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1: Elevated heart rate after non-cardiac surgery: post-hoc analysis of a prospective observational cohort study
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Posted 02 Nov 2019

Elevated heart rate after non-cardiac surgery: post-hoc analysis of a prospective observational cohort study
19,976 downloads medRxiv anesthesia

Amour B. U. Patel, Shaun M. May, Anna Reyes, Gladys Martir, David Brealey, Robert C. M. Stephens, Tom E. F. Abbott, Gareth L Ackland

BackgroundElevated heart rate (HR) is associated with accelerated mortality and independently predicts poorer outcomes in patients discharged from hospital after myocardial infarction and/or heart failure. We examined whether resting HR measured within 24 hours of hospital discharge following elective non-cardiac surgery was elevated compared to preoperative values. We also investigated the relationship between changes in HR with and/or autonomic function associated with morbidity after surgery. MethodsWe conducted a post-hoc analysis of HR data obtained in a prospective observational cohort study of patients [&ge;]18years in whom serial Holter-based measurements of cardiac autonomic activity were made before, and for 48h after, surgery. The primary outcome was absolute discharge HR (beats minute-1), recorded at rest before hospital discharge. We examined the association between quartiles of discharge HR and autonomic measures (time/frequency domain heart rate variability) associated with morbidity (defined by Postoperative morbidity survey). ResultsIn 157 patients (66 (42%) male; age 67(9) years), HR at hospital discharge (range: 53-122) increased by 5 beats minute-1 (95%CI:3-7;p<0.001) compared to preoperative values. Patients in the upper quartile of discharge HR ([&ge;]85bpm) were more likely to sustain pulmonary (odds ratio (OR):2.18 (95%CI:1.07-4.44);p=0.03) and infectious (OR:2.31 (95%CI:1.13-4.75);p=0.02) morbidity within seven days of surgery, compared to lower quartiles. Pulmonary/infectious morbidity was associated with loss of cardiac vagal activity. ConclusionsHeart rate on discharge from hospital following major elective non-cardiac surgery is frequently elevated and is promoted by morbidity associated with reductions in cardiac vagal activity.

2: The BathRC model: a method to estimate flow restrictor size for dual ventilation of dissimilar patients
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Posted 17 Apr 2020

The BathRC model: a method to estimate flow restrictor size for dual ventilation of dissimilar patients
2,564 downloads medRxiv anesthesia

Andrew R Plummer, Jonathan L du Bois, Joseph M Flynn, Jens Roesner, Siu Man Lee, Patrick Magee, Malcolm Thornton, Andy Padkin, Harinderjit S Gill

With large numbers of COVID-19 patients requiring mechanical ventilation and ventilators being in short supply, in extremis two patients are having to share one ventilator. This possibility has been discussed for at least two decades, and careful matching of patient ventilation requirements is advised. However, with a large range of lung compliance and other characteristics, which may also vary with time, good matching is difficult to achieve. Adjusting the impedance of the flow path between ventilator and patient gives the opportunity to control the airway pressure and hence flow and volume individually for each patient. Several groups are now investigating this, in particular the addition of a flow restrictor in the inspiration tube for the patient who is more compliant, or requires a lower tidal volume. In this paper, we show that a simple linear resistance-compliance model, termed the BathRC model, of the ventilator tubing system and lung allows direct calculation of the relationships between pressures, volumes, and required flow restriction. The BathRC model is experimentally validated using a GE Aisys CS2 ventilator connected to two test lungs. The pressure-flow relationships for two restrictors are experimentally determined, and despite the need to approximate them with a linear resistance characteristic, their effect in the breathing circuit is accurately predicted by the simple model. The BathRC model is freely available for download; we do not condone dual ventilation, but this tool is provided to demonstrate that flow restriction can be readily estimated. This research is part of a larger test, simulation and design investigation on dual ventilation being undertaken at the UoB and RUH.

3: Efficacy of Ultrasound-Guided Erector Spinae Plane Block for Perioperative Pain Control and Short-Term Outcomes in Lumbar Laminoplasty
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Posted 03 Feb 2020

Efficacy of Ultrasound-Guided Erector Spinae Plane Block for Perioperative Pain Control and Short-Term Outcomes in Lumbar Laminoplasty
1,684 downloads medRxiv anesthesia

Yanwu Jin, Shanshan Zhao, Jiahui Cai, Marcelle Blessing, Yongtao Sun, Shuai Hu, Qi Han, Xin Zhao, Haizhu Tan, Jinlei Li

