Team Relations and Role Perceptions During Anesthesia Crisis Management in Magnetic-Resonance Imaging Settings: A Mixed Methods Exploration.

BACKGROUND: An increasing number of procedures are performed in non-operating room anesthesia (NORA) settings, including magnetic resonance imaging (MRI) suites. Patient care in NORA is accomplished by interprofessional ad hoc teams (anesthesia clinicians, imaging technologists, and others), who do not regularly work together otherwise. The authors aimed to explore team relations and role perceptions during crisis situations in MRI settings among such ad hoc teams. METHODS: This mixed methods study used a convergent parallel design: The Relational Coordination Index (RCI) and a survey about role perceptions were administered to anesthesia and non-anesthesia personnel working in MRI settings, and semistructured interviews were conducted among a purposive sample. After descriptive statistics and thematic analysis, the authors integrated quantitative and qualitative findings to identify and describe overlapping and mismatched perceptions between the two groups. RESULTS: A total of 67 surveys (response rate 74.4%) and 17 interviews were analyzed. RCI ratings revealed moderate relational coordination between the anesthesia and non-anesthesia groups. Anesthesia and non-anesthesia respondents agreed that the anesthesia clinician assumes leadership during crisis management while non-anesthesia personnel assist. There were nuanced differences in expectations about the role of non-anesthesia personnel in calling for help, understanding specific equipment needs, and performing patient care actions. Many anesthesia clinicians felt unsure about crisis-relevant skills of their non-anesthesia colleagues. MRI technologists emphasized attention to magnetic safety as integral to their role, which was infrequently mentioned by anesthesia personnel. CONCLUSION: Nuanced mismatches in role expectations within the interprofessional care team exist, which may hinder effective crisis management in MRI settings.

Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a remote hybrid suite compared with the operating room.

BACKGROUND: Anaesthesia care outside of the standard operating room (OR) can be challenging. This prospective matched case-pair study describes the difference in anaesthesia clinicians' perception of safety, workload, anxiety, and stress in two settings by comparing similar neurosurgical procedures performed in either the OR or a remote hybrid room with intraoperative MRI (MRI-OR). METHODS: A visual numeric scale for safety perception and validated instruments for workload, anxiety, and stress were administered to enrolled anaesthesia clinicians after induction of anaesthesia and at the end of eligible cases. The difference in outcomes reported by the same clinician for unique pairs of similar operations performed in both settings (OR vs MRI-OR) was compared using the Student t-test with the general bootstrap algorithm to address the presence of clusters. RESULTS: Over 15 months, 37 clinicians provided data for 53 case pairs. Working in the remote MRI-OR vs OR was associated with lower perceived safety (7.3 [2.0] vs 8.8 [0.9]; P<0.001), higher scores in the workload subdomains effort and frustration (41.6 [24.1] vs 31.3 [21.6]; P=0.006 and 32.4 [22.9] vs 20.7 [17.2]; P=0.002, respectively), and higher anxiety (33.6 [10.1] vs 28.4 [9.2]; P=0.003) at the end of the case. Stress was rated higher in the MRI-OR after induction of anaesthesia (26.5 [15.5] vs 20.9 [13.4]; P=0.006). Effect sizes (Cohen's D) were moderate to good. CONCLUSIONS: Anaesthesia clinicians reported lower perceived safety and higher workload, anxiety, and stress in a remote MRI-OR compared with a standard OR. Improving non-standard work settings should benefit clinician well-being and patient safety. CLINICAL TRIAL REGISTRATION: .

Survey research in anesthesiology: a field guide to interpretation.

BACKGROUND: Survey research, indispensable for assessing subjective outcomes in anesthesiology, can nonetheless be challenging to undertake and interpret. OBJECTIVE: To present a user-friendly guide for the appraisal of survey-derived evidence, and to apply it to published survey research in the anesthesia literature. METHODS: Synthesizing published expert guidance regarding methodology and reporting, we discuss five essential criteria (with subcomponents) for evaluating survey research: (1) relevance of survey outcome to research objective, (2) trustworthiness of the instrument (testing/validation, availability), (3) collecting information well (sampling, administration), (4) representativeness (response rate), and (5) guidance towards interpretation of survey findings (generalizability, interpretation of numerical outcomes). These criteria were subsequently applied by two independent assessors to original research articles reporting survey findings, published in the five highest impact general anesthesia journals ('Anaesthesia', 'Anesthesia & Analgesia', 'Anesthesiology', 'British Journal of Anaesthesia' and 'European Journal of Anaesthesiology') between July 01, 2016, and December 31, 2017, which were identified using a prespecified PubMed search strategy. RESULTS: Among 1107 original articles published, we identified 97 reporting survey research either employing novel survey instruments (58%), established surveys (30%), or sets of single-item scores (12%). The extent to which reader-oriented benchmarks were achieved varied by component and between survey types. Results were particularly mixed for validation (mentioned for 41% of novel and 86% of established surveys) and discussion of generalizability (59% of novel survey reports, 45% of established surveys, and 17% of sets of single-item scores). CONCLUSION: Survey research is not uncommon in anesthesiology, frequently employs novel survey instruments, and demonstrates mixed results in terms of transparency and interpretability. We provide readers with a practical framework for critical interpretation of survey-derived outcomes.

