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NIRS during Organ Donation in Brain-dead Donors: Comment

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Authors: Martin Dworschak, M.D., M.B.A.; Ekaterina Pataraia, M.D., M.B.A.
Anesthesiology October 2024, Vol. 141, 808–809.

We read with great interest the article by Soehle et al.,  recently published in this journal. They used three devices employing near-infrared spectroscopy technology (i.e., the INVOS 5100 C and the INVOS 7100 [Medtronic Inc., USA] and the ForeSight Elite [Edwards Lifescience Corp., USA]) to measure regional cerebral oxygenation (rScO2) in a small group of 15 brain-dead subjects in the course of organ procurement. Like other researchers before, Soehle et al.  initially observed near-normal rScO2 values that only markedly dropped after the aorta had been clamped to facilitate organ perfusion. The corresponding nadirs that were reached with each technology were 21 ± 8% (INVOS 5100C and INVOS 7100) and 40 ± 8% (ForeSight Elite), respectively. Assuming that the near-infrared spectroscopy signal in brain-dead subjects is predominantly generated by blood flow within the extracerebral space, the authors conclude that all three devices are “unable to detect severe cerebral hypoxia/anoxia under conditions of normal extracerebral oxygenation.” However, they could still be used “to optimize oxygen supply to the head.”

We commend the authors for their novel approach, using these monitors in the extremes of clinical medicine to evaluate potential shortcomings of their inherent technology. Nevertheless, we feel that it requires some additional explanatory notes to fully appraise the findings of this research. First of all, we challenge the authors’ postulation upon which the whole investigation is actually based. They maintain that subjects whose brain functions are irreversibly lost when pronounced brain dead lack any cerebral blood flow. Consequently, they argue that the close-to-normal rScO2 measures that are determined in these situations must primarily be due to a still unaltered perfusion of the scalp and the skull via branches of the external carotid artery.

The diagnosis of brain death, however, is primarily made by a clinical investigation and in many countries does not require detection of cessation of cerebral blood flow. Moreover, irreversible loss of neuronal activity can still occur under persistently inadequate cerebral blood flow not meeting the metabolic demand of cerebral neurons that inevitably causes necrosis despite continuous oxygen transport into the brain. Although the absence of cerebral blood flow is a reliable marker of brain death, a person can be brain dead in spite of maintained or resumed cerebral blood flow.  Some neurologists even caution against the use of ancillary tests investigating cerebral perfusion, because in a substantial number of patients, patent cerebral blood flow or opacification of cerebral arteries at the time of brain death can be found.  These inconsistencies may cast doubt on the performed clinical brain death exam and can lead to postponements in the procurement of donor organ. The reasons for a persistent or reconstituted cerebral blood flow can be manyfold.  Those two patients without detectable cerebral blood flow the authors reported may therefore not be representative for the whole group. Without any information on the cause (primary or secondary brain injury), its initial location (supra- or infratentorial), on supportive measures in the intensive care unit (vasopressors to raise cerebral perfusion pressure, circulatory support with venoarterial extracorporeal membrane oxygenation, and others), and the time between cerebral damage, the diagnosis of brain death, and the final explantation of organs, any allegation on cerebral blood flow must remain hypothetical.

Furthermore, some potential flaw can be introduced by the different clamping sites of the aorta (ascending vs. descending aorta) because this can induce differing shifts in blood volume and affect compartmentalization of intracerebral blood.  In addition, the fact that rScO2 does not decline to 15% (the lowest detectable value of the INVOS devices), which has been observed during cardiac arrest or to even lower values with the Foresight Elite, further indicates that rScO2’s background signal in these organ donors may additionally be governed by other contributing factors (e.g., cytochromes within damaged brain tissue, oxyhemoglobin contained in brain vessels that cannot unload due to nonmetabolizing surrounding tissue, and others).

Comparison of absolute rScO2 values derived from three different near-infrared spectroscopy monitors is a further drawback of the current study, especially because the INVOS devices received U.S. Food and Drug Administration clearance as trend monitors only. Conversely, all the factors that can interfere with the rScO2 signal will also be operative when these measures are used as a guide to improve brain oxygenation, particularly when intracerebral blood flow conditions, the integrity of cerebral autoregulation, and compartmentalization are unknown.

In conclusion, due to the many confounders and the lack of critical information, the study of Soehle et al. neither clarifies the role and the extent of extracranial rScO2 signal contamination during cerebral desaturations nor supports assumptions regarding lack of residual brain perfusion in brain-dead organ donors.

Emergent Anesthetic Management in a Patient Recently Diagnosed With Stiff Person Syndrome

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Authors: Pinto A, Dinis R, Godinho P, et al.

Cureus 16(10): e70899. doi:10.7759/cureus.70899

Abstract

Stiff person syndrome (SPS) is a rare autoimmune neurological disorder characterized by muscle rigidity and episodic spasms that involve axial and limb musculature. It has important implications during anesthesia, as it leads to gamma-aminobutyric acid (GABA)-mediated inhibitory networks malfunction. This report describes the anesthetic management of a 56-year-old patient with SPS and hereditary spherocytosis undergoing emergent splenectomy due to splenic hematoma and hemoperitoneum after a fall. Total intravenous anesthesia (TIVA) was performed with the adjunctive administration of rocuronium in order to obtain adequate intubation and surgical conditions. Careful management of patients with SPS is strongly suggested given their sensitivity to inhalational anesthetics and neuromuscular blockers, which can lead to hypotonia and muscle weakness requiring maintenance of mechanical ventilation in the postoperative period.

Introduction

Stiff person syndrome (SPS) is a rare neurological condition first described in 1956 by Moersch and Woltman, with an estimated incidence of 1:1.000.000 [1]. Clinical symptoms typically manifest in the fourth decade of life and are characterized by muscle rigidity of the axial and limb musculature due to continuous co-contracture of the agonist and antagonist muscles; sudden painful spasms triggered by unexpected noises, tactile or visual stimuli, pain, and emotional stress [1,2].

