Author: xenonilli

Checklists have their origins in aviation—planes are complex vehicles with a host of features that need to be checked before flight. Checklists offer pilots an easy, standardized system that ensures safety and thoroughness. Similarly, surgery is a complex system with many moving parts. Over the past two decades, health organizations and hospitals have developed surgical checklists as part of their protocols. Today, the World Health Organization recommends that checklists be included as a standard part of every surgical procedure.[1] 

Medical errors cause up to 100,000 deaths every year in the U.S., according to the Institute of Medicine. Unfortunately, many of these deaths are due to a lack of error management precautions.[2] However, the implementation of appropriate precautions through checklists have been shown to have a markedly positive effect on patient health. A study by Pronovost et al. found that mortality rates for patients in intensive care declined by 3.1% after a checklist was implemented. Patients also spent less time in the ICU and fewer days on the ventilator.[3] 

Studies have also demonstrated that checklists are particularly effective in ensuring positive patient outcomes in high-intensity medical fields like anesthesiology. A study by Hart et al. used an electronic checklist device, like the ones used by pilots, in anesthesia trials. An overwhelming majority— 95%—of participating anesthesiologists reported finding the electronic checklist useful in their procedure. 

In these high-intensity environments, information exchange during the preoperative process is of utmost importance. A study by Tscholl et al. found that 88% of anesthesia teams using an anesthesia pre-induction checklist displayed better knowledge of critical information and increased information exchange. They also managed to complete all of the procedures without a single medical error. The control group, which did not use a surgical checklist, experienced two critical errors.[4]  

A smooth postoperative process is essential to positive patient outcomes. However, studies have shown that the handoff process is particularly prone to miscommunication or other errors. A study by Dai and Robbins found that just 14% of postoperative handoffs were considered acceptable.[5] This was because members of the operating team frequently forgot to relay information about patients to the postoperative team. However, after the implementation of surgical checklists, 100% of postoperative handoffs in the study were deemed adequate. 

There is a direct connection between patients’ postoperative outcomes and the use of a checklist. A global study by Haynes et al. found that, on average, the use of checklists led to a 36% drop in postoperative complications.[6] Postoperative mortality rates fell by a similar amount. Indeed, over the past decade, an array of literature has demonstrated that checklists are effective in improving patient safety during procedures and their outcomes after the operation. 

References 

[1] Borchard A, Schwappach DL, Barbir A, Bezzola P. “A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.” Annals of Surgery. vol. 256, no. 6, 2012, pp. 925–33. doi: 10.1097/SLA.0b013e3182682f27. 

[2] Hales, Brigette M., and Peter J. Pronovost. “The Checklist—a Tool for Error Management and Performance Improvement.” Journal of Critical Care, vol. 21, no. 3, Elsevier BV, Sept. 2006, pp. 231–235. doi:10.1016/j.jcrc.2006.06.002. 

[3] Pronovost, Peter, et al. “Improving Communication in the ICU Using Daily Goals.” Journal of Critical Care, vol. 18, no. 2, Elsevier BV, June 2003, pp. 71–75. doi:10.1053/jcrc.2003.50008. 

[4] Tscholl, David W., et al. “An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.” Anesthesia & Analgesia, vol. 121, no. 4, 2015, pp. 948–956., doi:10.1213/ane.0000000000000671. 

[5] Robins, Holly-May, and Feng Dai. “Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care.” AANA Journal, vol. 83, no. 4, Aug. 2015, pp. 264–268. PMID: 26390744. 

[6] Haynes, Alex B., et al. “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.” New England Journal of Medicine, vol. 360, no. 5, 2009, pp. 491–499., doi:10.1056/nejmsa0810119. 

The blood-brain barrier (BBB) separates the central nervous system (CNS) from peripheral blood circulation.¹ Both blood vessel and endothelial cells form the BBB; specifically, endothelial cells line the microvasculature in the CNS.^2,3 The BBB limits pathogen and toxin entry to the brain’s microenvironment in order to maintain homeostasis for the CNS.^1,4,5 This safe environment helps optimize normal neuronal function.⁴ Certain types of anesthesia may affect the characteristics of the blood-brain barrier; further research is needed to clarify this relationship. 

In the BBB, tight junctions made up of claudin and occludin proteins control the movement of substrates into the CNS .³ These tight junctions connect adjacent endothelial cells by their lateral membranes. Nanometer-scale pores constrain paracellular transport between endothelial cells while allowing the transport of certain small molecules. Efflux pumps and solute carrier transporters in endothelial cells mediate transcellular molecular passage. Critically, tight junction dysregulation potentially contributes to a loss of BBB integrity and BBB breakdown.⁴  

The BBB regulates the movement of peptides, nutrients such as glucose, and waste products into and out of the CNS. Importantly, it also regulates the transport of medications.³ Passive and active mechanisms contribute to the BBB’s highly selective nature.⁶ Passive diffusion across the lipid bilayer allows small, lipophilic molecules across the membrane. P-gp transporters, on the other hand, actively transport specific molecules.   

A compromised blood-brain barrier may contribute to cognitive impairment, brain damage, and neurodegenerative disorders.¹ An intact BBB protects the fluid and substrate homeostasis of the brain, preventing edema.⁷ In particular, CNS function declines in the presence of inflammation, which may originate from outside the BBB.⁸ In animal models, BBB disruption also plays a role in cognitive impairment in Alzheimer’s disease, cerebral ischemia, hypertension, and type 2 diabetes mellitus.¹ In addition, research links increased BBB permeability to proinflammatory cytokine transport and β-amyloid clearance.¹ Weakened BBB integrity may also be related to the cognitive decline that accompanies healthy aging.⁹  

Similarly, research indicates that anesthesia potentially alters cognitive function as well. For example, anesthesia likely contributes to postoperative cognitive impairment in rodents, potentially via increased neuroinflammation, Aβ accumulation, and dysregulated mitochondrial homeostasis.^10-12  

