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Defining and developing expertise in tracheal intubation using a GlideScope® for anaesthetists with expertise in Macintosh direct laryngoscopy: An in-vivo longitudinal study | Although videolaryngoscopy can provide excellent views of the laryngeal structures as both the primary method of tracheal intubation and as a rescue technique for difficult direct laryngoscopy, the existing literature is inadequate to define expertise or even competence. We observed the performance of nine trainees during 890 intubations, with an additional 72 intubations performed by expert anaesthetists used as a control group. Univariate and multivariate mixed-effects logistic regression models were applied to detect potential predictors of successful intubation and define the number of intubations necessary for a trainee to achieve expertise (> 90% probability of optimal performance). Optimal performance was predicted by single laryngoscope insertion (p < 0.001) and a Cormack and Lehane grade-1 view (p < 0.001), and not by normal lifting force applied to the device (p = 0.15), with expertise reached after 76 attempts. These results indicate that expertise in videolaryngoscopy requires prolonged training and practice. © 2014 The Association of Anaesthetists of Great Britain and Ireland. |
America's Opioid Epidemic: Supply and Demand Considerations | America is in the midst of an opioid epidemic characterized by aggressive prescribing practices, highly prevalent opioid misuse, and rising rates of prescription and illicit opioid overdose-related deaths. Medical and lay public sentiment have become more cautious with respect to prescription opioid use in the past few years, but a comprehensive strategy to reduce our reliance on prescription opioids is lacking. Addressing this epidemic through reductions in unnecessary access to these drugs while implementing measures to reduce demand will be important components of any comprehensive solution. Key supply-side measures include avoiding overprescribing, reducing diversion, and discouraging misuse through changes in drug formulations. Important demand-side measures center around educating patients and clinicians regarding the pitfalls of opioid overuse and methods to avoid unnecessary exposure to these drugs. Anesthesiologists, by virtue of their expertise in the use of these drugs and their position in guiding opioid use around the time of surgery, have important roles to play in reducing patient exposure to opioids and providing education about appropriate use. Aside from the many immediate steps that can be taken, clinical and basic research directed at understanding the interaction between pain and opioid misuse is critical to identifying the optimal use of these powerful pain relievers in clinical practice. |
Mothers of Africa - An anaesthesia charity | An anaesthetic charity 'Mothers of Africa' has been established as a link between the academic departments of anaesthesia in Togo and Benin and the University Hospital of Wales. Visits by UK consultant anaesthetists have identified a number of clinical areas where collaborative working in both classroom and theatre has the potential to improve outcomes in maternal mortality and morbidity. © 2007 The Authors. |
Learning to apply effective cricoid pressure using a part task trainer | An anatomically-correct model of a larynx inside a head and neck model was constructed so that the location, direction and amount of force applied to the neck could be measured. Fifty trained staff from three general hospitals were then asked to apply cricoid pressure on the model. None was able to state the force that should be applied (30 N), and only five (10%) actually applied cricoid pressure effectively. After training using the model, 45 (90%) applied cricoid pressure correctly (p < 0.001). This study demonstrates that improved training in cricoid pressure is needed and supports earlier researchers who suggested that this can be achieved using simulators. |
Remote monitoring using an induction loop | An electromagnetic induction loop is used to transmit signals from a pulse and respiration monitor to a standard National Health Service hearing aid to facilitate remote monitoring Copyright © 1986, Wiley Blackwell. All rights reserved |
The perioperative care of the transgender patient | An estimated 25 million people identify as transgender worldwide, approximately 1 million of whom reside in the United States. The increasing visibility and acceptance of transgender people makes it likely that they will present in general surgical settings; therefore, perioperative health care providers must develop the knowledge and skills requisite for the safe management of transgender patients in the perioperative setting. Extant guidelines, such as those published by the World Professional Association for Transgender Health and the University of California San Francisco Center of Excellence for Transgender Health, serve as critical resources to those caring for transgender patients; however, they do not address their unique perioperative needs. It is essential that anesthesia providers develop the knowledge and skills necessary for safely managing transgender patients in the perioperative setting. This review provides an overview of relevant terminology, the imperative for the provision of culturally sensitive care, and guidelines for preoperative, intraoperative, and postoperative management of the transgender patient. Copyright © 2018 International Anesthesia Research Society |
Endotracheal intubation training using a simulator: An evaluation of the laerdal adult intubation model in the teaching of endotracheal intubation | An evaluation of a human adult simulator for teaching endotracheal intubation is described. An observation study on the training of medical students is presented which shows that while the simulator is not ideally representative of the human anatomy, it is nevertheless a useful device for the teaching of this vital manoeuvre. © 1973 John Sherratt and Son Ltd. |
Morbidity and early retirement among anaesthetists and other specialists | An historically prospective study of the rates of early retirement due to permanent ill health, early retirement between 60 and 64 years of age for other reasons, and deaths while in post, among consultant anaesthetists in England was carried out. The control group comprised consultants in four other hospital specialty groups. Approximately two‐thirds of all consultants employed in the five specialties at National Health Service hospitals in England during 1966–83 were included in the study. Ill‐health retirements among male anaesthetists were more than twice those expected on the basis of rates in the control group (p < 0.001). The number of other early retirements between 60 and 64 was a third higher than expected (p < 0.005). The number of deaths in post was also raised. For the smaller group of female anaesthetists there was not a statistically significant excess of ill‐health retirements, but the number of early retirements between 60 and 64 was significantly greater than expected (p < 0.005), as was the number of deaths in post (p < 0.001). Possible causes of these excesses are discussed. Copyright © 1987, Wiley Blackwell. All rights reserved |
Anesthesia for cardiac surgery in patients receiving monoamine oxidase inhibitors | An increase in the number of patients receiving MAOI is likely to be seen in the clinical practice of anesthesiology. This report suggests that patients receiving MAOI may be safely anesthetized for major surgical procedures. Appropriate monitoring and preparation may obviate the need for withdrawal of MAOI prior to surgery. |
Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists | An increasing number of global initiatives aim to address the disconnection between the increasing number of women entering medicine and the persistence of gender imbalance in the physician anaesthesiologist workforce. This commentary complements the global movement's efforts to increase women's representation in academic anaesthesiology by presenting considerations for fostering inclusion for women in academic anaesthesiology from both the faculty and departmental leadership perspectives in a US academic anaesthesiology department. © 2019 The Author(s) |
Assessment of an interactive learning system with 'sensorized' manikin head for airway management instruction | An interactive, self-study learning system for airway management instruction that utilizes a 'sensorized' manikin head (Actronics Inc., Pittsburgh, PA) was compared to didactic instruction from anesthesiologists during third-year medical student anesthesia rotations. Before students were allowed to participate in airway management on anesthetized patients, they were randomly separated into two groups. One group received instruction from the learning system, and the other group was given a lecture with guided practice on a standard tracheal intubating manikin. Differences between groups were then assessed using 22 separate variables as all students performed actual airway management on patients undergoing general anesthesia. Anesthesia faculty, residents, and nurse anesthetists, blinded to group, served as assessors. There were 48 and 49 students in the didactic instruction and learning system groups, respectively. Beginning experience level of students with respect to airway management was similar between groups before the anesthesia rotations. There were 185 and 188 evaluation forms completed to assess the didactic instruction and learning system groups, respectively. Demographic data regarding patients were recorded. Patients in the learning system group on whom students performed airway management were older, had a larger average body mass index, and their airways more frequently received higher Mallampati classifications (glottic structures more difficult to visualize). No difference in the quality of airway management efforts or in students' appraisal of their own performances was seen between groups. Neither group demonstrated more rapid development of psychomotor skills. Students were equally satisfied with both methods of instruction. We conclude that the airway management self-study learning system is as efficacious as didactic instruction for preclinical airway management instruction during third-year medical student anesthesia rotations. |
Handover of responsibility for the anaesthetised patient - Opinion and practice | Anaesthesia is a critical and complex process that extends from the pre-operative assessment through to the postoperative management of patients. Handover of responsibility for logistical as opposed to patient-orientated reasons may compromise that process of care. If such handover becomes inevitable with shift-based patterns of working, the implications need to be considered and procedures developed in order to minimise adverse consequences. This survey of national practice reveals little formalisation of procedure and a spectrum of opinion on the relevance of the key considerations. There is, however, a majority view amongst respondents that national guidelines would be of value and that professional defensibility would be aided by standardisation and documentation of any handover. © 2004 Blackwell Publishing Ltd. |
Critical incident reports concerning anaesthetic equipment: Analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008 | Anaesthetic equipment plays a central role in anaesthetic practice but brings the potential for malfunction or misuse. We aimed to explore the national picture by reviewing patient safety incidents relating to anaesthetic equipment from the National Reporting and Learning System for England and Wales between 2006 and 2008. We searched the database using the system's own classification and by scrutinising the free text of relevant incidents. There were 1029 relevant incidents. Of these, 410 (39.8%) concerned patient monitoring, most commonly screen failure during anaesthesia, failure of one modality or failure to transfer data automatically from anaesthetic room to operating theatre. Problems relating to ventilators made up 185 (17.9%) of the reports. Sudden failures during anaesthesia accounted for 142 (13.8%) of these, with a further 10 cases (0.9%) where malfunction caused a sustained or increasing positive pressure in the patient's airway. Leaks made up 99 (9.6%) of incidents and 53 (5.2%) of incidents arose from the use of infusion pumps. Most (89%) of the incidents caused no patient harm; only 30 (2.9%) were judged to have led to moderate or severe harm. Although equipment was often faulty, user error or unfamiliarity also played a part. A large variety of causes led to a relatively small number of clinical scenarios, that anaesthetists should be ready, both individually and organisationally, to manage even when the cause is not apparent. We make recommendations for enhancing patient safety with respect to equipment. © 2011 The Association of Anaesthetists of Great Britain and Ireland. |
Anaesthesia equipment malfunction | Anaesthetic equipment was studied to determine whether the accuracy was improved and failure rate decreased by routine maintenance and calibration by a biomedical technician. Each piece was evaluated, and then repaired and rechecked at intervals by the same technician. Equipment failures were divided into three types: first, equipment that was completely nonfunctional; second, equipment that was functional but inaccurate; and third, equipment that was functional and accurate but needed minor repairs. The percentage of equipment failures in each group was compared on initial evaluation and after 6 months. Of the 311 pieces of equipment, 40% needed repair at the time of the initial survey; 8% was nonfunctional, and 18% was functional but inaccurate. After six months on a maintenance schedule, only 15% of the equipment needed repair, 3% was nonfunctional, and 6% was functional but inaccurate. The difference between the total percentage of equipment failure initially and after six months was statistically significant. After a regular maintenance, calibration, and checkout schedule by a biomedical technician was instituted, there was a significant improvement in the accuracy of the equipment and a reduction in the percentage of equipment needing repair. Copyright © 1985, Wiley Blackwell. All rights reserved |
Age‐dependent haematological disturbances in anaesthetic personnel chronically exposed to high occupational concentrations of halothane and nitrous oxide | Anaesthetic staff chronically exposed to high occupational concentrations of halothane and nitrous oxide were tested for numerous haematological and cellular function parameters at the peak of the working season and after 3 weeks vacation. The analysis of data was performed to compare differences in subjects younger and older than the age of 40 years, respectively when compared with normal controls. The analysis revealed a higher recovery of erythrocyte’count in the blood of older staff, and stronger disturbance of leucocyte formation in younger staff. In contrast, monocytes appeared to be more stable in the younger staff as were the T and B lymphocyte counts. After stimulation with PHA, Con A and PWM mitogens, lymphocytes from the older age group incorporated a significantly higher amount of tritiated thymidine, but stimulation indices did not differ. Natural killer cell numbers appeared equally affected; natural killer cell activity was unaffected, but there was an increase in activity in the younger staff after the vacation. Serum immunoglobulin concentrations tended to be more affected in older individuals at the peak of the working season. Copyright © 1994, Wiley Blackwell. All rights reserved |
Magnetic resonance for the anaesthetist: Part I: physical principles, applications, safety aspects | Anaesthetists are being increasingly involved in magnetic resonance (MR) procedures, both in patient care and as a research tool. This paper outlines the physical basis of nuclear magnetic resonance and describes its application in magnetic resonance imaging and spectroscopy. Principles of magnet design and safety relevant to anaesthetic practice in a magnetic resonance environment are discussed and guidelines for anaesthetic practice suggested. Some recent clinical magnetic resonance studies of anaesthetic interest are reviewed. Copyright © 1992, Wiley Blackwell. All rights reserved |
Magnetic resonance for the anaesthetist: Part II: anaesthesia and monitoring in MR units | Anaesthetists are increasingly involved in patient care during magnetic resonance imaging and spectroscopy. This paper describes a system which has been developed for the management of critically ill patients and the conduct of anaesthesia in a magnetic resonance unit with a 1.6 tesla whole body magnet. Difficulties which arise from working in a confined space in a high magnetic field are highlighted. Different approaches to anaesthesia, sedation and the modification of equipment for use in this environment are reviewed. The problems associated with patient monitoring within a magnetic field are discussed and some solutions are suggested. A transport system for critically ill patients is described and a protocol for management is outlined. Copyright © 1992, Wiley Blackwell. All rights reserved |
Substance use disorder in the anaesthetist: Guidelines from the Association of Anaesthetists | Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6–10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision. © 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. |
The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor | Anesthesia and Cardiopulmonary Services, University Health Systems East; Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania Continuous pulse oximetry (CPOX) has the potential to increase vigilance and decrease pulmonary complications and thus decrease intensive care unit (ICU) admissions. In a randomized nonblinded study of 1219 subjects we compared the effects of CPOX and standard monitoring on the rate of transfer to an ICU from a 33-bed postcardiothoracic surgery care floor. There was no difference in the rate of ICU readmission between the CPOX and standard monitor groups. Despite older age and comorbidity, estimated cost to time of censoring (enrollment to completion of the study) was less in the monitored patients who required ICU transfer than in the unmonitored patients who required ICU transfer (mean estimated cost difference of $28,195; P = 0.04). Use of CPOX altered the reasons that patients were transferred to an ICU but did not affect the rate of transfer. The duration, and thus estimated cost, of ICU stay was significantly less in the CPOX-monitored group. The potential for CPOX to allow for early intervention, or perhaps prevention of pulmonary complications, needs to be explored. Routine CPOX monitoring did not reduce transfer to ICU, mortality, or overall estimated cost of hospitalization, and it is unclear if there is any real benefit from the application of this technology in patients on a general care floor who are recovering from cardiothoracic surgery. ©2006 by the International Anesthesia Research Society. |
Radiation exposure to anesthesia personnel: The impact of an electrophysiology laboratory | Anesthesia care providers are vulnerable to radiation exposure during a number of diagnostic and therapeutic procedures. In this study I examined the radiation exposure to members of a small department of anesthesiology. The aggregate radiation exposure to all members of the department doubled subsequent to the introduction of an electrophysiology laboratory. ©2005 by the International Anesthesia Research Society. |
Anesthesia development in Mongolia: Strengthening anesthesia practice in Mongolia through education and continuing professional development | Anesthesia in Mongolia has undergone a period of major development over the past 17 years, thanks to the work of the Mongolian Society of Anesthesiologists (MSA) and the support of the World Federation of Societies of Anaesthesiologists and the Australian Society of Anaesthetists. The specialty has made major advances in training and in its standing among medical specialties in Mongolia. The MSA has produced members who are leaders in the development of anesthesia as well as emergency medicine and critical care. This has been achieved by engagement between the Ministry of Health and MSA, and with inexpensive but efficient programs to educate trainees and provide continuing professional development. There is now major work being done to achieve the Lancet Commission on Global Surgery goals of safe and accessible surgery for the population in a country that faces significant challenges of remote communities with vast distances. © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. |
Anesthesia information management system implementation: A practical guide | Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error. This collaborative effort summarizes essential considerations for successful AIMS implementation, including product evaluation, assessment of information technology needs, resource availability, leadership roles, and training. © 2008 International Anesthesia Research Society. |