BackgroundErector spinae plane (ESP) block has been reported to provide analgesia in spine surgery in case reports or case series, and there have been no controlled studies to date evaluating its efficacy. We aimed to exam the roles of ESP block in lumbar surgery in a single center randomized control trial by injecting local analgesic into the interfacial plane between the erector spinae muscles and the transverse process under ultrasound guidance. MethodsConsecutive elective lumbar surgery patients were randomized into either a control group (general anesthesia only, Group G, N=32) or a treatment group (general anesthesia plus ESP block, Group E, N=30). Several parameters including visual analog scale (VAS, primary outcome), perioperative anesthetics and analgesics usage, indexes of hemodynamics variation, return of bowel function and overall benefit of analgesia score (OBAS) were measured. ResultsSignificant differences in VAS scores over time were found between the two matched groups (P = 0.010). Group E patients had significantly lower pain scores than Group G patients in the early postoperative period within the first 6 hr. Group G and Group E VAS scores peaked at 1 hr and 12 hr, respectively, and the peak pain score in Group G is significantly higher than that of Group E (P = 0.002). In addition, patients who received ESP block had lower perioperative analgesic and sedative medication requirements, improved satisfaction with pain management, more stable hemodynamics, and earlier bowel function return than those using general anesthesia alone. ConclusionPre-incision bilateral single injection ESP blocks provided effective analgesia perioperatively during lumbar laminoplasty, decreased perioperative anesthesia and analgesia requirement, and accelerated short-term recovery.

4: Anaesthetic managment and clinical outcomes of parturients with COVID-19: a multicentre, retrospective, propensity score matched cohort study
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Posted 27 Mar 2020

Anaesthetic managment and clinical outcomes of parturients with COVID-19: a multicentre, retrospective, propensity score matched cohort study
1,636 downloads medRxiv anesthesia

Yuan Zhang, Rong Chen, Jie Wang, Yuan Gong, Qin Zhou, Hui-hui Cheng, Zhong-yuan Xia, Xiangdong Chen, Qing-tao Meng, Daqing Ma

ObjectiveTo analyse the clinical features of COVID-19 parturients, and to compare anaesthetic regimen and clinical outcomes in parturients with or without COVID-19 undergoing cesarean delivery. MethodData were extracted from the electronic medical record of 3 medical institutions in Hubei Province, China, from June 1, 2019 to March 20, 2020 according to inclusion and exclusion criteria. After propensity score matching with demographics, the clinical and laboratory characteristics of parturients with or without COVID-19 were analysed. The anaesthetic regimen and clinical outcomes of themselves and their infants were compared in these two groups of parturients. ResultsA total of 1,588 patients without SARS-CoV-2 infection undergoing cesarean delivery were retrospectively included. After achieving a balanced cohort through propensity score matching, 89 patients (COVID-19 group), who were diagnosed with COVID-19 by SARS-CoV-2 nucleic acid test and CT scan matched with 173 patients without COVID-19 (Control group). The SARS-CoV-2 infected parturients in the early stages of COVID-19 outbreak was much more than during the later stage. The main clinical characteristics of parturients with COVID-19 were fever (34.8%), cough (33.7%), an increased plasma CRP (52.8%) and a decreased lymphocyte counting (33.7%). A high rate of emergency and a high incidence of anaesthesia-related complications, such as pharyngalgia, multiple puncture, intraoperative hypotension, nausea, vomiting, vertigo and chills in the COVID-19 parturients. In addition, the parturients with COVID-19 had a long duration of operation and hospital stay, and an increased intraoperative oxytocin utilization and postoperative oxygen therapy. The newborns from the SARS-CoV-2 infected mothers, who received general anaesthesia, had a high risk of Apgar score [&le;] 8 at 1 and 5 minutes after delivery and a higher rate of neonatal intensive care unit (NICU) admission. ConclusionsAnaesthesia-related complications occur more frequently in the COVID-19 parturients and their newborns have a high risk of distress.

5: Modifying reusable elastomeric respirators to utilise breathing system filters with 3D printed adapters, a safe alternative to N95 during COVID-19
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Posted 15 Apr 2020

Modifying reusable elastomeric respirators to utilise breathing system filters with 3D printed adapters, a safe alternative to N95 during COVID-19
1,437 downloads medRxiv anesthesia

Dexter Chee Yuen Liu, Tai Hong Koo, Jackson Kai Kit Wong, Ying Hong Wong, Kitty Sau Chun Fung, Yung Chan, Huey Sing Lim

