Point-of-care ultrasound (POCUS) has become a highly beneficial tool for many clinicians, providing real-time bedside imaging that informs and enhances clinical decision-making. While gastric ultrasound remains a well-established use of POCUS for anesthesiologists to assess aspiration risk, the technology’s utility extends beyond the stomach. Non-gastric applications of POCUS—such as cardiac, pulmonary, vascular, and regional anesthesia imaging—offer the anesthesiologist a powerful toolset to optimize perioperative care, respond quickly to dynamic changes, and improve patient safety.

One of the most impactful non-gastric uses of POCUS for the anesthesiologist is in cardiac assessment. Focused cardiac ultrasound enables anesthesiologists to evaluate myocardial function, detect pericardial effusions, identify valvular pathology, and assess volume status with rapid, high-resolution visualization. In the perioperative setting, this proves invaluable in managing hemodynamic instability. Anesthesiologists can detect left ventricular dysfunction or assess for ischemic changes via regional wall motion abnormalities when electrocardiography or invasive monitors are inconclusive. This rapid diagnostic capability allows for timely interventions, particularly in high-risk surgical patients or those undergoing emergency procedures.

Pulmonary ultrasound has also become an important application of POCUS for anesthesiologists, especially in critical care and intraoperative monitoring. Its utility surpasses that of chest radiography for detecting pneumothorax, pleural effusion, atelectasis, and pulmonary edema. The absence of lung sliding is a reliable indicator of pneumothorax, while B-lines and pleural effusions can guide fluid management and ventilatory strategies. Anesthesiologists managing patients with acute respiratory decompensation can use POCUS to quickly distinguish between cardiogenic and non-cardiogenic pulmonary edema or confirm lung re-expansion after a thoracostomy.

Vascular access is another domain where POCUS has improved the precision and safety of anesthetic practice. Ultrasound guidance significantly increases success rates for central venous catheterization and arterial line placement while reducing complications such as arterial puncture, hematoma, and catheter malposition. Additionally, anesthesiologists can utilize venous compression ultrasound to evaluate for deep vein thrombosis (DVT), which is especially valuable in perioperative patients with risk factors for venous thromboembolism. In the intensive care unit and operating room alike, vascular ultrasound enhances procedural confidence and decreases reliance on confirmatory radiographic studies.

In regional anesthesia, POCUS allows for visualization of neural structures, surrounding anatomy, and local anesthetic spread during peripheral nerve blocks. This results in increased accuracy, reduced complications, and improved block efficacy. Compared to landmark-based techniques, ultrasound guidance shortens onset time, lowers the required dose of local anesthetic, and minimizes the risk of intravascular injection or nerve injury. These advantages have made POCUS the gold standard of care for many regional anesthetic procedures, especially in challenging anatomical regions or in patients with altered anatomy.

Despite these advantages, widespread anesthesiologist adoption of non-gastric POCUS has been met with logistical challenges. Barriers such as limited faculty expertise, inconsistent access to ultrasound equipment, and variability in training curricula remain. Many anesthesiology residency programs recognize the importance of POCUS education but lack the infrastructure or standardized curricula to deliver consistent training. To address these gaps, organizations like the American Society of Anesthesiologists have launched certification programs to promote competency-based learning and clinical proficiency in diagnostic POCUS.

In conclusion, non-gastric POCUS applications have transformed the scope of anesthesiology practice, offering dynamic, bedside assessments that support rapid decision-making across perioperative and critical care settings. From hemodynamic assessment and respiratory diagnostics to vascular access and regional anesthesia, the integration of POCUS significantly improves patient care. Continued emphasis on structured training and system-wide implementation will be crucial to realizing the full potential of this versatile imaging modality in anesthetic practice.

References

1. Naji A, Chappidi M, Ahmed A, Monga A, Sanders J. Perioperative point-of-care ultrasound use by anesthesiologists. Cureus. 2021;13(9):e18131. DOI: 10.7759/cureus.15217.
2. Haskins SC, Bronshteyn Y, Perlas A, et al. Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists. Reg Anesth Pain Med. 2021;46(12):1031-1036. DOI: 10.1136/rapm-2021-102561.
3. Li L, Yong RJ, Kaye AD, Urman RD. Perioperative point of care ultrasound (POCUS) for anesthesiologists: an overview. Curr Pain Headache Rep. 2020;24(12):84. DOI: 10.1007/s11916-020-0847-0.
4. Kalagara H, Coker B, Gerstein NS, Kukreja P. Point-of-care ultrasound (POCUS) for the cardiothoracic anesthesiologist. J Cardiothorac Vasc Anesth. 2022;36(7):2192-2200. DOI: 10.1053/j.jvca.2021.01.018.
5. Dhir A, Soni N, Bansal S, et al. Point-of-care ultrasound: a vital tool for anesthesiologists in the perioperative and critical care settings. J Clin Anesth. 2024;80:110-117. DOI: 10.7759/cureus.66908.

