Larger anesthesia practitioner per operating room ratios are needed to prevent unnecessary non-operative time than to mitigate patient risk: A narrative review.

When choosing the anesthesia practitioner to operating room (OR) ratio for a hospital, objectives are applied to mitigate patient risk: 1) ensuring sufficient anesthesiologists to meet requirements for presence during critical intraoperative events (e.g., anesthesia induction) and 2) ensuring sufficient numbers to cover emergencies outside the ORs (e.g., emergent reintubation in the post-anesthesia care unit). At a 24-OR suite with each anesthesiologist supervising residents in 2 ORs, because critical events overlapped among ORs, ≥14 anesthesiologists were needed to be present for all critical events on >90% of days. The suitable anesthesia practitioner to OR ratio would be 1.58, where 1.58 = (24 + 14)/24. Our narrative review of 22 studies from 17 distinct hospitals shows that the practitioner to OR ratio needed to reduce non-operative time is reliably even larger. Activities to reduce non-operative times include performing preoperative evaluations, making prompt evidence-based decisions at the OR control desk, giving breaks during cases (e.g., lunch or lactation sessions), and using induction and block rooms in parallel to OR cases. The reviewed articles counted the frequency of these activities, finding them much more common than urgent patient-care events. Our review shows, also, that 1 anesthesiologist per OR, working without assistants, is often more expensive, from a societal perspective, than having a few more anesthesia practitioners (i.e., ratio > 1.00). These results are generalizable among hundreds of hospitals, based on managerial epidemiology studies. The implication of our narrative review is that existing studies have already shown, functionally, that artificial intelligence and monitoring technologies based on increasing the safety of intraoperative care have little to no potential to influence anesthesia or OR productivity. There are, in contrast, opportunities to use sensor data and decision-support to facilitate communication among anesthesiologists outside of ORs to choose optimal task sequences that reduce non-operative times, thereby increasing production and OR efficiency.

Survey of Lactating Anesthesiologists Using Wearable Breast Milk Pumps While Working in Operating Rooms and Other Clinical Settings.

We performed a prospective Internet survey study of anesthesiologists lactating in 2022 or 2023. Approximately half (48%, 75 of 156) lacked convenient dedicated lactation space and approximately half (55%, 86 of 155) used a wearable breast pump. The vast majority using a wearable pump did so in clinical settings, including operating rooms (88%, 76 of 86). When using during cases, approximately half reported that milk production was sufficient to substitute for lactation pumping sessions (52%, 39 of 75). Based on probability distributions of surgical times, future research can evaluate the usefulness of wearable pumps based on the objective of reducing anesthesiologists' durations of lactation sessions to <15 minutes.

Feasibility of Anesthesiologists Giving Nurse Anesthetists 30-Minute Lunch Breaks and 15-Minute Morning Breaks at a University's Facilities.

Background Managers of an anesthesia department sought an estimation of how often each anesthesiologist can give lunch breaks and morning breaks to nurse anesthetists to plan staff scheduling. When an anesthesiologist supervising the nurse anesthetists can give a break, it would be preferred because fewer extra nurse anesthetists would be scheduled to facilitate breaks. Methodology Our methodological development used retrospective cohort data from the three surgical suites of a single anesthesia department. Surgical times were estimated using three years of data from October 2016 through September 2019, with 95,146 cases. Comparison was made with the next year from October 2019 through September 2020, with 30,987 cases. The 5% lower prediction bounds for surgical time were estimated based on two-parameter, log-normal distributions. The times when two and three sequential rooms had overlapping lower prediction limits were calculated. Sequential rooms were used because that was how anesthesiologists' assignments were made at the studied department, when feasible given constraints. Percentages of cases were reported with 15 minutes available starting sometime between 9:00 and 10:30 and 30 minutes starting sometime between 11:15 and 12:45, times characteristic for the studied department. At the studied university's facilities, the nurse anesthetists were independent practitioners (e.g., an anesthesiologist supervising two nurse anesthetists each with a long case could give a break to one of the two rooms). Results The percentage of days for which an anesthesiologist could give a lunch break (11:15-12:45) was close to the percentage of cases when an anesthesiologist could give the same-length break anytime throughout the workday. In other words, the length of the break was important, not the time of the day of the break. The absolute percentages also depended on how many rooms the anesthesiologist supervised, the duration of cases, and facility. For example, among anesthesiologists at the adult surgical suite supervising three nurse anesthetists, a lunch break could be given by the anesthesiologist on at most one-third of the days without affecting workflow. Conclusions Our results show that the feasibility of an anesthesiologist clinically supervising one, two, or three rooms to give lunch breaks to the nurse anesthetists in the rooms depends principally on how many rooms are supervised, the duration of the break, and the facility's percentage of cases with surgical times longer than that duration. The specific numerical results will differ among departments. Our methodology would be useful to other departments where anesthesiologists are clinically supervising independent practitioners, sometimes during cases long enough for a break, and there is anesthesiologist backup help. Such departments can use our methodology to plan their staff scheduling for additional nurse anesthetists to give the remaining breaks.

Lactation in Anesthesiology.

