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Browsing Duke Scholarly Works by Affiliation "Anesthesiology, Pediatrics"
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Item Open Access A cross-sectional survey study of United States residency program directors' perceptions of parental leave and pregnancy among anesthesiology trainees.(Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2021-06-22) Sharpe, Emily E; Ku, Cindy; Malinzak, Elizabeth B; Kraus, Molly B; Chandrabose, Rekha; Hartlage, Sarah EH; Hanson, Andrew C; Schulte, Phillip J; Pearson, Amy CSPurpose
Little is known about program directors' knowledge, attitudes, and beliefs regarding parental leave policies in anesthesiology training. This study sought to understand program director perceptions about the effects of pregnancy and parental leave on resident training, skills, and productivity.Methods
An online 43-question survey was developed to evaluate United States anesthesiology program directors' perceptions of parental leave policies. The survey included questions regarding demographics, anesthesiology program characteristics, parental leave policies, call coverage, and the perceived effects of parental leave on resident performance. Data were collected by Qualtrics (Qualtrics, Provo, UT, USA).Results
Fifty-six of 145 (39%) anesthesiology program directors completed the survey. Forty-eight of 54 (89%) program directors had a female resident take maternity leave in the past three years. When asked how parental leave affects residents' futures, 24/50 (48%) program directors felt it delayed board certification and 28/50 (56%) thought it affected fellowship opportunities. Program directors were split on their perceived impact of becoming a parent on a trainee's work. Yet, when compared with male trainees, program directors perceived that becoming a parent negatively affected female trainees' timeliness, technical skills, scholarly activities, procedural volume, and standardized test scores and affected training experience of co-residents. Program directors perceived no difference in impact on female trainees' dedication to patients and clinical performance.Conclusions
Program directors perceived that becoming a parent negatively affects the work performance of female but not male trainees. These negative perceptions could impact evaluations and future plans of female residents.Item Open Access A Study of Practice Behavior for Endotracheal Intubation Site for Children With Congenital Heart Disease Undergoing Surgery: Impact of Endotracheal Intubation Site on Perioperative Outcomes-An Analysis of the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database.(Anesthesia and analgesia, 2018-09-05) Greene, Nathaniel H; Jooste, Edmund H; Thibault, Dylan P; Wallace, Amelia S; Wang, Alice; Vener, David F; Matsouaka, Roland A; Jacobs, Marshall L; Jacobs, Jeffrey P; Hill, Kevin D; Ames, Warwick AIn adults undergoing cardiopulmonary bypass surgery, oral intubation is typically preferred over nasal intubation due to reduced risk of sinusitis and infection. In children, nasal intubation is more common and sometimes preferred due to perceived benefits of less postoperative sedation and a lower risk for accidental extubation. This study sought to describe the practice of nasal intubation in the pediatric population undergoing cardiopulmonary bypass surgery and assess the risks/benefits of a nasal route against an oral one.Patients <18 years of age in the Society of Thoracic Surgeons Congenital Heart Surgery Database between January 2010 and December 2015 were included. Patients with a preoperative endotracheal tube, tracheostomy, or known airway anomalies were excluded. Multivariable modeling was used to assess the association between route of tracheal intubation and a composite measure of infection risk (wound infection, mediastinitis, septicemia, pneumonia, and endocarditis). Covariates were included to adjust for important patient characteristics (eg, weight, age, comorbidities), case complexity, and center effects. Secondary outcomes included length of intubation, hospital length of stay, and airway complications including accidental extubations. We also performed a subanalysis in children <12 months of age in high-volume centers (>100 cases/y) examining how infection risk may change with age at the time of surgery.Nasal intubation was used in 41% of operations in neonates, 38% in infants, 15% in school-aged children, and 2% in adolescents. Nasal intubation appeared protective for accidental extubation only in neonates (P = .02). Multivariable analysis in infants and neonates showed that the nasal