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Global and Regional Heterogeneity of Lung Aeration in Neonates with Different Respiratory Disorders

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Authors: Barbara Loi, M.D. et al 
Anesthesiology October 2024, Vol. 141, 719–731.
Background

Aeration heterogeneity affects lung stress and influences outcomes in adults with acute respiratory distress syndrome (ARDS). The authors hypothesize that aeration heterogeneity may differ between neonatal respiratory disorders and is associated with oxygenation, so its evaluation may be relevant in managing respiratory support.

Methods

This was an observational prospective study. Neonates with respiratory distress syndrome, transient tachypnea of the neonate, evolving bronchopulmonary dysplasia, and neonatal ARDS were enrolled. Quantitative lung ultrasound and transcutaneous blood gas measurements were simultaneously performed. Global aeration heterogeneity (with its intra- and interpatient components) and regional aeration heterogeneity were primary outcomes; oxygenation metrics were the secondary outcomes.

Results

A total of 230 (50 respiratory distress syndrome, transient tachypnea of the neonate or evolving bronchopulmonary dysplasia, and 80 neonatal ARDS) patients were studied. Intrapatient aeration heterogeneity was higher in transient tachypnea of the neonate (mean ± SD, 61 ± 33%) and evolving bronchopulmonary dysplasia (mean ± SD, 57 ± 20%; P < 0.001), with distinctive aeration distributions. Interpatient aeration heterogeneity was high for all disorders (Gini–Simpson index, between 0.6 and 0.72) except respiratory distress syndrome (Gini–Simpson index, 0.5), whose heterogeneity was significantly lower than all others (P < 0.001). Neonatal ARDS and evolving bronchopulmonary dysplasia had the most diffuse injury and worst gas exchange metrics. Regional aeration heterogeneity was mostly localized in the upper anterior and posterior zones. Aeration heterogeneity and total lung aeration had an exponential relationship (P < 0.001; adj-R2 = 0.62). Aeration heterogeneity is associated with greater total lung aeration (i.e., higher heterogeneity means a relatively higher proportion of normally aerated lung zones, thus greater aeration; P < 0.001; adj-R2 = 0.83) and better oxygenation metrics upon multivariable analyses.

Conclusions

Global aeration heterogeneity and regional aeration heterogeneity differ among neonatal respiratory disorders. Transient tachypnea of the neonate and evolving bronchopulmonary dysplasia have the highest intrapatient aeration heterogeneity. Transient tachypnea of the neonate, evolving bronchopulmonary dysplasia, and neonatal ARDS have the highest interpatient aeration heterogeneity, but the latter two have the most diffuse injury and worst gas exchange. Higher aeration heterogeneity is associated with better total lung aeration and oxygenation.

Editor’s Perspective
What We Already Know about This Topic
  • Aeration heterogeneity affects lung stress and contributes to ventilator-induced lung injury. In adults, it is known to influence outcomes with acute respiratory distress syndrome. Neonates on mechanical ventilation with respiratory failure are particularly vulnerable to ventilator-induced lung injury; however, little is known about aeration heterogeneity in neonates and how it may vary with different respiratory disorders.
What This Article Tells Us That Is New
  • In a prospective observational study in neonates, global aeration heterogeneity and regional aeration heterogeneity differed among neonatal respiratory disorders. Neonates with transient tachypnea of the neonate and evolving bronchopulmonary dysplasia had the highest intrapatient aeration heterogeneity, while those with transient tachypnea of the neonate, evolving bronchopulmonary dysplasia, and neonatal respiratory distress syndrome had the highest interpatient aeration heterogeneity. Those with evolving bronchopulmonary dysplasia and neonatal respiratory distress syndrome had the most diffuse injury and worst gas exchange.

Social Media Trends for Anesthesiologists in 2024

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Author: Amy Pearson, MD, FASA
ASA Monitor July 2024, Vol. 88, 28–30.
graphic

For those of us in anesthesiology, social media can seem too risky and complicated to utilize well. The landscape is always changing, and as trusted health care professionals, we need to carefully balance our authenticity and professional objectivity. So how do we stay ahead in the social media space? Let’s check out some trends for 2024.

