High-Degree Heart Block During Noncardiac Surgery Soon After Transcatheter Aortic Valve Replacement: A Case Report.

Patients undergoing transcatheter aortic valve replacement (TAVR) as a bridge to noncardiac surgery have improved outcomes. Older clinical trials concluded no increased risk of performing noncardiac surgery within 30 days of the TAVR procedure. Emerging evidence suggests patients with preexisting conduction abnormalities may require additional intervention to proceed safely with noncardiac surgery. More data are needed to clarify this clinical situation, especially for the anesthesiologist whose job is to mitigate risk for these patients. We present a patient who received a TAVR and suffered associated complications during subsequent surgery. We further discuss preventative measures and perioperative considerations for this patient population.

Anesthesiology Resident Performance on the US Medical Licensing Examination Predicts Success on the American Board of Anesthesiology BASIC Staged Examination: An Observational Study.

BACKGROUND: Correlation has been found between the US Medical Licensing Examination (USMLE) Step 1 examination results and anesthesiology resident success on American Board of Anesthesiology (ABA) examinations. In 2014, the ABA instituted the BASIC examination at the end of the postgraduate year-2 year. We hypothesized a similar predictive value of USMLE scores on BASIC examination success. METHODS: After the Committee for the Protection of Human Subjects at UTHealth Institutional Review Board approved and waived written consent, we retrospectively evaluated USMLE Step examination performance on first-time BASIC examination success in a single academic department from 2014-2018. RESULTS: Over 5 years, 120 residents took the ABA BASIC examination and 108 (90%) passed on the first attempt. Ten of 12 first-time failures were successful on repeat examination but analyzed in the failure group. Complete data was available for 92 residents (76.7%), with absent scores primarily reflecting osteopathic graduates who completed Comprehensive Osteopathic Medical Licensing Examination of the United States level examinations rather than USMLE. In the failure cohort, all 3 USMLE examination step scores were lower (P < .02). USMLE Step 1 score independently predicted success on the BASIC examination (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.17, P < .001). Although USMLE Step 2 score predicted BASIC examination success (OR 1.10, 95% CI 1.04-1.18, P = .001), this did not remain after adjustment for Step 1 score using multiple logistic regression (P = .11). In multivariable logistical regression, first clinical anesthesia in-training examination score and USMLE Step 1 score were significant for predictors of success on the BASIC exam. CONCLUSIONS: In anesthesiology residency training, our preliminary single-center data is the first to suggest that USMLE Step 1 performance could be used as a predictor of success on the recently introduced ABA BASIC Examination. These findings do not support recent action to change USMLE scoring to a pass/fail report.

Quadratus Lumborum 2 Block as the Sole Anesthetic Technique for Open Hernia Repair in Multimorbid Patients.

Ultrasound-guided quadratus lumborum (QL, QL1-3) blocks have been used extensively for perioperative pain control for patients undergoing abdominal procedures. These blocks provide a more widespread and longer-lasting analgesic effect compared to the transversus abdominis plane (TAP) block. While QL blocks have been used as an adjunct in multimodal postoperative pain control, they are rarely used as the sole anesthetic technique for abdominal surgeries. We report the cases of two high-risk multimorbid patients requiring urgent open umbilical hernia repairs secondary to incarceration or obstruction. Bilateral QL2 blocks were utilized as the sole anesthetic technique to reduce anesthetic risk, with positive outcomes.  Utilization of the QL2 block technique for our patients enabled avoidance of general anesthesia in these high-risk patients because of the extensive area of anesthesia they provide when compared with the TAP and QL1 block techniques. The advantages of the QL2 block for high-risk patients include immediate perioperative pain control, reduced use of muscle relaxants, reduced opioid analgesic requirement for postoperative pain management, and enhanced postoperative recovery. Disadvantages include potential for local anesthetic toxicity, neural injury, or failure of the block. While regional anesthetic techniques may be beneficial options for those patients who are not candidates for general anesthesia, more studies in which these techniques are used need to be performed to determine the widespread efficacy and adequacy of this method.

Dramatic change in cerebral oximetry during liver transplantation.

We report dramatic changes in bilateral cerebral tissue oxygenation in a patient undergoing an orthotopic liver transplant coincident with clamping and subsequent restoration of flow through the inferior vena cava. Although hemodynamic stability was maintained with low-dose vasopressor support, cardiac output was decreased, suggesting preload dependence of the measured cerebral oxygenation. Further investigation is warranted in patients with end-stage liver disease and interruption of venous return.

The New Kidney Donor Allocation System and Implications for Anesthesiologists.

Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.

Reliability of a faculty evaluated scoring system for anesthesiology resident applicants (Original Investigation).

STUDY OBJECTIVE: To assess reliability and reproducibility of a recently instituted anesthesiology resident applicant interview scoring system at our own institution. DESIGN: Retrospective evaluation of 2 years of interview data with a newly implemented scoring system using randomly assigned interviewing faculty. SETTING: Interview scoring evaluations were completed as standard practice in a large academic anesthesiology department. SUBJECTS: All anesthesiology resident applicants interviewed over the 2013/14 and 2014/15 seasons by a stable cohort of faculty interviewers. Data collection blinded for both interviewers and interviewees. INTERVENTIONS: None for purposes of study - collation of blinded data already used as standard practice during interview process and analysis. MEASUREMENTS: None specific to study. MAIN RESULTS: Good inter-rater faculty reliability of interview scoring (day-of) and excellent inter-faculty reliability of application review (pre-interview). CONCLUSIONS: Development of a department-specific interview scoring system including many elements beyond traditional standardized tests shows good-excellent reliability of faculty scoring of both the interview itself (including non-technical skills) and the application resume.

Importance of patient selection for patient-controlled epidural analgesia (PCEA), as even low-concentration solutions may lead to a very high block.

Patient-controlled epidural analgesia (PCEA) is an excellent choice of analgesia technique in labor; however, patient selection for such treatment is important. A 14 year old healthy parturient receiving PCEA had a very high block due to patient noncompliance.