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Background: Limited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality. Methods: This retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes. Results: A total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7–32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7–29.5]), and attending-only surgical cases (21.0 [17.9–25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients. Conclusion: Anesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants. [ABSTRACT FROM AUTHOR]

Background: Forced-air warming is used as a mechanism to prevent hypothermia and adverse outcomes associated with hypothermia among patients undergoing surgery. Patient safety in healthcare includes the use of devices and technology that minimize potential adverse events to patients. The present study sought to compare the capabilities of patient warming between two different devices that use different mechanisms of warming: forced-air warming and non-air warming. Methods: One hundred twenty patients undergoing total hip or total knee arthroplasty received patient warming via a forced warming device or non-air warming fabric conductive material. The project was part of a quality improvement initiative to identify warming devices effective in maintaining normothermic patient core temperatures during orthopedic surgery. Results: Forced-air warming and non-air warming achieved similar results in maintaining the core temperature of patients undergoing total knee or hip arthroplasty. No adverse events were reported in either group. Operating room staff observed that the non-air warming device was less noisy and appreciated the disposable covers that could be changed after each surgical case. Conclusions: These findings demonstrate that hypothermia is achieved by both forced-air and non-forced air warming devices among total knee and hip arthroplasty patients. The potential for airflow disruption is present with the forced-air warming device and does not exist with the non-forced air device. The disruption of laminar airflow may be associated with surgical site infections. The disposable covers used to protect the device and patient have potential implications for surgical site infection. Quality improvement efforts aimed to enhance patient safety should include the implementation of healthcare equipment with the least known or suspected risk. [ABSTRACT FROM AUTHOR]

Comparing clinical productivity is important for strategic planning and the evaluation of resource allocation in any large organization. This process of benchmarking performance allows for the comparison of groups with similar characteristics. However, this process is often difficult when comparing the operative service productivity of large and small military treatment facilities because of the significant heterogeneity in mission focus and case complexity. However, in this article, we describe the application of a new method of benchmarking operative service productivity based on normalizing data for operating room sites, cases, and total American Society of Anesthesiologists units produced per hour. We demonstrate how these benchmarks allow for valid comparisons of operative service productivity among these military treatment facilities and how the data could be used in expanding or contracting operating locations. In addition, these benchmarks are compared with those derived from the use of this system in the civilian sector. [ABSTRACT FROM AUTHOR]

The inadequate availability of fuel substrates and sharp decline in cellular ATP have been implicated in a cascade of events associated with cell death and organ failure during hemorrhagic shock (HS). In this in vivo swine model of severe prolonged HS, the effect of exogenous pyruvate administration on various markers of cell damage in brain and liver was examined. Thirty minutes after the start of controlled arterial hemorrhage, 30% sodium pyruvate, 10% saline, or 0.9% saline was administered via jugular vein. Four hours after the initiation of hemorrhage, tissue samples from brain and liver were obtained and examined for the cellular and molecular markers of cellular damage. Results of our study suggest that pyruvate prevents loss of total NAD content, cleavage of poly-ADP ribose polymerase (PARP), and inhibits lipid peroxidation in both the brain and liver of swine during prolonged severe HS. We conclude that there are multiple mechanisms by which pyruvate can possibly prevent cell damage caused during HS. [Copyright &y& Elsevier]

Examines the mechanism of pyruvate in preventing liver damage during hemorrhagic shock. Maintenance of redox state by pyruvate; Prevention of intracellular antioxidants by pyruvate; Decrease of hepatic cellular death.

Presents a study which investigated the role of pyruvate administration in the improvement of cerebral metabolic and functional status after hemorrhagic shock. Methodology; Results; Discussion.

• IV extravasation is a common occurrence. • Overnight observation might not be necessary. • Variation in neuromuscular recovery. • Sugammadex for neuromuscular recovery and prevention of rebound. [ABSTRACT FROM AUTHOR]

Presents a study which evaluated the effects of intravenous pyruvate on cardiovascular and neocortical function in arterial hemorrhage in swine. Methodology; Results; Discussion.

Evaluates the effects of intravenous pyruvate on cardiovascular and neocortical function, indexes of the cytosolic redox state and cellular energy state during controlled arterial hemorrhage in sedated swine. Intravenous pyruvate effects on hemodynamics, oxygen delivery and oxygen consumption; Effects on blood electrolytes, acid-base status, lactate and lactate/pyruvate ratio.

Background: Inadvertent perioperative hypothermia (< 36 °C) occurs frequently during elective cesarean delivery and most institutions do employ perioperative active warming. The purpose of this retrospective observational cohort study was to determine if the addition of preoperative forced air warming in conjunction with intraoperative underbody forced air warming improved core temperature and reducing inadvertent perioperative hypothermia during elective repeat elective cesarean delivery with neuraxial anesthesia. Methods: We evaluated the addition of perioperative active warming to standard passive warming methods (preheated intravenous/irrigation fluids and cotton blankets) in 120 parturients scheduled for repeat elective cesarean delivery (passive warming, n = 60 vs. active + passive warming, n = 60) in a retrospective observational cohort study. The primary outcomes of interest were core temperature at the end of the procedure and a decrease in inadvertent perioperative hypothermia (< 36 °C). Secondary outcomes were surgical site infections and adverse markers of neonatal outcome. Results: The mean temperature at the end of surgery after instituting the active warming protocol was 36.0 ± 0.5 °C (mean ± SD, 95% CI 35.9–36.1) vs. 35.4 ± 0.5 °C (mean ± SD, 95% CI 35.3–35.5) compared to passive warming techniques (p < 0.001) and the incidence of inadvertent perioperative hypothermia at the end of the procedure was less in the active warming group - 68% versus 92% in the control group (p < 0.001). There was no difference in surgical site infections or neonatal outcomes. Conclusions: Perioperative active warming in combination with passive warming techniques was associated with a higher maternal temperature and lower incidence of inadvertent perioperative hypothermia with no detectable differences in surgical site infections or indicators of adverse neonatal outcomes. [ABSTRACT FROM AUTHOR]

