A Multi-Site Survey Study on the Association Between the COVID-19 Pandemic and United States Anesthesiology Residents' Mental Health.

BACKGROUND:  At the onset of the coronavirus disease 2019 (COVID-19) pandemic, anesthesiology residency programs were impacted differently due to various factors such as the local severity of COVID-19, exposure to patient suffering, and inability to complete rotations. We sought to investigate the impact of local-level pandemic severity on the well-being of anesthesiology residents. METHODS:  This multi-site study surveyed postgraduate year two residents from 15 United States (US) anesthesiology programs using the Perceived Stress Scale, Mini-Z, Patient Health Questionnaire-9,WHO-5 Well-Being Index,and the Multidimensional Scale of Perceived Social Support before the pandemic (baseline survey) and during the first COVID-19 surge (post survey). RESULTS:  A total of 144 (65%) residents responded to the initial baseline survey; 73 (33%) responded to the post survey, and 49 (22%) completed both surveys. There was not a statistically significant difference in any well-being outcomes of participants between the surveys, nor was there a significant difference based on the severity of COVID-19 impact at the program's hospital. Male participants had higher perceived stress scores (ß = 4.05, 95%CI: 0.42, 7.67, P = 0.03) and lower social support from family (ß = -6.57, 95%CI: -11.64, -1.51, P = 0.01) at the post survey compared to female participants after controlling for baseline scores. Additionally, married participants or those with domestic partners reported higher perceived social support in the post survey (ß = 5.79, 95%CI: -0.65, 12.23, P = 0.03). CONCLUSION:  The local COVID-19 severity at a residency program did not disproportionately impact well-being scores among anesthesiology residents. Those most vulnerable to diminished well-being appeared to be male and single participants. As a result, targeted well-being interventions, including those aiming to increase social support, to higher-risk resident groups may be indicated. Future work is needed to assess the longstanding COVID-19 pandemic impacts on resident well-being.

Cesarean Delivery in a Patient With Body Mass Index Over 100: Continuous Spinal Anesthesia in Two Consecutive Deliveries.

Anesthetic implications for morbidly obese parturients have been well described; however, the literature has not yet clarified whether there are additional or unique concerns if the body mass index (BMI) rises farther above the so-called super morbid obesity level: BMI >50 kg/m2. There have only been a few case reports focusing on patients with BMI close to or above 100. Parturients with BMI significantly greater than 50 are uncommon, but they represent an increasing proportion among the morbidly obese. In this report, we present the use of continuous spinal anesthesia in consecutive cesarean deliveries for a patient with a BMI of 102 at her first delivery and 116 at her second. For both deliveries, an intrathecal catheter dosing incrementally provided effective anesthesia with a cumulative dose of hyperbaric bupivacaine 12 mg, fentanyl 15 mcg, and morphine 100 mcg given in 0.25-ml increments over 12 minutes, with 0.25-ml sterile saline flushes between doses. While dosing the catheter, the patient was gradually lowered to a 30° semi-recumbent position for surgery. This strategy minimized the risk of high spinal block or respiratory distress. She did not develop any postdural puncture headache (PDPH). This case report offers an extreme example and provides estimates towards adjusting staffing, equipment, location, timing, positioning, anesthetic technique, and dosing for cesarean deliveries in patients with very high BMI levels.

Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis.

BACKGROUND: Continuous epidural infusion (CEI) is commonly used for labour analgesia, but concerns over potential motor block, second-stage labour complications, and ineffective analgesia in late labour have prompted examining intermittent epidural bolus (IEB) as an alternative. However, evidence comparing these modalities is conflicting. The meta-analysis evaluates the analgesic efficacy of CEI vs IEB. METHODS: Databases were searched for trials comparing CEI to IEB for labour analgesia. The two co-primary outcomes were risk of breakthrough pain and difference in area under the curve (AUC) for pain scores during the first 4 h post-epidural initiation. Local anaesthetic consumption, maternal outcomes (i.e. delivery mode, labour duration, and maternal satisfaction), and side-effects of epidural analgesia were also evaluated. Results were pooled using random-effects modelling. Trial sequential analysis (TSA) was used to evaluate evidence reliability. RESULTS: Twenty-seven studies (3133 patients) were analysed. Compared with CEI, IEB decreased risk of breakthrough pain by 38% (risk ratio [95% confidence interval {CI}] of 0.62 [0.48, 0.81]; P=0.0004; I2=47%; 1164 patients) and reduced AUC of pain during the 4 h interval by 32.9% (mean difference [95% CI] of -16.7 mm h-1 [-18.9, -14.4]; P<0.0001; 1638 patients). Intermittent epidural bolus enhanced maternal satisfaction, shortened labour duration, decreased motor block, and reduced local anaesthetic consumption. The difference between the two groups was not statistically significant for epidural side-effects or mode of delivery. The TSA indicated adequate power for reliable inferences. CONCLUSIONS: Intermittent epidural bolus provides improved labour pain control during the first 4 h after epidural initiation with less breakthrough pain. Moderate- to high-quality evidence of intermittent epidural bolus superiority support its use as a safe and effective continuous epidural infusion alternative for labour analgesia.