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Pharmacological consequence of the A118G μ opioid receptor polymorphism on morphine-and fentanyl-mediated modulation of Ca2+ channels in humanized mouse sensory neurons

Background: The most common functional single nucleotide polymorphism of the human OPRM1 gene, A118G, has been shown to be associated with interindividual differences in opioid analgesic requirements, particularly with morphine, in patients with acute postoperative pain. The purpose of this study was to examine whether this polymorphism would modulate the morphine and fentanyl pharmacological profile of sensory neurons isolated from a humanized mouse model homozygous for either the 118A or 118G allele. Methods: The coupling of wild-type and mutant μ opioid receptors to voltage-gated Ca channels after exposure to either ligand was examined by employing the whole cell variant of the patch-clamp technique in acutely dissociated trigeminal ganglion neurons. Morphine-mediated antinociception was measured in mice carrying either the 118AA or 118GG allele. RESULTS:: The biophysical parameters (cell size, current density, and peak current amplitude potential) measured from both groups of sensory neurons were not significantly different. In 118GG neurons, morphine was approximately fivefold less potent and 26% less efficacious than that observed in 118AA neurons. On the other hand, the potency and efficacy of fentanyl were similar for both groups of neurons. Morphine-mediated analgesia in 118GG mice was significantly reduced compared with the 118AA mice. Conclusions: This study provides evidence to suggest that the diminished clinical effect observed with morphine in 118G carriers results from an alteration of the receptor's pharmacology in sensory neurons. In addition, the impaired analgesic response with morphine may explain why carriers of this receptor variant have an increased susceptibility to become addicted to opioids. © 2011 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Perioperative mortality, 2010 to 2014: A retrospective cohort study using the national anesthesia clinical outcomes registry

Background: The National Anesthesia Clinical Outcomes Registry collects demographic and outcome data from anesthesia cases, with the goal of improving safety and quality across the specialty. The authors present a preliminary analysis of the National Anesthesia Clinical Outcomes Registry database focusing on the rates of and associations with perioperative mortality (within 48 h of anesthesia induction). Methods: The authors retrospectively analyzed 2,948,842 cases performed between January 1, 2010, and May 31, 2014. Cases without procedure information and vaginal deliveries were excluded. Mortality and other outcomes were reported by the anesthesia provider. Hierarchical logistic regression was performed on cases with complete information for patient age group, sex, American Society of Anesthesiologists physical status, emergency case status, time of day, and surgery type, controlling for random effects within anesthesia practices. Results: The final analysis included 2,866,141 cases and 944 deaths (crude mortality rate, 33 per 100,000). Increasing American Society of Anesthesiologists physical status, emergency case status, cases beginning between 4:00 pm and 6:59 am, and patient age less than 1 yr or greater than or equal to 65 yr were independently associated with higher perioperative mortality. A post hoc subgroup analysis of 279,154 patients limited to 22 elective case types, post hoc models incorporating either more granular estimate of surgical risk or work relative value units, and a post hoc propensity score-matched cohort confirmed the association with time of day. Conclusions: Several factors were associated with increased perioperative mortality. A case start time after 4:00 pm was associated with an adjusted odds ratio of 1.64 (95% CI, 1.22 to 2.21) for perioperative death, which suggests a potentially modifiable target for perioperative risk reduction. Limitations of this study include nonstandardized mortality reporting and limited ability to adjust for missing data. © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

Noxious stimulation response index: A novel anesthetic state index based on hypnotic-opioid interaction

