Hispanic/Latino Ethnicity and Loss of Post-Surgery Independent Living: A Retrospective Cohort Study from a Bronx Hospital Network.

BACKGROUND: Black race is associated with postoperative adverse discharge to a nursing facility, but the effects of Hispanic/Latino ethnicity are unclear. We explored the Hispanic paradox, described as improved health outcomes among Hispanic/Latino patients on postoperative adverse discharge to nursing facility. METHODS: A total of 93,356 adults who underwent surgery and were admitted from home to Montefiore Medical Center in the Bronx, New York, between January 2016 and June 2021 were included. The association between self-identified Hispanic/Latino ethnicity and the primary outcome, postoperative adverse discharge to a nursing home or skilled nursing facility, was investigated. Interaction analysis was used to examine the impact of socioeconomic status, determined by estimated median household income and insurance status, on the primary association. Mixed-effects models were used to evaluate the proportion of variance attributed to the patient's residential area defined by zip code and self-identified ethnicity. RESULTS: Approximately 45.9% (42,832) of patients identified as Hispanic/Latino ethnicity and 9.7% (9074) patients experienced postoperative adverse discharge. Hispanic/Latino ethnicity was associated with lower risk of adverse discharge (relative risk [RRadj] 0.88; 95% confidence interval [CI], 00.82-0.94; P < .001), indicating a Hispanic Paradox. This effect was modified by the patient's socioeconomic status (P-for-interaction <.001). Among patients with a high socioeconomic status, the Hispanic paradox was abolished (RRadj 1.10; 95% CI, 11.00-1.20; P = .035). Furthermore, within patients of low socioeconomic status, Hispanic/Latino ethnicity was associated with a higher likelihood of postoperative discharge home with health services compared to non-Hispanic/Latino patients (RRadj 1.06; 95% CI, 11.01-1.12; P = .017). CONCLUSIONS: Hispanic/Latino ethnicity is a protective factor for postoperative adverse discharge, but this association is modified by socioeconomic status. Future studies should focus on postoperative discharge disposition and socioeconomic barriers in patients with Hispanic/Latino ethnicity.

Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home.

OBJECTIVE: To evaluate whether patients of Black race are at higher risk of adverse postoperative discharge to a nursing home, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing. BACKGROUND: It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing. METHODS: A total of 368,360 adults undergoing surgery between 2007 and 2020 across 2 academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association. RESULTS: In all, 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients were discharged to a nursing home. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference: 1.9%; 95% confidence interval: 1.6%-2.2%; P <0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association ( P -for-interaction <0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission. CONCLUSIONS: Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes mellitus and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities.

Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Difficult Airway Management in Adult Coronavirus Disease 2019 Patients: Statement by the Society of Airway Management.

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

Patient Safety in Anesthesia.

Anesthesiologists and otolaryngologists share the airway in an elegant ballet that requires communication, collaboration, and mutual respect. This article addresses principles to prevent or manage challenging conditions such as airway fires, anatomically difficult airways, and post-tonsillectomy hemorrhage. Discussion includes rationales for the use of simulation and resilience engineering principles to achieve the safest patient care.

Anesthesia Residency Training in Airway Management: A Competency-Based Model Curriculum.

The Accreditation Council for Graduate Medical Education (ACGME) is moving toward competency-based medical education. This educational framework requires the description of educational outcomes based on the knowledge, skills, and behaviors expected of competent trainees. An assessment program is essential to provide formative feedback to trainees as they progress to competency in each outcome. This article describes the development of 2 model curricula for airway management training (basic and advanced) using a competency-based framework.

Hepatotoxicity due to red bush tea consumption: a case report.

Many conventional drugs used today, including isoniazid, dapsone, and acetaminophen, are well recognized culprits of hepatotoxicity. With increasing use of complementary and alternative medical therapies, several herbal medicines, such as Ma-Huang, kava, and chaparral leaf, have been implicated as hepatotoxins. Hepatotoxicity may be the most frequent adverse reaction to these herbal remedies when taken in excessive quantities. A myriad of liver dysfunctions may occur including transient liver enzyme abnormalities due to acute and chronic hepatitis. These herbal products are often overlooked as the causal etiologic agent during the evaluation of a patient with elevated liver function tests. We describe a case of hepatotoxicity due to ingestion of red bush tea diagnosed during preoperative assessment of a patient scheduled for laparoscopic appendectomy. Elevated liver enzymes and thrombocytopenia detected in the patient's laboratory work up confounded the initial diagnosis of acute appendicitis and additional investigations were required to rule out cholecystitis and other causes of hepatitis. Open appendectomy was done uneventfully under spinal anesthesia without any further deterioration of hepatic function.

Anesthetic Management in a Gravida with Type IV Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is an inherited disorder of the connective tissues caused by abnormalities in collagen formation. OI may present many challenges to the anesthesiologist. A literature review reveals a wide range of implications, from basic positioning to management of the difficult airway. We present the anesthetic management of a 25-year-old gravid woman with OI, fetal demise, and possible uterine rupture, admitted for an exploratory laparotomy.

Laparoscopic Sleeve Gastrectomy in a Morbidly Obese Patient with Myasthenia Gravis: A Review of the Management.

