BackgroundAnesthesia residents experience nonroutine clinical events during perioperative patient care, including workplace stressors or adverse incidents that may cause physical and emotional stress. These events can lead to burnout and negative mental health outcomes. Burnout and depression rates are lower when residents have adequate support systems within their workplace. Better resident wellness (BREW) Rounds are a weekly 1-hour peer discussion for anesthesia residents, facilitated by a registered psychologist at our institution. Although shown to improve residents’ well-being, a deeper understanding of the benefits of such programs may support their expansion to other residency programs.ObjectiveThis study aimed to explore the benefits and most effective features of BREW Rounds to guide the development of similar programs at other institutions.MethodsFollowing research ethics board approval, we conducted a qualitative descriptive study based on semistructured interviews with anesthesia residents who had participated in one or more BREW sessions and with the main BREW Rounds facilitator. Topics of discussion included community building, belonging, mentorship, facilitation, discussion of nonclinical aspects, and removal of hierarchy. Interviews were conducted on videoconferencing software by researchers who were not involved in supervising or assessing the trainees. Audio recordings were auto-transcribed, deidentified, verified, and interpreted using thematic content analysis. Further perspectives on BREW Rounds were obtained from staff anesthesiologists through an anonymous online survey.ResultsWe interviewed 10 residents (6 junior, 3 senior, and 1 transition-to-practice) and 1 facilitator. Emerging themes included (1) access to a safe space free of judgment, allowing participants to be vulnerable about clinical or nonclinical aspects of their training, (2) building a sense of community in a fast-paced and often isolating environment, (3) providing opportunities for mentorship between junior and senior residents in a frequently changing colleague network, (4) the characteristics that create a “BREW culture”, such as behavior norms during sessions and staff respect for protected time, (5) the importance of a good facilitator from outside the anesthesia department, especially during smaller sessions, (6) expanding BREW Rounds to other institutions, and (7) areas for improvement for the current program. Sixteen anesthesiology staff survey responses were available for analysis: 12/16 (75%) anesthesiologists supported residents leaving their clinical duties early for BREW Rounds and 12/16 (75%) believed BREW Rounds benefitted residents’ well-being.ConclusionsThis qualitative study confirms previous findings that BREW Rounds are beneficial to anesthesia training, improve the psychological wellness of residents, and may positively contribute to patient care. Program directors should recognize their potential positive impact on the learning environment, ensure that all staff and trainees understand the need to create protected time for this activity, consider partnering with wellness initiatives at the institutions in which residents are training, and endeavor to identify experienced and unbiased facilitators to moderate sessions.

