Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed.

Association of sugammadex reversal of neuromuscular block and postoperative length of stay in the ambulatory care facility: a multicentre hospital registry study

BACKGROUND

Encapsulation of rocuronium or vecuronium with sugammadex can reverse neuromuscular block faster than neostigmine reversal. This pharmacodynamic profile might facilitate patient discharge after ambulatory surgery.

METHODS

We included patients who underwent ambulatory surgery with general anaesthesia and neuromuscular block between 2016 and 2021 from hospital registries at two large academic healthcare networks in the USA. The primary outcome was postoperative length of stay in the ambulatory care facility (PLOS-ACF). We examined post hoc whether the type of reversal affects postoperative nausea and vomiting and direct hospital costs.

RESULTS

Among the 29 316 patients included, 8945 (30.5%) received sugammadex and 20 371 (69.5%) received neostigmine for reversal. PLOS-ACF and costs were lower in patients who received sugammadex vs neostigmine (adjusted difference in PLOS-ACF: -9.5 min; 95% confidence interval [95% CI], -10.5 to -8.5 min; adjusted difference in direct hospital costs: -US$77; 95% CI, -$88 to -$66; respectively; P<0.001). The association was magnified in patients over age 65 yr, with ASA physical status >2 undergoing short procedures (<2 h) (adjusted difference in PLOS-ACF: -18.2 min; 95% CI, -23.8 to -12.4 min; adjusted difference in direct hospital costs: -$176; 95% CI, -$220 to -$128; P<0.001). Sugammadex use was associated with reduced postoperative nausea and vomiting (17.2% vs 19.6%, P<0.001), which mediated its effects on length of stay.

CONCLUSIONS

Reversal with sugammadex compared with neostigmine was associated with a small decrease in postoperative length of stay in the ambulatory care unit. The effect was magnified in older and high-risk patients, and can be explained by reduced postoperative nausea and vomiting. Sugammadex reversal in ambulatory surgery may also help reduce cost of care.

Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned

The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.

Implementation of the telephone montreal cognitive assessment in a telemedicine based pre-admission testing clinic during COVID-19

Introduction

Postoperative delirium (POD) affects 10-70% of patients 60 years or older and has been linked to increasing length of hospitalization, mortality, and morbidity. Pre-existing cognitive impairment is a predictor of POD. COVID-19 restricted use of in-person cognitive screens. The Telephone Montreal Cognitive Assessment (T-MoCA) can screen for cognitive dysfunction remotely. We evaluated the feasibility of administering T-MoCA in a multiethnic population during pre-operative testing televisits.

Methods

Patients scheduled for surgery between July 2020 and August 2020 were asked to participate in the T-MoCA at the end of their preadmission testing (PAT) televisit. A retrospective chart review was conducted to collect patient comorbidities and demographics. Patients were stratified by negative (T-MoCA≥19) or positive (T-MoCA<19) for mild cognitive impairment (MCI) and compared using 2-tailed χ2-tests. Univariate logistic regression was used to identify associations between patient characteristics and positive T-MoCA result.

Results

Fifty out of 65 (77%) patients who consented to the T-MoCA completed the test. The average time to complete the assessment was 10.5 mins. Twenty two (44%) had a negative score and 28 (56%) had a positive score. Patients who had a positive T-MoCA were older (70.04±7.61 yrs) compared to those with a negative T-MoCA (67.68±4.69 yrs, p=0.007), although the distribution of patients above and below age 65 was not different (p=0.243). The two groups did not vary by gender, race/ethnicity, obesity, surgery type, or medical co-morbidities. When we examined our population for predictors of a positive T-MoCA, we found a trend toward men being less likely to score positive on T-MoCA (OR=0.33, 95% CI: 0.10-1.10, p=0.07) compared to women; and that patients with Hispanic race/ethnicity were more likely to test positive on the T-MoCA (OR=4.13, 95% CI: 0.84-20.28, p=0.08) compared to Non-Hispanic Whites.

Conclusions

Implementation of the T-MoCA in a telemedicine-based PAT setting is feasible. In our cohort, most people who consented to the assessment completed it, and more than half scored positively, which may have important implications on the surgical plan and post-operative recovery. There may be limitations in using T-MoCA in certain populations, such as non-English preferred language, hearing difficulties, lack of focus, and use of external aids, which would need to be explored in a larger sample size.

The Effect of Vibration on Pain During Intravenous Injection of Propofol: A Randomized Controlled Trial

PURPOSE

Pain is a common side effect of intravenous injection of propofol. We conducted a randomized, prospective, single-blinded controlled trial to assess the efficacy of vibration analgesia on pain during propofol infusion in ambulatory surgery.

METHODS

After institutional review board approval, 100 patients undergoing elective ambulatory surgery with general anesthesia were randomized into 2 groups. A control group (n = 50) consisted of patients who received infusion of propofol without vibration analgesia. A treatment group (n = 50) consisted of patients who received infusion of propofol with vibration analgesia using the Buzzy device. Pain was assessed using a 4-point pain manifestation scale scored by 2 independent, blinded observers.

RESULTS

Participants in the treatment group with vibration analgesia were 0.47 times less likely (95% confidence interval, 0.24-0.94; P = 0.03) to experience any pain than the control group. The median summative pain score in the treatment group was significantly less than that of the control group [1 (interquartile range, 1-2) vs 2 (interquartile range, 2-4); P < 0.01] among participants who experienced any pain. Agreement between the 2 blinded observers regarding pain scores was excellent with κw = 0.82 (P < 0.001). Age, sex, body mass index, needle location or size, and medication doses did not differ significantly between the 2 groups.

CONCLUSION

Vibration analgesia is an effective, low-risk modality that reduces the pain of intravenous propofol injection in general anesthesia.

Anesthesiology Training in the Time of COVID-19: Problems and Solutions

From March to June of 2020, Montefiore Medical Center faced one of the most acute surges in hospital admissions and critical illness ever experienced in the United States due to the severe acute respiratory syndrome coronavirus 2 pandemic. The pandemic had not yet spread to most of the country, and there was a relative deficit of knowledge regarding treatments, prognosis, and prevention of the virus, making this experience relatively unique and challenging. As part of a surge plan, our institution converted nonclinical spaces, such as conference rooms, to inpatient care settings and placed elective surgeries on hold to free up resources. A central deployment office suspended anesthesiology resident rotations and instead assigned them to intensive care settings based on need. For the Montefiore Medical Center Department of Anesthesiology, preserving its academic mission and commitment to Graduate Medical Education was essential. Adaptations included changing the residency rotation structure to biweekly, converting didactics online, ensuring adequate case numbers for graduating residents, actively pursuing wellness interventions, and prioritizing the safety of the residents caring for patients with coronavirus disease 2019 (COVID-19). In this brief report, the authors discuss solutions devised to maintain the quality of anesthesiology resident education and training as much as possible during the COVID-19 surge.