Perioperative Efficiency of Sugammadex Following Laparoscopic Cholecystectomy in Clinical Practice.

Background: Studies have proposed that the routine use of the modified gamma-cyclodextrin, sugammadex, could provide perioperative time savings. However, these investigations have been limited to small group analyses. The purpose of this study was to test the effectiveness of sugammadex on perioperative times when compared to neostigmine under general clinical practice conditions following rocuronium-induced neuromuscular blockade for laparoscopic cholecystectomy. Methods: Following institutional review board approval, data from 1,611 consecutive surgical records for laparoscopic cholecystectomy were reviewed. Patient characteristics, type of primary neuromuscular blocking reversal agent, operating room (OR) discharge times, and postanesthesia care unit (PACU) recovery times were the measures of interest. Equivalence testing was used to determine the between-group differences of the reversal agents in the two perioperative time periods of interest. Results: OR discharge times averaged 10.9 (95% CI, 10-11.8) minutes for patients administered sugammadex and 8.9 (95% CI, 8.2-9.7) minutes for patients administered neostigmine. PACU recovery times averaged 77.6 (95% CI, 74.1-81.1) minutes for sugammadex and 68.6 (95% CI, 65.9-71.3) minutes for neostigmine. Equivalence testing demonstrated no improvement in the two perioperative times with sugammadex. Conclusion: These results suggest no perioperative time savings with sugammadex when compared to neostigmine following laparoscopic cholecystectomy under general clinical practice conditions.

A randomized trial evaluating the safety profile of sugammadex in high surgical risk ASA physical class 3 or 4 participants.

BACKGROUND: The aim of this randomized, double-blind trial was to evaluate the safety and tolerability profile, including cardiac safety, of sugammadex-mediated recovery from neuromuscular block in participants undergoing surgery who met the American Society of Anesthesiologists (ASA) Physical Class 3 or 4 criteria. Specifically, this study assessed the impact of sugammadex on cardiac adverse events (AEs) and other prespecified AEs of clinical interest. METHODS: Participants meeting ASA Class 3 and 4 criteria were stratified by ASA Class and NMBA (rocuronium or vecuronium) then randomized to one of the following: 1) Moderate neuromuscular block, sugammadex 2 mg/kg; 2) Moderate neuromuscular block, neostigmine and glycopyrrolate (neostigmine/glycopyrrolate); 3) Deep neuromuscular block, sugammadex 4 mg/kg; 4) Deep neuromuscular block, sugammadex 16 mg/kg (rocuronium only). Primary endpoints included incidences of treatment-emergent (TE) sinus bradycardia, TE sinus tachycardia and other TE cardiac arrhythmias. RESULTS: Of 344 participants randomized, 331 received treatment (61% male, BMI 28.5 ± 5.3 kg/m2, age 69 ± 11 years). Incidence of TE sinus bradycardia was significantly lower in the sugammadex 2 mg/kg group vs neostigmine/glycopyrrolate. The incidence of TE sinus tachycardia was significantly lower in the sugammadex 2 and 4 mg/kg groups vs neostigmine/glycopyrrolate. No significant differences in other TE cardiac arrythmias were seen between sugammadex groups and neostigmine/glycopyrrolate. There were no cases of adjudicated anaphylaxis or hypersensitivity reactions in this study. CONCLUSIONS: Compared with neostigmine/glycopyrrolate, incidence of TE sinus bradycardia was significantly lower with sugammadex 2 mg/kg and incidence of TE sinus tachycardia was significantly lower with sugammadex 2 mg/kg and 4 mg/kg. These results support the safety of sugammadex for reversing rocuronium- or vecuronium-induced moderate and deep neuromuscular block in ASA Class 3 or 4 participants. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03346057 .

Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality.

STUDY OBJECTIVE: Physician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DESIGN: Time Series of prospectively recorded and historical data. SETTING: Academic tertiary care medical center and health system. PATIENTS: 449 patients undergoing elective primary hip surgery. INTERVENTIONS: For the intervention group we redesigned care with a comprehensive 14-16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MEASUREMENTS: The intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. MAIN RESULTS: Compared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). CONCLUSIONS: A perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.

Learning Curves of Emergency Tourniquet Use Exploring for Utility in Training.

