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Postpandemic Burnout: Comment

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Authors: Ruisong Gong, M.D. et al 
Anesthesiology October 2024, Vol. 141, 798–799.

We are writing to express our team’s keen interest and appreciation for the insightful study published in Anesthesiology, “U.S. Attending Anesthesiologist Burnout in the Postpandemic Era” by Afonso et al.  As peers from China, we are particularly intrigued by the parallels and variances we have observed between the findings presented and our analogous research in China. 

The use of the Maslach Burnout Inventory in both American and Chinese surveys reveals a disturbingly high prevalence of burnout among anesthesiologists across the board. Before the pandemic  59.2% of anesthesiologists in the United States experienced burnout, which increased to 67.7% after the pandemic. Our survey in China, which included all anesthesiologists, showed a national cross-sectional survey burnout rate of 69% prepandemic which interestingly decreased to 52.7% postpandemic.  Specifically for Chinese attending anesthesiologists, the burnout rate was 73% prepandemic and 42.6% postpandemic. 

This unexpected trend in China, despite high baseline levels, deserves attention. Risk factors for anesthesiologist burnout in both the United States and China include a perceived lack of support and severe staffing shortages.  In 2018, China had 76,000 anesthesiologists for a population of 1.4 billion, far fewer than the 2.4 anesthesiologists per 10,000 people in the United States and Europe. The United States has also recently faced severe staffing shortages, with 35.1% of attending anesthesiologists reporting shortages in 2020, rising to 78.4% in 2022.  These staffing challenges have likely contributed to high burnout rates in both countries. To address this, China has taken steps to increase its anesthesiologist workforce. In 2018, China’s National Health Commission (Beijing) released Document 21, which aims to increase the number of anesthesiologists to 90,000 by 2020 and 140,000 by 2030. Local governments and hospitals have also been working to increase the number of formally trained anesthesiologists and promote the sustainable development of this workforce. According to the Chinese Society of Anesthesiology, the number of anesthesiologists in China has increased to 105,000 in 2023, an increase of 38% from 2018. Although there is still a significant shortage, this increase may partially explain the decrease in burnout rates. However, we must acknowledge that our research did not follow the same individuals over time, and burnout has complex, multifactorial causes. Therefore, the observed improvements in staffing are likely only one of several contributing elements.

Understanding the complexities of anesthesiologist burnout is essential for developing better interventions and improving their well-being and job satisfaction. Both the U.S. and Chinese studies emphasize that support from leadership at an organizational level is crucial in preventing burnout.  Furthermore, our research in China investigated the psychologic status of anesthesiologists, revealing a positive association between burnout and mental health issues such as depression, anxiety, and posttraumatic stress disorder.  Although the causality between psychologic status and burnout and the impact of COVID-19 on mental health is not entirely clear, prioritizing the psychologic well-being of anesthesiologists is likely beneficial for mitigating burnout. In addition, we believe that pressures related to scientific research and advancement in one’s career might also influence burnout, an aspect that could be explored in future studies. Therefore, it is imperative for our team leaders to pay more attention to improving the work environment and providing additional support to colleagues. Of course, considering the differences in culture and healthcare systems, our interventions need to be adapted accordingly.

It is noticed that our studies have achieved response rates of greater than 70%, possibly due to our WeChat (Tencent, China)–based data collection. Frankly, our methodology took advantage of the use of WeChat, for either social interactions or professional communication to streamline the survey process. Our respondents could conveniently complete the questionnaire on their mobile devices in only a few minutes. Compared to traditional surveys, WeChat has contributed greatly to the response rate of our study.

In conclusion, anesthesiologist burnout is an international problem that requires a global response. Recent studies suggest significant regional variations and potential strategies for improvement. Further research is needed to understand these differences and develop effective interventions. We look forward to further research and dialogue in this area and hope to collaborate with researchers worldwide to improve the working conditions and mental health of anesthesiologists. Addressing burnout is a marathon, not a sprint, and our commitment to this effort is unwavering.