Research also suggests that different anesthetics – particularly volatile ones – modulate BBB permeability.^2,5,7 Yang et al., for example, hypothesized that anesthesia specifically induces age-dependent blood-brain barrier dysfunction in mice.² Volatile anesthetics  may disrupt BBB integrity via vasodilation, though other studies suggest alternate pathways, such as isoflurane-induced apoptosis and altered tight junction structure.^5,13 

Consequently, blood-brain barrier disruption may explain the mechanism by which anesthesia contributes to postoperative cognitive impairment. Interestingly, however, one study found the anesthesia-induced damage to the BBB to be reversible, yet the cognitive decline still persisted even after BBB recovery.⁵ Much of the present research uses in vitro models and rodents to study this phenomenon. Thal et al., however, posits that healthy brain tissue potentially compensates for the changes that volatile anesthetics indue.⁷ These models – and rodents – may detect BBB dysfunction even as it overestimates the effect in healthy brain tissue. As anesthesia is a critical part of surgery, more research needs to further clarify the relationship between anesthesia, the blood-brain barrier, and cognitive impairment.  

References 

1. Zlokovic, B. V. The blood-brain barrier in health and chronic neurodegenerative disorders. Neuron 57, 178–201 (2008). https://doi.org/10.1016/j.neuron.2008.01.003. 

2. Yang, S. et al. Anesthesia and Surgery Impair Blood–Brain Barrier and Cognitive Function in Mice. Front. Immunol. 8, (2017). https://doi.org/10.3389/fimmu.2017.00902. 

3. Viscusi, E. R. & Viscusi, A. R. Blood–brain barrier: mechanisms governing permeability and interaction with peripherally acting μ-opioid receptor antagonists. Reg. Anesth. Pain Med. 45, 688–695 (2020). https://doi.org/10.1136/rapm-2020-101403. 

4. Hu, N. et al. Involvement of the blood–brain barrier opening in cognitive decline in aged rats following orthopedic surgery and high concentration of sevoflurane inhalation. Brain Res. 1551, 13–24 (2014). https://10.1016/j.brainres.2014.01.015. 

5. Cao, Y. et al. Isoflurane anesthesia results in reversible ultrastructure and occludin tight junction protein expression changes in hippocampal blood–brain barrier in aged rats. Neurosci. Lett. 587, 51–56 (2015). https://doi.org/10.1016/j.neulet.2014.12.018. 

6. Theodorakis, P. E., Müller, E. A., Craster, R. V. & Matar, O. K. Physical insights into the blood-brain barrier translocation mechanisms. Phys. Biol. 14, 041001 (2017). https://doi.org/10.1088/1478-3975/aa708a. 

7. Thal, S. C. et al. Volatile Anesthetics Influence Blood-Brain Barrier Integrity by Modulation of Tight Junction Protein Expression in Traumatic Brain Injury. PLoS ONE 7, (2012). https://doi.org/10.1371/journal.pone.0050752. 

8. Girard, T. D. et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit. Care Med. 38, 1513–1520 (2010). https://doi.org/10.1097/CCM.0b013e3181e47be1. 

9. Kanner, A. A. et al. Serum S100β: A noninvasive marker of blood-brain barrier function and brain lesions. Cancer 97, 2806–2813 (2003). https://doi.org/10.1002/cncr.11409. 

10. Wan, Y. et al. Postoperative impairment of cognitive function in rats: a possible role for cytokine-mediated inflammation in the hippocampus. Anesthesiology 106, 436–443 (2007). https://doi.org/10.1097/00000542-200703000-00007. 

11. Wan, Y. et al. Cognitive decline following major surgery is associated with gliosis, β-amyloid accumulation, and τ phosphorylation in old mice. Crit. Care Med. 38, 2190–2198 (2010). https://doi.org/10.1097/CCM.0b013e3181f17bcb. 

12. Li, Z.-Q. et al. Activation of the canonical nuclear factor-κB pathway is involved in isoflurane-induced hippocampal interleukin-1β elevation and the resultant cognitive deficits in aged rats. Biochem. Biophys. Res. Commun. 438, 628–634 (2013). https://doi.org/10.1016/j.bbrc.2013.08.003. 

13. Iida, H., Ohata, H., Iida, M., Watanabe, Y. & Dohi, S. Isoflurane and sevoflurane induce vasodilation of cerebral vessels via ATP-sensitive K+ channel activation. Anesthesiology 89, 954–960 (1998). https://doi.org/10.1097/00000542-199810000-00020. 

Gabapentinoids were first developed and marketed in the 1990s as an anticonvulsant [1]. Not long after this introduction, they were approved for the treatment of chronic neuropathic pain conditions [1]. Now, they are widely recognized for their use in treating some types of post-operative pain [1]. The most commonly recognized drugs in the gabapentinoid class are gabapentin (Neurontin) and pregabalin (Lyrica) [1].

Due partly to the patent expiration of gabapentin and the search for non-opioid pharmacotherapeutics, gabapentinoids’ off-label prescription rates have tripled in the US over the last 15 years [2]. In 2015, about 4% of adults in the United States were treated with this class of medications [3]. In several other countries, off-label prescription rates have increased as well [1]. Prescribed to treat acute nociceptive/neuropathic pain, gabapentinoids have become a fixture in perioperative multimodal analgesia routines [1],[4].

Despite their wide-spread use, gabapentinoid functionality, indications, and abuse liability are still being investigated [2]. Biologically, these drugs target the calcium channel α-2-δ (CCα2δ), a crucial physiological locus for managing neuropathic pain [2]. Consequently, physicians have unanimously agreed that the prescription of this class of medication makes sense in alleviating patients’ neuropathic pain [2]. Although clinicians are aware of the connection between gabapentinoids and CCα2δ, practitioners may not fully understand the complex channel, resulting in over-prescription or utility in inapplicable settings [2].