It seems like just as you get comfortable with one platform, everyone has moved on to another. For many years, Twitter (now “X”) has been a top pick for medical professionals because we could join the chatter on the latest trending studies, share links to our publications, and interact with the experts in our field. Since new leadership took over in November 2022, X’s United States user base has been down 23% (asamonitor.pub/44oGQto). X has restricted searching for nonusers and limited third-party tools, which has made it more challenging for physicians to connect (asamonitor.pub/4dprFEo). While the X physician community remains strong, many have increased their presence on LinkedIn and Mastodon, which also support link sharing, connections with experts, and professionally focused content. Threads, a new text-based app fueled by Meta (which owns Facebook, Instagram, and WhatsApp), may have the potential to out-compete many of these current giants. Physicians are also making use of online forums, such as ASA Community, Doximity, Reddit, and Facebook groups, for crowdsourcing ideas for complex practice issues. Apps based in visual media, such as Instagram, TikTok, and YouTube, continue to rise and are preferred by younger generations.

You may have noticed that the first results to pop up in your internet searches have been videos rather than links. Social media platforms and even search engines like Google (which owns YouTube) now push video content regularly (asamonitor.pub/3JJ0RkR). For example, a Google search of “cosmetic enhancements anesthesia” will yield three videos from the Anesthesia Patient Safety Foundation (APSF) before listing the actual APSF Newsletter article (asamonitor.pub/3xVAWUq).

Video is quickly becoming the leading format among the fastest growing social media platforms. Web-based search engines are now in competition with social media platforms as the primary tool used for searches, with 40% of Generation Z using TikTok and Instagram instead of Google (asamonitor.pub/3Wo6koR). For anesthesiologists, it is increasingly important to put video and social media content behind important anesthesia initiatives to help increase visibility and enhance engagement with key audiences. Anesthesiologists like Drs. Max Feinstein, Robert Singleton III, Shonna Hargrove, and John Patton III are leading the way, using their creativity and medical knowledge to educate the public and guide hopeful students toward a career in medicine and anesthesiology.

It’s no surprise to anyone that a major incentive for social media companies is to keep users on their platforms as long as possible. Social media influencer Gary “Vee” Vaynerchuk quips, “I’m day trading attention.” With social media companies vying for a finite amount of attention among ever-increasing internet chatter, new tactics, many rooted in artificial intelligence (AI), have been developed to do just that, in spite of increasing public scrutiny and regulation. Some tactics include (Int J Environ Res Public Health 2019;16:2612):

  1. Endless scrolling. Your news feed never runs out of content.
  2. Peer pressure. Your friends can see if you’ve read their posts or are starting a reply (“…”), and you feel obligated to respond.
  3. Sunk costs. You may not have spent a dime on social media, but you have put in a lot of effort cultivating your community. You want to make it worth it, so you keep refreshing.
  4. Content discovery. Your news feed doesn’t just show you content from those you follow – it also presents ads and adjacent content (“You might also like…”), prompting you stick around to follow the platform’s suggestion.
  5. Profiling and visibility moderation. While profiling is associated with law enforcement, it’s done by social media companies as well, often with AI. The inferences made about your characteristics, preferences, and future actions or inactions are unknown to you as a user, yet they can lead to influences in real life, such as in job screening and credit scoring (Information, Communication & Society 2021;26:809-25). Algorithms tend to promote PRIME information (prestigious, ingroup, moral and emotional) for engagement, and this may be at the expense of non-PRIME posts (Trends in Cognitive Sciences 2023;27:947-60). TikTok, allegedly to prevent bullying, was found to suppress videos of users who were “unattractive” or who had developmental disorders (Policy & Internet 2022;14:79-95).

As a consumer

  1. It’s not just the algorithm, it’s you, too. Your feed is designed to give you more of the content you interact with the most. If you recently got into a comment war over your least favorite political candidate, don’t be surprised if your feed starts bringing you more of the same. If you find your feed stuffed with PRIME content, choose to intentionally interact with posts from people of different backgrounds. Why not influence the algorithm back?
  2. Don’t let the apps decide when you open them. While everyone loves the thrill of a new notification, the constant nudge to check an app will start to interfere with real life. Put all of your social media apps into one folder on your phone and check it during set periods of your choosing. You could even remove apps from your phone completely.
  3. Have an intention for each platform. It can be overwhelming and redundant to use every platform to meet all of your needs and interests. You can curate your professional profile on X and LinkedIn, and you can use media-heavy platforms like Instagram, YouTube, and TikTok to deep dive into anesthesia-adjacent topics or hear from patients themselves about their experiences.
  4. Online is not your only community. Those in my generation remember when social media was new. Finally, we discovered other people out there just like us. Growing up, I didn’t know a single woman with a doctoral degree. If it wasn’t for the connections I made on social media and message boards, I would never have become a physician. Social media remains vital for connecting the parts of us that don’t quite fit in elsewhere, but it doesn’t take the place of the real communities in which we physically exist. With less “third spaces” for adults and children to spend time, it becomes even more important to deliberately foster positive relationships with the neighbors, colleagues, relatives, and friends we see every day… even the ones we seem to have nothing in common with.