Anesthesia information management systems | Anesthesia information management systems (AIMS) have evolved from simple, automated intraoperative record keepers in a select few institutions to widely adopted, sophisticated hardware and software solutions that are integrated into a hospital's electronic health record system and used to manage and document a patient's entire perioperative experience. AIMS implementations have resulted in numerous billing, research, and clinical benefits, yet there remain challenges and areas of potential improvement to AIMS utilization. This article provides an overview of the history of AIMS, the components and features of AIMS, and the benefits and challenges associated with implementing and using AIMS. As AIMS continue to proliferate and data are increasingly shared across multi-institutional collaborations, visual analytics and advanced analytics techniques such as machine learning may be applied to AIMS data to reap even more benefits. Copyright © 2017 International Anesthesia Research Society. |
Percutaneous injuries in anesthesia personnel | Anesthesia personnel are at risk for occupationally acquired blood- borne infections from human immunodeficiency virus, hepatitis viruses, and others after percutaneous exposures to infected blood or body fluids. The risk is greater after an infected, blood-contaminated, percutaneous injury, especially from a hollow-bore blood-filled needle, than from other types of exposures. Few data are available on the specific occupational hazards to anesthesia personnel from needles and other sharp devices. Fifty-eight percutaneous injuries (PIs) from anesthesia personnel in nine hospitals were analyzed. Thirty-nine of 58 PIs were from contaminated devices (all needles), and 19 were from uncontaminated devices or of unknown contamination status. Forty-three percent of contaminated percutaneous injuries (CPI) were classified as moderate (some bleeding) or severe (deep injury with profuse bleeding), and most were to health-care workers' hands. Fifty-nine percent of CPI were potentially preventable. Eighty-seven percent of CPI were from hollow-bore needles, and 68% of these were potentially preventable. The largest categories of devices causing CPI were needle on syringe, intravenous (IV) or arterial catheter needle-stylet, suture needle, and standard hollow- bore needle for secondary IV infusion. Most CPI occurred between steps of a multistep procedure (8%), were recapping related (13%), or occurred at other times after use (41%). No CPI were reported from use of needlestick- prevention safety devices. The devices and mechanisms of injury identified in this study provide specific data that may lead to prevention strategies to reduce the risk of PI. |
The use of needles in the practice of anesthesiology and the effect of a needleless intravenous administration system | Anesthesia personnel are at risk for occupationally acquired blood-borne infections transmitted through needlestick injuries. To formulate strategies for the prevention of needlestick injuries, it is necessary to identify the types of needles used by anesthesia personnel and the devices associated with injuries. The introduction of a needleless intravenous (IV) administration system provided an opportunity to assess its effect on needle usage in the practice of anesthesiology. The contents of needle disposal containers placed in the preoperative holding area and five operating rooms before (control) and after the introduction of a needleless administration system (study) were categorized by needle type. The information on needles used by anesthesia personnel was compared with that on needles purchased for the entire hospital. During the control period, most of the needles used were 18-23- gauge hollow needles (51.6%), IV catheter stylets (23%), and 25-26-gauge small-bore hollow needles (17.1%). There was no difference in the total number of needles collected after the introduction of the needleless administration system, but there was an increase in capped 18-23-gauge hollow needles. Anesthesia personnel used a relatively greater number of small-bore hollow needles (25-26 gauge), IV catheters, and spinal and epidural needles, but fewer hollow needles (18-23 gauge) than were purchased for hospital-wide use. Small-bore hollow needles (25-26 gauge) were responsible for 31.6% of the 19 needlestick injuries reported by anesthesia personnel to the Employee Health Service. These data indicate that the practice of anesthesia is associated with a specific pattern of needle usage and that strategies for reducing needlestick injuries in anesthesia personnel should be directed toward finding alternatives to small-bore hollow needles and IV catheter stylet needles. |
Teaching neuraxial anesthesia techniques for obstetric care in a ghanaian referral hospital: Achievements and obstacles | Anesthesia providers in low-income countries may infrequently provide regional anesthesia techniques for obstetrics due to insufficient training and supplies, limited manpower, and a lack of perceived need. In 2007, Kybele, Inc. began a 5-year collaboration in Ghana to improve obstetric anesthesia services. A program was designed to teach spinal anesthesia for cesarean delivery and spinal labor analgesia at Ridge Regional Hospital, Accra, the second largest obstetric unit in Ghana. The use of spinal anesthesia for cesarean delivery increased significantly from 6% in 2006 to 89% in 2009. By 2012, >90% of cesarean deliveries were conducted with spinal anesthesia, despite a doubling of the number performed. A trial of spinal labor analgesia was assessed in a small cohort of parturients with minimal complications; however, protocol deviations were observed. Although subsequent efforts to provide spinal analgesia in the labor ward were hampered by anesthesia provider shortages, spinal anesthesia for cesarean delivery proved to be practical and sustainable. © 2015 International Anesthesia Research Society. |
Repeated measures designs and analysis of longitudinal data: If at first you do not succeed-try, try again | Anesthesia, critical care, perioperative, and pain research often involves study designs in which the same outcome variable is repeatedly measured or observed over time on the same patients. Such repeatedly measured data are referred to as longitudinal data, and longitudinal study designs are commonly used to investigate changes in an outcome over time and to compare these changes among treatment groups. From a statistical perspective, longitudinal studies usually increase the precision of estimated treatment effects, thus increasing the power to detect such effects. Commonly used statistical techniques mostly assume independence of the observations or measurements. However, values repeatedly measured in the same individual will usually be more similar to each other than values of different individuals and ignoring the correlation between repeated measurements may lead to biased estimates as well as invalid P values and confidence intervals. Therefore, appropriate analysis of repeated-measures data requires specific statistical techniques. This tutorial reviews 3 classes of commonly used approaches for the analysis of longitudinal data. The first class uses summary statistics to condense the repeatedly measured information to a single number per subject, thus basically eliminating within-subject repeated measurements and allowing for a straightforward comparison of groups using standard statistical hypothesis tests. The second class is historically popular and comprises the repeated-measures analysis of variance type of analyses. However, strong assumptions that are seldom met in practice and low flexibility limit the usefulness of this approach. The third class comprises modern and flexible regressionbased techniques that can be generalized to accommodate a wide range of outcome data including continuous, categorical, and count data. Such methods can be further divided into so-called "population-average statistical models" that focus on the specification of the mean response of the outcome estimated by generalized estimating equations, and "subject-specific models" that allow a full specification of the distribution of the outcome by using random effects to capture within-subject correlations. The choice as to which approach to choose partly depends on the aim of the research and the desired interpretation of the estimated effects (population-average versus subject-specific interpretation). This tutorial discusses aspects of the theoretical background for each technique, and with specific examples of studies published in Anesthesia & Analgesia, demonstrates how these techniques are used in practice. Copyright © 2018 The Author(s). |
Should we reevaluate the variables for predicting the difficult airway in anesthesiology? | Anesthesiologists have often been confronted with the difficult question of determining which patient will present an increased difficulty for endotracheal intubation. The limits of the previously reported morphometric airway measurements for predicting difficult intubation have inadequately addressed the normal patient population variables. We designed this prospective study to investigate the age and sex-related changes in the morphometric measurements of the airway in a large group of patients without anatomic abnormality and a group of cadavers. Hyomental, thyromental, sternomental distances, neck extension, and Mallampati scores were evaluated in 12 cadavers and in 334 patients. Patients were allocated to three groups based on age: Group 1 (20-30 yr), Group 2 (31-49 yr), and Group 3 (50-70 yr). Male and female sex differences were also evaluated. Hyomental distance was the only variable not affected by age. In addition, the mean population values were less than the threshold values suggested as criteria for difficult endotracheal intubation. All the other criteria were age-dependent and inversely affected by the increase in age. Male sex was also a distinction for increased measurements of all the morphometric distances. The mean degree of neck extension was similar in both sex groups. This study provides a more comprehensible approach to the morphometric measurements of the human airway. Adequate data of normal values may help the clinician to identify patients that are outside the range and therefore may be challenging. |
Analysis of variance of communication latencies in anesthesia: Comparing means of multiple log-normal distributions | Anesthesiologists rely on communication over periods of minutes. The analysis of latencies between when messages are sent and responses obtained is an essential component of practical and regulatory assessment of clinical and managerial decision-support systems. Latency data including times for anesthesia providers to respond to messages have moderate (> n = 20) sample sizes, large coefficients of variation (e.g., 0.60 to 2.50), and heterogeneous coefficients of variation among groups. Highly inaccurate results are obtained both by performing analysis of variance (ANOVA) in the time scale or by performing it in the log scale and then taking the exponential of the result. To overcome these difficulties, one can perform calculation of P values and confidence intervals for mean latencies based on log-normal distributions using generalized pivotal methods. In addition, fixed-effects 2-way ANOVAs can be extended to the comparison of means of log-normal distributions. Pivotal inference does not assume that the coefficients of variation of the studied log-normal distributions are the same, and can be used to assess the proportional effects of 2 factors and their interaction. Latency data can also include a human behavioral component (e.g., complete other activity first), resulting in a bimodal distribution in the log-domain (i.e., a mixture of distributions). An ANOVA can be performed on a homogeneous segment of the data, followed by a single group analysis applied to all or portions of the data using a robust method, insensitive to the probability distribution. © 2011 International Anesthesia Research Society. |
'Do Not Resuscitate' (DNR) orders and the anesthesiologist: A survey | Anesthesiologists were surveyed to determine their experience and opinions regarding 'Do Not Resuscitate' (DNR) orders in the perioperative period. Four hundred fifteen questionnaires were mailed and 193 (47%) were returned. One hundred sixty-one (87%) of 186 respondents had been requested to provide (and more than two-thirds had provided) monitored anesthesia care, regional anesthesia, or general anesthesia to a patient with a DNR order. Almost two- thirds of the respondents assume DNR suspension in the perioperative period and only half discuss this assumption with the patient/guardian. Less than 50% of respondents would require DNR suspension for a palliative procedure contrasted with >60% for an elective procedure. After agreeing to a patient's decision to retain their DNR status, >67%, >58%, <49%, and <33% would utilize positive pressure ventilation with a mask, vasoactive drugs, endotracheal intubation, or defibrillation, respectively, in the event of a cardiopulmonary arrest in the perioperative period. These findings suggest much ambiguity regarding DNR orders in the perioperative period. Further discussion among physicians and patients is warranted. |
Achieving Greater Health Equity: An Opportunity for Anesthesiology | Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity. Copyright © 2022 International Anesthesia Research Society. |
Anesthesiology critical care medicine fellowship training | Anesthesiology critical care medicine (ACCM) fellowship training was accredited in 1989, and a small number of graduating anesthesiology residents pursue this additional training. Considering the flexible program guidelines of the American Board of Anesthesiology (ABA), we hypothesized that ACCM fellowship training programs varied significantly among the 42 institutions accredited to offer this program. This study of ACCM fellowship programs used a six-part, 57-item questionnaire completed by 36 program directors to describe six aspects of the program: institution size, program director, attending staff, fellowship applicants, curriculum, and the role of the American Society of Critical Care Anesthesiologists (ASCCA). Ninety-four percent of ACCM fellowships are in facilities with more than 400 beds; 81% of these institutions have more than 20 intensive care unit (ICU) beds as the basis for fellowship teaching. Eighty-three percent of ACCM program directors have practiced critical care for more than 5 yr. All programs had more than one attending physician, with the majority having a multidisciplinary attending staff. During two academic years (1990-1992), 12 (33%) of 36 programs did not have a fellow, resulting in an average of less than one fellow for each program. ACCM fellow involvement in patient care was characterized as 'primary' in medical and pediatric ICUs and 'cooperative' in surgical ICUs. Fellowship curricula had varied requirements for research, intraoperative anesthesia, and ICU procedures performed by the fellow. In general, program directors believe that salary and on-call responsibility are not important issues for applicants. Nineteen percent of program directors train ACCM fellows longer than the 12 mo required by the ABA and believe that ACCM training should be lengthened. |
Increasing the value of time reduces the lost economic opportunity of caring for surgeries of longer-than-average times | Anesthesiology groups that provide care for surgical procedures of longer-than-average duration are economically disadvantaged by both increased staffing costs and reduced revenue. Under the current billing system, anesthesia time is valued the same regardless of the total case duration. In this study, we evaluated the effect on four academic anesthesiology departments of two hypothetical scenarios by changing the anesthesia care billing system to make more valuable either 1) all time units or 2) just second-hour and subsequent time units. From the four departments, case-specific data (anesthesia Current Procedural Terminology code and minutes of care) were collected for all anesthesia cases billed for 1 yr. Basic units were determined from the American Society of Anesthesiologists (ASA) relative value guide. The average time for each case was defined as the average anesthesia time for that specific Current Procedural Terminology code, as published by the Center for Medicare and Medicaid Services (CMS). The actual total ASA units per hour (tASA/h) was determined by adding all the basic units and time units and dividing by hours of anesthesia care (minutes of anesthesia care divided by 60). We then calculated a hypothetical CMS tASA/h for each group by substituting the CMS average time for each anesthesia procedure time for the actual time reported by each group and using 15-min time units. For each group, the Actual (Act) tASA/h and CMS tASA/h were calculated for both options-changing the interval for all time units or only for second and subsequent hours. Intervals were 15,12,10,7, 6, or 5 min. When changing all time units, Act tASA/h and CMS tASA/h were never equal for all groups. The two productivity measures became approximately equal if only time units after the first hour were changed to 6- to 7-min intervals. When changes were applied only to the Act tASA/h (with CMS tASA/h remaining at 15-min intervals), at the 12-min interval either option resulted in a similar or higher Act tASA/h than CMS tASA/h. Both options increase the value of time and help compensate for the lost economic opportunity of longer-than-average surgical durations. |
Outpatient evaluation: a new role for the anesthesiologist | Anesthesiology, although still a relatively young specialty, is expanding beyond the operating room. The author reports material savings in many areas through presurgical interviews in the outpatient department by anesthesiologists. |
Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing with Cost Savings and Reduced Greenhouse Gas Emissions | Anesthetic agents are known greenhouse gases with hundreds to thousands of times the global warming impact compared with carbon dioxide. We sought to mitigate the negative environmental and financial impacts of our practice in the perioperative setting through multidisciplinary staff engagement and provider education on flow rate reduction and volatile agent choice. These efforts led to a 64% per case reduction in carbon dioxide equivalent emissions (163 kg in Fiscal Year 2012, compared with 58 kg in Fiscal Year 2015), as well as a cost savings estimate of $25,000 per month. © 2019 International Anesthesia Research Society. |
Preoperative pregnancy testing in adolescents | Anesthetics and other drugs used during the perioperative period may have teratogenic or abortive effects. The pregnancy status of surgical patients is often unknown. This investigation examined retrospectively the results of 2 yr of mandatory pregnancy testing in 412 adolescent surgical patients. The overall incidence of positive tests was 1.2%. Five of 207 patients aged 15 yr and older tested positive, for an incidence of 2.4% in that group. None of the 205 patients under the age of 15 yr had a positive pregnancy test. We conclude that mandatory pregnancy testing is advisable in adolescent surgical patients aged 15 yr and older. |
Multicentre randomised trials in anaesthesia: an analysis using Bayesian metrics | Are the results of randomised trials reliable and are p values and confidence intervals the best way of quantifying efficacy? Low power is common in medical research, which reduces the probability of obtaining a ‘significant result’ and declaring the intervention had an effect. Metrics derived from Bayesian methods may provide an insight into trial data unavailable from p values and confidence intervals. We did a structured review of multicentre trials in anaesthesia that were published in the New England Journal of Medicine, The Lancet, Journal of the American Medical Association, British Journal of Anaesthesia and Anesthesiology between February 2011 and November 2021. We documented whether trials declared a non-zero effect by an intervention on the primary outcome. We documented the expected and observed effect sizes. We calculated a Bayes factor from the published trial data indicating the probability of the data under the null hypothesis of zero effect relative to the alternative hypothesis of a non-zero effect. We used the Bayes factor to calculate the post-test probability of zero effect for the intervention (having assumed 50% belief in zero effect before the trial). We contacted all authors to estimate the costs of running the trials. The median (IQR [range]) hypothesised and observed absolute effect sizes were 7% (3–13% [0–25%]) vs. 2% (1–7% [0–24%]), respectively. Non-zero effects were declared for 12/56 outcomes (21%). The Bayes factor favouring a zero effect relative to a non-zero effect for these 12 trials was 0.000001–1.9, with post-test zero effect probabilities for the intervention of 0.0001–65%. The other 44 trials did not declare non-zero effects, with Bayes factors favouring zero effect of 1–688, and post-test probabilities of zero effect of 53–99%. The median (IQR [range]) study costs reported by 20 corresponding authors in US$ were $1,425,669 ($514,766–$2,526,807 [$120,758–$24,763,921]). We think that inadequate power and mortality as an outcome are why few trials declared non-zero effects. Bayes factors and post-test probabilities provide a useful insight into trial results, particularly when p values approximate the significance threshold. © 2022 Association of Anaesthetists. |