The inappropriate usage of gabapentinoids has been documented across several studies. For instance, they have been used to treat carpal tunnel syndrome [5]. This application is not substantiated by enough evidence to justify its widespread use and may even endanger patients: one study found that prolonged use after surgery (80 to 91 days post-release) was common among patients prescribed gabapentinoids pre-surgery [5]. Other medical conditions for which gabapentinoid treatments have not been effective include acute zoster pain, back pain, central neuropathic pain, HIV neuropathy, phantom limb pain, and pain due to spinal cord injury or traumatic nerve injury [3].

Now, recent studies call into question the efficacy of gabapentinoids in treating neuropathic pain. A 2020 meta-analysis of 281 trials compared these medications with controls to gauge patients’ postoperative pain intensity [1]. The difference between the gabapentinoids and the controls was not clinically significant and, at the height of chronic and subacute pain levels, they did not affect pain intensity at all [1]. These results conflict with the regular use of gabapentinoids in perioperative settings [1].

Data suggesting gabapentinoid overuse are troubling when considering the wide range of mild to adverse side-effects that these drugs can produce. In the aforementioned meta-analysis, gabapentinoid prescription correlated with a higher risk of postoperative dizziness and visual disturbance [1]. Other possible side effects include confusion, ataxia, respiratory depression, and delirium [4]. There is also a risk of addiction to gabapentinoids, especially in patients with a history of opioid use [3]. The combination of opioids and gabapentinoids can augment the risk of hospitalization and death [3]. Prescribing gabapentinoids to older adults or people with several comorbidities should be followed by careful monitoring [3].

Given in the increased scrutiny of gabapentinoids for pain management, clinicians are advised to reconsider their routine use of this form of medication [3]. Increased selectivity when using gabapentinoids during surgery, as well as a recognition of the particular risk factors associated with individual patients, will promote improved use of gabapentinoids [3].

References 

[1] M. Verret et al., “Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis,” Anesthesiology, vol. 133, no. 2, p. 265-79, August 2020. [Online]. Available: http://doi.org/10.1097/ALN.0000000000003428. [Accessed September 3, 2020]. 

[2] H. McAnally, U. Bonnet, and A. D. Kaye., “Gabapentinoid Benefit and Risk Stratification: Mechanisms over Myth,” Pain and Therapy, p. 1-12, July 2020. [Online]. Available: http://doi.org/10.1007/s40122-020-00189-x. [Accessed September 3, 2020]. 

[3] C. W. Goodman and A. S. Brett, “Gabapentinoids for Pain: Potential Unintended Consequences,” American Family Physician, vol. 100, no. 11, p. 672-675, December 2019. [Online]. Available: https://www.aafp.org/afp/2019/1201/p672.html. [Accessed September 3, 2020]. 

[4] A. H. Kumar and A. S. Habib., “The Role of Gabapentinoids in Acute and Chronic Pain After Surgery,” Current Opinion in Anaesthesiology, vol. 32, no. 5, p. 629-634, October 2019. [Online]. Available: http://doi.org/10.1097/ACO.0000000000000767. [Accessed September 3, 2020]. 

[5] J. I. Billig et al., “Inappropriate Preoperative Gabapentinoid Use Among Patients With Carpal Tunnel Syndrome,” Journal of Hand Surgery, vol. 45, no. 8, p. 677-689, August 2020. [Online]. Available: http://doi.org/10.1016/j.jhsa.2020.04.011. [Accessed September 3, 2020]. 

Extracorporeal membrane oxygenation (ECMO) provides a potential rescue therapy for critically ill COVID-19 patients. ECMO therapy comprises of a machine that oxygenates a patient’s blood outside the body. Tubing connects blood flow to an artificial lung; this lung adds oxygen to and extracts carbon dioxide from the blood. The machine warms the blood to body temperature and pumps it back into the patient’s body.¹  

Two types of extracorporeal membrane oxygenation exist: venovenous (VV) and venoarterial (VA). In VV ECMO, the machine removes blood from the venous system, passes it through the oxygenator, and returns the blood to the lungs.² VV ECMO only provides pulmonary support. VA ECMO, however, provides both pulmonary and hemodynamic support.³ In VA ECMO, the machine removes blood from the venous system and returns it to the arterial system.   

Past precedent suggests that ECMO therapy may prove beneficial for COVID-19 patients who suffer acute respiratory distress syndrome (ARDS). Previously, numerous studies concluded that ECMO therapy appeared to lower mortality in influenza A (H1N1)-related ARDS patients compared to those who did not receive ECMO therapy.^4–8 Likewise, a retrospective study recommended ECMO as a rescue therapy for Middle East respiratory syndrome (MERS) patients with refractory respiratory failure.⁹ However, medicine has little experience that can directly inform the administration of ECMO therapy to critically ill COVID-19 patients.¹⁰ 

Only a few studies report ECMO therapy for COVID-19-related ARDS patients.^11–17 These studies show an approximate mortality of 82.3% for the adult patients who receive ECMO therapy.¹⁸ Yang et al.,¹⁴ for example, reported that five of six patients on ECMO died; the sixth patient remained on ECMO at the study’s conclusion. Furthermore, Zhang et al.¹⁷ observed 10 patients on ECMO: the hospital discharged two patients, three died, and five remained on ECMO when the study concluded.   

Recommendations suggest that physicians consider ECMO only when conventional management fails.¹⁹ Generally, protocol classifies patients who, despite optimal care, experience high mortality risk and a PaO₂/FiO₂ ratio below 100 as potential ECMO candidates.²⁰ Specifically, ECMO candidates present as adult and pediatric patients with ARDS-related refractory hypoxemia in whom lung-protective ventilation fails.²¹ Protocol, however, strongly emphasizes the maximization of conventional ARDS therapies prior to ECMO consideration.²² These therapies include prone positioning, neuromuscular blockade, positive end-expiratory pressure (PEEP), inhaled pulmonary vasodilators, and recruitment maneuvers.^22,23 

References 

1. UCSF Health. Extracorporeal Membrane Oxygenation (ECMO). ucsfhealth.org https://www.ucsfhealth.org/treatments/extracorporeal-membrane-oxygenation (2020). 

