Duke Anesthesiology By The Numbers

Divisions

AMBULATORY ANESTHESIOLOGY

Duke Health Opens Duke Ambulatory Surgery Center Arringdon

As part of Duke Health’s strategy to expand ambulatory surgical services while maintaining safe, convenient and value-based care, the first of several planned new surgery centers, Duke Ambulatory Surgery Center Arringdon, opened in May 2021. The Ambulatory Anesthesiology Division, along with partners from surgery, nursing and throughout the health system, collaborated to build the first new independent center in more than 25 years. Located between Durham and Wake counties, the new 35,000 square-foot center has eight state-of-the-art surgical suites that provide patients with the latest surgical technology and anesthetic techniques, in a center with abundant spaces filled with natural light. The large operating rooms are designed to facilitate the growth of ambulatory surgery and implement new and innovative programs, such as same-day total knee and hip replacement. The lead anesthesiologist at Arringdon is Dr. Steve Melton.

Ambulatory Surgery Center ArringdonTo prepare for Arringdon and the growth of ambulatory surgery, the division has been working diligently to organize efficient workflows, incorporate its expertise in regional anesthesia, and collaborate with health system partners to look for novel ways to improve patient outcome and experience. To help support this new endeavor, the Ambulatory Anesthesiology Division is pleased to welcome its newest members; Drs. Alex Cravanas and Michael Doden, who were specifically recruited for their experience in ambulatory anesthesia.

Dr. Steve Melton Quote


CARDIOTHORACIC ANESTHESIOLOGY

A Year of Clinical Firsts, Innovation and Leadership in Education and Research

Dr. Kamrouz GhadimiDuke’s Adult Cardiac Surgery program was awarded, for the first time, three simultaneous 3-star ratings by the Society of Thoracic Surgeons – for patient care and outcomes in the areas of coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement/repair. The 3-star rating, which denotes the highest category of quality, places our program among the top 10 percent of all centers in the United States and Canada. Furthermore, the Duke team was the first to perform a donation after circulatory death (DCD) heart transplantation in the nation and the first center in the Southeastern US to complete 1,500 heart transplants.

Dr. Sharon McCartney assumed leadership of the Duke University School of Medicine Acute Care Simulation course for medical students. And, an innovative approach to cardiothoracic (CT) anesthesia and critical care education, using the Sakai learning management system, has been spearheaded by Drs. Brandi Bottiger, Anne Cherry, Nazish Hashmi, Rebecca Klinger, Alina Nicoara, and Angela Pollak. On the national stage, Nicoara served as course director for the Society of Cardiovascular Anesthesiologists (SCA) Echo Week meeting.

Dr. Kamrouz Ghadimi completed the landmark INSPIRE-FLO randomized controlled trial and presented the results at the annual meetings of the International Society for Heart and Lung Transplantation and the SCA. And, Project Symphony – a digital transformation initiative aimed at integrating perioperative device data, predictive analytics, team communication, and clinician workflow – is being launched as a pilot in CT surgery patients, championed by Dr. Mihai Podgoreanu.

Only center in the southeast to complete 1,500 heart transplants.


COMMUNITY

 