As a creator

  1. Social media is social! You have so much to tell the world that it’s easy to get lost in content creation, sharing, and metrics. The real beauty of social media is the connection. There may be hundreds of creators saying the same thing, but there’s only one ∗you.∗ Users value authenticity and will follow you for your personality, style, and substance. Engage with each comment, follow your followers back, and create a community around your mission. Drs. Sasha Shillcutt, Ed Mariano, and Alopi Patel are great examples.
  2. Pause before you open the analytics page. It’s OK not to go viral. It’s OK not to have the biggest account in anesthesiology. In fact, a larger account might harm your mission. Our field is niche and remains mystifying even to our physician colleagues. If your passion is isoflurane spills or how to find free MOCA patient safety credits, you aren’t going to have the same worldwide audience as a doctor who does reaction videos to pimple popping. First think of what metrics are meaningful to you. A post that generates an engaging discussion among your followers may be more valuable than how many impressions it gets. Airway enthusiasts Drs. Laura Duggan and James DuCanto come to mind as high-quality niche creators who benefit their followers with education and discussion.
  3. Social media will always be there (in some form). If you’re reading this, you probably already have a day job. An important, cool, and highly demanding day job. While the advice to post daily on multiple platforms in multiple forms of media is not necessarily bad, this isn’t practical for a busy anesthesiologist. It’s OK to grow your following slowly, and if life gets in the way, take a step back for a while. You can even schedule your social media engagement around your own yearly rhythms. One of my favorite examples of this is Dr. Jeff Gadsden’s Blocktober (asamonitor.pub/4b0d6FF). Every October 1-31, he shares daily posts on different regional anesthesia techniques, and it’s something many of us have begun to look forward to each year.

New standards for anesthesia in out-of-hospital Cesarean sections

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Author: Deepak Gupta, MD
KevinMD.com

Unless planning to issue an update on practice guidelines for obstetric anesthesia, the American Society of Anesthesiologists (ASA), along with its subspecialty organization, the Society for Obstetric Anesthesia and Perinatology (SOAP), should formulate a consensus statement for peri-anesthesia management during out-of-hospital cesarean sections (OHCS). Florida has become the first state to allow OHCS, an infrastructural relaxation for obstetric care that other states may follow. Whether the ensuing outcomes among pregnant patients, mothers, and their newborn infants in Florida will accentuate or attenuate the spread of OHCS nationwide, a timely anesthesia advisory by ASA/SOAP for anesthesiologists practicing in Florida would be beneficial. Not only in-state but also out-of-state anesthesiologists could be providing general and conduction anesthesia-analgesia in Florida’s advanced birth centers (ABCs) during labor epidurals and OHCS among pregnant patients, postpartum sterilization among mothers, and potentially during circumcision among their newborn infants.

Although mothers may stay at ABCs for 48-72 hours after delivering their newborns vaginally or surgically, input from the Society for Ambulatory Anesthesia (SAMBA) in anesthesia advisory could be warranted. The historical experiences of ambulatory anesthesiologists at already-established ambulatory surgery centers (ASCs) could guide future outcomes among obstetric anesthesiologists managing obstetric patients and their newborns at the newly-invented ABCs. The health care cost-containment with ABCs delivering accessible care to pregnant patients, mothers, and their newborn infants would require ABCs to achieve non-inferior health care outcomes compared to hospitals. However, neither the pregnant patients, mothers, nor newborn infants can be allowed to fall through the cracks in the absence of preemptive anesthesia advisory, considering that along with at least one obstetrician per ABC, at least one anesthesiologist per ABC is mandated per the new Florida law.

Since it is not clearly stipulated in the new Florida law whether the ABCs must have at least one pediatrician per ABC, it may be assumed that the responsibility for neonatal resuscitation would fall on obstetric anesthesiologists. These professionals may need to meet the requirements of the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP) before acting as neonatal anesthesiologists. There could be a natural selection for obstetricians and anesthesiologists based on their competence in time efficiency when performing OHCS at ABCs. There are concerns about whether mean-median indemnity payments to injured parties and legal expenses for all parties will escalate due to OHCS at ABCs unless ASCs have historical non-obstetric data to prove otherwise, thus potentially overcoming the resistance among obstetricians and anesthesiologists to perform OHCS at ABCs.

