ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

Extracorporeal membrane oxygenation for airway emergencies

Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).

Cold Agglutinin Detected in the Intraoperative Period: A Case of Coronary Bypass.

Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32degreeC. It was noticed that there were clots in the cardioplegia delivery line(+1degreeC). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery.Copyright © Telif hakki 2022 Gogus-Kalp-Damar Anestezi ve Yogun Bakim Dernegi Dergisi - Available online at www.gkdaybd.org.

Cold Agglutinin Detected in the Intraoperative Period: A Case of Coronary Bypass.

Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32degreeC. It was noticed that there were clots in the cardioplegia delivery line(+1degreeC). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery.Copyright © Telif hakki 2022 Gogus-Kalp-Damar Anestezi ve Yogun Bakim Dernegi Dergisi - Available online at www.gkdaybd.org.

A Prospective Study of Patient-Reported Quality of Life Outcomes in Standard and Expanded Endoscopic Endonasal Skull Base Surgery at a Tertiary Center

Introduction: Transient alterations in patient's quality of life (QOL) following endoscopic endonasal approach skull base surgery (EEA) are inevitable despite substantial progress in techniques and equipment over the last two decades. We have prospectively evaluated patient-reported QOL at our institution using multiple metrics, to better understand the sensitivity of such testing and evaluate for risk factors for worsened quality of life after EEA. Method(s): Prospective, review-board-approved, single-institution cohort study of patients undergoing EEA surgery between 2019 and 2022 (enrollment was paused March to September 2020 due to COVID-19 research restrictions). Patient-reported global PROMIS-29 and sinonasal-specific ASK-Nasal 12 metrics were obtained prior to and at routine intervals after EEA. Result(s): We enrolled 90 patients with baseline and follow-up data available. Average age was 50 years and there was a 58:32 female:male predominance. Most procedures involved at least transsellar (N = 73) surgery, although numerous expanded anatomic compartments (total N = 61) were also accessed. Pituitary adenoma was the most common pathology treated, although a wide range of others were represented. PROMIS-29 evaluation of global QOL demonstrated an expected worsening in symptoms within physical function (+2.9), social interaction (+1.1), and pain (+0.4) metrics at 2-weeks postoperatively compared with baseline;averages in these domains returned to baseline or were improved by 6 months. Anxiety and depression symptom domains were immediately improved as early as 2-weeks after surgery (-1.2 and -0.8, respectively), remaining improved compared with baseline 6 months after surgery. Sinonasal-specific QOL demonstrated expected worsening at 2 weeks postoperative (average sum ASK-Nasal 12 score 21, versus 9.7 baseline, p < 0.05) but returned to baseline at 6 months (average 9.2, p = NS). Subgroup analysis revealed that patients with functional pituitary adenoma (FPA) reported worse baseline global QOL in every PROMIS-29 domain, but similar baseline sinonasal-specific QOL, when compared with the entire cohort. FPA patients reported more absolute improvement in every domain of PROMIS-29 global QOL than did the cohort average at 6 months post-surgery (average change across all PROMIS-29 symptom domains at 6 months -1.96 for FPA, versus -1.2 for all patients, p < 0.05). Discussion(s): We prospectively assessed patient-reported global and sinonasal-specific QOL after EEA at a tertiary center using modern techniques. The PROMIS-29 global QOL metric has not been previously utilized in this patient group;expected postoperative alterations in physical and social function and pain were found and these resolved within six months of surgery. Patient symptoms in Anxiety and Depression QOL domains immediately improved at two weeks postoperatively despite objectively worse reported sinonasal QOL in the same time interval;this implies patients are strongly relieved to have completed surgery even if still suffering sinonasal QOL alterations in the early perioperative period. Patients with functional pituitary tumors have, not surprisingly, worse baseline global QOL than do average EEA patients;nevertheless, functional tumor patients also show more absolute improvement in QOL after surgery. (Figure Presented).

Perioperative management strategies for surgical patients during the COVID-19 outbreak.

