Incidence and predictors of hypophosphataemia after ferric carboxymaltose use-A 3-year experience from a single institution in Singapore.

Ferric carboxymaltose (FCM) administration helps reduce transfusion requirements in the perioperative situation, which improves patient outcomes and reduces healthcare costs. However, there is increasing evidence of hypophosphataemia after FCM use. We aim to determine the incidence of hypophosphataemia after FCM administration and elucidate potential biochemical factors associated with the development of subsequent hypophosphataemia. A retrospective review of anonymised data of all FCM administrations in a single institution was conducted from August 2018 to August 2021. Each unique FCM dose administered was examined to assess its effect on Hb and serum phosphate levels within the subsequent 28 days from each FCM administration. Phosphate levels were repeatedly measured within the 28-day interval and the lowest phosphate level within that period was determined. Patients' serum phosphate levels within 28 days of FCM administration were compared against normal serum phosphate levels within 2 weeks before FCM administration. The odds ratios of various pre-FCM serum markers were calculated to elucidate potential biochemical predictors of post-FCM hypophosphataemia. In 3 years, a total of 1296 doses of FCM were administered to 1069 patients. The mean improvement in Hb was 2.45 g/dL (SD = 1.94) within 28 days of FCM administration, with the mean time taken to peak Hb levels being 6.3 days (SD = 8.63), which is earlier than expected, but was observed in this study and hence reported. The incidence of hypophosphataemia <0.8 mmol/L was 22.7% (n = 186), and <0.4 mmol/L was 1.6% (n = 9). This figure is lower than the numbers reported in previously published meta-analyses given that routine checks of serum phosphate levels were not conducted initially and hence could possibly be higher. The odds of developing hypophosphataemia (<0.8 mmol/L) were 27.7 (CI: 17.3-44.2, p < 0.0001) if baseline serum phosphate was less than 1 mmol/L. The odds of developing hypophosphataemia (<0.8 mmol/L) were 1.3 (CI: 1.08-1.59, p < 0.01) if the change in Hb levels observed after FCM administration were more than 4 g/dL. Hypophosphataemia after FCM administration is significant and FCM should be used by clinicians with caution.

A Feasibility Study on a Telemedicine Hybrid Protocol for Preoperative Anesthetic Assessment.

Background Over the past decade, telemedicine has experienced significant growth due to technological advancement, and the coronavirus disease 2019 (COVID-19) pandemic further accelerated its adoption. However, the field of anesthesiology has been slow in integrating and embracing telemedicine compared to other medical specialties. Methods We conducted an observational pilot feasibility study at a tertiary hospital in Singapore to assess the viability of a telemedicine hybrid protocol for preoperative anesthetic assessment. The study included patients aged 21 to 65 years, classified as American Society of Anesthesiology (ASA) physical status class 1 or 2, with a body mass index (BMI) below 35 kg/m2, who were capable of managing video conferencing. The patients selected were scheduled for low-risk surgeries. The primary objective was to evaluate the medical and technical feasibility of our telemedicine hybrid protocol, while the secondary objectives included assessing patient satisfaction and obtaining feedback from relevant stakeholders. Results From November 2021 to April 2022, a total of 116 patients were recruited, with 96 patients completing the study. No technical difficulties, surgical case cancellations, or incidents of unanticipated difficult airways were reported. The majority of survey respondents (88%) expressed satisfaction with the video consultation and indicated a preference for it over physical consultations for future preoperative anesthesia evaluations. Conclusion Based on our findings, a telemedicine hybrid protocol for preoperative anesthetic assessment demonstrated both technical and medical feasibility while yielding high patient satisfaction. Future research could focus on expanding the protocol to encompass more complex surgeries and include patients with higher ASA status.

Burnout in anaesthesiology residents: A systematic review of its prevalence and stressors.

