Airway Complications in Pregnant Patients Undergoing Electroconvulsive Therapy: A Retrospective Case-Control Study.

OBJECTIVES: Electroconvulsive therapy (ECT) is an evidence-based treatment for severe depression and bipolar disorder in pregnant women. Electroconvulsive therapy involves induction of general anesthesia, muscle relaxation, and positive-pressure ventilation. Airway manipulation may lead to complications such as vocal cord injury, aspiration, inability to ventilate, and death. The purpose of this study was to determine whether there were differences in the incidence of airway complications in pregnant patients who underwent mask ventilation (MV) versus endotracheal intubation (ETI) compared with nonpregnant control subjects. METHODS: We conducted a single-center retrospective chart review of all adult pregnant patients who underwent anesthesia for ECT from June 1, 2011, to June 30, 2020. Each ECT treatment delivered to a pregnant patient was matched with 2 ECT treatments delivered to a nonpregnant female control subject. Charts were queried for airway management (MV vs ETI), gestational age, and airway complications. Each ECT treatment was considered an independent event. RESULTS: Seventy-six ECT treatments from 11 pregnant patients were matched with 154 ECT treatments from 13 nonpregnant patients. In pregnant patients, airway management consisted of MV in 57 of the 76 treatments: 12 of 12 in the first trimester, 33 of 44 in the second trimester, and 12 of 20 in the third trimester. All 154 ECT treatments in the control group used MV. No airway complications were experienced in pregnant or nonpregnant patients with MV or ETI. CONCLUSIONS: No airway complications were observed in pregnant patients undergoing MV or ETI regardless of gestational age.

Impact of oral carbohydrate consumption prior to cesarean delivery on preoperative well-being: a randomized interventional study.

PURPOSE: Oral carbohydrate consumption before surgery improves insulin sensitivity, cardiac output and well-being, and shortens hospital stays without adverse effects. No work has compared higher-dose carbohydrate beverages made for preoperative consumption to common, commercial oral rehydration solutions with lower carbohydrate concentrations. METHODS: We recruited low-risk women undergoing scheduled cesarean deliveries with planned spinal anesthesia. Participants were randomized to one of three groups: those who consumed Clearfast® beverage, those who consumed Gatorade Thirst Quencher® beverage, or fasting control. Participants in the two beverage groups received 710 mL of the appropriate beverage the night before surgery and 355 mL 2 h before surgery. Participants in the control group fasted after midnight the night before surgery. Two hours before surgery, we recorded baseline patient well-being using visual analogue scales, followed by beverage consumption for subjects in the beverage groups. One hour later, we repeated the same assessment. Additional recorded measures included cord blood glucose level, intraoperative variables, breastfeeding success, and a quality of recovery assessment administered 1 day after surgery. RESULTS: Forty-seven patients were recruited: 15 received Clearfast®, 17 received Gatorade Thirst Quencher®, and 15 patients fasted after midnight. Group differences in change in patient well-being using visual analog scales were analyzed using linear regression. Both beverage-consuming groups showed significant improvements in patient well-being using visual analog scales while fasted patients showed no change. CONCLUSION: Either a common oral rehydration beverage or a higher-dose carbohydrate beverage consumed preoperatively resulted in superior well-being compared to fasting. No differences in other outcomes were noted. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov with clinical trial registration number: NCT02684513.

Concurrent intraoperative uterine rupture and placenta accreta. Do preoperative chronic hypertension, preterm premature rupture of membranes, chorioamnionitis, and placental abruption provide warning to this rare occurrence?

Uterine and placental pathology can be a major cause of morbidity and mortality in the parturient and infant. When presenting alone, placental abruption, uterine rupture, or placenta accreta can result in significant peripartum hemorrhage, requiring aggressive surgical and anesthetic management; however, the presence of multiple concurrent uterine and placental pathologies can result in significant morbidity and mortality. We present the anesthetic management of a parturient who underwent an urgent cesarean delivery for non-reassuring fetal tracing in the setting of chronic hypertension, preterm premature rupture of membranes, and chorioamnionitis who was subsequently found to have placental abruption, uterine rupture, and placenta accreta.

Delayed Neuraxial Hematoma in Parturient With Fontan Circulation Following Neuraxial Anesthesia for Cesarean Section.