route of intubation was not associated with the infection composite (relative risk [RR], 0.84; 95% CI, 0.59-1.18) or a shorter length of stay (RR, 0.992; 95% CI, 0.947-1.039), but was associated with a shorter intubation length (RR, 0.929; 95% CI, 0.869-0.992). Restricting to high-volume centers showed a significant interaction between age and intubation route with a risk change for infection occurring between approximately 6-12 months of age (P = .003).While older children undergoing nasal intubation trend similar to the adult population with an increased risk of infection, nasal intubation in neonates and infants does not appear to carry a similar risk. Nasal intubation in neonates and infants may also be associated with a shorter intubation length but not a shorter length of stay. Prospective studies are required to better understand these complex associations.Item Open Access Abdominal Gunshot Causing Ventricular Septal Injury Without Perforation into the Pericardium.(Journal of Cardiothoracic and Vascular Anesthesia, 2019-03-01) Sigurdsson, Martin I; Brockbank, Benjamin; Haney, John C; Andrews, Jon; MacLeod, David B; Vaslef, Steven N; Brooks, Kelli R; Manning, Erin L; Nicoara, AlinaItem Open Access Airway Management in a Patient with Wolf-Hirschhorn Syndrome.(Case Rep Pediatr, 2016) Gamble, John F; Kurian, Dinesh J; Udani, Andrea G; Greene, Nathaniel HWe present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general anesthesia for laparoscopic gastrostomy tube placement with a focus on airway management. WHS is a rare 4p microdeletion syndrome resulting in multiple congenital abnormalities, including craniofacial deformities. Microcephaly, micrognathia, and glossoptosis are common features in WHS patients and risk factors for a pediatric airway that is potentially difficult to intubate. We discuss anesthesia strategies for airway preparation and management in a WHS patient requiring general anesthesia with endotracheal intubation.Item Open Access Anesthetic Management in Adults with Congenital Heart Disease(Current Cardiology Reports) Andrews, Jon S; Hashmi, Nazish KItem Open Access Aprotinin improves functional outcome but not cerebral infarct size in an experimental model of stroke during cardiopulmonary bypass.(Anesthesia and analgesia, 2010-07) Homi, H Mayumi; Sheng, Huaxin; Arepally, Gowthami M; Mackensen, G Burkhard; Grocott, Hilary PBackground
Aprotinin, a nonspecific serine protease inhibitor, has been used to decrease bleeding and reduce the systemic inflammatory response after cardiopulmonary bypass (CPB). Studies have variably linked aprotinin administration with both improved as well as adverse cerebral consequences after cardiac surgery. We designed this study to determine whether an antiinflammatory dose of aprotinin could improve the histologic and functional neurologic outcome in a rat model of focal cerebral ischemia during CPB.Methods
After surgical preparation, the animals were randomized into 2 groups: an aprotinin group (60,000 kIU/kg IV) and a control group (0.9% NaCl IV). Normothermic CPB was performed for 60 minutes during which time a partial overlapping 60 minutes of right middle cerebral artery occlusion was induced. Cytokines (tumor necrosis factor-alpha, interleukin [IL]-1beta, IL-6, and IL-10) were measured at baseline, the end of CPB, then 2 and 24 hours after CPB. On postoperative day 3, the animals underwent functional neurologic testing and histologic assessment of cerebral infarct volume.Results
There was a reduction in systemic inflammation in the aprotinin group compared with the control group, demonstrated by lower levels of IL-1beta (P = 0.035) and IL-6 (P = 0.047). The aprotinin group also had a better functional neurologic performance (median [interquartile range]: aprotinin 27 [8] vs control 32 [6]; P = 0.042). However, there was no difference in cerebral infarct volume (aprotinin 306 [27] mm(3) vs control 297 [52] mm(3); P = 0.599).Conclusions