A Great CRNA and Anesthesiologist Opportunity in Lubbock TX

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We are seeking a dedicated anesthesia care team to join our new anesthesia care team contract at Lubbock Heart and Surgery Hospital in Lubbock TX.

Position Highlights:

  • Anesthesiologist call is 1:3
  • Competitive salary of $575,000 plus benefits.
  • 8 weeks of vacation.
  • CRNA no call
  • Competitive salary of $280,000 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

The Agreement Between Transthoracic and Transesophageal Echocardiography in the Assessment of Right Ventricular Diastolic Dysfunction Grades in Adult Patients Undergoing Cardiac Surgery

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Authors: Singh N C, Biswas I, Kumar B, et al.

Cureus 16(10): e70976. doi:10.7759/cureus.70976

Introduction

The importance of right ventricular (RV) diastolic function in cardiac surgery cannot be overstated, as it significantly affects prognosis and long-term outcomes. Conventionally, RV diastolic dysfunction (RVDD) is assessed and graded using criteria from either the American Society of Echocardiography (ASE) or the British Society of Echocardiography (BSE), with measurements done by transthoracic echocardiography (TTE). However, during cardiac surgery, perioperative echocardiographic evaluation is done predominantly by transesophageal echocardiography (TEE). This study aimed to assess the agreement between TTE and TEE in grading RVDD using both ASE and BSE criteria.

Methods

Key two-dimensional (2D) and Doppler parameters were measured in 81 patients undergoing cardiac surgery by both TTE and TEE after anesthesia induction within 10 minutes of each other, under similar hemodynamic, anesthetic, and ventilatory conditions. RVDD gradings were done separately by TTE and TEE with both ASE and BSE criteria using the measured values of the key parameters by TTE and TEE, respectively. RVDD gradings derived from TTE were compared with those derived from TEE. The tricuspid inflow Doppler and tricuspid annular tissue Doppler parameters were measured in TEE in both mid-esophageal RV inflow-outflow (MERVIO) and deep transgastric RV inflow-outflow (DTGRVIO) views. Gradings were done separately for both views of TEE by using the Doppler values measured in the respective views (TEE-MERVIO and TEE-DTGRVIO). The TTE-derived RVDD grades were compared with those derived by both TEE-MERVIO and TEE-DTGRVIO. Weighted κ values were used to assess observed agreement beyond chance. Inter-rater reliability of the RVDD grades derived by both TTE and TEE (both views) was also checked. Individual 2D and Doppler parameters were compared between TTE and TEE in terms of Bland-Altman limits of agreement.

Results

As per ASE criteria, disagreement of RVDD by ≥1 grade was seen in 43 (53.1%) patients and by 2 grades in eight (9%) patients when comparing TTE and TEE-MERVIO, yielding a weighted κ of 0.14 (p=0.123). Disagreement by ≥1 grade was observed in 32 (39.5%) patients and by 2 grades in 10 (12.3%) patients when comparing TTE and TEE-DTGRVIO, yielding a weighted κ of 0.3 (p=0.002). Using the BSE Criteria, disagreement of RVDD grades occurred in nine (11.1%) patients when comparing TTE and TEE-MERVIO, yielding an unweighted κ of 0.25 (p=0.295). Disagreement occurred in 12 (14.8%) patients when comparing TTE and TEE-DTGRVIO, yielding an unweighted κ of 0.260 (p=0.187). There was almost perfect agreement between independent raters regarding both TTE- and TEE-derived RVDD grades per the ASE criteria, and substantial to almost perfect agreement per BSE criteria. Bland-Altman analysis of paired data between the TTE- and TEE-measured values of individual 2D and Doppler parameters showed wide limits of agreement.