The optimization of patients with cardiac disease before anesthesia and surgery is critical for reducing perioperative morbidity and mortality. The physiological stress of anesthesia and surgery can precipitate major cardiac events, particularly in individuals with preexisting cardiovascular disease. Effective preoperative preparation includes comprehensive assessment, risk stratification, medical optimization, and planning for perioperative management. Risk assessment tools such as the Revised Cardiac Risk Index (RCRI) are widely used to identify patients at increased risk for myocardial infarction, heart failure, arrhythmia, or cardiac death during surgery, allowing clinicians to tailor interventions accordingly (1).

To determine a strategy for optimization, patients should undergo a thorough physical and cardiovascular history examination, supplemented by diagnostic testing, including electrocardiography and echocardiography when indicated by pre-existing cardiac conditions and/or results from their physical exam. Functional capacity remains a strong predictor of perioperative risk, and patients with poor exercise tolerance may require non-invasive stress testing to assess for significant coronary artery disease. Medical therapy is a cornerstone of preparation, with beta-blockers, statins, and angiotensin-converting enzyme inhibitors forming the mainstay for patients with coronary artery disease or heart failure. Careful adjustment of medications can help minimize the risk of ischemic events and maintain hemodynamic stability during surgery (2).

Patients with heart failure, particularly those with reduced ejection fraction, require special attention to volume status, electrolyte balance, and optimization of cardiac output. Preoperative echocardiographic assessment provides valuable information on ventricular function, valvular abnormalities, and pulmonary pressures, which can inform intraoperative monitoring and fluid management strategies. Maintaining a delicate balance to prevent both fluid overload and hypoperfusion is essential to avoid exacerbation of cardiac dysfunction during the perioperative period (2).

Arrhythmias, especially atrial fibrillation, must be treated preoperatively to avoid hemodynamic instability during anesthesia. Rate control with beta-blockers or calcium channel blockers and appropriate anticoagulation management are essential elements of preoperative planning. Decisions regarding continuation or interruption of anticoagulation must carefully balance the risks of thrombosis versus bleeding. The use of bridging anticoagulation with low-molecular-weight heparin may be indicated in select high-risk patients, although the need for this practice has been questioned in recent guidelines (3).

Patients with congenital heart disease represent a unique subset that requires careful individualized planning. Even small hemodynamic changes can have profound effects in these patients. Multidisciplinary collaboration between cardiology, anesthesia, and surgical teams is essential to ensure optimal outcomes. Preoperative imaging, tailored anesthetic approaches, and readiness for advanced hemodynamic monitoring are integral to minimizing perioperative complications. Specialized strategies, including maintenance of preload, avoidance of increased pulmonary vascular resistance, and careful selection of anesthetic agents, are key considerations in this population (4).

In addition to disease-specific considerations, general principles such as smoking cessation, control of hypertension, glycemic control in diabetic patients, and treatment of anemia should be addressed in the preoperative period. Systematic identification of modifiable risk factors may further reduce perioperative cardiac events. Postoperative monitoring for myocardial injury, particularly by monitoring troponin levels in high-risk patients, has been associated with improved detection and management of perioperative myocardial infarction (3).

In cases where cardiac optimization cannot be achieved before anesthesia and surgery, postponement of elective surgery should be considered. Ultimately, preoperative optimization is a dynamic and patient-specific process that requires thorough assessment, evidence-based medical management, and interdisciplinary coordination to achieve the best possible outcomes for patients with cardiac disease undergoing anesthesia and surgery.