Science Without Conscience Is but the Ruin of the Soul: The Ethics of Big Data and Artificial Intelligence in Perioperative Medicine | Artificial intelligence-driven anesthesiology and perioperative care may just be around the corner. However, its promises of improved safety and patient outcomes can only become a reality if we take the time to examine its technical, ethical, and moral implications. The aim of perioperative medicine is to diagnose, treat, and prevent disease. As we introduce new interventions or devices, we must take care to do so with a conscience, keeping patient care as the main objective, and understanding that humanism is a core component of our practice. In our article, we outline key principles of artificial intelligence for the perioperative physician and explore limitations and ethical challenges in the field. © 2020 International Anesthesia Research Society. |
A national survey (NAP5-Ireland baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in Ireland | As part of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland concerning accidental awareness during general anaesthesia, we issued a questionnaire to every consultant anaesthetist in each of 46 public hospitals in Ireland, represented by 41 local co-ordinators. The survey ascertained the number of new cases of accidental awareness becoming known to them for patients under their care or supervision for a calendar year, as well as their career experience. Consultants from all hospitals responded, with an individual response rate of 87% (299 anaesthetists). There were eight new cases of accidental awareness that became known to consultants in 2011; an estimated incidence of 1:23 366. Two out of the eight cases (25%) occurred at or after induction of anaesthesia, but before surgery; four cases (50%) occurred during surgery; and two cases (25%) occurred after surgery was complete, but before full emergence. Four cases were associated with pain or distress (50%), one after an experience at induction and three after experiences during surgery. There were no formal complaints or legal actions that arose in 2011 related to awareness. Depth of anaesthesia monitoring was reported to be available in 33 (80%) departments, and was used by 184 consultants (62%), 18 (6%) routinely. None of the 46 hospitals had a policy to prevent or manage awareness. Similar to the results of a larger survey in the UK, the disparity between the incidence of awareness as known to anaesthetists and that reported in trials warrants explanation. Compared with UK practice, there appears to be greater use of depth of anaesthesia monitoring in Ireland, although this is still infrequent. © 2014 The Association of Anaesthetists of Great Britain and Ireland. |
A national survey of anaesthetists (NAP5 Baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in the UK | As part of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland concerning accidental awareness during general anaesthesia, we issued a questionnaire to every consultant and staff and associate specialist anaesthetist in the UK. The survey was designed to ascertain the number of new cases of accidental awareness that became known to them, for patients under their direct or supervised care, for a calendar year, and also to estimate how many cases they had experienced during their careers. The survey also asked about use of monitoring designed to measure the depth of anaesthesia. All local co-ordinators responsible for each of 329 hospitals (organised into 265 'centres') in the UK responded, as did 7125 anaesthetists (82%). There were 153 new cases of accidental awareness notified to respondents in 2011, an estimated incidence of 1:15 414, lower than the 1-2:1000 previously reported in prospective clinical trials. Almost half the cases (72, 47%) occurred at or after induction of anaesthesia but before surgery, with 46 (30%) occurring during surgery and 35 (23%) after surgery before full recovery. Awareness during surgery appeared to lead more frequently to pain or distress than at induction and emergence (62% vs 28% and 23%, respectively). Depth of anaesthesia monitors were available in 164 centres (62%), but routinely used by only 132 (1.8%) of anaesthetists. The disparity between the incidence of awareness as notified to anaesthetists and that reported in trials warrants further examination and explanation. © 2013 The Authors Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland. |
100 Years of Pediatric Anesthesia With Anesthesia & Analgesia: Growing Together | As the practice of pediatric anesthesiology grew in the early 20th century, Anesthesia & Analgesia (A&A) became the most important practical resource of pediatric fundamentals for general anesthesiologists. With continued growth in the mid-20th century, focus then shifted to complex cases performed by dedicated pediatric anesthesiologists. To this day, A&A continues to serve as a crucial forum for our subspecialty as it matures. The International Anesthesia Research Society (IARS) also remains pivotal in addressing the crucial questions of modern practice, such as the recent founding of the SmartTots initiative to investigate the potential neurotoxicity of anesthetics in children. While A&A celebrates 100 years of publication, we reflect upon pediatric anesthesiology's evolution and the impact of the IARS and A&A on pediatric anesthesiology's scholarship, clinical practice, and professionalization. © 2022 Lippincott Williams and Wilkins. All rights reserved. |
Teaching anesthesia motor skills by review of videotaped performances | As with various areas of training, from sports to surgery, anesthesia motor skills are being taught by films and videotapes. Group comparisons and critiques stimulate interest and enthusiastic acceptance by trainees. |
Assessing the learning needs of college tutors in anaesthesia: Proposals for an introductory learning package | At present there is no nationwide formal training course at which college tutors in anaesthesia can develop the specific skills required to perform their important role effectively. The purpose of this study was to ascertain whether there is a need for an introductory learning package for college tutors and if so, what learning needs ought to be addressed in such a package. A needs assessment was performed involving the use of individual interviews and the administration of two sequential questionnaires. The questionnaire was completed by 208 college tutors, a return rate of 83%. Most college tutors (93%) said they had had no formal training to perform their role and 94% felt there was a need for an introductory course for college tutors in anaesthesia. Of those, 77% said they would be interested in taking such a course. The study identified a number of learning needs. |
Anesthesia and World War II: When the Battlefield Becomes a Research Field - A Bibliometric Analysis of the Influence of World War II on the Development of Anesthesiology | At the outbreak of World War II (WWII), anesthesiology was struggling to establish itself as a medical specialty. The battlefield abruptly exposed this young specialty to the formidable challenge of mass casualties, with an urgent need to provide proper fluid resuscitation, airway management, mechanical ventilation, and analgesia to thousands. But while Europe was suffering under the Nazi boot, anesthesia was preparing to rise to the challenge posed by the impending war. While war brings death and destruction, it also opens the way to medical advances. The aim of this study is to measure the evolution of anesthesia owing to WWII. We conducted a retrospective observational bibliometric study involving a quantitative and statistical analysis of publications. The following 7 journals were selected to cover European and North American anesthesia-related publications: Anesthesia & Analgesia, the British Journal of Anaesthesia, Anesthesiology, Schmerz-Narkose-Anaesthesie, Surgery, La Presse Médicale, and The Military Surgeon (later Military Medicine). Attention was focused on journal volumes published between 1920 and 1965. After reviewing the literature, we selected 12 keywords representing important advances in anesthesiology since 1920: "anesthesia," "balanced anesthesia," "barbiturates," "d-tubocurarine," "endotracheal intubation," "ether," "lidocaine," "morphine," "spinal anesthesia," "thiopental," "transfusion," and "trichloroethylene." Titles of original articles from all selected journals editions between 1920 and 1965 were screened for the occurrence of 1 of the 12 keywords. A total of 26,132 original article titles were screened for the occurrence of the keywords. A total of 1815 keywords were found. Whereas Anesthesia & Analgesia had the highest keyword occurrence (493 citations), Schmerz-Narkose-Anaesthesie had the lowest (38 citations). The number of publications of the 12 keywords was significantly higher in the postwar than in the prewar period (65% and 35%, respectively; P <.001). Not surprisingly, the anesthesiology journals have a higher occurrence of keywords than those journals covering other specialties. The overall occurrence of keywords also showed peaks during other major conflicts, namely the Spanish Civil War (1936-1939), the Korean War (1950-1953), and the Vietnam War (1955-1975). For the first time, this study demonstrates statistically the impact of WWII on the progress of anesthesiology. It also offers an objective record of the chronology of the major advances in anesthesiology before and after the conflict. While the war arguably helped to enhance anesthesiology as a specialty, in return anesthesiology helped to heal the wounds of war. © 2022 Lippincott Williams and Wilkins. All rights reserved. |
Anaesthetists' attitudes to parental presence at induction of general anaesthesia in children | Attitudes of anaesthetists of various grades working in different types of hospital in England and Wales, to parental presence in the anaesthetic room during induction of anaesthesia in children were assessed by means of a postal questionnaire. Of the 300 questionnaires sent out, 244 (82%) were completed. The majority of anaesthetists were in favour of parental presence in the anaesthetic room for induction of anaesthesia in children over the age of 1 year undergoing routine day case surgery. A small but significant number expressed reservations about some aspects of parental presence. The grade of anaesthetist and type of hospital did not appear to influence the response. Copyright © 1993, Wiley Blackwell. All rights reserved |
Availability of anesthesia equipment in Chinese hospitals: Is the safety of anesthesia patient care assured? | Availability of physiologic monitoring equipment to ensure the safe administration of anesthesia is an expected standard in many parts of the world. Many hospitals in China may not have an adequate quantity and variety of anesthesia delivery and patient monitoring equipment to assure safe administration of anesthesia patient care. We present some typical cases of hospitals of different sizes and located in regions with different economic levels; our data demonstrate that there is a lack of available anesthesia administration and patient monitoring equipment in small hospitals and hospitals in economically underdeveloped regions. Copyright © 2012 International Anesthesia Research Society. |
Surgicric 2: A comparative bench study with two established emergency cricothyroidotomy techniques in a porcine model | Background 'Can't Intubate, Can't Oxygenate' is a rare but life threatening event. Anaesthetists must be trained and have appropriate equipment available for this. The ideal equipment is a topic of ongoing debate. To date cricothyroidotomy training for anaesthetists has concentrated on cannula techniques. However cases reported to the NAP4 audit illustrated that they were associated with a high failure rate. A recent editorial by Kristensen and colleagues suggested all anaesthetists must master a surgical technique. The surgical technique for cricothyroidotomy has been endorsed as the primary technique by the recent Difficult Airway Society 2015 guidelines. Methods We conducted a bench study comparing the updated Surgicric 2 device with a scalpel-bougie-tube surgical technique, and the Melker seldinger technique, using a porcine model. Twenty six senior anaesthetists (ST5+) participated. The primary outcome was insertion time. Secondary outcomes included success rate, ease of use, device preference and tracheal trauma. Results There was a significant difference (P<0.001) in the overall comparisons of the insertion times. The surgical technique had the fastest median time of 62 s. The surgical and Surgicric techniques were significantly faster to perform than the Melker (both P<0.001). The surgical technique had a success rate of 85% at first attempt, and 100% within two attempts, whereas the others had failed attempts. The surgical technique was ranked first by 50% participants and had the lowest grade of posterior tracheal wall trauma, significantly less than the Surgicric 2 (P=0.002). Conclusions This study supports training in and the use of surgical cricothyroidotomy by anaesthetists. © 2016 The Author 2016. |
Teicoplanin allergy - An emerging problem in the anaesthetic allergy clinic | Background Anaphylaxis to teicoplanin appears to be extremely rare, with only one confirmed case report worldwide. Two anaesthetic allergy clinics in the UK have received a number of suspected cases referred for investigation, and we present here the first case series of teicoplanin allergy. Methods We investigated 20 cases of suspected teicoplanin allergy, identified from the two clinics over a period of two years. We devised a set of five criteria to categorize the certainty of their diagnosis. These included: (1) reaction within 15 min of administration of teicoplanin, (2) 2 features of anaphylaxis present, (3) positive skin testing or challenge testing, (4) raised serum mast cell tryptase (MCT), (5) alternative diagnosis excluded. Based on these criteria we defined the likelihood of IgE-mediated allergy to teicoplanin as: definite-met all criteria; probable-met criteria 1.2 and 5, plus 3 or 4; uncertain-met criteria 1.2 and 5; excluded- any others. Results We identified 7 'definite', 7 'probable' and 2 'uncertain' cases of teicoplanin allergy. Four cases were excluded. Conclusions IgE-mediated anaphylaxis to teicoplanin appears to be more common than previously thought. This is true even if only definitive cases are considered. Investigation of teicoplanin allergy is hampered by the lack of standardized skin test concentrations. In some cases, there was a severe clinical reaction, but without any skin test evidence of histamine release. The mechanism of reaction in these cases is not known and requires further study. © 2015 The Author 2015. |
An instrument designed for faculty supervision evaluation by anesthesia residents and its psychometric properties | BACKGROUND AND OBJECTIVES:: We aimed 1) to develop a valid and reliable instrument for faculty supervision evaluation by anesthesia residents and 2) to disclose the sources of error in residents' ratings. METHODS:: A qualitative study involving residents and faculty identified constructs of supervisory ability, which were entered as items in a measurement instrument used by 19 residents to evaluate 39 instructors during a 6-mo period. The instrument was psychometrically tested under classical item and generalizability theories. A decision study, using the parameters of the generalizability (G) study, estimated the number of resident ratings needed to produce dependable measures of a single faculty. RESULTS:: Nine dimensions emerged from the qualitative study: planning perianesthesia care, providing feedback ("the instructor provides me timely, informal, non-threatening comments on my performance and shows me ways to improve"); being available ("the instructor is promptly available to help me solve problems with patients and procedures"); giving opportunities/fostering resident autonomy; stimulating patient-based learning; demonstrating professionalism; being present during the critical events; demonstrating interpersonal skills; being concerned about safety. Residents provided 970 evaluations. The instrument exhibited internal consistency (Cronbach's α = 0.93), content and face validities, and a single-factor structure. Generalizability and dependability coefficients were 0.93. Between-instructors differences accounted for 56% of score variance. Resident-instructor interactions accounted for 44% of score variance, indicating that scores were influenced by each resident's unique perceptions of instructors (halo effect). According to the results of the decision study, dependability of measures within the 75% to 95% range could be expected with 3 to 33 residents rating each faculty member, respectively. CONCLUSIONS:: The nine-item instrument produced valid and reliable measures of faculty supervision. However, a significant amount of halo effect biased such measures. G-studies may help identify the type and magnitude of rater biases affecting resident-generated faculty supervision evaluations, and can be useful for interpreting their results, especially if personnel decisions (e.g., tenure, promotion) rely on such measures. © 2008 International Anesthesia Research Society. |
Intraoperative arterial blood pressure lability is associated with improved 30 day survival | Background Arterial blood pressure lability, defined as rapid changes in arterial blood pressure, occurs commonly during anaesthesia. It is believed that hypertensive patients exhibit more lability during surgery and that lability is associated with poorer outcomes. Neither association has been rigorously tested. We hypothesized that hypertensive patients have more blood pressure lability and that increased lability is associated with increased 30 day mortality. Methods This was a retrospective single-centre study of surgical patients from July 2008 to December 2012. Intraoperative data were extracted from the electronic anaesthesia record. Lability was calculated as the modulus of the percentage change in mean arterial pressure between consecutive 5 min intervals. The number of episodes of lability >10% was tabulated. Multivariate logistic regression was performed to determine the association between lability and 30 day mortality using derivation and validation cohorts. Results Inclusion criteria were met by 52 919 subjects. Of the derivation cohort, 53% of subjects were hypertensive and 42% used an antihypertensive medication. The median number of episodes of lability >10% was 9 (interquartile range 5-14) per patient. Hypertensive subjects demonstrated more lability than normotensive patients, 10 (5-15) compared with 8 (5-12), P<0.0001. In subjects taking no antihypertensive medication, lability >10% was associated with decreased 30 day mortality, odds ratio (OR) per episode 0.95 [95% confidence interval (CI) 0.92-0.97], P<0.0001. This result was confirmed in the validation cohort, OR 0.96 (95% CI 0.93-0.99), P=0.01, and in hypertensive patients taking no antihypertensive medication, OR 0.96 (95% CI 0.93-0.99), P=0.002. Use of any antihypertensive medication class reduced this effect. Conclusions Intraoperative arterial blood pressure lability occurs more often in hypertensive patients. Contrary to common belief, increased lability was associated with decreased 30 day mortality. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. |
Using educational video to enhance protocol adherence for medical procedures | Background Better education of clinicians is expected to enhance patient safety. An important component of education is adherence to standard protocols, which are mainly available in written form. Believing in the potential power of videos, we hypothesized that the introduction of an educational video, based on an institutional standard protocol, would foster adherence to the protocol. Methods We conducted a prospective intervention study of 425 anaesthesia procedures and teams (202 pre-video and 223 post-video) involving 1091 team members (516 pre-video and 575 post-video) in seven individual operating areas (with a total of 30 operating rooms) in a university hospital. Failure of adherence to safety-critical tasks during rapid sequence anaesthesia inductions was assessed during systematic on-site observations pre- and post-introduction of an educational video demonstrating evidence-based and best practice guidelines. Results The odds for failure of adherence to safety-critical tasks between the pre- and post-intervention period were reduced, odds ratio 0.34 (95% confidence interval 0.27-0.42, P<0.001). The risk for failure of adherence was reduced significantly for eight of the 14 safety-critical tasks (all P<0.001). Conclusions This study provides empirical evidence for the effectiveness of an educational video to enhance adherence to a standard protocol during complex medical procedures. The introduction of a video can reduce failure of adherence to safety-critical tasks and contribute to patient safety. We recommend the introduction of videos to improve protocol adherence. © 2016 The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