BACKGROUND: Burnout is an occupational hazard precipitated by chronic exposure to excessive work-related stress. It can have negative impacts on the health and safety of patients and clinicians. Anaesthesiologists are at a high risk of burnout; anaesthetic residents especially may experience higher levels of stress as a result of training requirements and postgraduate examinations. However, the scale of burnout among anaesthesiology residents is not well evaluated. OBJECTIVES: To determine the prevalence of burnout and identify risk factors contributing to it among anaesthesiology residents worldwide and evaluate preventive strategies at institutional and departmental levels. DESIGN: A systematic review without meta-analysis. DATA SOURCES: We searched PubMed, Embase, Scopus and PsycInfo for English language articles published up to 24 May 2021. ELIGIBILITY CRITERIA: The inclusion criteria for qualitative analysis were a reported burnout prevalence in anaesthesiology residents and the use of an assessment tool. Exclusion criteria were reviews/meta-analyses/correspondence, non-English articles, articles without anaesthesiology residents and lacking information on burnout prevalence and metrics for assessment. RESULTS: Twelve studies met the inclusion criteria; seven studies utilised the 22-item Maslach Burnout Inventory Human Services Survey (MBI-HSS) and five utilised the abbreviated Maslach Burnout Inventory (aMBI). The reported burnout prevalence among anaesthesiology residents varied between 2.7 and 67.0% (median = 24.7%). Differences in burnout criteria contributed significantly to methodological heterogeneity. Factors predisposing to burnout included long working hours, poor workplace relationships, professional examinations and adverse clinical events. Protected rest time and restricted work hours were identified as effective strategies to prevent burnout. Other preventive strategies include mindfulness and resilience courses, as well as departmental initiatives such as exercise. CONCLUSION: Burnout is common amongst anaesthesiology residents. Standardised tools and diagnostic criteria are needed to distinguish methodological heterogeneity from true heterogeneity in study populations. Interventions have been proposed to improve management strategies to minimise burnout anaesthesiology residents. PROSPERO REFERENCE: CRD42019140472.

An Evaluation of the Performance of Five Burnout Screening Tools: A Multicentre Study in Anaesthesiology, Intensive Care, and Ancillary Staff.

Burnout is an important occupational hazard and early detection is paramount in preventing negative sequelae in physicians, patients, and healthcare systems. Several screening tools have been developed to replace lengthy diagnostic tools for large-scale screening, however, comprehensive head-to-head evaluation for performance and accuracy are lacking. The primary objective of this study was to compare the diagnostic performance of five burnout screening tools, including a novel rapid burnout screening tool (RBST). This was a cross-sectional study involving 493 hospital staff (anaesthesiology and intensive care doctors, nurses, and ancillary staff) at the COVID-19 frontline across four hospitals in Singapore between December 2020 and April 2021. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used as the reference standard. Five burnout screening tools, the single-item MBI measure of burnout (SI-MBI), dual-item MBI (DI-MBI), abbreviated MBI (aMBI), Single Item Burnout Question (SIBOQ), and the RBST, were administered via a 36-item online survey. Tools were administered simultaneously and responses were anonymised. Burnout prevalence was 19.9%. The RBST and the SI-MBI had the two highest accuracies (87.8% and 81.9% respectively) and AUROC scores (0.86, 95% CI: 0.83-0.89 and 0.86, 95% CI: 0.82-0.89 respectively). However, the accuracy of the RBST was significantly higher than the SI-MBI (p < 0.0001), and it had the highest positive likelihood ratio (+LR = 7.59, 95% CI 5.65-10.21). Brief screening tools detect burnout albeit with a wide range of accuracy. This can strain support services and resources. The RBST is a free screening tool that can detect burnout with a high degree of accuracy.

Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study.

BACKGROUND: Preoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron. METHODS: Retrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis. RESULTS: After PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1-15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days. CONCLUSIONS: Preoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.

Burnout and work-related stressors in gastroenterology: a protocol for a multinational observational study in the ASEAN region.