Background: The noxious stimulation response index (NSRI) is a novel anesthetic depth index ranging between 100 and 0, computed from hypnotic and opioid effect-site concentrations using a hierarchical interaction model. The authors validated the NSRI on previously published data. METHODS:: The data encompassed 44 women, American Society of Anesthesiology class I, randomly allocated to three groups receiving remifentanil infusions targeting 0, 2, and 4 ng/ml. Propofol was given at stepwise increasing effect-site target concentrations. At each concentration, the observer assessment of alertness and sedation score, the response to eyelash and tetanic stimulation of the forearm, the bispectral index (BIS), and the acoustic evoked potential index (AAI) were recorded. The authors computed the NSRI for each stimulation and calculated the prediction probabilities (PKs) using a bootstrap technique. The PKs of the different predictors were compared with multiple pairwise comparisons with Bonferroni correction. Results:The median (95% CI) P K of the NSRI, BIS, and AAI for loss of response to tetanic stimulation was 0.87 (0.75-0.96), 0.73 (0.58-0.85), and 0.70 (0.54-0.84), respectively. The PK of effect-site propofol concentration, BIS, and AAI for observer assessment of alertness and sedation score and loss of eyelash reflex were between 0.86 (0.80-0.92) and 0.92 (0.83-0.99), whereas the P Ks of NSRI were 0.77 (0.68-0.85) and 0.82 (0.68-0.92). The P K of the NSRI for BIS and AAI was 0.66 (0.58-0.73) and 0.63 (0.55-0.70), respectively. CONCLUSION:: The NSRI conveys information that better predicts the analgesic component of anesthesia than AAI, BIS, or predicted propofol or remifentanil concentrations. Prospective validation studies in the clinical setting are needed.

Norepinephrine infusion into nucleus basalis elicits microarousal in desflurane-anesthetized rats

Background: The nucleus basalis of Meynert of the basal forebrain has been implicated in the regulation of the state of consciousness across normal sleep-wake cycles. Its role in the modulation of general anesthesia was investigated. Methods: Rats were chronically implanted with bilateral infusion cannulae in the nucleus basalis of Meynert and epidural electrodes to record the electroencephalogram in frontal and visual cortices. Animals were anesthetized with desflurane at a concentration required for the loss of righting reflex (4.6 ± 0.5%). Norepinephrine (17.8 nmol) or artificial cerebrospinal fluid was infused at 0.2 μl/min (1 μl total). Behavioral response to infusion was measured by scoring the orofacial, limb, and head movements, and postural changes. Results: Behavioral responses were higher after norepinephrine (2.1 ± 1) than artificial cerebrospinal fluid (0.63 ± 0.8) infusion (P < 0.01, Student t test). Responses were brief (1-2 min), repetitive, and more frequent after norepinephrine infusion (P < 0.0001, chi-square test). Electroencephalogram delta power decreased after norepinephrine in frontal (70 ± 7%) but not in visual cortex (P < 0.05, Student t test). Simultaneously, electroencephalogram cross-approximate entropy between frontal and visual cortices increased from 3.17 ± 0.56 to 3.85 ± 0.29 after norepinephrine infusion (P < 0.01, Student t test). Behavioral activation was predictable by the decrease in frontal delta power (logistic regression, P < 0.05). Conclusions: Norepinephrine infusion into the nucleus basalis of Meynert can modulate anesthetic depth presumably by ascending activation of the cortex. The transient nature of the responses suggests a similarity with microarousals normally observed during natural sleep, and may imply a mechanism for transient awareness under light anesthesia. © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Unanticipated difficult airway in obstetric patients: Development of a new algorithm for formative assessment in high-fidelity simulation

Background: The objective of this study was to develop a consensus-based algorithm for the management of the unanticipated difficult airway in obstetrics, and to use this algorithm for the assessment of anesthesia residents' performance during high-fidelity simulation. Methods: An algorithm for unanticipated difficult airway in obstetrics, outlining the management of six generic clinical situations of "can and cannot ventilate" possibilities in three clinical contexts: elective cesarean section, emergency cesarean section for fetal distress, and emergency cesarean section for maternal distress, was used to create a critical skills checklist. The authors used four of these scenarios for high-fidelity simulation for residents. Their critical and crisis resource management skills were assessed independently by three raters using their checklist and the Ottawa Global rating scale. Results: Sixteen residents participated. The checklist scores ranged from 64-80% and improved from scenario 1 to 4. Overall Global rating scale scores were marginal and not significantly different between scenarios. The intraclass correlation coefficient of 0.69 (95% CI: 0.58, 0.78) represents a good interrater reliability for the checklist. Multiple critical errors were identified, the most common being not calling for help or a difficult airway cart. Conclusions: Aside from identifying common critical errors, the authors noted that the residents' performance was poorest in two of our scenarios: "fetal distress and cannot intubate, cannot ventilate" and "maternal distress and cannot intubate, but can ventilate." More teaching emphasis may be warranted to avoid commonly identified critical errors and to improve overall management. Our study also suggests a potential for experiential learning with successive simulations. Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.

Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents

Background: The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a wholebody point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training. Methods: For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data. Results: Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%. Conclusions: Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home. Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Chronic Pain Management: American Society of Anesthesiologists Closed Claims Project

Background: The practice of chronic pain management has grown steadily in recent years. The purpose of this study was to identify and describe issues and trends in liability related to chronic pain management by anesthesiologists. Methods: Data from 5,475 claims in the American Society of Anesthesiologists Closed Claims Project database between 1970 and 1999 were reviewed to compare liability related to chronic pain management with that related to surgical and obstetric (surgical/obstetric) anesthesia. Acute pain management claims were excluded from analysis. Outcomes and liability characteristics between 284 pain management claims and 5,125 surgical/ obstetric claims were compared. Results: Claims related to chronic pain management increased over time (P < 0.01) and accounted for 10% of all claims in the 1990s. Compensatory payment amounts were lower in chronic pain management claims than in surgical/obstetric anesthesia claims from 1970 to 1989 (P < 0.05), but during the 1990s, there was no difference in size of payments. Nerve injury and pneumothorax were the most common outcomes in invasive pain management claims. Epidural steroid injections accounted for 40% of all chronic pain management claims. Serious injuries, involving brain damage or death, occurred with epidural steroid injections with local anesthetics and/or opioids and with maintenance of implantable devices. Conclusions: Frequency and payments of claims associated with chronic pain management by anesthesiologists increased in the 1990s. Brain damage and death were associated with epidural steroid injection only when opioids or local anesthetics were included. Anesthesiologists involved in home care of patients with implanted devices such as morphine pumps and epidural injections or patient-controlled analgesia should be aware of potential complications that may have severe outcomes.

Human alzheimer and inflammation biomarkers after anesthesia and surgery

Background: The prevalence of postoperative cognitive disturbance, coupled with growing in vitro, cell, and animal evidence suggesting anesthetic effects on neurodegeneration, calls for additional study of the interaction between surgical care and Alzheimer neuropathology. The authors studied human cerebrospinal fluid (CSF) biomarkers during surgery. Methods: Eleven patients undergoing idiopathic nasal CSF leak correction were admitted to this Institutional Review Board-approved study. Lumbar subarachnoid catheters were placed before the procedure. Anesthesia was total intravenous propofol or remifentanil or inhalational sevoflurane, depending on provider choice. CSF samples were taken after catheter placement (base), at procedure end (0 h), and then at 6, 24, and 48 h. CSF was analyzed using xMAP Luminex immunoassay (Luminex, Austin, TX). Results: Of the 11 patients (age range, 53 ± 6 yr), 8 were women; 4 received intravenous anesthesia, 6 sevoflurane, and 1 mixed. Procedures lasted 6.4 ± 2 h. Mean CSF amyloid-β(1-42) remained unchanged, but total-tau and phosphorylated-tau181P increased progressively until at least 48 h. Total-tau, phosphorylated-tau, or amyloid-β(1-42) concentrations were not different between anesthetic groups. CSF interleukin-10, S100Beta, and tumor necrosis factor α were increased similarly in both anesthetic groups at 24 h, but interleukin-6 was increased more in the inhalational group. Conclusion: These data indicate a robust neuroinflammatory response, including not only the usual markers (interleukin-6, tumor necrosis factor α, interleukin-10), but also S100Beta and tau, markers of injury. The total-tau/amyloid-β(1-42) ratio increased in a pattern consistent with Alzheimer disease, largely because of an increase in total-tau rather than a decline in amyloid-β(1-42). The differences in CSF interleukin-6 concentrations suggest that anesthetic management may make a difference in neuroinflammatory response. © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Impact of the prone position in an animal model of unilateral bacterial pneumonia undergoing mechanical ventilation