Until ABCs evolve to effectively screen their patients for high-risk peripartum hemorrhage and preemptively refer them to hospitals for peripartum management, it may fall to obstetric anesthesiologists to advocate for the prophylactic use of tranexamic acid in low-resource settings. This could supplement the strategy for liberal use of intrauterine balloons during OHCS at ABCs, with the question always lingering whether all pregnant patients who have been typed and crossmatched for blood transfusion should go to hospitals rather than staying at ABCs. These patients might be at high risk for peripartum hemorrhage compared to those only typed and screened for blood group and antibodies.

It would be interesting to see what an anesthesia advisory might say about restricting management at ABCs based on ASA-approved adult examples like body mass index and ASA-approved obstetric examples like complicated pregnancy, which could upgrade patients’ ASA physical status classification and thus their peri-anesthesia risks. Only time will tell whether OHCS at ABCs will remain limited to elective and planned OHCS. Obstetric anesthesiologists must be well-prepared for emergent and unplanned OHCS, whether or not their labor epidurals could be deemed to risk an increased prevalence of such emergent and unplanned OHCS. Obstetricians at ABCs might defer timely referrals of their patients to hospitals for CS when ABCs have the infrastructure to support OHCS.
There could be additional challenges for obstetric anesthesiologists regarding the use of opioids vs. non-opioids as neuraxial adjuvants at ABCs and postoperative pain management with opioids vs. non-opioids with and without regional nerve blocks. Inspired by trauma anesthesiologists’ perioperative roles in transporting hemorrhaging trauma patients, the role of obstetric anesthesiologists must be clearly defined when transporting intraoperative and postoperative obstetric patients who could be actively hemorrhaging. If and when ABCs choose to have mobile operating suites, it might be feasible to transport the mobile operating suites themselves to collaborating hospitals rather than transporting hemorrhaging obstetric patients to those hospitals.

As society has finally arrived at this point, anesthesiologists should not delve into how escalating health care costs might be evolving health care deserts, either due to reimbursement difficulties or medicolegal liabilities. Neither the diverse geography nor the dispersed demography helps contain health care deserts. Anyhow, OHCS might be here to stay, and anesthesiologists should not reminisce the time when OHCS was only limited to the rarest of rare perimortem CS, now more appropriately termed resuscitative hysterotomy.

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

Physicians in hospital-owned practices aren’t happy: 10 insights

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Autor: Patsy Newitt
Becker’s ASC Review

Physicians working in hospital-owned practices are nearly three times more likely to report dissatisfaction compared to those in physician-owned practices, according to consulting firm Bain & Company’s Frontline of Healthcare Survey, highlighted in an October blog post.

“As healthcare continues to adopt a system-led approach, many practices have strayed from the foundational principles that made the physician practice model successful,” the blog states. “These shifts have left many organizations at risk of losing discontented physicians.”

Here are 10 key insights from the survey:

1. Health system-led practices have consistently underperformed on the “Net Promoter Score” — a measure of employees’ willingness to recommend their workplace — by 25 to 40 points compared to physician-led practices since 2017.

2. Nearly 25% of physicians in health system-led organizations are contemplating a change in employers, compared to just 14% in physician-led practices. Of those considering a switch, 37% are looking to move to physician-owned settings.

3. The survey identified several professional aspects with a “disproportionately high potential to delight or disappoint.” In hospital-led practices, these critical dimensions include compensation, staffing levels, workload and autonomy.

4. The blog suggests that improving physician satisfaction in hospital-led organizations is straightforward when referring to these dimensions: fair compensation, sufficient staffing, manageable workloads, leadership alignment, involvement in decision-making and greater autonomy.

5. Physician-led organizations outperform in satisfaction across all professional metrics. The average satisfaction scores range from 70% to 90%, while hospital-employed physicians report lower satisfaction, between 50% and 75%.

6. Resource access shows a significant disparity as well. Among surveyed physicians, 87% in physician-led practices reported having access to necessary supplies and equipment, compared to 68% in health system-led practices.

7. Additionally, 78% of physicians in physician-led practices said their organizations have effective processes and workflows, compared to only 59% in hospital-led organizations.

