisms necessary for vascular protection, we investigated how estrogen modulates hypoxic-adenosinergic vascular signaling responses and angiogenesis. Expression of estrogen receptors, purinergic mediators inclusive of adenosine, adenosine deaminase (ADA), and ATP were measured in human endothelial cells. Standard tube formation and wound healing assays were performed to assess angiogenesis in vitro. The impacts on purinergic responses in vivo were modeled using cardiac tissue from ovariectomized mice. CD39 and estrogen receptor alpha (ERα) levels were markedly increased in presence of estradiol (E2). Suppression of ERα resulted in decreased CD39 expression. Expression of ENT1 was decreased in an ER-dependent manner. Extracellular ATP and ADA activity levels decreased following E2 exposure while levels of adenosine increased. Phosphorylation of ERK1/2 increased following E2 treatment and was attenuated by blocking adenosine receptor (AR) and ER activity. Estradiol boosted angiogenesis, while inhibition of estrogen decreased tube formation in vitro. Expression of CD39 and phospho-ERK1/2 decreased in cardiac tissues from ovariectomized mice, whereas ENT1 expression increased with expected decreases in blood adenosine levels. Estradiol-induced upregulation of CD39 substantially increases adenosine availability, while augmenting vascular protective signaling responses. Control of CD39 by ERα follows on transcriptional regulation. These data suggest novel therapeutic avenues to explore in the amelioration of post-menopausal cardiovascular disease, by modulation of adenosinergic mechanisms.

Timing of Blood Transfusions and 30-Day Patient Outcomes After Coronary Artery Bypass Graft Surgery

OBJECTIVE

Packed red blood cell transfusion during coronary artery bypass graft surgery is known to be associated with adverse outcomes. However, the association of the timing between transfusions in relation to discharge and 30-day postoperative outcomes has not been studied. The study authors investigated the impact of transfusion timing on 30-day surgical outcomes.

DESIGN

A retrospective review.

SETTING

At a single tertiary-care academic hospital.

PARTICIPANTS

A total of 2,481 adult patients underwent primary coronary artery bypass graft surgery between January 2014 and December 2020.

MEASUREMENTS AND MAIN RESULTS

The relationship between the timing of packed red blood cell transfusion (intraoperative, postoperative, or both) and 30-day postoperative outcome variables was calculated as an odds ratio. The influence of timing of transfusion on adjusted probability of postoperative complications was plotted against the lowest intraoperative hematocrit. The median age of the population was 67 years (60.0-74.0), body mass index was 28.5 (25.6-32.3) kg/m², and 497 (20.0%) were female. A total of 1,588 (36%) patients received packed red blood cell transfusions; 182 (7.3%) received intraoperative transfusions, 489 (19.7%) received postoperative transfusions, and 222 (9.0%) received both (intraoperative and postoperative transfusions). Postoperative transfusion was associated with significantly higher odds of readmission (1.83 [1.32-2.54], p = 0.002) and heart failure (1.64 [1.2-2.23], p = 0.008) compared to patients with no transfusions; whereas intraoperative transfusions were not.

CONCLUSION

The authors' data suggested that the postoperative timing of transfusion in patients undergoing coronary artery bypass graft surgery may be associated with an increased incidence of 30-day heart failure and readmission. Prospective research is needed to conclusively confirm these findings.

Novel Three-Dimensional Printed Human Heart Models and Ultrasound Omniplane Simulator for Transesophageal Echocardiography Training

Simulation-based training plays an essential role in transesophageal echocardiography (TEE) education. Using 3-dimensional printing technology, the authors invented a novel TEE teaching system consisting of a series of heart models that can be segmented according to actual TEE views, and an ultrasound omniplane simulator to demonstrate how ultrasound beams intersect the heart at different angles and generate images. This novel teaching system is able to provide a more direct way to visualize the mechanics of obtaining TEE images than traditional online or mannequin-based simulators. It can also provide tangible feedback of both an ultrasound scan plane and a TEE view of the heart, which has been proven to improve trainees' spatial awareness and can significantly help in understanding and memorizing complex anatomic structures. This teaching system itself is also portable and inexpensive, making it conducive to teaching TEE in regions of diverse economic status. This teaching system also can be expected to be used for just-in-time training in a variety of clinical scenarios, including operating rooms, intensive care units, etc.

Abstract WP180: Gender-specific Risk Of Stroke In Patients With Peripheral Artery Disease

Objective: Peripheral artery disease (PAD) is a common atherosclerotic disease associated with increased morbidity and mortality. We conducted a retrospective review to investigate the role of gender in influencing the incidence of stroke after surgery for PAD.

Methods: We conducted a retrospective review using data from the Vascular Quality Initiative database for patients who underwent supra-inguinal and infra-inguinal surgery between 2010 and 2020. The relationship between gender and 30-day post-operative outcomes was calculated as an odds ratio; the threshold of significance was p =0.05 for univariate and multivariable analysis. Gender-based influence of age and adjusted probability of stroke was plotted using Sigma Plot.

Results: A total of 79,981 patients were included based on our eligibility criteria, 34% of which were female. Although only 0.6% of patients experienced stroke, risk of stroke was significantly higher in female patients ( p <0.001). Female patients were more commonly hypertensive ( p =0.007) and diabetic ( p =0.003), while also presenting decreased pre-operative use of statin ( p <0.001) and aspirin ( p <0.001) as compared to males. Additional predictors of post-operative stroke include age > 65 years ( p =0.015), hypertension ( p =0.002), and pre-operative use of beta blockers ( p <0.001). Overall, females had higher risk of all-cause morbidity ( p =0.004), stroke ( p <0.001), mortality ( p <0.001), and major adverse cardiovascular events ( p <0.001), while males had increased risk of returning to the operating room ( p =0.006). Regression analysis revealed a significantly stronger bearing of high age on probability of post-operative stroke in women ( p <0.001).