SPS is also frequently associated with other autoimmune diseases, such as diabetes mellitus, which affects up to 35% of the patients, thyroiditis, and pernicious anemia [2]. The underlying pathophysiology of SPS is related to autoantibodies that attack the glutamic acid decarboxylase (GAD) enzyme, which is crucial for the synthesis of GABA. Although a positive serology is not required for the diagnosis (about 60% of patients have anti-GAD antibodies in the blood and cerebrospinal fluid (CSF)), reduced GABA production leads to decreased inhibitory signals in various brain regions, including the cortex, striated nucleus, and basal ganglia. This results in chronic motor neuron activation, causing muscle spasms and rigidity [3,4]. The management of SPS typically includes GABA-enhancing drugs (such as sedative anxiolytics and antiepileptic drugs), antispasticity drugs (such as baclofen, tizanidine, and dantrolene), and immunomodulating therapies. Benzodiazepines, like diazepam, are considered the first-line treatment as they enhance GABAA receptor opening [2].

A notable concern in SPS management is the interaction of anesthetic drugs with GABA receptors. Clinical reports have documented hypotonia, delayed awakening, and prolonged mechanical ventilation following general anesthesia with muscle relaxants and volatile anesthetics, especially in those receiving baclofen, a GABAB agonist agent [2,5]. This case report describes the anesthetic management of a patient with SPS who required emergency splenectomy under general anesthesia due to hemoperitoneum following a fall.

Case Presentation

A 56-year-old male (height 176 cm, weight 92 kg) with a medical history of hereditary spherocytosis was admitted to the neurology department for the investigation of muscle weakness in the lower limbs, accompanied by pronounced stiffness and generalized myotatic hyperreflexia, of a six-week duration. The patient had previously presented to the emergency department, where he was discharged with a prescription for non-steroidal anti-inflammatory drugs (NSAIDs), but his clinical condition deteriorated, and he experienced a fall and progressive loss of mobility.

Neurological evaluation revealed hypertonia with spasticity in all four limbs, generalized myotatic hyperreflexia, and slight weakness in the left lower limb (grade four out of five). The patient also reported painful spasms in the lower limbs during hospitalization. The etiological investigation revealed reactive hematopoietic bone marrow hyperplasia and marked homogeneous splenomegaly (measuring 18.3 cm x 20 cm), consistent with the patient’s known medical records. Both the electromyogram and CSF analysis were normal. The patient was initiated on a treatment regimen of clonazepam, methylprednisolone, and baclofen, resulting in improvements in spasticity, painful spasms, and the ability to walk by the third day of treatment.

On the seventh day of hospitalization, following a fall from a standing height, a splenic subcapsular hematoma with hemoperitoneum was documented (Figure 1), and an emergency laparotomy with splenectomy was performed. Previous medical history included ophthalmic and orthopedic surgery before the SPS diagnosis, without recorded complications.

Abdominal-computed-tomography-showing-large-hemoperitoneum-(white-arrows)-and-splenic-subcapsular-hematoma-(black-arrow)
Figure 1: Abdominal computed tomography showing large hemoperitoneum (white arrows) and splenic subcapsular hematoma (black arrow)

L: left; P: posterior

Regarding the preoperative tests, the patient showed a decrease in hemoglobin from 9.8 to 8.9 g/dL and worsening renal function in a probable prerenal context, with an increase in creatinine from 0.82 to 2.25 mg/dL. The chest X-ray (Figure 2), the remaining laboratory results, as well as the electrocardiogram, showed no significant abnormalities in this context.

Chest-X-ray-with-a-slight-elevation-of-the-right-hemidiaphragm-(black-arrow)-and-an-enlarged-cardiothoracic-ratio
Figure 2: Chest X-ray with a slight elevation of the right hemidiaphragm (black arrow) and an enlarged cardiothoracic ratio

On admission to the operating room, the patient was obnubilated, with slightly low blood pressure (98/58 mmHg) and sinus tachycardia (114 bpm). He was monitored according to standard American Society of Anesthesiologists (ASA) guidelines, with additional monitoring of invasive blood pressure, neuromuscular blockade (TOFscan® (Dräger, Lübeck, Germany), which monitors the adductor pollicis muscle), and depth of anesthesia (BISTM monitoring system (Medtronic plc, Minneapolis, MN, USA)). Anesthetic induction was performed with propofol (80 mg), ketamine (50 mg), fentanyl (0.15 mg), and rocuronium (80 mg). The patient did not exhibit signs of a difficult airway nor any limitations in cervical extension so airway management was performed under deep anesthetic conditions using direct laryngoscopy. The procedure lasted two and a half hours, during which anesthesia was maintained with a target-controlled infusion of propofol. The patient was warmed with a forced air warming blanket and heated intravenous fluids, and analgesia was administered with fentanyl (0.05 mg), paracetamol (1000 mg), and metamizole (2000 mg). Resuscitation was conducted with 2000 mL of crystalloids, 3000 mg of fibrinogen, 1000 mg of tranexamic acid, three units of red blood cell concentrate, and three units of fresh frozen plasma, addressing an estimated blood loss of 3100 mL. Urinary output during the surgical procedure was 0.65 mL/kg/h. The patient remained hemodynamically stable throughout the surgery and there was no need to administer vasoactive drugs. At the end of the procedure, a morphine infusion was initiated at 2 mg/h following a 6 mg bolus. Based on the TOFscan® monitoring system, the patient was successfully extubated after administering 200 mg of sugammadex and transferred to the intensive care unit, where he remained for three days without complications.

The patient was subsequently transferred to the Neurology ward and was discharged on the eighteenth day of hospitalization with significant improvement in rigidity, particularly in the upper limbs, while maintaining the ability to walk independently. He continued treatment with baclofen and clonazepam and underwent six cycles of intravenous immunoglobulin in the outpatient clinic, resulting in a nearly complete resolution of symptoms.