References

1. Guasti L, Fumagalli S, Afilalo J, et al. Cardiovascular diseases, prevention, and management of complications in older adults and frail patients treated for elective or post-traumatic hip orthopaedic interventions. Eur J Prev Cardiol. Published online January 15, 2025. doi:10.1093/eurjpc/zwaf010
2. Iaconi M, Maritti M, Ettorre GM, Tritapepe L. Echocardiographic evaluation in patient candidate for liver transplant: from pathophysiology to hemodynamic optimization. J Anesth Analg Crit Care. 2024;4(1):75. Published 2024 Nov 14. doi:10.1186/s44158-024-00211-0
3. Wang MK, Sabac D, Sadhak R, et al. Management of Patients with Myocardial Injury After Noncardiac Surgery: A Retrospective Chart Review. CJC Open. 2024;7(1):103-109. Published 2024 Oct 11. doi:10.1016/j.cjco.2024.10.004
4. Müller M, Lurz F, Zajonz T, et al. Perioperative anesthetic management of patients with hypoplastic left heart syndrome undergoing the comprehensive stage II surgery-A review of 148 cases. Paediatr Anaesth. 2024;34(12):1223-1230. doi:10.1111/pan.14995

The recent wave of federal layoffs within the Department of Health and Human Services (HHS) has sparked significant debate about its implications for the U.S. healthcare system. These workforce reductions, totaling 20,000 positions, aim to streamline operations and reduce costs while reallocating resources to priority areas. However, many concerns remain about the potential negative impacts on public health services, patient care, and research initiatives.

HHS announced plans to cut 10,000 full-time positions across its agencies in March 2025, following an earlier reduction of 10,000 employees through early retirement or voluntary separation offers. These cuts have reduced the department’s workforce from 82,000 to 62,000 employees—a nearly 25% decrease. As part of this restructuring, HHS is consolidating its 28 divisions into 15 and is reducing its ten regional offices to five. Agencies such as the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), National Institutes of Health (NIH), and Centers for Medicare and Medicaid Services (CMS) are among those affected, with the CDC losing approximately 2,400 positions and the FDA seeing reductions of 3,500 employees.

The immediate impacts of federal layoffs on the healthcare system are multifaceted. On one hand, the administration anticipates significant cost savings that can be redirected toward addressing chronic illnesses such as diabetes and heart disease or improving environmental health initiatives. On the other hand, critics warn that reduced staffing levels at key agencies could compromise their ability to fulfill essential functions. For instance, layoffs at the CDC may hinder its capacity to monitor infectious disease outbreaks effectively. Similarly, the FDA could face delays in reviewing medical products and food safety regulations due to diminished workforce capacity. CMS reductions may result in delayed enrollment or assistance for millions of Americans relying on Medicare or Affordable Care Act coverage.

From a fiscal perspective, these layoffs aim to reduce operational costs and improve resource allocation within healthcare at the federal level. Proponents argue that these changes will save $1.8 billion annually and improve efficiency by eliminating redundancies. However, these savings may come at the cost of efficiency and healthcare outcomes. Delays in regulatory approvals at the FDA could slow market entry for life-saving drugs and devices, potentially increasing healthcare costs for providers and patients alike. Additionally, reduced public health surveillance could lead to higher expenditures associated with managing preventable disease outbreaks. While streamlining operations may yield short-term financial benefits, there is concern that these savings could be offset by long-term inefficiencies.

One of the most pressing concerns surrounding these layoffs is their potential impact on patient safety and quality of care. Reduced staffing at CMS may result in delays that disproportionately affect vulnerable populations who depend on timely access to healthcare services. At NIH, workforce reductions could curtail research initiatives aimed at developing innovative treatments for diseases such as cancer or long COVID—conditions that affect millions of Americans annually. Furthermore, diminished capacity at the CDC could weaken its ability to respond swiftly to emerging health crises like pandemics or natural disasters.

The long-term consequences of federal layoffs extend beyond immediate disruptions to healthcare. A smaller workforce at HHS agencies may weaken the nation’s preparedness for future public health emergencies by limiting expertise and institutional knowledge within critical agencies like NIH and FDA. Additionally, widespread layoffs could deter talented professionals from pursuing careers in public health due to job insecurity and limited resources. Rebuilding institutional capacity will require substantial time and investment—resources that may be difficult to secure amid ongoing budget constraints.

While these federal layoffs present significant challenges for healthcare systems, proponents argue that they offer opportunities for reform by prioritizing chronic disease prevention over bureaucratic inefficiencies. Health Secretary Robert F. Kennedy Jr., who spearheaded this restructuring effort, has emphasized that these changes are part of a broader strategy to align HHS with its fundamental mission while achieving more with fewer resources. However, critics remain skeptical about whether these goals can be achieved without compromising essential services.

