Timothy R. Long

Preoperative Gabapentin for Acute Post-thoracotomy Analgesia: A Randomized, Double-Blinded, Active Placebo-Controlled Study

Background:  The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients.

Perioperative interscalene blockade: an overview of its history and current clinical use

Use of single-dose and continuous interscalene brachial plexus block (ISB) are gaining widespread popularity. When compared with general anesthesia, ISB has been reported to provide superior postoperative analgesia with fewer side effects, and it is associated with greater patient satisfaction. Anatomical landmarks are readily identifiable, which contributes to the ease of performing this block. In the future, we anticipate increased use of continuous interscalene catheters or injection of biodegradable local anesthetic impregnated microspheres to provide prolonged perioperative outpatient analgesia.

Changes in red blood cell transfusion practice during the past two decades: a retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery

BACKGROUND: Others have reported significant changes in red blood cell (RBC) transfusion practice during the past two decades during knee, hip, prostate, and carotid surgery. Similar data for patients undergoing major spine surgery, however, are not available.

Looking into learning: Visuospatial and psychomotor predictors of ultrasound-guided procedural performance

Background and Objectives Despite widespread use of ultrasound in regional anesthesia, little understanding of the psychomotor and visuospatial skills required to achieve and maintain procedural proficiency exists. Despite its procedural nature, anesthesiology lags behind other fields in assessing technical aptitude among practitioners and trainees. The goals of this study were to measure relevant visuospatial and psychomotor aptitudes of anesthesia residents-in-training and to evaluate the relationship between these skill sets and the performance of ultrasound-guided regional anesthesia. Methods Forty residents from the Mayo Clinic Department of Anesthesiology were enrolled, and 39 (PGY-1 through PGY-4) voluntarily completed a demographic survey, 4 psychomotor and 4 visuospatial aptitude assessments, and an ultrasound-based performance assessment. Results The Block Design Test, a subtest of the Wechsler Adult Intelligent Scale - III, correlated with ultrasound guided skill performance (correlation coefficient, 0.47; P < 0.002). By contrast, psychomotor aptitude assessments did not correlate with ultrasound task performance. Psychomotor skill performance was significantly reduced by indirect hand-eye coordination visual feedback (projected image) compared with direct hand-eye coordination (P < 0.001). A learning effect was observed between the first and second ultrasound skill task attempts and was independent of hand dominance. Discussion This study reveals that visuospatial aptitude is a better predictor of ultrasound-based procedural performance than psychomotor ability. The type of real-time visual feedback (indirect versus direct) used for hand-eye coordination significantly impacts procedural performance and has implications for anesthesia and other procedural specialties. The learning effect noted during initial ultrasound skill trials suggests visuospatial assimilation and underscores the importance of early ultrasound instruction.

Changes in red blood cell transfusion practice during the past quarter century: a retrospective analysis of pediatric patients undergoing elective scoliosis surgery using the Mayo database.

BACKGROUND CONTEXT Previous studies have demonstrated significant changes in red blood cell (RBC) transfusion practice over several decades. PURPOSE The purpose of the present study was to ascertain changes in transfusion practice during a 25-year study epoch and determine whether these changes had any impact on the frequency of perioperative morbidity and mortality in pediatric patients undergoing major spine surgery. STUDY DESIGN Retrospective chart review. PATIENT SAMPLE Pediatric patients undergoing elective scoliosis surgery. OUTCOME MEASURES Impact of RBC transfusion on perioperative morbidity and mortality. METHODS Pediatric patients undergoing elective scoliosis surgery were stratified into one of two transfusion-related groups: 1975 to 1985 (ie, pre-human immunodeficiency virus screening, early practice group, n=177) or 1990 to 2000 (ie, recent practice group, n=192). Transfusion and perioperative outcome data were obtained from medical records. Red blood cell use was analyzed as a continuous variable and compared between groups using the Wilcoxon rank sum test, as were preoperative, postoperative, and discharge hemoglobin concentration. Age-adjusted data were compared between groups using chi-square or Fisher exact tests. RESULTS Patients in the recent practice group had significantly worse comorbid disease and more complex procedures compared with those in the early practice group. The percentage of patients in the recent practice group receiving allogeneic RBC transfusions was significantly less than the early group (37.5% vs. 89.8%, p<.001). Utilization of autologous RBC and intraoperative autotransfusion was significantly greater in the recent practice group (5.1% vs. 47.4% and 20.9% vs. 95.8%, respectively). Hemoglobin concentrations were significantly lower for all time periods in the recent practice group. There were no differences in major morbidity or mortality between groups. CONCLUSIONS In this retrospective review, we report a significant change in blood management strategies in pediatric patients undergoing elective scoliosis surgery. We demonstrated a shift from utilization of allogeneic RBC transfusion toward preoperative donation and intraoperative autotransfusion. Although transfusion triggers were significantly lower in the recent practice group, we were unable to demonstrate a difference in major morbidity or mortality. Utilization of autologous RBC transfusion was safe and effective in reducing allogeneic RBC transfusions in this study. The advantages of autologous blood transfusion may be in preserving a relatively scarce resource (ie, allogeneic blood), rather than mitigating transfusion-related complications.