8. Only about 60% of hospital-employed physicians expressed satisfaction with their organization’s leadership alignment.

9. In contrast, 81% of physicians in physician-led organizations reported satisfaction with their involvement in strategic decision-making, compared to just 50% in health system-led practices.

10. The blog outlines four key strategies for hospitals and health systems to improve physician satisfaction: establishing a strong physician value proposition, involving physicians in decision-making, enhancing technology, and implementing closed-loop feedback systems.

The IV supply crisis: What ASCs need to know

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Author: Patsy Newitt
Becker’s ASC Review

Amid the fallout from Hurricane Helene, hospitals across the nation are conserving IV fluids.

Here are nine things to know:

1. Flooding from Hurricane Helene damaged Baxter’s manufacturing plant in Marion, N.C., which supplies around 60% of the U.S. market’s IV fluids. On Oct. 3, Baxter informed customers they would only receive 40% of their typical IV fluid orders due to the damage.

2. By Oct. 9, Baxter had increased allocations to 60% of normal levels, citing anticipated shipments from its foreign facilities. In a news release on the same day, the company said allocations for IV solutions and nutrition products for designated children’s hospitals were increased to 100% due to the vulnerable population the facilities serve.

3. On Oct. 8 Baxter said it has resumed shipments of IV products to hospitals and dialysis patients after a temporary weeklong suspension. The company also revealed it was inspecting its finished products to support current distribution levels. Baxter’s global manufacturing plants have ramped up production to meet U.S. demand, with expected product deliveries continuing throughout October.

4. More than 86% of U.S. healthcare providers are experiencing IV fluid shortages, according to a Premier survey published Oct. 10. More than half of respondents said they had 10 days’ worth of supplies or less on hand, and some smaller providers noted they had received none of their requested supplies.

5. The shortage is forcing hospitals to make difficult choices regarding patient care, the New York Times reported Oct. 9. In Chicago, physicians from Northwestern Medicine have been working to secure IV fluids for nearly 90 patients in their home dialysis program. Additionally, almost 17% of surveyed providers have canceled elective surgeries and other procedures due to the shortage, while 58% are considering similar measures, according to the survey.

6. On October 7, the American Hospital Association called on President Biden to declare the IV fluid shortage a national emergency, citing severe difficulties for healthcare providers across the country. The American Society of Health-System Pharmacists echoed the call Oct. 8.

7. Most recently, the FDA said it might temporarily allow the importation of IV fluids from overseas to alleviate the shortage caused by Hurricane Helene. An FDA spokesperson said, “We are expediting the evaluation of new sites and manufacturing lines, actively considering temporary importation, and will take necessary regulatory actions, including those needed to help Baxter’s North Cove plant recover.”

8. HHS Secretary Xavier Beccera said in an Oct. 9 letter to healthcare providers that around 400 federal workers would be deployed to help communities recover from Hurricane Helene. He also said the department is coordinating with Baxter to ensure staff safety and mitigate the supply shortage.

9. Experts have raised concerns about the over-concentration of critical supplies like IV fluids in a few manufacturing locations. Tom Cotter, executive director of Healthcare Ready, emphasized the need for greater investment in supply chain resilience. “There is an increased need to widen the scope of what we think is vulnerable in our medical supply chain,” Mr. Cotter told the Times Oct. 9. 

Gastric Volume and Diabetes: Reply

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Authors: Anahi Perlas, M.D.; Vincent W. S. Chan, M.D.
Anesthesiology November 2024, Vol. 141, 1025–1026.

We thank Dr. Sethuraman for their interest in our article and the opportunity to address their study design points. First, there was a concern that a non-inferiority design is only suitable for clinical trials in which a treatment or intervention is being compared to another (usually previously existing and well established as effective) treatment. While these types of studies were indeed early examples of noninferiority trials, application of this type of design has expanded rapidly in the last decade.  From a statistical standpoint, it is possible to use a noninferiority design any time two continuous variables are being compared when one is expected to be “not different” (if double-sided) or either not higher or not lower (if single-sided) than the other.

In our study, we hypothesized that the gastric volume of diabetic patients who have followed standard fasting instructions prior to elective surgery would be “no higher” than that of nondiabetic patients. Therefore, we considered a noninferiority design to be more appropriate than a “superiority design” to test our hypothesis.