BACKGROUND: Emergency tourniquet use to control hemorrhage from limb wounds is associated with improved survival and control of shock. In 2013, we introduced a way to measure learning curves of tourniquet users. With a dataset from an unrelated study, we had an opportunity to explore learning in detail. The study aim was to generate hypotheses about measurement methods in the learning of tourniquet users. METHODS: We gathered data from a previous experiment that yielded a convenient sample of repeated tourniquet applications used as a marker of learning. Data on consecutive applications on a manikin were used in the current report and were associated with two users, three models of tourniquet, and six metrics (i.e., effectiveness, pulse cessation, blood loss, time to effectiveness, windlass turn number, and pressure applied). There were 840 tests (140 tests per user, two users, three models). RESULTS: Unique characteristics of learning were associated with each user. Hypotheses generated included the following: trainee learning curves can vary in shape (e.g., flat, curved) by which metric of learning is chosen; some metrics may show much learning, whereas others show almost none; use of more than one metric may assess more comprehensively than using only one metric but may require more assessment time; number of uses required can vary by instructional goal (e.g., expertise, competence); awareness of the utility of specific metrics may vary by instructor; and some, but not all, increases in experience are associated with improved performance. CONCLUSIONS: This first-aid study generated hypotheses about caregiver learning for further study of tourniquet education and standards.

Genetic variation in male sexual behaviour in a population of white-footed mice in relation to photoperiod.

In natural populations, genetic variation in seasonal male sexual behaviour could affect behavioural ecology and evolution. In a wild-source population of white-footed mice, Peromyscus leucopus, from Virginia, U.S.A., males experiencing short photoperiod show high levels of genetic variation in reproductive organ mass and neuroendocrine traits related to fertility. We tested whether males from two divergent selection lines, one that strongly suppresses fertility under short photoperiod (responder) and one that weakly suppresses fertility under short photoperiod (nonresponder), also differ in photoperiod-dependent sexual behaviour and responses to female olfactory cues. Under short, but not long, photoperiod, there were significant differences between responder and nonresponder males in sexual behaviour and likelihood of inseminating a female. Males that were severely oligospermic or azoospermic under short photoperiod failed to display sexual behaviour in response to an ovariectomized and hormonally primed receptive female. However, on the day following testing, females were positive for spermatozoa only when paired with a male having a sperm count in the normal range for males under long photoperiod. Males from the nonresponder line showed accelerated reproductive development under short photoperiod in response to urine-soiled bedding from females, but males from the responder line did not. The results indicate genetic variation in sexual behaviour that is expressed under short, but not long, photoperiod, and indicate a potential link between heritable neuroendocrine variation and male sexual behaviour. In winter in a natural population, this heritable behavioural variation could affect fitness, seasonal life history trade-offs and population growth.

Does anesthesiology residency training result in decreasing intraoperative drug cost from a resident's first to second month's experience in adult cardiac anesthesiology?

BACKGROUND: All physicians bear the responsibility of minimizing cost while providing care that meets or exceeds national quality benchmarks. Intraoperative anesthetic drug costs constitute a small but significant fraction of the total cost in the perioperative period. Previous studies have revealed that anesthesiologists are generally unaware of drug costs. In order to determine if experience and education improve anesthetic drug cost containment, we compared the total anesthetic drug cost per case as residents progressed through their rotations in cardiac anesthesia. METHODS: We considered the total anesthetic drug cost for 202 adult cardiac cases, including coronary artery bypass grafting, mitral valve repair/replacement, and aortic valve repair/replacement. 77 of the cases analyzed were done by residents in their first month of cardiac anesthesia, and 125 were done by residents in their second month of cardiac anesthesia. In the interval between these rotations, residents participate in didactics and other educational activities including a practice management rotation in the CA-3 year where they are exposed to financial topics in healthcare. RESULTS: The average total drug cost per case for residents in their first month was $193.50; SD= $82.00. The average total cost per case for residents in their second month was $223.30; SD=$96.10. With multivariate analysis considering case type, length of procedure and patient age, the resident training level did not impact the cost in a significant way (p=0.062). CONCLUSIONS: In the multivariate analysis considering case type, length of procedure and patient age, more experienced residents did not have a significantly different total drug cost per case. This finding suggests that didactic educational efforts and implicit modeling over time did not reduce drug costs in the operating room during adult cardiac surgery.

Endotracheal tube size does not affect time to extubation in adult cardiac surgery.

Managed care over the last 20 years has brought considerable attention to the impact of clinical variables on time to extubation in adult cardiac surgery. One variable that has not yet been analyzed is the endotracheal tube (ETT) size. Our retrospective electronic database review was performed on adult subjects that had a primary, non-emergent cardiac surgery in the last four years. The records of 936 patients were analyzed to find 193 patients meeting inclusion criteria. Due to the low number of 7.0 ETTs used in the study, this group was eliminated from analysis. The means for times to extubation for the two remaining groups were 7:45 standard deviation (SD) 4:27 (hrs:min) and 7:30 SD 4:48 (hrs:min) for patients managed with 8.0 and 9.0 ETTs respectively, with no statistically significant differences between the tube sizes p=0.2389. Analysis of variance did not demonstrate a statistically significant impact with age (p=0.3199), gender (p=0.5394), body mass index (BMI) (p=0.4060), nor intravenous (IV) anesthetic adjuvants midazolam (p= 0.4815) or opiates (p=0.3617) used in the operating room (OR), but length of time on cardiopulmonary bypass did play a role (p=0.0274). These data suggest that the size of the ETT utilized during cardiovascular surgery in adult patients does not play a role in the length of time of postoperative ventilation.