Discussion

Due to the extremely low incidence of the disease, limited data is available on the anesthetic management of patients with SPS. However, considering the surgical procedure, total intravenous anesthesia (TIVA) appeared to be the most appropriate and widely accepted choice. Propofol is a safe choice for induction, and other good alternatives include thiopental [6]. These agents should reduce postoperative muscle spasms and pain in SPS patients. Ferrandis et al. have reported etomidate as having a higher risk of intraoperative myoclonus [7]. Propofol has also been implicated to cause intraoperative myoclonus, but it has a lower risk [8,9]. Moreover, it improves postoperative muscle rigidity and spasms, as reported by Obara et al. [10]. The published literature suggests that propofol reduces spinal activity through its agonistic action on GABAA receptors, with some partial effect on central GABAB receptors unlike baclofen, which is a selective GABAB receptor agonist [11-13]. There is even a report of immediate improvement in acute symptoms following continuous propofol infusion [12]. It is known that volatile anesthetics cause muscular relaxation and potentiate the effects of non-depolarizing neuromuscular blockers through their inhibitory actions on GABAB receptors, and hypotonia and prolonged weakness after general anesthesia with these agents have been reported. The proposed hypothesis is that there may be an interaction between volatile agents and baclofen. So, baclofen amplifies the gabanergic effects of volatile agents during general anesthesia by extending postsynaptic inhibitory currents when GABA is released [5]. Therefore, the dose of volatile anesthetics should be adjusted in patients undergoing treatment with baclofen [6]. The use of ketamine in SPS patients is rarely reported in the literature. Hanna et al., in a recent case report, described the use of monthly ketamine infusions to alleviate symptoms of pain and muscle spasms [14]. Currently, ketamine is utilized in various neurological and autoimmune diseases for symptom management. However, its use in the context of anesthetic induction, as described in our case, is scarcely reported [14]. Based on current evidence, propofol seems to be the drug of choice for anesthesia induction in SPS patients, with concomitant use of midazolam, which also modulates GABAA receptor activity [6]. Since the patient was already managed with benzodiazepine and baclofen, and given the emergency context with an altered state of consciousness, we decided not to administer premedication.

There is conflicting evidence on the use of muscle relaxants [7,15]. Baclofen is a centrally acting muscle relaxant that suppresses monosynaptic and polysynaptic reflex transmission in the spinal cord by stimulating GABAB receptors without affecting neuromuscular transmission. Peripheral muscle relaxants, on the other hand, act on the postsynaptic nicotinic acetylcholine receptors at the motor endplate, either causing depolarization or binding to the receptor, resulting in competitive blockade [3]. Johnson and Miller reported cases of muscular weakness following general anesthesia with muscle relaxants despite appropriate reversal, and the need for postoperative mechanical ventilation for up to 48 hours is also reported in the literature [15]. However, Obara et al. reported that the use of neuromuscular blockers was not associated with a greater or more prolonged response than usual [5,10]. It seems that there is no anesthetic interaction or additional contraindication to use neuromuscular blocking agents in SPS patients [6,16], and it is possible that the prolonged weakness reported in some cases could be due to an interaction between the volatile agents and GABA receptors or from the volatile agents and other commonly used medications, such as baclofen or diazepam, as reported by Bouw et al. and Johnson and Miller [5,15]. Careful individual monitoring of neuromuscular response in the form of TOF is important and rocuronium/vecuronium would be the recommended drugs of choice, which can be reversed promptly with sugammadex even in situations of a profound neuromuscular blockade [17].

In our case report, we decided to use rocuronium as it was an emergent procedure, to improve intubation conditions (since muscle rigidity can impair optimal intubation position) and to provide better surgical conditions. There were no complications during anesthetic recovery, and neuromuscular blockade reversal occurred as expected, without any signs of associated muscle weakness at the time of extubation. Since there was no need to administer additional doses of rocuronium, it could be speculated that a prolonged action of this drug may have occurred in this case, and this may be taken into consideration when planning the anesthetic plan of these patients. Given that the patient was on baclofen therapy, maintaining an appropriate temperature was also a concern, especially considering the administration of a substantial amount of fluids and blood products during surgery. Patients under baclofen usually have poor temperature perception, as it increases both the threshold for warm and cold stimuli through the activation of GABAB receptors [6,18]. Although it did not apply to this clinical case, both neuraxial regional anesthesia and local anesthesia appear to be safe options, although spine deformity and rigidity may pose technical challenges. Additionally, it is important to note that pain or discomfort may trigger painful spasms [19,20].

Finally, it is recommended that postoperative surveillance occur in a level II or III care unit due to the increased risk of hypotonia and respiratory depression. Although the patient did not exhibit significant organ dysfunction that would warrant admission to an intensive care unit, the multidisciplinary team considered that the postoperative period should be managed at this level of care due to the patient’s recent diagnosis of a rare syndrome, as well as the surgical complexity and associated blood loss.

Conclusions

SPS is a rare disease with a suspected autoimmune etiology that can present anesthetic challenges due to its effects on the GABA pathway. The use of a TIVA with propofol and opioids is a suitable option. Although some reports associate volatile anesthetics with muscle weakness, they appear to be safe, as does rocuronium, which can be reversed with sugammadex if necessary.

Explaining the procedure and the use of premedication with a benzodiazepine can relax the patient and prevent any spasms or other SPS symptomatology. The patient’s anesthetic depth and neuromuscular blockade should be under continuous monitoring. Given the low incidence of this disease, more data are needed for the optimal anesthetic approach of these patients.