BACKGROUND: Clinician burnout is an important occupational hazard that may be exacerbated by the novel COVID-19 pandemic. Within Southeast Asia, burnout in gastroenterology is understudied. The primary objective of this study is to estimate the prevalence of burnout symptoms within gastroenterology, in member states of the Associations of Southeast Asian Nations (ASEAN), during and after the COVID-19 pandemic. The secondary objective is to identify work-related stressors that contribute to burnout in ASEAN gastroenterologists. METHODS AND ANALYSIS: This is an observational study that will use anonymised online surveys to estimate the prevalence of burnout symptoms at two time points: during the COVID-19 pandemic in 2020 and in 2022 (assumed to be after the pandemic). Gastroenterologists from Singapore, Malaysia, Thailand, Indonesia, Philippines and Brunei will be invited to participate in the online survey through their national gastroenterology and endoscopy societies. Burnout will be assessed using the Maslach Burnout Inventory-Human Services Survey tool. Supplementary questions will collect demographic and qualitative data. Associations between demographic characteristics and burnout will be tested by multiple regression. RESULTS: The prevalence of burnout symptoms in gastroenterology during the COVID-19 pandemic, and the baseline prevalence after COVID-19, will be established in the above-mentioned countries. Work-related stressors commonly associated with burnout will be identified, allowing the introduction of preventative measures to reduce burnout in the future. ETHICS AND DISSEMINATION: Ethical approval was granted by the Singhealth Centralised Institutional Review Board (2020/2709). Results will be submitted for publication.

Comparison of glottic visualisation through supraglottic airway device (SAD) using bronchoscope in the ramped versus supine 'sniffing air' position: A pilot feasibility study.

BACKGROUND AND AIMS: Airway management in obese patients is associated with increased risk of difficult airway and intubation. After failed intubation, supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI) may be required. It is uncertain whether SAGFBI is best performed in the ramped versus conventional supine "sniffing air" position. We conducted a feasibility study to evaluate the logistics of positioning, compared glottic views, and evaluated SAGFBI success rates. METHODS: We conducted a prospective, pilot study in patients with a body mass index (BMI) 30-40 kg/m2 undergoing elective operations requiring tracheal intubation. All patients were placed in a ramped position. After induction, a supraglottic airway device (SAD) was inserted. A flexible bronchoscope was inserted into the SAD and a photograph of the glottic view taken. The patient was repositioned to the supine position. A second photograph was taken. SAGFBI was performed. Images were randomised and assessed by two independent anesthetists. RESULTS: Of 17 patients recruited, 15 patients were repositioned successfully. There were no differences in glottic views observed in the two positions. SAGFBI was successful in 92.9% of patients (median time 91.5 s). Haemodynamic changes were noted in 42.7% of patients which resolved spontaneously. CONCLUSION: Our pilot study was completed within 5 months, achieved low dropout rate and protocol feasibility was established. SAGFBI was successfully and safely performed in obese patients, with a median time of 91.5 s. The time taken for SAGFBI was similar to awake intubation using FBI and videolaryngoscopy. Our study provided preliminary data supporting future, larger-scale studies to evaluate glottic views in the ramped versus supine positions.

Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review.

