Identification, Characterization, and Ranking of Candidate Metrics for Selection to Anesthesiology Residency: An Iterative Survey of Program Directors.

Background: The primary aim of this study was to identify and stratify candidate metrics used by anesthesiology residency program directors (PDs) to develop their residency rank lists through the National Resident Matching Program. Methods: Sixteen PDs comprised the participants, selected for diversity in geography and program size. We used a 3-round iterative survey to identify and stratify candidate metrics. In the first round, participants listed metrics they planned to use to evaluate candidates. In the second round, metrics from the first round were ranked by importance, and criteria were solicited to define an exceptional, strong, average, marginal, and uncompetitive candidate for each metric. In the third round, aggregated results were presented and participants refined their rankings. Results: Of the 16 PDs selected, 15 participated in the first and second survey rounds, and 10 in the third. Eighteen candidate metrics were indicated by 8 or more PDs for residency selection. All 10 PDs from the final round identified passing Step 1 of the United States Medical Licensing Exam (USMLE) and the absence of "red flags" like a failed rotation as key selection metrics, both averaging an importance score of 4.9 out of 5. Other metrics identified by all PDs included clerkship evaluation comments, USMLE Step 2 scores, class rank, letters of recommendation, personal statement, and program and geographical signals. Conclusions: The study reveals key metrics anesthesiology residency PDs use for candidate ranking, which may offer candidates insights into their competitiveness for anesthesiology residency.

Effect of an increased dose of intrathecal fentanyl on cesarean delivery anesthesia at a Texas level IV maternal care center.

Background: We hypothesized that increasing our intrathecal fentanyl dose for cesarean delivery from 10 µg to 15 µg would result in fewer patients receiving a rescue analgesia intervention. Methods: Patients who had a cesarean delivery from February 15, 2021 to February 14, 2023 and received a single injection spinal or combined spinal-epidural anesthetic for cesarean delivery were eligible for inclusion. We defined a rescue analgesia intervention as administration of local anesthetic through an epidural catheter, administration of systemic anesthetic adjuvant medication, or conversion to general anesthesia. Results: A total of 520 and 556 patients received 10 µg and 15 µg of intrathecal fentanyl for cesarean delivery, respectively, of which 154 (29.6%) and 122 (21.9%) patients required rescue analgesia interventions, respectively (P = 0.004). The odds ratio for receiving a rescue analgesia intervention was 0.668 (95% confidence interval 0.507 to 0.880; P = 0.004) for patients who received 15 µg of intrathecal fentanyl compared to 10 µg. Conclusion: Following implementation of an increased dose of intrathecal fentanyl, patients who received 15 µg of intrathecal fentanyl for cesarean delivery were approximately 33% less likely to require a rescue analgesia intervention during cesarean delivery compared to patients who received 10 µg.

Early versus delayed postoperative adductor canal block in total knee arthroplasty.

Background: We hypothesized that patients who received an adductor canal block (ACB) in the operating room following unilateral total knee arthroplasty would have a lower oral morphine milligram equivalent (MME) consumption during the postanesthesia care unit (PACU) phase 1 recovery period compared to patients who received an ACB in the PACU. Methods: This was a retrospective cohort study of patients who underwent robotic-assisted unilateral total knee arthroplasty under general anesthesia between March 1, 2020, and February 28, 2021, and received postoperative ACB either in the operating room or the PACU. Results: A total of 36 and 178 patients received postoperative ACB in the operating room and PACU, respectively, and had median and interquartile range MME consumption in the PACU of 22.5 (20-40) mg and 30.0 (20-40) mg (P = 0.76), respectively. Patients who had an ACB performed in the operating room and PACU had median and interquartile ranges of time spent in the PACU of 101 (75-178) minutes and 186 (125-272) minutes (P < 0.01), respectively. Conclusion: Patients who received an ACB in the operating room did not have a lower OME consumption than patients who received an ACB in the PACU but did have a shorter PACU length of stay.

Effect of programmed intermittent epidural bolus protocol on physician-administered rescue boluses of labor analgesia.