2. Makdisi, G. & Wang, I. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J. Thorac. Dis. 7, E166–E176 (2015). 

3. Hoyler, M. M., Flynn, B., Iannacone, E. M., Jones, M.-M. & Ivascu, N. S. Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation. J. Cardiothorac. Vasc. Anesth. (2020) doi:10.1053/j.jvca.2019.12.047. 

4. The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ & ECMO) Influenza Investigators. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA 302, 1888–1895 (2009). 

5. Noah, M. A. et al. Referral to an Extracorporeal Membrane Oxygenation Center and Mortality Among Patients With Severe 2009 Influenza A(H1N1). JAMA 306, 1659–1668 (2011). 

6. Peek, G. J. et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet Lond. Engl. 374, 1351–1363 (2009). 

7. Goligher, E. C. et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial. JAMA 320, 2251–2259 (2018). 

8. Hong, H. a. et al. The safety of Bacillus subtilis and Bacillus indicus as food probiotics. J. Appl. Microbiol. 105, 510–520 (2008). 

9. Alshahrani, M. S. et al. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann. Intensive Care 8, 3 (2018). 

10. Hong, X., Xiong, J., Feng, Z. & Shi, Y. Extracorporeal membrane oxygenation (ECMO): does it have a role in the treatment of severe COVID-19? Int. J. Infect. Dis. 94, 78–80 (2020). 

11. Huang, C. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 395, 497–506 (2020). 

12. Chen, N. et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet 395, 507–513 (2020). 

13. Wang, D. et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA 323, 1061–1069 (2020). 

14. Yang, X. et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir. Med. 8, 475–481 (2020). 

15. Guan, W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N. Engl. J. Med. (2020). doi:10.1056/NEJMoa2002032. 

16. Zhou, F. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet 395, 1054–1062 (2020). 

17. Zhang, G. et al. Clinical features and short-term outcomes of 221 patients with COVID-19 in Wuhan, China. J. Clin. Virol. 127, 104364 (2020). 

18. Ñamendys-Silva, S. A. ECMO for ARDS due to COVID-19. Heart Lung 49, 348–349 (2020). 

19. Alhazzani, W. et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 46, 854–887 (2020). 

20. Bartlett, R. H. et al. Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure. Asaio J. 66, 472–474 (2020). 

21. World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance. 19 http://www.pimr.pl/index.php/issues/2020-vol-16-no-1/clinical-management-of-severe-acute-respiratory-infection-sari-when-covid-19-disease-is-suspected-interim-guidance?aid=1463 (2020). 

22. Extracorporeral Life Support Organization (ELSO). Guidelines for Adult Respiratory Failure. 32 (2017). 

23. Matthay, M. A., Aldrich, J. M. & Gotts, J. E. Treatment for severe acute respiratory distress syndrome from COVID-19. Lancet Respir. Med. 8, 433–434 (2020). 

24. Extracorporeral Life Support Organization (ELSO). COVID-19 Interim Guidelines: A consensus document from an international group of interdisciplinary ECMO providers. 37 (2020). 

25. Extracorporeral Life Support Organization (ELSO). Guidelines for Adult Cardiac Failure. 5 (2013). 

26. MacLaren, G., Fisher, D. & Brodie, D. Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation. JAMA 323, 1245–1246 (2020). 

27. Ramanathan, K. et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir. Med. 8, 518–526 (2020). 

Mass lockdowns and other curtailment strategies during the early phases of the COVID-19 outbreak, including suspension of voluntary blood donation camps [1], has put a major strain on the global blood supply. Blood drives scheduled in the spring and summer—the time of year that traditionally sees the largest uptake of blood donation—have been canceled as a result of new social distancing guidance. Challenges will continue to present themselves as the virus leads to uncertain patterns of demand for blood components and loss of critical staff due to illness or fear thereof.  

The number of donations in hospital-based or separate blood transfusion services has sharply declined since the outbreak, jeopardizing inventory. Closely monitoring supply and demand is necessary to ensure the availability of sufficient blood supply to support major trauma and other conditions. Platelet donations require particularly close attention due to their short shelf life [3]. Though many patients with COVID-19 do not require transfusion [3], diminishing blood supply raises concerns for those with conditions necessitating regular transfusions, such as cancer, leukemia, and sickle cell diseases. 

Another primary concern surrounding blood donation is product safety. Though there is no evidence of SARS-CoV-2 transmission by transfusion to date, detectable RNA has been found in the blood of some infected people, even if symptoms are light. Traces of RNA, however, do not necessarily represent infectious viral particles, and low concentrations suggest the potential of false positive results [3]. Additional studies are needed to determine the presence of the virus in blood donors as well as the consequences on blood transfusion. Strict deferral periods must be applied for those with confirmed or suspected exposure to the virus and those who have recently visited high risk regions; furthermore, appointments should be encouraged over walk-ins. 

The decreasing availability of personnel due to quarantine measures, illness, and/or fear of the virus will continue to present another major hurdle for blood collection. Concerns about exposure to ill donors or the need to self-isolate due to other instances of potential exposure could lead to substantial reductions in blood-collection staff. With blood supply shortages in some areas across the U.S. already being observed, plans for staff replacement will increasingly be put into effect, such as the training of non-essential personnel for blood collection and processing [2]. Furthermore, staff should be encouraged to self-report illness or potential exposure and be given supportive policies for sick leave. 

Safety concerns have also risen in laboratories for blood transfusion during the COVID-19 pandemic. These may be alleviated through partial or full automation of tests and additional equipment with anti-aerosol or disinfection function, in addition to proactive measures such as temporarily isolating blood for 14 days after collection [2]. Delaying the release of donor blood for clinical use has already been enforced in areas seriously affected by COVID-19 [2]. 