BackgroundPreoperative anxiety is a common psychological condition, and many patients express a desire for more information before surgery. Understanding the prevalence and associated factors of both preoperative anxiety and the desire for information can improve patient care.ObjectiveThis study aimed to assess the prevalence of preoperative anxiety and desire for information, as well as their associated sociodemographic, medical, and surgical factors, among patients undergoing elective surgery in Northern State, Sudan.MethodsA hospital-based, multicenter, cross-sectional study was conducted from November 2024 to February 2025 in Northern State, Sudan, involving patients undergoing elective surgery. Data were collected through face-to-face interviews using a structured questionnaire and the validated Arabic version of the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Chi-square tests and univariate and multivariate logistic regression were performed to identify the associated factors and the magnitude, with statistical significance set at P<.05.ResultsOf the 380 patients approached, 305 participated in the study (response rate=80.3%): 173 of the 305 participants (56.7%) were male, and the median age was 43 (IQR 30‐64) years. Most participants were married (n=207, 67.9%), educated (n=248, 81.3%), and had family support (n=253, 83.0%). Regarding surgical characteristics, the majority underwent either intermediate (n=136, 44.6%) or major (n=142, 46.6%) procedures. General anesthesia was the most common type used (n=159, 52.2%), and most participants (n=169, 55.4%) underwent surgery in public hospitals. Most participants reported that their surgeries were not covered by insurance (n=264, 86.6%) and described good sleep quality the night before surgery (n=221, 72.5%). Of the 305 participants, 75 (24.6%) experienced preoperative anxiety, whereas 92 (30.1%) expressed a moderate to high desire for information. Preoperative anxiety was significantly associated with family support (adjusted odds ratio [aOR] 7.12, 95% CI 2.64‐19.23; P<.001), surgery in public hospitals (aOR 4.31, 95% CI 2.30‐8.07; P<.001), poor sleep quality the night before surgery (aOR 2.85, 95% CI 1.51‐5.38; P=.001), and American Society of Anesthesiologists (ASA) classification III/IV (aOR 2.36, 95% CI 1.00‐5.54; P=.049). Similarly, a higher desire for information was significantly associated with being educated (aOR 2.48, 95% CI 1.00‐6.11; P=.049), having family support (aOR 4.10, 95% CI 1.81‐9.30; P=.001), undergoing surgery in a public hospital (aOR 3.57, 95% CI 1.93‐6.61; P<.001), and being classified as ASA III/IV (aOR 3.26, 95% CI 1.39‐7.64; P=.001).ConclusionsPreoperative anxiety and desire for information are common among Sudanese patients. Family involvement may paradoxically increase anxiety and the desire for more information due to shared concerns and cultural factors. Other significant predictors of anxiety include poor sleep quality and higher ASA classification. Additionally, education, family support, and chronic diseases were associated with a higher desire for information. Addressing these factors may alleviate preoperative anxiety, satisfy communication needs, and improve preoperative care.

Surgical education has shifted from the traditional Halstedian apprenticeship model toward incorporating simulation due to work-hour restrictions, increasing case complexity, and economic and liability pressures. Building on the success of the Fundamentals of Laparoscopic Surgery program for general surgery, the Fundamentals of Arthroscopic Surgery Training (FAST) program was developed to establish proficiency benchmarks for orthopedic trainees in basic arthroscopic skills. We aimed to establish benchmarks for 5 FAST workstation modules. Sports medicine fellowship-trained faculty members were given instructions on the modules and 2 minutes of practice time, and they then performed each task 3 times with both their dominant and nondominant hand. For each module, mean faculty performance was used to establish an efficiency benchmark (time) and precision benchmark (errors). The Probing module should be completed in less than 95 seconds with no errors. The Ring Transfer module should be completed in less than 134 seconds with no more than 1 error. The Maze module should be completed in less than 99 seconds with no errors. The Meniscectomy module should be completed in less than 68 seconds with no more than 1 error. Lastly, the Suture Passing module should be completed in less than 195 seconds with no more than 1 error. The FAST workstation can be used as a proficiency-based learning tool for residents to safely and effectively develop arthroscopic skills outside of the operating room. These benchmarks were established via a method previously validated in surgical simulation and balance precision and efficiency for skills that are considered generalizable and transferable to arthroscopic surgeries.

The journey of receiving blood as a patient with transfusion-dependent beta thalassemia has profoundly shaped my understanding of the life-saving power of blood donation. This personal experience underscores the critical importance of blood donors, not just for individual recipients but for the broader community, enhancing public health, productivity, and well-being. There are several challenges to securing a blood donor pool in current health care climate. Solutions that focus on the engagement of donors, clinicians, and patients are key to improving the donor pool and utilizing the blood supply in a judicious manner.

Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation. This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes. A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre-EMR form implementation), and from July 1, 2022, to June 30, 2023 (post-EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE). A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post-EMR form, matched cohort had lower cardiology consultation (pre-EMR form: n=2698, 23.2% vs post-EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre-EMR form: n=808, 6.9% vs post-EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with "possible indications" for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%. In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.