Dr. Sethuraman is correct to state that to prove non-inferiority, one needs to test the 95% CI of the difference between means and one needs to establish an “a priori” noninferiority margin. In our study, the primary outcome in question was gastric volume per unit of weight (in ml/kg) as estimated using bedside ultrasound. We established the “a priori” noninferiority margin of 0.4 ml/kg as this was 50% of the expected SD of baseline values, which is usually considered to be a small difference, and any difference below that margin could be considered a clinically insignificant difference. Our findings confirmed the hypothesis of noninferiority as the mean difference between the two groups was 0.07 ml/kg and the 95% CI of this difference was –0.24 to 0.1 ml/kg. These results are illustrated and contrasted with the noninferiority margin in figure 3 of our original article.

Finally, we respectfully disagree that our “observational” study would be difficult to reconcile with a noninferiority design. Our study was an observational cross-sectional study without treatment intervention. We merely evaluated the baseline gastric volume of diabetic and nondiabetic patients who have fasted for elective surgery. We did not study the effect of any treatment, but rather compared the effect of an “exposure to a condition” (diabetes mellitus) in an observed biologic outcome (fasting gastric volume). We therefore believe that a noninferiority design is scientifically appropriate for this purpose.

Polygenic Score for the Prediction of Postoperative Nausea and Vomiting

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Authors: Nicholas J. Douville, MD, PhD et al 
Anesthesiology September 2024.
Background

Postoperative nausea and vomiting (PONV) is a key driver of unplanned admission and patient satisfaction following surgery. Because traditional risk factors do not completely explain variability in risk, we hypothesize that genetics may contribute to the overall risk for this complication. The objective of this research is to perform a genome-wide association study of PONV, derive a polygenic risk score for PONV, assess associations between the risk score and PONV in a validation cohort, and compare any genetic contributions to known clinical risks for PONV.

Methods

Surgeries with integrated genetic and perioperative data performed under general anesthesia at Michigan Medicine and Vanderbilt University Medical Center were studied. PONV was defined as nausea or emesis occurring and documented in the PACU. In the Discovery Phase, genome-wide association studies were performed on each genetic cohort and the results were meta-analyzed. Next, in the Polygenic Phase, we assessed whether a polygenic score, derived from genome-wide association study in a derivation cohort from Vanderbilt University Medical Center, improved prediction within a validation cohort from Michigan Medicine, as quantified by discrimination (C-statistic) and net reclassification index.

Results

Of 64,523 total patients, 5,703 developed PONV (8.8%). We identified 46 genetic variants exceeding P<1×10-5 threshold, occurring with minor allele frequency > 1%, and demonstrating concordant effects in both cohorts. Standardized polygenic score was associated with PONV in a basic model, controlling for age and sex, (aOR 1.027 per standard deviation increase in overall genetic risk, 95% CI 1.001-1.053, P=0.044), a model based on known clinical risks (aOR 1.029, 95% CI 1.003-1.055, P=0.030), and a full clinical regression, controlling for 21 demographic, surgical, and anesthetic factors, (aOR 1.029, 95% CI 1.002-1.056, P=0.033). The addition of polygenic score improved overall discrimination in models based on known clinical risk factors (c-statistic: 0.616 compared to 0.613, P=0.028) and improved net reclassification of 4.6% of cases.

Conclusion

Standardized polygenic risk was associated with PONV in all three of our models, but the genetic influence was smaller than exerted by clinical risk factors. Specifically, a patient with a polygenic risk score > 1 standard deviation above the mean, has 2-3% greater odds of developing PONV when compared to the baseline population, which is at least an order of magnitude smaller than the increase associated with having prior PONV/motion sickness (55%), having a history of migraines (17%), or being female (83%), and is not clinically significant. Furthermore, the use of a polygenic risk score does not meaningfully improve discrimination compared to clinical risk factors and is not clinically useful.

Association between Glucagon-like Peptide-1 Receptor Agonists and Aspiration Pneumonia during Endoscopic Procedures

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Authors: Chun-Yu Peng, M.D. et al 
Anesthesiology November 2024, Vol. 141, 1009–1012.