Conclusions

This study revealed, at best, only fair agreement between TTE and TEE in grading RVDD. The measured 2D and Doppler echocardiographic parameters showed wide limits of agreement between TTE and TEE. We recommend further research to develop a TEE-based algorithm for grading RVDD, and to evaluate the prognostic effectiveness of perioperative TEE for predicting adverse clinical outcomes associated with RVDD.

Understanding the Pain Scale

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Author: Dr Nikesh Seth

Feedspot Weekly

Effective communication about pain is crucial in healthcare. Understanding and articulating your pain accurately to your healthcare provider can significantly enhance the management and treatment of your condition. The pain scale, a common tool used in clinical settings, helps in quantifying pain, providing a more objective measure of something inherently subjective. This guide explores how to use the pain scale to communicate your pain effectively.

What is the Pain Scale?

The pain scale is a tool designed to help patients and healthcare providers gauge the intensity of pain. It provides a quantitative measure that helps in assessing the severity of pain, facilitating more accurate treatment decisions. Historically developed for better pain management, these scales are simple yet powerful tools for describing an individual’s pain experience.

Types of Pain Scales

There are several types of pain scales used in medical practice:

  • Numeric Rating Scale (NRS): This scale ranges from 0 (no pain) to 10 (the worst possible pain). It is straightforward and widely used for adults.
  • Visual Analog Scale (VAS): This scale features a line, usually 10 centimeters long, where patients mark their pain level along the continuum from ‘no pain’ to ‘worst pain imaginable.’
  • Faces Pain Scale-Revised (FPS-R): Particularly useful for children, this scale uses faces with varying expressions from no pain to very much pain to help describe pain levels.

Each type of scale may be more suitable depending on the patient’s age, cognitive abilities, and specific medical conditions.

How to Use the Pain Scale

Using the pain scale involves several steps:

  1. Select the appropriate scale: Choose a scale that you understand and feel comfortable using.
  2. Consider the type of your pain: Reflect on whether your pain is acute or chronic, as this might affect your perception of pain intensity.
  3. Evaluate the impact on activities: Think about how your pain affects your daily activities and overall quality of life.
  4. Incorporate emotional aspects: Recognize any emotional or psychological components to your pain, as these can amplify the physical sensation of pain.

Challenges in Using Pain Scales

While pain scales are incredibly useful, they are not without challenges. Pain is subjective, and individual tolerance varies significantly. Some patients may find it difficult to quantify their pain, while others might underestimate or exaggerate their pain unintentionally. Healthcare providers can aid in this process by offering clear explanations and ensuring the patient feels comfortable expressing their pain accurately.

Enhancing Pain Communication with Your Doctor

When discussing your pain with your doctor:

  • Be descriptive: Use the scale to provide a baseline, but also describe the nature of your pain (e.g., stabbing, burning, throbbing).
  • Update regularly: Communicate any changes in your pain or its characteristics.
  • Discuss the effectiveness of treatments: Share what has or hasn’t worked in managing your pain.

Key Takeaways

Accurately communicating pain using the pain scale is integral to effective pain management. It helps your healthcare provider understand your pain better, leading to more tailored and effective treatment strategies.

FAQs

1. What does a pain scale score really tell my doctor?

A pain scale score provides your doctor with a quantitative measure of your pain, which can help in assessing the severity and nature of your pain. It’s a crucial part of your medical history and treatment plan, aiding in decisions about diagnostics, treatment adjustments, and monitoring of your condition over time.

2. How do I choose which pain scale to use?

The choice of a pain scale often depends on the clinical setting and your personal comfort with the scale. Adults typically use the Numeric Rating Scale (NRS) for its simplicity. For children or individuals who might struggle with abstract numerical concepts, the Faces Pain Scale-Revised (FPS-R) is often more appropriate. Discuss with your healthcare provider which scale would be best suited for your needs.

3. Can I use the pain scale for chronic pain, or is it only for acute pain?

Pain scales are useful for both acute and chronic pain. Chronic pain, however, may require additional considerations, such as the pain’s impact on daily activities and emotional well-being. It’s important to communicate the persistent nature of your pain and any variations in its intensity over time when using the scale.