The COVID-19 pandemic has caused a worldwide shortage of personal protective equipment including N95 and FFP3 respirators. Reusable elastomeric respirators are suitable alternatives when used with compatible filters. These filters may be difficult to source and elastomeric respirators are not recommended for surgical use as the exhaled air is not filtered. Breathing system filters are routinely used in anaesthetic circuits to filter virus and bacteria. In this study, we designed 3D printed adapters that allowed elastomeric respirators to utilise breathing system filters and made simple modifications to the respirators to filter exhaled breaths. We then evaluated the performance and safety of our modified elastomeric respirators with quantitative fit tests. We recruited 8 volunteers to perform quantitative fit tests. Fit factors, respiratory rate and end-tidal carbon dioxide were recorded before and after wearing the modified respirators for 1 hour. All 8 volunteers obtained fit factors of 200+, the maximum achievable, for all tests exercises in all fit tests. The mean (range) end-tidal carbon dioxide was 4.5 (3.9-5.5) kPa and 4.6 (range 4.1-5.3) kPa before and after 1 hour of usage. The mean (range) respiratory rate was 16.5 (11-24) min-1 and 17.4 (15-22) min-1 before and after 1 hour of usage. Four (50%) did not experience any subjective discomfort while 2 (25%) reported pressure on the face, 1 (12.5%) reported exhalation resistance and 1 (12.5%) reported transient dizziness with exertion. Breathing system filters combined with properly fitted reusable elastomeric respirators is a safe alternative to N95 during the COVID-19 pandemic.

6: Tumescent Local Anesthesia: A Systematic Review of Outcomes
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Posted 14 Aug 2020

Tumescent Local Anesthesia: A Systematic Review of Outcomes
1,431 downloads medRxiv anesthesia

Yu Liu, Sanjana Lyengar, Chrysalyne D Schmults, Emily S Ruiz, Robert Besaw, Laura K Tom, Michelangelo Giovanni Vestita, Jason Kass, Abigail H Waldman

IMPORTANCE: Tumescent local anesthesia (TLA, whereby anesthesia is achieved by injection of a highly diluted solution of local anesthesia into skin and subcutaneous tissues) is a technique for delivering anesthesia for superficial surgical procedures. TLA obviates the need for general anesthesia or intravenous sedation in most cases. Pain control and TLA-related complications are key factors in determining the success of TLA. OBJECTIVE: To conduct a systematic review of the English medical literature data regarding pain control and TLA-related complications in TLA surgical cases to determine its efficacy and safety EVIDENCE REVIEW: The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Searches of both the MEDLINE and EMBASE databases were performed. Articles using 10-point quantitative scales were included in the pain analysis. Complications were tabulated from cohort studies, case series, and case reports. A total of 184 articles cotaining reports of 71,483 surgical procedures met inclusion criteria, including 43 with pain outcomes and 141 reporting complications. FINDINGS: Liposuction procedures were associated with relatively low degree of both intra-operative pain (10-point visual analog scale 1.1 +/- 2.1) and post-operative pain (0.53 +/- 0.44) and the fewest complications (1.2%). The highest intra-operative and post-operative pain was reported in facial/cleft-lip surgery (3.7 and 3.99, respectively), while mastectomy was associated with highest post-operative complication risk (20.8%). There were 8 reported cases of death unlikely related to TLA: pulmonary embolus (4 cases), complications related to concurrent general anesthesia (2 cases), hemorrhage, and visceral perforation. There were 5 reported cases of death related to TLA (lidocaine/bupivacaine toxicity in 4 cases and one case of fluid overload) during its development when optimal dose and volume parameters were being established. There have been no TLA-associated deaths reported in the 33,429 cases published since 2003. CONCLUSIONS AND RELEVANCE This systematic review demonstrates TLA to be a safe and effective anesthetic approach. Its low-cost and rapid patient recovery warrant further studies of cost-reduction and patient satisfaction. Expanded education of TLA techniques in surgical and anesthesia training programs may be considered to broaden patient access to this anesthetic modality for cutaneous and subcutaneous surgical procedures.

7: Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19
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Posted 30 Mar 2020

Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19
1,342 downloads medRxiv anesthesia

C.T. Matava, J Yu, S. Denning

Protection of frontline HCPs is paramount. However, PPE is a limited resource and often requires providers to be adaptive and resourceful in a crisis. The inexpensive and simple method of using clear drapes during extubation (and possibly intubation) of COVID-19 patients may be considered by frontline HCPs and infection control specialists as an additional precaution. Modifications of the clear plastics can be adapted for surgical procedures that may be AGMPs.

8: Evaluation of the comparative risk of aerosol generation by tracheal intubation and extubation in the operating theatre
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Posted 31 Aug 2020

Evaluation of the comparative risk of aerosol generation by tracheal intubation and extubation in the operating theatre
1,229 downloads medRxiv anesthesia

Jules Brown, Florence KA Gregson, Andrew Shrimpton, Bryan R Bzdek, Anthony E Pickering, Jonathan P Reid