Glucagon-like peptide-1 (GLP-1) receptor agonists are approved for type 2 diabetes mellitus and weight loss. However, concerns have emerged regarding their potential to increase the risk of perioperative regurgitation and aspiration pneumonitis, despite standard fasting protocols.  The American Society of Anesthesiologists (ASA; Schaumburg, Illinois) published a consensus-based guideline in 2023 recommending holding GLP-1 agonists before procedures.  In contrast, the American Gastroenterology Association (AGA; Bethesda, Maryland) recommended an individualized approach regarding the use of GLP-1 agonists during the pre-endoscopic period.  These recommendations were based on observations of increased gastric content in fasting patients treated with semaglutide.  A recent cohort study reported an increased risk of aspiration pneumonia among GLP-1 agonist users undergoing endoscopic procedures. However, in this study, there appeared to be differences in the baseline characteristics between patients who received GLP-1 agonists and those who did not, raising concerns about confounding bias influencing the risk estimates.  We aimed to perform a propensity score-matched cohort study to compare the risk of aspiration pneumonia between patients who were on GLP-1 agonists within 1 month before endoscopic procedures and those who were on GLP-1 agonists more than 1 month before endoscopic procedures.

We utilized the TriNetX Analytics Network database, which includes de-identified electronic health records from greater than 101 million individuals and 70 healthcare organizations.  The study was deemed exempt by the institutional review board and followed the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines.  We included adult (age 18 yr or older) patients with type 2 diabetes, body mass index (BMI) 30 kg/m2 or greater, or BMI 27 kg/m2 or greater with a weight-related comorbidity between April 2005 and February 2024 (Supplemental Digital Content 5, https://links.lww.com/ALN/D646). Pregnant patients were excluded because GLP-1 agonists are contraindicated in this population. Because there is a shortage of GLP-1 agonists in the United States, some patients might not have started their prescribed medication. As this was a database-driven study without direct access to the electronic health records, we were not able to determine if patients in the GLP-1 agonist cohort were actually on GLP-1 agonists. To overcome this issue, we specified that patients in the GLP-1 agonist cohort received a GLP-1 agonist prescription at least once between 1 and 12 months before the endoscopy and at least once within 1 month before the procedure. The non-GLP-1 agonist cohort included patients who were prescribed GLP-1 agonists within 12 months but not within 1 month, 3 months, or 6 months before the procedure, and those never prescribed GLP-1 agonists before the endoscopy. The index date was the endoscopy date. The primary outcome was the incidence of aspiration pneumonia within 7 days after endoscopy (Supplemental Digital Content 1, https://links.lww.com/ALN/D646). Cohorts were propensity score-matched in a 1:1 ratio using predetermined variables that included demographics, BMI, hemoglobin A1c, comorbidities, and the use of glucose-lowering and gastrointestinal agents. We estimated the association between GLP-1 agonists and outcomes by computing the relative risk using a matched pair logistic regression model on the TriNetX platform, which utilizes SAS version 9.4. We evaluated the effects of GLP-1 agonists on intubation, admission to the intensive care unit, and death within 7 days after endoscopy. We performed a sensitivity analysis evaluating the duration of GLP-1 agonists and risk of aspiration pneumonia. We also conducted subgroup analyses evaluating patients who received upper or lower GI endoscopy, had GI comorbidities, received daily or weekly GLP-1 agonists, and endoscopy with or without general anesthesia. All P-values were two-tailed and considered statistically significant if less than 0.05.

Of the 82,004 eligible patients, 29,820 (36.4%) were in the GLP-1 agonist cohort and 52,184 (63.6%) in the non-GLP-1 agonist cohort (Supplemental Digital Content 5, https://links.lww.com/ALN/D646). Patients in the GLP-1 agonists cohort had a higher baseline prevalence of morbid obesity (20.0% vs. 16.9%) and type 2 diabetes (78.4% vs. 69.2%). After propensity score matching, all covariates were well-balanced between cohorts (table 1). Mean ages were 58.5 (±10.9) and 58.4 (±11.1) years, respectively. Esophagogastroduodenoscopy and colonoscopy were performed on 48.7% and 68.7% of patients, respectively. In the logistic regression analysis, patients on a GLP-1 agonist within 1 month of endoscopy had a similar risk of aspiration pneumonia compared with patients on a GLP-1 agonist between 1 and 12 months of the endoscopy (risk ratio [RR], 1.14 [95% CI: 0.88-1.47]) (table 2). Similarly, patients on a GLP-1 agonist within 1 month of endoscopy had a similar risk of aspiration pneumonia compared with patients not on a GLP-1 agonist within 3 or 6 months or those who were never prescribed a GLP-1 agonist before the endoscopy. Similarly, in the sensitivity and subgroup analyses, the use of GLP-1 agonists was not associated with an increased risk of aspiration pneumonia or other outcomes (Supplemental Digital Content 2, 3, 4, https://links.lww.com/ALN/D646).

Table 1.