Community Division Cases


CRITICAL CARE MEDICINE

Division Plays Integral Role During a Pandemic

Heroes Work Here GraphicEvery intensive care unit (ICU) at Duke University Health System came together to care for critically ill patients with COVID-19, and the Critical Care Medicine Division faculty were instrumental in staffing these ICUs. The division worked with the hospital command center to manage not only critically ill COVID patients, but also critically ill surgical and trauma patients. Dr. Raquel Bartz worked with Duke University Hospital leadership, while Drs. Nitin Mehdiratta and Arturo Suarez worked closely with Duke Regional and Duke Raleigh Hospital leadership, training every ICU across the health system to prone hypoxemic mechanically ventilated patients – providing the highest quality of care to patients in all ICUs. Additionally, the division played a key role in education, with Dr. Kamrouz Ghadimi organizing critical care education for its non-critical care anesthesiologists and Drs. Ankeet Udani (from the GVT Division), John Whittle, and John Lemm training non-anesthesia intensivists in emergency airway management. Bartz and Dr. Vijay Krishnamoorthy helped build real-time tools to understand the COVID population and determine post-surgical ICU needs to prioritize scheduling of surgical patients. Despite COVID clinical needs, research continued to flourish in the division with more than 100 publications (from primary and secondary faculty and CAPER Unit members in fiscal year 2020) and the CAPER Unit reaching a milestone of more than $1 million in industry support. Dr. Paul Wischmeyer began studies to understand the nutritional and metabolic needs of critically ill COVID+ patients. And, Dr. Nancy Knudsen has taken on a key leadership position in the School of Medicine, with her appointment as the associate dean for learning environment and well-being.


GENERAL, VASCULAR & TRANSPLANT ANESTHESIOLOGY

Dr. Warwick Ames demonstrating proper PPE useSimulation for Donning and Doffing

Drs. Ankeet Udani, John Whittle and Warwick Ames led the development of an airway management protocol for COVID patients. 

The protocol was tested iteratively at the Duke Human Simulation and Patient Safety Center in collaboration with intensivists, respiratory therapists, nurses, and the Regional Biocontainment Laboratory at Duke. Once developed, the team trained more than 300 members of the airway management teams within days. The COVID airway teams received commendation from the hospital for prioritizing safety, teamwork and preparedness. The airway management protocol was shared widely to assist other hospitals in their care of COVID patients.


NEUROANESTHESIOLOGY, OTOLARYNGOLOGY & OFFSITE ANESTHESIOLOGY

Spinal Fluid of People with Alzheimer’s Risk Gene Signals Inflammation

Dr. Miles BergerPeople who have a gene variant associated with an increased risk of developing Alzheimer’s disease also tend to have changes in the fluid around their brain and spinal cord that are detectable years before symptoms arise, according to new research from Duke Health.

The work found that in people who carry the APOE4 gene variant, which is found in roughly 25 percent of the population, the cerebrospinal fluid contains lower levels of certain inflammatory molecules. This raises the possibility that these inflammatory molecules may be collecting in the brain where they may be damaging synapses, rather than floating freely in the cerebrospinal fluid.

Graphic showing a puzzle of the brainThe findings, published online in January in the Journal of Alzheimer’s Disease, provide a potential means to identify the earliest mechanisms occurring among APOE4 carriers that might contribute to Alzheimer’s disease before people develop memory problems or other symptoms of dementia.

“Our work suggests a potential role for a long-studied molecule called C-reactive protein (CRP), which is typically elevated when there’s inflammation, as a factor in the increased Alzheimer’s disease risk seen in APOE4 carriers,” says lead author Dr. Miles Berger. “Our results raise the possibility that processes like these operating over many years and even decades in APOE4 carriers could eventually result in Alzheimer’s disease pathology and cognitive decline.”

Source: Duke Health News


ORTHOPAEDICS, PLASTICS & REGIONAL ANESTHESIOLOGY

Drs. Joshua Dooley and Andrew Wong at the Resident Regional Anesthesia Workshop.

Launch of Educational Initiatives

The Orthopaedics, Plastics and Regional Anesthesiology Division continued to promote its innovative educational mission with three new activities in 2020. In February, the division co-hosted (with UNC) a free Resident Regional Anesthesia Workshop, which was quickly filled to capacity by residents and fellows from both institutions, as well as out-of-state trainees and international trainees from as far away as Brazil. The comprehensive workshop was taught by faculty and Regional Anesthesiology and Acute Pain Medicine fellows, and incorporated hands-on scanning of live models. “Workshops of this caliber are taught by our faculty at ASRA, NYSORA and ASA meetings, and participants pay up to $1,500 for this kind of experience,” says Division Chief Jeff Gadsden, MD. “We wanted to create a high-quality learning opportunity for trainees without the cost barrier.” The division also launched a new preceptorship program, which has drawn practicing anesthesiologists from around the country and Europe who want to observe state-of-the-art innovations in regional anesthesia and learn from our world-class faculty. October 2020 saw the launch of “#Blocktober,” a month-long, daily educational event on social media that saw interaction from six continents and generated more than 38 million impressions from more than 5,000 participants.


