Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned.

The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.

Anesthesiology Training in the Time of COVID-19: Problems and Solutions.

From March to June of 2020, Montefiore Medical Center faced one of the most acute surges in hospital admissions and critical illness ever experienced in the United States due to the severe acute respiratory syndrome coronavirus 2 pandemic. The pandemic had not yet spread to most of the country, and there was a relative deficit of knowledge regarding treatments, prognosis, and prevention of the virus, making this experience relatively unique and challenging. As part of a surge plan, our institution converted nonclinical spaces, such as conference rooms, to inpatient care settings and placed elective surgeries on hold to free up resources. A central deployment office suspended anesthesiology resident rotations and instead assigned them to intensive care settings based on need. For the Montefiore Medical Center Department of Anesthesiology, preserving its academic mission and commitment to Graduate Medical Education was essential. Adaptations included changing the residency rotation structure to biweekly, converting didactics online, ensuring adequate case numbers for graduating residents, actively pursuing wellness interventions, and prioritizing the safety of the residents caring for patients with coronavirus disease 2019 (COVID-19). In this brief report, the authors discuss solutions devised to maintain the quality of anesthesiology resident education and training as much as possible during the COVID-19 surge.

Opioid-free anesthesia for adenotonsillectomy in children.

INTRODUCTION: Opioids are administered during the intraoperative and postoperative periods in pediatric adenotonsillectomy and tonsillectomy. Non-opioid analgesics are often used as an analgesic during pediatric adenotonsillectomy and tonsillectomy. In this hypothesis generating study, we are evaluating safety and efficacy of stand-alone opioid analgesia for adenotonsillectomy and tonsillectomy. METHODS: This is a single-center retrospective chart review of patients ages 2 to 13 who underwent elective adenotonsillectomy and tonsillectomy. We used a convenience sampling method to select patients who received intraoperative intravenous fentanyl, acetaminophen, ibuprofen, or any combination thereof. The following outcomes were analyzed in this study: (i) the length of Post Anesthesia Care Unit stay, (ii) administration of postoperative opioids; (iii) postoperative opioid equivalents required; (iv) administration of postoperative non-opioid analgesics; and (v) inpatient admission from ED within 30 days. We used univariate analysis to compare the data points. RESULTS: We analyzed data from 323 patients who underwent adenotonsillectomy and tonsillectomy. The Post Anesthesia Care Unit length stay was similar for the intraoperative opioid-free and intraoperative opioid groups, 146.68 (±67.35) and 143.18 (±37.85) minutes, respectively (p = 0.586). Additionally, 102 patients (73.4%) in the intraoperative opioid-free group and 184 patients (83.2%) in the intraoperative opioid group did not receive any postoperative opioids (p = 0.033). The incidence of adverse events was similar between the intraoperative opioid-free and intraoperative opioid groups 3 (2.2%) and 5 (2.7%) respectively, p-value 0.749. A subgroup analysis comparing extracapsular 235 (72.8%) versus intracapsular 88 (27.2%) tonsillectomy yielded similar results. CONCLUSION: In this study, our data indicates that American Society of Anesthesiologists I- II pediatric patients undergoing adenotonsillectomy and tonsillectomy can be efficiently and safely managed with an opioid-free intraoperative and postoperative analgesic regimen. Due to the explained limitations, our study results should be interpreted cautiously.

Erroneous Activated Coagulation Time During Atrial Flutter Ablation.

When performing left-sided catheter ablation, anticoagulation is used to prevent formation of thrombi that might embolize. After heparin administration, appropriate anticoagulation is confirmed by measuring Activated Coagulation Time (ACT). We report a case during which ACT results were erroneous, and review alternatives to the ACT under such circumstances.

Titration of Bivalirudin Infusion in the Pediatric Cardiac Catheterization Laboratory: A Case Report.

Bivalirudin is a direct thrombin inhibitor that is used as a procedural anticoagulant during percutaneous coronary interventions and cardiac surgery for patients with heparin-resistant thrombosis or heparin-induced thrombocytopenia. There is a robust literature describing its safety and efficacy in adults; however, its use in the pediatric population is relatively rare, with dosing extrapolated from adult data. In this case report, we describe a 4-year-old with complex congenital heart disease and history of heparin-induced thrombocytopenia who required bivalirudin dose uptitration during cardiac catheterization.

A Program Director Survey of the Clinical Base Year in Anesthesiology Residency Programs.

BACKGROUND: To maintain compliance with the current shift towards competency-based milestone assessment in graduate medical education, residency training programs must reflect this emphasis in their curricula starting with the intern year of training.1 In working towards collaborative efforts in curricular development between Accreditation Council for Graduate Medical Education (ACGME) anesthesiology residency programs, understanding the structure and design of the clinical base year for anesthesiology residency programs nationwide will serve as a valuable initial step. METHODS: Anonymous online surveys were sent to anesthesiology residency program directors to collect data regarding their program's anesthesiology clinical base year (CBY) required, elective, and novel rotations. The survey was also designed to characterize the educational resources provided by the department, changes in the design of the clinical base year, and the feedback received from interns or other rotation department heads. RESULTS: Thirty-nine out of 130 US anesthesiology residency program directors responded (30%). The majority of respondents (87%) provide an in-house categorical intern CBY with a majority of those (94%) including a month dedicated to anesthesiology, during which some form of mentorship by anesthesiology faculty or senior house staff was provided. The majority of respondents with anesthesiology exposure stated that they provide educational resources such as textbook materials (82%) or simulation sessions (89%) to their residents. CONCLUSIONS: With the evolution of the role of the anesthesiologist, advancements in biotechnology, and newly created board examinations, it is imperative that the CBY prepares rising anesthesiology residents to meet these demands. Results from this survey study can serve as the initial step in improving the clinical base year structure for anesthesiology residents nationally. Collaborative efforts can be undertaken to better incorporate clinical competency, feedback mechanisms, and educational tools through the collection of experiential evidence of successful strategies as well as challenges faced by program directors nationwide.

Follicle-stimulating hormone accelerates mouse oocyte development in vivo.

During folliculogenesis, oocytes grow and acquire developmental competence in a mutually dependent relationship with their adjacent somatic cells. Follicle-stimulating hormone (FSH) plays an essential and well-established role in the differentiation of somatic follicular cells, but its function in the development of the oocyte has still not been elucidated. We report here that oocytes of Fshb(-/-) mice, which cannot produce FSH, grow at the same rate and reach the same size as those of wild-type mice. Consistent with this observation, the granulosa cells of Fshb(-/-) mice express the normal quantity of mRNA encoding Kit ligand, which has been implicated in oocyte growth. Oocytes of Fshb(-/-) mice also accumulate normal quantities of cyclin B1 and CDK1 proteins and mitochondrial DNA. Moreover, they acquire the ability to complete meiotic maturation in vitro and undergo transition from non-surrounded nucleolus to surrounded nucleolus. However, these events of late oocyte development are significantly delayed. Following in vitro maturation and fertilization, only a small number of embryos derived from oocytes of Fshb(-/-) mice reach the blastocyst stage. Administration of equine chorionic gonadotropin, which provides FSH activity, 48 h before in vitro maturation increases the number of blastocysts obtained subsequently. These results indicate that FSH is not absolutely required for oocyte development in vivo but that this process occurs more rapidly in its presence. We suggest that FSH may coordinate the development of the germline and somatic compartments of the follicle, ensuring that ovulation releases a developmentally competent egg.