At present, the prevention and control situation of epidemics of Corona Virus Disease 2019 (COVID-19) is still serious, medical institutions should provide quality and safe routine medical services while doing their best in the prevention and control of this disease. The purpose of this article is to suggest a way to give quality and safe medical services to patients who need surgical treatment, especially to those who need emergency surgical treatment, with strict classified managements and standard precaution during perioperative period. With those suggestions, we may reduce the incidence of nosocomial infection and contribute to the prevention and control of COVID-19.Copyright © 2020 by the Chinese Medical Association.

Renal transplantation

Individuals with kidney failure face a future requiring long-term treatment with either dialysis or renal transplantation. Renal transplantation is the preferred form of renal replacement therapy, and is associated with a better quality of life, and usually increased longevity. Unfortunately, owing to excessive co-morbidities, only 30% of patients who develop end-stage renal failure are fit enough for transplantation. Over 90% of kidney transplants still function after 1 year, and most function for >15 years. Improvements in transplant outcomes are attributable to advances in histocompatibility testing, organ procurement, organ preservation, surgical techniques and perioperative care. Long-term outcomes have shown only minor improvements over the last two decades, although this should be considered in the context of deteriorating organ quality as older deceased donors with increasing co-morbidity are used more often to satisfy the need for donor organs. An overall increase in deceased donor numbers has boosted transplant activity in the UK, and it is hoped this will continue with the adoption of the 'opt-out' consent system. Living donor activity remains stable, but the use of non-directed altruistic donation and the living donor exchange scheme have reduced the need for higher immunological risk incompatible transplantation. The COVID-19 pandemic has reduced transplant rates globally, although national transplant systems are now recovering.Copyright © 2022

Use of Impella Devices for Acute Cardiogenic Shock in the Perioperative Period of Cardiac Surgery.

INTRODUCTION: The Impella ventricular support system is a device that can be inserted percutaneously or directly across the aortic valve to unload the left ventricle. The purpose of this study is to determine the role of Impella devices in patients with acute cardiogenic shock in the perioperative period of cardiac surgery. METHODS: A retrospective single-surgeon review of 11 consecutive patients who underwent placement of Impella devices in the perioperative period of cardiac surgery was performed. Patient records were evaluated for demographics, indications for placement, and postoperative outcomes. RESULTS: Impella devices were placed for refractory cardiogenic shock preoperatively in 6 patients, intraoperatively in 4 patients, and postoperatively as a rescue in 1 patient. Seven patients received Impella CP, 1 Impella RP, 1 Impella CP and RP, and 2 Impella 5.0. Additionally, 3 patients required preoperative venovenous extracorporeal membrane oxygenation (VV-ECMO), and 1 patient required intraoperative venoarterial extracorporeal membrane oxygenation (VA-ECMO). All Impella devices were removed 1 to 28 days after implantation. Length of stay in the intensive care unit stay ranged from 2 to 53 days (average 23.9±14.6). The 30-day and 1-year mortality were 0%. Ten of 11 patients were alive at 2 years. Also, 1 patient died 18 months after surgery from complications of coronavirus disease (Covid-19). Device-related complications included varying degrees> of hemolysis in 8 patients (73%) and device malfunction in 1 patient (9%). CONCLUSIONS: The Impella ventricular support system can be combined with other mechanical support devices for additional hemodynamic support. All patients demonstrated myocardial recovery with no deaths in the perioperative period and in 1-year of follow-up. Larger studies are necessary to validate these findings.

Effect of COVID-19 on Shoulder Arthroplasty at a Tertiary Care Medical Center in New York City.

Objective The COVID-19 pandemic led to an unprecedented pause in elective surgeries, including shoulder arthroplasty. We sought to determine whether clinical and/or demographic differences would be seen between patients who presented for shoulder arthroplasty during the pandemic compared with the previous year (2019). Methods Institutional records were queried for patients who underwent shoulder replacement between March 1 and July 1 of 2019 and 2020. Demographics, range of motion, surgical duration, hospitalization time, discharge disposition, and postoperative management were analyzed. Results The mean duration of surgery was 160 ± 50 minutes in 2020 and 179 ± 54 minutes in 2019 ( p = 0.13). The mean hospitalization time was 36 ± 13 hours in 2020 and 51 ± 40 hours in 2019 ( p = 0.04). In 2019, 96% of the patients participated in physical therapy, while 71% did it in 2020 ( p = 0.003). A total of 100% of the 2019 patients and 86% of the 2020 patients participated in an in-person postoperative follow-up ( p = 0.006). The 2019 patients reported for an office visit on average 14 ± 11 days after surgery; the 2020 patients waited 25 ± 25 days to return for a follow-up ( p = 0.10). Range of motion, age, American Society of Anesthesiologists (ASA) scores, and complication rates did not differ between the cohorts. Conclusion Patients presenting for surgery during the initial phase of the pandemic were demographically and clinically similar to 2019 patients. However, the length of stay was significantly reduced during the COVID-19 pandemic. Postoperative follow-up and physical therapy were delayed in 2020, but this did not lead to differences in complication or readmission rates compared with those of the 2019 cohort. Level of Evidence III.

