Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial.

PURPOSE: Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation. METHODS: A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival. RESULTS: Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval - 13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence interval - 9.3, 3.9, p = 0.294). CONCLUSION: While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.

Metabolic syndrome - Evidence-based strategies for patient optimization.

With the increasing prevalence of obesity worldwide, it is inevitable that anesthesiologists will encounter patients with metabolic syndrome. Metabolic syndrome encompasses multiple diseases, which include central obesity, hypertension, dyslipidemia, and hyperglycemia. Given the involvement of multiple diseases, metabolic syndrome involves numerous complex pathophysiological processes that negatively impact several organ systems. Some of the organ systems that have been well-documented to be adversely affected include the cardiovascular, pulmonary, and endocrine systems. Metabolic syndrome also leads to prolonged hospital stays, increased rates of infections, a greater need for care after discharge, and overall increased healthcare costs. Several interventions have been suggested to mitigate these negative outcomes ranging from lifestyle modifications to surgeries. Therefore, anesthesiologists should understand metabolic syndrome and formulate management strategies that may modify perianesthetic and surgical risks.

Are morbidly obese patients suitable for ambulatory surgery?

PURPOSE OF REVIEW: The incidence of morbid obesity continues to increase worldwide. Associated comorbidities, particularly obstructive sleep apnea, increase the perioperative morbidity for this group of patients. The purpose of this review is to discuss appropriate selection of morbidly obese patients for ambulatory surgery. RECENT FINDINGS: Patients with BMI <40 kg/m can safely undergo ambulatory surgery, provided their comorbidities are optimized before surgery. However, patients who are super obese (BMI ≥ 50 kg/m) have an increased risk of perioperative complications, suggesting that these patients should be selected with caution for ambulatory surgery. The outcomes data for patients with BMI between 40-50 kg/m are limited, and therefore, it is suggested that other factors such as obstructive sleep apnea are taken into consideration. SUMMARY: Recent evidence suggests that carefully selected morbidly obese patients can safely undergo surgery on an ambulatory basis. Individualized evaluations taking into account patient-related factors, surgery-related factors, and anesthesia-related factors should dictate which patients are appropriate for ambulatory surgery.

A survey of education and confidence level among graduating anesthesia residents with regard to selected peripheral nerve blocks.

BACKGROUND: As peripheral nerve blockade has increased significantly over the past decade, resident education and exposure to peripheral nerve blocks has also increased. This survey assessed the levels of exposure and confidence that graduating residents have with performing selected peripheral nerve blocks. METHODS: All program directors of ACGME-accredited anesthesiology programs in the USA were asked to distribute an online survey to their graduating residents. Information was gathered on the number and types of nerve blocks performed, technique(s) utilized, perceived comfort level in performing nerve blocks, perceived quality of regional anesthesia teaching during residency, and suggested areas for improvement. RESULTS: One hundred and seven residents completed the survey. The majority completed more than 60 nerve blocks. Femoral and interscalene blocks were performed most frequently, with 59% and 41% of residents performing more than 20 of each procedure, respectively. The least-performed block was the lumber plexus block, with just 9% performing 20 or more blocks. Most residents reported feeling "very" to "somewhat" comfortable performing the surveyed blocks, with the exception of the lumber plexus block, where 64% were "not comfortable." Overall, 78% of residents were "mostly" to "very satisfied" with the quality of education received during residency. CONCLUSIONS: Most of the respondents fulfilled the ACGME requirement and expressed satisfaction with the peripheral nerve block education received during residency. However, the ACGME requirement for 40 nerve blocks may not be adequate for some residents to feel comfortable in performing a full range of blocks upon graduation. Many residents felt that curriculums incorporating simulator training and didactic lectures would be the most helpful method of improving the quality of their education pertaining to peripheral nerve blocks.