SmartPilot ® view-guided anaesthesia improves postoperative outcomes in hip fracture surgery: A randomized blinded controlled study | Background Both under-dosage and over-dosage of general anaesthetics can harm frail patients. We hypothesised that computer-Assisted anaesthesia using pharmacokinetic/pharmacodynamic models guided by SmartPilot ® View (SPV) software could optimise depth of anaesthesia and improve outcomes in patients undergoing hip fracture surgery. Methods This prospective, randomized, single-centre, blinded trial included patients undergoing hip fracture surgery under general anaesthesia. In the intervention group, anaesthesia was guided using SPV with predefined targets. In the control group, anaesthesia was delivered by usual practice using the same agents (propofol, sufentanil and desflurane). The primary endpoint was the time spent in the "appropriate anaesthesia zone" defined as bispectral index (BIS) (blinded to the anaesthetist during surgery) of 45-60 and systolic arterial pressure of 80-140 mm Hg. Postoperative complications were recorded for one month in a blinded manner. Results Of 100 subjects randomised, 97 were analysed (n=47 in SPV and 50 in control group). Anaesthetic drug consumption was reduced in the SPV group (for propofol and desflurane). Intraoperative duration of low BIS (<45) was similar, but cumulative time of low systolic arterial pressure (<80 mm Hg) was significantly shorter in the SPV group (median (Q1-Q3); 3 (0-40) vs 5 (0-116) min, P=0.013). SPV subjects experienced fewer moderate or major postoperative complications at 30-days (8 (17)% vs 18 (36)%, P=0.035) and shorter length of hospitalisation (8 (2-20) vs 8 (2-60) days, P=0.017). Conclusions SmartPilot ® View-guided anaesthesia reduces intraoperative hypotension duration, occurrence of postoperative complications and length of stay in hip fracture surgery patients. Clinical trial registration NCT 02556658. © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
Use of a hand-held digital cognitive aid in simulated crises: The MAX randomized controlled trial | Background Cognitive AIDS improve the technical performance of individuals and teams dealing with high-stakes crises. Hand-held electronic cognitive AIDS have rarely been investigated. A randomized controlled trial was conducted to investigate the effects of a smartphone application, named MAX (for Medical Assistance eXpert), on the technical and non-Technical performance of anaesthesia residents dealing with simulated crises. Methods This single-centre randomized, controlled, unblinded trial was conducted in the simulation centre at Lyon, France. Participants were anaesthesia residents with >1 yr of clinical experience. Each participant had to deal with two different simulated crises with and without the help of a digital cognitive aid. The primary outcome was technical performance, evaluated as adherence to guidelines. Two independent observers remotely assessed performance on video recordings. Results Fifty-Two residents were included between July 2015 and February 2016. Six participants were excluded for technical issues; 46 participants were confronted with a total of 92 high-fidelity simulation scenarios (46 with MAX and 46 without). Mean (sd) age was 27 (1.8) yr and clinical experience 3.2 (1.0) yr. Inter-rater agreement was 0.89 (95% confidence interval 0.85-0.92). Mean technical scores were higher when residents used MAX [82 (11.9) vs 59 (10.8)%; P<0.001]. Conclusion The use of a hand-held cognitive aid was associated with better technical performance of residents dealing with simulated crises. These findings could help digital cognitive AIDS to find their way into daily medical practice and improve the quality of health care when dealing with high-stakes crises. Clinical trial registration NCT02678819. © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.All rights reserved. |
Evaluating the ORSIM® simulator for assessment of anaesthetists' skills in flexible bronchoscopy: Aspects of validity and reliability | Background Developing expertise in flexible bronchoscopy is limited by inadequate opportunities to train on difficult airways. The new ORSIM bronchoscopy simulator aims to address this by creating virtual patients with difficult airways. This study aims to provide evidence on the validity and reliability of the ORSIM for assessment of subjects on both normal and abnormal airway simulations. Methods Novice, trainee, and expert subjects performed seven simulations of varying difficulty and scored the perceived difficulty for each. Time to completion was measured. Three blinded raters independently scored videos of each subject's performance. We measured inter-rater agreement and the difference in raters' scores between subject groups. Results We recruited 28 study subjects, generating 196 videos for analysis. Expert subjects consistently completed the scenarios faster than novices. Overall performance scores showed significant differences between subject groups (P<0.0001). Inter-rater reliability of scores was >0.8. Conclusions Our results provide initial evidence on the validity and reliability of the ORSIM bronchoscopy simulator, supporting its potential value in training and assessment. © 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
Sufentanil administration guided by surgical pleth index vs standard practice during sevoflurane anaesthesia: A randomized controlled pilot study | Background Evaluation of analgesia and antinociception during anaesthesia is still a challenging issue and routinely based on indirect and non-specific signs such as movement, tachycardia, or lacrimation. Recently, the surgical pleth index (SPI) derived by finger plethysmography was introduced to detect nociceptive stimulation during anaesthesia. While SPI guidance reduced the number of unwanted events during total i.v. anaesthesia (TIVA), the impact of SPI during volatile-based anaesthesia with intermittent opioid administration has not yet been elucidated. Methods Ninety-four patients were randomized into either SPI-guided analgesia or standard practice (Control). In both groups, anaesthesia was maintained with sevoflurane to keep bispectral index values between 40 and 60. In the SPI group, patients received a sufentanil bolus (10 Ig) whenever SPI value increased above 50, whereas in the control group, sufentanil was administered according to standard clinical practice. The number of unwanted somatic events, haemodynamics, sufentanil consumption, and recovery times were recorded. Results The incidence of intraoperative unwanted somatic events was comparable between the groups (P=0.89). No significant differences with respect to hypotensive or hypertensive events were found. The mean (95% confidence interval) sufentanil consumption was non-significantly (P=0.07) reduced in the SPI group, 0.64 (0.57-0.71) vs 0.78 (0.64-0.91) μg min a1. Recovery times were comparable between the groups. Conclusions Sufentanil administration guided by SPI during sevoflurane anaesthesia is clinically feasible. In contrast to TIVA, it did not improve anaesthesia conduct with respect to unwanted somatic events, haemodynamic stability, sufentanil consumption, emergence time, or post-anaesthesia care unit care. Therefore, we conclude that anaesthesia regimen has an impact on beneficial effects by SPI guidance. Clinical trial registration NCT01525537. (Registered at Clinicaltrials.gov.) © 2014 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
Simulation as a set-up for technical proficiency: Can a virtual warm-up improve live fibre-optic intubation? | Background Fibre-optic intubation (FOI) is an advanced technical skill, which anaesthesia residents must frequently perform under pressure. In surgical subspecialties, a virtual 'warm-up' has been used to prime a practitioner's skill set immediately before performance of challenging procedures. This study examined whether a virtual warm-up improved the performance of elective live patient FOI by anaesthesia residents. Methods Clinical anaesthesia yr 1 and 2 (CA1 and CA2) residents were recruited to perform elective asleep oral FOI. Residents either underwent a 5 min, guided warm-up (using a bronchoscopy simulator) immediately before live FOI on patients with predicted normal airways or performed live FOI on similar patients without the warm-up. Subjects were timed performing FOI (from scope passing teeth to viewing the carina) and were graded on a 45-point skill scale by attending anaesthetists. After a washout period, all subjects were resampled as members of the opposite cohort. Multivariate analysis was performed to control for variations in previous FOI experience of the residents. Results Thirty-three anaesthesia residents were recruited, of whom 22 were CA1 and 11 were CA2. Virtual warm-up conferred a 37% reduction in time for CA1s (mean 35.8 (sd 3.2) s vs. 57 (sd 3.2) s, P<0.0002) and a 26% decrease for CA2s (mean 23 (sd 1.7) s vs. 31 (sd 1.7) s, P=0.0118). Global skill score increased with warm-up by 4.8 points for CA1s (mean 32.8 (sd 1.2) vs. 37.6 (sd 1.2), P=0.0079) and 5.1 points for CA2s (37.7 (sd 1.1) vs. 42.8 (sd 1.1), P=0.0125). Crossover period and sequence did not show a statistically significant association with performance. Conclusions Virtual warm-up significantly improved performance by residents of FOI in live patients with normal airway anatomy, as measured both by speed and by a scaled evaluation of skills. © 2016 The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com. |
Team-based model for non-operating room airway management: Validation using a simulation-based study | Background Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. Methods Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). Results Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. Conclusions Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method. © 2016 The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
Tracheal intubation by trainees does not alter the incidence or duration of postoperative sore throat and hoarseness: A teaching hospital-based propensity score analysis | Background Postoperative throat complications, such as sore throat and hoarseness, are frequent complications of tracheal intubation. To assess whether severity of throat complications is related to the experience of physicians performing tracheal intubation, we compared the incidence and duration of postoperative sore throat and hoarseness and patient satisfaction between tracheal intubation performed by trainees and experienced consultant anaesthetists. Methods This is a retrospective review of an institutional registry containing records of 21 606 patients undergoing general anaesthesia and was conducted with ethics board approval. All tracheal intubations by trainees were performed under the supervision of consultant anaesthetists. To avoid channel bias, the propensity score analysis was used to generate a set of matched cases (intubations by trainees) and controls (intubations by anaesthetists), yielding 3465 (sore throat) and 3267 (hoarseness) matched patient pairs. The incidence and sustained rate of symptoms were compared as primary outcomes. We also compared patient satisfaction with perioperative care. Results After propensity score matching, there was no difference between tracheal intubation by trainees and tracheal intubation by consultant anaesthetists in the incidences of sore throat (32.9 vs 32.6%, P=0.84) or hoarseness (35.8 vs 35.2%, P=0.60). Odds ratios and 95% confidence intervals for tracheal intubation by trainees were 1.01 (0.91-1.12) for sore throat and 1.03 (0.93-1.14) for hoarseness. The rates of sustained sore throat and hoarseness over the course were low (P=0.85 and P=0.67, respectively). Hazard ratios and 95% confidence intervals for tracheal intubation by trainees were 0.99 (0.94-1.05) for sustained sore throat and 0.99 (0.93-1.05) for sustained hoarseness. Patient satisfaction did not differ between matched groups (P=0.66 and P=0.83). Conclusions Tracheal intubation by trainees under the supervision of consultant anaesthetists did not worsen the postoperative airway outcomes, such as sore throat and hoarseness. © 2015 The Author. |
Improving team information sharing with a structured call-out in anaesthetic emergencies: A randomized controlled trial | Background Sharing information with the team is critical in developing a shared mental model in an emergency, and fundamental to effective teamwork. We developed a structured call-out tool, encapsulated in the acronym 'SNAPPI': Stop; Notify; Assessment; Plan; Priorities; Invite ideas. We explored whether a video-based intervention could improve structured call-outs during simulated crises and if this would improve information sharing and medical management. Methods In a simulation-based randomized, blinded study, we evaluated the effect of the video-intervention teaching SNAPPI on scores for SNAPPI, information sharing, and medical management using baseline and follow-up crisis simulations. We assessed information sharing using a probe technique where nurses and technicians received unique, clinically relevant information probes before the simulation. Shared knowledge of probes was measured in a written, post-simulation test. We also scored sharing of diagnostic options with the team and medical management. Results Anaesthetists' scores for SNAPPI were significantly improved, as was the number of diagnostic options they shared. We found a non-significant trend to improve information-probe sharing and medical management in the intervention group, and across all simulations, a significant correlation between SNAPPI and information-probe sharing. Of note, only 27% of the clinically relevant information about the patient provided to the nurse and technician in the pre-simulation information probes was subsequently learnt by the anaesthetist. Conclusions We developed a structured communication tool, SNAPPI, to improve information sharing between anaesthetists and their team, taught it using a video-based intervention, and provide initial evidence to support its value for improving communication in a crisis. © 2014 The Author. |
Use of the NexfinTM device to detect acute arterial pressure variations during anaesthesia induction | Background Standard non-invasive arterial pressure (AP) measurements are discontinuous. By providing non-invasive beat-to-beat AP measurements, Nexfin™ might limit duration of intraoperative hypotension and hypertension. We assessed the ability of Nexfin™ to detect AP variations by comparing its trending ability with invasive AP monitoring. Methods Thirty-one subjects undergoing elective surgery under general anaesthesia were included. During induction, simultaneous pairs of AP measurements were collected every 5 s from the NexfinTM finger sensor and a homolateral radial artery catheter. Magnitude and time lags of AP variations from baseline to nadir and peak were calculated for both methods. Concordance analysis was performed by the Bland-Altman method (for comparison of repeated measures when appropriate). Results Nexfin™ detected 100% of AP changes with the median delays of 0 s (-13 to 7) and 0 s (-5 to 12) for nadir and peak, respectively. Bias [limits of agreement (LOA)] of systolic AP (SAP) variations was -0.5 mm Hg (-31.2 to 30.2) and -9.4 mm Hg (-31.3 to 12.6) from baseline to nadir and from baseline to peak, respectively. For 3479 analysed paired measurements, bias was -3.8 and -8.8 mm Hg for SAP and diastolic AP, with LOA of (-36.0 to 28.5) and (-29.8 to 12.3), respectively. Conclusions Nexfin™ detects AP variations accurately and can be a useful warning device during anaesthesia. However, it is not interchangeable with invasive monitoring, given the large LOA between the two measurements. © 2014 The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: Closing the safety gap in anaesthesia, intensive care and the emergency department | Background The 4th National Audit Project of the Royal College of Anaesthetists' and Difficult Airway Society (NAP4) made recommendations to improve reliability and safety of airway management in hospitals. This survey examines its impact. Methods A survey was sent to all UK National Health Service hospitals to examine changes in practice in response to NAP4. We performed a 'gap analysis' to determine whether NAP4 had reduced the 'safety gap' between actual and ideal practice. Results The response rate was 62% (192 of 307 hospitals), and 78% answered all questions. Most (97%) respondents reported changes in practice in response to NAP4 but these differed by specialty: 95% in anaesthesia; 80% in intensive care (ICU) and 59% in the emergency department (ED). Approximately 25% reported changes in organizational aspects of airway and human factors teaching. Practice changes led to a median closure of the 'safety gap' in anaesthesia of 39% (IQR 14-66%, range 11-83%), 59% in ICU (IQR 54-73%, range 31-81%) and 48% in ED (IQR 39-53%, range 35-53%). Conclusions Publication of NAP4 was followed by changes in practice in the majority of responding departments within two yr. Improvements included improved provision of difficult airway equipment and more widespread routine use of capnography. The biggest change occurred in ICU; the impact on training nursing and junior staff was modest and here, significant safety gaps remain. © 2016 The Author 2016. |
Can i leave the theatre? A key to more reliable workplace-based assessment | Background The value of workplace-based assessments such as the mini-clinical evaluation exercise (mini-CEX), and clinicians' confidence and engagement in the process, has been constrained by low reliability and limited capacity to identify underperforming trainees. We proposed that changing the way supervisors make judgements about trainees would improve score reliability and identification of underperformers. Anaesthetists regularly make decisions about the level of trainee independence with a case, based on how closely they need to supervise them. We therefore used this as the basis for a new scoring system. Methods We analysed 338 mini-CEXs where supervisors scored trainees using the conventional system, and also scored trainee independence, based on the need for direct, or more distant, supervision. As supervisory requirements depend on case difficulty, we then compared the actual trainee independence score and the expected trainee independence score obtained externally. Results Compared with the conventional scoring system used in previous studies, reliability was very substantially improved using a system based on a trainee's level of independence with a case. Reliability improved further when this score was corrected for case difficulty. Furthermore, the new scoring system overcame the previously identified problem of assessor leniency and identified a number of trainees performing below expectations. Conclusions Supervisors' judgements on trainee independence with a case, based on the need for direct or more distant supervision, can generate reliable scores of trainee ability without the need for an onerous number of assessments, identify trainees performing below expectations, and track trainee progress towards independent specialist practice. © 2014 The Author. |
Physical properties and functional alignment of soft-embalmed Thiel human cadaver when used as a simulator for ultrasound-guided regional anaesthesia | Background We evaluated the physical properties and functional alignment of the soft-embalmed Thiel cadaver as follows: by assessing tissue visibility; by measuring its acoustic, mechanical and elastic properties; by evaluating its durability in response to repeated injection; and by aligning images with humans. Methods In four soft-embalmed Thiel cadavers, we conducted three independent studies. We assessed the following factors: (i) soft tissue visibility in a single cadaver for 28 weeks after embalming; (ii) the displacement of tissues in response to 1 and 5 ml interscalene and femoral nerve blocks in a single cadaver; and (iii) the stiffness of nerves and perineural tissue in two cadavers. We aligned our findings with ultrasound images from three patients and one volunteer. Durability was qualified by assessing B-mode images from repetitive injections during supervised training. Results There was no difference in visibility of nerves between 2 and 28 weeks after embalming {geometric mean ratio 1.13 [95% confidence interval (CI): 0.75-1.68], P=1.0}. Mean tissue displacement was similar for cadaver femoral and interscalene blocks [geometric mean ratio 1.02 (95% CI: 0.59-1.78), P=0.86], and for 1 and 5 ml injection volumes [geometric mean ratio 0.84 (95% CI: 0.70-1.01), P=0.19]. Cadavers had higher intraneural than extraneural stiffness [Young's modulus; geometric mean ratio 3.05 (95% CI: 2.98-3.12), P<0.001] and minimal distortion of anatomy when conducting 934 left-sided interscalene blocks on the same cadaver throughout a 10 day period. Conclusions The soft-embalmed Thiel cadaver is a highly durable simulator that has excellent physical and functional properties that allow repeated injection for intensive ultrasound-guided regional anaesthesia training. © 2016 The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
Teaching lifesaving procedures: The impact of model fidelity on acquisition and transfer of cricothyrotomy skills to performance on cadavers | BACKGROUND: A decline in emergency surgical airway procedures in recent years has resulted in a decreased exposure to cricothyrotomy. Consequently, residents have very little experience or confidence in performing this intervention. In this study, we compared cricothyrotomy skills acquired on a simple inexpensive model to those learned on a high fidelity simulator using valid evaluation instruments and testing on cadavers. METHODS: First and second year anesthesiology residents were recruited. All subjects performed a videotaped pretest cricothyrotomy on cadavers. Subjects were randomized into two groups: The high fidelity group (n = 11) performed two cricothyrotomies on a full-scale simulator with an anatomically accurate larynx. The low fidelity group (n = 11) performed two cricothyrotomies on a low fidelity model constructed from corrugated tubing. Within 2 wk all subjects performed a posttest. Two blinded examiners graded and timed the performances using a checklist and a global rating scale. RESULTS: There was no significant difference in the change from pretest to posttest performance between the model groups as evaluated by all three measures (all: P = NS). Training on both models significantly improved performance on all measures (all: P < 0.001). Inter-rater reliability was strong (checklist: r = 0.90; global rating scale: r = 0.89). CONCLUSIONS: Our study shows that a simple inexpensive model achieved the same effect on objectively rated skill acquisition as did an expensive simulator. The skills acquired on both models transferred effectively to cadavers. Training for this life-saving skill does not need to be limited by simulator accessibility or cost. © 2008 International Anesthesia Research Society. |
