Predicting cardiac risk in noncardiac surgery: a narrative review.

Risk stratification endeavors to categorize patients into groups based on the level of risk for each group. Improved perioperative screening tests using more sensitive cardiac biomarkers have revealed that about 68% of perioperative myocardial infarctions (MI) are asymptomatic and may only be detected by routine postoperative screening with troponin measurements. This is important since myocardial injury not meeting criteria for myocardial infarction is associated with increased risk of 30-day mortality (Botto et al. in Anesthesiology 120:564-578, 2014). Traditional risk indices including the revised cardiac risk index (RCRI) and the myocardial infarction cardiac arrest (MICA) index were developed based on overt clinical signs of myocardial infarction and significantly underestimate adverse cardiac events. Recently, brain type natriuretic peptides (BNP) and its precursor n- terminal pro-brain type natriuretic peptide (nt-proBNP) have been shown to be powerful prognostic markers. Incorporating serum biomarkers into updated clinical risk indices is likely to improve their performance. Further studies are needed to determine appropriate clinical interventions to treat isolated elevations in cardiac troponin levels and further mitigate the increased risk of morbidity and mortality. The objective of this review is to summarize the current literature on the clinical diagnoses of perioperative myocardial injury in the setting of noncardiac surgery.

Anesthesiologist Age and Sex Influence Patient Perceptions of Physician Competence.

BACKGROUND: Uncovering patients' biases toward characteristics of anesthesiologists may inform ways to improve the patient-anesthesiologist relationship. The authors previously demonstrated that patients prefer anesthesiologists displaying confident body language, but did not detect a sex bias. The effect of anesthesiologists' age on patient perceptions has not been studied. In this follow-up study, it was hypothesized that patients would prefer older-appearing anesthesiologists over younger-appearing anesthesiologists and male over female anesthesiologists. METHODS: Three hundred adult, English-speaking patients were recruited in the Preanesthesia Evaluation and Testing Center. Patients were randomized (150 per group) to view a set of four videos in random order. Each 90-s video featured an older female, older male, younger female, or younger male anesthesiologist reciting the same script describing general anesthesia. Patients ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member. Patients also chose the one anesthesiologist who seemed most like a leader. RESULTS: Three hundred patients watched the videos and completed the questionnaire. Among patients younger than age 65 yr, the older anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.92; 95% CI, 1.41 to 2.64; P < 0.001) and more intelligent (odds ratio, 2.24; 95% CI, 1.62 to 3.11; P < 0.001), and had greater odds of being considered a leader (odds ratio, 2.62; 95% CI, 1.72 to 4.00; P < 0.001) when compared with younger anesthesiologists. The preference for older anesthesiologists was not observed in patients age 65 and older. Female anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.46; 95% CI, 1.13 to 1.87; P = 0.003) and more likely to be chosen to care for one's family member (odds ratio, 1.80; 95% CI, 1.40 to 2.31; P < 0.001) compared with male anesthesiologists. The ranking preference for female anesthesiologists on these two measures was observed among white patients and not among nonwhite patients. CONCLUSIONS: Patients preferred older anesthesiologists on the measures of confidence, intelligence, and leadership. Patients also preferred female anesthesiologists on the measures of confidence and likelihood of choosing the anesthesiologist to care for one's family member.

Gender Differences in Postoperative Outcomes After Cardiac Surgery.

Women presenting for cardiac surgery tend to be older and have hypertension, diabetes, and overweight or underweight body mass index than men. Despite improvements in surgical techniques and medications, women have increased risk for morbidity and mortality after multiple types of cardiac surgery. Women presenting for transcatheter aortic valve replacement are older and frailer than men, and have increased risk of intraoperative complications, but lower mortality at mid- and long-term ranges compared with men. Adherence to recovery and rehabilitation from cardiac surgery is challenging for women. Solutions should focus on increased family support, and use of group exercise and activities.

Detection of intratracheal accumulation of thick secretions by using continuous monitoring of respiratory acoustic spectrum: a preliminary analysis.