References

1. CNN Health News. HHS cuts 10,000 employees in major overhaul of health agencies. Published March 27, 2025. https://www.cnn.com/2025/03/27/health/hhs-rfk-job-cuts/index.html
2. NBC News Health News. HHS plans to shutter or downsize several health agencies including CDC. Published March 27, 2025. https://www.nbcnews.com/health/health-news/hhs-plans-shutter-downsize-several-health-agencies-cdc-rcna198254
3. Forbes Health Analysis Team. How the layoff of 10,000 health workers from HHS could affect your health. Published March 30, 2025. https://www.forbes.com/sites/omerawan/2025/03/30/how-the-layoff-of-10000-health-workers-from-hhs-could-affect-your-health/
4. Taylor L. Mass layoffs hit US public health agencies, but infection experts appear to be spared. BMJ. 2025 Feb 19;388:r356. doi: 10.1136/bmj.r356

Perioperative management of anticoagulation is a critical aspect of patient care. Virchow’s triad, consisting of hypercoagulability, stasis, and endothelial injury, explains the increased risk of venous thromboembolism (VTE) in the perioperative period. Surgical patients often experience all three components: tissue damage activates the coagulation cascade, immobility leads to blood stasis, and vascular manipulation causes endothelial disruption. These factors collectively elevate the risk of deep vein thrombosis and pulmonary embolism, necessitating effective prophylaxis strategies. At the same time, bleeding must be controlled during surgery to maintain hemodynamic stability. Anesthesia and surgery teams must carefully consider the use of anticoagulants such as enoxaparin in the perioperative period, as well as the potential stoppage of ongoing anticoagulant therapy.

Enoxaparin, a low molecular weight heparin (LMWH), acts by enhancing the inhibitory effect of antithrombin III on factor Xa and thrombin. This mechanism effectively reduces the risk of VTE without significantly increasing bleeding complications. Studies have shown that prophylactic use of enoxaparin can decrease the incidence of VTE by up to 50% in surgical patients, making it a valuable tool in perioperative thromboprophylaxis.

The indications for perioperative enoxaparin use include prophylaxis in high-risk surgical patients and bridging therapy for those on long-term anticoagulation. Timing is crucial: for prophylactic doses, the last dose should be administered at least 12 hours before the procedure. For therapeutic doses, a minimum of 24 hours should elapse between the last dose and surgery. Postoperatively, enoxaparin can typically be resumed 12-24 hours after minor surgery, but for major procedures with high bleeding risk, resumption may be delayed up to 48-72 hours.

Drug interactions between enoxaparin and anesthesia agents are an important consideration. While direct interactions with anesthetics are limited, the combination of enoxaparin with neuraxial anesthesia (spinal or epidural) requires careful timing to minimize the risk of spinal hematoma. The FDA recommends that catheter placement or removal should be delayed for at least 12 hours after prophylactic enoxaparin doses and 24 hours after therapeutic doses. Conversely, postprocedural enoxaparin should not be administered sooner than 4 hours after catheter removal.

Other considerations when administering enoxaparin during anesthesia include potential interactions with drugs that affect hemostasis. Non-steroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding when used concurrently with enoxaparin. Additionally, both enoxaparin and certain antibiotics like trimethoprim can elevate potassium levels, necessitating close monitoring of serum electrolytes. Renal function is another critical factor, as enoxaparin is primarily eliminated through the kidneys. Patients with impaired renal function may require dose adjustments or extended intervals between the last dose and surgical intervention to prevent excessive anticoagulation.

In conclusion, the use of enoxaparin in the perioperative period requires a delicate balance between thromboprophylaxis and bleeding risk. Anesthesia providers must be aware of the timing considerations, potential drug interactions, and patient-specific factors that influence the safe administration of enoxaparin. Close collaboration between surgical, anesthesia, and pharmacy teams is essential to optimize patient outcomes and minimize complications associated with perioperative anticoagulation management.

