Sam D. Gumbert

Trauma-Associated bleeding: Management of massive transfusion

Purpose of review Early treatment goals in the bleeding trauma patient have changed based on recent research findings. Trauma patients requiring a massive transfusion protocol have shown a decreased mortality based on a more aggressive and balanced approach to blood product resuscitation. This chapter will review the recent advances in managing the bleeding trauma patient. Recent findings Recent data have suggested a combined approach of early ratio-based blood product use, bedside viscoelastic hemostatic assays, hemostatic resuscitation, and finally goal-directed therapy to complete resuscitation. Summary There is now evidence to support the early use of a 1 : 1 : 1 blood product transfusion protocol to restore lost circulating volume, improve oxygen carrying capacity, replace diluted platelets, and replenish clotting factors in massively bleeding trauma patients. Further study is needed to determine whether prehospital initiation of blood products and pharmacological adjuncts will improve outcomes.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technique that allows for temporary occlusion of the aorta in patients with severe, life-threatening, trauma-induced noncompressible hemorrhage arising below the diaphragm. REBOA utilizes a transfemoral balloon catheter inserted in a retrograde fashion into the aorta to provide inflow control and support blood pressure until definitive hemostasis can be achieved. Initial retrospective and registry clinical data in the trauma surgical literature demonstrate improvement in systolic blood pressure with balloon inflation and improved survival compared to open aortic cross-clamping via resuscitative thoracotomy. However, there are no significant reports of anesthetic implications and perioperative management in this challenging cohort. In this narrative, we review the principles, technique, and logistics of REBOA deployment, as well as initial clinical outcome data from our level-1 American College of Surgeons–verified trauma center. For anesthesiologists who may not yet be familiar with REBOA, we make several suggestions and recommendations for intraoperative management based on extrapolation from these initial surgical-based reports, opinions from a team with increasing experience, and translated experience from emergency aortic vascular surgical procedures. Further prospective data will be necessary to conclusively guide anesthetic management, especially as potential complications and implications for global organ function, including cerebral and renal, are recognized and described.

Respiratory volume monitoring in an obese surgical population and the prediction of postoperative respiratory depression by the STOP-bang OSA risk score

STUDY OBJECTIVE To evaluate use of a respiratory volume monitor (RVM; ExSpiron, Respiratory Motion, Inc., Waltham, MA, USA) that provides minute ventilation (MV), tidal volume (TV) and respiratory rate (RR) measurements in obese surgical patients, hitherto undescribed. DESIGN Prospective, IRB-approved observational study of RVM parameter accuracy in obese surgical patients, designed to test the ability of the RVM to detect predefined postoperative respiratory depression (PORD) and apneic events (POA) and to correlate STOP-Bang scores with PORD and POA. SETTING Pre-, intra-, and post-op patient-care areas, including the post-anesthesia care unit (PACU) in 2 academic centers with bariatric populations. PATIENTS 80 patients (47±12 years), BMI of 43±7 kg/m(2) undergoing elective surgery were enrolled. INTERVENTIONS Data collected included patient characteristics, STOP-Bang scores and RVM data from immediately preoperatively through PACU completion without effecting standard clinical care. MEASUREMENTS Low minute ventilation (LMV) was defined as 40% of predicted MV, and PORD was defined as sustained LMV for 5 minutes. Appropriate parametric and non-parametric statistical analyses were performed, P<.05 considered significant. MAIN RESULTS In 56 patients with complete intraoperative ventilator data, correlation between RVM and ventilator MV measurements was r=0.89 (measurement bias 1.5%, accuracy 11%). Measurement error was 0.13 L/min (95% confidence interval-0.93 L/min - 1.20 L/min). In PACU, 16.3% and 31% of patients had PORD and POA respectively. There were no significant differences in the incidence of PORD and POA in 3 STOP-Bang risk categories (P>.2). CONCLUSIONS There was excellent correlation and accuracy between the RVM and ventilator volumes in obese surgical patients. A considerable number of patients exhibited PORD and POA in the PACU. The STOP-Bang risk scores correlated poorly with PORD and POA which suggests that obese surgical patients remain at risk for early post-operative respiratory events irrespective of the STOP-Bang score.

Is Hand Contamination of Anesthesiologists Really an “important” Risk Factor for Intraoperative Bacterial Transmission?