There are several work-related barriers to breastfeeding among physician mothers including: lack of appropriate place for breastmilk expression, unpredictable and inflexible schedules, and lack of time to breastfeed or express milk. In a survey of physician mothers, those who were in surgical and procedural subspecialties, including anesthesiology, reported a lack of lactation facilities in close proximity to the operating room as a barrier to breastfeeding. Unlike other physicians and clinicians in different health care environments, anesthesiology is unique in that there is often no built-in time for breaks or a predictable end time to the operating room schedule. A break system is typically established, within an institution, for meal break relief for trainees, Certified Registered Nurse Anesthetist, and Anesthesia Assistants. This system for breaks may not be sufficient to accommodate the frequency or length required for lactation sessions. In addition, these break systems do not typically provide relief for supervising anesthesiologists for meals or lactation sessions. A study of physician mothers across specialties identified anesthesiologists as significantly more likely than women of other medical specialties to self-report maternal discrimination. The study defined maternal discrimination as discrimination based on pregnancy, maternity leave, or breastfeeding. As a workforce and specialty, we must support our breastfeeding anesthesiologists and facilitate lactation needs on return to the workplace.

Transient End-Tidal Carbon Dioxide Elevation During Pediatric Upper Endoscopy With Carbon Dioxide Insufflation: Is It True Hypercapnia?

BACKGROUND: Endoscopic insufflation, long performed using air, is being replaced by carbon dioxide (CO2) at many pediatric centers, despite limited published data on its use in children. We have previously demonstrated that CO2 use during esophagogastroduodenoscopy (EGD) in non-intubated children is associated with transient elevations of end-tidal CO2 (EtCO2). This observation raised concerns about possible CO2 inhalation and systemic absorption. Here, we investigate this concern by concurrently measuring both EtCO2 and transcutaneous CO2 (tCO2) during upper endoscopic procedures in children. AIM: To determine if elevations in EtCO2 levels seen in non-intubated children undergoing CO2 insufflation during EGD are associated with elevated systemic CO2 levels. METHODS: Double-blinded, prospective, randomized clinical trial. Children were randomized 1:1 to receive either CO2 or air for endoscopic insufflation. EtCO2 was sampled with a CO2-sampling nasal cannula and tCO2 was monitored using the Radiometer transcutaneous monitoring device. RESULTS: Fifty nine patients were enrolled; 30 patients in the CO2 insufflation group and 29 in the air group. All patients underwent a procedure involving an EGD. Transient elevations in EtCO2 (defined as >60 mmHg) were observed only in the CO2 insufflation group. This contrasted with the similar elevations of tCO2 between the CO2 and air insufflation groups. None of these events were of clinically significant magnitude or duration. CONCLUSION: This study demonstrates that the observed transient elevations in EtCO2 seen during EGD in non-intubated children receiving CO2 insufflation are most likely measurements of eructated CO2 without evidence of excessive systemic absorption of CO2.

Low Prevalence of Designated Lactation Spaces at Hospitals and Ambulatory Surgery Centers in Iowa: An Educational Tool for Graduates' Job Selection.

Many anesthesiologists and nurse anesthetists want to continue breastfeeding their babies when returning to work from maternity leave. The cornerstone of breast milk supply maintenance is breast milk pumping sessions at regular intervals. These breast milk pumping sessions require time and private space for lactation. We surveyed Iowa hospitals and ambulatory surgery centers and created an educational spreadsheet to guide inquiry and postgraduate job selection of our anesthesiology residents and nurse anesthetist students (eg, when considering future family planning). The survey and spreadsheet showed a low prevalence of dedicated lactation space for anesthesia practitioners near the surgical suites.

Suggested Work Guidelines, Based on Operating Room Data, for Departments with a Breast Milk Pumping Supervising Anesthesiologist.

Objective: Coordinating breast milk pumping sessions is challenging for lactating anesthesiologists who supervise multiple simultaneous anesthetics. We quantify the minimum percentages of adjacent operating rooms (ORs) for which there could reliably (≥95%) be at least 30 minutes during the surgical time when the anesthesiologist covering three anesthetics could have her rooms covered by another anesthesiologist. Methods: The historical cohort study was from a large U.S. teaching hospital. We calculated the 5% lower prediction bounds of surgical times from 3 years of historical data, and then applied them to surgical start times from adjacent ORs during the next 1 year. Results: For >2/3rd of cases, an anesthesiologist supervising three ORs would lack a reliable 30-minute period of overlapping surgical times, and an even smaller chance per case at the ambulatory surgery center, 10% (9-11%). For approximately 42% (41-43%) of sufficiently long individual cases, there was absence of a 30-minute period during which both of the two adjacent ORs' cases were suitable for the anesthesiologist to receive a break (p < 0.0001 compared with one-third). Conclusions: Even when making assumptions that were deliberately unrealistic (e.g., anesthesiologists' responsibilities are only for ongoing OR cases), there is no practical mechanism for an anesthesiologist supervising three ORs to start cases, be relieved for a breast milk pumping session, and then return in time for the end of the anesthetics (e.g., tracheal extubation). Departments with anesthesiologists who are breastfeeding should consider having options for temporary clinical assignments, commensurate with training and experience, that do not require supervising >2 ORs.

When fiberoptic intubation fails in patients with unstable craniovertebral junctions.

Fiberoptic intubation (FOI) is generally regarded as the preferred method to achieve endotracheal intubation in patients with cervical spine instability. When performed electively, FOI has a very high level of success. Nevertheless, rarely, FOI may fail. Recently, using the fiberoptic scope to obtain a view of the glottis, with the endotracheal tube being inserted independently, guided by the fiberoptic view has been described. In this report, we describe our experience with a variation of this technique in both adults and children with occipito-cervical instabilities in whom FOI failed.