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George Tewfik, Nivetha Srinivasan, Daniel Rodriguez-Correa, Christopher Tenorio Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USACorrespondence: George Tewfik, Rutgers New Jersey Medical School, 185 South Orange Ave, Newark, NJ, 07103, USA, Tel +1-(973)972-5007, Email glt31@njms.rutgers.eduBackground: Morbidity and mortality (M&M) conferences are essential components for resident education and provide a valuable tool to improve patient safety and quality of care. M&M conferences help identify important gaps in safety and reduce avoidable events in future patient care. Active methods to improve the utilization of M&M conferences have been shown to enhance their educational value for residents, faculty and multidisciplinary teams in healthcare institutions.Objective: The purpose of this study was to use a survey-based methodology to assess how morbidity and mortality conferences are conducted in residency programs, including characteristics such as frequency, involvement of personnel and the effects of COVID-19.Methods: From February to October 2021, a validated 19 question survey was electronically distributed to residency program directors in anesthesiology, emergency medicine and general surgery, after a search for email addresses in the ACGME database. The survey was created and hosted on Google Forms.Results: A total of 125 of 713 program directors (17.5%) responded to the survey. Eighty-three percent of respondent programs reported mandatory participation for residents, with residents providing most of the presentations. Case presentations utilized various formats including SBAR, adverse event analysis and root cause analysis as the most common modalities. Though most programs reported no change in frequency of M&M conferences due to COVID-19, most respondents reported a shift to a virtual or hybrid platform.Conclusion: M&M conferences are an important educational and quality improvement modality, and many residency directors changed practice to incorporate virtual platforms due to the COVID-19 pandemic to maintain uninterrupted educational sessions. Nonetheless, significant variation still exists in how these conferences are conducted between different institutions.Keywords: morbidity and mortality, graduate medical education, quality assurance

BACKGROUND Learning in the operating room (OR) for residents in anesthesiology is difficult but essential for successful resident education. Numerous approaches have been attempted in the past to varying degrees of success, with efficacy often judged afterward using surveys distributed to participants. The OR presents a particularly complex set of challenges for academic faculty due to the pressures required by concurrent patient care, production pressures, and a noisy environment. Often, educational reviews in ORs are personnel specific, and instruction may or may not take place in this setting, as it is left to the discretion of the parties without regular direction. OBJECTIVE This study aims to determine if a structured intraoperative keyword training program could be used to implement a curriculum to improve teaching in the OR and to facilitate impactful discussion between residents and faculty. A structured curriculum was chosen to allow for the standardization of the educational material to be studied and reviewed by faculty and trainees. Given the reality that educational reviews in the OR tend to be personnel specific and are often focused on the clinical cases of the day, this initiative sought to increase both the time and efficiency of learning interactions between learners and teachers in the stressful environment of the OR. METHODS The American Board of Anesthesiology keywords from the Open Anesthesia website were used to construct a weekly intraoperative didactic curriculum, which was distributed by email to all residents and faculty. A weekly worksheet from this curriculum included 5 keywords with associated questions for discussion. The residents and faculty were instructed to complete these questions on a weekly basis. After 2 years, an electronic survey was distributed to the residents to evaluate the efficacy of the keyword program. RESULTS A total of 19 teaching descriptors were polled for participants prior to and following the use of the intraoperative keyword program to assess the efficacy of the structured curriculum. The survey results showed no improvement in intraoperative teaching based on respondent perception, despite a slight improvement in teaching time, though this was statistically insignificant. The respondents reported some favorable aspects of the program, including the use of a set curriculum, suggesting that greater structure may be beneficial to facilitate more effective intraoperative teaching in anesthesiology. CONCLUSIONS Although learning is difficult in the OR for residents, the use of a formalized didactic curriculum, centered on daily keywords, does not appear to be a useful solution for residents and faculty. Further efforts are required to improve intraoperative teaching, which is well known to be a difficult endeavor for both teachers and trainees. A structured curriculum may be used to augment other educational modalities to improve the overall intraoperative teaching for anesthesia residents.

Telemedicine is a branch of healthcare that uses communication technology to deliver medical information and services between patients and healthcare providers. The applicability of telemedicine is vast and increasingly relevant. There is a lack of research on utilizing telemedicine for remote evaluation of the airway. The primary aim of this pilot study was to validate a telemedical airway exam as a viable alternative to an in-person evaluation. Three anesthesiologists evaluated 48 volunteers by telemedicine and live examination. The telemedical exam consisted of transmitting still images of four established, predictive parameters of difficult airways: Mallampati score; neck extension; ability to prognath; and thyromental distance. Each subject’s telemedical and face-to-face scores were compared to determine their degree of correlation. Still images were taken using standardized positioning with four pictures of mouth opening, neck extension, prognath, and thyromental distance. Data were analyzed using Wilcoxon signed-rank tests and free-marginal multirater kappa analysis. Average respective scores for live versus telemedicine examination were as follows: Mallampati scores were 1.73 versus 2.54; neck extension scores were 3.77 versus 3.60; thyromental distance (measured in finger breadths) was 2.95 versus 2.92; and prognath scores were 0.97 versus 0.94. There was no difference in grading of thyromental distance or prognathy ability between live and telemedical exams, and interrater reliability was very good for both parameters. This study supports telemedicine as a reliable tool for preoperative anesthesia airway exams to identify airway difficulties. This may be especially useful as an alternative in patients with COVID-19 undergoing urgent surgery.