Anesthesia preparation time is not affected by the experience level of the resident involved during his/her first month of adult cardiac surgery.

OBJECTIVE: This study was designed to answer the question of whether the experience level of the resident on his/her first month of adult cardiothoracic anesthesiology has an impact on operating room efficiency in a large academic medical center. Traditionally, the resident's 1st month of cardiac anesthesia had been reserved for the clinical anesthesia (CA)-2 year of training. This study analyzed the impact on operating room efficiency of moving the 1st month of cardiac anesthesia into the CA-1 year. The authors hypothesized that there would be no difference in anesthesia preparation times (defined as the interval between "in-room" and "anesthesia-ready" times) between CA-1 and CA-2 residents on their 1st month of cardiac anesthesia. DESIGN: This study was retrospective and used an electronic anesthesia information management system database. SETTING: This study was conducted on care provided at a single 450-bed academic medical center. PARTICIPANTS: This study included 12 residents in their 1st month of cardiac anesthesia. INTERVENTIONS: The anesthesia preparation time (defined as the interval between "in-room" and "anesthesia-ready" times) was measured for cases involving residents on their first month of cardiac anesthesia. MEASUREMENTS AND MAIN RESULTS: Anesthesia preparation times for 6 CA-1 resident months and 6 CA-2 resident months (100 adult cardiac procedures in total) were analyzed (49 for the CA-1 residents and 51 for the CA-2s). There were no differences in preparation time between CA-1 and CA-2 residents as a group (p = 0.8169). The CA-1 residents had an unadjusted mean (±standard error) of 51.1 ± 3.18 minutes, whereas the CA-2 residents' unadjusted mean was 50.2 ± 2.41 minutes. Adjusting for case mix (valves v coronary artery bypass graft surgery), the CA-1 mean was 49.1 ± 5.22 minutes, whereas the CA-2 mean was 49.1 ± 4.54 minutes. CONCLUSIONS: These findings suggest that operating room efficiency as measured by the anesthesia preparation time may not be affected by the level of the resident on his/her 1st month of adult cardiac anesthesia.

John adriani banned from FDA by pharmaceutical industry: an historical vignette and cartoon.

In 1969, Food and Drug Administration Commissioner Herbert Ley offered New Orleans anesthesiologist John Adriani, MD, the role of director of the Bureau of Medicine. Dr Adriani accepted the offer, but it was quickly withdrawn, in part based on pressure from the pharmaceutical industry. It opposed Dr Adriani's appointment because of his work promoting generic drugs. This episode was the subject of a 1969 cartoon in the Hartford Times by Pulitzer Prize-winning cartoonist Ed Valtman.

Anesthesia for left ventricular assist device insertion: a case series and review.

From October 2008 to June 2010, a total of 42 patients had the HeartMate II left ventricular assist device inserted surgically at Ochsner Medical Center in New Orleans, LA. A retrospective electronic record review was conducted on this series of patients to analyze elements of perioperative anesthetic care, including general anesthetic care, echocardiographic considerations, and blood product usage. Etomidate was used to induce anesthesia for 34 of 42 patients (81%) in this series, with an average dose of 16.5 mg (±6 mg). The average intraoperative fentanyl dose was 1,318 µg (±631 µg). On average, patients were extubated 91 hours (±72 hours) after arrival to the intensive care unit and left on day 9 (±5 days). The average left ventricular ejection fraction of the patients in this series was 13% (±5%). Sixteen patients were evaluated as having severe right-heart dysfunction preoperatively. Two of 42 patients required surgical closure of echocardiographically identified patent foramen ovale. Twelve of 42 patients underwent surgical correction of tricuspid regurgitation. On average, 3 units (±2.6 units) of fresh frozen plasma were transfused intraoperatively and 10 units postoperatively. Intraoperative red blood cell usage averaged 1.1 units (maximum, 7 units), with an average 9.3 units administered in the first 48 hours postoperatively.

The influence of Dr. John Adriani on the American Board of Anesthesiology Oral Examination.