Background: Prior studies have shown that programmed intermittent epidural bolus (PIEB) techniques, with or without patient-controlled epidural analgesia (PCEA) boluses, provide better pain relief, reduced motor block, and better patient satisfaction compared to continuous epidural infusion (CEI) techniques. We hypothesized that patients who had labor epidural analgesia (LEA) maintained with PIEB and PCEA would be less likely to receive a physician-administered rescue analgesia bolus compared to patients who had CEI and PCEA. Methods: We searched our electronic medical record for patients who had CEI and PCEA from August 1, 2021 to December 31, 2021 and for patients who had PIEB and PCEA from August 2, 2022 to December 31, 2022. Results: A total of 792 and 665 patients had maintenance of LEA with CEI/PCEA and PIEB/PCEA, respectively. A multivariate logistic regression was performed and, after adjusting for variables of interest, patients who had PIEB and PCEA were less likely to receive one or more physician-administered rescue analgesia boluses (odds ratio 0.504; 95% confidence interval 0.392, 0.649; P < 0.001) compared to patients who had CEI and PCEA. Conclusion: PIEB/PCEA was associated with fewer physician-administered boluses of rescue analgesia compared to CEI/PCEA when used for LEA.

Effect of initial anesthetic technique on fetal cord blood gas pH for cesarean deliveries performed for the indication of fetal heart rate abnormalities.

Background: We hypothesized that parturients who had general anesthesia as the initial anesthetic technique for cesarean deliveries performed for fetal heart rate abnormalities would have a lower fetal cord blood gas pH compared to parturients who had regional anesthesia as the initial anesthetic technique. Methods: We searched our electronic medical record for patients who had cesarean deliveries for the indication of fetal heart rate abnormalities from July 1, 2019, to June 30, 2021, at our hospital. An obstetrics resident and a maternal fetal medicine physician determined if the fetal heart tracing was category 2 or 3. Results: A total of 130 and 29 patients with category 2 and 3 fetal heart tracing had regional and general anesthesia as the initial anesthetic technique, respectively. Fourteen and 20 patients with a category 3 fetal heart tracing had regional and general anesthesia as the initial anesthetic techniques, respectively. There were no differences in fetal cord blood gas pH between patients who had regional or general anesthesia as the first attempted anesthetic technique when patients with category 2 and 3 tracings were evaluated separately. Conclusion: The initial anesthetic technique attempted for cesarean delivery was not associated with a worse fetal cord blood gas pH.

Effect of the COVID-19 pandemic on racial disparities in postpartum visits at a Texas level IV maternal center.

Background: The primary aim of our study was to determine the attendance of postpartum visits stratified by race and if the COVID-19 pandemic affected racial disparities in postpartum visit attendance. Methods: We searched our labor and delivery records from July 1, 2019 to December 31, 2019 and from July 1, 2020 to December 31, 2020 and included patients who delivered liveborn infants. The final analysis was restricted to patients who identified as White or Caucasian only, Black or African American only, or Hispanic. We then performed joint tests on the logistic regression with an interaction term of race and year of delivery to determine the final model. Results: The odds ratio of Black or African American and Hispanic patients attending a postpartum visit was 0.589 (95% CI 0.456, 0.760; P < .001) and 0.836 (95% CI 0.676, 1.034; P = 0.099), respectively, compared to White or Caucasian patients. The interaction term of race and year of delivery was not statistically significant. Conclusion: Black or African American patients at our hospital had a clinically and statistically significant lower utilization of postpartum visits compared to White or Caucasian patients and this disparity was not exacerbated by the COVID-19 pandemic.

A comparison of anesthetic outcomes between activation and removal of epidural catheters for patients who underwent unscheduled intrapartum cesarean delivery.