Exposure to opioids after surgery is the initial contact for some people who develop chronic opioid use disorder. Hence, effective postoperative pain management, with less reliance on opioids, is critical. The Perioperative Opioid Quality Improvement (POQI) program developed (1) a digital health platform leveraging patient-survey-reported risk factors and (2) a postsurgical pain risk stratification algorithm to personalize perioperative care by integrating several commercially available digital health solutions into a combined platform. Development was reduced in scope by the COVID-19 pandemic. This pilot study aims to assess the screening performance of the risk algorithm, quantify the use of the POQI platform, and evaluate clinicians' and patients' perceptions of its utility and benefit. A POQI platform prototype was implemented in a quality improvement initiative at a Canadian tertiary care center and evaluated from January to September 2022. After surgical booking, a preliminary risk stratification algorithm was applied to health history questionnaire responses. The estimated risk guided the patient assignment to a care pathway based on low or high risk for persistent pain and opioid use. Demographic, procedural, and medication administration data were extracted retrospectively from the electronic medical record. Postoperative inpatient opioid use of >90 morphine milligram equivalents per day was the outcome used to assess algorithm performance. Data were summarized and compared between the low- and high-risk groups. POQI use was assessed by completed surveys on postoperative days 7, 14, 30, 60, 90, and 120. Semistructured patient and clinician interviews provided qualitative feedback on the platform. Overall, 276 eligible patients were admitted for colorectal procedures. The risk algorithm stratified 203 (73.6%) as the low-risk group and 73 (26.4%) as the high-risk group. Among the 214 (77.5%) patients with available data, high-risk patients were younger than low-risk patients (age: median 53, IQR 40-65 years, vs median 59, IQR 49-69 years, median difference five years, 95% CI 1-9; P=.02) and were more often female patients (45/73, 62% vs 80/203, 39.4%; odds ratio 2.5, 95% CI 1.4-4.5; P=.002). The risk stratification was reasonably specific (true negative rate=144/200, 72%) but not sensitive (true positive rate=10/31, 32%). Only 39.7% (85/214) patients completed any postoperative quality of recovery questionnaires (only 14, 6.5% patients beyond 60 days after surgery), and 22.9% (49/214) completed a postdischarge medication survey. Interviewed participants welcomed the initiative but noted usability issues and poor platform education. An initial POQI platform prototype was deployed operationally; the risk algorithm had reasonable specificity but poor sensitivity. There was a significant loss to follow-up in postdischarge survey completion. Clinicians and patients appreciated the potential impact of preemptively addressing opioid exposure but expressed shortcomings in the platform's design and implementation. Iterative platform redesign with additional features and reevaluation are required before broader implementation.

BackgroundAnesthesiologists require an understanding of their patients’ outcomes to evaluate their performance and improve their practice. Traditionally, anesthesiologists had limited information about their surgical outpatients’ outcomes due to minimal contact post discharge. Leveraging digital health innovations for analyzing personal and population outcomes may improve perioperative care. BC Children’s Hospital’s postoperative follow-up registry for outpatient surgeries collects short-term outcomes such as pain, nausea, and vomiting. Yet, these data were previously not available to anesthesiologists.ObjectiveThis quality improvement study aimed to visualize postoperative outcome data to allow anesthesiologists to reflect on their care and compare their performance with their peers.MethodsThe postoperative follow-up registry contains nurse-reported postoperative outcomes, including opioid and antiemetic administration in the postanesthetic care unit (PACU), and family-reported outcomes, including pain, nausea, and vomiting, within 24 hours post discharge. Dashboards were iteratively co-designed with 5 anesthesiologists, and a department-wide usability survey gathered anesthesiologists’ feedback on the dashboards, allowing further design improvements. A final dashboard version has been deployed, with data updated weekly.ResultsThe dashboard contains three sections: (1) 24-hour outcomes, (2) PACU outcomes, and (3) a practice profile containing individual anesthesiologist’s case mix, grouped by age groups, sex, and surgical service. At the time of evaluation, the dashboard included 24-hour data from 7877 cases collected from September 2020 to February 2023 and PACU data from 8716 cases collected from April 2021 to February 2023. The co-design process and usability evaluation indicated that anesthesiologists preferred simpler designs for data summaries but also required the ability to explore details of specific outcomes and cases if needed. Anesthesiologists considered security and confidentiality to be key features of the design and most deemed the dashboard information useful and potentially beneficial for their practice.ConclusionsWe designed and deployed a dynamic, personalized dashboard for anesthesiologists to review their outpatients’ short-term postoperative outcomes. This dashboard facilitates personal reflection on individual practice in the context of peer and departmental performance and, hence, the opportunity to evaluate iterative practice changes. Further work is required to establish their effect on improving individual and department performance and patient outcomes.