To the Editor Although it is encouraging to read of the awareness of the potential impact of anesthesiologists on disease transmission in the operating room (OR) through a prospective study and expert opinion, with emphasis on more diligent handwashing, the data do not support the conclusion by Loftus et al. that “bacterial organisms on hands of providers explained a fairly large proportion of overall environmental and patient IV stopcock set contamination.” More specifically, anesthesia providers were identified as the origin in 12% of environmental contamination cases (10% of total cases) and 5.5% of the IV stopcock cases. Neither of these are “a fairly large proportion.” More pressing is the origin of 88% of environmental and 94.5% of stopcock contaminants. These could be innumerable personnel in the OR, preoperative area, patient escort, or even the valet parking attendant. Anesthesiologist transmission to the stopcock is no more likely than ineffective decontamination between cases (7% for environment, 5% for stopcock). How does this documented transmission rate compare to the daily OR activity with 6-armed robots, lengthy laparoscopic instruments or orthopedic nailing apparatus, or redraping of the radiograph machine for multiple lateral views? One editorial opines, “If we have reached a plateau in attempts to lower the SSI rate because we have gone as far as we reasonably can with surgical antisepsis, then remaining targets are the patient and anesthesia provider.” Clearly, we have not reached any plateau of surgical antisepsis given daily OR logistics. How does the anesthesia provider become a primary focus when the anesthesiologist is associated with contamination in 1/12 (environmental) and 1/20 (stopcock) cases? As leaders in patient safety, identification of any ill effect that anesthesiologists could have on patients is necessary. However, an individual’s “microbiome” does not equal infection. Evidence cannot be overinterpreted, as we run the risk of being “slimed” in the more customary fashion: if a surgical patient has complications, it must have been due to the coincidental anesthetic.

Utilization of C-MAC videolaryngoscopy for direct and indirect assisted endotracheal intubation

Background: The experiences of seasoned practitioners with the new C-MAC indirect videolaryngoscope system have shown promising results in the management of difficult airways. However, a comparison of direct and indirect laryngoscopy utilizing the C-MAC system as its own control has not been performed in a cohort of anesthesiologists-in-training. The primary aim was to compare direct and indirect laryngoscopy in terms of intubation time with secondary outcomes including laryngoscopy time and airway view with the same size 3 blade. Methods: The study was registered with www.clinicaltrials.gov (NCT01104090). Oral and written informed consent was obtained from 50 adult patients with BMI < 40 kg/m 2 who required general anesthesia for elective surgery with tracheal tube placement. The patients were randomized to two groups, each receiving two laryngoscopies, n=25 direct-first and n=25 indirect-first. Results: All patients except for one were successfully intubated on the first attempt. The intubation time was 12.3±11.1 sec immediately following videolaryngoscopy (direct laryngoscopy first group) and 9.8±7.1 sec immediately following direct laryngoscopy (videolaryngoscopy first group), p=0.35. The first laryngoscopy time was 8.7±4.7 sec in the direct group and 13.3±10.7 sec in the indirect group, p=0.06. Twenty-percent of direct first cases compared to 0% of indirect first cases showed an improvement in airway view score by at least two classes on the second laryngoscopy, p=0.02. Backward-upward-rightward pressure was used in 36% of direct first and 12% of indirect first patients, p=0.047. Conclusions: This study corroborates previous results on the use of the C-MAC videolaryngoscopy system during endotracheal-assisted intubation. Although there was no difference in intubation time between direct laryngoscopy and videolaryngoscopy, the C-MAC system was found to improve laryngeal views and reduce the number of necessary laryngeal manipulations. A larger randomized study utilizing a similar model is necessary to definitively determine significant clinical results. Trial registration: ClinicalTrials.gov NCT01104090.

Scheduled Intravenous Acetaminophen Improves Patient Satisfaction with Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study

Background: Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. Materials and Methods: In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. Results: There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. Conclusions: IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.

Reliability of a faculty evaluated scoring system for anesthesiology resident applicants (Original Investigation)

STUDY OBJECTIVE To assess reliability and reproducibility of a recently instituted anesthesiology resident applicant interview scoring system at our own institution. DESIGN Retrospective evaluation of 2 years of interview data with a newly implemented scoring system using randomly assigned interviewing faculty. SETTING Interview scoring evaluations were completed as standard practice in a large academic anesthesiology department. SUBJECTS All anesthesiology resident applicants interviewed over the 2013/14 and 2014/15 seasons by a stable cohort of faculty interviewers. Data collection blinded for both interviewers and interviewees. INTERVENTIONS None for purposes of study - collation of blinded data already used as standard practice during interview process and analysis. MEASUREMENTS None specific to study. MAIN RESULTS Good inter-rater faculty reliability of interview scoring (day-of) and excellent inter-faculty reliability of application review (pre-interview). CONCLUSIONS Development of a department-specific interview scoring system including many elements beyond traditional standardized tests shows good-excellent reliability of faculty scoring of both the interview itself (including non-technical skills) and the application resume.