Though Dr. John Adriani was respected worldwide for his contributions in the clinical arena, he has received little acknowledgement for his influence on the American Board of Anesthesiology (ABA) oral exam. His essay, "The oral examination of the American Board of Anesthesiology" was the first work of its kind helping new and experienced examiners approach the examination process. An analysis of the literature investigating the reliability of the ABA oral exam from before and after the release of Dr. Adriani's document reveals that Dr. Adriani's suggestions likely helped improve the examination process.

Intraoperative oxygen administration does not reduce the incidence or severity of nausea or vomiting associated with neuraxial anesthesia for cesarean delivery.

BACKGROUND: Supplemental oxygen may reduce postoperative nausea and vomiting after general anesthesia. We designed this study to evaluate the efficacy of supplemental oxygen administration for reducing nausea and vomiting in women having neuraxial anesthesia for cesarean delivery. METHODS: We conducted a prospective, randomized, double-blind study of women having standardized neuraxial anesthesia and postoperative analgesia for cesarean delivery. After umbilical cord clamp, women were randomized to receive either 70% or 21% oxygen for surgery. Nausea and vomiting were recorded at three time intervals: induction until delivery, delivery until the end of surgery, and at 24 postoperative hours. chi2 and Student's t-tests were used to determine significant differences. RESULTS: The study groups were similar with respect to demographic and procedural variables. There was no significant difference between groups in the overall incidences of nausea and vomiting. The incidence of severe nausea (rated by mothers) in the oxygen group predelivery, postdelivery, and postoperatively was 3%, 7%, and 9%, respectively, and in the medical air group was 3%, 9%, and 7%, respectively. Severe vomiting (>2 episodes) in both the oxygen and medical air groups were 0%, 2%, and 4% at the corresponding time intervals. These differences were not statistically significant. CONCLUSION: Administration of supplemental oxygen during cesarean delivery with neuraxial anesthesia does not decrease the incidence or severity of intraoperative or postoperative nausea or vomiting.

Number of immunoreactive GnRH-containing neurons is heritable in a wild-derived population of white-footed mice (Peromyscus leucopus).

The evolution of mammalian brain function depends in part on levels of natural, heritable variation in numbers, location, and function of neurons. However, the nature and amount of natural genetic variation in neural traits and their physiological link to variation in function or evolutionary change are unknown. We estimated the level of within-population heritable variation in the number of gonadotropin-releasing hormone (GnRH) neurons, which play a major role in reproductive regulation, in an unselected outbred population recently derived (<10 generations) from a single natural population of white-footed mice (Peromyscus leucopus, Rafinesque). Young adult male mice exhibited an approximately threefold variation in the number of neurons immunoreactive for GnRH in the brain areas surveyed, as detected using SMI-41 antibody with a single-label avidin-biotin complex method. Consistent with earlier findings of selectable variation in GnRH neurons in this population, the level of genetic variation in this neuronal trait within this single population was high, with broadsense heritability using full-sib analysis estimated at 0.72 (P<0.05). Either weak selection on this trait or environmental variation that results in inconsistent selection on this trait might allow a high level of variation in this population.

Ochsner Health System Department of Anesthesiology: the first thirty years.

The Department of Anesthesiology at Ochsner Clinic Foundation was founded in 1947 at the original Ochsner Hospital at Camp Plauche in New Orleans. An anesthesiology residency training program was accredited in 1953, making Ochsner one of the early and leading producers of anesthesiologists for the Gulf South region. Staff members over the years have held prominent national leadership positions, including two American Society of Anesthesiology presidents, the founder of the Society of Cardiovascular Anesthesiology, and the president of the Society for Obstetric Anesthesiology and Perinatology.

Developmental changes in respiratory mechanics in the neonatal rat.

The rat lung undergoes rapid changes during the first several weeks of life. Respiratory function on neonatal rats was performed to determine if physiologic alterations coincides with classically described lung growth, and morphologic and morphometric changes. The authors examined respiratory mechanics during normal postnatal lung development in the rat utilizing both a forced oscillation technique, which partitions the mechanical properties of the lung tissue from the airways, as well as pressure-volume (PV) curves to assess lung elasticity. Respiratory function testing was performed on each postnatal days of life 10 to 20. The PV curves were characterized by a leftward shift over days 10 to 16, followed by a shift back to the right over days 17 to 20. Both tissue damping (G) and elastance (H) decreased from days of life 10 to 15, and then equilibrated from days 15 to 21. Hysteresivity (=G/H) at positive end-expiratory pressure (PEEP) = 1 and 3 cm H2O declined significantly with age. The effect of PEEP was significantly greater in the younger animals than in the older animals. The respiratory function assessments coincide well with the classically described periods of lung growth. These studies provide a normal baseline for correlating changes in structural with respiratory function.