The coronavirus disease 2019 (COVID-19) pandemic is caused by a coronavirus that is transmitted primarily via aerosol, droplets or direct contact. This may place anesthetists at higher risk of infection due to their frequent involvement in aerosol-generating airway interventions. Many anesthethetic COVID-19 guidelines have emerged, whose underlying management principles include minimizing aerosol contamination and protecting healthcare workers. These guidelines originate from Australia and New Zealand, Canada, China, India, Italy, Korea, Singapore, the United States and the United Kingdom. Hospitalized COVID-19 patients may require airway interventions, and difficult tracheal intubation secondary to laryngeal edema has been reported. Pre-pandemic difficult airway guidelines include those from Canada, France, Germany, India, Japan, Scandinavia, the United States and the United Kingdom. These difficult airway guidelines require modifications in order to align with the principles of the anesthetic COVID-19 guidelines. In turn, most of the anesthetic COVID-19 guidelines do not, or only briefly, discuss an airway strategy after failed tracheal intubation. Our article identifies and compares pre-pandemic difficult airway guidelines with the recent anesthetic COVID-19 guidelines. We combine the principles from both sets of guidelines and explain the necessary modifications to the airway guidelines, to form a failed tracheal intubation airway strategy in the COVID-19 patient. Valuing, and a greater understanding of, these differences and modifications may lead to greater adherence to the new COVID-19 guidelines.

Burnout in gastroenterology registrars: a feasibility study conducted in the East of England using a 31-item questionnaire.

OBJECTIVE: The scale of burnout in UK gastroenterology trainees and the feasibility to determine its prevalence using the validated Maslach Burnout Inventory-Human Services Survey (MBI-HSS) tool are unknown. The primary objective of this region-wide pilot study was to evaluate the response rate to a 31-item questionnaire. The secondary objectives were to estimate the prevalence of burnout in gastroenterology trainees within the East of England deanery (EoE) and identify common stressors that trainees experience. DESIGN: This was a cross-sectional study involving gastroenterology trainees from 16 hospitals across the EoE using a 31-item questionnaire. The questionnaire consisted of the 22-item MBI-HSS and nine additional free-text questions. All gastroenterology trainees in the EoE were invited to complete the anonymised survey online. Data were analysed quantitatively and qualitatively. RESULTS: The response rate for the survey was acceptable: 44.0% (40/91). 57.5% (23/40) of gastroenterology trainees reported emotional exhaustion. 23.5% (8/34) had depersonalisation and 63.9% (23/36) experienced low professional accomplishment. Burnout prevalence was 35.3% (12/34). 48.4% (15/31) of gastroenterology trainees were aware of professional support services within EoE. Stressors related to service requirements (eg, workload, staffing levels) and professional relationships with colleagues and patients were commonly reported: 65.6% and 25.0%, respectively. CONCLUSIONS: It is feasible to use a 31-item questionnaire in a national cohort of UK gastroenterology trainees for future burnout studies. Burnout in EoE gastroenterology trainees was high and this may reflect a national prevalence within the specialty. More extensive studies, greater awareness of burnout and improved access to professional support services are required.

Anesthesia guidelines for COVID-19 patients: a narrative review and appraisal.

The coronavirus disease 2019 (COVID-19) pandemic has challenged health systems globally and prompted the publication of several guidelines. The experiences of our international colleagues should be utilized to protect patients and healthcare workers. The primary aim of this article is to appraise national guidelines for the perioperative anesthetic management of patients with COVID-19 so that they can be enhanced for the management of any resurgence of the epidemic. PubMed and EMBASE databases were systematically searched for guidelines related to SARS-CoV and SARS-CoV-2. Additionally, the World Federation Society of Anesthesiologists COVID-19 resource webpage was searched for national guidelines; the search was expanded to include countries with a high incidence of SARS-CoV. The guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Guidelines from Australia, Canada, China, India, Italy, South Africa, South Korea, Taiwan, the United Kingdom, and the United States of America were evaluated. All the guidelines focused predominantly on intubation and infection control. The scope and purpose of guidelines from China were the most comprehensive. The UK and South Africa provided the best clarity. Editorial independence, the rigor of development, and applicability scored poorly. Heterogeneity and gaps pertaining to preoperative screening, anesthesia technique, subspecialty anesthesia, and the lack of auditing of guidelines were identified. Evidence supporting the recommendations was weak. Early guidelines for the anesthetic management of COVID-19 patients lacked quality and a robust reporting framework. As new evidence emerges, national guidelines should be updated to enhance rigor, clarity, and applicability.