ACE_18B_Behind_the_Scenes_transcript

American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page ACE 18B Behind-the-Scenes 2021 {Music] Host: Welcome to the ACE Behind-the-Scenes podcast, giving you an exclusive look at the creation of the popular continuing education program from the American Society of Anesthesiologists ACE, testing your knowledge of the fundamentals of anesthesia Russell K McAllister, MD: Welcome everyone to the ACE Behind-the-Scenes podcast This is Russell McAllister I am one of the editors for ACE, and I am currently in Temple, Texas with the Texas A&M College of Medicine, Baylor Scott & White Department of Anesthesiology And we also have Dr Stacy Jones, Dr Joel Johnson and Dr Kofi Vandyck with us I’ll let them introduce themselves Stacy L Jones, MD: Hi, I’m Stacey Jones, and I’m in Little Rock, Arkansas Joel O Johnson, MD: I’m Joel Johnson, and I am in Madison, Wisconsin Along with Stacy I am one of the co-editors-in-chief of the ACE product Kofi B Vandyck, MD: My name is Kofi Vandyck I am at the University of Oklahoma Medical Center in Oklahoma City Russell K McAllister, MD: All right, thank you everybody So the purpose of ACE as most of us know is that it was designed to provide some walking around knowledge in anesthesiology It’s issued twice a year, and there’s 100 questions per issue And it’s published in April and October It’s certified for up to 60 AMA PRA Category Credits™ per year, and it’s also available in print or on the web through the app American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page This is our Behind-the-Scenes podcast, and we’re going to use this time to discuss some items of interest in the ACE 18B issue, which we’ll be launching in October So that’s coming up soon First of all I’d like to talk about some of the questions and content that were inspired by our own experiences And what we’ve found is some of the best questions and content come from that experience Dr Johnson, you had some experiences that you wanted to talk about Joel O Johnson, MD: One in particular, and that was, we were doing an anesthetic and the anesthesia machine, which tracks a lot of things, including the QT interval, popped up a warning that our QT interval had become too long And it was after about an hour into our anesthetic, and at the time we were running the sevoflurane anesthetic So after some discussion and reading and looking up, we decided, well, let’s see if this really makes a difference if we were to change to a TIVA Interestingly enough, after about another 15 to 20 minutes, when the sevoflurane had worn off or worn down to a reasonable level, we saw resolution of the QT prolongation And so that inspired me to look that up, write a question about that and also it added to some teaching value for the resident Russell K McAllister, MD: That’s great and a great learning opportunity Stacy, you had a learning case that you wanted to talk about as well Stacy L Jones, MD: Yes Russ, and this was pretty similar to the situation Joel described, in that I had a patient with myasthenia gravis who was having a fairly significant operation Our surgeon wasn’t really aware of the patient’s entire medical history So if you look at item 88 in the discussion, we really give a list of all American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page of the risk factors for patients with myasthenia that put them at an increased risk for postop ventilation And I think knowing that, it really increases your ability to have a critical discussion with your surgeon about how to craft your anesthetic and how to craft your whole perioperative plan for your patient And I think in my situation we actually changed where we were going to place this patient postoperatively And it really allowed us to talk about more than just what was going to go on in the operating room But how we were going to manage this patient throughout the whole continuum of their perioperative stay So again in item 88, there’s a good discussion of what are the things that make a patient with myasthenia at an increased risk for postop ventilation Russell K McAllister, MD: That’s great Yeah, and having those discussions ahead of time with the surgeon really does change things for how you care for those patients And that’s really great Dr Vandyck, you had something as well Kofi B Vandyck, MD: It’s not really a specific case But I pick up a lot of thoracic and cardiac patients and as anesthesiologists, we are expected to be the experts in respiration and ventilation and stuff like that But I have seen that probably the hardest thing for residents to grasp is respiratory physiology And you can look in our premier textbooks (inaudible), the concepts under the respiratory topic are very, very hard to grasp So over the years I’ve taken it upon myself to try to, when I’m working with the residents, to try to get them interested in that Because wherever they go practice wise, they will be required to be the experts in respiratory physiology and respiratory mechanics A lot of them will probably go into private practice with a lot of the (inaudible) and people in there are going to be working who don’t know much about respiratory process American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page