COVID-19 has put donor blood in critical supply and noninfected patients at risk. Transitioning to a state of normalcy depends on the duration of the pandemic and related behavioral changes, which will likely remain in effect well beyond original estimates [1]. 

References 

[1] Apelseth, Torunn O et al. “Effects of the COVID-19 Pandemic on Supply and Use of Blood for Transfusion.” The Lancet Haematology, 2020, doi:10.1016/S2352-3026(20)30186-1. 

[2] Cai, Xiaohong et al. “Blood Transfusion During the COVID-19 Outbreak.” Blood Transfus, vol. 18(2), 2020, 79-82, doi:10.2450/2020.0076-20. 

[3] Raturi, Dr. Manish & Kusum, Anuradha. “The Blood Supply Management Amid the COVID-19 Outbreak.” Transfusion Clinique et Biologique, 2020, doi:10.1016/j.tracli.2020.04.002. 

            It is not only important to assess the efficacy of a surgery or a procedure based on its direct, physical effects, but also based on its long-term, often unseen and indirect effects. These effects are the cognitive and psychological outcomes people experience such as decreased quality of life through increased rates of depression or decreased cognitive abilities. Previously, literature on this topic was quite scarce; however, research on this is now increasing, particularly for patients undergoing cardiac surgery. Cardiac surgery is often quite invasive, and thus incredibly intense for patients¹. Up to 25% of postoperative cardiac surgery patients can develop PTSD and, depending on the type of cardiac surgery, approximately 30-60% of patients can go on to develop depression¹. These numbers are alarming, clearly justifying the need for a deeper understanding of how patient’s cognitive and psychological abilities change following cardiac surgery.

            Rothenhäusler et al. (2005) conducted one of the earlier studies to investigate the psychiatric and psychosocial effects of cardiopulmonary bypass². Following patients one-year after surgery, the researchers administered neuropsychological tests to understand the before and after effects of surgery². Directly following surgery, about 30% of patients had developed delirium, while a smaller percentage of people had developed depression and PTSD². However, these psychological changes did not last for a majority of the patients in the long-term as most patients returned to their preoperative psychological state². Although psychological outcomes did not last in the long-term, changes in cognitive function did². Given this cognitive decline, as well as lasting psychological effects in a select few patients, it is important to understand these changes in great detail in order to develop effective interventions to reduce these effects.

            For a deeper understanding of the psychological outcomes of cardiac surgery, Tully (2012) reviewed current research on the depressive episodes that patients experience after surgery³. Tully (2012) found that much of the current literature comes to varying conclusions about changes in mental health after surgery, citing that these studies have highly heterogeneous methodologies in the neuropsychological assessments that are used, and that these studies do little to control other factors that may influence psychological outcomes³. With this, it thus becomes incredibly difficult to understand the true psychological effects of cardiac surgery, putting those who do develop some issues at risk as proper interventions have not been developed. This is clear through Whalley et al. (2014), which assesses a set of psychological interventions in present cardiac rehabilitation programs⁴. After analyzing multiple interventions, the reviewers found that these interventions only led to minimal improvement in levels of depression in patients, and that there was much is still unknown about what makes a postoperative cardiac psychological intervention successful⁴.

            It is clear that some patients experience psychological or cognitive issues to some extent following cardiac surgery. However, there is a lot of uncertainty about the details of these outcomes, such as how they arise as well as how various factors that might interact to produce these effects. It is necessary for medical professionals to have this knowledge so that better interventions can be developed. Even if a majority of patients do not continue to experience psychological problems in the long-term, there are a select few who do. There is thus is a definite need for proper interventions to allay these effects, especially as some of these patients also experience cognitive dysfunction.

References:

(1) Ackerman MG, Shapiro PA. Psychological Effects of Invasive Cardiac Surgery and Cardiac Transplantation. Handbook of Psychocardiology. 2016:567-584. doi:10.1007/978-981-287-206-7_26.

(2) Rothenhäusler HB, Grieser B, Nollert G, Reichart B, Schelling G, Kapfhammer HP. Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study. Gen Hosp Psychiatry. 2005;27(1):18-28. doi:10.1016/j.genhosppsych.2004.09.001

(3) Tully PJ. Psychological depression and cardiac surgery: a comprehensive review. J Extra Corpor Technol. 2012;44(4):224-232.

(4) Whalley B, Thompson DR, Taylor RS. Psychological Interventions for Coronary Heart Disease: Cochrane Systematic Review and Meta-analysis. International Journal of Behavioral Medicine. 2012;21(1):109-121. doi:10.1007/s12529-012-9282-x.

Individuals interested in pursuing a career in medicine, particularly in the prevention of pain and management of anesthesia, have the option of studying to become a Certified Registered Nurse Anesthetist (CRNA). 

Similarly to anesthesiologists, CRNAs are tasked with ensuring that patients undergo surgery without pain or recollection.¹ They are also able to prescribe medicine and order diagnostic tests. The roles are very similar. Two 2010 studies “concluded that there is no significant difference in the quality of care when the anesthetic is delivered by a [CRNA] or by an anesthesiologist.”² What separates CRNAs and anesthesiologists is the amount of education and the work environment.^1,3 

Anesthesiologists are medical doctors, who have completed undergrad, medical school, residency and sometimes a fellowship as well. This amounts to over a decade of school.⁴ CRNAs have a shorter path. Most complete undergrad, obtain their RN license, complete a year of critical care experience, and then complete a CRNA program. These programs can range from two to three years.³ One reason to choose a career as a CRNA is this accelerated career path.  