References

  1. MO FP, WO HW: Progressive fluctuating muscular rigidity and spasm (“stiff-man” syndrome); report of a case and some observations in 13 other cases. Proc Staff Meet Mayo Clin. 1956, 31:421-7.
  2. Dalakas MC: Advances in the pathogenesis and treatment of patients with stiff person syndrome. Curr Neurol Neurosci Rep. 2008, 8:48-55. 10.1007/s11910-008-0009-y
  3. Marín T, Hernando D, Kinast N, Churruca I, Sabate S: Anaesthetic management of stiff man syndrome. Rev Esp Anestesiol Reanim. 2015, 62:222-7. 10.1016/j.redar.2014.04.009
  4. Ciccotto G, Blaya M, Kelley RE: Stiff person syndrome. Neurol Clin. 2013, 31:319-28. 10.1016/j.ncl.2012.09.005
  5. Bouw J, Leendertse K, Tijssen MA, Dzoljic M: Stiff person syndrome and anesthesia: case report. Anesth Analg. 2003, 97:486-7. 10.1213/01.ANE.0000072701.97699.79
  6. Chan DYL, Gillies R: Anaesthetic recommendations for stiff person syndrome. J Anesth Intensive Care Med. 2017, 3:555615. 10.19080/JAICM.2017.03.555615
  7. Ferrandis R, Belda J, Llau JV, Belda C, Bahamonde JA: Anesthesia for cardiac surgery on a patient with stiff person syndrome. J Cardiothorac Vasc Anesth. 2005, 19:370-2. 10.1053/j.jvca.2005.03.018
  8. Nimmaanrat S: Myoclonic movements following induction of anesthesia with propofol: a case report. J Med Assoc Thai. 2005, 88:1955-57.
  9. Kiyama S, Yoshikawa T: Persistent intraoperative myoclonus during propofol-fentanyl anaesthesia. Can J Anaesth. 1998, 45:283-4. 10.1007/BF03012925
  10. Obara M, Sawamura S, Chinzei M, Komatsu K, Hanaoka K: Anaesthetic management of a patient with stiff-person syndrome. Anaesthesia. 2002, 57:511. 10.1046/j.1365-2044.2002.262617.x
  11. Misgeld U, Bijak M, Jarolimek W: A physiological role for GABAB receptors and the effects of baclofen in the mammalian central nervous system. Prog Neurobiol. 1995, 46:423-62. 10.1016/0301-0082(95)00012-k
  12. Hattan E, Angle MR, Chalk C: Unexpected benefit of propofol in stiff-person syndrome. Neurology. 2008, 70:1641-2. 10.1212/01.wnl.0000284606.00074.f1
  13. Schwieler L, Delbro DS, Engberg G, Erhardt S: The anaesthetic agent propofol interacts with GABAB-receptors: an electrophysiological study in rat. Life Sci. 2003, 72:2793-801. 10.1016/s0024-3205(03)00182-6
  14. Hanna AF, Bolling D, Tadros M: From wheelchair bound to working: a case study of intravenous ketamine infusions in treating stiff person syndrome. Cureus. 2024, 16:e59397. 10.7759/cureus.59397
  15. Johnson JO, Miller KA: Anesthetic implications in stiff-person syndrome. Anesth Analg. 1995, 80:612-13. 10.1097/00000539-199503000-00032
  16. Cassavaugh JM, Oravitz TM: Multiple anesthetics for a patient with stiff-person syndrome. J Clin Anesth. 2016, 31:197-79. 10.1016/j.jclinane.2016.02.003
  17. Chambers D, Paulden M, Paton F, et al.: Sugammadex for the reversal of muscle relaxation in general anaesthesia: a systematic review and economic assessment. Health Technol Assess. 2010, 14:1-211. 10.3310/hta14390
  18. Oliviero A, Rubio-Esteban M, Foffani G, et al.: Effects of baclofen on temperature perception in humans. Neurosci Res. 2007, 59:89-92. 10.1016/j.neures.2007.06.1463
  19. Shanthanna H: Stiff man syndrome and anaesthetic considerations: successful management using combined spinal epidural anaesthesia. J Anaesthesiol Clin Pharmacol. 2010, 26:547-48.
  20. Yamamoto K, Hara K, Horishita T, Sata T: Considerations for general anesthesia combined with epidural anesthesia in a patient with stiff-person syndrome. J Anesth. 2007, 21:490-92. 10.1007/s00540-007-0542-x

Ultrasound-Guided Epidural Anaesthesia in a 73-Year-Old Female With Bilateral Osteoarthritis and a History of Difficult Epidural Placement: A Case Report

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Authors: Bhalsod D, Taksande K, Paul A, et al.

Cureus 16(10): e70907. doi:10.7759/cureus.70907

Abstract

Osteoarthritis (OA) of the knee is highly prevalent in the elderly population and generally causes disabling pain and dysfunction. Thus, knee OA has become one of the most common indications for total knee replacement (TKR) surgery. Neuraxial anaesthesia management in patients could be very challenging when there is a previous history of difficult epidural placements. The anatomical deformities and degenerative changes can limit the precise positioning of needles and increase the complication rates. This is a case of ultrasound-guided epidural and spinal anaesthesia administration in a 73-year-old female with a history of bilateral OA of the knee with previous difficult epidural placement. The patient had severe OA with severe pain and significant limitations in function. Epidural catheter placement was difficult in a prior bilateral tibial fracture repair, and she needed general anaesthesia for the procedure. Preoperative imaging showed significant degenerative change and decreased intervertebral spaces, which could compromise the accuracy of conventional epidural placement techniques. Real-time ultrasound was used for both epidural and spinal anaesthesia. Intraoperative and postoperative analgesia was provided with bolus doses of bupivacaine following the test dose that confirmed correct catheter placement. On the third postoperative day, the patient was discharged with oral analgesics. This report describes the use of ultrasound guidance to overcome the anatomical obstacles and challenges in epidural and spinal anaesthesia. The use of ultrasound guidance can contribute to a decrease in the complication rate, ensure adequate analgesia, and increase the accuracy of epidural treatment.

Introduction

Osteoarthritis (OA) is a degenerative joint disorder that attacks the knees of elderly patients and is associated with extraordinary pain, stiffness, and loss of functional abilities. Cases with severities are most commonly treated by surgery, one of which is total knee replacement (TKR), relieving pain and improving such joint functioning [1]. In elderly patients with OA, the administration of anaesthesia has presented some intricate difficulties, particularly if prior difficulties inserting epidural catheters have occurred. Epidural anaesthesia is considered the standard of care for lower limb and intra-abdominal surgeries. It provides excellent analgesia and decreases the requirement for systemic analgesics. Although epidural anaesthesia offers a myriad of advantages, its ease of administration may be limited by degenerative changes as well as anatomic variations common in older patients with OA. Various factors may impede the right positioning of the catheter: distorted anatomical landmarks, reduced intervertebral spaces, and modified epidural structure [2].

Traditional approaches to epidural placements rely on palpation and anatomical reference points, which can be imprecise in cases with extensive degenerative changes or complications of previous interventions. Ultrasound guidance has perhaps become a significant advance for neuraxial anaesthesia in modern times. It provides the user with multiple advantages over conventional techniques. Real-time ultrasound visualization allows detailed imaging of the spinal anatomy. It thus permits more precise localization of the epidural space, further accuracy in needle placement, and a reduction in some of the complications like accidental dural puncture or inadequate block. These are useful in enhancing the visualization of anatomical structures that may become distorted or obscured as a result of degenerative changes and, by that very virtue, very helpful in increasing the success rate of neuraxial procedures [3]. Recent studies proved that ultrasound-guided epidural anaesthesia has a higher success rate with lower complication rates when compared to the traditional landmark-based approaches. It thus provides for the placement of the needle and the advancement of a catheter in patients whose anatomy is complicated to detect or with a history of neuraxial block placements that are problematic. It reduces the number of attempted insertions of the needle by lowering discomfort to the patients and any potential failure of the procedure through ultrasound guidance [4].

The current report presents a case of ultrasound-guided neuraxial anaesthesia in a 73-year-old female patient with a history of bilateral knee OA and prior difficult epidural insertions. We applied ultrasound guidance to overcome the anatomical challenges presented by the degenerative changes in this patient and complications related to previous anaesthetics. This concept ensured an optimal approach toward perioperative analgesia and patient safety by a dual mechanism, enabling appropriate placement of epidural catheters and providing a practical alternative to general anaesthesia.