4. What if my pain changes during the day? Should I average my pain score when reporting it?

Instead of averaging your pain scores, it’s more helpful to note the range of pain you experience throughout the day and the circumstances under which it changes. This information can give your healthcare provider a clearer picture of your pain’s dynamics and help tailor your treatment plan.

5. Is the pain scale used the same way in every medical situation?

While the basic use of the pain scale is consistent, its application can vary based on the medical setting and the specific condition being treated. For instance, in post-operative care, frequent pain assessments are crucial to managing acute pain, whereas, in chronic pain management, longer intervals between assessments may be appropriate. Always discuss with your healthcare provider how to use the pain scale effectively in your specific situation.

Regional Analgesia and Cancer Recurrence: Comment

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Authors: Philip J. Peyton, M.D., Ph.D., M.B.B.S.; Simon W. Chong, M.B.B.S., B.Med.Sci., D.med.Sc.
Anesthesiology October 2024, Vol. 141, 797–798.

We wish to thank Dr. Cata and Dr. Sessler for their carefully considered review of factors contributing to the failure of promising preclinical study findings to be confirmed in subsequent large clinical trials of the effects of anesthetic technique on cancer surgery outcomes.  Their forensic analysis of the reasons focused on experimental methodology in animal research, and the mechanistic drivers and reductionist approach that characterize preclinical science. Their explanation also included “often unjustified” small sample sizes and “unsophisticated” statistical analysis. (A common example might be failure to correct for multiplicity in experimental comparisons when determining statistical significance, for instance.) They pointed to the “huge effort and the expense” of the clinical trials prompted by this preclinical work, but ultimately with negative findings.

However, the authors did not mention the likely contribution of positive publication bias to this failure in research translation. The damaging effect of publication bias on evidence quality in medicine has been lamented for many years by experts who estimate half of research activity goes unpublished.  In the field of anesthesiology, we and other authors have confirmed this.  We found that, among more than 1,000 abstracts of clinical trials presented at the annual American Society of Anesthesiologists (ASA; Schaumburg, Illinois) meeting from 2001 to 2004, those with positive findings were twice as likely (odds ratio 2.01) to proceed to eventual peer-reviewed journal publication as those with negative findings.  The hallmarks of clinical research that promote publication bias are single center, small trial design, and lack of transparency in prospective hypothesis formation with potential for selective outcome reporting.  These features can all be shared by animal laboratory research, and there is certainly no reason to believe that it is any less prone to publication bias than clinical trials.

With a view to future solutions, we repeated our analysis by using ASA abstracts from 2010 to 2016, following the implementation by the International Committee of Medical Journal Editors (ICMJE) of mandatory prospective clinical trial registration for publication after 2005. We found that the magnitude of imbalance in publication outcome had significantly reduced (odds ratio 1.3), suggesting that this policy successfully limits the influence of publication bias in clinical anesthesiology.  However, mandatory prospective trial registration does not extend to preclinical trials and animal studies, nor to the publication policies of journals in other fields of the biologic sciences. Leaders in preclinical science have recently called for integration of trial registration into the animal ethics review process.  Animal research registries have been established, but with only sporadic use. 

We fear therefore that, in combination with the factors which Dr. Cata and Dr. Sessler have described, the persistence of publication bias offers little prospect that the problem of false promises by preclinical research will be solved any time soon. We can thus expect much wasted cost and effort in subsequent clinical trials to continue into the future.

Hypertension and Kidney Function After Living Kidney Donation

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Authors: Amit X Garg et al
JAMA . 2024 Jul 23;332(4):287-299

Importance: Recent guidelines call for better evidence on health outcomes after living kidney donation.

Objective: To determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. Their rates of estimated glomerular filtration rate (eGFR) decline and risk of albuminuria were also compared.