The accumulation of tracheobronchial secretions may contribute to a deterioration in pulmonary function and its early detection is important. In this study, we analyzed the respiratory sound spectrum in patients with intratracheal secretion, and compared acoustic characteristics before and after therapeutic endotracheal suctioning. After review of anesthetic records of liver transplant recipients, we included recipients with identified intratracheal secretion during surgery. Intraoperative breath sounds recorded through esophageal stethoscope were sampled in 20 s-period before and after suctioning of secretion and analyzed using fast Fourier transform. We also analyzed normal breath sounds from recipients without any respiratory problem as control group. The maximal power (dBmMax), total power from whole frequency range of 80-500 Hz (Pt), total power of each frequency range (80-200 Hz, P80-200; 200-300 Hz, P200-300; 300-400 Hz, P300-400; 400-500 Hz, P400-500), and their ratio (P80-200/Pt, P200-300/Pt, P300-400/Pt, P400-500/Pt) were compared. Breath sounds were obtained from 20 recipients; 9 pairs of breath sound before and after suctioning of secretion and 11 normal breath sounds. Patients with intratracheal secretion showed significantly higher P80-200, P200-300, P300-400, P400-500 when compared to the those of normal control patients (P = 0.003, P = 0.002, and P = 0.009, respectively), while dBmMax did not differ. Elimination of secretions attenuated P80-200, P200-300, P300-400, and P400-500 by 22.4%, 25.7%, 48.5%, and 15.3%, respectively (P = 0.002, 0.024, 0.009, and 0.016, respectively). Identifying the presence of intratracheal secretions with power ratio at 80-200 Hz and 300-400 Hz showed the highest area under the curve of 0.955 in receiver operating characteristic curve analysis. We suggest that spectral analysis of breath sounds obtained from the esophageal stethoscope might be a useful non-invasive respiratory monitor for accumulation of intratracheal secretion. Further prospective studies to evaluate the utility of acoustic analysis in surgical patients are warranted.

Anesthesiology Resident Night Float Duty Alters Sleep Patterns: An Observational Study.

BACKGROUND: Residency programs utilize night float systems to adhere to duty hour restrictions; however, the influence of night float on resident sleep has not been described. The study aim was to determine the influence of night float on resident sleep patterns and quality of sleep. We hypothesized that total sleep time decreases during night float, increases as residents acclimate to night shift work, and returns to baseline during recovery. METHODS: This was a single-center observational study of 30 anesthesia residents scheduled to complete six consecutive night float shifts. Electroencephalography sleep patterns were recorded during baseline (three nights), night float (six nights), and recovery (three nights) using the ZMachine Insight monitor (General Sleep Corporation, USA). Total sleep time; light, deep, and rapid eye movement sleep; sleep efficiency; latency to persistent sleep; and wake after sleep onset were observed. RESULTS: Mean total sleep time ± SD was 5.9 ± 1.9 h (3.0 ± 1.2.1 h light; 1.4 ± 0.6 h deep; 1.6 ± 0.7 h rapid eye movement) at baseline. During night float, mean total sleep time was 4.5 ± 1.8 h (1.4-h decrease, 95% CI: 0.9 to 1.9, Cohen's d = -1.1, P < 0.001) with decreases in light (2.2 ± 1.1 h, 0.7-h decrease, 95% CI: 0.4 to 1.1, d = -1.0, P < 0.001), deep (1.1 ± 0.7 h, 0.3-h decrease, 95% CI: 0.1 to 0.4, d = -0.5, P = 0.005), and rapid eye movement sleep (1.2 ± 0.6 h, 0.4-h decrease, 95% CI: 0.3 to 0.6, d = -0.9, P < 0.001). Mean total sleep time during recovery was 5.4 ± 2.2 h, which did not differ significantly from baseline; however, deep (1.0 ± 0.6 h, 0.4-h decrease, 95% CI: 0.2 to 0.6, d = -0.6, P = 0.001 *, P = 0.001) and rapid eye movement sleep (1.2 ± 0.8 h, 0.4-h decrease, 95% CI: 0.2 to 0.6, d = -0.9, P < 0.001 P < 0.001) were significantly decreased. CONCLUSIONS: Electroencephalography monitoring demonstrates that sleep quantity is decreased during six consecutive night float shifts. A 3-day period of recovery is insufficient for restorative sleep (rapid eye movement and deep sleep) levels to return to baseline.

