Dissociative identity precipitated by emergence from general anesthesia: A case report and analytical framework.

Background: Dissociative identity disorder (DID) is a complex and controversial psychiatric condition in which one person maintains at least two separate and distinct personalities. Patients with DID often report a history of childhood abuse and may have other comorbid psychiatric conditions. Psychosocial stressors may be triggers for DID inception or recurrence. While anesthetic agents, in particular ketamine, may induce a temporary dissociative state, it has not yet been reported that anesthesia can precipitate a dissociative identity. Case report: We report a case of a woman with a history of childhood sexual abuse and past suicide attempt who experienced an episode of dissociative identity on emergence from anesthesia. The episode resolved within 90 minutes and the patient was discharged home safely on hospital day two. Conclusion: This case adds to the literature of potentially precipitating factors of DID and we provide a unifying mechanistic hypothesis linking anesthesia to functional brain connectivity.

Assessing the Efficacy of an Online Preoperative Evaluation Course for PGY-1 Anesthesiology Residents.

BACKGROUND: The impact of an online postgraduate year (PGY-1) education program on anesthesiology resident knowledge base, anxiety, or preparedness has not been described previously. The literature shows resident knowledge of perioperative care is lower than expected. METHODS: The Johns Hopkins Preoperative Evaluation and Anesthesia Course was designed as an 8 module, 8 month online academic curriculum for the program's PGY-1 class. Each module includes a pretest, topic synopsis, lecture video, moderated case discussion and a posttest. All PGY-1 residents entering the program in July 2012 were eligible to participate. Residents starting in July 2010 served as the control group. A survey was administered to measure self-assessed knowledge of and comfort with components of preoperative anesthesia care and perceived anxiety about starting the clinical anesthesia year. Additional outcome measures included performance on the pretest and postmodule tests and Anesthesia Knowledge Test scores from day 1 of Clinical Anesthesia year 1 (CA-1, PGY-2) orientation. Statistical analysis included independent t tests, the Mann-Whitney test, and sensitivity analyses. RESULTS: Residents in the intervention group showed an improvement of 16.25 to 39.60 percentage points between the pretest and posttest in each of the 8 subjects (P < .0001 in every subject). The intervention group median score was 24 percentile points higher on the Anesthesia Knowledge Test as compared with the control group (P = .0488; lower 95% CI, 9.92). Significant improvement was also seen across measures including comfort advising about medications (P < .0001), understanding of coexisting disease (P < .0001), comfort assessing patient airway (P = .0002), and anxiety about starting PGY-2 year (P = .0116). CONCLUSIONS: We have demonstrated significantly positive impact of a comprehensive, longitudinal online, asynchronous, multimodal educational intervention on PGY-1 residents using objective and subjective data.

Odds of transfusion for older adults compared to younger adults undergoing surgery.

BACKGROUND: Recent randomized controlled trials have shown no benefit for transfusion to a hemoglobin >10 g/dL compared with lower hemoglobin thresholds in the perioperative period, even among older adults. Nevertheless, physicians may choose to transfuse older adults more liberally than younger adults. It is unclear whether older patients have higher odds than younger patients of being transfused in the perioperative period. Our objective in this study was to determine whether the odds of transfusion are higher in older patients than in younger patients in the perioperative period. METHODS: We conducted this retrospective observational cohort study at a tertiary care academic medical center. We included adults who had undergone a surgical procedure as an inpatient at our institution from January 2010 to February 2012. The primary analysis compared the odds of transfusion for patients >65 years old with the odds of transfusion in younger patients based on multilevel multivariable logistic regression analyses including adjustment for comorbidities, surgical service, lowest in-hospital hemoglobin value, gender, and estimated surgical blood loss and accounted for clustering by the surgeon and procedure. RESULTS: We included 20,930 patients in this analysis. In multilevel models adjusted for comorbidities, surgical service, estimated surgical blood loss, and lowest in-hospital hemoglobin value, with surgeon and procedure as random effects, patients > 65 years old had 62% greater odds (odds ratio, 1.62; 95% confidence interval, 1.40-1.88; P < 0.0001) of being transfused than did younger patients. When patients were stratified by lowest in-hospital hemoglobin (7.00-7.99, 8.00-8.99, 9.00-9.99, and ≥10.00 g/dL), the odds of transfusion generally increased with each additional decade of age in every stratum, except for that containing patients in whom the lowest in-hospital hemoglobin did not decrease below 10 g/dL. When the odds of transfusion were compared between younger and older patients, significant differences were observed among surgical services (P = 0.02) but not among anesthesia specialty divisions (P = 0.9). CONCLUSIONS: Older adults have greater odds of receiving red blood cell transfusion in the perioperative period than do younger patients, despite the lack of evidence supporting higher hemoglobin triggers in elderly patients. Further research is needed to determine whether transfusion practice in the elderly is an opportunity for education to improve blood management.

Optimizing preoperative blood ordering with data acquired from an anesthesia information management system.

BACKGROUND: The maximum surgical blood order schedule (MSBOS) is used to determine preoperative blood orders for specific surgical procedures. Because the list was developed in the late 1970s, many new surgical procedures have been introduced and others improved upon, making the original MSBOS obsolete. The authors describe methods to create an updated, institution-specific MSBOS to guide preoperative blood ordering. METHODS: Blood utilization data for 53,526 patients undergoing 1,632 different surgical procedures were gathered from an anesthesia information management system. A novel algorithm based on previously defined criteria was used to create an MSBOS for each surgical specialty. The economic implications were calculated based on the number of blood orders placed, but not indicated, according to the MSBOS. RESULTS: Among 27,825 surgical cases that did not require preoperative blood orders as determined by the MSBOS, 9,099 (32.7%) had a type and screen, and 2,643 (9.5%) had a crossmatch ordered. Of 4,644 cases determined to require only a type and screen, 1,509 (32.5%) had a type and crossmatch ordered. By using the MSBOS to eliminate unnecessary blood orders, the authors calculated a potential reduction in hospital charges and actual costs of $211,448 and $43,135 per year, respectively, or $8.89 and $1.81 per surgical patient, respectively. CONCLUSIONS: An institution-specific MSBOS can be created, using blood utilization data extracted from an anesthesia information management system along with our proposed algorithm. Using these methods to optimize the process of preoperative blood ordering can potentially improve operating room efficiency, increase patient safety, and decrease costs.