Anesthesia Experts

About Dr. Clemens

Here are my most recent posts

End-Tidal Control Versus Manual Control of Inhalational Anesthesia Delivery

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AUTHORS: McCabe, Melissa D. MD, FASA, MSCR et al 

Anesthesia & Analgesia 139(4):p 812-820, October 2024.

BACKGROUND:

Precise anesthesia delivery helps ensure amnesia, analgesia, and immobility. Conventionally, the end-tidal anesthetic concentration is maintained through manual adjustment of the fresh gas flow and anesthetic vaporizer output. Some anesthesia delivery systems can deliver and maintain clinician-selected end-tidal anesthetic agent (EtAA) concentration using a modified closed-loop system. We evaluated the performance of an End-tidal Control (EtC) system on the Aisys CS2 anesthesia machine (GE HealthCare). We hypothesized EtC anesthetic delivery would be noninferior to manually controlled anesthetic delivery.

METHODS:

The Multi-site Anesthesia randomized controlled STudy of End-tidal control compared to conventional Results (MASTER) Trial evaluated anesthetic delivery in 210 adult patients receiving inhaled anesthesia. Patients were randomized to either EtC or manual control (MC) anesthetic delivery. The primary objective was to determine whether, compared to conventional anesthesia practice, EtC achieves and maintains clinician-specified EtAA and end-tidal oxygen (Eto2) concentrations within defined noninferiority limits. Noninferiority was concluded if the lower limit of the 95% confidence interval (CI) of the difference between the percent duration within the acceptable range (5% of steady state or a margin of ~10% of each agent’s minimum alveolar concentration) for EtC and MC was ≥ −5% for both EtAA and Eto2. Secondary objectives included performance measures: response time: time required to attain 90% of the first desired EtAA, overshoot: amount the controller (or vaporizer delivery) exceeded the desired EtAA, and accuracy: average deviation from the desired EtAA.

RESULTS:

EtC achieved and sustained targeted EtAA and Eto2 concentrations within the noninferiority threshold. The EtAA was within 5% of the desired value 98% ± 2.05% of the time with EtC compared to 45.7% ± 31.7% of the time with MC (difference 52.3% [95% CI, 45.9%–58.6%], P < .0001). For Eto2, EtC was within the noninferiority limit 86.3% ± 22.8% of the time compared with MC at 41% ± 33.3% (P < .0001, difference 45.3% [95% CI, 36.1%–54.5%]). The median response time for achieving 90% of the initial EtAA desired value was 75 seconds with EtC and 158 seconds with MC (P = .0013). EtC exhibited a median overshoot of 6.64% of the selected EtAA concentration, whereas MC often failed to reach the clinician’s desired value. The difference in median percent deviation from desired EtAA value was 15.7% ([95% CI, 13.5%–19.0%], P < 0001).

CONCLUSIONS:

EtC achieves and maintains the EtAA and Eto2 concentration in a manner that is noninferior to manually controlled anesthesia delivery.

KEY POINTS

Question: Can an end-tidal-controlled anesthesia delivery system achieve and maintain a desired anesthesia concentration?

Findings: The end-tidal-controlled anesthesia delivery system achieves and maintains a desired anesthetic concentration.

Meaning: End-tidal-controlled anesthesia delivery is a viable alternative to conventional, manually titrated anesthesia delivery.

CRNA workforce by the numbers

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Author: Francesca Mathewes
Becker’s ASC Review

There are currently 65,745 active certified registered nurse anesthetists in the United States, according to Medicus’ 2024 white paper on the anesthesia provider shortage.

Here are seven other numbers on the CRNA workforce:

80% — The percentage of anesthesia providers represented by CRNAs in rural counties.

More than 50 million — The amount of anesthetics CRNAs administer to  patients each year in the U.S.

62% — The percentage of CRNAs that are over 40-years-old. Another 36% are between 30- and 40-years old and 2% are 20- to 30-years-old.

56% — The percentage of CRNAs that reported feeling very or somewhat burned out.

15% — The percentage of CRNAs that said a good work/life balance is the most rewarding aspect of their job.

14% — The percentage of CRNAs that said they valued workplace autonomy.

A Great Anesthesiologist Opportunity in Gadsden AL

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We are seeking a dedicated anesthesia care team to join our new anesthesia care team contract at Riverview Regional Medical Center.  Gadsden is a town of over 100,000 people that is located 1 hour from Birmingham AL and 2 hours from Atlanta GA.