Case Presentation

A 73-year-old female diagnosed with bilateral OA knees was scheduled to undergo bilateral TKR. The severity of the OA (as seen in Figure 1) had progressed to a level where she experienced significant pain and limited mobility, making surgery a necessary course of action. The patient’s medical history included a prior bilateral tibial fracture, for which a combined spinal epidural anaesthesia technique was intended. Due to complications when placing the epidural catheter, the tibial fracture procedure was carried out under general anaesthesia.

 

Anteroposterior-and-lateral-X-rays-showing-severe-osteoarthritis-of-both-knees-with-decreased-joint-space
Figure 1: Anteroposterior and lateral X-rays showing severe osteoarthritis of both knees with decreased joint space

Pre-anaesthetic evaluation

The patient complained of pain in both knees with stiffness and a decrease in functional capacity. The BMI of the patient was noted to be 27.2 kg/m². The patient had a history of bilateral OA knee, which was treated with medication and physiotherapy. On the contrary, no significant comorbid conditions were found, and systemic examination findings were also within normal limits. She had one previous surgery for a bilateral tibial fracture seven years ago, where the planned epidural and spinal anaesthesia had to be abandoned and general anaesthesia was given because of difficulty in placing the epidural catheter. No functional cardiac incapacitation to surgery was noted on preanesthetic examination. Pulse rate was 80/minute, blood pressure was 120/80 mmHg, respiratory rate was 16 breaths/minute, and oxygen saturation (SpO2) was 98% on room air. All routine laboratory investigations like complete blood count, renal function tests, and liver function tests were within normal limits (Table 1). The preceding anaesthetic history necessitated an X-ray examination of the lumbar spine, which revealed significant degenerative changes and reduced intervertebral spaces indicative of the ageing process (Figure 2). Given the patient’s previous difficulties with epidural insertion and the radiographic findings, it was decided to do a bilateral TKR and to employ ultrasound guidance for the epidural catheterisation, with general anaesthesia as a contingency. Following a detailed explanation of the risks and advantages associated with the procedure, informed consent was obtained.

Laboratory Test Result Reference Range
Complete Blood Count (CBC)
Hemoglobin (g/dL) 13.5 12.0 – 15.5 (Female)
Hematocrit (%) 40 37.0 – 47.0 (Female)
White Blood Cell Count (×10³/µL) 6.5 4.0 – 10.0
Platelet Count (×10³/µL) 250 150 – 450
Renal Function Tests
Serum Creatinine (mg/dL) 0.9 0.6 – 1.2
Blood Urea Nitrogen (mg/dL) 15 7-20
Liver Function Tests
Alanine Aminotransferase (U/L) 20 7-56
Aspartate Aminotransferase (U/L) 18 10-40
Alkaline Phosphatase (U/L) 70 44 – 147
Total Bilirubin (mg/dL) 0.8 0.1 – 1.2
Table 1: Laboratory values
Xray-of-the-lumbar-spine-showing-decreased-intervertebral-spaces
Figure 2: Xray of the lumbar spine showing decreased intervertebral spaces

 

Anaesthetic management

An 18G intravenous access was established during arrival in the operation theatre and fluid therapy was instituted to ensure adequate hydration with hemodynamic stability. The monitors attached included electrocardiography, pulse oximetry, and a non-invasive blood pressure and heart rate monitor. Base-line parameters were pulse rate of 78 bpm, blood pressure of 118/76 mmHg, respiration rate of 16 breaths/minute, and SpO2 of 100% on room air, which indicated that the patient was in stable preoperative condition. The patient was positioned in the sitting position to allow for the precision of the neuraxial block and to maximize access to the lumbar spine for the anesthesiologist. The position enhanced accuracy in the placement of the needle by allowing for the correct orientation of the spinal structures. Ultrasound guidance was utilized to perform spinal and epidural anesthesia techniques as seen in Figure 3.

Ultrasound-image-showing-L3-L4-intervertebral-space
Figure 3: Ultrasound image showing L3-L4 intervertebral space

 

The posterior epidural space was identified, followed by the visualization of the lumbar spine with a linear probe operating within a frequency range of 3-13 MHz. Keeping the orientation marker cranially, the probe was placed in the paramedian sagittal plane, approximately 1-2 cm lateral to the spinous processes. This technique allowed visualization of the L3-L4 intervertebral space, the intended target site for the epidural block. An in-plane approach was used with the insertion of the 18-gauge Tuohy needle from the caudal direction, with its advancement watched in real time under ultrasound guidance as it moved toward the ligamentum flavum and into the epidural space. This helped minimize the complication rate while allowing correct placement of the needle. A catheter was then introduced through the needle and placed in the epidural space following confirmation of appropriate placement by loss of resistance technique. After that, a sterile dressing was used to secure the catheter. A 25G Quincke needle was used to inject a combination of 15 mg of hyperbaric bupivacaine and 5 mcg of dexmedetomidine into the subarachnoid space at the L3-L4 intervertebral space, following an identical approach to spinal anaesthesia with ultrasonographic guidance. Dexmedetomidine was given to improve the analgesic and sedative effects of the spinal block and to extend its duration. A test dose of 3 mL of 1.5% lidocaine with epinephrine was given through the epidural catheter to verify proper catheter placement and guarantee safety. Supplemental dosages of 10 ml of 0.25% bupivacaine were given every 45-60 minutes to make certain that there was satisfactory analgesia during the time of surgery, and no other intravenous analgesic was given.

Surgical management

Bilateral medial parapatellar incisions were made. Much care was taken at each incision to make sure of minimum trauma to the soft tissues. The soft tissues of both knee joints were carefully dissected to expose the knee joints. The patellae were mobilized and retracted to give good exposure to the femur and tibia. Subsequently, resection started after the knees had been exposed, including specified bone cuts to prepare the surface for total knee implants, also aligning them accordingly with adequate preparation of the bony surfaces following meticulous removal of the degenerated bone and osteophytes in both knees from the femoral and tibial surfaces. Following this, the whole knee prostheses for both knees were precisely prepared and positioned. Each knee’s femoral and tibial components were implanted following the guidelines provided by the manufacturer (Meril Life Sciences Pvt. Ltd., Gujarat, India). To get the best possible joint function and stability, it was made sure the implants were securely fixed and aligned. Each knee joint was extensively irrigated to guarantee haemostasis and eliminate any debris following the implants. Absorbable sutures were used to close the wounds in layers, and sterile bandages were placed on each knee to aid in healing and preserve the surgical sites. Postoperative X showing the implants are seen in Figure 4.