Characterizing Anesthetic Management and Perioperative Outcomes Associated with a Novel, Fusionless Scoliosis Surgery in Adolescents.

Anterior vertebral tethering (AVT) is a novel "fusionless" surgical approach to correct scoliosis. This study aims to characterize the anesthetic management and perioperative outcomes of AVT and traditional posterior spinal fusion (PSF) after establishing the technique at our institution. Scoliosis correction procedures performed in patients aged 10 to 21 years between January 2014 and August 2017 were identified in the electronic medical record. Patient characteristics and perioperative data about anesthetic use and pain management were extracted. Descriptive statistics were generated. Thirty-five patients undergoing AVT and 40 patients undergoing PSF met inclusion criteria. Preoperative fluoroscopy-guided epidural placement was used only in the AVT group (86%). The worst pain score on postoperative day (POD) 1 after AVT was a mean (SD) of 5.6 (2.3), with average pain scores on subsequent days ranging from 2.9 (1.2) to 3.6 (1.7). Total in-hospital opioid consumption in morphine milligram equivalents was 70 (76.6) for AVT and 193.4 (137.2) for PSF (P < .01). Discharge occurred on POD 4.4 (1.4) for AVT and POD 6.2 (1.9) for PSF (P < .01). The worst pain score on POD 1 for PSF was 6.6 (2.1), and average pain scores ranged from 3.7 (1.8) to 4.2 (1.8). These results help inform about the expected recovery profile and narcotic requirement after AVT and PSF.

Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review.

BACKGROUND AND OBJECTIVE: Hybrid operating room suites with intraoperative magnetic resonance imaging enable image guided surgery in a fully functional operating room environment. While this environment creates challenges to anesthetic care, the effects on anesthetic adverse events and outcomes are largely unknown. This systematic scoping review aims to map the existing knowledge about anesthetic care in advanced imaging hybrid operating rooms. METHODS: A broad-based literature search was performed using the PubMed (Medline), Embase, Cochrane Library, Web of Science, and Google Scholar databases. References published in English between January 1994 and August 2017 were included. Quality of evidence was assessed using the GRADE guidelines. RESULTS: Forty-seven manuscripts were eligible for data collection. Adverse events were heterogeneously defined across 17 manuscripts and occurred in 0 to 100% (quality of evidence mostly very low). Monitoring difficulty was reported in 4 manuscripts of very low data quality. Interference between the magnet and the electrocardiogram was investigated in 2 manuscripts (quality of evidence low and very low, respectively). None of the reported events appeared to result in long-term patient harm. Author recommendations or a narrative review of the literature were provided in 40 manuscripts. Common safety concerns included lower equipment reliability, inaccessibility of the patient and airway, and the relative isolation of the suite (in relationship to other anesthesia care areas). Most authors also emphasized the importance of safety checklists, protocols, and provider training. DISCUSSION: While intraoperative magnetic resonance imaging hybrid operating rooms are increasingly utilized, the existing literature does not allow estimating adverse event rates in this location. Prospective studies quantifying the effect of the environment on anesthesia outcomes are lacking. Despite this, there is a broad consensus regarding the anesthetic and safety concerns. More research is needed to inform practice standards and training requirements for this challenging environment.

Time Trends and Predictors of Abnormal Postoperative Body Temperature in Infants Transported to the Intensive Care Unit.