OBJECTIVE: Neuraxial hematoma is a rare complication of spinal or epidural anesthesia. However, variable coagulation factor defects are relatively common in patients with Fontan circulation, and may predispose such patients to either increased risk of thrombosis or coagulopathy. These defects may indirectly increase their risk of neuraxial hematoma. CASE REPORT: We report a case of delayed neuraxial hematoma after the start of full-dose anticoagulation for pulmonary embolus on a postpartum patient with Fontan physiology who had continuous spinal anesthesia for cesarean delivery 4 days earlier. CONCLUSIONS: Parturients with single ventricle physiology present numerous challenges to balance, including pregnancy-related physiologic alterations in blood volume, cardiac output, systemic vascular resistance, oxygen consumption, and coagulation. Although neuraxial anesthesia is common in this population, it is not without risks. We report the circumstances surrounding a parturient with single ventricle physiology who experienced neuraxial hematoma 4 days after continuous spinal anesthesia despite adherence to accepted guidelines. Eighteen months after undergoing a cesarean section, she had a full recovery and returned to her baseline medical status.

Do Variations in Agency Indirectly Affect Behavior with Others? An Analysis of Gaze Behavior.

In a group setting, it is possible for attributes of one group member to indirectly affect how other group members are perceived. In this paper, we explore whether one group member's agency (e.g. if they are real or virtual) can indirectly affect behavior with other group members. We also consider whether variations in the agency of a group member directly affects behavior with that group member. To do so, we examined gaze behavior during a team training exercise, in which sixty-nine nurses worked with a surgeon and an anesthesiologist to prepare a simulated patient for surgery. The agency of the surgeon and the anesthesiologist were varied between conditions. Nurses' gaze behavior was coded using videos of their interactions. Agency was observed to directly affect behavior, such that participants spent more time gazing at virtual teammates than human teammates. However, participants continued to obey polite gaze norms with virtual teammates. In contrast, agency was not observed to indirectly affect gaze behavior. The presence of a second human did not affect participants' gaze behavior with virtual teammates.

The Effect of Cricoid Pressure on the Unstable Cervical Spine.

BACKGROUND: It has been proposed that cricoid pressure can exacerbate an unstable cervical injury and lead to neurologic deterioration. OBJECTIVE: We sought to examine the amount of motion cricoid pressure could cause at an unstable subaxial cervical spine injury, and whether posterior manual support is of any benefit. METHODS: Five fresh, whole cadavers had complete segmental instability at C5-C6 surgically created by a fellowship-trained spine surgeon. Cricoid pressure was applied to the anterior cricoid by an attending anesthesiologist. In addition, the effect of posterior cervical support was tested during the trials. The amount of angular and linear motion between C5 and C6 was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). RESULTS: When cricoid pressure is applied, the largest angular motion was 3 degrees and occurred in flexion-extension at C5-C6. The largest linear displacement was 1.36 mm and was in anterior-posterior displacement of C5-C6. When manual posterior cervical support was applied, the flexion-extension was improved to less than half this value (1.43 degrees), and this reached statistical significance (p = 0.001). No other differences were observed to be significant in the other planes of motion with the applications of support. CONCLUSIONS: Based on the evidence presented, we believe that the application of cricoid pressure to a patient with a globally unstable subaxial cervical spine injury causes small displacements. There may be some benefit to the use of manual posterior cervical spine support for reducing motion at such an injured segment.

Teaming Up with Virtual Humans: How Other People Change Our Perceptions of and Behavior with Virtual Teammates.

In this paper we present a study exploring whether the physical presence of another human changes how people perceive and behave with virtual teammates. We conducted a study (n = 69) in which nurses worked with a simulated health care team to prepare a patient for surgery. The agency of participants' teammates was varied between conditions; participants either worked with a virtual surgeon and a virtual anesthesiologist, a human confederate playing a surgeon and a virtual anesthesiologist, or a virtual surgeon and a human confederate playing an anesthesiologist. While participants perceived the human confederates to have more social presence (p <; 0.01), participants did not preferentially agree with their human team members. We also observed an interaction effect between agency and behavioral realism. Participants experienced less social presence from the virtual anesthesiologist, whose behavior was less in line with participants' expectations, when a human surgeon was present.

Using a Critical Incident Scenario With Virtual Humans to Assess Educational Needs of Nurses in a Postanesthesia Care Unit.

INTRODUCTION: During critical incidents, teamwork failures can compromise patient safety. This study provides evidence that virtual humans can be used in simulated critical incidents to assess the learning needs of health professionals, and provide important information that can inform the development of continuing education programs in patient safety. We explored the effectiveness of information transfer during a devolving medical situation between postanesthesia care unit (PACU) nurses and a virtual attending physician. METHODS: We designed a three-stage scenario: tutorial, patient transfer, and critical incident. We developed 2 checklists to assess information transfer: Critical Patient Information and Interprofessional Communication Skills. All participants were videotaped; 2 raters reviewed all videos and assessed performance using the checklists. RESULTS: Participants (n = 43) who completed all 3 stages scored 62.3% correct on critical patient information transfer and 61.6% correct on interprofessional communication skills. Almost 87% missed a fatal drug error. The checklists measured each item on a 1/0 (done/not) calculation. Additionally, no relationship was found between years of nursing experience and performance on either checklist. DISCUSSION: The PACU nurses in this study did not consistently share critical information with an attending (virtual) physician during a critical incident, and most missed a fatal dosage error. These findings strongly suggest a crucial need for additional structured team training among practicing health care teams, and they demonstrate the utility of using virtual humans to simulate team members.