Generative retrieval results in positive academic emotions and long-term retention of cardiovascular anatomy using transthoracic echocardiography.

With increasing medical knowledge, procedural, and diagnostic skills to learn, it is vital for educators to make the limited amount of teaching time available to students effective and efficient. Generative retrieval is an effective and efficient learning tool, improving long-term retention through the practice of retrieval from memory. Forty medical students were randomized to learn normal cardiovascular anatomy using transthoracic echocardiography video clips in a generative retrieval (GR) or standard practice (SP) group. GR participants were required to verbally identify each unlabeled cardiovascular structure after viewing the video. After answering, participants viewed the correctly labeled video. SP participants viewed the same video clips labeled with the correct cardiovascular structure for the same amount of total time without verbally generating an answer. All participants were tested for intermediate (1-wk), late (1-mo), and long-term (6- to 9-mo) retention of cardiovascular anatomy. Additionally, a three-question survey was incorporated to assess perceptions of the learning method. There was no difference in pretest scores. The GR group demonstrated a trend toward improvement in recall at 1 wk [GR = 74.3 (SD 12.3); SP = 65.4 (SD 16.7); P = 0.10] and 1 mo [GR = 69.9 (SD15.6); SP = 64.3 (SD 15.4); P = 0.33]. At the 6- to 9-mo time point, there was a statistically significant difference in scores [GR = 74.3 (SD 9.9); SP = 65.0 (SD 14.1); P = 0.042]. At nearly every time point, learners had a statistically significantly higher perception of effectiveness, enjoyment, and satisfaction with GR. In addition to improved recall, GR is associated with increased perceptions of effectiveness, enjoyment, and satisfaction, which may lead to increased engagement, time spent studying, and improved retention.

Influence of Sex and Body Language on Patient Perceptions of Anesthesiologists.

BACKGROUND: Patient perception of physician competence is important. The role of body language and physician sex on patient perceptions has not been investigated. The authors hypothesized that patients perceive anesthesiologists displaying confident body language as more competent and that patients would prefer male anesthesiologists. METHODS: Two hundred adult patients presenting to the Preanesthesia Evaluation and Testing Center at the University of Virginia Health System were recruited to participate using consecutive sampling. Patients viewed four 90-s videos in random order. Each video featured a male or female actor displaying confident, high-power poses or unconfident, low-power poses. Each actor recited the same script describing general anesthesia. Patients were randomized (100 per group) to view one of two sets of videos to account for any actor preferences. Participants ranked each actor anesthesiologist on perceived confidence, intelligence, and likelihood of choosing that anesthesiologist to care for their family member. Participants also chose the one actor anesthesiologist who seemed most like a leader. RESULTS: Two hundred patients watched the videos and completed the questionnaire. Actor anesthesiologists displaying confident, high-power body language had greater odds of being ranked as more confident (odds ratio, 2.27; 95% CI, 1.76 to 2.92; P < 0.0001), more intelligent (odds ratio, 1.69; 95% CI, 1.13 to 2.18; P < 0.0001), more likely chosen to care for one's family member (odds ratio, 2.34; 95% CI, 1.82 to 3.02; P < 0.0001), and more likely to be considered a leader (odds ratio, 2.60; 95% CI, 1.86 to 3.65; P < 0.0001). Actor anesthesiologist sex was not associated with ranking for any response measures. CONCLUSIONS: Patients perceive anesthesiologists displaying confident body language as more confident, more intelligent, more like a leader, and are more likely to choose that anesthesiologist to care for their family member. Differences in patient perceptions based on sex of the anesthesiologist were not detected.

Generative Retrieval Does Not Improve Long-Term Retention of Regional Anesthesia Ultrasound Anatomy in Unengaged Learners.