Background. Despite increasing adoption of active warming methods over the recent years, little is known about the effectiveness of these interventions on the occurrence of abnormal postoperative temperatures in sick infants. Methods. Preoperative and postoperative temperature readings, patient characteristics, and procedural factors of critically ill infants at a single institution were retrieved retrospectively from June 2006 until May 2014. The primary endpoints were the incidence and trend of postoperative hypothermia and hyperthermia on arrival at the intensive care units. Univariate and adjusted analyses were performed to identify factors independently associated with abnormal postoperative temperatures. Results. 2,350 cases were included. 82% were normothermic postoperatively, while hypothermia and hyperthermia each occurred in 9% of cases. During the study period, hypothermia decreased from 24% to 2% (p < 0.0001) while hyperthermia remained unchanged (13% in 2006, 8% in 2014, p = 0.357). Factors independently associated with hypothermia were higher ASA status (p = 0.02), lack of intraoperative convective warming (p < 0.001) and procedure date before 2010 (p < 0.001). Independent associations for postoperative hyperthermia included lower body weight (p = 0.01) and procedure date before 2010 (p < 0.001). Conclusions. We report an increase in postoperative normothermia rates in critically ill infants from 2006 until 2014. Careful monitoring to avoid overcorrection and hyperthermia is recommended.

Seizure After Abdominal Surgery in an Infant Receiving a Standard-Dose Postoperative Epidural Bupivacaine Infusion.

We present the case of an otherwise healthy 12-month-old girl undergoing repair of a giant omphalocele, who experienced a postoperative seizure attributed to accumulation of bupivacaine from an epidural infusion. Whereas a standard dose was used, this patient experienced temporary liver dysfunction postoperatively, presumably from elevated intra-abdominal pressures, predisposing her to toxicity after a prolonged infusion. This case illustrates how the type of surgery can influence the margin of safety of routinely used neuraxial local anesthetic doses in infants and young children.

Airway laser procedures in children and the American Society of Anesthesiologists' Practice Advisory: a survey among pediatric anesthesiologists.

BACKGROUND AND OBJECTIVES: Recognizing the risk of fire during laser procedures involving the airway, the American Society of Anesthesiologists (ASA) developed recommendations designed to promote safe practice and reduce burn injuries. The aim of this study was to identify how reported anesthetic management of airway laser endoscopies in pediatric patients aligns with the ASA Practice Advisory (ASA-PA). METHODS: An online survey was created in an iterative process, pilot-tested, and distributed using the Society for Pediatric Anesthesia's (SPA) membership email list. Responses were analyzed using descriptive statistics. RESULTS: Responses from 322 respondents were included, 296 (92%) of whom participated in pediatric laser airway procedures. Fifty-nine respondents (20%) reported the use of an inspired fraction of oxygen (FiO2) of 90% or greater during laser activation in patients with a native airway, and 101 (34%) reported not waiting after the reduction of the FiO2 and laser activation in the airway. Sixty-four (36%) of respondents reporting the use of a non-laser-safe tube during laser airway cases did so due to a lack of availability of a laser specific tube or size limitations. Six respondents (2%) reported an airway fire during a laser procedure in a child under their care. CONCLUSIONS: Our results indicate that, in general, pediatric anesthesiologists do not adhere to the ASA-PA in several important aspects. Possible explanations might be knowledge deficiencies about the Practice Advisory or a perceived limited clinical applicability in the pediatric setting. Regardless, airway fires during laser airway surgeries in this population do occur, emphasizing the need for safe practice standards for both anesthesiologists and surgeons.

Vocal cord function and bispectral index in pediatric bronchoscopy patients emerging from propofol anesthesia.

OBJECTIVE: In children undergoing bronchoscopy for evaluation of stridor or respiratory symptoms, movement of the vocal cords is routinely assessed at the conclusion of flexible bronchoscopy with children still anesthetized. The effect of anesthesia on vocal cord function is not well described. This study aimed to characterize the relationship between depth of propofol anesthesia, as measured by Bispectral Index (BIS), and vocal cord movement in pediatric patients. METHODS: Children between 6 months and 12 years of age presenting for diagnostic flexible bronchoscopy were enrolled in this prospective observational study. Anesthesia was maintained with a propofol infusion which was discontinued upon completion of the lower airway evaluation. An independent observer recorded the BIS score every 15 sec from discontinuation of propofol whereas the pulmonologist continued to observe vocal cord motion. BIS scores were also recorded for each observed clinical endpoint (paradoxical and normal vocal cord movement, complete vocal cord closure, and volitional movement). RESULTS: Data were analyzed for 47 subjects. The BIS values increased significantly from the conclusion of the lower airway evaluation with return of normal vocal cord movement, complete vocal cord closure, and volitional movement (P < 0.0005). BIS readings were higher for patients younger than 2 years. Paradoxical vocal cord movement was documented in 10.6% of subjects, but resolved in all subjects. CONCLUSIONS: Our findings suggest that return of vocal cord function during emergence from propofol anesthesia is related to decreasing anesthetic depth with complete vocal cord closure occurring at BIS values near those associated with volitional movement.