A comparison of 4 airway devices on cervical spine alignment in cadaver models of global ligamentous instability at c1-2.

BACKGROUND: The effects of advanced airway management on cervical spine alignment in patients with upper cervical spine instability are uncertain. METHODS: To examine the potential for mechanical disruption during endotracheal intubation in cadavers with unstable cervical spines, we performed a prospective observational cohort study with 3 cadaver subjects. We created an unstable, type II odontoid fracture with global ligamentous instability at C1-2 in lightly embalmed cadavers, followed by repetitive intubations with 4 different airway devices (Airtraq laryngoscope, Lightwand, intubating laryngeal mask airway [LMA], and Macintosh laryngoscope) while manual in-line stabilization was applied. Motion analysis data were collected using an electromagnetic device to assess the degree of angular movement in 3 axes (flexion-extension, axial rotation, and lateral bending) during the intubation trials with each device. Intubation was performed by either an emergency medical technician or attending anesthesiologist. RESULTS: Overall, 153 intubations were recorded with the 4 devices. The Lightwand technique resulted in significantly less flexion-extension and axial rotation at C1-2 than with the intubating LMA (mean difference in flexion-extension 3.2° [95% confidence interval {CI}, 0.9°-5.5°], P = 0.003; mean difference in axial rotation 1.6° [95% CI, 0.3°-2.8°], P = 0.01) and Macintosh laryngoscope (mean difference in flexion-extension 3.1° [95% CI, 0.8°-5.4°], P = 0.005; mean difference in axial rotation 1.4° [95% CI 0.1°-2.6°], P = 0.03). CONCLUSIONS: In cadavers with instability at C1-2, the Lightwand technique produced less motion than the Macintosh and intubating LMA.

Case report of a parturient with cyanotic congenital heart disease palliated with a Glenn procedure.

As the prevalence of adults with palliated congenital heart disease continues to increase, so, too, does the number of these patients who will become pregnant. Practicing physicians need to be familiar with the impact that normal physiologic changes associated with pregnancy and delivery has on patients with palliated congenital heart disease. The physiologic impact of pregnancy on a patient with palliated cyanotic congenital heart disease and the management of her delivery are presented.

Regional anesthesia as compared with general anesthesia for surgery in geriatric patients with hip fracture: does it decrease morbidity, mortality, and health care costs? Results of a single-centered study.

INTRODUCTION: Hip fracture in geriatric patients has a substantial economic impact and represents a major cause of morbidity and mortality in this population. At our institution, a regional anesthesia program was instituted for patients undergoing surgery for hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly after July 2007) vs general anesthesia (mainly prior to July 2007) on morbidity, mortality and hospitalization costs. METHODS: This retrospective cohort study involved data collection from electronic and paper charts of 308 patients who underwent surgery for hip fracture from September 2006 to December 2008. Data on postoperative morbidity, in-patient mortality, and cost of hospitalization (as estimated from data on hospital charges) were collected and analyzed. Seventy-three patients received regional anesthesia and 235 patients received general anesthesia. During July 2007, approximately halfway through the study period, a regional anesthesia and analgesia program was introduced. RESULTS: The average cost of hospitalization in patients who received surgery for hip fracture was no different between patients who receive regional or general anesthesia ($16,789 + 631 vs $16,815 + 643, respectively, P = 0.9557). Delay in surgery and intensive care unit (ICU) admission resulted in significantly higher hospitalization costs. Age, male gender, African American race and ICU admission were associated with increased in-hospital mortality. In-hospital mortality and rates of readmission are not statistically different between the two anesthesia groups. CONCLUSIONS: There is no difference in postoperative morbidity, rates of rehospitalization, in-patient mortality or hospitalization costs in geriatric patients undergoing regional or general anesthesia for repair of hip fracture. Delay in surgery beyond 3 days and ICU admission both increase cost of hospitalization.

Comparison of 4 airway devices on cervical spine alignment in a cadaver model with global ligamentous instability at C5-C6.