BackgroundDespite its presence as a critical procedure in the trauma setting, airway management is not performed uniformly, varying between institutions, particularly with personnel involved in decision-making. Past literature has noted a trend in which emergency medicine physicians assumed greater responsibility for primary management of airways in the trauma ward. Many institutions have adopted tiered activation systems for traumas in order to improve patient care, deploying resources more effectively.MethodsIn this study, a survey of residency directors was deployed to assess trends in airway management. A validated survey was distributed to residency directors in anesthesiology, general surgery and emergency medicine in 190 Level I trauma centers in the United States. Questions assessed personnel management, complication tracking and difficult airway prediction factors, amongst other considerations for airway management in the trauma bay.ResultsRespondents completed the survey at a rate of 23.8% of those solicited. A majority of respondents indicated that emergency medicine physicians are primary airway managers in the trauma bay and that their institutions utilize tiered trauma activation systems at 77.4% and 95.6% respectively. Anesthesia providers were immediately available in 81% of respondent institutions with inconclusive data regarding protocols for delineating anesthesia involvement in difficult airways. More than a third of respondents indicated their institution either does not track airway complications or they did not know if complications were tracked. Finally, nine different criteria were used in varying degrees by respondents’ institutions to predict the presence of a difficult airway, including such factors as head/face trauma, airway fluid and obesity. ConclusionsEmergency medicine physicians are the primary airway managers in many trauma centers, although they are often supported by the presence of anesthesiology for advanced airway interventions. Delineation of anesthesia involvement is unclear, and criteria to determine a difficult airway varies amongst institutions.

Acetaldehyde, the first metabolite of ethanol, is implicated in several of ethanol’s actions, including the reinforcing and aversive effects. The neuronal mechanisms underlying acetaldehyde’s aversive effect, however, are poorly understood. The lateral habenula (LHb), a regulator of midbrain monoaminergic centers, is activated by negative valence events. Although the LHb has been linked to the aversive responses of several abused drugs, including ethanol, little is known about acetaldehyde. We, therefore, assessed acetaldehyde’s action on LHb neurons in rats. The results showed that intraperitoneal injection of acetaldehyde increased cFos protein expression within the LHb and that intra-LHb infusion of acetaldehyde induced conditioned place aversion in male rats. Furthermore, electrophysiological recording in brain slices of male and female rats showed that bath application of acetaldehyde facilitated spontaneous firing and glutamatergic transmission. This effect of acetaldehyde was potentiated by an aldehyde dehydrogenase inhibitor, disulfiram, but attenuated by the antagonists of dopamine receptor subtype 1 (SCH23390) and subtype 2 (raclopride), and partly abolished by the pretreatment of dopamine or dopamine reuptake blocker (GBR12935). Moreover, application of acetaldehyde initiated a depolarizing inward current (IACD) and enhanced the hyperpolarizing-activated currents in LHb neurons. Bath application of Rp-cAMPs, a selective cAMP-PKA inhibitor attenuated acetaldehyde-induced potentiation of EPSCs and IACD. Finally, bath application of ZD7288, a selective blocker of hyperpolarization-activated cyclic nucleotide-gated channels attenuated acetaldehyde-induced potentiation of firing, EPSCs, and IACD. These results show that acetaldehyde exerts its aversive property by exciting LHb neurons via multiple cellular mechanisms, and new treatments targeting the LHb may be beneficial for alcoholism. SIGNIFICANCE STATEMENT: Acetaldehyde has been considered aversive peripherally and rewarding centrally. However, whether acetaldehyde has a central aversive property is unclear. Here we report that acetaldehyde excites the LHb, a brain region associated with aversion and negative valence, through multiple cellular and molecular mechanisms. Intra-LHb acetaldehyde produces significant conditioned place aversion. These results suggest that acetaldehyde’s actions on the LHb neurons might contribute to its central aversive property and new treatments targeting the LHb may be beneficial for alcoholism.