Conclusion: Our data suggests that incidence of post-operative stroke and other cardiovascular complications is influenced by gender in surgery of PAD. Future research investigating underlying gender-based mechanisms is necessary to personalize treatment in patients with PAD.

National Delphi Survey on Anesthesiology Resident Training in Perioperative Ultrasound

OBJECTIVE

To establish agreement among nationwide experts through a Delphi process on the key components of perioperative ultrasound and the recommended minimum number of examinations that should be performed by a resident upon graduation.

DESIGN

A prospective cross-sectional study.

SETTING

A survey on multiinstitutional academic medical centers.

PARTICIPANTS

Anesthesiology residency program directors and/or experts in perioperative ultrasound.

INTERVENTIONS

A list of components and examinations recommended for anesthesiology resident training in perioperative ultrasound was developed based on guidelines and 2 survey rounds among a steering committee of 10 experts. A questionnaire asking for a rating of each component on a 5-point Likert scale subsequently was sent to an expert panel of 120 anesthesiology residency program directors across the United States. An agreement of at least 70% of participants, rating a component as 4 or 5, was compulsory to list a component as essential for anesthesiology resident training in perioperative ultrasound.

MEASUREMENTS AND MAIN RESULTS

The nationwide survey's response rate was 62.5%, and agreement was reached after 2 Delphi rounds. The final list included 44 essential components for basic ultrasound physics and knobology, cardiac ultrasound, lung ultrasound, and ultrasound-guided vascular access. Agreement was not reached for abdominal ultrasound, gastric ultrasound, and ultrasound-guided airway assessment. Agreement for the recommended minimum number of examinations that should be performed by a resident upon graduation included 50 each for transthoracic and transesophageal echocardiography, and 20 each for lung ultrasound, ultrasound-guided central line, and ultrasound-guided arterial line placements.

CONCLUSIONS

The recommendations outlined in this survey can be used to establish standardized training for perioperative ultrasound by anesthesiology residency programs.

A Systematic Review and Meta-analysis of General versus Regional Anesthesia for Lower Extremity Amputation

OBJECTIVE

Postoperative morbidity in patients undergoing lower extremity amputation (LEA) has remained high. Studies investigating the influence of the anesthetic modality on the postoperative outcomes have yielded conflicting results. The aim of our study was to assess the effects of regional anesthesia vs general anesthesia on postoperative complications for patients undergoing LEA.

METHODS

We systematically searched PubMed, Embase, MEDLINE, Web of Science, and Google Scholar from 1990 to 2022 for studies investigating the effect of the anesthetic modality on the postoperative outcomes after LEA. Regional anesthesia (RA) included neuraxial anesthesia and peripheral nerve blocks. The outcomes included 30-day mortality, respiratory failure (unplanned postoperative intubation, failure to wean, mechanical ventilation >24 hours), surgical site infection, cardiac complications, urinary tract infection, renal failure, sepsis, venous thrombosis, pneumonia, and myocardial infarction.

RESULTS

Of the 25 studies identified, we included 10 retrospective observational studies with 81,736 patients, of whom 69,754 (85.3%) had received general anesthesia (GA) and 11,980 (14.7%) had received RA. In the GA group, 50,468 patients were men (63.8%), and in the RA group, 7813 patients were men (62.3%). The results of the meta-analyses revealed that GA was associated with a higher rate of respiratory failure (odds ratio, 1.38; 95% confidence interval, 1.06-1.80; P = .02) and sepsis (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; P < .0001) compared with RA. No differences were found in postoperative 30-day mortality, surgical site infection, cardiac complications, urinary tract infection, renal failure, venous thrombosis, pneumonia, and myocardial infarction between the GA and RA groups.

CONCLUSIONS

The results of our meta-analysis have shown that GA could be associated with a higher rate of respiratory failure and sepsis compared with RA for LEA.

Influence of Increasing Age and Body Mass Index of Gender in COVID-19 Patients

Background: The impact of gender on outcomes in patients suffering from coronavirus disease 2019 (COVID-19) is frequently debated. However, the synchronous influence of additional risk factors is seldom mentioned. With increasing emphasis on identifying patients who are at risk of complications from COVID-19, we decided to conduct a retrospective review to assess the influence of age and body mass index (BMI) on gender-based differences in outcomes. Materials and Methods: A retrospective review of 1288 patients was conducted at a tertiary care hospital. Binary logistic regression was used to assess differences in risk factors and outcomes between genders. The associations between predictors and outcomes were described using odds ratios in tables, forest plots, and regression curves plotted using Sigma Plot. Results: Majority of patients were women (53.6% vs. 46.4%). Median BMI in men was higher than women (p = 0.003). Key predictors for all-cause morbidity/mortality in men were diabetes, chronic kidney disease, and regular use of angiotensin-converting enzyme inhibitors. In women, age >65 and regular use of inhaled steroid were additional risk factors. Men had a higher risk of acute respiratory distress syndrome (2.83 [1.70-4.70]), acute renal failure (1.96 [1.20-3.20]), and had a longer length of stay (0.11 [1.52]). Obesity has a stronger bearing on outcomes in women, and age has a more pronounced effect on outcomes in men. Conclusion: Extremes of BMI and older age are associated with worse outcomes in both men and women. Obesity has a stronger bearing on outcomes of COVID-19 infection in women, while the effect of older age on outcomes is more pronounced in men.

Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics

BACKGROUND

Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers.

MATERIALS AND METHODS

Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE).

RESULTS

The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%.

CONCLUSION

A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.