Another reason is CRNAs have the highest job satisfaction among advanced practice nurses, according to Marc Code, director of the Samuel Merritt University nurse anesthesia program.¹ A 2011 AANA study reported that 89% of the CRNAs surveyed described themselves as being “very satisfied” with the mean response being 4.4/5.⁵ The study found their satisfaction was impacted by their sense of autonomy and their ability to work with clinically competent peers. It was also affected by CRNA representation at administrative levels and employers who provided opportunities for education and advancement.⁵ 

Code suggests that part of the appeal of the role is the growth and freedom. “[CRNAs] can work in a team setting and [they] can work independently. Nurse practitioners cannot work independently.”¹ CRNAs are able to move beyond the operating room and find roles in more areas within the perioperative setting. This results in more opportunities for CRNAs to practice the full scope of their education. Their level of training allows CRNAs to collaborate with surgeons, anesthesiologists, dentists, and other health care professionals.¹ 

As a result, CRNAs also have a high level of compensation reflective of their ability to handle critical tasks. Their skill level also allows CRNA to have their own anesthesia service and earn more than they would at a hospital or surgery center.¹ In recent years, 17 states have opted out of physician supervision for CRNAs. These conditions not only allow CRNAs to have lucrative independent practices, but it also allows them to travel into underserved areas to provide anesthesia care.¹ In rural areas, ⅔ of all anesthetic care is administered by a CRNA.³ 

While compensation and satisfaction are both high, a 2019 AANA review reported a surge in burnout amongst CRNAs. Their median burnout score (2.45) was higher compared with nursing (2.2) and other personnel (2.1), which was similar to physicians (2.45), and low compared with residents (4.05).⁶ 

Studies suggest an effective way to improve CRNA burnout is to develop and implement interventions.⁶ In response, hospitals have started wellness initiatives. Surveys of those initiatives suggest that of those surveyed, 70% planned to attend future wellness events, and 42% stated that the event provided at least some information or skills that will improve their overall job satisfaction. Studies performed at the Mayo Clinic suggest that careful focus on the contributing factors can help to minimize burnout while creating a culture of highly engaged anesthesiologist and CRNAs.⁷ 

1. Farmer, Robin. “Why You Should Consider Becoming a Nurse Anesthetist.” Daily Nurse, Springer Publishing Company, 17 June 2016, https://dailynurse.com/consider-becoming-nurse-anesthetist/. 

2. “Who Should Provide Anesthesia Care?” The New York Times, The New York Times, 7 Sept. 2010, https://www.nytimes.com/2010/09/07/opinion/07tue3.html?_r=2&ref=opinion. 

3. “CRNA vs. Anesthesiologist: What’s the Difference?” Texas Wesleyan University, 23 Mar. 2016, https://txwes.edu/academics/health-professions/graduate-programs/nurse-anesthesia/news-and-events/department-news/top-five-list/top-five-list-news-archive/crna-vs-anesthesiologist-whats-the-difference/. 

4. Scherman, Jess. “What Is It REALLY Like Being a Nurse Anesthetist?” Rasmussen College, 10 Dec. 2018, https://www.rasmussen.edu/degrees/nursing/blog/what-is-nurse-anesthetist/. 

5. Mileto, Lisa, and Barbara Penprase. “Job Satisfaction Among Certified Registered Nurse Anesthetists: A Multigenerational Analysis.” Anesthesia EJournal, vol. 2, no. 1, 1 July 2014, https://anesthesiaejournal.com/index.php/aej/article/view/17/20. 

6. Del Grosso, Brian, and A Suzanne Boyd. “Burnout and the Nurse Anesthetist: An Integrative Review .” AANA Journal, vol. 87, June 2019, https://www.aana.com/docs/default-source/aana-journal-web-documents-1/burnout-and-the-nurse-anesthetist-an-integrative-review-june-2019.pdf?sfvrsn=d49f0a19_4. 

7. Tarantur, Natalie. “Anesthesia Professional Burnout-A Clear and Present Danger.” Anesthesia Patient Safety Foundation, Anesthesia Patient Safety Foundation, Oct. 2018, www.apsf.org/article/anesthesia-professional-burnout-a-clear-and-present-danger/. 

Anesthesia providers provide patients with medications in a variety of contexts, ranging from critical care to cardiothoracic surgery to obstetrics.¹ Across these settings, patients may present with preexisting morbidities, such as neurologic diseases² or hypertension³ that make anesthesia provision more complicated. One such preexisting issue is sepsis, which is a potentially life-threatening condition caused by infection. Anesthesia providers should be knowledgeable about the biology and symptomology of sepsis, as well as perioperative and anesthetic implications. 

Sepsis is a syndrome caused by the body’s dysregulated immune response to an infection.⁴ Normally, the body releases chemicals into the bloodstream to fight infection.⁵ Sepsis occurs when these chemicals, which have pro- and anti-inflammatory effects, are out of balance.⁶ The stages of sepsis include sepsis, marked by a system inflammatory immune response to an infection;⁷ severe sepsis, which occurs when organs begin to fail; and septic shock, which is marked by a sustained drop in blood pressure that impairs blood flow to the tissues.⁸ Diagnosing sepsis is difficult and remains unstandardized.⁷ However, common clinical manifestations include fever, mental status changes, elevated respiration and heart rate, low blood pressure, increased white blood cell count and blood coagulation abnormalities.⁷ Severe sepsis is characterized by multiple organ dysfunction syndrome (MODS).⁹ Septic shock includes all of the signs of sepsis and severe sepsis, along with severe hypotension.¹⁰ Any infection from bacteria, fungi or viruses can result in sepsis.⁴ Sepsis is considered the final step before patients with severe infections die,⁴ and the overall sepsis-related mortality rate ranges from 18 to 25 percent.¹¹ Sepsis is common among intensive care unit (ICU) patients, with prevalence ranging from 8.2 to 35.3 percent of all ICU patients.¹¹ It is also one of the most frequent cause of death among hospitalized patients⁴ and among humans in general,⁶ making it a significant public health problem.¹² 