Maternal and foetal outcomes in pregnant women undergoing lower segment caesarean section during COVID-19 pandemic: a retrospective analysis

Background and Aims: Coronavirus disease 2019 (COVID-19) adds more challenges to the perioperative management of pregnant women. The aim of this study is to examine severity of COVID-19 disease and maternal and foetal outcome among COVID-19 positive pregnant women undergoing caesarean section. Methods: This retrospective observational study was conducted at a tertiary teaching hospital in Karnataka between 1stApril to 31st July 2021, during which 100 COVID-19 positive pregnant women with ASA physical class II, III and IV who have undergone lower segment emergency caesarean section were selected on the basis of simple random sampling method. Results: A total of 100 women who had undergone caesarean section under spinal anaesthesia with positive SARS-CoV-2 PCR tests were assessed. Mean age was 24.45± 4.3 years, eight women were having severe covid-19 infection and overall mortality rate was 5% (5/100) in women and 1 woman had HELPP syndrome and one met with PPH (post-partum haemorrhage). Seven (7%) COVID-19 pregnant women required intensive care in the perioperative period. Eight neonates required NICU admission and had APGAR score less than 7. Fifty-five (55%) women were asymptomatic. While the rate of pneumonia in symptomatic women was 3.6% (8/45), the pneumonia incidence among all SARS-CoV-2 PCR (+) pregnant women was 8% (8/100). Conclusion: In our study, 61% of patients had pulmonary involvement and the mortality rate was 8% among mothers and 1% in neonates.

Anesthetic Approach and Perioperative Complications in Cleft Lip/Palate Surgery: A Single Center Retrospective Study

Objective: The objective of this study was to determine factors that may affect anesthesia and surgical complications, difficult airway, and the need for intensive care unit (ICU) care in cleft lip and cleft palate (CLCP) surgeries. Materials and Methods: The study was a retrospective review of the records of 617 patients who underwent CLCP surgery between 2015–2019. Results: The number of anesthesia complications was higher in patients with difficult mask ventilation. Surgical complications were more common in patients >1 year of age. Isolated cleft palate (CP) surgery;presence of a concomitant disease, syndrome, or micrognathia;age >1 year;and the CP subtype were associated with a higher rate of difficult intubation. Isolated cleft palate, concomitant disease, syndrome, micrognathia, difficult intubation, difficult mask ventilation, and anesthesia complications were associated with ICU admission. Conclusion: The CP subtype was associated with a higher rate of difficult intubation and ICU hospitalization even in patients who were nonsyndromic and/or >1 year of age. Therefore, special attention should be paid to the anesthesia and surgical management of these patients.

Perioperative Telehealth Interventions in Geriatric Surgery-A Systematic Review

INTRODUCTION: Telehealth has become mainstream during the COVID-19 pandemic, but its role in managing older patients is not well defined. This systematic review aims to assess the postoperative benefits of perioperative telehealth interventions in older adults. METHODS: PubMed, Cochrane, and Embase databases were searched through October 2020. Two separate reviewers screened s from the search. Studies were included in the final list if they measured outcomes of telehealth interventions in the perioperative period for patients > 65 years old. Disagreements were settled by a third reviewer, and results were compiled from the final list of articles. Due to heterogeneity, a meta-analysis was not pursued. RESULTS: The search yielded a total of 770 s. Five were included in the review, three randomized and two prospective pilot projects with a collective total of 395 patients. Four studies found that there was a postoperative benefit following perioperative telehealth interventions. Specifically, the interventions improved subjective perceptions of recovery and symptom severity. Though not statistically significant, patients in all included studies had improvements in physical functioning. There was a consistent pattern of steady improvement from baseline in all health areas in older patients. A notable limitation in one study was that participants experienced technical difficulties and required ongoing technical support. CONCLUSION: Perioperative telehealth interventions in older adults can lead to improved clinical outcomes, but existing data are limited. More studies are needed to evaluate the application of telehealth to older adults with frailty, whose ability to participate in the technology may be limited.