Background Transmission of SARS-CoV-2 by bioaerosols is of increasing concern. The enhanced levels of personal protective equipment (PPE) and preventative measures to attenuate viral transmission during aerosol generating procedures (AGPs) are having a huge impact on healthcare provision. There is no quantitative evidence on the number and size of airborne particles produced during AGPs to inform risk assessments. Methods Real-time, high-resolution environmental monitoring was conducted in ultraclean ventilation operating theatres. Continuous sampling with an optical particle sizer allowed characterization of aerosol generation within the airway management zone during endotracheal intubation and extubation for urgent orthopaedic trauma or neuro-surgery. Results Aerosol monitoring showed a very low background particle count allowing resolution of the transient airborne particle plume produced by reference volitional coughs (maximum concentration, 1,690{+/-}140 particles.L 1,n=38). By comparison, endotracheal intubation including mask ventilation produced negligible quantities of aerosolized particles (maximum concentration, 80{+/-}10 L 1,n=14, P<0.001 vs cough). Extubation, particularly when the patient coughed, produced a detectable aerosol plume but with a smaller number of particles (<25%) than a volitional cough. Conclusions Using a volitional cough as a reference we have been able to produce a relative risk ranking for endotracheal intubation and extubation as potential AGPs. The study does not support the assignation of endotracheal intubation by direct laryngoscopy with manual ventilation as an AGP. Extubation does generate aerosols, particularly if the patient coughs, but these are weaker than a standard reference. These findings indicate the need for a reappraisal of guidance on PPE for AGPs.

9: Delirium and Neuropsychological Outcomes in Critically Ill Patients with COVID-19: an Institutional Case Series
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Posted 04 Nov 2020

Delirium and Neuropsychological Outcomes in Critically Ill Patients with COVID-19: an Institutional Case Series
1,031 downloads medRxiv anesthesia

Jacqueline Ragheb, Amy McKinney, Mackenzie Zierau, Joseph Brooks, Maria Hill-Caruthers, Mina Iskander, Yusuf Ahmed, Remy Lobo, Graciela Mentz, Phillip E. Vlisides

Delirium is a serious and common complication among critically ill patients with COVID-19. The objective of this study was to characterize the clinical course of delirium for COVID-19 patients in the intensive care unit, including post-discharge cognitive outcomes. A retrospective chart review was conducted for patients diagnosed with COVID-19 (n=148) admitted to an intensive care unit at Michigan Medicine between 3/1/2020 and 5/31/2020. Delirium was identified in 107/148 (72%) patients in the study cohort, with median (interquartile range) duration lasting 10 (4 - 17) days. Sedative regimens, inflammation, deviation from delirium prevention protocols, and hypoxic-ischemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/148, 38%). Among patients who were delirious during hospitalization, 4/17 (24%) later tested positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia, and 3/25 (12%) screened positive for depression within two months after discharge. Overall, patients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.

10: A hidden Markov model reliably characterizes ketamine-induced spectral dynamics in macaque LFP and human EEG
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Posted 16 Nov 2020

A hidden Markov model reliably characterizes ketamine-induced spectral dynamics in macaque LFP and human EEG
997 downloads medRxiv anesthesia

Indie C. Garwood, Sourish Chakravarty, Jacob Donoghue, Pegah Kahali, Shubham Chamadia, Oluwaseun Akeju, Earl K. Miller, Emery N Brown

Ketamine is an NMDA receptor antagonist commonly used to maintain general anesthesia. At anesthetic doses, ketamine causes bursts of 30-50 Hz oscillations alternating with 0.1 to 10 Hz oscillations. These dynamics are readily observed in local field potentials (LFPs) of non-human primates (NHPs) and electroencephalogram (EEG) recordings from human subjects. However, a detailed statistical analysis of these dynamics has not been reported. We characterize ketamines neural dynamics using a hidden Markov model (HMM). The HMM observations are sequences of spectral power in 10 Hz frequency bands between 0 to 50 Hz, where power is averaged within each band and scaled between 0 and 1. We model the observations as realizations of multivariate beta probability distributions that depend on a discrete-valued latent state process whose state transitions obey Markov dynamics. Using an expectation-maximization algorithm, we fit this beta-HMM to LFP recordings from 2 NHPs, and separately, to EEG recordings from 9 human subjects who received anesthetic doses of ketamine. Together, the estimated beta-HMM parameters and optimal state trajectory revealed an alternating pattern of states characterized primarily by gamma burst and slow oscillation activity, as well as intermediate states in between. The mean duration of the gamma burst state was 2.5s([1.9,3.4]s) and 1.2s([0.9,1.5]s) for the two NHPs, and 2.7s([1.9,3.8]s) for the human subjects. The mean duration of the slow oscillation state was 1.6s([1.1,2.5]s) and 0.7s([0.6,0.9]s) for the two NHPs, and 2.8s([1.9,4.3]s) for the human subjects. Our beta-HMM framework provides a useful tool for experimental data analysis. Our characterizations of the gamma-burst process offer detailed, quantitative constraints that can inform the development of rhythm-generating neuronal circuit models that give mechanistic insights into this phenomenon and how ketamine produces altered states of arousal.