Anesthesia Care Transitions and Risk of Postoperative Complications | BACKGROUND: A patient undergoing surgery may receive anesthesia care from several anesthesia providers. The safety of anesthesia care transitions has not been evaluated. Using unconditional and conditional multivariable logistic regression models, we tested whether the number of attending anesthesiologists involved in an operation was associated with postoperative complications. METHODS: In a cohort of patients undergoing elective colorectal surgical in an academic tertiary care center with a stable anesthesia care team model participating in the American College of Surgeons National Surgical Quality Improvement Program, using unconditional and conditional multivariable logistic regression models, we tested adjusted associations between numbers of attending anesthesiologists and occurrence of death or a major complication (acute renal failure, bleeding that required a transfusion of 4 units or more of red blood cells within 72 hours after surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma of 24 hours or longer, myocardial infarction, unplanned intubation, ventilator use for 48 hours or more, pneumonia, stroke, wound disruption, deep or organ-space surgical-site infection, superficial surgical-site infection, sepsis, septic shock, systemic inflammatory response syndrome). RESULTS: We identified 927 patients who underwent elective colectomy of comparable surgical intensity. In all, 71 (7.7%) patients had major nonfatal complications or death. One anesthesiologist provided care for 530 (57%) patients, 2 anesthesiologists for 287 (31%), and 3 or more for 110 (12%). The number of attending anesthesiologists was associated with increased odds of postoperative complication (unadjusted odds ratio [OR] = 1.52, 95% confidence interval [CI] 1.18-1.96, P = 0.0013; adjusted OR = 1.44, 95% CI 1.09-1.91, P = 0.0106). In sensitivity analyses, occurrence of a complication was significantly associated with the number of in-room providers, defined as anesthesia residents and nurse anesthetists (adjusted OR = 1.39, 95% CI 1.01-1.92, P = 0.0446) and for all anesthesia providers (adjusted OR = 1.58, 95%CI 1.20-2.08, P = 0.0012). Findings persisted across multiple, alternative adjustments, sensitivity analyses, and conditional logistic regression with matching on operative duration. CONCLUSIONS: In our study, care by additional attending anesthesiologists and in-room providers was independently associated with an increased odds of postoperative complications. These findings challenge the assumption that anesthesia transitions are care neutral and not contributory to surgical outcomes. © 2015 International Anesthesia Research Society. |
Determinants, associations, and psychometric properties of resident assessments of anesthesiologist operating room supervision | Background: A study by de Oliveira Filho et al. reported a validated set of 9 questions by which Brazilian anesthesia residents assessed faculty supervision in the operating room. The aim of this study was to use this question set to determine whether faculty operating room supervision scores were associated with residents' year of clinical anesthesia training and/or number of specific resident-faculty interactions. We also characterized associations between faculty operating room supervision scores and resident assessments of: (1) faculty supervision in settings other than operating rooms, (2) faculty clinical ability (family choice), and (3) faculty teaching effectiveness. Finally, we characterized the psychometric properties of the de Oliveira Filho etal. question set in an United States anesthesia residency program. Methods: All 39 residents in the Department of Anesthesia of the University of Iowa in their first (n = 14), second (n = 13), or third (n = 12) year of clinical anesthesia training evaluated the supervision provided by all anesthesia faculty who staffed in at least 1 of 3 clinical settings (operating room [n = 49], surgical intensive care unit [n = 10], pain clinic [n = 6]). For all resident-faculty pairs, departmental billing data were used to quantitate the number of resident-faculty interactions and the interval between the last interaction and the assessment. A generalizability study was performed to determine the minimum number of resident evaluations needed for high reliability and dependability. RESULTS: There were no significant associations between faculty mean operating room supervision scores and: (1) resident-faculty patient encounters (Kendall τb = 0.01; 95% confidence interval [CI], -0.02 to +0.04; P = 0.71), (2) resident-faculty days of interaction (τb = -0.01; 95% CI, -0.05 to +0.02; P = 0.46), and (3) days since last resident-faculty interaction (τb = 0.01; 95% CI, -0.02 to 0.05; P = 0.49). Supervision scores for the operating room and surgical intensive care unit were highly correlated (τb = 0.71; 95% CI, 0.63 to 0.78; P < 0.0001). Supervision scores for the operating room also were highly correlated with family choice scores (τb = 0.77; 95% CI, 0.70 to 0.84; P < 0.0001) and teaching scores (τb = 0.87; 95% CI, 0.82 to 0.92; P < 0.0001). High reliability and dependability (both G- and φ-coefficients > 0.80) occurred when individual faculty anesthesiologists received assessments from 15 or more different residents. CONCLUSION: Supervision scores provided by all residents can be given equal weight when calculating an individual faculty anesthesiologist's mean supervision score. Assessments of supervision, teaching, and quality of clinical care are highly correlated. When the de Oliveira Filho et al. question set is used in a United States anesthesia residency program, supervision scores are highly reliable and dependable when at least 15 residents assess each faculty. © 2013 International Anesthesia Research Society. |
Demographic Trends from 2005 to 2015 among Physicians with Accreditation Council for Graduate Medical Education-Accredited Anesthesiology Training and Active Medical Licenses | BACKGROUND: A temporary decrease in anesthesiology residency graduates that occurred around the turn of the millennium may have workforce implications. The aims of this study are to describe, between 2005 and 2015, (1) demographic changes in the workforce of physicians trained as anesthesiologists; (2) national and state densities of these physicians, as well as temporal changes in the densities; and (3) retention of medical licenses by mid- and later-career anesthesiologists. METHODS: Using records from the American Board of Anesthesiology and state medical and osteopathic boards, the numbers of licensed physicians aged 30-59 years who had completed Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training were calculated cross-sectionally for 2005, 2010, and 2015. Demographic trends were then described. Census data were used to calculate national and state densities of licensed physicians. Individual longitudinal data were used to describe retention of medical licenses among older physicians. RESULTS: The number of licensed physicians trained as anesthesiologists aged 30-59 years increased from 32,644 in 2005 to 36,543 in 2010 and 36,624 in 2015, representing a national density of 1.10, 1.18, and 1.14 per 10,000 population in those years, respectively. The density of anesthesiologists among states ranged from 0.37 to 3.10 per 10,000 population. The age distribution differed across the years. For example, anesthesiologists aged 40-49 years predominated in 2005 (47%), but by 2015, only 31% of anesthesiologists were aged 40-49 years. The proportion of female anesthesiologists grew from 22% in 2005, to 24% in 2010, and to 28% in 2015, particularly among early-career anesthesiologists. For anesthesiologists with licenses in 2005, the number who still had active licenses in 2015 decreased by 9.6% for those aged 45-49 years, by 14.1% for those aged 50-54 years, and by 19.7% for those aged 55-59 years. CONCLUSIONS: The temporary decrease in anesthesiology residency graduates around the turn of the 21st century decreased the proportion of anesthesiologists who were midcareer as of 2015. This may affect the future availability of senior leaders as well as the future overall workforce in the specialty as older anesthesiologists retire. National efforts to plan for workforce needs should recognize the geographical variability in the distribution of anesthesiologists. © 2022 American Society of Mechanical Engineers (ASME). All rights reserved. |
Determinants of a subject's decision to participate in clinical anesthesia research | BACKGROUND: A top priority for research studies is to ensure that potential participants receive adequate information to make a truly informed decision. Understanding patient experiences with the recruitment process may identify areas for improvement in the consent process. We examined which factors were associated with the decision to consent in a clinical research study. METHODS:: Patients scheduled for elective surgery were asked to complete a questionnaire about the consent process, immediately after being approached to participate in an anesthesia-related research study. Sociodemographic characteristics, preoperative levels of anxiety and depression, medical comorbidities, factors that may affect decision to participate in a research study, and study design features were collected. A multivariable logistic regression model was estimated to identify factors associated with providing consent. Performance of the prediction model was assessed using the receiver operating characteristic curve. Internal validity was assessed by a bootstrap analysis. RESULTS:: In all, 282 participants completed the questionnaire. Of those, 179 (63%) had consented to participate in research, and 103 (37%) had declined to participate. In the multivariable logistic regression model, the odds of providing consent were higher for males (odds ratio [OR] [95% confidence interval] = 2.49 [1.29-4.79]) and for patients with higher levels of patient comfort (OR = 1.84 [1.22-2.78]). The odds of providing consent were lower for protocols that require additional testing (OR = 0.15 [0.06-0.39]) and patients with higher levels of concern about blood sampling (OR = 0.70 [0.54-0.90]) or worry about study risks (OR = 0.72 [0.55-0.95]). Bootstrap analysis revealed a stable model with high internal validity. CONCLUSIONS:: The 2 strongest predictors of consent were male gender and comfort; predictors of refusal were protocol type that requires additional testing, greater concern about blood sampling and study risks, and lower overall patient comfort with the study. These patient and study characteristics may inform modification of the consent process for clinical research studies and facilitate the development of more accurate enrollment projections and strategies. Copyright © 2013 International Anesthesia Research Society. |
Discrepancies in medication entries between anesthetic and pharmacy records using electronic databases | BACKGROUND: Accurate recording of disposition of controlled substances is required by regulatory agencies. Linking anesthesia information management systems (AIMS) with medication dispensing systems may facilitate automated reconciliation of medication discrepancies. METHODS: In this retrospective investigation at a large academic hospital, we reviewed 11,603 cases (spanning an 8-mo period) comparing records of medications (i.e., narcotics, benzodiazepines, ketamine, and thiopental) recorded as removed from our automated medication dispensing system with medications recorded as administered in our AIMS. RESULTS: In 15% of cases, we found discrepancies between dispensed versus administered medications. Discrepancies occurred in both the AIMS (8% cases) and the medication dispensing system (10% cases). Although there were many different types of user errors, nearly 75% of them resulted from either an error in the amount of drug waste documented in the medication dispensing system (35%); or an error in documenting the medication in the AIMS (40%). CONCLUSIONS: A significant percentage of cases contained data entry errors in both the automated dispensing and AIMS. This error rate limits the current practicality of automating the necessary reconciliation. An electronic interface between an AIMS and a medication dispensing system could alert users of medication entry errors prior to finalizing a case, thus reducing the time (and cost) of reconciling discrepancies. © 2007 by International Anesthesia Research Society. |
Leaving More Than Your Fingerprint on the Intravenous Line: A Prospective Study on Propofol Anesthesia and Implications of Stopcock Contamination | BACKGROUND: Acute care handling of IV stopcocks during anesthesia and surgery may result in contaminated IV tubing sets. In the context of widespread propofol use, a nutrient-rich hypnotic drug, we hypothesized that propofol anesthesia increases bacterial contamination of IV stopcocks and may compromise safety of IV tubing sets when continued to be used after propofol anesthesia. METHODS: We conducted an in vitro trial by collecting IV tubing sets at the time of patient discharge from same-day ambulatory procedures performed with and without propofol anesthesia. These extension sets were then held at room temperature for 6, 24, or 48 hours. We cultured 50 samples at each interval for both cohorts. Quantitative cultures were done by aspirating the IV stopcock dead space and plating the aspirate on blood agar for colony count and speciation. RESULTS: Positive bacterial counts were recovered from 17.3% of propofol anesthesia stopcocks (26/150) and 18.6% of nonpropofol stopcocks (28/150). At 6 hours, the average bacterial counts from stopcocks with visible residual propofol was 44 colony forming units (CFU)/mL, compared with 41 CFU/mL with no visible residual propofol and 37 CFU/mL in nonpropofol anesthesia stopcocks. There was a 100-fold increase in bacterial number in contaminated stopcock dead spaces at 48 hours after propofol anesthesia. This difference remained significant when comparing positive counts from stopcocks with no visible residual propofol and nonpropofol anesthesia (P = 0.034). CONCLUSIONS: There is a covert incidence and degree of IV stopcock bacterial contamination during anesthesia which is aggravated by propofol anesthetic. Propofol anesthesia may increase risk for postoperative infection because of bacterial growth in IV stopcock dead spaces. © 2015 International Anesthesia Research Society. |
Digital Quality Improvement Approach Reduces the Need for Rescue Antiemetics in High-Risk Patients: A Comparative Effectiveness Study Using Interrupted Time Series and Propensity Score Matching Analysis | BACKGROUND: Affecting nearly 30% of all surgical patients, postoperative nausea and vomiting (PONV) can lead to patient dissatisfaction, prolonged recovery times, and unanticipated hospital admissions. There are well-established, evidence-based guidelines for the prevention of PONV; yet physicians inconsistently adhere to them. We hypothesized that an electronic medical record-based clinical decision support (CDS) approach that incorporates a new PONV pathway, education initiative, and personalized feedback reporting system can decrease the incidence of PONV. METHODS: Two years of data, from February 17, 2015 to February 16, 2016, was acquired from our customized University of California Los Angeles Anesthesiology perioperative data warehouse. We queried the entire subpopulation of surgical cases that received general anesthesia with volatile anesthetics, were ≥12 years of age, and spent time recovering in any of the postanesthesia care units (PACUs). We then defined PONV as the administration of an antiemetic medication during the aforementioned PACU recovery. Our CDS system incorporated additional PONV-specific questions to the preoperative evaluation form, creation of a real-time intraoperative pathway compliance indicator, initiation of preoperative PONV risk alerts, and individualized emailed reports sent weekly to clinical providers. The association between the intervention and PONV was assessed by comparing the slopes from the incidence of PONV pre/postintervention as well as comparing observed incidences in the postintervention period to what we expected if the preintervention slope would have continued using interrupted time series analysis regression models after matching the groups on PONV-specific risk factors. RESULTS: After executing the PONV risk-balancing algorithm, the final cohort contained 36,796 cases, down from the 40,831 that met inclusion criteria. The incidence of PONV before the intervention was estimated to be 19.1% (95% confidence interval [CI], 17.9%-20.2%) the week before the intervention. Directly after implementation of the CDS, the total incidence decreased to 16.9% (95% CI, 15.2%-18.5%; P =.007). Within the high-risk population, the decrease in the incidence of PONV went from 29.3% (95% CI, 27.6%-31.1%) to 23.5% (95% CI, 20.5%-26.5%; P <.001). There was no significant difference in the PONV incidence slopes over the entire pre/postintervention periods in the high-or low-risk groups, despite an abrupt decline in the PONV incidence for high-risk patients within the first month of the CDS implementation. CONCLUSIONS: We demonstrate an approach to reduce PONV using individualized emails and anesthesia-specific CDS tools integrated directly into a commercial electronic medical record. We found an associated decrease in the PACU administration of rescue antiemetics for our high-risk patient population. © 2019 Lippincott Williams and Wilkins. All rights reserved. |
High-fidelity simulation demonstrates the influence of anesthesiologists' age and years from residency on emergency cricothyroidotomy skills | BACKGROUND: Age-related deterioration in both cognitive function and the capacity to control fine motor movements has been demonstrated in numerous studies. However, this decline has not been described with respect to complex clinical anesthesia skills. Cricothyroidotomy is an example of a complex, lifesaving procedure that requires competency in the domains of both cognitive processing and fine motor control. Proficiency in this skill is vital to minimize time to reestablish oxygenation during a "cannot intubate, cannot ventilate" scenario. In this prospective, controlled, single-blinded study, we tested the hypothesis that age affects the learning and performance of emergency percutaneous cricothyroidotomy in a high-fidelity simulated cannot intubate/cannot ventilate scenario. METHODS: Thirty-six staff anesthesiologists (19 aged younger than 45 years and 17 older than 45 years) managed a high-fidelity cannot intubate/cannot ventilate scenario in a high-fidelity simulator before and after a 1-hour standardized training session. The group division cutoff age of 45 years was based on the median age of our sample subject population before enrollment. The scenarios required the insertion of an emergency percutaneous cricothyroidotomy. We compared cricothyroidotomy skills in the older group with those in the younger group using procedural time, 5-point task-specific checklist score, and global rating scale score. Correlation based on age, years from residency, weekly clinical hours worked, previous continuing medical education in airway management, and previous simulation experience was also performed. RESULTS: In both prestandardization and poststandardization, age and years from residency correlated with procedural time, checklist scores, and global rating scores. Baseline, prestandardization variables were all better for the younger group, with a mean age of 37 years, compared with the older group, with a mean age of 58 years. Procedural time was 100 (72-128) seconds versus 152 (120-261) seconds. Checklist scores were 7.0 (6.1-8.0) versus 6.0 (4.8-8.0). Global rating scale scores were 22.0 (17.8-29.8) versus 17.5 (10.4-20.6). After the 1-hour standardized training session, the younger group continued to perform better than the older group with procedural time of 75 (66-91) seconds versus 87 (78-123) seconds, checklist scores of 10.0 (9.1-10.0) versus 9.0 (8.0-10.0), and global rating scale scores of 35.0 (32.1-35.0) versus 32.0 (29.0-33.8). Regression analysis was performed on the poststandardization data. Both age and years from residency independently affected procedural time, checklist scores, and global rating scale scores (all P < 0.05). CONCLUSIONS: Baseline proficiency with simulated emergency cricothyroidotomy is associated with age and years from residency. Despite standardized training, operator age and years from residency were associated with decreased proficiency. Further research should explore the potential of using age and years from residency as factors for implementing periodic continuing medical education. Copyright © 2010 International Anesthesia Research Society. |
