Sir, The anesthesiologist is more than occasionally confronted with having to obtain or "augment" intravenous (IV) access. This frequently occurs with changes in patient positioning. Moreover, "tucking" or adduction of the arms may create "resistance" and additionally interfere with the appropriate flow of IV fluids. Existing IV access may also "clot off" or infiltrate; despite previously working successfully. Once in the prone position, the ability to obtain additional IV access can be challenging. The authors have utilized the external jugular vein (EJV) under these circumstances with relative ease Figure 1. On two occasions, EJV cannulation was achieved quickly. Furthermore, enough "backflow" was available to allow for venous blood gas assessment. Use of ultrasound guidance (USG) may also be beneficial to locate the vessel. In each of the two instances, the patients' arms were covered with padding and adducted. In addition, extensive hospitalization, obesity, and IV drug abuse made localization for peripheral venous access unobtainable; despite untucking of the patients' arms and employing USG and infrared-based optical devices.Figure 1: The external jugular vein should be considered when vascular access is required in prone-positioned patientsIt should be noted that EJV pressures, in supine-positioned patients, have been utilized for volume status measurement and have been documented to correlate with internal jugular venous pressures.[1] However, central venous pressure, measured from the internal jugular vein in the prone position, does not appear to correlate with measurements obtained using transesophageal echo.[2] Other devices, such as the esophageal Doppler monitor, have been reported for volume assessment and management in prone-positioned patients.[34] The anesthesiologist should be aware of the availability of the EJV should the need arise to obtain IV access in those patients who are in the prone position. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking.To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck.The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016.Microvascular reconstructive surgery of the head and neck.Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality.A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16).Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery.3.
Transesophageal echocardiography can be a useful monitor during noncardiac surgery, in patients with comorbidities and/or undergoing procedures associated with substantial hemodynamic changes. The goal of this study was to investigate if transesophageal-echocardiography-related knowledge could be acquired during anesthesia residency.After institutional review board approval, a prospective observational study was performed in two anesthesiology residency programs. After a 41-week didactic transesophageal-echocardiography-education curriculum residents' exam scores were compared to baseline. The educators' examination was validated against the National Board of Echocardiography's Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography.After the 41-week course, clinical anesthesia (CA)-3 exam scores increased 12% compared to baseline (P = .03), CA-2 scores increased 29% (P = .007), and CA-1 scores increased 25% (P = .002). Pearson correlation coefficient between the educators' exam score and the special competence exam percentile rank was 0.69 (P = .006). Pearson correlation coefficient between the educators' exam score and the special competence exam scaled score was 0.71 (P = .0045).The 41-week course resulted in significant increases in exam scores in all 3 CA-classes. While didactic knowledge can be learned by anesthesiology residents during training, it requires significant time and effort. It is important to educate residents in echocardiography, to prepare them for board examinations and to care for the increasingly older and sicker patient population. Further work needs to be done to determine optimal methods to provide such education.
During orthotopic liver transplantation a patient received epsilon-aminocaproic acid and clotting factors. Shortly after hepatic artery clamping the patient developed a massive intracardiac/intravascular thrombosis that resulted in cardiac arrest. After diagnosis by transesophageal echocardiography, the patient was treated with recombinant tissue plasminogen activator through a central venous catheter advanced into the right atrium. After treatment with recombinant tissue plasminogen activator, the patient's hemodynamic status improved, permitting the liver transplant to be completed. The patient was ultimately discharged to home. We report the successful intraoperative resuscitation of a patient with acute intracardiac/intravascular thrombosis during an orthotopic liver transplantation using thrombolytic therapy.