Design, setting, and participants: Prospective cohort study of 924 standard-criteria living kidney donors enrolled before surgery and a concurrent sample of 396 nondonors. Recruitment occurred from 2004 to 2014 from 17 transplant centers (12 in Canada and 5 in Australia); follow-up occurred until November 2021. Donors and nondonors had the same annual schedule of follow-up assessments. Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics.

Exposure: Living kidney donation.

Main outcomes and measures: Hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure [DBP] ≥90 mm Hg, or antihypertensive medication), annualized change in eGFR (starting 12 months after donation/simulated donation date in nondonors), and albuminuria (albumin to creatinine ratio ≥3 mg/mmol [≥30 mg/g]).

Results: Among the 924 donors, 66% were female; they had a mean age of 47 years and a mean eGFR of 100 mL/min/1.73 m2. Donors were more likely than nondonors to have a family history of kidney failure (464/922 [50%] vs 89/394 [23%], respectively). After statistical weighting, the sample of nondonors increased to 928 and baseline characteristics were similar between the 2 groups. During a median follow-up of 7.3 years (IQR, 6.0-9.0), in weighted analysis, hypertension occurred in 161 of 924 donors (17%) and 158 of 928 nondonors (17%) (weighted hazard ratio, 1.11 [95% CI, 0.75-1.66]). The longitudinal change in mean blood pressure was similar in donors and nondonors. After the initial drop in donors’ eGFR after nephrectomy (mean, 32 mL/min/1.73 m2), donors had a 1.4-mL/min/1.73 m2 (95% CI, 1.2-1.5) per year lesser decline in eGFR than nondonors. However, more donors than nondonors had an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up (438/924 [47%] vs 49/928 [5%]). Albuminuria occurred in 132 of 905 donors (15%) and 95 of 904 nondonors (11%) (weighted hazard ratio, 1.46 [95% CI, 0.97-2.21]); the weighted between-group difference in the albumin to creatinine ratio was 1.02 (95% CI, 0.88-1.19).

Conclusions and relevance: In this cohort study of living kidney donors and nondonors with the same follow-up schedule, the risks of hypertension and albuminuria were not significantly different. After the initial drop in eGFR from nephrectomy, donors had a slower mean rate of eGFR decline than nondonors but were more likely to have an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up.

US hospitals face IV fluid shortage

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Author: Erica Carbajal
Becker’s Hospital Review

Hospitals across the nation are conserving IV fluids amid a new shortage of supplies — the latest example of fallout from Hurricane Helene.

Somerville, Mass.-based Mass General Brigham held a press call Oct. 3, saying Baxter International, the nation’s largest supplier of IV solutions, sent a letter to the health system and other customers stating it would be receiving 40% of the level of supply it typically receives.

“We have been informed that due to the devastating effects of Hurricane Helene, we will be receiving a reduced supply of IV fluids from Baxter International as they work to mitigate disruptions in their manufacturing operations,” Paul Biddinger, MD, chief preparedness and continuity officer, said in a statement to Becker’s. “Having experienced similar challenges in the wake of Hurricane Maria in 2017, we continue to be mindful of how we manage the supply of these medications to ensure minimal impact on our patients. Hospital operations continue as normal and patient care remains unaffected.”

The supply disruptions affect hospitals across the country and stem from the closure of a Baxter International plant in North Carolina, which suffered significant damage during the storm. The company supplies about 60% of IV solutions used in the U.S., manufacturing around 1.5 million bags per day. The company is assessing the extent of the damage and communicating with customers about actions it is taking to minimize potential disruptions.

In a Sept. 30 statement, Baxter said product allocations will help prevent stockpiling and “increases the likelihood of equitable access to available products.”

It’s unclear when the facility will be able to resume operations

In the meantime, hospitals have put conservation measures into action. At Mass General Brigham, which consumes more than 100,000 liters of IV fluid each month, is giving patients who are healthy enough Gatorade or water instead of IVs. The hospital has also temporarily halted the practice of discarding IV units, regardless of their current volume, and replacing them with new units when patients are transferred from one unit to another. In an email to staff obtained by The Boston Globe, the health system called the shortage as “serious and immediate.”