Objective: The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients. Methods: Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients. Conclusion: Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing—the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients. Level of evidence: NA

A critical step in understanding and preventing potentially disastrous complications in the perioperative period is the accurate recording of their occurrence and subsequent analysis. However, the recording of intravenous infiltration and extravasation is likely inaccurate due to several factors: rare serious complications associated with infiltration/extravasation, limitation in ICD-10 codes to describe the injury, reliance on coders to record these events in searchable databases, and limited quality measures in anesthesiology to record these events. Although current literature cites results of studies that found rates of 16% and higher for intravenous infiltration, a limited internal review at University Hospital in Newark, NJ found significantly lower rates with only 14 instances recorded in an 18-month period across the institution. This leads the author to conclude that interventions are required to better track these events including such steps as staff education and more efficient/accessible reporting systems. The accurate recording and analyzing of data related to adverse events, and in particular regarding infiltration and extravasation, require revision and reinterpretation to gain an accurate picture of their rates.

BackgroundYouTube™ (“YouTube”) is often used as an educational tool to instruct anesthesia providers on regional anesthesia nerve blocks. However, there is no current objective standard to assess the educational quality of these user-uploaded videos. A new approach was used to objectively validate these videos by comparing them to high quality educational sources for the seven most commonly used nerve blocks.ObjectiveWe sought to evaluate the educational quality of user-uploaded videos when compared to the highest quality anesthesia society websites (NYSORA, ACEP, USRA).MethodsAfter reviewing the instructional material available for the seven most frequently conducted nerve blocks on high-quality reference websites, we documented the educational characteristics present including such things as indications, volume, anatomy, etc. Next we reviewed the five most popular videos on YouTube for each block (by views) and documented the presence or absence of these educational characteristics.ResultsEighteen educational characteristics were documented in the “high-quality” anesthesia society reference material. Correlation was sought between this material and YouTube videos. Although there were varying degrees of correlation between the high quality sources and the videos, rarely did YouTube videos contain as high a percentage of these educational characteristics as the well-established sources. Some videos contained very few of these important educational characteristics.ConclusionAlthough YouTube has been used an educational tool, we recommend that only high quality sources be used to teach or illustrate regional anesthesia nerve blocks.

Background: YouTubeTM (“YouTube”) is often used as an educational tool to instruct anesthesia providers on regional anesthesia nerve blocks. However, there is no current objective standard to assess the educational quality of these user-uploaded videos. A new approach was used to objectively validate these videos by comparing them to high quality educational sources for the seven most commonly used nerve blocks.Objective: We sought to evaluate the educational quality of user-uploaded videos when compared to the highest quality anesthesia society websites (NYSORA, ACEP, USRA)Methods: After reviewing the instructional material available for the seven most frequently conducted nerve blocks on high-quality reference websites, we documented the educational characteristics present including such things as indications, volume, anatomy, etc. Next we reviewed the five most popular videos on YouTube for each block (by views) and documented the presence or absence of these educational characteristics. Results: Eighteen educational characteristics were documented in the “high-quality” anesthesia society reference material. Correlation was sought between this material and YouTube videos. Although there were varying degrees of correlation between the high quality sources and the videos, rarely did YouTube videos contain as high a percentage of these educational characteristics as the well-established sources. Some videos contained very few of these important educational characteristics. Conclusion: Although YouTube has been used an educational tool, we recommend that only high quality sources be used to teach or illustrate regional anesthesia nerve blocks.

With billions of monthly active users, Facebook has an unprecedented ability for the dissemination of information. In healthcare, attempts have been made to utilize this tool for goals such as predicting disease onset; however, shared articles that omit information or propagate incorrect statements may have a negative effect. The goal of this study was to assess the accuracy of information in the nascent months of the 2019-2020 Covid-19 outbreak.The fifty most popular articles on Facebook for the period between November 2019 and March 25, 2020 (as collated by Buzzsumo- a social media analyzing tool) were analyzed by independent researchers and sorted into classifications for accurate, inaccurate and misleading. Following evaluation, 32% of articles were deemed to be accurate, 18% inaccurate, and 50% misleading (as defined by containing both accurate and inaccurate information). To restate, 68% of the 50 most popular articles on Facebook were not accurate during the study period. Impressions, shares and comments on Facebook in a summation of inaccurate and misleading articles were also analyzed in separate fashion and found to be 71.44%, 74.97%, and 80.22% respectively. These numbers outpace the 68% of total articles for which these types of stories account.In addition, shares were individually assessed as they indicate a desire to propagate the information forward on the part of the user, and were found to have occurred 6.61 million times in the inaccurate and misleading group compared to 2.2 million for accurate articles, for a cumulative rate of 74.9% of shares, again outpacing the 68% expected.There is a high rate of both inaccurate and misleading information related to the Covid-19 outbreak on Facebook, as assessed by physician reviewers. This information is not only more prevalent than the accurate information, but also received more engagement via overall impressions, as well as shares and comments. Although there is no clear remedy for this phenomenon, its implications range from general distrust to non-adherence to precaution guidelines or required actions. There is also a question regarding Facebook’s policing of itself and the content on its site, as well as that content published to it from other websites.