BackgroundPelvic organ prolapse (POP) refers to symptomatic descent of the vaginal wall. To reduce surgical failure rates, surgical correction can be augmented with the insertion of polypropylene mesh. This benefit is offset by the risk of mesh complication, predominantly mesh exposure through the vaginal wall. If mesh placement is under consideration as part of prolapse repair, patient selection and counseling would benefit from the prediction of mesh exposure; yet, no such reliable preoperative method currently exists. Past studies indicate that inflammation and associated cytokine release is correlated with mesh complication. While some degree of mesh-induced cytokine response accompanies implantation, excessive or persistent cytokine responses may elicit inflammation and implant rejection.ObjectiveHere, we explore the levels of biomaterial-induced blood cytokines from patients who have undergone POP repair surgery to (1) identify correlations among cytokine expression and (2) predict postsurgical mesh exposure through the vaginal wall.MethodsBlood samples from 20 female patients who previously underwent surgical intervention with transvaginal placement of polypropylene mesh to correct POP were collected for the study. These included 10 who experienced postsurgical mesh exposure through the vaginal wall and 10 who did not. Blood samples incubated with inflammatory agent lipopolysaccharide, with sterile polypropylene mesh, or alone were analyzed for plasma levels of 13 proinflammatory and anti-inflammatory cytokines using multiplex assay. Data were analyzed by principal component analysis (PCA) to uncover associations among cytokines and identify cytokine patterns that correlate with postsurgical mesh exposure through the vaginal wall. Supervised machine learning models were created to predict the presence or absence of mesh exposure and probe the number of cytokine measurements required for effective predictions.ResultsPCA revealed that proinflammatory cytokines interferon gamma, interleukin 12p70, and interleukin 2 are the largest contributors to the variance explained in PC 1, while anti-inflammatory cytokines interleukins 10, 4, and 6 are the largest contributors to the variance explained in PC 2. Additionally, PCA distinguished cytokine correlations that implicate prospective therapies to improve postsurgical outcomes. Among machine learning models trained with all 13 cytokines, the artificial neural network, the highest performing model, predicted POP surgical outcomes with 83% (15/18) accuracy; the same model predicted POP surgical outcomes with 78% (14/18) accuracy when trained with just 7 cytokines, demonstrating retention of predictive capability using a smaller cytokine group.ConclusionsThis preliminary study, incorporating a sample size of just 20 participants, identified correlations among cytokines and demonstrated the potential of this novel approach to predict mesh exposure through the vaginal wall following transvaginal POP repair surgery. Further study with a larger sample size will be pursued to confirm these results. If corroborated, this method could provide a personalized medicine approach to assist surgeons in their recommendation of POP repair surgeries with minimal potential for adverse outcomes.