11: Pathway for Enhanced Recovery after Spinal Surgery-A Systematic Review of Evidence for use of Individual Components
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Posted 17 Aug 2020

Pathway for Enhanced Recovery after Spinal Surgery-A Systematic Review of Evidence for use of Individual Components
981 downloads medRxiv anesthesia

Ana Licina, Andrew J Silvers, Harry Laughlin, Jeremy Russell, Crispin Wan

Background Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on societal recommendations and qualitative reviews. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. Methods We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined care components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). We searched the following databases (1990 onwards) MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. A narrative synthesis was provided. Where applicable, we constructed Evidence Profile (EP) tables for each individual element. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. Confidence in cumulative evidence for each component of the pathway was classified according to the GRADE system. Results We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We found specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables for 12/22 components. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. Discussion We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

12: Modified Long-Axis In-Plane Ultrasound Versus Short-Axis Out-of-Plane Ultrasound For Radial Arterial Cannulation:A Prospective Randomized Controlled Trial
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Posted 04 Sep 2019

Modified Long-Axis In-Plane Ultrasound Versus Short-Axis Out-of-Plane Ultrasound For Radial Arterial Cannulation:A Prospective Randomized Controlled Trial
947 downloads medRxiv anesthesia

Jiebo Wang, Liangcheng Zhang, Qijian Huang, Zhongmeng Lai, Guohua Wu, Lei Lin, Junle Liu, Xianfeng Weng

BACKGROUNDGiven a low first-pass success rate of the conventional SAX (short-axis) or LAX (long-axis) approach, ultrasound-guided radial artery cannulation in adults with radial artery diameter less than 2.2 mm may be still challenging. OBJECTIVETo assess the efficacy of modified long-axis in-plane(M-LAIP) versus short-axis out-of-plane (SAOP) or conventional palpation(C-P) approaches for ultrasound-guided radial artery cannulation. DESIGNA prospective, randomized and controlled trial. SETTINGOperating room in a tertiary university hospital, from 1 July 2018 to 24 November 2018. PATIENTSA total of 201 patients (age 18 to 85 years, the diameter of the radial artery less 2.2 mm) were included. Patients with history of forearm surgery, ulnar artery occlusion, abnormal Allen test, etc, were excluded from this study. INTERVENTIONSAll patients were randomized 1:1:1 to M-LAIP, SAOP or C-P. MAIN OUTCOME MEASURESThe primary outcome was the cannulation success rate. Secondary outcomes included first location time and cannulation time, number of attempts. RESULTSThe cannulation success rate was significantly higher in the M-LAIP group than in the SAOP group or C-P group (first success rate: 80.3% vs 53.8% or 33.8%; p =0.000; total success rate: 93.9% vs 78.5% or 50.8%; p =0.000). First location time (s) was significantly longer in the M-LAIP group compared with the SAOP group (31(28-35[12-44]) vs 15(14-17[10-21]); p =0.000) and the C-P group (31(28-35[12-44]) vs 12(8-13.5 [6-37]); p =0.000). However, the time of cannulation in the M-LAIP group (29(24-45[16-313])) was significantly shorter than that in the SAOP group (45(28.5-135.5[14-346]), p =0.002) and in the C-P group(138(27-308[12-363]), p =0.000). The number of attempts decreased in the M-LAIP group compared with SAOP or C-P group (1.29{+/-}0.63 vs 1.8{+/-}0.89 or 2.22{+/-}0.93, p =0.000). CONCLUSIONThe M-LAIP procedure for ultrasound-guided radial artery cannulation can offer a higher success rate of the first-attempt and total cannulation, fewer attempts and less time of cannulation. TRIAL REGISTRATIONThe study was registered at ClinicalTrials.gov (http://www.chictr.org.cn/index.aspx, number: ChiCTR-IOR-17011474).

13: Estimation of the number of general anesthesia cases based on a series of nationwide surveys on Twitter during COVID-19 in Japan: A statistical analysis
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Posted 12 May 2020

Estimation of the number of general anesthesia cases based on a series of nationwide surveys on Twitter during COVID-19 in Japan: A statistical analysis
946 downloads medRxiv anesthesia

Yosuke Fujii, Hiroki Daijo, Kiichi Hirota

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in Wuhan, Hubei, China, and has since spread to more than 200 other countries at the time of writing. In light of this situation, the Japanese Government declared a state of emergency in seven regions of Japan on the April 7, 2020 under the provisions of the law. The medical care delivery system has been under pressure. Although various surgical societies have published guidelines on which to base their surgical decisions, it is not clear how general anesthesia has been performed and will be performed in Japan. Social networks such as Twitter are becoming a part of society, as various information is accumulated on the web. One of the services provided by Twitter is a voting function-Twitter Polls-through which anonymous surveys can be conducted. We analyzed the results of a series of surveys on Twitter on the status of operating restrictions using a mathematical model, and public data provided by the Japanese Government were used to estimate the current and future changes in the number of general anesthesia performed in Japan. The number of general anesthesia was estimated as 2.77*104 cases per week on 2nd May 2020 and 0.68*104 cases in 24 weeks.