The anesthesia provider plays a central role in managing patients with severe sepsis, including the initial deterioration in the ward, transfer to the diagnostic imaging area, intraoperative care for emergency surgery and even resuscitation during sepsis-induced cardiac arrest.^13,14 Before surgery, the anesthesia provider is responsible for administering antimicrobial medications, fluids, vasopressors (medications that cause constriction of blood vessels) and positive inotropes (medications that cause an increased force of cardiac contraction).¹⁴ During surgery, the anesthesia provider will carefully induce and maintain anesthesia, avoid lung injury during mechanical ventilation and keep blood volumes at an optimal level.¹⁴ Because patients with severe sepsis have significant respiratory and cardiovascular issues,¹⁵ anesthesia providers must be especially vigilant during intraoperative monitoring of vital signs such as oxygenation, blood pressure, kidney indices and electrolyte levels.¹⁴ Though general anesthesia is usually indicated during surgery for sepsis, the majority of anesthetics have cardiovascular depressant effects and can potentiate hemodynamic instability.¹⁵ A paper by Yoon suggests using drugs such as ketamine or etomidate, which avoid the cardiovascular depression of propofol, thiopental and midazolam, along with vasopressors and inotropes.¹⁶ Overall, it is crucial that the anesthesia provider use antibiotics and stabilizing medications, avoid lung injury during ventilation, closely monitor vital signs and provide adequate resuscitation for septic patients.¹⁷ 

Anesthesiology practitioners must be prepared for patients who present with a variety of preexisting conditions. Sepsis, which is a leading cause of death worldwide, is caused by dysfunction in the body’s response to infection and may lead to organ failure and shock. The anesthesia provider is vital to the multidisciplinary management of a patient with sepsis undergoing surgery, from the time the patient shows septic symptoms to the surgery itself. Anesthesiologists must administer several medications including general anesthesia, provide safe ventilation, diligently monitor vital signs and resuscitate patients intraoperatively. Future research should investigate the possibility of using alternative forms of anesthesia for sepsis, which may have fewer cardiovascular and respiratory side effects.¹⁸ 

1.American Society of Anesthesiologists. ​Guide to a Career in Anesthesiology. ASA Medical Student Component 2020; https://www.asahq.org/education-and-career/asa-medical-student-component/guide-to-a-career-in-anesthesiology. 

2.McSwain JR, Doty JW, Wilson SH. Regional anesthesia in patients with pre-existing neurologic disease. Current Opinion in Anaesthesiology. 2014;27(5):538–543. 

3.Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. British Journal of Anaesthesia. 1999;83(2):262–270. 

4.Van Der Poll T, Wiersinga WJ. Sepsis. In: Cohen J, Powderly WG, Opal SM, eds. Infectious Diseases (Fourth Edition): Elsevier; 2017:415–426.e411. 

5.Clinic M. Sepsis. Diseases & Conditions November 16, 2018; https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214. 

6.Nedeva C, Menassa J, Puthalakath H. Sepsis: Inflammation Is a Necessary Evil. Frontiers in Cell and Developmental Biology. 2019;7(108). 

7.Balk RA. Systemic inflammatory response syndrome (SIRS): Where did it come from and is it still relevant today? Virulence. 2014;5(1):20–26. 

8.León AL, Hoyos NA, Barrera LI, et al. Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals. BMC Infectious Diseases. 2013;13:345. 

9.Gavins FNE. Sepsis. In: Gavins FNE, Stokes KY, eds. Vascular Responses to Pathogens. Boston: Academic Press; 2016:1–9. 

10.Norrby-Teglund A, Treutiger C-J. Sepsis. In: Finch RG, Greenwood D, Norrby SR, Whitley RJ, eds. Antibiotic and Chemotherapy (Ninth Edition). London: W.B. Saunders; 2010:472–482. 

11.Rosner MH. Sepsis. In: Lerma EV, Sparks MA, M. Topf J, eds. Nephrology Secrets (Fourth Edition): Elsevier; 2019:84–88. 

12.Lewis AJ, Billiar TR, Rosengart MR. Biology and Metabolism of Sepsis: Innate Immunity, Bioenergetics, and Autophagy. Surgical Infections. 2016;17(3):286–293. 

13.Ben-Jacob TK, Sreedharan R, Nunnally ME, Chang BPM. Perioperative Management of the Septic Patient. ASA Newsletter. 2017;81(11):18–20. 

14.Eissa D, Carton EG, Buggy DJ. Anaesthetic management of patients with severe sepsis. BJA: British Journal of Anaesthesia. 2010;105(6):734–743. 

15.Yuki K, Murakami N. Sepsis pathophysiology and anesthetic consideration. Cardiovascular & Hematological Disorders—Drug Targets. 2015;15(1):57–69. 

16.Yoon SH. Concerns of the anesthesiologist: Anesthetic induction in severe sepsis or septic shock patients. Korean Journal of Anesthesiology. 2012;63(1):3–10. 

17.Nunnally ME. Sepsis for the anaesthetist. British Journal of Anaesthesia. 2016;117(Suppl 3):iii44–iii51. 

18.Mutz C, Vagts DA. Thoracic epidural anesthesia in sepsis – Is it harmful or protective? Critical Care. 2009;13(5):182. 

Anesthesiology practitioners often need to provide care in a variety of settings, ranging from the emergency department¹ to the post-anesthesia care unit (PACU);² in fact, they may need to follow a patient through many areas of the clinic or hospital. In different spaces and circumstances, the anesthesia provider’s job involves prioritizing issues such as airway management or vital signs monitoring.³ Magnetic resonance imaging (MRI) is a technique to produce images of a patient’s soft tissues, and it is used for imaging the central nervous, musculoskeletal and cardiovascular systems, as well as the pelvis and liver.⁴ MRI technology has evolved extensively over recent years, and it now has an active role inside the operating room.⁴ Also, some patients may need anesthesia within the MRI scanner to reduce anxiety and allow clinicians to obtain the high-quality images.⁵ In either type of case, anesthesia providers must perform their usual duties, such as administering anesthetic drugs, providing mechanical ventilation and stabilizing vitals. In order to give the best care to their patients, anesthesia providers should be familiar with anesthesia in the MRI suite, complications that may arise and emergency airway management for MRI. 