Airway management practice in adults with an unstable cervical spine: The harborview medical center experience | Background: Airway management in the presence of acute cervical spine injury (CSI) is challenging. Because it limits cervical spine motion during tracheal intubation and allows for neurological examination after the procedure, awake fiberoptic bronchoscopy (FOB) has traditionally been recommended. However, with the widespread availability of video laryngoscopy (VL), its use has declined dramatically. Our aim was to describe the frequency of airway management techniques used in patients with CSI at our level I trauma center and report the incidence of neurological injury attributable to airway management. Methods: Adults presenting to the operating room with CSI without a tracheal tube in situ between September 2010 and June 2017 were included. All patients were intubated in the presence of manual-in-line stabilization, a hard cervical collar, or surgical traction. Worsening neurological status was defined as new motor or sensory deficits on postoperative examination. Results: Two hundred fifty-two patients were included, of which 76 (30.2%) had preexisting neurological deficits. VL was the most frequent initial airway management technique used (49.6%). Asleep FOB was commonly performed alone (30.6%) or in conjunction with VL (13.5%). Awake FOB was rarely performed (2.3%), as was direct laryngoscopy (2.8%). All techniques were associated with high first-attempt success rates, and no cases of neurological injury attributable to airway management technique were identified. Conclusions: Among patients with acute CSI at a high-volume academic trauma center, VL was the most commonly used initial intubation technique. Awake FOB and direct laryngoscopy were performed infrequently. No cases of neurological deterioration secondary to airway management occurred with any method. Assuming care is taken to limit neck movement, providers should use the intubation technique with which they have the most comfort and skill. Copyright © 2018 International Anesthesia Research Society. |
Barriers to adverse event and error reporting in anesthesia | BACKGROUND: Although anesthesiologists are leaders in patient safety, there has been little research on factors affecting their reporting of adverse events and errors. First, we explored the attitudinal/emotional factors influencing reporting of an unspecified adverse event caused by error. Second, we used a between-groups study design to ask whether there are different perceived barriers to reporting a case of anaphylaxis caused by an error compared with anaphylaxis not caused by error. Finally, we examined strategies that anesthesiologists believe would facilitate reporting. Where possible, we contrasted our results with published findings from other physician groups. METHODS: An anonymous, self-administered, mailed survey was conducted of 629 consultant anesthesiologists and 263 anesthesiology residents on the mailing list of the Australian and New Zealand College of Anaesthetists in Victoria, Australia. Participants were randomized into "Error" versus "No Error" groups for the specified anaphylaxis adverse event section of the survey. Data were analyzed using nonparametric descriptive and inferential tests. RESULTS: There were 433 usable returned surveys, a usable response rate of 49%. First, there was only 1 of 13 statements on attitudinal/emotional factors that influenced reporting of an unspecified adverse event caused by error with which more anesthesiologists agreed/strongly agreed than disagreed/strongly disagreed: "Doctors who make errors are blamed by their colleagues." Second, when an error rather than no error had caused anaphylaxis, participants were more likely to agree/strongly agree that 6 statements about litigation, getting into trouble, disciplinary action, being blamed, unsupportive colleagues, and not wanting the case discussed in meetings, were perceived as reporting barriers. Finally, the most favored assistive strategies for reporting were generalized deidentified feedback about adverse event and error reports, role models such as senior colleagues who openly encourage reporting, and legislated protection of reports from legal discoverability. CONCLUSION: The majority of anesthesiologists in our study did not agree that the attitudinal/emotional barriers surveyed would influence reporting of an unspecified adverse event caused by error, with the exception of the barrier of being concerned about blame by colleagues. The probable influence of 6 perceived barriers to reporting a specified adverse event of anaphylaxis differed with the presence or absence of error. Anesthesiologists in our study supported assistive reporting strategies. There seem to be some differences between our results and previously published research for other physician groups. © 2012 International Anesthesia Research Society. |
A prospective study on anesthesia machine fault identification | BACKGROUND: Although few studies have been performed recently, several have suggested that some practitioners are not well able to detect preset anesthesia machine faults. METHODS: We performed a prospective study to determine whether there is a correlation between duration of anesthesia practice and the ability to detect anesthesia machine faults. Our hypothesis was that more anesthesia practice would increase the ability to detect anesthesia machine faults. This study was performed during a nationally attended anesthesia meeting held at a large academic medical center, where 87 anesthesia providers were observed performing anesthesia machine checkouts. The participants were asked to individually check out an anesthesia machine with an unspecified number of preset faults. The primary outcome measures were the written listing of faults detected during an anesthesia machine checkout. RESULTS: Of the five faults preset into the test machine, participants with 0-2 yr experience detected a mean of 3.7 faults, participants with 2-7 yr experience detected a mean of 3.6 faults, and participants with more than 7 yr experience detected a mean of 2.3 faults (P < 0.001). CONCLUSIONS: Our prospective study demonstrated that anesthesia machine checkout continues to be a problem. © 2007 by International Anesthesia Research Society. |
In the Aftermath: Attitudes of Anesthesiologists to Supportive Strategies after an Unexpected Intraoperative Patient Death | Background: Although most anesthesiologists will have 1 catastrophic perioperative event or more during their careers, there has been little research on their attitudes to assistive strategies after the event. There are wide-ranging emotional consequences for anesthesiologists involved in an unexpected intraoperative patient death, particularly if the anesthesiologist made an error. We used a between-groups survey study design to ask whether there are different attitudes to assistive strategies when a hypothetical patient death is caused by a drug error versus not caused by an error. First, we explored attitudes to generalized supportive strategies. Second, we examined our hypothesis that the presence of an error causing the hypothetical patient death would increase the perceived social stigma and self-stigma of help-seeking. Finally, we examined the strategies to assist help-seeking. Methods: An anonymous, mailed, self-administered survey was conducted with 1600 consultant anesthesiologists in Australia on the mailing list of the Australian and New Zealand College of Anaesthetists. The participants were randomized into "error" versus "no-error" groups for the hypothetical scenario of patient death due to anaphylaxis. Nonparametric, descriptive, parametric, and inferential tests were used for data analysis. P′ is used where P values were corrected for multiple comparisons. Results: There was a usable response rate of 48.9%. When an error had caused the hypothetical patient death, participants were more likely to agree with 4 of the 5 statements about support, including need for time off (P′ = 0.003), counseling (P′ < 0.001), a formal strategy for assistance (P′ < 0.001), and the anesthesiologist not performing further cases that day (P′ = 0.047). There were no differences between groups in perceived self-stigma (P = 0.98) or social stigma (P = 0.15) of seeking counseling, whether or not an error had caused the hypothetical patient death. Finally, when an error had caused the patient death, participants were more likely to agree with 2 of the 5 statements about help-seeking, including the need for a formal, hospital-based process that provides information on where to obtain professional counseling (P′ = 0.006) and the availability of after-hours counseling services (P′ = 0.035). Conclusions: Our participants were more likely to agree with assistive strategies such as not performing further work that day, time off, counseling, formal support strategies, and availability of after-hours counseling services, when the hypothetical patient death from anaphylaxis was due to an error. The perceived stigma toward attending counseling was not affected by the presence or absence of an error as the cause of the patient death, disproving our hypothesis. © 2016 International Anesthesia Research Society. |
A survey of obstetric perianesthesia care unit standards | BACKGROUND: Although obstetric patients are generally healthy, population risk is increasing because of increases in maternal age, obesity, and rates of multifetal pregnancies, and complications may occur in the immediate postoperative period. In this study, we sought to identify the current level of recovery care for obstetric patients in North American academic institutions after either general or major neuraxial anesthesia for cesarean delivery. METHODS: A survey of obstetric anesthesia recovery practices was delivered electronically to 135 obstetric anesthesiology directors of North American academic institutions from June to October, 2007. Surveys were completed electronically and anonymously. RESULTS: The response rate was 54.8% (74 of 135). Respondents reported a median of 2550 deliveries per year (interquartile range [IQR] 2000, 4000), with 30% delivered by cesarean delivery (IQR 25.5%, 32.5%) and 5% of cesarean deliveries performed under general anesthesia (IQR 4%, 8%). Most institutions recovered postcesarean patients in either an obstetric perianesthesia care unit or a labor, delivery, and recovery room. Recovery care was staffed solely by perinatal nurses, rather than dedicated perianesthesia care unit nurses in most institutions. Forty-five percent (28 of 62) of institutions had no specific postanesthesia recovery training for nursing staff providing postcesarean care for patients recovering from neuraxial or general anesthesia. Forty-three percent (29 of 67) of respondents rated the recovery care provided to cesarean delivery patients as lower quality than care given to general surgical patients. Respondents who relied solely on perinatal nurses to provide postanesthesia care were most likely to perceive that postanesthetic care for cesarean delivery was of lower quality than that given to general surgery patients (P = 0.008). CONCLUSIONS: Guidelines put forth by the American Society of Anesthesiologists Task Force on Postanesthetic Care and the American Society of PeriAnesthesia Nurses apply to all postoperative patients regardless of their recovery locations. Results from this survey suggest that the level of care provided for postanesthesia recovery from cesarean delivery in North American academic institutions may not meet these guidelines. © 2009 International Anesthesia Research Society. |
Growth of nonoperating room anesthesia care in the United States: A contemporary trends analysis | Background: Although previous publications suggest an increasing demand and volume of nonoperating room anesthesia (NORA) cases in the United States, there is little factual information on either volume or characteristics of NORA cases at a national level. Our goal was to assess the available data using the National Anesthesia Clinical Outcomes Registry (NACOR). Methods: We performed a retrospective analysis of NORA volume and case characteristics using NACOR data for the period 2010-2014. Operating room (OR) and NORA cases were assessed for patient, provider, procedural, and facility characteristics. NACOR may indicate general trends, since it COLLECTS data on about 25% of all anesthetics in the United States each year. We examined trends in the annual proportion of NORA cases, the annual mean age of patients, the annual proportions of American Society of Anesthesiologists physical status (ASA PS) III-V patients, and outpatient cases. Regression analyses for trends included facility type and urban/ rural location as covariables. The most frequently reported procedures were identified. Results: The proportion of NORA cases overall increased from 28.3% in 2010 to 35.9% in 2014 (P < .001). The mean age of NORA patients was 3.5 years higher compared with OR patients (95% CI 3.5-3.5, P < .001). The proportion of patients with ASA PS class III-V was higher in the NORA group compared with OR group, 37.6% and 33.0%, respectively (P < .001). The median (quartile 1, 3) duration of NORA cases was 40 (25, 70) minutes compared with 86 (52, 141) minutes for OR cases (P < .001). In comparison to OR cases, more NORA cases were started after normal working hours (9.9% vs 16.7%, P < .001). Colonoscopy was the most common procedure that required NORA. There was a significant upward trend in the mean age of NORA patients in the multivariable analysis-the estimated increase in mean age was 1.06 years of age per year of study period (slope 1.06; 95% confidence interval [CI] 1.05-1.07, P < .001). Multivariable analysis demonstrated that the mean age of NORA patients increased significantly faster compared with OR patients (difference in slopes 0.39; 95% CI 0.38-0.41, P < .001). The annual increase in ordinal ASA PS of NORA patients was small in magnitude, but statistically significant (odds ratio 1.03; 95% CI 1.03-1.03, P < .001). The proportion of outpatient NORA cases increased from 69.7% in 2010 to 73.3% in 2014 (P < .001). Conclusions: Our results demonstrate that NORA is a growing component of anesthesiology practice. The proportion of cases performed outside of the OR increased during the study period. In addition, we identified an upward trend in the age of patients receiving NORA care. NORA cases were different from OR cases in a number of aspects. Data collected by NACOR in the coming years will further characterize the trends identified in this study. Copyright © 2016 International Anesthesia Research Society. |
A survey of propofol abuse in academic anesthesia programs | BACKGROUND: Although propofol has not traditionally been considered a drug of abuse, subanesthetic doses may have an abuse potential. We used this survey to assess prevalence and outcome of propofol abuse in academic anesthesiology programs. METHODS: E-mail surveys were sent to the 126 academic anesthesiology training programs in the United States. RESULTS: The survey response rate was 100%. One or more incidents of propofol abuse or diversion in the past 10 yr were reported by 18% of departments. The observed incidence of propofol abuse was 10 per 10,000 anesthesia providers per decade, a fivefold increase from previous surveys of propofol abuse (P = 0.005). Of the 25 reported individuals abusing propofol, 7 died as a result of the propofol abuse (28%), 6 of whom were residents. There was no established system to control or monitor propofol as is done with opioids at 71% of programs. There was an association between lack of control of propofol (e.g., pharmacy accounting) at the time of abuse and incidence of abuse at the program (P = 0.048). CONCLUSIONS: Propofol abuse in academic anesthesiology likely has increased over the last 10 yr. Much of the mortality is in residents. Most programs have no pharmacy accounting or control of propofol stocks. This may be of concern, given that all programs reporting deaths from propofol abuse were centers in which there was no pharmacy accounting for the drug. © 2007 by International Anesthesia Research Society. |
National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals | Background: Although sedation during gastrointestinal endoscopy is widely used in China, the characteristics of sedation use, including regional distribution, personnel composition, equipment used, and drug selection, remain unclear. The present study aimed to provide insights into the current practice and regional distribution of sedation for gastrointestinal endoscopy in China. Methods: A questionnaire consisting of 19 items was distributed to directors of anaesthesiology departments and anaesthesiologists in charge of endoscopic sedation units in mainland China through WeChat. Results: The results from 2758 participating hospitals (36.7% of the total) showed that 9 808 182 gastroscopies (69.3%) and 4 353 950 colonoscopies (30.7%), with a gastroscopy-to-colonoscopy ratio of 2.3, were conducted from January to December 2016. Sedation was used with 4 696 648 gastroscopies (47.9%) and 2 148 316 colonoscopies (49.3%), for a ratio of 2.2. The most commonly used sedative was propofol (61.0% for gastroscopies and 60.4% for colonoscopies). Haemoglobin oxygen saturation (SpO2) was monitored in most patients (96.1%). Supplemental oxygen was routinely administered, but the availability of other equipment was variable (anaesthesia machine in 64.9%, physiological monitor in 84.4%, suction device in 72.3%, airway equipment in 75.5%, defibrillator in 32.7%, emergency kit in 57.0%, and difficult airway kit in 20.8% of centres responding). Conclusions: The sedation rate for gastrointestinal endoscopy is much lower in China than in the USA and in Europe. The most commonly used combination of sedatives was propofol plus an opioid (either fentanyl or sufentanil). Emergency support devices, such as difficult airway devices and defibrillators, were not usually available. © 2021 British Journal of Anaesthesia |
Occupational chronic sevoflurane exposure in the everyday reality of the anesthesia workplace | BACKGROUND: Although sevoflurane is one of the most commonly used volatile anesthetics in clinical practice, anesthesiologists are hardly aware of their individual occupational chronic sevoflurane exposure. Therefore, we studied sevoflurane concentrations in the anesthesiologists' breathing zones, depending on the kind of induction for general anesthesia, the used airway device, and the type of airflow system in the operating room. Furthermore, sevoflurane baselines and typical peaks during general anesthesia were determined. METHODS: Measurements were performed with the LumaSense Photoacoustic Gas Monitor. As we detected the gas monitor's cross-sensitivity reactions between sevoflurane and disinfectants, regression lines for customarily used disinfectants during surgery (Cutasept®, Octeniderm®) and their alcoholic components were initially analyzed. Hospital sevoflurane concentrations were thereafter measured during elective surgery in 119 patients. The amount of inhaled sevoflurane by anesthesiologists was estimated according to mVA = cVA × × t × ρVA aer. RESULTS: Induction of general anesthesia stopped after tracheal intubation with the patient's expiratory sevoflurane concentration of 1.5%. Thereby, inhalational inductions (INH) caused higher sevoflurane concentrations than IV inductions (mean [SD]: [ppm] INH 2.43 ±1.91 versus IV 0.62 ± 0.33, P < 0.001; mVA [mg] INH 1.95 ± 1.54 versus IV 0.30 ± 0.22, P < 0.001). The use of laryngeal mask airway (LMA™) led to generally higher sevoflurane concentrations in the anesthesiologists' breathing zones than tracheal tubes ([ppm] tube 0.37 ± 0.16 versus LMA™ 0.79 ± 0.53, P = 0.009; [ppm] tube 1.91 ± 0.91 versus LMA™ 2.91 ± 1.81, P = 0.057; mVA [mg] tube 1.47 ± 0.64 versus LMA™ 2.73 ± 1.81, P = 0.019). Sevoflurane concentrations were trended higher during surgery in operating rooms with turbulent flow (TF) air-conditioning systems compared with laminar flow (LF) air-conditioning systems ([ppm] TF 0.29 ± 0.12 versus LF 0.13 ± 0.06, P = 0.012; mVA [mg/h] TF 1.16 ± 0.50 versus LF 0.51 ± 0.25, P = 0.007). CONCLUSIONS: Anesthesiologists are chronically exposed to trace concentrations of sevoflurane during work. Inhalational inductions, LMA™, and TF air-conditioning systems in particular are associated with higher sevoflurane exposure. However, the amount of inhaled sevoflurane per day was lower than expected, perhaps because concentrations in previous measurements could be overestimated (10%-15%) because of the cross-sensitivity reaction. © 2015 International Anesthesia Research Society. |