Position Highlights:

  • Anesthesiologist call is 1:3
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Discover The Best Anesthesiologist Opportunity in New Mexico

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We are seeking a dedicated anesthesiologist to join our all-anesthesiologist group. Our team will consist of 4 full-time providers and 1 for vacation relief, managing 3 operating rooms.

Position Highlights:

  • Zero call for 3 weeks, followed by 1 week of call without daytime work only call after 7 PM therefore you may not work the entire week.
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

This is the best job on GasWork #370670

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Changes in Intrinsic Connectivity Networks Topology Across Levels of Dexmedetomidine-Induced Alteration of Consciousness

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AUTHORS: Staquet, Cecile MD et al 

Anesthesia & Analgesia 139(4):p 798-811, October 2024.

BACKGROUND:

Human consciousness is generally thought to emerge from the activity of intrinsic connectivity networks (resting-state networks [RSNs]) of the brain, which have topological characteristics including, among others, graph strength and efficiency. So far, most functional brain imaging studies in anesthetized subjects have compared wakefulness and unresponsiveness, a state considered as corresponding to unconsciousness. Sedation and general anesthesia not only produce unconsciousness but also phenomenological states of preserved mental content and perception of the environment (connected consciousness), and preserved mental content but no perception of the environment (disconnected consciousness). Unresponsiveness may be seen during unconsciousness, but also during disconnectedness. Deep dexmedetomidine sedation is frequently a state of disconnected consciousness. In this study, we were interested in characterizing the RSN topology changes across 4 different and steady-state levels of dexmedetomidine-induced alteration of consciousness, namely baseline (Awake, drug-free state), Mild sedation (drowsy, still responding), Deep sedation (unresponsive), and Recovery, with a focus on changes occurring between a connected consciousness state and an unresponsiveness state.

METHODS:

A functional magnetic resonance imaging database acquired in 14 healthy volunteers receiving dexmedetomidine sedation was analyzed using a method combining independent component analysis and graph theory, specifically looking at changes in connectivity strength and efficiency occurring during the 4 above-mentioned dexmedetomidine-induced altered consciousness states.

RESULTS:

Dexmedetomidine sedation preserves RSN architecture. Unresponsiveness during dexmedetomidine sedation is mainly characterized by a between-networks graph strength alteration and within-network efficiency alteration of lower-order sensory RSNs, while graph strength and efficiency in higher-order RSNs are relatively preserved.

CONCLUSIONS:

The differential dexmedetomidine-induced RSN topological changes evidenced in this study may be the signature of inadequate processing of sensory information by lower-order RSNs, and of altered communication between lower-order and higher-order networks, while the latter remain functional. If replicated in an experimental paradigm distinguishing, in unresponsive subjects, disconnected consciousness from unconsciousness, such changes would sustain the hypothesis that disconnected consciousness arises from altered information handling by lower-order sensory networks and altered communication between lower-order and higher-order networks, while the preservation of higher-order networks functioning allows for an internally generated mental content (or dream).

Carboxyhemoglobin in Cardiac Surgery Patients and Its Association with Risk Factors and Biomarkers of Hemolysis

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AUTHORS: Maeda, Akinori MD et al 

Anesthesia & Analgesia 139(4):p 789-797, October 2024.

BACKGROUND:

Cardiac surgery with cardiopulmonary bypass (CPB) is associated with hemolysis. Yet, there is no easily available and frequently measured marker to monitor this hemolysis. However, carboxyhemoglobin (CO-Hb), formed by the binding of carbon monoxide (a product of heme breakdown) to hemoglobin, may reflect such hemolysis. We hypothesized that CO-Hb might increase after cardiac surgery and show associations with operative risk factors and indirect markers for hemolysis.

METHODS:

We conducted a retrospective descriptive cohort study of data from on-pump cardiac surgery patients. We analyzed temporal changes in CO-Hb levels and applied a generalized linear model to assess patient characteristics associated with peak CO-Hb levels. Additionally, we examined their relationship with red blood cell (RBC) transfusion and bilirubin levels.