The MRI suite is a highly specialized environment, with intense magnetic fields that create unique problems for patients and clinicians alike.⁵ MRI is based on technology that excites and detects rotational change of protons in the water of living tissues. The powerful magnets of a MRI machine produce a strong magnetic field that forces protons in the body to align with that field. Then, a radiofrequency current is pulsed through the patient, stimulating the protons and straining them against the magnetic field.⁶ As the protons are moved, they emit energy that is detected by a coil in the scanner.⁷ An anesthesia provider should be familiar with the complexities of MRI in order to understand the hazards associated with MRI machines.⁸ MRI technology comes with high levels of noise, systemic and localized heating and accidental projectiles.⁸ Additionally, the MRI environment is dark and may obstruct a clinician’s view of the patient.⁸ Anesthesia providers in particular might be asked to use particular types of airway management devices, such as supraglottic airways (SGAs), to optimize image quality.⁹ Overall, the MRI environment is a busy area for anesthesia providers and patients alike. 

MRI can cause various complications that make an anesthesia provider’s role more difficult. For one, the provider will have reduced access to the patient during the scan, requiring vigilant observation of vital signs and respiration.¹⁰ The patient’s distance from the anesthesiology practitioner creates problems with airway management, intravenous access, patient visualization and monitor application. In some cases, anesthesia providers may need to position themselves within the scanner to evaluate the airway during a scan.¹¹ Additionally, the presence of a magnetic field can create problems with standard anesthesia machines, syringe pumps and vital signs monitors.⁵ Oxygen saturation monitors, for example, are subject to interference from changing magnetic fields and will occasionally be deactivated by radiofrequency currents.¹¹ Machines must be tested and approved in order to be used in the MRI suite, requiring the anesthesia provider to become familiar with such machines and make adjustments if they are not available.⁸ Clearly, anesthesia provision in the MRI suite can be complex and requires high levels of caution. 

In some cases, patients may encounter airway-related issues. In these cases, such as unintentional extubation, clinicians will need to stop the scan and readjust the patient.¹¹ Anesthesia providers should prepare themselves for unanticipated airway emergencies by creating checklists and focusing on teamwork and roles.¹⁰ For example, the anesthesia team can map out zones of the MRI suite and have laryngoscopes, blades and MRI-compatible anesthesia machines available in different areas of the room.¹² Providers should also use acceptable oximeters, and may consider using a laryngeal mask as an adjunct to airway maintenance and support.¹¹ Before administering anesthesia during a MRI, the anesthesiology professional must ensure that all equipment is compatible with the MRI.¹³ Though most airway emergencies can be prevented with proper planning, anesthesia providers should be prepared to stop a MRI scan or move the patient to a different zone at any time. 

Anesthesia provision occurs in many settings, some of which can add complexity to the process. In order to administer anesthesia during MRI, clinicians must understand the basic magnetic functions of the MRI machine, the ways MRI can affect anesthesia machines and practice and the proper management of airway emergencies. Future studies should focus on the best types of ventilation to reduce airway complications while optimizing MRI image quality. 

1.Mort TC. Anesthesia practice in the emergency department: Overview, with a focus on airway management. Current Opinion in Anaesthesiology. 2007;20(4):373–378. 

2.Barone CP, Pablo CS, Barone GW. A history of the PACU. Journal of PeriAnesthesia Nursing. 2003;18(4):237–241. 

3.Texas Society Of Anesthesiologists. The Role of the Anesthesiologist—from Surgical Anesthesia to Critical Care Medicine and Pain Medicine. Public Info 2020; https://www.tsa.org/public/anesthesiologist_role.php. 

4.Reddy U, White MJ, Wilson SR. Anaesthesia for magnetic resonance imaging. Continuing Education in Anaesthesia Critical Care & Pain. 2012;12(3):140–144. 

5.Sasao-Takano M, Misumi K, Suzuki M, Kamiya Y, Noguchi I, Kawahara H. Propofol drip infusion anesthesia for MRI scanning: two case reports. Anesthesia Progress. 2013;60(2):60–66. 

6.National Institute of Biomedical Imaging and Bioengineering. Magnetic Resonance Imaging (MRI). 2020; https://www.nibib.nih.gov/science-education/science-topics/magnetic-resonance-imaging-mri. 

7.Roda RD, Milne AD. Respiratory Management in the Magnetic Resonance Imaging Suite. Hung’s Difficult and Failed Airway Management (Third Edition). New York: McGraw Hill; 2018. 

8.American Society of Anesthesiologists Committee on Standards and Practice Parameters, Task Force on Anesthetic Care for Magnetic Resonance Imaging. Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2015;122(3):495–520. 

9.Ucisik-Keser FE, Chi TL, Hamid Y, Dinh A, Chang E, Ferson DZ. Impact of airway management strategies on magnetic resonance image quality. BJA: British Journal of Anaesthesia. 2016;117(Suppl 1):i97–i102. 

10.Berkow LC. Anesthetic management and human factors in the intraoperative MRI environment. Current Opinion in Anesthesiology. 2016;29(5):563–567. 

11.Patteson SK, Chesney JT. Anesthetic management for magnetic resonance imaging: Problems and solutions. Anesthesia & Analgesia. 1992;74(1):121–128. 

12.McClung HA, Subramanyam R. Airway Emergencies and Safety in Magnetic Resonance Imaging (MRI) Suite. APSF Newsletter. February 2020. 

13.Wellis V, Krane E. Practice Guidelines for the MRI & MRT. Lucile Packard Children’s Hospital: Stanford University Medical Center;1998.