Demographic and clinical characteristics of GLP-1 agonist group and non-GLP-1 agonist group, before and after propensity score matching

Demographic and clinical characteristics of GLP-1 agonist group and non-GLP-1 agonist group, before and after propensity score matching

Table 2.

Association between GLP-1 agonist and risk of aspiration pneumonia

Association between GLP-1 agonist and risk of aspiration pneumonia

In this cohort study, the use of GLP-1 agonists within 1 month before endoscopy was not associated with an increased risk of aspiration pneumonia among patients with type 2 diabetes or obesity undergoing endoscopic procedures. Contrary to guideline recommendations, our results suggest that GLP-1 agonists are likely safe in the perioperative period, and whether GLP-1 agonists should be held before endoscopies should be individually assessed. Limitations of this study include the observational design, which implies that there were likely unmeasured or unmatched confounders. This was a database-driven study without direct access to medical records. Therefore, we were only able to capture the outcomes using International Classification of Diseases (ICD) codes, raising the possibility of misclassification. We were unable to obtain the doses of GLP-1 agonist treatment as the TriNetX database did not provide data on doses. It is important to note that this study only showed no increased risk of aspiration pneumonia in patients who had GLP-1 agonist treatment within 1 month before endoscopy. Of note, we were unable to confirm if patients in the GLP-1 agonist cohort were started on GLP-1 agonists due to the lack of access to electronic health records. Nevertheless, we specified that patients should have been prescribed a GLP-1 agonist at least once between 1 and 12 months before the endoscopy and at least once within 1 month before it.

In conclusion, this population-based study found no association between the use of GLP-1 agonists within 1 month before endoscopy and the risk of post-endoscopy aspiration pneumonia. Further studies are warranted to guide an individualized approach to the management of GLP-1 agonists during the pre-endoscopic period.

Anesthesiologists to CMS: ‘We want to be valued’

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Author: Francesca Mathewes
Becker’s ASC Review

Anesthesiology faces numerous pressure points, including provider shortages and decreasing reimbursements. And, as private payers typically look to Medicare to determine their reimbursement rates, some look to CMS to change the course of consistent rate declines.

Here is what four anesthesiologists told Becker’s they would like to see from CMS: 

Editor’s note: Responses have been lightly edited for clarity and length. 

Mark Destache, MD. Anesthesiologist with Associated Anesthesiologists, P.A. (Plymouth, Minn.): What anesthesiologists want from CMS is a fair wage for taking care of this patient population. The conversion factor for anesthesia has been cut by a third since 1992 when not adjusted for inflation. It is currently $20.77 per 15 minutes, which is the same whether it is open heart surgery or cataracts. That is less than what CRNA wages are, so in effect, the anesthesiologist makes less than nothing once the case is going.

Christian Welch, MD. Anesthesiologist at UT Health San Antonio: In short, we want to be valued. Despite an ever-increasing percentage of patients on Medicare, which typically represents an older and sicker patient population, our profession is taxed with annual cuts. The 2025 proposed anesthesia conversion factor is $20.33, down from $20.43 in 2024 and $20.67 in 2023. Commercial insurers typically follow CMS reductions. In addition, we are taking care of more ASA 3 and sometimes ASA 4 patients in ASCs. Anesthesia has become very safe, mostly due to the work of the Anesthesia Patient Safety Foundation. That does not mean, however, that our role as perioperative physicians and “guardians” of the OR should be taken for granted.

Donald Keusch, MD. Anesthesiologist at Boca Raton (Fla.) Plastic Surgery Center: Anesthesiologists would like fair reimbursement for their services. Currently, Medicare pays 28% of the anesthesia rate that is received from commercial insurance. This is intolerable and is not sustainable. Rather than increasing reimbursement over the years to account for inflation, there has been a further absolute decline in payments to physicians. The situation for Medicaid is even worse.

Javier Marull, MD. Associate Professor in the Department of Anesthesiology and Pain Management at UT Southwestern Medical Center (Dallas): As anesthesiologists, what we really want is to give our patients the best care possible without getting bogged down in unnecessary red tape. We are with our patients through every step of their journey, not just in the operating room, and we would love to see that dedication reflected in fair compensation. 

A big part of the challenge we face is the amount of time spent on paperwork and approvals, which takes us away from what really matters: our patients! If CMS could simplify these processes, it would make a huge difference, allowing us to focus more on patient care and less on administrative tasks. At the heart of it all, we just want to do what we are trained to do, care for people without the constant barriers that make that harder than it should be

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