CHALLENGES IN THE NEUROSURGICAL CARE OF PEDIATRIC PATIENTS WITH CENTRAL NERVOUS SYSTEM TUMORS DURING THE COVID-19 PANDEMIC

INTRODUCTION: Central nervous system (CNS) tumors account for 20 - 30% of all childhood cancers. The Philippines is a lower-middle income country, wherein brain centers are located mostly in urban areas. We aimed to identify challenges that pediatric patients with CNS tumors encountered during the COVID-19 pandemic, which aggravated delays in their diagnosis and treatment. METHODS: This is a retrospective review of all pediatric patients who underwent neurosurgery for CNS tumors at the Jose R. Reyes Memorial Medical Center, a tertiary referral center, from January 2020 until December 2021. We summarized patients' demographic data, clinical course, and perioperative outcomes. RESULTS: A total of 38 pediatric patients underwent neuro-oncologic surgery in our center during the study period. There were 18 males and 20 females, with a mean age of 7.5 ± 4.9 years. Tumor was biopsied and/or resected in 35 cases (92%). The most common histologic diagnoses were medulloblastoma (n=8, 21%) and high-grade glioma/glioblastoma (n=5, 13%). Median preoperative length of stay and total length of stay were 10 (IQR: 17) and 28 (IQR 33.75), respectively. There was a high perioperative mortality rate in 2020 (71%), but this decreased to 20% in 2021. Six patients (16%) developed COVID-19 infection during the perioperative period. There were nine patients (24%) who had documented tumor progression because of delays in adjuvant therapy. DISCUSSION: Aside from geographic barriers and catastrophic health expenditure, the major challenges that disrupted the care of pediatric patients with CNS tumors in our center during the COVID-19 pandemic were delays in neuroimaging for diagnosis, unavailability of operating room slots, deficiency in critical care beds, and workforce shortage due to COVID-19 infection among health workers. Health care systems must adapt to the changes brought about by the pandemic, so that children with CNS tumors are not neglected.

TCAR Can Safely Be Performed With Regional Anesthesia and No ICU Stay

Objectives: Hospital resource usage is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures has been especially relevant in the setting of the COVID-19 (coronavirus disease 2019) pandemic and its impact on staffed intensive care unit (ICU) beds. We evaluated the feasibility of regional anesthesia and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution. Methods: All patients at high risk for carotid endarterectomy undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management was standardized by the use of an institutional protocol that included hemodynamic parameters and requisite medications, anticoagulation and/or antiplatelet regimens, neurovascular examination guidelines, and nursing instructions. The anesthetic modality was at the surgeon’s preference. Patients were transferred to the postanesthesia care unit (PACU) for 2 hours (with a 1:1 or 1:2 nursing ratio) followed by the step-down unit (1:4 nursing ratio) for 4 hours, followed by transfer to the floor (1:6 ratio) or, alternatively, were transferred to the ICU (1:1 ratio). Intravenous (IV) blood pressure medications could be administered in all environments, except for the floor. The recovery location and length of stay were recorded. Results: A total of 83 patients had undergone TCAR during the study period. The mean age was 72 ± 9 years, 59% were men, and 36% were symptomatic. Regional anesthesia was used for 84%, with none converted to general anesthesia intraoperatively. Postoperatively, only seven patients (8%) had required monitoring in the ICU overnight (decided perioperatively). This was mostly for patients with prior neurologic symptoms but for one patient was because of a postoperative neurologic event and for another patient because of pulseless electrical activity arrest. Of the 83 patients, 76 (92%) had been monitored in the PACU, with 8 transferred to the floor after 4 hours and 13 discharged directly from the PACU (owing to limited bed availability). Of the patients in the PACU, 55 were transferred to the step-down unit after 2 hours and discharged from there. Six patients had required IV antihypertensive agents, and eight had required IV vasoactive support postoperatively. The mean length of stay in the ICU was 3.7 days (range, 1-15 days). The mean length of hospital stay was 1.8 ± 2.3 days (3.7 ± 5.4 days for those requiring the ICU and 1.4 ± 1.2 days for those not requiring the ICU). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of a prior stroke, and one respiratory arrest fatality in a frail patient with a neck hematoma, both of whom had been treated under general anesthesia. Conclusions: Using perioperative care protocols, TCAR can safely be performed while avoiding both general anesthesia and an ICU stay for most patients.