Publication misrepresentation among anesthesiology residency applicants.

BACKGROUND:Publication misrepresentation has been documented among applicants for residency positions in several specialties. However, these data are not available for anesthesiology applicants. Our purpose in this study was to document the prevalence of publication misrepresentation among applicants to a single anesthesiology residency, to compare anesthesiology publication misrepresentation data with similar data in other specialties, and to determine how often publication misrepresentation leads to an unfair competitive advantage in the application process. METHODS:Applications to the Mayo School of Graduate Medical Education anesthesiology core residency in Rochester, Minnesota, were reviewed for publication misrepresentations using Medline and PubMed databases, Mayo Clinic library databases, and/or review by a qualified medical librarian. Misrepresented publications underwent further review to identify fraudulent publications and/or citation errors that provide an unfair competitive advantage. RESULTS:The authors found that 2.4% of the applications (13 of 532) included fraudulent publications, 6.6% of the applications with at least 1 publication (13 of 197) included ≥1 that was fraudulent, and 2.9% of all cited publications (15 of 522) were fraudulent. In addition, 0.9% of the applications (5 of 532) contained a citation error that, although not grossly fraudulent, could have favorably affected the applicants competitiveness for a residency position. CONCLUSIONS:Misrepresented publications were fairly common among anesthesiology residency applicants. However, only a small percentage of applicants listed misrepresented publications that were clearly fraudulent or contained a citation error that conferred a competitive advantage. Identification of fraudulent publications on Electronic Residency Application Service applications is important to maintain the integrity of the application process.

The psychological and physiological effects of acute occupational stress in new anesthesiology residents: A pilot trial

Background:Occupational stress in resident physicians has profound implications for wellness, professionalism, and patient care. This observational pilot trial measured psychological and physiological stress biomarkers before, during, and after the start of anesthesia residency. Methods:Eighteen physician interns scheduled to begin anesthesia residency were recruited for evaluation at three time points: baseline (collected remotely before residency in June 2013); first-month visit 1 (July); and follow-up visit 2 (residency months 3 to 5, September–November). Validated scales were used to measure stress, anxiety, resilience, and wellness at all three time points. During visits 1 and 2, the authors measured resting heart-rate variability, responses to laboratory mental stress (hemodynamic, catecholamine, cortisol, and interleukin-6), and chronic stress indices (C-reactive protein, 24-h ambulatory heart rate and blood pressure, 24-h urinary cortisol and catecholamines, overnight heart-rate variability). Results:Thirteen interns agreed to participate (72% enrollment). There were seven men and six women, aged 27 to 33 yr. The mean ± SD of all study variables are reported. Conclusion:The novelty of this report is the prospective design in a defined cohort of residents newly exposed to the similar occupational stress of the operating environment. Because of the paucity of literature specific to the measures and stress conditions in this investigation, no data were available to generate a priori definition of primary outcomes and a data analytic plan. These findings will allow power analysis for future design of trials examining occupational stress and stress-reducing interventions. Given the importance of physician burnout in our country, the impact of chronic stress on resident wellness requires further study.