BackgroundThe current assessment of recovery after total hip or knee replacement is largely based on the measurement of health outcomes through self-report and clinical observations at follow-up appointments in clinical settings. Home activity-based monitoring may improve assessment of recovery by enabling the collection of more holistic information on a continuous basis.ObjectiveThis study aimed to introduce orthopedic surgeons to time-series analyses of patient activity data generated from a platform of sensors deployed in the homes of patients who have undergone primary total hip or knee replacement and understand the potential role of these data in postoperative clinical decision-making.MethodsOrthopedic surgeons and registrars were recruited through a combination of convenience and snowball sampling. Inclusion criteria were a minimum required experience in total joint replacement surgery specific to the hip or knee or familiarity with postoperative recovery assessment. Exclusion criteria included a lack of specific experience in the field. Of the 9 approached participants, 6 (67%) orthopedic surgeons and 3 (33%) registrars took part in either 1 of 3 focus groups or 1 of 2 interviews. Data were collected using an action-based approach in which stimulus materials (mock data visualizations) provided imaginative and creative interactions with the data. The data were analyzed using a thematic analysis approach.ResultsEach data visualization was presented sequentially followed by a discussion of key illustrative commentary from participants, ending with a summary of key themes emerging across the focus group and interview data set.ConclusionsThe limitations of the evidence are as follows. The data presented are from 1 English hospital. However, all data reflect the views of surgeons following standard national approaches and training. Although convenience sampling was used, participants’ background, skills, and experience were considered heterogeneous. Passively collected home monitoring data offered a real opportunity to more objectively characterize patients’ recovery from surgery. However, orthopedic surgeons highlighted the considerable difficulty in navigating large amounts of complex data within short medical consultations with patients. Orthopedic surgeons thought that a proposed dashboard presenting information and decision support alerts would fit best with existing clinical workflows. From this, the following guidelines for system design were developed: minimize the risk of misinterpreting data, express a level of confidence in the data, support clinicians in developing relevant skills as time-series data are often unfamiliar, and consider the impact of patient engagement with data in the future.International Registered Report Identifier (IRRID)RR2-10.1136/bmjopen-2018-021862

BackgroundHyponatremia and hypernatremia, as conventionally defined (<135 mEq/L and >145 mEq/L, respectively), are associated with increased perioperative morbidity and mortality. However, the effects of subtle deviations in serum sodium concentration within the normal range are not well-characterized.ObjectiveThe purpose of this analysis is to determine the association between borderline hyponatremia (135-137 mEq/L) and hypernatremia (143-145 mEq/L) on perioperative morbidity and mortality.MethodsA retrospective cohort study was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database. This database is a repository of surgical outcome data collected from over 600 hospitals across the United States. The National Surgical Quality Improvement Program database was queried to extract all patients undergoing elective, noncardiac surgery from 2015 to 2019. The primary predictor variable was preoperative serum sodium concentration, measured less than 5 days before the index surgery. The 2 primary outcomes were the odds of morbidity and mortality occurring within 30 days of surgery. The risk of both outcomes in relation to preoperative serum sodium concentration was modeled using weighted generalized additive models to minimize the effect of selection bias while controlling for covariates.ResultsIn the overall cohort, 1,003,956 of 4,551,726 available patients had a serum sodium concentration drawn within 5 days of their index surgery. The odds of morbidity and mortality across sodium levels of 130-150 mEq/L relative to a sodium level of 140 mEq/L followed a nonnormally distributed U-shaped curve. The mean serum sodium concentration in the study population was 139 mEq/L. All continuous covariates were significantly associated with both morbidity and mortality (P<.001). Preoperative serum sodium concentrations of less than 139 mEq/L and those greater than 144 mEq/L were independently associated with increased morbidity probabilities. Serum sodium concentrations of less than 138 mEq/L and those greater than 142 mEq/L were associated with increased mortality probabilities. Hypernatremia was associated with higher odds of both morbidity and mortality than corresponding degrees of hyponatremia.ConclusionsAmong patients undergoing elective, noncardiac surgery, this retrospective analysis found that preoperative serum sodium levels less than 138 mEq/L and those greater than 142 mEq/L are associated with increased morbidity and mortality, even within currently accepted “normal” ranges. The retrospective nature of this investigation limits the ability to make causal determinations for these findings. Given the U-shaped distribution of risk, past investigations that assume a linear relationship between serum sodium concentration and surgical outcomes may need to be revisited. Likewise, these results question the current definition of perioperative eunatremia, which may require future prospective investigations.