Anaesthetic management of adrenal tumours presenting with combination of rare syndromes during a pandemic: Experience from a tertiary cancer care centre in Northeast India

Background and Aims: Perioperative management of functional adrenal tumours is resource intensive. Due to the covid 19 pandemic, there has been sizeable delay in preparing and conducting these time sensitive surgeries.Quality of care andresource utilisation may worsen. This retrospective review was aimed at finding if care quality deteriorated due to covid 19 related restrictions, from anaesthetic perspective. Methods:Three cases of hormone-secreting adrenal tumours operated during a two year period in a tertiary cancer centre in India were retrospectively reviewed.Summary of the demographic profile, tumour characteristics, and the perioperative care were described using tables and analysed in the discussion. Results: Out of the three cases operated for adrenal gland tumour, pheochromocytoma tumour type with distant metastasis had prolonged hospital stay. One patient developed covid 19 infection in hospital. Cases were adequately managed during the perioperative period and the covid 19 related constraints didn't affect the quality of care. Conclusion:As in any other major surgery, adhering to a unique checklist, multidisciplinary approach, clear communication, knowledge sharing and establishing a care pathway helps to maintainquality care in high risk cases and at times of crisis.

How Should Anesthesiologists Face Coronavirus Disease 2019?

Coronavirus disease 2019 (COVID-19) is a highly contagious disease. Most infected patients manifest mild flu-like symptoms, but in some cases, the patients rapidly develop severe lung infections and pneumonia. It is estimated that about 15-20% of patients with COVID-19 develop hypoxemia and require some form of oxygen therapy and ventilation support. Further, exacerbation of the disease usually requires an emergency tracheal intubation, where the patients are more prone to coughing and aerosol diffusion, placing the anesthesiologist at an extremely high risk of infection. In this review, after a brief introduction to the epidemiology and pathogenesis of the COVID-19, we describe various recommendations that the anesthesiologists should employ to avoid the chances of infection during the management of severely ill patients. We describe key steps such as not removing the patient's mask prematurely and using sedatives, analgesics, and muscle relaxants for rapid and orderly intubation. The use of spinal cord and regional nerve block anesthesia should also be promoted to avoid general anesthesia. Since the patients with COVID-19 may also have disorders related to other parts of the body (other than lungs), short-acting drugs are recommended to actively maintain the perfusion pressure of the peripheral and important organs without metabolism of the drugs by the liver and kidney. Multimodal analgesia is advocated, and non-steroidal anti-inflammatory analgesic drugs can be used appropriately. In this review, we also discuss key studies and experiences of anesthesiologists from China, highlights research findings, and inform on the proper management of patients with perspective on anesthesiologists.