In this experimental model of stroke occurring during CPB, aprotinin decreased the systemic inflammatory response to CPB. Although there was no difference in the cerebral infarct volume, there was a small improvement in the short-term functional neurologic outcome in the aprotinin group.Item Open Access Building a safety culture in global health: lessons from Guatemala.(BMJ global health, 2018-01) Rice, Henry E; Lou-Meda, Randall; Saxton, Anthony T; Johnston, Bria E; Ramirez, Carla C; Mendez, Sindy; Rice, Eli N; Aidar, Bernardo; Taicher, Brad; Baumgartner, Joy Noel; Milne, Judy; Frankel, Allan S; Sexton, J BryanProgrammes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work-life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.Item Open Access Complete Obstruction of Endotracheal Tube in an Infant with a Retropharyngeal and Anterior Mediastinal Abscess.(Case Rep Pediatr, 2017) Thapa, Dennis B; Greene, Nathaniel H; Udani, Andrea GIntraoperative ventilatory failure is not an uncommon complication; however, acute endotracheal obstruction by a foreign body or blood clot can be difficult to quickly discriminate from other causes. Once the diagnosis is made, quick action is needed to restore ventilation. The ultimate solution is to exchange the endotracheal tube; however, there can be other ways of resolving this in situations where reintubation would be difficult or unsafe. This case report discusses such an event in an infant with multiple airway challenges including a retropharyngeal and anterior mediastinal abscess. We have also formulated a pathway based on various case reports involving complete ETT obstruction.Item Open Access Designing Leadership Programming for Anesthesiology TraineesMalinzak, elizabeth; Grantham, ashley; McCarthy, graceItem Open Access Home is Where the Heart Is: Interstage Home Monitoring in Infants With Single-Ventricle Heart Disease.(Journal of cardiothoracic and vascular anesthesia, 2021-10) Andrews, Jon S; Machovec, Kelly AItem Open Access Measurements of Epidural Space Depth Using Preexisting CT Scans Correlate with Loss of Resistance Depth during Thoracic Epidural Catheter Placement.(Anesthesiol Res Pract, 2015) Greene, NH; Cobb, BG; Linnau, KF; Kent, CDBackground. Thoracic epidural catheters provide the best quality postoperative pain relief for major abdominal and thoracic surgical procedures, but placement is one of the most challenging procedures in the repertoire of an anesthesiologist. Most patients presenting for a procedure that would benefit from a thoracic epidural catheter have already had high resolution imaging that may be useful to assist placement of a catheter. Methods. This retrospective study used data from 168 patients to examine the association and predictive power of epidural-skin distance (ESD) on computed tomography (CT) to determine loss of resistance depth acquired during epidural placement. Additionally, the ability of anesthesiologists to measure this distance was compared to a radiologist, who specializes in spine imaging. Results. There was a strong association between CT measurement and loss of resistance depth (P < 0.0001); the presence of morbid obesity (BMI > 35) changed this relationship (P = 0.007). The ability of anesthesiologists to make CT measurements was similar to a gold standard radiologist (all individual ICCs > 0.9). Conclusions. Overall, this study supports the examination of a recent CT scan to aid in the placement of a thoracic epidural catheter. Making use of these scans may lead to faster epidural placements, fewer accidental dural punctures, and better epidural blockade.Item Open Access Midazolam for Anxiolysis and Postoperative Nausea and Vomiting Prophylaxis: Can We Kill Two Birds with One Stone?(Anesth Analg, 2016-03) Greene, Nathaniel H; Habib, Ashraf SItem Open Access Modern and Evolving Understanding of Cerebral Perfusion and Autoregulation(Advances in Anesthesia, 2012-11-16) Greene, Nathaniel H; Lee, Lorri AItem Open Access Perioperative care of adults with Down syndrome: a narrative review.(Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2021-06-24) Malinzak, Elizabeth BBecause of enhanced life expectancy due to medical and surgical therapeutic advances, it is estimated that there are more adults than children living with Down syndrome (DS), or trisomy 21, in the United States. Therefore, DS can no longer be considered a syndrome limited to the pediatric population. These patients are presenting for surgery and anesthesia in adult care settings, where anesthesiologists will encounter these patients more frequently. As these patients age, their commonly associated co-morbidities not only progress, but they also develop other cardiac, respiratory, gastrointestinal, and neurologic conditions. The manifestations and consequences of chronic disease can present new challenges for the anesthesiologist and require expertise and judgement to minimize patient risk. The purpose of this narrative review is to describe the common pediatric co-morbidities associated with DS and discuss the age-acquired manifestations. Additionally, considerations for anesthetic care of the adult with DS will be presented, including the preoperative assessment, intraoperative management, and postoperative care.Item Open Access Perioperative management of carotid