References

1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-e350S. doi:1378/chest.11-2298
2. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018;43(3):263-309. doi:1097/AAP.0000000000000763
3. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:1378/chest.11-2404
4. Garcia DA, Baglin TP, Weitz JI, Samama MM. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e24S-e43S. doi:1378/chest.11-2291
5. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352. doi:1016/j.chest.2015.11.026
6. Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Intern Med. 2019;179(11):1469-1478. doi:1001/jamainternmed.2019.2431

Obstructive sleep apnea (OSA) is a common sleep disorder characterized by repeated episodes of upper airway collapse during sleep, leading to breathing pauses and reduced blood oxygen levels. The prevalence of OSA has increased over time, with recent studies indicating that it affects a significant portion of the adult population. According to a systematic review, the prevalence of OSA, defined as ≥5 apnea or hypopnea events per hour, ranges from 9% to 38% in the general adult population, with higher rates in men, older adults, and individuals with obesity. In some elderly groups, the prevalence can be as high as 90% in men and 78% in women. Because OSA negatively impacts long-term health and increases the risk of complications during anesthesia, refining treatment is an important focus of some medical research. The recent approval of Zepbound for treating obstructive sleep apnea represents a major step forward.

Traditionally, the primary treatment for moderate to severe OSA has been continuous positive airway pressure (CPAP) therapy. CPAP involves wearing a mask during sleep that delivers pressurized air to keep the airway open. While effective, CPAP adherence can be challenging for many patients. Other treatments include oral appliances, positional therapy, and in some cases, surgical interventions. However, the landscape of OSA treatment is evolving.

On December 20, 2024, the U.S. Food and Drug Administration (FDA) approved Zepbound® (tirzepatide) as the first medication for the treatment of moderate to severe obstructive sleep apnea in adults with obesity. Zepbound is a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist. It works by activating receptors of hormones secreted from the intestine, which reduces appetite and food intake. By promoting weight loss in patients with obesity, Zepbound can indirectly improve OSA symptoms.

The efficacy of Zepbound for OSA was demonstrated in the SURMOUNT-OSA phase 3 clinical trials. These studies evaluated Zepbound (10 mg or 15 mg) in adults with obesity and moderate to severe OSA, both with and without positive airway pressure (PAP) therapy. In patients not using PAP therapy, Zepbound reduced breathing disruptions by an average of 25 events per hour, compared to 5 events per hour with placebo. For those on PAP therapy, Zepbound led to 29 fewer breathing disruptions per hour, versus 6 with placebo. After one year of treatment, 42% of adults on Zepbound without PAP therapy and 50% of those on Zepbound with PAP therapy experienced remission or mild, non-symptomatic OSA, compared to 16% and 14% on placebo, respectively.

While Zepbound shows promising results for the treatment of obstructive sleep apnea, it is important to consider its potential risks and complications. Common side effects include nausea, diarrhea, vomiting, constipation, abdominal pain, and injection site reactions. More serious side effects, though less common, can include severe gastrointestinal issues, pancreatitis, gallbladder problems, hypoglycemia (especially when combined with insulin or sulfonylureas), and kidney damage. Additionally, Zepbound carries a boxed warning for the potential risk of thyroid C-cell tumors, based on animal studies.

In conclusion, the approval of Zepbound represents a significant advancement in the treatment of obstructive sleep apnea, particularly for patients with obesity. Its dual mechanism of promoting weight loss and directly improving OSA symptoms offers a novel approach to managing this prevalent sleep disorder. However, as with any medication, the benefits of Zepbound must be weighed against its potential risks. Patients considering Zepbound for OSA should consult with their healthcare providers to determine if it is an appropriate treatment option based on their individual health profile and medical history.

References

1. Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev. 2017;34:70-81. doi:10.1016/j.smrv.2016.07.002
2. Food and Drug Administration. FDA Approves First Medication for Obstructive Sleep Apnea. Published December 20, 2024. Accessed January 11, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea
3. Eli Lilly and Company. FDA approves Zepbound® (tirzepatide) as the first and only prescription medicine for moderate-to-severe obstructive sleep apnea in adults with obesity. Published December 20, 2024. Accessed January 11, 2025. https://investor.lilly.com/news-releases/news-release-details/fda-approves-zepboundr-tirzepatide-first-and-only-prescription
4. Baptist Health. Zepbound Side Effects: What You Need to Know. Published August 30, 2024. Accessed January 11, 2025. https://www.baptisthealth.com/blog/weight-management/zepbound-side-effects
5. Drugs.com. Zepbound Side Effects: Common, Severe, Long Term. Updated December 30, 2024. Accessed January 11, 2025. https://www.drugs.com/sfx/zepbound-side-effects.html