We read with interest the article, “A Critical Disconnect: Residency Selection Factors Lack Correlation With Intern Performance,” by Burkhardt et al and would like to commend the authors for their valuable investigation into the status quo of the residency match process.1 Their conclusion corroborates our experience. All residency programs seek to identify and recruit whom they believe are the most promising medical school graduates—typically based on USMLE scores, class ranking, clinical grades, letters of recommendation, etc.2 The assumption in this ranking process is that competitiveness via these criteria is the best available metric for judging future performance of resident physicians. Existing evidence suggests that programs are not particularly efficient at determining whether applicants selected in this manner will become top performers during their residency training.3We suspected that current applicant metrics are not adequate predictors and ultimately do not correlate strongly with eventual resident performance. We examined National Resident Matching Program (NRMP) rank order list data over a 15-year period of anesthesiology residents from our institution, with class sizes varying from 6 to 12 residents per year. We were able to ask 4 longstanding, full-time faculty members who were present for the entire residency experience of these classes to reflect and “re-rank” the matched candidates relative to each other. We were limited to faculty who felt that they remembered the candidates well enough to complete the task. Each eligible faculty member independently ranked the past graduates of each class from highest to lowest compared to their class peers. The ranking was based on the faculty's recollection of the residents after working with them during their residency. Faculty essentially re-ranked these residents based on their overall impression of the graduates after they experienced their individual strengths, shortcomings, and limitations. Descriptive analysis was performed comparing correlation between the percentile in the actual NRMP rank list position vs faculty raters' ranking of each resident.From our preliminary findings, there was general agreement among the faculty raters with considerable correlation (R = 0.567). While some variation in rankings among the faculty existed, no faculty member was an obvious outlier. Despite some evidence that residents taken higher in the NRMP rank list received higher impression ratings from the faculty, the association was quite weak with a lower correlation (R = 0.204).Our findings reinforce the authors' results and suggest some insight into how difficult it is to identify and predict potential for clinical excellence. Extensive time and resources are devoted to parameters that, in our opinion, weakly predicts future resident performance. Exploration of nontraditional metrics may prove more valuable than currently emphasized parameters.
Objective and Importance: Transient adenosine-induced asystole is a reliable method for producing short periods of relative hypotension during surgical and endovascular procedures. This technique has been described in the treatment of complex anterior and posterior circulation aneurysms and as a means of controlling bleeding during an intraoperative aneurysmal rupture. We describe the use of intravenous adenosine-induced asystole as a means of rapidly gaining control of intraoperative bleeding during the resection of a large cerebellopontine angle hemangioblastoma in a patient who could not receive blood transfusions due to religious belief.
Expert witnesses serve a crucial role in the medicolegal system, interpreting evidence so that it can be understood by jurors. Guidelines have been established by both the legal community and professional medical societies detailing the expectations of expert witnesses. The primary objective of this analysis was to evaluate the expertise of anesthesiologists testifying as expert witnesses in malpractice litigation.The WestlawNext legal database was searched for cases over the last 5 years in which anesthesiologists served as expert witnesses. Internet searches were used to identify how long each witness had been in practice. Departmental websites, the Scopus database, and state medical licensing boards were used to measure scholarly impact (via the h-index) and determine whether the witness was a full-time faculty member in academia.Anesthesiologists testifying in 295 cases since 2008 averaged over 30 years of experience per person (mean ± SEM, defense, 33.4 ± 0.7, plaintiff, 33.1 ± 0.6, P = 0.76). Individual scholarly impact, as measured by h-index, was found to be lower among plaintiff experts (mean ± SEM, 4.8 ± 0.5) than their defendant counterparts (mean ± SEM, 8.1 ± 0.8; P = 0.02). A greater proportion of defense witnesses were involved in academic practice (65.7% vs 54.8%, P = 0.04).Anesthesiologists testifying for both sides are very experienced. Defense expert witnesses are more likely to have a higher scholarly impact and to practice in an academic setting. This indicates that defense expert witnesses may have greater expertise than plaintiff expert witnesses.
Objective. Medicolegal examination of an intervention as common as endotracheal intubation may be valuable to physicians in many specialties. Our objectives were to comprehensively detail the factors raised in litigation to better educate physicians on strategies for minimizing liability and augmenting patient safety. Methods. Publicly available court records were searched for pertinent litigation. Ultimately, 214 jury verdict and settlement reports were examined for various factors, including outcome, award, geographic location, defendant specialty, setting in which an injury occurred, patient demographics, and other causes of malpractice. Results. Ninety-two cases (43.0%) were resolved in the defendant’s favor, with the remaining cases resulting in out-of-court settlement or a plaintiff’s verdict. Payments from these cases were considerable, averaging $2.5 M. The most frequent physician defendants were anesthesiologists (59.8%) and emergency-physicians (19.2%), although other specialties were well represented. The most common setting of injury was the operating room (45.3%). Common factors included sustaining permanent deficits (89.2%), death (50.5%), and anoxic brain injury (37.4%). Injuries occurring in labor and delivery mostly involved newborns and had among the highest awards. Conclusions. Litigation involves injuries sustained in numerous settings. The most common factors present included sustaining permanent deficits, including anoxic brain injury. The presence of this latter injury increased the likelihood of a case being resolved with payment. Finally, deficits in informed consent were noted in numerous cases, stressing the importance of a clear process in which the physician explains specific risks (such as those detailed in this analysis), benefits, and alternatives.