RESULTS:

We studied 38,487 CO-Hb measurements in 1735 patients. CO-Hb levels increased significantly after cardiac surgery, reaching a peak CO-Hb level 2.1 times higher than baseline (P < .001) at a median of 17 hours after the initiation of surgery. Several factors were independently associated with higher peak CO-Hb, including age (P < .001), preoperative respiratory disease (P = .001), New York Heart Association Class IV (P = .019), the number of packed RBC transfused (P < .001), and the duration of CPB (P = .002). Peak CO-Hb levels also significantly correlated with postoperative total bilirubin levels (Rho = 0.27, P < .001).

CONCLUSIONS:

CO-Hb may represent a readily obtainable and frequently measured biomarker that has a moderate association with known biomarkers of and risk factors for hemolysis in on-pump cardiac surgery patients. These findings have potential clinical implications and warrant further investigation.

Validation of a Novel Method for Noninvasive Mixed Venous Oxygen Saturation Monitoring in Anesthetized Children

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AUTHORS: Svedmyr, Anders MD et al 

Anesthesia & Analgesia 139(4):p 781-788, October 2024.

BACKGROUND:

Mixed venous oxygen saturation (SvO2) is a critical variable in the assessment of oxygen supply and demand but is rarely used in children due to the invasive nature of pulmonary artery catheters. The aim of this prospective, observational study was to investigate the accuracy of noninvasively measured SvO2 acquired by the novel capnodynamic method, based on differential Fick equation (Capno-SvO2), against gold standard CO-oximetry.

METHODS:

Capno-SvO2 was compared to SvO2 measured by pulmonary artery blood gas CO-oximetry in children undergoing cardiac catheter interventions and subjected to moderate hemodynamic challenges. Bland-Altman analysis was used to describe the agreement of absolute values between CO-oximetry and Capno-SvO2, and a concordance rate was calculated to evaluate the ability of Capno-SvO2 to track change.

RESULTS:

Twenty-five procedures were included in the study. Capno-SvO2 showed a bias toward CO-oximetry of +3 percentage points; upper and lower limits of agreement were +11 percentage points (95% confidence interval [CI], 9–14) and −5 percentage points (95% CI, −8 to −3), respectively. The concordance rate was 92% (95% CI, 89–96).

CONCLUSIONS:

In conclusion, this first clinical application of a novel concept for noninvasive SvO2 monitoring without the need for a pulmonary artery catheter indicates that Capno-SvO2 generates absolute values and trending capacity in close agreement with the gold standard reference method.

Efficacy of Single-Bolus Administration of Remimazolam During Induction of Anesthesia in Patients Undergoing Cardiac Surgery

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AUTHORS: Lee, Sou-Hyun MD, PhD et al 

Anesthesia & Analgesia 139(4):p 770-780, October 2024.

BACKGROUND:

Remimazolam is a recently marketed ultrashort-acting benzodiazepine. This drug is considered safe and effective during general anesthesia; however, limited information is available about its effects on patients undergoing cardiac surgery. Therefore, the present study was conducted to evaluate the efficacy and hemodynamic stability of a bolus administration of remimazolam during anesthesia induction in patients undergoing cardiac surgery.

METHODS:

Patients undergoing elective cardiac surgery were randomly assigned to any 1 of the following 3 groups: anesthesia induction with a continuous infusion of remimazolam 6 mg/kg/h (continuous group), a single-bolus injection of remimazolam 0.1 mg/kg (bolus 0.1 group), or a single-bolus injection of remimazolam 0.2 mg/kg (bolus 0.2 group). Time to loss of responsiveness, defined as modified Observer’s Assessment of Alertness/Sedation Scale <3, and changes in hemodynamic status during anesthetic induction were measured.

RESULTS:

Times to loss of responsiveness were 137 ± 20, 71 ± 35, and 48 ± 9 seconds in the continuous, bolus 0.1, and bolus 0.2 groups, respectively. The greatest mean difference was observed between the continuous and bolus 0.2 groups (89.0, 95% confidence interval [CI], 79.1–98.9), followed by the continuous and bolus 0.1 groups (65.8, 95% CI, 46.9–84.7), and lastly between the bolus 0.2 and bolus 0.1 groups (23.2, 95% CI, 6.6–39.8). No significant differences were found in terms of arterial blood pressures and heart rates of the patients.

CONCLUSIONS:

A single-bolus injection of remimazolam provided efficient anesthetic induction in patients undergoing cardiac surgery. A 0.2 mg/kg bolus injection of remimazolam resulted in the shortest time to loss of responsiveness among the 3 groups, without significantly altering the hemodynamic parameters. Therefore, this dosing can be considered a favorable anesthetic induction method for patients undergoing cardiac surgery.