Particularly for me I’ve always been interested in the concept of hypoxic pulmonary vasoconstriction Especially under one lung ventilation And it’s really, really fascinating how the body, we can collapse one lung and in ventilating one lung because able to - the surgeons be able to operate on one lung without much bleeding in that particular deflated lung And so I’ve really taken - over the years I’ve really taken interest in that concept I try to impart it today to the residents Russell K McAllister, MD: Excellent, yeah, and we’ve all had experience teaching residents, and this is - that’s important information and very helpful and very rewarding to be able to impart that knowledge onto the next generation of residents So sometimes things of interest outside of medicine can play a role in some of the questions that we write and the topics that we gravitate towards Stacy, you had one that was inspired by a hobby that you have Can you tell us about that? Stacy L Jones, MD: Okay, my background prior to going to medical school was in marine science And I’ve been certified to dive for a really long time And I can’t help myself But in my defense, several of our major textbooks have chapters devoted strictly to anesthesia in extreme environments Anesthesia in extreme environments appears on the content outline both for the ITE exam and the advanced exam So anesthesia is a pathway towards fellowship training in hypobaric - in undersea medicine But every once in a while I will feel compelled to write the hypobaric questions for ACE And I think this one applies to someone you might see in the emergency room and their process of going forward if they’ve been exposed to a hypobaric environment American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page Russell K McAllister, MD: Yeah, no, I agree I think it’s definitely in the content, and I recall even when I was a resident having to study hypobaric medicine Those were some tough questions and difficult concepts So I still find those types of questions interesting So I’m personally happy that you added it Kofi, you mentioned that one of Stacy’s items intersected a couple of areas of interest for you Can you talk about those? Kofi B Vandyck, MD: Yes, so my main background in my practice is mainly in cardiac thoracic anesthesia But due to some personnel changes, personnel moving on to other practices, I’ve been asked to liver transplant It’s been very interesting for me because I didn’t realize at first that a lot of these patients with end-stage liver disease and cirrhosis have a lot of cardiac pathology Particularly the more familiar ones that I think people are aware of, hepatopulmonary syndrome and pulmonary hypertension Hepatopulmonary syndrome is mainly a problem with severe vasal dilation in the lung causing VV̇/QV̇ mismatch (Inaudible) pulmonary syndrome is kind of the opposite Is more of a vasal constriction, typical pulmonary hypertension associated with portal hypertension Now a new concept that we actually realized that is actually more prevalent in these patients, actually as much as 50% in some of the papers is cirrhotic cardiomyopathy Which they think is due to the impairment of beta-adrenergic receptors So as we know, these liver transplant patients are very hyperdynamic They are severely vasal dilated So they have seen that when they put them under stress they are not able to mount a stress response, and this is due to the fact that they don’t have much beta one – there is beta one receptor impairment They also have an derangement of their RAS system They also have increased nitric oxide And all that leads to what they call cirrhotic cardiomyopathy Which in seeing that, that kind of pique my interest By the way, they also have electrophysiological American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page abnormalities, commonly QT prolongation I was trying to give an example yesterday, I actually did a liver transplant where my patient that we took care of had all these symptoms of cirrhotic cardiomyopathy So it’s very, very interesting and something that folks like us who are all about cardiac and thoracic, it gives an intersection between liver transplants and cardiac anesthesia Russell K McAllister, MD: That’s right, and we don’t all liver transplants, or we don’t all cardiac But we certainly take care of patients that have those diseases And so I think that information on the physiology that’s underlying these conditions is definitely useful even for the anesthesiologist that does not those subspecialty cases It also seems like in every issue we have one or two items that might be controversial Does anyone want to discuss one of those items from 18B? Joel O Johnson, MD: Yeah, I have one This one actually was written by Dr Jeff Lu who is pediatric trained And so it’s understandable where it comes from But he had written yet another question about Mapleson classification of the different airways And this is almost a historical subject, and that’s where our controversy came in, in that the Mapleson system for many of us was a very common topic on written and oral boards You had to know which particular circuit a patient could breathe on their own and not rebreathe carbon dioxide Other that works better or were more