BACKGROUND: Ultrasound-guided regional anesthesia is increasingly used in the perioperative period but performance requires a mastery of regional ultrasound anatomy. We aimed to study whether the use of generative retrieval to learn ultrasound anatomy would improve long-term recall. METHODS: Fourth-year medical students without prior training in ultrasound techniques were randomized into standard practice (SP) and generative retrieval (GR) groups. An initial pre-test consisted of 74 regional anesthesia ultrasound images testing common anatomic structures. During the study/learning session, GR participants were required to verbally identify an unlabeled anatomical structure within 10 seconds of the ultrasound image appearing on the screen. A labeled image of the structure was then shown to the GR participant for 5 seconds. SP participants viewed the same ultrasound images labeled with the correct anatomical structure for 15 seconds. Retention was tested at 1 week and 1 month following the study session. Participants completed a satisfaction survey after each session. RESULTS: Forty-five medical students were enrolled with forty included in the analysis. There was no statistically significant difference in baseline scores (GR = 11.5 ± 4.9; SP = 11.2 ± 6.2; P = 0.84). There was no difference in scores at both the 1-week (SP = 54.5 ± 13.3; GR = 53.9 ± 10.5; P = 0.88) and 1-month (SP = 54.0 ± 14.5; GR = 50.7 ± 11.1; P = 0.42) time points. There was no statistically significant difference in learner satisfaction metrics between the groups. CONCLUSIONS: The use of generative retrieval practice to learn regional anesthesia ultrasound anatomy did not yield significant differences in learning and retention compared with standard learning.

Concomitant lipomatous hypertrophy and left atrial mass: Distinguishing benign from malignant.

Masses in and near the interatrial septum may be either benign or malignant. The most common mass near the interatrial septum is lipomatous atrial septal hypertrophy (LASH). LASH can be present in patients with intracardiac malignancies, myxomas, lipomas, or other cardiac masses. It is important to recognize the transesophageal echocardiography (TEE) characteristics of these pathologies to arrive at an accurate diagnosis with an appropriate plan for intraoperative resection. At the authors' institution, patients have been referred for surgery due to a finding of significant LASH masquerading as a left atrial myxoma. In challenging cases, TEE offers a thorough evaluation of the interatrial septum to delineate between multiple intracardiac masses.

Generative Retrieval Improves Learning and Retention of Cardiac Anatomy Using Transesophageal Echocardiography.

BACKGROUND: Transesophageal echocardiography (TEE) is a valuable monitor for patients undergoing cardiac and noncardiac surgery as it allows for evaluation of cardiovascular compromise in the perioperative period. It is challenging for anesthesiology residents and medical students to learn to use and interpret TEE in the clinical environment. A critical component of learning to use and interpret TEE is a strong grasp of normal cardiovascular ultrasound anatomy. METHODS: Fifteen fourth-year medical students and 15 post-graduate year (PGY) 1 and 2 anesthesiology residents without prior training in cardiac anesthesia or TEE viewed normal cardiovascular anatomy TEE video clips; participants were randomized to learning cardiac anatomy in generative retrieval (GR) and standard practice (SP) groups. GR participants were required to verbally identify each unlabeled cardiac anatomical structure within 10 seconds of the TEE video appearing on the screen. Then a correctly labeled TEE video clip was shown to the GR participant for 5 more seconds. SP participants viewed the same TEE video clips as GR but there was no requirement for SP participants to generate an answer; for the SP group, each TEE video image was labeled with the correctly identified anatomical structure for the 15 second period. All participants were tested for intermediate (1 week) and late (1 month) retention of normal TEE cardiovascular anatomy. Improvement of intermediate and late retention of TEE cardiovascular anatomy was evaluated using a linear mixed effects model with random intercepts and random slopes. RESULTS: There was no statistically significant difference in baseline score between GR (49% ± 11) and SP (50% ± 12), with mean difference (95% CI) -1.1% (-9.5, 7.3%). At 1 week following the educational intervention, GR (90% ± 5) performed significantly better than SP (82% ± 11), with mean difference (95% CI) 8.1% (1.9, 14.2%); P = .012. This significant increase in scores persisted in the late posttest session at one month (GR: 83% ± 12; SP: 72% ± 12), with mean difference (95% CI) 10.2% (1.3 to 19.1%); P = .026. Mixed effects analysis showed significant improvements in TEE cardiovascular anatomy over time, at 5.9% and 3.5% per week for GR and SP groups respectively (P = .0003), and GR improved marginally faster than SP (P = .065). CONCLUSIONS: Medical students and anesthesiology residents inexperienced in the use of TEE showed both improved learning and retention of basic cardiovascular ultrasound anatomy with the incorporation of GR into the educational experience.