Postoperative-X-ray-of-both-knees-showing-implants
Figure 4: Postoperative X-ray of both knees showing implants

Postoperative management

The patient was kept in the postoperative unit for four hours and then shifted to the ward. During the postoperative stage, continuous epidural analgesia was continued with 10 ml of 0.125% bupivacaine administered every six to eight hours through the catheter for 48 hours. This regimen provided excellent pain control with reduced consumption of systemic analgesics. She was discharged on postoperative day three after a satisfactory recovery with appropriate follow-up instructions and oral analgesics.

Discussion

OA of the knee is widespread, especially in older patients. It may cause severe pain coupled with poor mobility which will raise the need for TKR [1]. Under such circumstances, as reported here, many challenges arise in anaesthesia management in such patients presenting with severe OA and a history of difficult epidural placements. Besides that, anatomical changes due to age and complications from previous surgeries may render conventional anesthetic techniques ineffective. The case highlighted the difficulties with epidural anaesthesia due to marked degenerative spinal changes, having had tibial fracture repair where epidural placement was difficult, and hence was done under general anaesthesia. The preoperative imaging of the lumbar spine showed significant degenerative changes with decreased intervertebral spaces that could distort the anatomical landmarks and complicate the identification and placement of an epidural catheter; thus, it is necessary to tailor anaesthetic strategies based on the scenario. Most conventional approaches to epidural anaesthesia rely on anatomical landmarks and palpation, which, in turn, are highly unreliable in patients with such pronounced degenerative changes in the spine.

Anatomical distortion and reduced intervertebral space can make it challenging to locate the epidural space precisely, which increases the risk of multiple needle attempts and procedural discomfort. These methods also increase the procedural difficulty and the risk of complications, such as accidental dural puncture or inadequate analgesia [5]. Ultrasound-guided neuraxial anaesthesia is an advancement over conventional techniques as it provides real-time visualization of the spinal anatomy. This allows better localization of the epidural space, thus more precise placement of the needle, reducing the possibility of complications arising and hence increasing the success rate of the procedure. In the current case, ultrasound guidance played a vital role in overcoming anatomical difficulties due to the patient’s degenerative changes. Linear probes provide high-resolution images within a frequency range of 3-13 MHz of the lumbar spine and hence allow for accurate and precise localization of intervertebral spaces, which are important during the administration of epidural and spinal anaesthesia [6].

Ultrasound guidance increased overall procedural safety while at the same time augmenting precision in needle placement. With the capability to visualize the path of the needle in real time, the number of insertions could be reduced, thereby minimizing discomfort for the patient. This approach helped to execute successful insertions of both the spinal needle and the placement of an epidural catheter important for perioperative pain management. Other factors contributing to patient comfort, other than the use of ultrasound guidance in the procedure, were the addition of dexmedetomidine to the formulation of spinal anesthetic. Dexmedetomidine has been reported as exhibiting properties contributing to analgesia, extending the quality and duration of the spinal block, offering additional analgesia, and maintaining intraoperative stability [7]. Epidural boluses of bupivacaine allowed adequate analgesia in the postoperative period, with less systemic use of analgesia, and were given every six to eight hours through the epidural catheter. This kept consistent analgesia throughout the recovery period. The patient’s discharge on the third postoperative day with oral analgesics demonstrated the effectiveness of the perioperative pain management plan.

Conclusions

This case report outlines the fact that the use of ultrasound guidance while carrying out neuraxial anaesthesia does confer very significant benefits in both anatomically difficult patients and those with a history of difficult epidural placements. It enhances the preciseness of needle placement, thereby enhancing pain management in a way that the more significant part of inefficiencies gets neutralized. This ensures that in the constantly evolving field of anesthesia, the usage of ultrasound improves patient outcomes, particularly those with very challenging anatomy and complex anaesthesia requirements.

References

  1. Rönn K, Reischl N, Gautier E, Jacobi M: Current surgical treatment of knee osteoarthritis. Arthritis. 2011, 2011:454873. 10.1155/2011/454873
  2. Moraca RJ, Sheldon DG, Thirlby RC: The role of epidural anesthesia and analgesia in surgical practice. Ann Surg. 2003, 238:663-73. 10.1097/01.sla.0000094300.36689.ad
  3. Elsharkawy H, Sonny A, Chin KJ: Localization of epidural space: a review of available technologies. J Anaesthesiol Clin Pharmacol. 2017, 33:16-27. 10.4103/0970-9185.202184
  4. Huang C, Chen Y, Kou M, et al.: Evaluation of a modified ultrasound-assisted technique for mid-thoracic epidural placement: a prospective observational study. BMC Anesthesiol. 2024, 24:31. 10.1186/s12871-024-02415-x
  5. Jagadish A, Swaminathan S, Bidkar PU, Gupta SL, Adinarayanan S: Ease of lumbar epidural catheter insertion with prepuncture ultrasound as guidance compared with conventional palpatory technique when performed by anesthesiology residents: a randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2021, 37:216-20. 10.4103/joacp.JOACP_394_19
  6. Zhang Y, Peng M, Wei J, Huang J, Ma W, Li Y: Comparison of ultrasound-guided and traditional localisation in intraspinal anesthesia: a systematic review and network meta-analysis. BMJ Open. 2023, 13:e071253. 10.1136/bmjopen-2022-071253
  7. Afonso J, Reis F: Dexmedetomidine: current role in anesthesia and intensive care. Braz J Anesthesiol. 2012, 62:118-33. 10.1016/S0034-7094(12)70110-1

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Postpandemic Burnout: Reply

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Authors: Amy E. Vinson, M.D. et al 
Anesthesiology October 2024, Vol. 141, 802–804.

One of the hardest parts of writing an article broadly addressing the issue of burnout in anesthesiologists is the breadth of contributing, mitigating, and ambiguous factors that arise in both the experience of clinical practice and the analysis of data. Our presented data demonstrate an increase in the incidence of burnout and self-reported staffing shortages and highlights a high intention to leave the current job within the next 2 yr.

When presenting the latest results on our colleagues’ experiences, we were limited by not just word count but also our own experience and perspectives. In such an instance, we awaited eagerly the responses of our fellow anesthesiologists to glean from our presented data additional points of view, broader consideration of potential causes, and deeper exploration into possible solutions.