Background: We hypothesized that patients who underwent unscheduled intrapartum cesarean delivery and had removal of an indwelling epidural catheter followed by an attempt of a new regional anesthetic would be more likely to have regional anesthesia without conversion to general anesthesia or administration of additional anesthetic medication compared to patients who had activation of an epidural catheter. Methods: Patients who had an unscheduled intrapartum cesarean delivery from July 1, 2019, through June 30, 2021, who had an indwelling labor epidural catheter were included. Patients were propensity matched based on obstetric indication for cesarean delivery and number of physician-administered rescue analgesia boluses administered during labor. A multivariate proportional odds regression was performed. Results: After adjusting for parity, depression, last neuraxial labor analgesic technique, physician-administered rescue analgesia boluses, and duration from neuraxial placement to entering the operating room for cesarean delivery, patients who had removal of their epidural catheters were more likely to have regional anesthesia without conversion to general anesthesia or administration of additional anesthetic medication (odds ratio 4.298; 95% confidence interval 2.448, 7.548; P < 0.01). Conclusion: Removal of epidural catheters was associated with a greater chance of avoiding conversion to general anesthesia or administration of additional anesthetic medication.

A 29-year-old woman presenting for urgent cesarean hysterectomy: a multidisciplinary care challenge.

This case describes a patient who needed an urgent cesarean hysterectomy for new-onset fetal heart rate abnormalities and preexisting placenta accreta spectrum. Rapid assembly of a multidisciplinary team consisting of obstetrics, anesthesiology, neonatology, and nursing contributed to a favorable clinical outcome.

Airway management for 362 cesarean deliveries performed with general anesthesia at a Texas level IV maternal facility.

At our hospital, direct and video laryngoscopy are used in airway management for cesarean deliveries performed with general anesthesia. We hypothesized that video laryngoscopy would have a higher success rate of endotracheal intubation on the first attempt compared to direct laryngoscopy. We used our electronic medical record system to search for patients who had cesarean deliveries with general anesthesia with endotracheal intubation performed in the operating room from July 1, 2017, through June 30, 2021. Totals of 186 and 176 patients had direct and video laryngoscopy for the first intubation attempts, respectively; 177 (95%) and 163 (93%) patients, respectively, had a successful intubation on the first attempt with each method. The odds ratio of successful intubation on the first attempt for video laryngoscopy was 0.64 (95% CI 0.27, 1.53; P = 0.31) compared to patients who had direct laryngoscopy. There was no statistically significant difference in Cormack-Lehane grade views of the glottis between direct and video laryngoscopy on the first attempt. In conclusion, there was no statistically significant improvement in the success rate of intubation on the first attempt when video laryngoscopy was used for patients undergoing general anesthesia for cesarean delivery.

Effect of the COVID-19 pandemic on racial disparities in neuraxial labor analgesia at a Texas level IV maternal care center.

We hypothesized that racial disparities in labor epidural analgesia at our hospital that existed prior to the COVID-19 pandemic would be exacerbated during the COVID-19 pandemic. We examined patients who delivered vaginally at our hospital for the last 6 months of 2019 and the last 6 months of 2020. We performed joint testing of coefficient P values, and the interaction term between race and year of delivery was not significant (0.364). A multivariate logistic regression model found that Hispanic patients (odds ratio 0.555 [0.408, 0.756], P < 0.001) and Black or African American patients (odds ratio 0.613 [0.408, 0.921], P = 0.018) were less likely to receive labor epidural analgesia compared to White or Caucasian patients. Odds ratios of receiving labor epidural analgesia were higher with increasing gestational age (1.116 [1.067, 1.168], P < 0.001) and lower with increasing parity (0.789 [0.719, 0.867], P < 0.001). The year of birth that corresponded to before or during the COVID-19 pandemic did not predict whether a patient received labor epidural analgesia (1.247 [0.941, 1.652], P = 0.124). Because the interaction between race and year of birth was not statistically significant, we conclude that the COVID-19 pandemic did not exacerbate racial disparities in labor epidural analgesia at our hospital.

Effect of a placenta accreta spectrum multidisciplinary team and checklist on maternal outcomes for planned hysterectomy at time of cesarean delivery.