All Work Hours Are Not Equal

To the Editor: We read Baird et al.’s1 recent description of gender differences and trends in the anesthesiology workforce with great interest. As members of a large, vibrant academic level 1 trauma center with busy transplant and neurosurgical services, we observe that several issues raised by the 2013 RAND survey are relevant. We are a particularly diverse faculty group with a greater proportion of female anesthesiologists (49%) than represented in the study (26%). At first glance, the conclusion that female anesthesiologists receive lower total and hourly compensation irrespective of the fewer hours worked is alarming. However, the context for this is the significantly three-fold greater part-time (defined as less than 35 h/week) employees in the female group, which in itself may explain the apparent discrepancy as 11% of that gender cohort. In a busy facility such as ours with increasing hospital demand for expansion of services, an employee working part-time in a 7 Am to 3 or 5 pm shift adds value to meeting the elective needs of the operating room. However, a significant proportion of urgent and emergency service is provided after hours, on weekends, and on public holidays, and it is both plausible and logical for the larger full-time (by definition, larger male) cohort taking these calls to receive greater compensation. If, as the authors suggest, marital status and the presence of children affect gender hours, then on-call overnight and weekend hours must be valued more significantly than routine office hours. With reasonable call shifts (14 h on weekdays and 12 h on weekends) and generous use of postcall days, it is not surprising that a faculty member taking calls, irrespective of gender, may not have significantly total increased hours compared to a weekday-only anesthesiologist. However, with increasing hospital demands, the flexibility of on-call faculty members to take additional preand/or postcall shifts is increasingly valuable and facilitates management of the daily schedule. Given the increasing proportion of female anesthesiologists in almost all age groups documented in the article, there will also be an increasing proportion of part-time anesthesiologists, which may negatively impact both the on-call cohort and flexibility in schedule management. For these population. The intuition of Dr. pivalizza et al. regarding the conduct of reasonable clinicians is therefore unsupported. Carette et al. raise the important point that using non–age-adjusted mAC values might have affected our conclusions. They could be right in that “single high” (age) might be much more important than “triple low” and that some of the patients in our study included in the “triple low” group might only have had “double low” (low mean arterial pressure and low bispectral index) when considering age-adjusted mAC. We chose the methodology in our study to approximate the approach that was used by Sessler et al.,5 who chose not to use ageadjusted mAC values. But our findings would not have changed substantially had we used age-adjusted mAC. Based on the population in our study, the low mAC cutoff would likely have shifted from the (arbitrary) 0.8 age-unadjusted value to about 0.9 age-adjusted mAC.6,7 Furthermore, although age was associated with 30and 90-day mortality in the multivariable analyses, “triple low” remained independently linked to death despite the inclusion of age as a variable in the models. It is also notable that age was one of the variables used in our propensity score matching. In conclusion, we apologize if the letter writers or readers were alarmed by our study or our conclusions. We wish to clarify that we do not believe that our findings mandate any changes in clinical practice, and we remain skeptical that “triple low” is causally implicated in postoperative death.

Is the “triple Low” Association with Death Statistically Valid or Reflective of Clinical Practice?

To the Editor: We are intrigued to read Willingham et al.’s1 strongly worded retrospective, observational conclusion from three previously reported trials that the concurrence of intraoperative hypotension, low minimum alveolar concentration, and low bispectral index (BIS), the so-called “triple low,” was independently associated with postoperative death. We have several observations noting that several of the current authors were original contributors to the referenced studies.

Dangerous Regulations for a Level 1 Trauma Operating Room.

1. Their estimated 5to 10-minute arterial line monitoring system setup time presumes immediate availability of a dedicated technician or anesthesiologist. At our busy facility, especially in after-hours scenarios, this may be longer. Recent data from Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) highlighted the first 3 hours of traumarelated mortality,2 and delaying arterial line access for a fraction of these golden hours has the ability to cause patient harm. 2. Direct admissions from the helipad or emergency room frequently occur in <5 minutes and would preclude safe preparation of monitoring systems or necessary medications at that time. 3. As with many academic centers, clinical responsibility is coupled with educational requirements, including a new intake of one-third of the effective resident and one-half of the Anesthesiologist Assistant student cohort every summer, coinciding with the busiest period of the trauma season. With new personnel, it is imperative that arterial line monitoring systems, induction, and rescue medications are prepared and immediately available to avoid delay in care. 4. We agree with the plea for evidence-based recommendations. In our collective experience, we have not seen an infection at an arterial line site that was placed urgently or emergently in the operating room. If there is concern for sterility or infection, the arterial line can be safely replaced once the patient is not in extremis.