PAIN MEDICINE

Pain Medicine Fellowship Expands to Wake County

Dr. Peter YiDuke Anesthesiology’s Pain Medicine Fellowship is thriving under the leadership of the division’s Dr. Peter Yi. In the 2021-2022 application period, the program received more than 300 applications and interviewed 35 candidates, matching all four candidates in the top 2/3 of that highly-selective group. In July 2020, the division began incorporating its fellows into clinical rotations at its Wake County practices of Raleigh Spine and Pain and Duke Raleigh Hospital Pain Clinic. In those clinics, they work directly with Drs. Scott Runyon, Jay Kumar and Kevin Vorenkamp, who provided the fellows with an even greater exposure to procedures and operative cases, including celiac plexus blocks, spinal cord stimulator implants, and vertebral augmentation cases for both chronic and cancer pain indications. The Wake County pain practices have grown to nearly 15,000 patient visits in fiscal year 2019-2020, despite COVID-19. New pain fellowship educational activities have also been incorporated, including a suturing workshop and simulation/cadaver courses for spinal cord stimulation, dorsal root ganglion stimulation, peripheral nerve stimulation and ablation procedures targeting knee/hip/shoulder joint articular nerves. Pain fellows continue to rotate through the Duke Pain Medicine clinic, Duke Perioperative Pain Care clinic, VA pain clinic and the Inpatient Pain Service, where they spend additional time on the Palliative Care Service and gain exposure to interpreting radiological imaging with an attending radiologist. In addition to the Duke Raleigh Hospital operating rooms, the fellows perform operative cases at Duke ASC, Davis ASC and Duke University Hospital.


PEDIATRIC ANESTHESIOLOGY

Drs. Lisa Einhorn and Alison BrownPost-Operative Opioid Stewardship Project in Pediatric Patients

The opioid epidemic has led to research that shows that prescribing schedules can optimize pain management while reducing unused doses. Dr. Lisa Einhorn led a multi-disciplinary team of pediatric providers in developing and implementing post-operative recommendations for children. She was awarded a PDC Outcomes Research Team (PORT) project to create a tableau dashboard which allows medication data from more than 16,000 pediatric surgical patients to be reviewed in an ongoing basis to guide prescribing patterns. Analysis of this data shows that following the implementation of the new opioid practices, the average number of oxycodone doses prescribed to children following surgery is down between 30 and 66 percent (based on surgical service) with no increase in refill requests. This change represents an important quality and safety improvement in the perioperative care of pediatric surgery patients.

Dr. Edmund JoosteWork from this project was recognized at this year’s Society for Pediatric Anesthesia national meeting when Dr. Alison Brown was awarded second prize in the Resident Research Award for the abstract, titled “Opioid Prescribing Patterns for Tonsillectomy in Children.”

Additionally, a transition in leadership was announced in April 2021 with the appointment of Dr. Edmund Jooste as chief of the Pediatric Anesthesiology Division – a position that Dr. Allison Ross held for 15 years; her outstanding career will continue with new endeavors within and outside the department, focused on fostering career development in others.