Baxter aims to import 18K tons of product: 6 IV shortage updates

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Author: Alexandra Murphy
Becker’s Hospital Review

Baxter International is responding to critical IV supply shortages affecting patients after Hurricane Helene disrupted its North Cove manufacturing facility, which produces 60% of the U.S. IV fluid market’s supply.

With the situation growing urgent, Baxter is importing 18,000 tons of essential products to alleviate these shortages by the end of the year, according to a news release from the company.

Here are five more IV shortage updates:

  1. Baxter has made significant strides in recovery, restoring utilities and IT systems at the site. Over 2,500 employees are returning to work at normal pre-hurricane staffing levels this week, supported by 1,000 additional remediation contractors for site cleanup and recovery. A support center has also been established to provide essential supplies to affected staff.
  2. In coordination with the FDA, Baxter has activated seven manufacturing plants worldwide to boost production and initial shipments from Spain and Mexico have arrived to the U.S. The first shipments of product authorized for temporary importation also arrive in the U.S. over the weekend.
  3. Two weeks after Hurricane Helene damaged the Baxter plant, CVS announced it was closing its Coram infusion pharmacy division, which has led to care disruptions for patients who depend on parenteral nutrition, KFF Health News reported. Around 25,000 patients in the U.S. depend on IV nutrition.
  4. Allocations for IV fluid products remain at 60% of normal levels, which Baxter first commuted to customers Oct. 9.
  5. According to an Oct. 20 report from The Hill, patients and clinicians have been notified to expect between 50 and 90% of the peritoneal dialysis fluids they normally receive. Baxter said it is also temporarily importing additional PD products to improve supply levels. The company has also been partering with healthcare professionals to limit new PD patient starts to pediatric patients

    “Our goal is to restore the number of new [PD] patient starts to pre-Hurricane Helene levels by the end of the year,” Baxter said in an Oct. 21 update. “Over the next couple of weeks, we plan to communicate with providers and patients to ensure they are well equipped to adapt and implement adjustments to their prescriptions for new patients as appropriate.”

A Great Anesthesiologist Opportunity in Gadsden AL

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We are seeking a dedicated anesthesia care team to join our new anesthesia care team contract at Riverview Regional Medical Center.  Gadsden is a town of over 100,000 people that is located 1 hour from Birmingham AL and 2 hours from Atlanta GA.

Position Highlights:

  • Anesthesiologist call is 1:3
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Call (660) 596-2224
What people thought about us

Testimonials

“As Director of Surgical Services Departments there has been considerable changes have occurred in my department and Anesthesia Experts has always risen to meet our demands of our facility. They have been very pro-active in meeting the increase volumes allowing us to keep our surgeons and patients very satisfied with our services.”

AR BSN 346 beds AL   

“Before AE took over the anesthesia department was described by the surgeons as the worst in the history of our hospital. The prior management company was having a cancelled surgery per day. I am happy to report there has not been one since they have taken over the department. Additionally we have seen a 905 reduction if requested preop
lab tests. The anesthesia department is now the very best hospital department in our entire facility.”

DS CEO 272 beds MS   

“Anesthesia Experts has provided consistent anesthesia providers who display a high degree of integrity, responsibility and professionalism. They have become a more valuable part of our facility and community.”

LR CEO 150 beds TX   

“Even though they are physically located 1000 miles away Anesthesia Experts just does not provide great anesthesia coverage they personally engage surgeons to increase their business. Last year my surgical volume rose by 24% and we are currently 50% ahead of last year and all of that growth is organic.”

JE FACHE CEO AL 92 bed hospital   

“Anesthesia Experts is more responsive than anyone I have dealt with. They are available by phone whenever needed and will be on site for any need or request and has been on site to address issues before we can make the request.”

SW CEO 25 beds NM   

“While problems are extremely rare when they do occur Anesthesia Experts quickly and professionally implements a solution. Our surgical volume has grown over 100 cases per month and now our GI docs want to perform all of their endoscopies in our hospital instead of their GI lab that they own!”

SP CEO 346 beds AL   

“Our anesthesia department was a thorn in my side that kept me awake at night. Anesthesia Experts swept in and brought order to our mess and our department was quickly redirected.”

JAM CNO AL 89 bed hospital   

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