Cedars-Sinai in Los Angeles remains fully operational, though the hospital has implemented contingency plans.

“We are utilizing alternative solutions based on guidelines from national medical associations and exploring other ways to source IV fluids,” a Cedars-Sinai spokesperson said in a statement to Becker’s. “We are closely monitoring the situation, which is evolving quickly, and will keep our community and patients informed.”

Chicago-based Northwestern Medicine told NBC News it anticipates IV fluid supply disruptions to be a “long-term issue.”

Aside from conservation efforts, hospitals have few options to bolster supplies, an official from Premier, a group purchasing organization for hospitals, told The Wall Street Journal. For example, the U.S. can’t rely on European manufacturers due to existing global shorages.

Meanwhile, other U.S. suppliers are stepping in to try and fill supply gaps. B. Braun Medical, a manufacturer that makes around 23% of supplies used in the U.S., told NBC it is hiring new employees as it works to build up to 24/7 operations at two of its facilities in the coming weeks.

“It’s too early to say what would happen if this [shortage] continues for many weeks or months,” Dr. Biddinger said.

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

Electroencephalographic Features of Elderly Patients during Anesthesia Induction with Remimazolam

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Authors: Hyoungkyu Kim, Ph.D. et al 
Anesthesiology October 2024, Vol. 141, 681–692.
Background

Although remimazolam is used as a general anesthetic in elderly patients due to its hemodynamic stability, the electroencephalogram characteristics of remimazolam are not well known. The purpose of this study was to identify the electroencephalographic features of remimazolam-induced unconsciousness in elderly patients and compare them with propofol.

Methods

Remimazolam (n = 26) or propofol (n = 26) were randomly administered for anesthesia induction in surgical patients. The hypnotic agent was blinded only to the patients. During the induction of anesthesia, remimazolam was administered at a rate of 6 mg · kg−1 · h−1, and propofol was administered at a target effect-site concentration of 3.5 μg/ml. The electroencephalogram signals from eight channels (Fp1, Fp2, Fz, F3, F4, Pz, P3, and P4, referenced to A2, using the 10 to 20 system) were acquired during the induction of anesthesia and in the postoperative care unit. Power spectrum analysis was performed, and directed functional connectivity between frontal and parietal regions was evaluated using normalized symbolic transfer entropy. Functional connectivity in unconscious processes induced by remimazolam or propofol was compared with baseline. To compare each power of frequency over time of the two hypnotic agents, a permutation test with t statistic was conducted.

Results

Compared to the baseline in the alpha band, the feedback connectivity decreased by averages of 46% and 43%, respectively, after the loss of consciousness induced by remimazolam and propofol (95% CI for the mean difference: −0.073 to −0.044 for remimazolam [P < 0.001] and −0.068 to −0.042 for propofol [P < 0.001]). Asymmetry in the feedback and feedforward connectivity in the alpha band was suppressed after the loss of consciousness induced by remimazolam and propofol. There were no significant differences in the power of each frequency over time between the two hypnotic agents (minimum q value = 0.4235).

Conclusions

Both regimens showed a greater decrease in feedback connectivity compared to a decrease in feedforward connectivity after loss of consciousness, leading to a disruption of asymmetry between the frontoparietal connectivity.

Editor’s Perspective
What We Already Know about This Topic
  • Because of its superior cardiovascular stability, remimazolam may have advantages over propofol as an induction agent in elderly patients
  • The electroencephalographic features of remimazolam in elderly patients have not been well characterized
What This Article Tells Us That Is New
  • During induction of anesthesia, remimazolam caused patterns in electroencephalographic spectral power similar to those seen with propofol
  • Remimazolam nearly halved the directed electroencephalogram alpha-band connectivity from the frontal to the parietal lobes of the brain—again almost identical to the propofol effects on functional connectivity
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