Factors associated with neonatal resuscitation knowledge and comfort across academic anesthesia institutions.

BACKGROUND: Neonatal resuscitation training is a requirement for all obstetric anesthesia fellows. However, while the majority of anesthesiologists who work on labor and delivery report having been involved in the resuscitation of a newborn, most do not have NRP training. OBJECTIVE: By studying a national cohort of anesthesiologists, our objective was to identify factors associated with knowledge and comfort with neonatal resuscitation and to inform decisions about neonatal resuscitation in obstetric anesthesia fellowship training. MATERIALS AND METHODS: After receiving exempt status, a survey assessing knowledge and comfort with neonatal resuscitation was sent to US academic institutions. Univariable and multiple variable regression analyses were performed to assess factors associated with knowledge and comfort. All statistical analyses were performed using R software (R version 3.4.3 [2017-11-30]; R Foundation for Statistical Computing, Vienna, Austria). RESULTS: Responses were received from 32 (84%) of 38 academic institutions that participated. A total of 245 surveys were collected from 20 December 2018 to 27 September 2019. The mean (standard deviation (SD)) percentage of correct knowledge answers in the cohort was 43.3% (22.6%). Knowledge scores were associated with obstetric anesthesia fellowship training, regularly working with infants, and current neonatal resuscitation program (NRP) training. The mean (SD) sum of comfort ratings from the individual questions was 49.9 (17.9). Comfort ratings were associated with pediatric anesthesia fellowship training, regularly working with infants, current NRP training, and having at least one year of general pediatrics residency training. CONCLUSIONS: Obstetric anesthesiologists have the knowledge but appear to lack the comfort to perform neonatal resuscitation. As obstetric anesthesiologists are sometimes involved in neonatal resuscitation, maintenance of certification is important in maintaining comfort with neonatal resuscitation if not regularly working with infants.

Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA). SUMMARY OF BACKGROUND DATA: Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication. METHODS: AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared. RESULTS: There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation. CONCLUSION: This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Minimally Invasive Scoliosis Surgery: A Novel Technique in Patients with Neuromuscular Scoliosis.

Minimally invasive surgery (MIS) has been described in the treatment of adolescent idiopathic scoliosis (AIS) and adult scoliosis. The advantages of this approach include less blood loss, shorter hospital stay, earlier mobilization, less tissue disruption, and relatively less pain. However, despite these significant benefits, MIS approach has not been reported in neuromuscular scoliosis patients. This is possibly due to concerns with longer surgery time, which is further increased due to more levels fused and instrumented, challenges of pelvic fixation, size and number of incisions, and prolonged anesthesia. We modified the MIS approach utilized in our AIS patients to be implemented in our neuromuscular patients. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, partial/complete facet resection, and all standard reduction maneuvers. Operative time needed to complete this surgery is comparable to the standard procedure and the majority of our patients have been extubated at the end of procedure, spending 1 day in the PICU and 5-6 days in the hospital. We feel that MIS is not only a feasible but also a superior option in patients with neuromuscular scoliosis. Long-term results are unavailable; however, short-term results have shown multiple benefits of this approach and fewer limitations.

Paradoxical hemodynamic collapse after subxiphoid pericardial window.

A 56-year-old man with a history of coronary artery disease, 4 months of cough and shortness of breath, a new lung mass, and increasing hypoxemia presented to the operating room emergently for a subxiphoid pericardial window for cardiac tamponade. After 1200 mL of pericardial fluid was drained, the patient immediately went into acutely decompensated right heart failure as seen on a transesophageal echocardiogram. The patient had cardiovascular collapse refractory to high-dose vasopressors, necessitating emergent venous-arterial extracorporeal membrane oxygenation for successful resuscitation.