Background YouTube™ (“YouTube”) is often used as an educational tool to instruct anesthesia providers on regional anesthesia nerve blocks. However, there is no current objective standard to assess the educational quality of these user-uploaded videos. A new approach was used to objectively validate these videos by comparing them to high quality educational sources for the seven most commonly used nerve blocks. Objective We sought to evaluate the educational quality of user-uploaded videos when compared to the highest quality anesthesia society websites (NYSORA, ACEP, USRA) Methods We first catalogued the characteristics of the instructional material on three of the highest quality anesthesia society websites (NYSORA, ACEP, USRA) into 18 different items. Next, we surveyed the five most popular anesthesia block videos on YouTube for each of the seven peripheral nerve blocks in question. The presence or absence of each category was recorded. Results Although there were varying degrees of correlation between the high quality sources and the videos, rarely did YouTube videos contain as high a percentage of these educational characteristics as the well-established sources. Some videos contained very few of these important educational characteristics. Conclusion Although YouTube has been used an educational tool, we recommend that only high quality sources be used to teach or illustrate regional anesthesia nerve blocks.

Background. Quality assurance (QA) programs are critical to ensuring patient safety in current anesthesiology practices. While challenging to adapt to daily practice, rates of case entry into other Anesthesiology quality assurance databases have ranged from 48% to 85.1%. The goal of this study was to investigate entry rates at our institution’s voluntary QA database and uncover patterns of reporting. Methods. From 2013 to 2017, a total of 61,492 surgeries were analyzed to determine the rates of voluntary reporting of all cases (with or without a reportable incident) in our QA database by comparing the number of total procedures billed in that time to the total number of cases input into the QA system. Results. The overall compliance rate of entry of cases into the QA database during the 5 year period analyzed was 65.51%. Cases in the Main OR had a higher 5 year rate of entry compared to cases in the Same Day Surgery center. Interestingly, during the 5 year period, July has consistently had the highest rate of case entry (72.54%) into the QA Database, perhaps due to the start of the new academic year for residents. More importantly, there was a decreasing trend of entry into the QA database over the 5 year period of study. From an initial rate of 84.37% in 2013, compliance rates have gradually declined to 78.88% in 2014, 67.30% in 2015, 54.18% in 2016, and 45.16% in 2017. Conclusion. The inherent disadvantages of a voluntary reporting system combined with the growing requirement for quality improvement measures in today’s healthcare system reflect the necessity for particular interventions at our institution aimed at increasing QA compliance rates.

The United States (US) aviation industry provides a potentially useful mental model for dealing with certain cost-benefit decisions in aesthesiology. The Federal Aviation Administration (FAA), the national aviation authority of the United States, quantifies a price for the value of a human life based on the U.S. Department of Transportation's (DOT) value of a statistical life (VSL) unit. The current VSL is around $9.6 million, indexed to grow with consideration given to inflation and wage changes from the 2016 baseline of $9.4 million [1]. To illustrate the concept, if the FAA estimates that 100 people are likely to die in the future given the current practice standards then the monetary cost of this loss will be $940 million. The FAA uses this estimated monetary value as an official reference point in its regulatory decisions, and the agency publishes in detail how it derives the estimated value. When proposing new regulations, the FAA bases its decisions on comparisons of the human life cost associated with the existing regulation versus the alternative cost that the industry stakeholders will incur subsequent to the adoption of the regulation. In this example, if the cost incurred by the industry is more than the $940 million cost then the FAA will not adopt the proposed regulation and hence will not require the industry to undertake this cost.

SummaryBackground Laryngeal mask is frequently the airway device of choice in routine general anesthesia for many procedures in children. Several studies have described the use of laryngeal masks in unconventional situations. This survey was undertaken to assess how laryngeal masks are being used by pediatric anesthesiologists. Method The 40-question electronic survey using SurveyMonkey™ was sent to 2740 members of the Society for Pediatric Anesthesia (SPA). This survey assessed the age, work environment, types of practice, and training levels, as well as clinical situations in which the practitioners use laryngeal masks across different pediatric age groups. Results Seven hundred and forty-three (27.1%) responses were obtained. The use of laryngeal mask increased as the patient age increased in nearly every queried situation. The practitioners routinely utilize laryngeal masks in a variety of challenging scenarios, such as in patients with a recent upper respiratory infection, in the difficult airway, remote locations, and long-duration surgeries. A small percentage of pediatric anesthesiologists use laryngeal masks in laparoscopic surgery and prone position procedures. Conclusion Pediatric anesthesiologists are using laryngeal masks in both routine and challenging/unconventional situations. Although many of the uses for laryngeal masks are not explicitly stated in the manufacturer guidelines, literature and current practice support the use of laryngeal masks in several of these scenarios.