Quality of supervision as an independent contributor to an anesthesiologist's individual clinical value | BACKGROUND: Although the clinical (operating room) production of individual anesthesiologists has been measured in multiple related ways (e.g., hours of direct clinical care), the same is not true for the quality of that effort. In our study, we consider the quality of clinical supervision provided by anesthesiologists who are supervising anesthesia residents and nurse anesthetists. The quality of the daily supervision can be measured reliably and validly using the scale developed by de Oliveira Filho et al. If clinical production and supervisory quality were not positively correlated, then it would be important for departments to measure the quality of clinical supervision because, essentially, the clinical value provided by an anesthesiologist would be correlated with, but not necessarily proportional to, their clinical hours. METHODS: Our department sends daily e-mail requests to anesthesia residents and nurse anesthetists to evaluate the supervision provided by each anesthesiologist with whom they worked the previous day in an operating room setting. We compared anesthesiologists' clinical activity (total operating room hours) and supervision scores obtained during the first (July 1, 2013 to December 31, 2013) and last (July 1, 2014 to December 31, 2014) of 3 consecutive 6-month periods. During the first 6 months, anesthesiologists received no feedback regarding the supervision scores. During the last 6 months, there was feedback to all anesthesiologists regarding their individual supervision scores and comments provided by residents (during the preceding 6 months) and nurse anesthetists (during the preceding 12 months). RESULTS: Anesthesiologists' mean supervision scores were not positively correlated with their total (weekly) hours of clinical activity. For the first 6 months, the correlations were r = -0.18 among scores provided by residents (P = 0.92 for positive correlation, N = 57 anesthesiologists) and r = -0.04 among scores provided by nurse anesthetists (P = 0.70, N = 61). For the last 6 months, the correlations were r = -0.28 (P = 0.98) and r = -0.10 (P = 0.79), respectively. Pairwise by anesthesiologist, the mean supervision scores provided by residents increased by 0.08 ± 0.01 points (P < 0.0001, N = 44). The mean supervision scores provided by nurse anesthetists increased by 0.28 ± 0.02 points (P < 0.0001, N = 49). CONCLUSIONS: When anesthesiologists supervise anesthesia residents and nurse anesthetists, the amount of clinical work performed and the quality of the supervision provided do not necessarily follow one another. Thus, faculty supervision scores serve as an independent measure of the contribution of an individual anesthesiologist to the care of the patient. Furthermore, when supervision quality is monitored and feedback is provided to anesthesiologists, quality can increase. The results suggest that anesthesiology department managers should not only be monitoring (and perhaps reporting) the quality of their departments' level of supervision, but also establishing processes so that individual anesthesiologists can learn about the quality of supervision they provide. © 2015 International Anesthesia Research Society. |
Optimal nasopharyngeal temperature probe placement | Background: Although the nasopharynx is a commonly used temperature-monitoring site during general anesthesia, it is unknown whether the position of nasopharyngeal temperature probes placed blindly by anesthesia practitioners is optimal. The purposes of this study were (1) to determine where the nasopharyngeal mucosa is in closest proximity to the internal carotid artery (ICA) and (2) to evaluate the tip position of nasopharyngeal temperature probes that were placed by anesthesiology residents and nurse anesthetists.Methods: In the first phase of the study, we reviewed enhanced axial computed tomography images of 100 patients to determine where the nasopharyngeal mucosa was in closest proximity to the left or the right ICA. The distance from this point to the nares was then measured in the sagittal image. In the second phase of the study, nasendoscopy was used to evaluate the positioning of nasopharyngeal temperature probes placed by anesthesiology residents (244 patients) or nurse anesthetists (116 patients). Malpositioned probes were repositioned to an optimal location, and the temperature differences were recorded.Results: In the computed tomography images, the mucosa in closest proximity to the ICA was in the upper, mid-, and lower nasopharynx in 60%, 38%, and 2% of patients, respectively. The average distances between the ICA and the nasopharyngeal mucosa in the upper portion were significantly shorter than those in the lower portion (female: 9.4 vs 16.8 mm, P < 0.001; male: 12.4 vs 18.8 mm, P < 0.001). The average distances (95% prediction interval) from the nares to the upper portion of the nasopharynx through the inferior meatus were 9.1 (8.1-10.2) cm in females and 9.7 (8.6-10.8) cm in males. Temperature probes were correctly positioned in the upper or mid-nasopharynx by residents and nurses in 43% (95% confidence interval [CI], 37%-49%) and 41% (95% CI, 36%-50%), respectively. When the probe was inadvertently placed in the nasal cavity, the median (95% CI) temperature difference from the upper nasopharynx was 0.2°C (0.15°C-0.25°C).Conclusions: The closest portion of the nasopharyngeal mucosa to the ICA is within the upper or mid-nasopharynx. The depth from the nares to the upper one-third of the nasopharynx is approximately 10 cm. Less than half of nasopharyngeal temperature probes placed blindly by practitioners were optimally positioned. © 2014 International Anesthesia Research Society. |
Representation of Women as Editors in Anesthesiology Journals | BACKGROUND: Although there has been a considerable increase in the representation of women in medicine, a gender gap still exists with regard to leadership positions. This gender discrepancy has been identified in the field of anesthesiology, in terms of first and senior authorship, as well as in general composition of editorial boards in Anesthesiology and Anesthesia & Analgesia. The goal of this study is to examine the current representation of women in editorial boards of anesthesia journals with respect to the hierarchy of different editorial positions and to assess whether there has been improvement toward equity in recent years. METHODS: A comprehensive search was performed for anesthesiology journals indexed in the Scimago Journal and Country Rank in May 2020. The editorial boards of the top 20 journals by impact factor were analyzed. Editorial board members were categorized based on their title. Gender was assigned using images or pronouns on research databases or hospital-affiliated websites. The percentage of women within each category was calculated. When available, the year the editors obtained their medical degree was collected. A binomial proportion test was used to analyze the distribution of women overall and among editorial roles, compared to the proportion of women anesthesiologists (26%). A Wilcoxon rank-sum test was used to compare time since medical degree between genders. Additionally, women representation in anesthesiology editorial boards in 2020 was compared to 2010. RESULTS: A total of 19 journals were included in this study, as 1 journal did not disclose editorial board membership. Overall, women occupied 18% of all editorial board positions. All editors-in-chief and assistant/associate/deputy editors-in-chief were men. Women consisted of 17.1% of executive/section/senior editors, 17.9% of editors, and 20.6% of associate/assistant editors. There were significantly fewer women editorial board members than the percentage of women anesthesiologists (18% vs 26%; P < .001). Editorial boards from 2010 were available for 14 journals, and of these journals, women comprised 12% of editorial board members in 2010 compared to 19% in 2020 (P = .001). CONCLUSIONS: These findings suggest that in anesthesiology journals, women are underrepresented at all editorial levels, especially at higher levels. As editorial boards have a significant impact on which articles are published by a journal and thereby significant influence on the specialty as a whole, the lack of gender equity in editorial boards should be addressed. Copyright © 2022 International Anesthesia Research Society |
Coordination of appointments for anesthesia care outside of operating rooms using an enterprise-wide scheduling system | BACKGROUND: An anesthesia department implemented scheduling of anesthetics outside of operating rooms (non-OR) by clerks and nurses from other departments using its hospital's enterprise-wide scheduling system. METHODS: Observational studies chronicled the change over 2 yr as non-OR time was allocated by specialty, and nonanesthesia clerks and nurses scheduled anesthesia teams. Experimental studies investigated how tabular and graphical displays affected the scheduling of milestones (e.g., NPO times) and appointments before anesthetics. RESULTS: Anesthetics performed in allocated time increased progressively from 0% to 75%. Scheduling of anesthetics by nonanesthesia clerks and nurses increased progressively from 0% to 77%. Consistency of patient instructions was improved. The quality of resulting schedules was good. Implementation was not associated with worsening of multiple operational measures of performance such as cancellation rates, turnover times, or complaints. However, schedulers struggled to understand fasting and arrival times of patients, despite using a web site with statistically generated values in tabular formats. Experiments revealed that people ignored their knowledge that anesthetics can start earlier than scheduled. Participants made good decisions with both tabular and graphical displays when scheduling appointments preceding anesthesia. CONCLUSIONS: Enterprise-wide scheduling can coordinate anesthetics with other appointments on the same date and improve consistency and accuracy of patient instructions customized to the probability of an anesthetic starting early. The usefulness of implementation depends on the value in having more patient-centered care and/or in having patients arrive just in time for non-OR anesthesia, surgery, or regional block placement (e.g., at facilities with limited physical space). © 2007 by International Anesthesia Research Society. |
Humanistic medicine in anaesthesiology: development and assessment of a curriculum in humanism for postgraduate anaesthesiology trainees | Background: An unintended consequence of medical technologies is loss of personal interactions and humanism between patients and their healthcare providers, leading to depersonalisation of medicine. As humanism is not integrated as part of formal postgraduate anaesthesiology education curricula, our goal was to design, introduce, and evaluate a comprehensive humanism curriculum into anaesthesiology training. Methods: Subject-matter experts developed and delivered the humanism curriculum, which included interactive workshops, simulation sessions, formal feedback, and patient immersion experience. The effectiveness of the programme was evaluated using pre- and post-curriculum assessments in first-year postgraduate trainee doctors (residents). Results: The anaesthesiology residents reported high satisfaction scores. Pre-/post-Jefferson Scale of Patient Perceptions of Physician Empathy showed an increase in empathy ratings with a median improvement of 12 points (range; P=0.013). After training, patients rated the residents as more empathetic (31 [4] vs 22 [5]; P<0.001; 95% confidence interval [CI]: 7–12) and professional (47 [3] vs 35 [8]; P<0.001; 95% CI: 9–16). Patient overall satisfaction with their anaesthesia provider improved after training (51 [6] vs 37 [10]; P<0.001; 95% CI: 10–18). Patients rated their anxiety lower in the post-training period compared with pretraining (1.8 [2.3] vs 3.6 [1.6]; P=0.001; 95% CI: 0.8–2.9). Patient-reported pain scores decreased after training (2.3 [2.5] vs 3.8 [2.1]; P=0.010; 95% CI: 0.4–2.8). Conclusions: Implementation of a humanism curriculum during postgraduate anaesthesiology training was well accepted, and can result in increased physician empathy and professionalism. This may improve patient pain, anxiety, and overall satisfaction with perioperative care. © 2019 British Journal of Anaesthesia |
Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice | Background: Anaesthetists may fail to recognize and manage certain rare intraoperative events. Simulation has been shown to be an effective educational adjunct to typical operating room-based education to train for these events. It is yet unclear, however, why simulation has any benefit. We hypothesize that learners who are allowed to manage a scenario independently and allowed to fail, thus causing simulated morbidity, will consequently perform better when re-exposed to a similar scenario. Methods: Using a randomized, controlled, observer-blinded design, 24 first-year residents were exposed to an oxygen pipeline contamination scenario, either where patient harm occurred (independent group, n=12) or where a simulated attending anaesthetist intervened to prevent harm (supervised group, n=12). Residents were brought back 6 months later and exposed to a different scenario (pipeline contamination) with the same end point. Participants' proper treatment, time to diagnosis, and non-technical skills (measured using the Anaesthetists' Non-Technical Skills Checklist, ANTS) were measured. Results: No participants provided proper treatment in the initial exposure. In the repeat encounter 6 months later, 67% in the independent group vs 17% in the supervised group resumed adequate oxygen delivery (P=0.013). The independent group also had better ANTS scores [median (interquartile range): 42.3 (31.5-53.1) vs 31.3 (21.6-41), P=0.015]. There was no difference in time to treatment if proper management was provided [602 (490-820) vs 610 (420-800) s, P=0.79]. Conclusions: Allowing residents to practise independently in the simulation laboratory, and subsequently, allowing them to fail, can be an important part of simulation-based learning. This is not feasible in real clinical practice but appears to have improved resident performance in this study. The purposeful use of independent practice and its potentially negative outcomes thus sets simulation-based learning apart from traditional operating room learning. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. |
Written comments made by anesthesia residents when providing below average scores for the supervision provided by the faculty anesthesiologist | BACKGROUND: Anesthesia residents in our department evaluate the supervision provided by the faculty anesthesiologist with whom they worked the previous day. What advice managers can best provide to the faculty who receive below-average supervision scores is unknown. METHODS: The residents provided numerical answers (1 "never," 2 "rarely," 3 "frequently," or 4 "always") to each of the 9 supervision questions, resulting in a total supervision score. A written comment could also be provided. RESULTS: Over 2.5 years, the response rate to requests for evaluation was 99.1%. There were 13,664 evaluations of 76 faculty including 1387 comments. There were 25 evaluations with a comment of disrespectful behavior. For all 25, the question evaluating whether "the faculty treated me respectfully" was answered <4 (i.e., not "always"). The supervision scores were less than for the other evaluations with comments (P < 0.0001). Each increase in the faculty's number of comments of being disrespectful was associated with a lesser mean score (P = 0.0002). A low supervision score (<3.00; i.e., less than "frequent") had an odds ratio of 85 for disrespectful faculty behavior (P < 0.0001). The predictive value of the supervision score not being low for absence of a comment of disrespectful behavior was 99%. That finding was especially useful because 94% of scores below average (<3.80) were not low (≥3.00). There were 6 evaluations with a comment of insufficient faculty presence. Those evaluations had lesser scores than the other evaluations with comments (P < 0.0001). The 6 faculty with 1 such comment had lesser mean scores than the other faculty (P = 0.0071). There were 34 evaluations with a comment about poor-quality teaching. The evaluations related to poor teaching had lesser scores than the other evaluations with comments (P < 0.0001). The faculty who each received such a comment had lesser mean scores than the other faculty (P < 0.0001). Each increase in the faculty's number of comments of poor-quality teaching was associated with a lesser mean score (P = 0.0002). The 9 supervision questions were internally consistent (Cronbach α = 0.948). A faculty with a comment about poor-quality teaching had significant odds of also having a comment about insufficient presence (P = 0.0044). A comment with negative sentiment had significant odds of being about poor-quality teaching rather than being about insufficient presence (odds ratio, 6.00; P < 0.0001). CONCLUSIONS: A faculty who has insufficient presence cannot be providing good teaching. Furthermore, there was negligible correlation between supervision scores and faculty clinical assignments. Thus, insufficient faculty presence accounted for a small proportion of below-average supervision scores and low-quality supervision. Furthermore, scores ≥3 have a predictive value for the absence of disrespectful behavior ≅99%. Approximately 94% of the faculty supervision scores that were below average were still ≥3. Consequently, for the vast majority of the faculty-resident-days, quality of teaching distinguished between below- versus above-average supervision scores. This result is consistent with our prior finding of a strong correlation between 6-month supervision scores and assessments of teaching effectiveness. Taken together, when individual faculty anesthesiologists are counseled about their clinical supervision scores, the attribute to emphasize is quality of clinical teaching. © 2016 International Anesthesia Research Society. |
Incentive payments to academic anesthesiologists for late afternoon work did not influence turnover times | Background: Anesthesiologists are often paid extra for hours worked in the late afternoon and evening. Although anesthesiologists have little influence on their operating room (OR) assignments and workloads late in the afternoon, they can influence turnover times. Methods: OR turnover times on workdays were reviewed for n = 30 mo before there was incremental pay, for n = 15 mo with incremental pay for work past 3:30 pm, and for n = 8 mo with pay for work past 4:00 pm. The end point was the percentage of turnovers that were prolonged, defined as longer than 1 h. Turnovers straddling 3:30 pm (n = 3945), 4:00 pm (n = 3602), and 5:00 pm (n = 2834) were studied, as were those straddling 2:00 pm (n = 4407) as a control. In addition, qualitative (survey) assessment of n = 30 anesthesiologists was performed the last month to learn about their opinions on working late on weekdays. Results: Most respondents considered an OR to run late if it finished after a specific time of day (87%, P < 0.001), unrelated to the room's type of procedures (90%, P < 0.001) or to the payment for working after 4:00 pm (100%, P < 0.001). There was no significant effect of implementation or changes to the incentive program on the incidences of prolonged turnover times at each of the studied times in the afternoon (all P > 0.14). Conclusion: Our results suggest that hospital administrators, deans, and other executives need not be especially concerned about disincentives produced by methods of internal compensation of anesthesiologists on highly visible OR turnover times late in afternoons. © 2009 International Anesthesia Research Society. |
Anesthesiologists with substance use disorders: A 5-year outcome study from 16 state physician health programs | BACKGROUND: Anesthesiologists have a higher rate of substance use disorders than other physicians, and their prognoses and advisability to return to anesthesiology practice after treatment remain controversial. Over the past 25 yr, physician health program (PHPs), created under authority of state medical regulatory boards, have become primary resources for management and monitoring of physicians with substance abuse and other mental health disorders. METHODS: We conducted a 5-yr, longitudinal, cohort study involving 904 physicians consecutively admitted to 1 of 16 state PHPs between 1995 and 2001. This report analyzed a subset of the data involving the 102 anesthesiologists among the subjects and compared them with other physicians. The main outcome measures included relapse (defined as any unauthorized addictive substance use, including alcohol), return to anesthesiology practice, disciplinary actions, physician death, and patient harm. RESULTS: Anesthesiologists were significantly less likely to enroll in a PHP because of alcohol abuse (odds ratio [OR] 0.4 [confidence interval {CI}: 0.2-0.6], P lt; 0.001) and much more likely to enroll because of opioid abuse (OR 2.8 [CI: 1.7-4.4], P lt; 0.001). Anesthesiologists had a higher rate of IV drug use, 41% vs 10% (OR 6.3 [CI: 3.8-10.7], P lt; 0.001). During similar periods of monitoring, anesthesiologists received more drug tests, 101 vs 82 (mean difference = 19 [CI: 3-35], P = 0.02); however, anesthesiologists were less likely to fail at least one drug test during monitoring, 11% vs 23% (OR 0.4 [CI: 0.2-0.9], P = 0.02). There was no statistical difference among rates of program completion, disciplinary actions, return to practice, or deaths, and there was no report of significant patient harm from relapse in any record. CONCLUSIONS: Anesthesiologists in our sample treated and monitored for substance disorders under supervision of PHPs had excellent outcomes similar to other physicians, with no higher mortality, relapse rate, or disciplinary rate and no evidence in their records of patient harm. It is postulated that differences of study design account for contradictory conclusions from other reports. Copyright © 2009 International Anesthesia Research Society. |
A new approach to pathogen containment in the operating room: Sheathing the laryngoscope after intubation | BACKGROUND: Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. METHODS: Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. RESULTS: Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. CONCLUSIONS: The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced. Copyright © 2015 International Anesthesia Research Society. |