STUDY DESIGN: Human cadaveric study using various intubation devices in a cervical spine instability model. OBJECTIVE: We sought to evaluate various intubation techniques and determine which device results in the least cervical motion in the setting of a global ligamentous instability model. SUMMARY OF BACKGROUND DATA: Many patients presenting with a cervical spine injury have other injuries that may require rapid airway management with endotracheal intubation. Secondary neurologic injuries may occur in these patients because of further displacement at the level of injury, vascular insult, or systemic decrease in oxygen delivery. The most appropriate technique for achieving endotracheal intubation in the patient with a cervical spine injury remains controversial. METHODS: A global ligamentous instability at the C5-C6 vertebral level was created in lightly embalmed cadavers. An electromagnetic motion analysis device (Liberty; Polhemus, Colchester, VT) was used to assess the amount of angular and linear translation in 3 planes during intubation trials with each of 4 devices (Airtraq laryngoscope, lighted stylet, intubating LMA, and Macintosh laryngoscope). The angular motions measured were flexion-extension, axial rotation, and lateral bending. Linear translation was measured in the medial-lateral (ML), axial, and anteroposterior planes. Intubation was performed by either an emergency medical technician or by a board-certified attending anesthesiologist. Both time to intubate as well as failure to intubate (after 3 attempts) were recorded. RESULTS: There was no significant difference shown with regards to time to successfully intubate using the various devices. It was shown that the highest failure-to-intubate rate occurred with use of the intubating LMA (ILMA) (23%) versus 0% for the others. In flexion/extension, we were able to demonstrate that the Lightwand (P = 0.005) and Airtraq (P = 0.019) resulted in significantly less angular motion than the Macintosh blade. In anterior/posterior translation, the Lightwand (P = 0.005), Airtraq (P = 0.024), and ILMA (P = 0.021) all caused significantly less linear motion than the Macintosh blade. In axial rotation, the Lightwand (P = 0.017) and Airtraq (P = 0.022) resulted in significantly less angular motion than the Macintosh blade. In axial translation (P = 0.037) and lateral bending (P = 0.003), the Lightwand caused significantly less motion than the Macintosh blade. CONCLUSION: In a cadaver model of C5-C6 instability, the greatest amount of motion was caused by the most commonly used intubation device, the Macintosh blade. Intubation with the Lightwand resulted in significantly less motion in all tested parameters (other than ML translation) as compared with the Macintosh blade. It should also be noted that the Airtraq caused less motion than the Macintoshblade in 3 of the 6 tested planes. There were no significant differences in failure rate or the amount of time it took to successfully intubate in comparing these techniques. We therefore recommend the use of the Lightwand, followed by the Airtraq, in the setting of a presumed unstable cervical spine injury over the Macintosh laryngoscope.

Virtual humans versus standardized patients: which lead residents to more correct diagnoses?

PURPOSE: Medical educators frequently use standardized patient (SP) encounters to bridge the gap between didactic education and practical application. Typically, SPs are healthy adults with no consistent physical findings; however, highly immersive virtual humans (VHs) may enable the consistent presentation of abnormal physical findings to multiple learners across multiple repetitions. Thus, the authors conducted this study to compare how frequently junior anesthesiology residents suspected obstructive sleep apnea (OSA) in preoperative assessments of SPs versus a VH. METHOD: The authors presented a patient whose case included the historical features of OSA (snoring, daytime fatigue, observed apnea, hypertension, and obesity). Three SPs (in 2008) and one VH (in 2009) were necessary to run the residents through the assessment. The VH appeared morbidly obese and had a neck circumference of 40 cm [corrected]. An airway exam of the VH displayed an image of redundant soft tissue, prominent tongue, and tonsillar hypertrophy. The VH responded to natural speech by recognizing "triggers" in a human's voice. The 849 triggers and 259 VH responses were designed with a technique that collects information from user interactions. RESULTS: Five of 21 residents (23.8%) suspected OSA after interviewing the SPs, whereas 11 of 13 residents (84.6%) suspected OSA after interviewing the VH (odds ratio of 17.6; 95% CI of 2.9-107). CONCLUSIONS: Residents suspected OSA much more frequently after interviewing the VH than after interviewing the SPs. The VH provides a unique opportunity to display numerous abnormal physical findings as part of SP encounters.

Anesthetic management for cesarean section in a patient with rupture of a cerebellar arteriovenous malformation.

Intracranial hemorrhage in the pregnant patient is a rare cause of peripartum morbidity, and it presents a diagnostic and management dilemma. The case of a term parturient who presented with headache is presented. Clinical suspicion led to the diagnosis of ruptured cerebellar arteriovenous malformation. Optimal timing of interventions, both neurosurgical and obstetric, are discussed. We chose to pursue Cesarean section prior to definitive neurosurgical intervention in this term parturient. Delivery of the fetus before surgery eliminates concern for adverse pregnancy outcome when interventions for cerebral protection are used, such as hyperventilation, administration of mannitol, barbiturate coma, and induced hypertension or hypotension. Subsequent management options, including general, spinal, epidural, and combined-spinal epidural (CSE) anesthesia for Cesarean delivery, are discussed. We selected CSE anesthesia so as to provide a hemodynamically stable delivery followed by planned endovascular embolization.