We were not disappointed. In the intervening months since publication of our follow-up study of burnout in U.S. attending anesthesiologists who were American Society of Anesthesiologists members, four letters have been published by Anesthesiology, taking on some of the points of view related to our follow-up. 

In their letter, Gong, Tan, and Huang highlight similar scholarly work being done for the Chinese anesthesiologist population but it surprisingly shows an improvement in rates of burnout since the start of the COVID-19 pandemic. These authors speculate that the improvement may be a result of enhanced investment in both the overall healthcare system but also human resource management within the healthcare system since the beginning of the COVID-19 pandemic and even before then since the 2018 recognition of anesthesiologist shortages. Specifically, they cite the targeted national focus on increasing the anesthesiologist workforce to combat staffing shortages, a concern echoed by an increasing number of anesthesiologists in the United States over time.

Furthermore, their response rate was greater than our own, and they credit this to the use of more agile social media constructs to conduct the actual survey instrument, removing an avoidance barrier often encountered when soliciting participation via email only. Finally, it is our hope that this correspondence may lead to a collaboration between two very large national societies to address burnout in anesthesiologists with a broader base of experience.

Sorensen and Cleary present the vital role of residents and the unique burnout-inducing impacts of training.  While residency is a brief period in comparison to the length of a career, it is a critical period for establishing habits and approaches to work–life integration. It is a wonderful perspective offered and we agree with the points made. Our group attempted to study this population in a similar manner with surveys yielding minimal responses, leading to an inability to analyze that data. Clearly, a recruitment process other than email invitations is required for our youngest colleagues.

However, as we have heard from attending anesthesiologist colleagues throughout the country, the attending anesthesiologists are burned out. As such, we are not bringing our best teaching selves to the table and are not being the best advocates for our vulnerable trainees. Even while most of us are doing the best we can, this dynamic weakens the teacher–trainee relationship and erodes both the quality of education received by the trainee and professional fulfillment experienced by the attending anesthesiologist. We have heard from attendings their deep frustration that they seem unable to muster the same enthusiasm for teaching that once came naturally. This adds a layer of guilt and shame to the burnout being experienced by attending anesthesiologists, while trainees feel frustrated and undervalued.

There is a natural tension that must exist among education, professionalism, and well-being, which is addressed by one of the authors of this response. In “The Weaponization of Wellness,” written for the Pediatric Anesthesia Article of the Day in response to an article by Rosenbaum, “Being Well while Doing Well – Distinguishing Necessary from Unnecessary Discomfort in Training,” leaders in anesthesiology education and well-being highlight that an outsized focus on education, professionalism, or well-being will erode the neglected forces. It is the work of those in teaching roles to at once promote appropriate discomfort required for growth while advocating for reasonable working conditions that support and optimal educational conditions for trainees.

In their letter, Ellinas, Njoku, and Chandrabose focused on the link between sense of support in the workplace, burnout, and intention to leave.3  They contend that sense of “belonging” links all three of these factors (attrition, burnout, and sense of support) and outline the ways in which belonging is specifically difficult in anesthesiology (e.g., isolation, relative anonymity within the team). They concentrate on the act of community building as a strategy that ought to be employed by anesthesia leadership at every level in order to enhance employee belonging and retention.

Phillips and Ballard focus on the motivational aspects of a career in anesthesiology  citing their perception of an unfortunate shift from anesthesiology being “a calling” to being “a job.” Our findings suggest a similar trend. The combination of the corporatization of medicine, the exhaustion of the attending anesthesiologist workforce through the pandemic that compounded and increased staffing shortages, and the resultant decline of teaching and mentoring quality for our youngest colleagues as noted above are the result of this shift. Phillips and Ballard cite the Areas of Worklife Model to approach improvement in workplace engagement. They explain that, although the cost of burnout is alarming, and the solutions seem elusive, approaching the problem from a problem-solving standpoint, where one seeks incremental positive progress, will ultimately improve the environment and fulfillment for us all.

We are deeply grateful to our colleagues all over the world and humbled to have written something garnering such varied interest from so many perspectives. The problem of burnout, belonging, sense of support, and progress is one that must be tackled by not just one country, but by the entire global medical community—by not just one cohort, but by clinicians at all career stages. Our work represents just the tip of the iceberg and the true work toward improved culture is only beginning. Put simply, the interest represented by these letters gives us hope for the future of our healthcare community.

Postpandemic Burnout: Comment

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Autors: Mitchell L. Phillips, M.D.; Heather A. Ballard, M.D.
Anesthesiology October 2024, Vol. 141, 801–802.

We were intrigued by the article titled “U.S. Attending Anesthesiologist Burnout in the Postpandemic Era”  by Afonso et al. This piece delves into the factors contributing to the high prevalence of burnout among U.S. attending anesthesiologists, revealing a significant association between perceived support at work and the risk of burnout and burnout syndrome. As physicians on the front line of patient care, we find ourselves navigating a labyrinth of challenges, chief among them the erosion of autonomy and the shifting perception of medicine from a calling to merely a job. 

Autonomy, once the cornerstone of medical practice, now faces siege from numerous external forces. The modern healthcare landscape increasingly encroaches upon our autonomy, relegating us to the role of mere cogs in a bureaucratic machine more interested in financial gain than patient well-being. In the revered halls of medical schools, aspiring physicians are instilled with a sense of purpose—a calling to serve humanity. However, the harsh realities of modern healthcare have dulled that idealism. The Areas of Worklife Model identifies six key dimensions of the work environment (workload, control, reward, community, fairness, and values) that significantly influence individuals’ engagement with their work.This model emphasizes the importance of aligning these aspects with employees’ needs and expectations to foster a positive work experience. Research, such as that referenced by the authors, consistently underscores the detrimental impact of perceived lack of control on burnout, highlighting the critical role of autonomy in mitigating workplace stress and dissatisfaction.