WOMEN’S ANESTHESIOLOGY

Division Grows Team and Leadership

Dr. Marie-Louise MengThe Women’s Anesthesiology Division has expanded its faculty with two recruits who bring new expertise and a unique skill set. Dr. Marie-Louise Meng is dual fellowship trained in obstetric and cardiothoracic anesthesia. This unique combination culminated in her clinical and research interest in the management of cardiac disease in pregnancy and investigating cardiovascular complications of pre-eclampsia. Dr. Melissa BauerDr. Melissa Bauer is dual fellowship trained in obstetric anesthesia and critical care. Bauer has an interest in maternal sepsis and is a recognized leader in this area. She was also the lead author of the recently published guidelines by the Society of Obstetric Anesthesia and Perinatology for the management of neuraxial procedures in parturients with thrombocytopenia. The Obstetric Anesthesiology Fellowship program, led by Dr. Jennifer Dominguez, gained further momentum in 2020 with the addition of a second position, expanding the educational and research opportunities of the program. Divisional faculty also continue to support departmental focus in promoting diversity and inclusion with the recent appointment of Drs. Dominguez and Adeyemi Olufolabi as the department Diversity and Inclusion Program leaders. Additionally, members of the division stepped up their efforts throughout the pandemic, establishing protocols for the safe management of pregnant women with COVID and making themselves available for an extra call pool to take care of more than 130 women delivering with COVID, some of whom were critically ill.


VETERANS AFFAIRS ANESTHESIOLOGY SERVICE

The Transitional Pain Service team sees their first patient.Durham VA Health Care System Launches Innovative Service

Patients with chronic pain syndromes and mental health conditions who are scheduled to undergo complex surgery present a significant challenge to the anesthesia care team and the entire perioperative team. To address this issue, Srinivas Pyati, MD, and Vijaya Raavi, CRNA, assembled a multidisciplinary team of surgeons, anesthesiologists, nurse anesthetists, and psychologists to create the Transitional Pain Service; it aims to provide preoperative optimization in the form of education and expectation-setting, consultation with Duke Psychology to address anxiety and any pre-existing mental health conditions, medication management, and use of complementary and alternative therapies such as acupuncture, music listening and mindfulness.

Under this new paradigm, care around the time of surgery is highly protocolized and evidence-based, with daily visits following surgery and implementation of a host of pharmacological and non-pharmacological interventions to alleviate pain and anxiety. The Transitional Pain Service team follows each patient for up to 12 months following hospital discharge and ensures a smooth transition to primary care.

The service launched in December 2020 and has been well received by patients, colleagues and the Durham VA Health Care System.

Centers and Programs

CENTER FOR TRANSLATIONAL PAIN MEDICINE

Duke Anesthesiology Awarded Program Project Grant

Dr. William MaixnerThe NIH awarded the department an $8.5 million Center of Excellence award that is supported via its PPG mechanism, which marks the funding of a new national center and represents the first PPG to the department in 40 years. The designation as a Center of Excellence within the CTPM by the NCCIH brings the department both national and international recognition; there are only 1-3 Centers of Excellence funded as PPGs by NCCIH in the country. The new center represents a nidus that not only advances Duke Anesthesiology’s mission in translational pain research, but brings it increased visibility in the pain field, further expanding international collaboration and increasing its value and recognition as a leader in translational pain medicine. The PPG, “Resolution of Neuroinflammation and Persistent Pain by Complementary Approaches,” aims to identify novel complimentary approaches to the treatment of pain conditions. This award and designation is the culmination of a nearly three-year effort by the CTPM, initiated by the late Dr. William Maixner, who worked closely to develop the proposal with the center’s members and affiliates.

CTPM Director and Postdoctoral Fellow Earn Awards

Dr. Ru-Rong JiDr. Christopher DonnellyDr. Ru-Rong Ji received the prestigious American Society of Anesthesiologists Excellence in Research Award and American Academy of Pain Medicine Founder’s Award, recognizing his achievements and impact in the fields of anesthesiology and pain medicine. Dr. Christopher Donnelly won first place in the highly-competitive AADR Hatton Awards and the IADR Unilever Hatton Awards competitions for his study, “STING Agonism as a Therapeutic Strategy to Treat Chronic Pain,” in which he discovered a new role for the STING protein.