efficient when you’re machine breathing for a patient And so Jeff had given in this item an extensive discussion, and I think it pointed out the value of going over this historical subject But at the same time, we still had a little bit of controversy We decided to include this in the issue, and probably will be including this topic at least for a few more years American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page Russell K McAllister, MD: All right, yeah I think I’ve learned the Mapleson classification system several times and have to relearn it if I go for more than a year without studying it It’s a difficult concept for sure Dr Vandyck, I think you had a different area of controversy that you wanted to talk about Kofi B Vandyck, MD: This is a question that Dr Dutton put in, which I think is very interesting because it’s something that we all deal with in the operating room and a question of preoperative testing Personally from reading, in a year in the US we spend almost as much as $18 billion on preoperative testing They found out a vast majority of the preoperative tests don’t really impact what the care that we’re doing in the operating room And it’s something that we deal with on a daily basis, and it causes a lot of disagreement between us and surgeons Because for them, they want their cases to move forward They don’t want their cases to be cancelled Recently we have noticed that a lot of our surgeons preemptively have been ordering a lot of echocardiograms on their patients without even consulting us We came to find out that the reason why they have been doing that is because – they’re requesting a lot of that and they don’t want their cases to be cancelled So for me, seeing this question, it drives at the heart of what we And I think for the residents coming up and even for people like us who are maybe general attendings and in the middle part of our training, the idea of good history and physical examination is very, very important Through your history and physical exams you might need to order some tests that might change your intraoperative plan But I’ve been practicing for the last ten years and to be frank with you, the amount of tests that I have done before taking patients to the operating room, I haven’t – I can count on one hand the number that has really impacted what I in the operating room American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page If we need to order the test we go ahead and order the test, if we think it can impact what we in the operating room But beyond that I think we really need to think very well before we ask the surgeons to order these tests or cancel the surgeries, that kind of thing Russell K McAllister, MD: Yeah, I agree, and there’s been a lot of work done in the last couple of decades trying to figure out which tests are the most useful and which ones are absolutely necessary So yeah, that’s an interesting point I appreciate that Switching gears just a little bit, people that have been long time subscribers to ACE will probably notice that there are some topics that get repeated more often than others Dr Johnson, you’ve been an editor for ACE for a number of years and now editor-in-chief Can you speak to that? Joel O Johnson, MD: Sure, and this really matches well with Kofi’s earlier discussion here about the preoperative evaluation and basically what the advantage of the preoperative clinic is Matter of fact this very topic came up just recently in our own hospital in that we had a patient who was having a surgical procedure that was a breast procedure and was going to get blocks And the recommendation from us was basically the regional anesthesia recommendations that currently exist that she should stop her anticoagulant medication three days beforehand And then the surgeon and also the person who was doing the preop, an internist, both recommended that well, don’t stop it three days Stop it two days beforehand And that just ended up – this patient not getting her block for her surgical procedure And so this topic about anticoagulants and when to stop them, when to continue them, comes up often in our topics, because there are changes, but also there’s changes in the types of medications American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page And so we have almost one item per issue in ACE that tries to keep up with the pace of information and new technologies in regional anesthesia, which is really moving along Even though some of the initial content of each question when you start reading the discussion is a repeat The discussions provide a great update and a review of these different topics Russell K McAllister, MD: Right, great Thanks Joel Speaking of topics that repeat in multiple different issues, some readers may not realize that our ACE product frequently contains some ethics content that might meet your state ethics requirements Now Stacy, I think you wrote an ethics item for ACE 18B Can you talk about that? Stacy L Jones, MD: Sure I guess we haven’t talked about this recently, but one of the things we try to cover in ACE are the different topics required for state licensure And if you look at the front [back] pages, either in the book or through the link in the electronic version, we’ll present a list