Anaesthetists’ knowledge of airborne infections

Background: Anaesthetists need to be knowledgeable regarding the control of airborne infection to ensure safe practice. The aim of this study was to determine anaesthetists’ knowledge regarding airborne infections in the perioperative period in the Department of Anaesthesiology at the University of the Witwatersrand. Methods: A cross-sectional research design was followed using an anonymous self-administered questionnaire. Data were collected at academic departmental meetings by convenience sampling. Returning the questionnaire implied consent. A score of 65% was considered adequate knowledge. Results: Of the 150 questionnaires distributed, 137 (91.3%) questionnaires were returned. An overall mean (standard deviation [s.d.]) score of 58.8% (4.252) was achieved, and only 11 (8.1%) of anaesthetists had adequate knowledge. There was no statistically significant association between seniority and passing or failing (p = 0.327). The highest mean (s.d.) score, 67.4% (6.979), was reported in the section pertaining to patients, followed by the section regarding operating theatre staff at 58.1% (11.899) and the lowest mark, 53.5% (5.553), for the environment section. Anaesthetists scored significantly better in the knowledge regarding patients’ section than in other sections (p < 0.0005). Conclusion: Knowledge of airborne infections in this study was poor, with only 8.1% achieving a pass, and no difference in knowledge between junior and senior anaesthetists was observed. Considering the ongoing coronavirus disease 2019 (COVID-19) pandemic at the time of the study, this was a surprising finding. Urgent action needs to be taken to ensure the safety of anaesthetists, other operating theatre staff and patients.

OPIOID-FREE SURGERY: IMPLEMENTATION OF SUCCESSFUL NON- OPIATE COLECTOMY AT COMMUNITY TEACHING CENTER

Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.

The utility of using genomic testing on needle core biopsies during the COVID-19 pandemic: Molecular characterization, risk stratification, neoadjuvant outcome, and future implications

Introduction: The COVID-19 pandemic has caused an extraordinary challenge for global health. New guidelines were implemented, including postponing non-essential surgical procedures to conserve resources. In response, the COVID19 Pandemic Breast Cancer Consortium expert opinion suggested the use of core biopsies for genomic testing to help triage patients for surgical vs. systemic treatment. To better understand how expedited genomic results could impact peri-operative care, we performed a pre-operative quality project to assess testing Mammaprint (MP), a 70-gene risk of recurrence assay, and Blueprint (BP), an 80-gene molecular subtyping assay, on core biopsies. Here we report our experience with MP and BP testing on core biopsies, and the correlation between test results and response to neoadjuvant therapy.Design: From April to December 2020, all core biopsies with a breast carcinoma diagnosis from our clinic (300 patients) were routinely sent for MP and BP testing as part of a rapid result program that was initiated to see whether test results could be obtained in time and whether they would lead to more informed pre-operative treatment decisions. Unstained slides were sent for genomic and receptor testing concurrently. When genomic results differed from IHC/FISH results or suggested a different S treatment plan vs. clinical factors alone, we referred to this as "reclassification." For those patients who completed their neoadjuvant chemotherapy, we grouped them by their genomic results and by their conventional IHC/FISH/Clinical classification, and compared the outcome. Results: MP and BP results from core biopsy were available for 96.6% of patients (n=290/300). The average time from biopsy to test results was 10 days, and the average lab turnaround time was 5 days. Results were available for tumor conference discussions 100% of the time. MP and BP re-classified 84 of 300 patients (28%) from conventional IHC/FISH subtyping, and reclassified 42 of 195 patients (22%) of patients from their risk category based on traditional clinical factors (Table-1). Of the 38 patients with available post-neoadjuvant therapy outcome, 13 patients (34%) achieved pathologic complete response (pCR). 16 patients were classified as Her-2 enriched by IHC/FISH of which 9 (56%) achieved pCR. MP/BP aligned with the IHC/FISH Her-2 enriched classification in 11/16 patients, while 5 patients were reclassified to Luminal B by MP/BP. Of the 11 patients with concordant IHC/FISH and MP/BP results, 8 achieved pCR (73%), while one of the 5 cases reclassified to Luminal B achieved pCR (20%). Of the patients who were classified Luminal by IHC (9 patients), one patient achieved pCR (11%), and of the patients classified luminal (A or B) by MP/BP (12 patients) two achieved pCR (16%). Of the IHC-triple negative patients and genomic basal patients, three patients achieved pCR in each group (23% and 20%, respectively). Conclusion: Performing MP/BP tests on core needle biopsies hold a high success rate. Incorporating test results into peri-operative discussions may result in better-informed decisions about treatment planning and timing of surgery versus systemic therapy. A higher rate of pCR was seen in the MP/BP Her-2 enriched group compared to the IHC/FISH Her-2 enriched group. Although this workflow was designed to triage patients during the COVID pandemic, this approach has great potential beyond the pandemic.