14: A Novel Multi-ventilation Technique to Split Ventilators
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Posted 05 May 2020

A Novel Multi-ventilation Technique to Split Ventilators
934 downloads medRxiv anesthesia

Albert Lee, Soban Umar, Nir Hoftman

Background: Despite efforts to initially contain Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), it has spread worldwide and has strained international healthcare systems to the point where advanced respiratory resources and ventilators are depleted. This study aims to explore splitting ventilators, or multi-ventilation, as a viable alternative in these demanding times. We investigated whether individualized tidal volume and positive end expiratory pressure (PEEP) delivery is possible to lungs of different compliances that are being simultaneously ventilated from one anesthesia ventilator. Methods: We performed a controlled experiment in an operating room environment without animal or human participants. Two test lungs were connected to distinct modified Y-pieces that were ventilated in parallel from a single anesthesia ventilator. Results: Ventilation can be manipulated to qualitatively deliver individually tailored tidal volumes in the setting of varying PEEP and compliance requirements in pressure control mode. Conclusions: Splitting ventilators, or multi-ventilation, is a viable alternative to acute ventilator shortage during a pandemic. Ventilators can be split for individualized tidal volume and positive end-expiratory pressure delivery in multiple subjects of differing compliances and demographics.

15: A Processed EEG based Brain Anesthetic Resistance Index Predicts Postoperative Delirium in Older Adults: A Dual Center Study
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Posted 08 Jan 2021

A Processed EEG based Brain Anesthetic Resistance Index Predicts Postoperative Delirium in Older Adults: A Dual Center Study
872 downloads medRxiv anesthesia

Mary Cooter, Thomas Bunning, Sarada S. Eleswarpu, Mitchell T. Heflin, Shelley McDonald, Sandhya Lagoo-Deenadalayan, Heather Whitson, Stacie G. Deiner, Miles Berger

BackgroundSome older adults show exaggerated responses to drugs that act on the brain, such as increased delirium risk in response to anticholinergic drugs. The brains response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG based-measure of the brains neurophysiologic resistance to anesthetic dose-related changes, and hypothesized that it would predict postoperative delirium. MethodsWe defined the Duke Anesthesia Resistance Scale (DARS) as the average BIS index divided by the quantity 2.5 minus the average age-adjusted end-tidal MAC (aaMAC) inhaled anesthetic fraction. The relationship between DARS and postoperative delirium was analyzed in derivation (Duke; N=69), validation (Mt Sinai; N=70), and combined estimation cohorts (N=139) of older surgical patients (age [&ge;]65). In the derivation cohort, we identified a threshold relationship between DARS and for delirium and identified an optimal cut point for prediction. ResultsIn the derivation cohort, the optimal DARS threshold for predicting delirium was 27.0. The delirium rate was 11/49 (22.5%) vs 11/20 (55.0%) and 7/57 (12.3%) vs 6/13 (46.2%) for those with DARS [&ge;] 27 vs those with DARS < 27 in the derivation and validation cohorts respectively. In the combined estimation cohort, multivariable analysis found a significant association of DARS <27.0 with postoperative delirium (OR=4.7; 95% CI: 1.87, 12.0; p=0.001). In the derivation cohort, the DARS had an AUC of 0.63 with sensitivity of 50%, specificity of 81%, positive predictive value of 0.55, and negative predictive value of 0.78. The DARS remained a significant predictor of delirium after accounting for opioid, midazolam, propofol, non-depolarizing neuromuscular blocker, phenylephrine and ketamine dosage, and for nitrous oxide and epidural usage. ConclusionsThese results suggest than an intraoperative processed EEG-based measure of lower brain anesthetic resistance (i.e. DARS <27) could be used in older surgical patients as an independent predictor of postoperative delirium risk.

16: Minimising exposure to droplet and aerosolised pathogens: a computational fluid dynamics study
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Posted 03 Jun 2020

Minimising exposure to droplet and aerosolised pathogens: a computational fluid dynamics study
854 downloads medRxiv anesthesia