Evidence suggests that multidisciplinary teams that perform cesarean hysterectomy for placenta accreta spectrum have better maternal outcomes. The aim of this study was to assess the effects of a multidisciplinary team on outcomes for patients with placenta accreta spectrum at our institution. We examined all planned cesarean hysterectomy procedures performed for placenta accreta syndrome at our hospital between July 1, 2015, and June 30, 2021. Nine and 21 subjects had planned cesarean hysterectomy before and after implementation of the new procedures, respectively. Overall, there was an increase in volume of cases and depth of placental invasion but no change in the demographic characteristics of patients. Additionally, we found decreased blood loss, decreased blood transfusions from a median of 2 units to 0 units, and decreased intensive care unit admission rates from 22.2% to 4.8%, but these results did not reach statistical significance. The main limitation of our study was our small number of subjects. Our findings suggest that multidisciplinary placenta accreta teams improve maternal outcomes for hysterectomy at the time of cesarean delivery.

Choice of anesthetic technique for dilation and curettage for indication of pregnancy loss.

We hypothesized that patients at our hospital who received general anesthesia as the initial anesthetic technique for dilation and curettage for loss of pregnancy during the first or second trimesters would have a higher estimated blood loss compared to patients who had sedation. We searched our electronic medical record system for patients who had a dilation and curettage for the indication of loss of pregnancy during the first or second trimesters from July 1, 2018, to June 30, 2021. A total of 165 (72%) and 64 (28%) patients had general anesthesia and sedation, respectively, as the initial anesthetic technique. Patients who had general anesthesia and sedation had estimated blood loss interquartile ranges of 50 to 500 mL and 30 to 100 mL, respectively (P < 0.01). A multivariate model that controlled for gestational age and location of procedure found that the odds ratio of patients receiving sedation for dilation and curettage in the labor and delivery suite was 7.24 (95% confidence interval 2.92, 17.94; P < 0.01) compared to the main operating room. Dilation and curettage that used sedation was associated with a lower estimated blood loss and was more likely to be performed in the labor and delivery suite.

Effect of encouraging a combined spinal epidural technique for cesarean delivery anesthesia.

A combined spinal epidural anesthetic technique allows an anesthesia provider to administer local anesthetic through an epidural catheter in the event of a failed spinal anesthetic. Prior to May 2019, our hospital performed single-shot spinal anesthesia exclusively for cesarean deliveries. In May 2019, anesthesia providers at our hospital were encouraged to perform combined spinal epidural anesthesia for cesarean delivery. We hypothesized that subjects who received combined spinal epidural anesthesia would have superior anesthetic outcomes compared to subjects who received single-shot spinal anesthesia. We performed a retrospective review of subjects who had cesarean deliveries at our hospital from May 15, 2019, through April 15, 2021, who received either single-shot spinal anesthesia or combined spinal epidural anesthesia. Subjects who received combined spinal epidural anesthesia were older, had a higher body mass index, had higher parity, were more likely to have had a cesarean delivery in the past, were more likely to have had the neuraxial anesthetic technique performed by a junior resident, and had a lower intrathecal dose of hyperbaric bupivacaine. Combined spinal epidural anesthesia had similar anesthetic outcomes to single-shot spinal anesthesia for cesarean delivery despite more complex subjects with less experienced operators.

Predictors of intraoperative pain during cesarean delivery under regional anesthesia.

It is unclear why some patients experience pain during cesarean delivery despite receiving appropriate regional anesthesia. Our primary aim was to determine what demographic and clinical variables predict intraoperative pain during cesarean delivery with neuraxial anesthesia. From July 2019 through March 2020, we administered a previously validated patient satisfaction survey to parturients who had a cesarean delivery under regional anesthesia for nonemergent obstetric indications. We performed a post hoc analysis restricted to subjects who had single injection spinal and combined spinal-epidural anesthesia. Parturients who did and did not report pain differed in height, intrathecal hyperbaric bupivacaine dose, and the time from incision to wound closure. We performed an ordinal logistic regression analysis on the 168 subjects with complete data using the aforementioned variables along with the time of day of cesarean delivery. Incision to wound closure time (P < 0.01) predicted intraoperative pain. The multivariate logistic regression model was statistically significant (P < 0.01) and had a receiver operator curve value of 0.74. The duration of time from incision to wound closure predicted intraoperative pain during cesarean delivery under regional anesthesia.