endarterectomy: A survey of clinicians' backgrounds and practices(Journal of Cardiothoracic and Vascular Anesthesia, 2014-01-01) Greene, Nathaniel H; Minhaj, Mohammed M; Zaky, Ahmed F; Rozet, IreneObjective To examine current trends in anesthetic practice for management of carotid endarterectomy (CEA) and how practice may differ by groups of practitioners. Design An online survey was sent to the Society of Cardiovascular Anesthesiologists and Society of Neuroscience, Anesthesiology, and Critical Care e-mail list servers. Responses were voluntary. Setting Academic medical centers and community-based hospitals providing perioperative care for a CEA in the United States and abroad. Participants Anesthesiologists who provide perioperative care for patients undergoing a CEA. Interventions None Measurements and Main Results Of 664 responders (13% response rate), most (66%) had subspecialty training in cardiovascular anesthesiology, had been in practice more than 10 years (68%), and practiced in the United States (US, 81%). About 75% of responders considered general anesthesia as a preferable technique for CA, and about 89% of responders provided it in real life, independent of subspecialty training. The most preferable intraoperative neuromonitoring was cerebral oximetry (28%), followed by EEG (24%), and having an awake patient (23%). Neuroprotection was not considered by 33% of responders, and upon conclusion of a case, 59% preferred an awake patient for extubation, while 15% preferred a deep extubation. Neuroanesthesiologists and non-US responders more often risk stratify patients for perioperative cerebral hyperperfusion syndrome, compared with cardiac anesthesiologists and US responders (p = 0.004 and p<0.005, respectively). Additionally, reported management strategies vary substantially from anesthetic practice 20 years ago. Conclusions Although there are areas of perioperative management in which there seems to be agreement for the CEA, there are also areas of divergent practice that could represent potential for improvement in overall outcomes. There are many potential reasons to explain divergence in practice by location or subspecialty training, but it remains unclear what the "best practice" may be. Future studies examining outcomes after carotid endarterectomy should include perioperative anesthetic management strategies to help delineate "best practice." © 2014 Elsevier Inc.Item Open Access Representation of Female Faculty at US Medical Schools and Success in Obtaining National Institutes of Health Funding, 2008-2018.(JAMA network open, 2021-03) Malinzak, Elizabeth Burney; Weikel, Daniel; Swaminathan, MadhavItem Open Access Spinal anesthesia for cesarean delivery in a woman with neuromyelitis optica.(A A Case Rep, 2014-05-01) Greene, NH; Dinges, E; Ciliberto, C; Sedensky, M; Landau, RNeuromyelitis optica (NMO), or Devic's disease, is an idiopathic severe demyelinating disease that preferentially affects the optic nerve and spinal cord. Neuraxial anesthesia in women with multiple sclerosis is widely accepted, but reports of the use of neuraxial anesthesia in patients with NMO are scarce. We report the case of a morbidly obese primigravida undergoing a planned cesarean delivery at 32 weeks' gestation due to an acute exacerbation of NMO, managed with spinal anesthesia. Other than increased intraoperative hyperalgesia requiring inhaled nitrous oxide/oxygen, the mother experienced no apparent anesthetic-related complications.Item Open Access Systematic Postoperative Nausea Prophylaxis Feedback Improves Clinical Performance in Anesthesiology Residents.(J Educ Perioper Med, 2015-07) Greene, Nathaniel H; Norstedt, Peter A; Nair, Bala G; Souter, Karen JBACKGROUND: Electronic medical records can generate a wealth of information regarding compliance with perioperative clinical guidelines as well as patient outcomes. Utilizing this information to provide resident physicians with measures of their own clinical performance may positively impact residents' clinical performance. We hypothesize that providing residents with objective measures of their individual adherence to evidence based postoperative nausea and vomiting (PONV) management protocols will improve their compliance with standardized treatment methods. METHODS: We conducted a retrospective baseline analysis of junior anesthesiology residents' compliance with PONV prophylaxis guidelines for high-risk patients. This was followed by a prospective cohort study, before and after an educational intervention, a 15 minute lecture on PONV prophylaxis. The number of pharmacologic prophylactic interventions were tabulated for