Study Objective: The efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures.Design: A pre- and post-implementation quality improvement evaluation.Setting: Operating room and post-anesthesia care unit.Patients: Ninety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020.Interventions: A preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration.Measurements: The primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery.Main Results: PACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0-6] vs. 0 [IQR 0-4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10-23] vs. 15 [IQR 15-25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07).Conclusions: Liposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups. [ABSTRACT FROM AUTHOR]

: Study objectiveTo reinforce concepts presented in the lectures; understand the complexity and speed of casualty and information generation during a Weapons of Mass Destruction and Terrorism (WMD/T) event; experience the novelty of combined weapons'' effects; recognize the time course of the various chemical, biological, and radiation agents; and make challenging decisions with incomplete and conflicting information.: SettingsTwo environments simulated simultaneously: one a major trauma center emergency room (ER) with two patient simulators and several human actors; the other an Emergency Operations Command Center (EOC).: Target audienceStudents for this course included: clinicians, scientists, military and intelligence officers, lawyers, administrators, and logistic personnel whose jobs involve planning and executing emergency response plans to WMD/T.: Simulation scriptA WMD/T attack in Washington, D.C., has occurred. Clinical students performed in their real life roles in the simulated ER, while nonclinical students did the same in the simulated EOC. Six ER casualties with combined WMD/T injuries were presented and treated over 40 minutes. In the EOC, each person was given his or her role title with identification tag. The EOC scenario took cues from the action in the ER via two television (TV) news feeds and telephone calls from other Emergency Operations Assets.: Performance expectationsStudents were expected to actively engage in their roles. Student performances were self-evaluated during the debriefing.: DebriefingThe two groups were reunited and debriefed utilizing disaster crisis resource management tools.: Assessment of effectivenessStudents answered an 18-point questionnaire to help evaluate the usefulness and acceptance of multimodality patient simulation.: Lessons learnedLarge-scale multimodality patient simulation can be used to train both clinicians and nonclinicians for future events of WMD/T. Students accepted the simulation experience and thought that scenario was appropriately realistic, complex, and overwhelming. Difficulties include the extensive man-hours involved in designing and presenting the live simulations. EOC-only sessions could be staged with only a few video cassette recorders, TVs, telephones, and callers. [Copyright &y& Elsevier]

The feasibility and acceptance of an Advanced Distance Education Network (ADEN) in bringing the simulated operating room (OR) to second-year medical students learning the pharmacology of anesthetic drugs is reviewed. A MedSim-Eagle (Binghamton, NY) full-scale mannequin simulator was used. Using an ADEN, students were linked in real time to a simulated OR where the anesthesiologist instructor was using a MedSim-Eagle patient simulator to present for discussion the physiologic effects of volatile anesthetics on cardiac output (CO), heart rate (HR), mean arterial pressure (MAP), and systemic vascular resistance (SVR). The use of simulation to present basic science principles of isoflurane and halothane''s effect on CO, HR, MAP, and SVR in a clinical setting via an ADEN is feasible. Student acceptance of this method of education is high, as measured by a post-exercise survey. Ninety-five percent of students felt this exercise was a valuable use of their time; 93% felt the ADEN-delivered clinical simulation presentation contributed to their understanding of the pharmacology of anesthesia. Eighty-three percent of students preferred this integrated clinically oriented review to a didactic review of the material, and 92% of students who had experienced previous small group hands-on session simulation felt the ADEN-delivered session was the same or better. [Copyright &y& Elsevier]

This in vitro study was designed to examine the efficacy of exogenous pyruvate and glucose as a fuel substrate to protect rat astrocytes from post-ischemic injury. Astrocytes were incubated in Kreb''s buffer deprived of oxygen and glucose for 6 h (ischemia) followed by incubation with added pyruvate or glucose and normoxia for the next 6 h (reperfusion). The transformation of reactive astrocytes in response to various treatments was examined by immunostaining with glial fibrillary acidic protein. The extent of cell damage was evaluated in terms of lactate dehydrogenase leakage from the cells and altered intracellular redox status. The mechanism of cell death was determined by immunoblotting with cytochrome C, caspase-3 and PARP antibodies. The mechanism of the action of pyruvate was determined by measuring the activity of pyruvate dehydrogenase complex, and cellular metabolic status by measuring ATP levels. In comparison to glucose, supply of exogenous pyruvate restored the morphological integrity of post-ischemic astrocytes and prevented gliosis. Pyruvate prevented the cell death of post-ischemic astrocytes by inhibiting the leakage of lactate dehydrogenase, decreasing the redox ratio and restraining the activation of apoptotic events such as release of mitochondrial cytochrome c and fragmentation of caspase-3 and PARP. This study also suggests that pyruvate may accelerate its own metabolism by increasing the activity of pyruvate dehydrogenase and thus restores the cellular ATP levels in post-ischemic astrocytes. Use of pyruvate as an alternate fuel substrate may provide a possibility for the novel therapeutic approach to the treatment of cerebral ischemia. [Copyright &y& Elsevier]