of topics, and we try to be as up to date as we can I’m not going to claim this is perfect But concepts that are common to different state licensures will be listed And then alongside of the topic will be the item numbers for the questions that pertain to that topic Again, this may change with different states adding on new concepts But several states, Texas being one of them, requires ethics for re-licensure and initial licensure So we try to put in some ethics questions, some pain management questions—because those seem to be very common topics required—into every issue The ethics question that I wrote on this was about the False Claims Act And I think the history of the False Claims Act is really interesting because it has its origins during the Lincoln administration at the time of the Civil War And it was pretty much passed in response to contractors selling nonexistent or defective products or animals to the federal government, specifically the US Army American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page 10 Today any hospital, health care organization or provider that accepts reimbursement from the federal government, is subject to this law And even as anesthesiologists, we can be aware of what the federal government considers fraud, waste or abuse and work to prevent it Russell K McAllister, MD: Excellent Yeah, and that’s important I enjoyed that question and found it – I learned a lot from it Now Joel, I want to go back to what we were talking about before about topics that seem to be recurring topics But I recall that for this issue we had two almost identical questions And since you’ve been on the ACE Editorial Board for quite a while, I wonder if you would just talk a little bit about the process of how we things and how that can happen sometimes Joel O Johnson, MD: Sure This particular question was one that Dr Gali from Rochester, Minnesota had written, and I had also written a similar question about central temperature measurement That I thought the unusual thing about this was that the stems were almost the same The stem is the part of the question where it introduces the question and then the correct answer and the distracters, which are the A, B or C that you get in the question content, were exactly the same It’s almost like we copied it off each other When this happens, and it does happen every once in a while, just because we leave all of the editors pretty much free rein as far as the topics that they are covering Interestingly enough, over the years we pretty much cover the entire range of topics that are listed by the ASA What we then is save one, put it into the next issue or two issues away And then the other one we go ahead and publish American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page 11 Russell K McAllister, MD: Yeah, and I’ve had that happen to me a couple of times as well So it’s always an interesting dynamic when that occurs, when we edit each other’s questions and it looks so familiar because we’ve actually tackled that topic before Stacy, I wanted to switch to you a little bit about living donors, and we’ve covered living donors before for organ donation But this time we had an item on neurologically dead donors, the organ donations I wonder if you would elaborate on that question Stacy L Jones, MD: I have spent most of my career in the transplant environment in one way or another And this is a topic obviously near and dear to my heart Appropriate donor management of the neurologically dead organ donor is critical to donor graft survival Both prior to procurement as well as in the operating room So the way we manage these people before they come to us for procurement is critical And what we see in many areas is that our donors don’t always appear in your tertiary care center, and our teams are often going out to more remote places and doing the procurement there And as an anesthesiologist, if you’re not in a major medical center and even if you’re out in a small community hospital, there’s always the potential for you to be managing or assisting in the management of a neurologically dead organ donor prior to procurement This really is an area where our management can have a big impact, and we have the opportunity to save two or three lives at one time Which is unusual for us because we tend to focus on one patient at a time But we know that graft survival is dependent on management, and the physiological preservations that occur with neurologic death can be very dramatic and can be very damaging on the heart especially And so the proper management of that I think is pretty critical American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page 12 Russell K McAllister, MD: I agree That is a very important aspect of the care that we provide We frequently in these behind-the-scenes discussions for ACE, we like to talk about the illustrations that come with the ACE product, and I think that’s a huge part of the value of the product Usually it’s Stacy that’s the one that’s talking a lot about it But this time Joel, I heard you mention something about it I wonder if you would tell us about what you were talking about Joel O Johnson, MD: Well, yeah, the illustrations that we get come from numerous different sources Oftentimes we are