Paolo Perella, Mohammad Tabarra, Ertan Hataysal, Amir Pournasr, Ian Renfrew

Background Hazardous pathogens are spread in either droplets or aerosols produced during aerosol generating procedures (AGP). Adjuncts minimising exposure of healthcare workers to hazardous pathogens released during AGP may be beneficial. We used state-of-the-art Computational Fluid Dynamics modelling to optimise the performance of a custom-designed shield. Methods We modelled airflow patterns and trajectories of particles (size range 1-500{micro}m) emitted during a typical cough using Computational Fluid Dynamics (ANSYS Fluent software), in the presence and absence of a protective shield enclosing the head of a patient. We modelled the effect of different shield designs, suction tube position, and suction flow rate on particle escape from the shield. Results Use of the shield prevented escape of 99.1-100% of particles, which were either trapped on the shield walls (16-21%) or extracted via suction (79-82%). At most, 0.9% particles remained floating inside the shield. Suction flow rates (40-160L min-1) had no effect on the final location of particles in a closed system. Particle removal from within the shield was optimal when a suction catheter was placed vertically next to the head of the patient. Addition of multiple openings in the shield reduced the purging performance from 99% at 160 L min-1 to 67% at 40 L min-1. Conclusion Computational fluid dynamics modelling provides information to guide optimisation of the efficient removal of hazardous pathogens released during AGP from a custom-designed shield. These data are essential to establish before clinical use and/or pragmatic clinical trials.

17: Electronic Computer-Based Model of Combined Ventilation Using a New Medical Device
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Posted 20 Jan 2021

Electronic Computer-Based Model of Combined Ventilation Using a New Medical Device
839 downloads medRxiv anesthesia

Matias Ramos, Roberto Orofino, Diego Riva, Maria Fernanda Biancolini, Ignacio Lugones

IntroductionThe increased demand for mechanical ventilation caused by SARS-CoV-2 could generate a critical situation where patients may lose access to mechanical ventilators. Combined ventilation, in which two patients are connected to a single ventilator has been proposed as a bridge while waiting for new ventilators availability. DuplicAR is a new device that allows individualization of ventilatory parameters in combined ventilation models. Materials and MethodsWith an electronic circuit simulator applet, an electrical model of combined ventilation was created using resistor-capacitor circuits. The DuplicAR system electrical analog was added to the model. Through computational simulation, the model is tested in different scenarios with the aim of achieving adequate ventilation of two subjects under different circumstances: 1) two identical subjects; 2) two subjects with the same size but different lung compliance; and 3) two subjects with different size and compliance. The goal is to achieve the established load per unit of size on each capacitor under different levels of end-expiratory voltage (analog of end-expiratory pressure). Data collected included capacitor load and voltage, and load normalized to the weight of the simulated patient. ResultsIn the three simulated stages, it is possible to provide the proper load to each capacitor under different circumstances. If the pair of connected capacitors have different capacitances, adjustments must be made to the source voltage and/or the resistance of the DuplicAR system to provide the appropriate load for each capacitor under initial conditions. In pressure control simulation, increasing the end-expiratory voltage on one capacitor requires increasing the source voltage and the resistance on the other capacitor. On the other hand, in the volume control simulation, it is only required to intervene in the resistance. ConclusionsUnder simulated conditions, the electrical model of the DuplicAR system allows individualization of combined mechanical ventilation.

18: Anaesthetic Higher Specialty Training Recruitment in the United Kingdom During the COVID-19 Pandemic: A National Survey
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Posted 07 Jul 2021

Anaesthetic Higher Specialty Training Recruitment in the United Kingdom During the COVID-19 Pandemic: A National Survey
811 downloads medRxiv anesthesia

Fionnuala Durrant, Stuart Edwardson, Sally El-Ghazali, Christopher Holt, Roopa McCrossan, Ileena Pramanik, Jeevakan Subramaniam, Danny Jon Nian Wong

The most recent ST3 Anaesthetic recruitment for posts commencing in August 2021 saw larger numbers of applicants (n = 1,056) compared to previous years, with approximately 700 applicants failing to secure an ST3 post. We surveyed 536 anaesthetic junior doctors who applied for ST3 posts during this application round with the aim of investigating their experience of the recruitment process this year (response rate 536/1,056 = 51%). Approximately 61% were not offered ST3 posts (n = 326), a similar proportion to that previously reported. We asked all respondents what their potential career plans were for the next 12 to 24 months. The majority expressed intentions to take up either CT3 top-up posts or non-training fellow posts from August 2021 (79%). Other options considered by respondents included: pursuing work abroad (17%), embarking on a career break (16%), taking up an ST3 post in intensive care medicine instead of anaesthetics (15%) and permanently leaving the medical profession (9%). A number of respondents expressed a desire to pursue training in a different medical specialty (9%). Some respondents expressed an intention to pursue further education or research (10%). A large proportion of respondents (42%) expressed a lack of confidence in being able to achieve the necessary training requirements to later apply for ST4 in August 2023. The majority of respondents reported not feeling confident in achieving GMC Specialty Registration in Anaesthesia in the future without a training number (75%), and that their wider life plans have been disrupted due to the impending time out of training (78%). We received a total of 384 free-text responses to a question asking about general concerns regarding the ST3 applications process. Sentiment analysis of these free-text responses indicated that respondents felt generally negatively about the ST3 recruitment process. Some themes that were elicited from the responses included: respondents feeling the recruitment process lacked fairness, respondents suffering burnout and negative impacts on their wellbeing, difficulties in making plans for their personal lives, and feeling undervalued and abandoned despite having made personal sacrifices to support the health service during the COVID-19 pandemic. These results suggest that junior anaesthetic doctors in the UK currently have a negative perception towards postgraduate training structures, which has been exacerbated by the COVID-19 pandemic, changes to the postgraduate training curriculum and difficulties in securing higher training posts.