Anesthesiologists and disaster medicine: A needs assessment for education and training and reported willingness to respond | BACKGROUND: Anesthesiologists provide comprehensive health care across the emergency department, operating room, and intensive care unit. To date, anesthesiologists' perspectives regarding disaster medicine and public health preparedness have not been described. METHODS: Anesthesiologists' thoughts and attitudes were assessed via a Web-based survey at 3 major academic institutions. Frequencies, percentages, and odds ratios (ORs) were used to assess self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, employee development, professional obligation, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond (WTR). Three representative disaster scenarios (natural disaster [ND], radiological event [RE], and pandemic influenza [PI]) were investigated. Results are reported as percent or OR (95% confidence interval). RESULTS: Participants included 175 anesthesiology attendings (attendings) and 95 anesthesiology residents (residents) representing a 47% and 51% response rate, respectively. A minority of attendings indicated that their hospital provides adequate pre-event preparation and training (31% [23-38] ND, 14% [9-21] RE, and 40% [31-49] PI). Few residents felt that their residency program provided them with adequate preparation and training (22% [14-33] ND, 16% [8-27] RE, and 17% [9-29] PI). Greater than 85% of attendings (89% [84-94] ND, 88% [81-92] RE, and 87% [80-92] PI) and 70% of residents (81% [71-89] ND, 71% [58-81] RE, and 82% [70- 90] PI) believe that their hospital or residency program, respectively, should provide them with preparation and training. Approximately one-half of attendings and residents are confident that they would be safe at work during response to a ND or PI (55% [47-64] and 58% [49-67] of attendings; 59% [48-70] and 48% [35-61] of residents, respectively), whereas approximately one-third responded the same regarding a RE (31% [24-40] of attendings and 28% [18-41] of residents). Fewer than 40% of attendings (34% [26-43]) and residents (38% [27-51]) designated who would take care of their family obligations in the event they were called into work during a disaster. Regardless of severity, 79% (71-85) of attendings and 73% (62-82) of residents indicated WTR to a ND, whereas 81% (73-87) of attendings and 70% (58-81) of residents indicated WTR to PI. Fewer were willing to respond to a RE (63% [55-71] of attendings and 52% [39-64] of residents). In adjusted logistic regression analyses, those anesthesiologists who reported knowing one's role in response to a ND (OR, 15.8 [4.5-55.3]) or feeling psychologically prepared to respond to a ND (OR, 6.9 [2.5-19.0]) were found to be more willing to respond. Similar results were found for RE and PI constructs. Both attendings and residents were willing to respond in whatever capacity needed, not specifically to provide anesthesia. CONCLUSIONS: Few anesthesiologists reported receiving sufficient education and training in disaster medicine and public health preparedness. Providing education and training and enhancing related employee services may further bolster WTR and help to build a more capable and effective medical workforce for disaster response. © 2017 International Anesthesia Research Society. |
Diversity and similarity of anesthesia procedures in the United States during and among regular work hours, evenings, and weekends | BACKGROUND: Anesthesiologists providing care during off hours (ie, weekends or holidays, or cases started during the evening or late afternoon) are more likely to care for patients at greater risk of sustaining major adverse events than when they work during regular hours (eg, Monday through Friday, from 7:00 am to 2:59 pm). We consider the logical inconsistency of using subspecialty teams during regular hours but not during weekends or evenings. METHODS: We analyzed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR). Among the hospitals in the United States, we estimated the average number of common types of anesthesia procedures (ie, diversity measured as inverse of Herfindahl index), and the average difference in the number of common procedures between 2 off-hours periods (regular hours versus weekends, and regular hours versus evenings). We also used NACOR data to estimate the average similarity in the distributions of procedures between regular hours and weekends and between regular hours and evenings in US facilities. Results are reported as mean ± standard error of the mean among 399 facilities nationwide with weekend cases. RESULTS: The distributions of common procedures were moderately similar (ie, not large, <.8) between regular hours and evenings (similarity index.59 ±.01) and between regular hours and weekends (similarity index,.55 ±.02). For most facilities, the number of common procedures differed by <5 procedures between regular hours and evenings (74.4% of facilities, P <.0001) and between regular hours and weekends (64.7% of facilities, P <.0001). The average number of common procedures was 13.59 ±.12 for regular hours, 13.12 ±.13 for evenings, and 9.43 ±.13 for weekends. The pairwise differences by facility were.13 ±.07 procedures (P =.090) between regular hours and evenings and 3.37 ±.12 procedures (P <.0001) between regular hours and weekends. In contrast, the differences were -5.18 ±.12 and 7.59 ±.13, respectively, when calculated using nationally pooled data. This was because the numbers of common procedures were 32.23 ±.05, 37.41 ±.11, and 24.64 ±.12 for regular hours, evenings, and weekends, respectively (ie, >2x the number of common procedures calculated by facility). CONCLUSIONS: The numbers of procedures commonly performed at most facilities are fewer in number than those that are commonly performed nationally. Thus, decisions on anesthesia specialization should be based on quantitative analysis of local data rather than national recommendations using pooled data. By facility, the number of different procedures that take place during regular hours and off hours (diversity) is essentially the same, but there is only moderate similarity in the procedures performed. Thus, at many facilities, anesthesiologists who work principally within a single specialty during regular work hours will likely not have substantial contemporary experience with many procedures performed during off hours. © 2016 International Anesthesia Research Society. |
An analysis of risk factors for patient complaints about ambulatory anesthesiology care | Background: Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. Methods: We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS: A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04-2.08), 0.22 (95% CI, 0.07-0.62), and 1.27 (95% CI, 1.10-1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47-0.92), 0.67 (95% CI, 0.47-0.95), 1.18 (95% CI, 1.01-1.38), and 1.96 (95% CI, 1.17-3.29), respectively. CONCLUSIONS: There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints. © 2013 International Anesthesia Research Society. |
Contemporary Academic Contributions From Anesthesiologists in Adult Critical Care Medicine | BACKGROUND: Anesthesiology has a long relationship with critical care medicine (CCM). However, US anesthesiologists are less likely to practice CCM than non-US anesthesiologists. To date, no studies have compared academic contributions in CCM between US anesthesiologists and non-US anesthesiologists. The objective of our study was to use recent trends in critical care publications as a surrogate for academic contribution among US and non-US anesthesiologists. METHODS: Research articles published between 2010 and 2015 in 3 anesthesiology journals (Anesthesiology, Anesthesia & Analgesia, and British Journal of Anaesthesia) and 3 multidisciplinary CCM journals (Critical Care Medicine, Intensive Care Medicine, and Journal of Critical Care) were reviewed. Author information, including the primary department appointment and geographic location for the first and senior author(s), and article details, including topic and publication type, were collected. Odds ratios for having a first or senior author from the United States were calculated. Anesthesiologists’ contributions in individual journals were summarized, as were trends in anesthesiology CCM publications during the 6-year study period. RESULTS: A total of 3831 articles were reviewed, with 1050 (27.4%) having US authors. Eighty-two and one-half percent of CCM articles in anesthesiology journals had a US anesthesiologist as first author, and 81% had a US anesthesiologist as senior author, while fewer CCM articles in multidisciplinary journals had a US anesthesiologist as first (12.1%) or senior (12.3%) author. When considering all publications, 16.3% and 16.4% of articles had a US anesthesiologist as the first or senior author compared with articles for which non-US anesthesiologists were first (23.8%) or senior (20.9%) authors. The odds of having a US anesthesiologist as first or senior author compared to a non-US anesthesiologist for all publications were 0.6 (0.5–0.7) and 0.7 (0.6–0.9). The number of publications trended downward for both US anesthesiologists and non-US anesthesiologists during the study period. CONCLUSIONS: When compared to non-US anesthesiologists, US anesthesiologists had more CCM publications in anesthesiology journals and fewer publications in multidisciplinary CCM journals. The number of anesthesiology CCM publications decreased for both US and non-US anesthesiologists throughout the study period. Copyright © 2018 International Anesthesia Research Society |
Resident Physicians Improve Nontechnical Skills When on Operating Room Management and Leadership Rotation | BACKGROUND: Anesthesiology residency primarily emphasizes the development of medical knowledge and technical skills. Yet, nontechnical skills (NTS) are also vital to successful clinical practice. Elements of NTS are communication, teamwork, situational awareness, and decision making. METHODS: The first 10 consecutive senior residents who chose to participate in this 2-week elective rotation of operating room (OR) management and leadership training were enrolled in this study, which spanned from March 2013 to March 2015. Each resident served as the anesthesiology officer of the day (AOD) and was tasked with coordinating OR assignments, managing care for 2 to 4 ORs, and being on call for the trauma OR; all residents were supervised by an attending AOD. Leadership and NTS techniques were taught via a standardized curriculum consisting of leadership and team training articles, crisis management text, and daily debriefings. Resident self-ratings and attending AOD and charge nurse raters used the Anaesthetists' Non-Technical Skills (ANTS) scoring system, which involved task management, situational awareness, teamwork, and decision making. For each of the 10 residents in their third year of clinical anesthesiology training (CA-3) who participated in this elective rotation, there were 14 items that required feedback from resident self-assessment and OR raters, including the daily attending AOD and charge nurse. Results for each of the items on the questionnaire were compared between the beginning and the end of the rotation with the Wilcoxon signed-rank test for matched samples. Comparisons were run separately for attending AOD and charge nurse assessments and resident self-assessments. Scaled rankings were analyzed for the Kendall coefficient of concordance (ω) for rater agreement with associated χ2 and P value. RESULTS: Common themes identified by the residents during debriefings were recurrence of challenging situations and the skills residents needed to instruct and manage clinical teams. For attending AOD and charge nurse assessments, resident performance of NTS improved from the beginning to the end of the rotation on 12 of the 14 NTS items (P <.05), whereas resident self-assessment improved on 3 NTS items (P <.05). Interrater reliability (across the charge nurse, resident, and AOD raters) ranged from ω =.36 to.61 at the beginning of the rotation and ω =.27 to.70 at the end of the rotation. CONCLUSIONS: This rotation allowed for teaching and resident assessment to occur in a way that facilitated resident education in several of the skills required to meet specific milestones. Resident physicians are able to foster NTS and build a framework for clinical leadership when completing a 2-week senior elective as an OR manager. Copyright © 2016 International Anesthesia Research Society. |
A Descriptive Survey of Anesthesiology Residency Simulation Programs: How Are Programs Preparing Residents for the New American Board of Anesthesiology APPLIED Certification Examination? | BACKGROUND: Anesthesiology residency programs may need new simulation-based programs to prepare residents for the new Objective Structured Clinical Examination (OSCE) component of the American Board of Anesthesiology (ABA) Primary Certification process. The design of such programs may require significant resources, including faculty time, expertise, and funding, as are currently needed for structured oral examination (SOE) preparation. This survey analyzed the current state of US-based anesthesiology residency programs regarding simulation-based educational programming for SOE and OSCE preparation. METHODS: An online survey was distributed to every anesthesiology residency program director in the United States. The survey included 15 to 46 questions, depending on each respondent's answers. The survey queried current practices and future plans regarding resident preparation specifically for the ABA APPLIED examination, with emphasis on the OSCE. Descriptive statistics were summarized. χ2 and Fisher exact tests were used to test the differences in proportions across groups. Spearman rank correlation was used to examine the association between ordinal variables. RESULTS: The responding 66 programs (49%) were a representative sample of all anesthesiology residencies (N = 136) in terms of geographical location (χ2 P =.58). There was a low response rate from small programs that have 12 or fewer clinical anesthesia residents. Ninety-one percent (95% confidence interval [CI], 84%-95%) of responders agreed that it is the responsibility of the program to specifically prepare residents for primary certification, and most agreed that it is important to practice SOEs (94%; 95% CI, 88%-97%) and OSCEs (89%; 95% CI, 83%-94%). While 100% of respondents reported providing mock SOEs, only 31% (95% CI, 24%-40%) of respondents provided mock OSCE experiences. Of those without an OSCE program, 75% (95% CI, 64%-83%) reported plans to start one. The most common reasons for not having an OSCE program already in place, and the perceived challenges for implementing an OSCE program, were the same: lack of time (faculty and residents), expertise in OSCE development and assessment, and funding. CONCLUSIONS: The results provide data from residency programs for benchmarking their simulation curriculum and ABA APPLIED Examination preparation offerings. Despite agreement that residency programs should prepare residents for the ABA APPLIED Examination, many programs have yet to implement an OSCE preparation program, in part due to lack of financial resources, faculty expertise, and time. Additionally, in contrast to the SOE, the OSCE is a new format for ABA primary certification. As a result, the lack of consensus concerning preparation needs could be related to the amount information that is available regarding the examination content and assessment process. Copyright © 2017 International Anesthesia Research Society. |
Anesthesiology Residents' Experiences and Perspectives of Residency Training | BACKGROUND: Anesthesiology residents' experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice. METHODS: Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-Administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study-3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1-3), 2 surveys for the 2015 cohort (clinical anesthesia years 1-2), and 1 survey for the 2016 cohort (clinical anesthesia year 1). RESULTS: The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as "very unimportant" and 5 as "very important," quality of clinical experience (4.7-4.8 among the cohorts) and departmental commitment to education (4.3-4.5) were rated as the most important factors in anesthesiologists' choice of residency. Approximately 70% of first-and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4-4.5 on a 5-point scale among cohort-Training levels) and their residency programs (4.0-4.1). The residency training experiences mostly met their expectations (3.8-4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1-4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7-4.9) and interpersonal and communication skills (4.6-4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position. CONCLUSIONS: Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program. © 2021 Lippincott Williams and Wilkins. All rights reserved. |
Reliability and validity of performance evaluations of pain medicine clinical faculty by residents and fellows using a supervision scale | BACKGROUND: Annual and/or semiannual evaluations of pain medicine clinical faculty are mandatory for multiple organizations in the United States. We evaluated the validity and psychometric reliability of a modified version of de Oliveira Filho et al clinical supervision scale for this purpose. METHODS: Six years of weekly evaluations of pain medicine clinical faculty by resident physicians and pain medicine fellows were studied. A 1-4 rating (4 = "Always") was assigned to each of 9 items (eg, "The faculty discussed with me the management of patients before starting a procedure or new therapy and accepted my suggestions, when appropriate"). RESULTS: Cronbach α of the 9 items equaled.975 (95% confidence interval [CI], 0.974-0.976). A G coefficient of 0.90 would be expected with 18 raters; the N = 12 six-month periods had mean 18.8 ± 5.9 (standard deviation [SD]) unique raters in each period (median = 20). Concurrent validity was shown by Kendall τb= 0.45 (P <.0001) pairwise by combination of ratee and rater between the average supervision score and the average score on a 21-item evaluation completed by fellows in pain medicine. Concurrent validity also was shown by τb= 0.36 (P =.0002) pairwise by combination of ratee and rater between the average pain medicine supervision score and the average operating room supervision score completed by anesthesiology residents. Average supervision scores differed markedly among the 113 raters (η2= 0.485; CI, 0.447-0.490). Pairings of ratee and rater were nonrandom (Cramér V = 0.349; CI, 0.252-0.446). Mixed effects logistic regression was performed with rater leniency as covariates and the dependent variable being an average score equaling the maximum 4 vs <4. There were 3 of 13 ratees with significantly more averages <4 than the other ratees, based on P <.01 criterion; that is, their supervision was reliably rated as below average. There were 3 of 13 different ratees who provided supervision reliably rated as above average. Raters did not report higher supervision scores when they had the opportunity to perform more interventional pain procedures. CONCLUSIONS: Evaluations of pain medicine clinical faculty are required. As found when used for evaluating operating room anesthesiologists, a supervision scale has excellent internal consistency, achievable reliability using 1-year periods of data, concurrent validity with other ratings, and the ability to differentiate among ratees. However, to be reliable, routinely collected supervision scores must be adjusted for rater leniency. © 2020 Lippincott Williams and Wilkins. All rights reserved. |
Computational modeling and prototyping of a pediatric airway management instrument | BACKGROUND: Anterior retraction of the tongue is used to enhance upper airway patency during pediatric fiberoptic intubation. This can be achieved by the use of Magill forceps as a tongue retractor, but lingual grip can become unsteady and traumatic. Our objective was to modify this instrument using computer-aided engineering for the purpose of stable tongue retraction. METHODS: We analyzed the geometry and mechanical properties of standard Magill forceps with a combination of analytical and empirical methods. This design was captured using computeraided design techniques to obtain a 3-dimensional model allowing further geometric refinements and mathematical testing for rapid prototyping. RESULTS: On the basis of our experimental findings we adjusted the design constraints to optimize the device for tongue retraction. Stereolithography prototyping was used to create a partially functional plastic model to further assess the functional and ergonomic effectiveness of the design changes. To reduce pressure on the tongue by regular Magill forceps, we incorporated (1) a larger diameter tip for better lingual tissue pressure profile, (2) a ratchet to stabilize such pressure, and (3) a soft molded tip with roughened surface to improve grip. CONCLUSION: Computer-aided engineering can be used to redesign and prototype a popular instrument used in airway management. On a computational model, our modified Magill forceps demonstrated stable retraction forces, while maintaining the original geometry and versatility. Its application in humans and utility during pediatric fiberoptic intubation are yet to be studied. (Anesth Analg 2010;111:649-52). Copyright © 2010 International Anesthesia Research Society. |