The estimated cost of burnout is astronomically expensive for healthcare organizations, amounting to more than $4 billion each year due to increased staff turnover and reduced work hours. While this represents a potent motivator to invest in in burnout mitigation efforts, the cost of attrition puts these numbers into perspective: replacing a physician is estimated to cost two to three times that physician’s yearly salary. As hospitals and leaders strategize ways to combat burnout, they must prioritize efforts to restore the perception of medicine as a calling rather than merely a job. The work of Teresa Amabile and Steven Kramer describes the Progress Principle: “Of all the things that can boost inner work life, the most important is making progress in meaningful work.”  The importance of progress is foundational, yet few leaders grasp how to harness it successfully to enhance positive emotion, perception, and motivation. Implementing the Progress Principle demands a unified endeavor to remove inhibitors (actions that fail to support) and toxins (undermining events) that hinder the path of physicians. Healthcare institutions must prioritize reinstating physician autonomy to cultivate environments that nurture professional development and promote clinical care, instead of increasing profit margins and reducing cost.

As we confront the specter of burnout within our profession of anesthesiology, let us heed the timeless wisdom of the Progress Principle. Together, we can embark on a journey fueled by the pursuit of progress toward a brighter, more compassionate future for ourselves and, importantly, for those we serve.

Postpandemic Burnout: Comment

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Authors: Elizabeth H. Ellinas, M.D., M.S. et al 
Anesthesiology October 2024, Vol. 141, 800–801.

We read with interest “U.S. Attending Anesthesiologist Burnout in the Postpandemic Era” by Afonso et al.  This work advances our understanding of anesthesiologists’ wellness, support, and retention. Its key findings indicate that compared to prepandemic data, anesthesiologists are experiencing worsening burnout, which in turn predicted increased intent to leave their institutions. In multivariate analysis, by far the strongest predictor of burnout was lack of workplace support, a finding that we believe connects burnout, retention, and workplace support to a potential driver for all of those realities: belonging.

Belonging has been described as a fundamental human need by American psychologist Abraham Maslow and is defined as “the experience of personal involvement in a system where an individual feels valued, needed, and in alignment with the values or goals of a larger social group.”  Feeling supported is critical to belonging, and belonging has been strongly linked to decreased burnout and turnover. Schaechter et al. have identified a number of workplace belonging factors including feeling valued, having input regarding decisions, and feeling supported in professional advancement.  Belonging has been shown to be protective against burnout in residents and in women physicians, increasing numbers of belonging factors are associated with decreasing intent to leave.  We suggest, therefore, that belonging is a key missing factor in the model linking burnout to turnover, and may even break the link between burnout and intent to leave that was found in this study.

Structurally, our role as anesthesiologists can be isolating, presenting unique challenges to intradisciplinary connectedness. Limited common space and limited contact with anesthesiology colleagues decrease connectedness. Our workplace communities are multidisciplinary and change daily, with most of our time spent with nonanesthesiologists. Surgical and nursing colleagues are often our closest workplace relationships, and the high turnover of our teammates from these and other disciplines puts strain on our connectedness, belonging, and well-being. Conversely, those close relationships with operating room colleagues are sometime fraught with conflict, and occasional depersonalization decreases feelings of value. For example, knowing colleagues’ names seems a baseline factor for workplace support and belonging. Birnbach et al. found that although 98% of operating room staff correctly named the surgery attending, only 62% could similarly name the anesthesiology attending.  Stressful workplace conditions contribute not only to burnout and mental distress but also to decreased physical health.  Social isolation conveys a host of physical ailments as measured by elevated markers of chronic inflammation.  Taken together, structural and cultural elements unique to anesthesiology leave practitioners vulnerable to stress, isolation, and mental and physical health concerns, making engendering belonging both difficult and urgently important.

Anesthesiologists, already at high risk for burnout and turnover prepandemic, have reached a critical state in the postpandemic world. Given the risk to mental and physical health, and the correlation between burnout and intent-to-leave, the factor of belonging should be a key target in reduction of burnout and turnover. Afonso et al. suggest that organizations “[build] an inclusive community that allows for constructive associations between peers and leaders within the organization.” We wholeheartedly agree. Given the enormous healthcare cost associated with physician turnover, these factors should be a priority target in asset allocation and employee retention. We believe that belonging is critical to inclusive communities, physician well-being, and lowered attrition, and suggest that it be both included in further iterations of this important survey work and prioritized by departments, leaders, and their institutions.

Postpandemic Burnout: Comment

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Authors: Bennett D. Sorensen, M.D.; Courtney A. Cleary, M.D.
Anesthesiology October 2024, Vol. 141, 799–800.

We have read with great interest the article by Afonso et al. in the January 2024 issue of Anesthesiology.  Focusing on attending anesthesiologists, the authors found that burnout has become more prevalent in the postpandemic area. As resident physicians, we want to add how this pressing issue substantially affects trainees.

The article cites several studies that demonstrate increased burnout among trainees and younger physicians, explaining that this phenomenon is likely secondary to less-developed “coping mechanisms” and “low levels of personal accomplishments” without acknowledging other well-known causes of trainee burnout. A previous article in Anesthesiology identified even before the pandemic that a lack of institutional and social support, work–life balance, and manageable workload markedly affects resident burnout.  The COVID-19 pandemic and its aftermath only exacerbated the challenges trainees face. Alfonso et al. identified “staffing shortages” and “lack of support at work” as the strongest risk factors for burnout, and trainees are especially implicated in these problems.

The shortage of anesthesiologists and other physicians is anticipated to only increase over time.  Institutions are under more pressure to utilize residents as a major part of their workforce productivity. The inherently conflicting role of residents as students and employees is strained as hospitals become reliant on operating room productivity to meet the hospital’s bottom line. We have seen a corresponding increase in residency programs and positions in order to meet this need.  As a more cost-effective alternative to advanced practice providers, resident physicians often serve as the first-line staff members to fill work hours.  Institutions prioritize their mission to the education and well-being of residents with great consideration of the financial cost.

Although improved over the past few decades, residents have the highest work hours with comparatively lower hourly pay and flexibility. Salaries, benefits, and support for residents have not been commensurate with the demands for efficiency, productivity, and costs of modern life. Unable to leave their work environment conditions, trainees have resorted to change from the bottom up, exemplified in recent unionizing efforts across the country at major academic centers.  Under intense pressure to meet competing demands of their institution and trainees, program leadership are at a great risk of burnout themselves. 

We write this letter not only to shed light on the challenges faced by resident physicians but also to urge the consideration of trainees while thinking about burnout and well-being of attending anesthesiologists. Although not all current attending anesthesiologists work in an academic setting or with residents, all attendings were trainees at some point. Training is a crucial and seminal period of any physician’s journey, and it is imperative that we work toward solving these problems in burnout from the bottom to the top. By doing so, we can improve the culture and fulfillment in medicine of all members of our specialty.

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.

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