19: The Effects of Pericapsular nerve group (PENG) block on Postoperative Recovery in Elderly Patients with Hip fracture: a study protocol for randomized, parallel controlled, double-blind trial
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Posted 17 Mar 2021

The Effects of Pericapsular nerve group (PENG) block on Postoperative Recovery in Elderly Patients with Hip fracture: a study protocol for randomized, parallel controlled, double-blind trial
807 downloads medRxiv anesthesia

Wei Luo, Quehua Luo, Jieting Wu, Jianhui Liang, Huiyi Wu, Yanhua Ou, Yuhui Li, Wuhua Ma

Introduction Hip fracture is a common and serious emergency in the elderly, it is associated with severe pain, significant postoperative morbidity and mortality. Featuring peripheral nerve block in Enhanced recovery after surgery (ERAS) pathway may have significantly effect on shortening length of hospital stay, decreasing complications and costs ,particular in improvement in dynamic pain and reducing the use of opioid . Pericapsular Nerve Group Block(PENG), suggested by Arango et al, may provide a effective blockade to the articular branches of the anterior hip joint,which innervate the most section of the hip capsule richly, with a potential motor-sparing effect.The purpose of this trail is to investigate whether PENG is effective to enhanced recovery in elderly patients with hip fracture. Methods and analysis This study will be a single centre,randomized, parallel controlled, double-blind trail. 92 elderly patients scheduled for hip fracture surgery will be divided into two groups randomly to receive ultrasound-guided PENG block or ultrasound-guided femoral nerve(FN) block. The primary outcome will be compare the quality of recovery-15(QoR-15) score at 24h postoperatively between two groups.The secondary outcomes include the strength of quadriceps, the visual analogue scale(VAS) at rest and on movement, the total morphine consumption, the rescue analgesic, the first time of postoperative out-of-bed mobilization, the complications. Ethics and dissemination This study has been approved by the Medical Science Research Ethics Committees of The First Affiliated Hospital of Guangzhou University of Chinese Medicine on 15 December 2020 (Reference K2020-110) . The results of this study will be published in peer-reviewed international journals. Trial registration number ChiCTR2100042341. Key words Quality of recovery; hip fracture; Pericapsular nerve group; elderly patients

20: Paracoracoid versus Costoclavicular Approach to Infraclavicular Block: A Prospective, Two Arm, Parallel design, Single-centre Randomized Controlled Trial
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Posted 06 Oct 2020

Paracoracoid versus Costoclavicular Approach to Infraclavicular Block: A Prospective, Two Arm, Parallel design, Single-centre Randomized Controlled Trial
795 downloads medRxiv anesthesia

Brigid Brown, Pauline Magsaysay, Yves Bureau, Janice Yu, Shalini Dhir

IntroductionParacoracoid approach to the brachial plexus block is the conventional infraclavicular technique for upper limb surgeries. In this approach, the ultrasound transducer is placed in the parasagittal plane below the clavicle, medial to the coracoid process. In this view, three cords are separated from each other and are rarely visualized in a single ultrasound window. In the costoclavicular approach, the ultrasound transducer is placed parallel to and below the clavicle. In this view, the cords are clustered together, at a more superficial level. We conducted a randomized controlled trial to compare these two infraclavicular brachial plexus approaches. MethodsSeventy patients were randomized to receive either a paracoracoid or costoclavicular infraclavicular block. Both groups received 35 ml of 0.5% ropivacaine under ultrasound guidance. The primary outcome was sensory block onset time while secondary outcomes included performance times, complications during block insertion (paresthesia, vascular puncture, pleural puncture), block failure, patient satisfaction, and postoperative complications. Telephone follow-up was done 24 h and 7 days later. ResultsSensory block onset time was significantly shorter in the paracoracoid group 18.7 (4.4) min versus 22.2 (6.2) min (p=0.045). Block success at 30 minutes was the same between both groups. There was no difference in any secondary outcomes. ConclusionsThis randomized controlled trial demonstrated that the novel costoclavicular approach to the infraclavicular brachial plexus block had similar procedure time, block success and similar complication rates for upper limb surgery when compared to the traditional paracoracoid technique. However, it resulted in longer sensory block onset time.

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