each operative case and reported back to individual residents in blind and anonymous fashion. The primary outcome was the use of two or more prophylactic interventions for a high-risk patient, while the secondary outcome was the use of three or more prophylactic interventions. A follow up survey was administered to participating residents regarding the use of their individualized clinical performance. RESULTS: After implementation of feedback, patients received a significantly higher amount of PONV prophylactic treatments (p=0.001, means of 1.35 vs. 1.99). Comparison of percentage compliance was 38% vs 73%, respectively (p<0.001). In a follow up survey, residents received the feedback intervention well and had no significant concern in the dissemination of deidentified performance outcomes publically. CONCLUSIONS: Resident compliance with PONV treatment guidelines was improved merely by auditing performance and providing individualized feedback. High-risk patients appear to receive more prophylactic agents after performance feedback and may be more effective than a more commonly used educational intervention to address the same topic. Providing direct performance feedback may be a useful tool for integration into graduate medical education programs.Item Open Access The 2018 Lake Louise Acute Mountain Sickness Score.(High Altitude Medicine and Biology, 2018-03-13) Roach, Robert C; Hackett, Peter H; Oelz, Oswald; Bärtsch, Peter; Luks, Andrew M; MacInnis, Martin J; Baillie, J Kenneth; Lake Louise AMS Score Consensus CommitteeRoach, Robert C., Peter H. Hackett, Oswald Oelz, Peter Bärtsch, Andrew M. Luks, Martin J. MacInnis, J. Kenneth Baillie, and The Lake Louise AMS Score Consensus Committee. The 2018 Lake Louise Acute Mountain Sickness Score. High Alt Med Biol 19:1-4, 2018.- The Lake Louise Acute Mountain Sickness (AMS) scoring system has been a useful research tool since first published in 1991. Recent studies have shown that disturbed sleep at altitude, one of the five symptoms scored for AMS, is more likely due to altitude hypoxia per se, and is not closely related to AMS. To address this issue, and also to evaluate the Lake Louise AMS score in light of decades of experience, experts in high altitude research undertook to revise the score. We here present an international consensus statement resulting from online discussions and meetings at the International Society of Mountain Medicine World Congress in Bolzano, Italy, in May 2014 and at the International Hypoxia Symposium in Lake Louise, Canada, in February 2015. The consensus group has revised the score to eliminate disturbed sleep as a questionnaire item, and has updated instructions for use of the score.Item Open Access The impact of gestational age and fetal weight on the risk of failure of spinal anesthesia for cesarean delivery.(Int J Obstet Anesth, 2016-05) Adesope, OA; Einhorn, LM; Olufolabi, AJ; Cooter, M; Habib, ASBACKGROUND: There are limited data about spinal dosing for cesarean delivery in preterm parturients. We investigated the hypothesis that preterm gestation is associated with an increased incidence of inadequate spinal anesthesia for cesarean delivery compared with term gestation. METHODS: We searched our perioperative database for women who underwent cesarean delivery under spinal or combined spinal-epidural anesthesia with hyperbaric bupivacaine ⩾10.5mg. The primary outcome was the incidence of inadequate surgical anesthesia needing conversion to general anesthesia or repetition or supplementation of the block. We divided patients into four categories: <28, 28 to <32, 32 to <37 and ⩾37weeks of gestation. The chi-square test was used to compare failure rates and a multivariable regression analysis was performed to investigate potential confounders of the relationship between gestational age and failure. RESULTS: A total of 5015 patients (3387 term and 1628 preterm) were included. There were 278 failures (5.5%). The incidence of failure was higher in preterm versus term patients (6.4% vs. 5.1%, P=0.02). Failure rates were 10.8%, 7.7%, 5.3% and 5% for <28, 28 to <32, 32 to <37 and ⩾37weeks of gestation, respectively. In the multivariable model, low birth weight (P<0.0001), gestational age (P=0.03), ethnicity (P=0.02) and use of combined spinal-epidural anesthesia (P<0.0001) were significantly associated with failure. CONCLUSIONS: At standard spinal doses of hyperbaric bupivacaine used in our practice (⩾10.5mg), there were higher odds of inadequate surgical anesthesia in preterm parturients. When adjusting for potential confounders, low birth weight was the main factor associated with failure.