Changes in transfusion practice over time in adult patients undergoing liver transplantation

OBJECTIVE The aim of this study was to investigate changes in transfusion practice over time in liver transplantation surgery and to evaluate potential causes for changes in practice and report associated perioperative morbidity and mortality. DESIGN A retrospective cohort study. SETTING A single tertiary referral academic hospital. PARTICIPANTS Two cohorts of 100 sequential adult primary liver transplant recipients: Early practice (1990-1991) and recent practice (2005-2006). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Perioperative transfusion and hemoglobin data were recorded. Mortality and postoperative complications were identified up to 30 days postoperatively. Appropriate intergroup statistical comparisons were made; p ≤ 0.05 was considered statistically significant. Compared with the early group, the recent group had significantly fewer perioperative allogeneic red blood cell transfusions, intraoperative autotransfusions, and transfusions of other blood products. No change in perioperative transfusion triggers was identified. There were no significant alterations in perioperative morbidity or mortality. CONCLUSIONS When compared with patients in the early group, recent cohort patients received significantly fewer blood transfusions. The authors attribute this observation to changes in surgical technique rather than a significant alteration in transfusion triggers over the studied time period.

Inadequate tidal volume: Asymmetric endotracheal tube cuff inflation resulting in a massive persistent airway leak

Massive persistent airway leak (defined as a leak large enough to necessitate endotracheal tube [ETT] replacement) (1) during mechanical ventilation may result from a variety of etiologies. We report a unique case of a defective ETT cuff that caused massive persistent airway leak in a 9-year-old, 24-kg female patient undergoing tympanoplasty and myringotomy tube removal. Following induction of general anesthesia, the trachea was intubated with a 5.0-mm inner diameter (sized according to diameter matching with fifth finger) wire spiral ETT (Bivona Aire-Cuf, Model 35W050, Gary, IN). A substantial air leak was heard at approximately 5 cm H2O pressure, resulting in delivery of inadequate tidal volume. Despite adding additional air to the ETT cuff (which resulted in a taut pilot cuff), the air leak persisted. The trachea was extubated and reintubated with a new—yet identical—ETT and the case proceeded uneventfully. Examination of the initial ETT revealed asymmetric cuff inflation (Fig. 1). Possible explanations for leaking—yet intact—ETTs are numerous (1,2). This is, to our knowledge, the first reported case of an asymmetrical ETT cuff causing massive persistent airway leak resulting in inadequate tidal ventilation.

Changes in Red Blood Cell Transfusion Practice during the Turn of the Millennium: A Retrospective Analysis of Adult Patients Undergoing Elective Open Abdominal Aortic Aneurysm Repair Using the Mayo Database

BACKGROUND Significant changes in perioperative red blood cell (RBC) transfusion practice during the past two decades have been reported but similar data are not available for patients undergoing abdominal aortic aneurysm (AAA) surgery. METHODS Adult patients who had undergone primary, elective, open AAA repair were stratified into one of two transfusion-related groups: early practice (1980-1982) or late practice (2003-2006). RBC transfusion and hemoglobin concentration (Hb) were analyzed as a continuous variable and compared between groups with use of the rank sum test. Perioperative complications were compared between groups with Fishers exact test. Data were age adjusted, and analyses were corrected for multiple comparisons. RESULTS Compared with the early practice group, patients in the late practice group had significantly lower intraoperative (mean 10 +/- 1.4 vs. 11.5 +/- 1.5 g/dL), postoperative (11.9 +/- 1.4 vs. 13.4 +/- 1.5 g/dL), and discharge Hbs (mean 10.8 +/- 1.2 vs. 12.5 +/- 1.5 g/dL) (p < 0.0001 for each variable). Patients in the late practice group were significantly less likely to receive intraoperative allogenic transfusions (46% vs. 99%, p < 0.0001). Additionally, significantly fewer total allogenic units of RBCs per patient were transfused in the late practice group (mean 1.7 vs. 4.3, p < 0.0001). Intraoperative autotransfusions were used in 97% of the late practice patients but in none of the early practice patients (p < 0.0001). In the late practice group, 119 patients (40%) experienced a major perioperative morbidity or mortality event compared with 106 patients (35%) in the early practice group (p = 0.27). CONCLUSION In this retrospective analysis, we observed significantly lower perioperative Hb, fewer allogenic RBC transfusions, and more autotransfusions in open AAA repairs done in 2003-2006 versus those done in 1980-1982. Additionally, late transfusion practice patients were older and had more comorbid diseases. Despite these observations, no significant differences in perioperative morbidity or mortality were observed between groups.