getting permission to publish tables and graphs that show medical information in the form that we’re all used to But occasionally we find an infographic and particularly the ANESTHESIOLOGY publication and A&A have been looking more at infographics And one of them that really struck me was, there was an infographic on the presence of drugs in breast milk You all might recall that It had a picture of a baby feeding bottle, and then it had the different drugs listed and how they interacted with breast milk And this is one example of how we can transmit information, not only by reading the discussions Then we try to pick these great illustrations to cement in the reader’s mind the single points that we’re making for each of the different questions that we have Then besides that, it’s a lot of fun For instance, we might have a question or it’s been a question about scorpions and questions about sea snails and those kinds of things when you have a nice picture that illustrates something that is pertinent to the question And sometimes even historical things as far as who Claude Bernard is Those things lend a little more interest to our publication, but also a lot of interest to the Editorial Board So it’s been a great thing to find all these illustrations Russell K McAllister, MD: And just to tag on to what Stacy has said in previous podcasts, we’ve got our own illustrator as well that does a fantastic job and creates the American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page 13 wonderful covers that appear on each of our products as well as additional illustrations within the publication itself We really appreciate that So we’re getting pretty close to the end of our time together But I think we’ve got time for one more discussion Dr Vandyck, you wanted to talk a little bit about one of Dr Johnson’s items Kofi B Vandyck, MD: I think my colleagues might think that I’m obsessed about respiratory physiology, but again, this question, usually when I go through these ACE questions I just try to identify questions that I can – particular questions I can apply to what I am doing It reminds me of why we the things that we in the operation room Like a simple thing like preoxygenation, which over the years, due to the pressures of trying to get cases through the operating room and doing as many cases as we can, some of these little things have kind of fallen by the wayside But the concept of preoxygenation has become utterly for me very, very important, especially in these times that our patients are becoming more obese as the years go by and therefore be less FRC For folks like me who have trainees in the operating room, any little time that we can get with the trainees, especially in difficult intubations, to be able to show good techniques to these trainees is always important So for me, I always stress the importance of preoxygenation Actually, over the years, I’ve seen that the quickest way to actually this preoxygenation is to actually have a very – a good seal on the face mask and just close the popup valve a little bit And that improves actually preoxygenation quickly So I think seeing this question by Dr Johnson was – for me was very interesting Joel O Johnson, MD: And Kofi, I’d just add that for us that are in teaching situations, the preoxygenation time is a great time to be doing a little bit of teaching American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page 14 Kofi B Vandyck, MD: Yes, I agree Joel O Johnson, MD: Someone like myself and sounds like you that are a little long winded, then all that little bit more time to preoxygenate Stacy L Jones, MD: And Russ, I’d like to throw this in really quickly before we conclude We really appreciate all of our subscribers, and I know how it can be a little annoying to have to fill out that whole evaluation at the end of ACE to get your credit for it But we do, as an Editorial Board, both Joel and myself as co-editors-in chief and all of the editors, review all of the comments that our subscribers give us about ACE for every edition And we try to craft the product to meet your expectations and to meet your needs So please, please give us your opinions when you fill out that evaluation And thank you again for subscribing to ACE Russell K McAllister, MD: Yeah, I agree Stacy It’s an honor to be on the ACE Editorial Board, and I’ve learned a lot from both Joel and Stacy as they’ve mentored me over the last three years I think it’s a fun thing for everyone, and I’m glad to be a part of it It’s very time consuming for sure, but definitely rewarding But we’ve come to the end of our time together, and I just want to say thank you to all of our guests, Dr Joel Johnson, Dr Stacy Jones and Dr Kofi Vandyck It’s been a pleasure chatting with all of you, and I hope this has been interesting to our listeners I want to remind everyone that the 18B issue of ACE launches in October You can order it now at asahq.org/ace So asahq.org/ace We all hope that you really enjoy it and it’s beneficial for you Appreciate everyone’s time American Society of Anesthesiologists ACE 18B Behind-the-Scenes 2021 Page 15 Host: Thank you for listening to the ACE Behind-the-Scenes podcast For more information or to subscribe to the ACE program, visit asahq.org/ace THE END