Myasthenia gravis, a disorder of neuromuscular transmission, presents a unique challenge to the perioperative anesthetic management of morbidly obese patients. This report describes the case of a 27-year-old morbidly obese woman with a past medical history significant for myasthenia gravis and fatty liver disease undergoing bariatric surgery. Anesthesia was induced with intravenous agents and maintained with an inhalational and balanced intravenous technique. The nondepolarizing neuromuscular blocker Cisatracurium was chosen so that no reversal agents were given. Neostigmine was not used to antagonize the effects of Cisatracurium. The goal of this approach was to reduce the risk of complications such as postoperative mechanical ventilation. The anesthetic and surgical techniques used resulted in an uneventful hospital course. Therefore, we can minimize perioperative risks and complications by adjusting the anesthetic plan based on the patient's physiology and comorbidities as well as the pharmacology of the drugs.

An Innovative Use of an Online Procedure Logbook to Improve Airway Training among Anesthesiology Residents.

INTRODUCTION: We performed a single-institution pilot study to determine the potential value of an electronic logbook of airway procedures performed during a one month airway rotation for anesthesiology residents. For two years, CA-3 residents taking an advanced airway management rotation entered all airway procedures in this electronic logbook. We expected this logbook to produce results of potential use to program directors by determining the numbers of specific procedures performed by each resident. METHODS: All residents taking this rotation were required to enter specific data from each airway procedure into our on-line electronic logbook. Entered information was available in tabular form to the program director and each resident. Numbers of procedures with each technique were compared among residents and to a previously determined target number of procedures for several techniques. RESULTS: Sixty seven residents entered data for nine specific airway procedures over a 24 month pilot study duration. When compared to target numbers of procedures for specific techniques, we discovered most residents performed less than 2 standard deviations from the target number with flexible fiberoptic intubation (usually exceeding the target number) but greater than 3 standard deviations with surgical and percutaneous procedures (usually falling short of the target number). Analysis also determined that resident experience exhibited considerable variability as shown by the ranges of several techniques. Though there was a wide range of numbers for most techniques, most were within two standard deviations of the mean values of the technique. CONCLUSIONS: The authors conclude that this electronic logbook was easily administered at minimal cost and administrative effort. Future studies may confirm the logbook as a feasible intervention permitting anesthesiology training programs to in crease the breadth of data related to their resident airway education.

Intraoperative inflation of laryngocele with LMA.

OBJECTIVES: Laryngoceles are pathologic air filled dilations of the laryngeal ventricle. They are most often benign and incidental findings. Resection may be necessary in the setting of infection, airway obstruction, dysphagia, and phonatory disturbances. External laryngoceles are almost universally treated with open resection via a lateral or midline cervical approach. Care must be taken to resect the laryngocele in its entirety to avoid recurrence. In cases of recurrent infection, normal surgical planes are often fibrosed and obscured increasing the risk of neurovascular sacrifice and functional losses. METHODS: We are reporting a case of recurrent infections in a large, palpable external laryngocele. During resection the patient was ventilated using an endotracheal tube (ETT). Additionally, a laryngeal mask airway (LMA) was inserted posterior to the ETT, resting in the hypopharynx and attached to a Jackson Rees circuit. Air was passed through the LMA to inflate the laryngocele and better define its borders. The LMA was also used to identify the root of the laryngocele in the paraglottic space and ensure its airtight closure. RESULTS: The LMA assisted our dissection and helped progress the surgery safely in a fibrosed surgical field. We have not seen this method described previously. The patient continues to be free of recurrence 2 years after surgery. CONCLUSION: While in most cases, with careful surgical technique, even a fibrotic and scarred laryngocele can be excised in its entirety without neurovascular sacrifice. In some cases where this may be difficult with a traditional approach, we offer the intra-operative trumpet maneuver as a viable method of better delineating the borders of a laryngocele.

Impossible airway requiring venovenous bypass for tracheostomy.

The elective surgical airway is the definitive management for a tracheal stenotic lesion that is not a candidate for tracheal resection, or who has failed multiple-tracheal dilations. This case report details the management of a patient who has failed an elective awake tracheostomy secondary to the inability to be intubated as well as severe scar tissue at the surgical site. A combination of regional anesthesia and venovenous bypass is used to facilitate the surgical airway management of this patient. Cerebral oximetry and a multidisciplinary team approach aid in early detection of an oxygenation issue, as well as the emergent intervention that preserved this patient's life.

Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals.

STUDY OBJECTIVE: To determine whether shoulder and head elevation, such that the patient's ear lies at or higher than the sternum ("ramp"), improves laryngoscopic grade in adult patients of various body mass index (BMI) values. DESIGN: Prospective, unblinded study, with patients and laryngoscopists acting as their own controls. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 189 adult ASA physical status 1, 2, and 3 patients. INTERVENTIONS: After performing a standard preoperative airway evaluation and inducing general anesthesia, the anesthetist performed and graded two laryngoscopies: one in the "ramp" position and one in the "sniff" position. MEASUREMENTS: Patient BMI, Mallampati airway class, thyromental distance, neck circumference, cervical extension ability, Cormack and Lehane laryngoscopic grade for each laryngoscopy, subjective lifting force required, and need for external laryngeal pressure were recorded. MAIN RESULTS: Use of the "ramp" provided significantly better or equal laryngoscopic views, relative to those with the "sniff" position, in the entire study population. CONCLUSIONS: Shoulder and head elevation by any means that brings the patient's sternum onto the horizontal plane of the external auditory meatus maintains or improves laryngoscopic view significantly.