Delirium Superimposed on Dementia Intersects with COVID-19

Dr. Niccolo TerrandoClose up of COVID-19The National Institutes of Health awarded Niccolò Terrando, PhD, a $322,620 supplement grant to his R01-funded project. He aims to develop a model of COVID-19 lung injury that activates the immune system to damage the brain, affecting areas that serve attention, memory, and thinking, and reverse these changes with an experimental drug in development. Findings from this research will provide fundamental knowledge on the pathogenesis of delirium following COVID-19-like infection. Such work has the potential to reduce the health care burden of COVID-19 associated with delirium and related neurologic complications, such as Alzheimer’s disease and other dementias.


PERIOPERATIVE ENHANCEMENT TEAM (POET)

PASS and POET Clinics in the Time of COVID and Beyond

POET Graph2020 marked a period of rapid evolution within medicine. The need for social distancing, the implementation of preoperative COVID testing, and a temporary mandatory pause on all but critical surgeries required seemingly overnight changes to our care delivery framework. Our response to these COVID-related challenges has also catapulted us forward in ways that in the recent past would have been unthinkable. Our Preoperative Anesthesia and Surgical Screening (PASS) clinic and PeriOperative Enhancement Teams (POET) did their best to capitalize on the opportunity that the pause in planned surgeries afforded to expand the timeframe and format of our preoperative optimization initiatives. The PASS clinic and POET programs now offer virtual visits. The accelerated expansion into telehealth has resulted in significant increases in patient volume for many POET programs by expanding service radius, and decreasing no-shows and cancellations. Overall, completed POET appointments increased from 1,736 in 2019 to 3,085 in 2020, with 60 percent of visits provided on the telemedicine platform. Our smoking cessation, nutrition, and diabetes programs saw the greatest increase in volume.

While COVID-related constraints have redirected some resources away from the PASS and POET core mission to re-engineer clinical care pathways for the surgically declared patient to best ensure their readiness for surgery, there have been nonetheless important impacts observed from the programs’ nearly three year history of proactive preoperative optimization efforts on postoperative outcomes. Emerging data from our POET programs now demonstrates fewer days in the hospital (or none at all), less blood product utilization, and a reduction in postoperative admission to the ICU and 30 days readmission after discharge for patients treated by our POET teams. The POET anemia program, under the direction of Dr. Nicole Guinn, has demonstrated cost avoidance via a reduction in blood transfusion, length of stay and 30 day readmission. Dr. Paul Wischmeyer, Dr. David Williams, Elizabeth Villalta, RD, and the POET nutrition team have also shown success in reducing length of stay and readmission for patients at risk of malnutrition with preoperative nutritional supplementation. Despite the addition of the virtual visit format, the POET smoking team, under the directorship of Dr. James Davis, has sustained a quit rate nearly triple that of patients who attempt to quit on their own, or use a quit line. Perhaps most interesting is the impact our POET diabetes team has on patients’ long-term outcomes. Dr. Tracy Setji and the POET diabetes team are noting a sustained reduction in A1c levels for up to two years after their intervention.

While this past year was fraught with challenges, the PASS and POET programs continued to demonstrate the value of patient preoperative optimization. Going forward, we are excited to explore, measure and ultimately demonstrate why preoperative optimization is a critical component to an institution’s value-based care strategy.

Contents

COVER STORY
Anesthesiologists on the Front Lines of a Pandemic

FEATURE
A Comprehensive Approach to Pain

FACULTY SPOTLIGHT
Dr. Nicole Guinn

INNOVATIVE RESEARCH
Dr. Padma Gulur
Dr. Vijay Krishnamoorthy
Dr. Katherine Martucci

DEPARTMENTAL
Message from the Chair
Full Frame: Run for the Warriors
Departmental Highlights
Departmental Listing
ASA Highlights

DREAM CAMPAIGN
Donor Honor Roll
About DIG
2020-2021 DREAM Innovation
Grant Recipients

GLOBAL HEALTH
Duke Health Sends Supplies to India to Assist with Covid-19 Crisis
Blogs from Abroad

RESIDENCY CORNER
Resident Spotlight
Welcome Match Classes of
2024 and 2025
Alumni Shoutout
New and Noteworthy

Chris KeithDepartmental Highlights – BluePrint