Background: The prone position (PP) has proven beneficial in patients with severe lung injury subjected to mechanical ventilation (MV), especially in those with lobar involvement. We assessed the impact of PP on unilateral pneumonia in rabbits subjected to MV. Methods: After endobronchial challenge with Enterobacter aerogenes, adult rabbits were subjected to either "adverse" (peak inspiratory pressure = 30 cm H2O, zero end-expiratory pressure; n = 10) or "protective" (tidal volume = 8 ml/kg, 5 cm H2O positive end-expiratory pressure; n = 10) MV and then randomly kept supine or turned to the PP. Pneumonia was assessed 8 h later. Data are presented as median (interquartile range). Results: Compared with the supine position, PP was associated with significantly lower bacterial concentrations within the infected lung, even if a "protective" MV was applied (5.93 [0.34] vs. 6.66 [0.86] log10 cfu/g, respectively; P = 0.008). Bacterial concentrations in the spleen were also decreased by the PP if the "adverse" MV was used (3.62 [1.74] vs. 6.55 [3.67] log10 cfu/g, respectively; P = 0.038). In addition, the noninfected lung was less severely injured in the PP group. Finally, lung and systemic inflammation as assessed through interleukin-8 and tumor necrosis factor-α measurement was attenuated by the PP. Conclusions: The PP could be protective if the host is subjected to MV and unilateral bacterial pneumonia. It improves lung injury even if it is utilized after lung injury has occurred and nonprotective ventilation has been administered. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Preoperative fasting practices in pediatrics

Background: The purpose of this study was to determine current practice patterns for preoperative fasting at major pediatric hospitals. Methods: Fasting guidelines for children at each of the hospitals listed in the second edition of the Directory of Pediatric Anesthesiology Fellowship Programs were solicited and analyzed. Results: Fifty-one institutions were surveyed, and 44 responded. In 50%, clear fluids were permitted up to 2 h prior to anesthesia for all children. Breast milk was restricted to 4 h for children younger than 6 months in 61% of hospitals. Institutions were equally divided (39% each) between a 4-h and a 6-h fast for formula in infants younger than 6 months; for infants older than 6 months, 50% of hospitals restricted formula feeding to 6 h. There was no consensus for solid feeding in children younger than 3 yr, but 50% of hospitals agree that solids should be restricted after midnight in children older than 3 yr. Conclusions: There is no uniform fasting practice for children before elective surgery in the United States and Canada. However, there is agreement among most institutions that ingestion of clear fluids 2-3 h prior to general anesthesia is acceptable. Most also accept a 4-h restriction for breast milk and a 6-h restriction for nonhuman formula. There is great diversity among institutions regarding fasting for solids in children, with many restricting intake after midnight. There is little agreement about whether infant formula should be treated in the same way as solid food or how to categorize breast milk.

Autopsy utilization in medicolegal defense of anesthesiologists

Background: The rate of autopsy in hospital deaths has declined from more than 50% to 2.4% over the past 50 yr. To understand the role of autopsies in anesthesia malpractice claims, we examined 980 closed claims for deaths that occurred in 1990 or later in the American Society of Anesthesiologists Closed Claims Project Database. Methods: Deaths with autopsy were compared with deaths without autopsy. Deaths with autopsy were evaluated to answer the following four questions: Did autopsy findings establish a cause of death? Did autopsy provide new information? Did autopsy identify a significant nonanesthetic contribution to death? Did autopsy help or hurt the defense of the anesthesiologist? Reliability was assessed by κ scores. Differences between groups were compared with chi-square analysis and Kolmogorov-Smirnov test with P < 0.05 for statistical significance. Results: Autopsies were performed in 551 (56%) of 980 claims for death. Evaluable autopsy information was available in 288 (52%) of 551 claims with autopsy. Patients in these 288 claims were younger and healthier than those in claims for death without autopsy (P < 0.01). Autopsy provided pathologic diagnoses and an unequivocal cause of death in 21% of these 288 claims (κ= 0.71). An unexpected pathologic diagnosis was found in 50% of claims with evaluable autopsy information (κ = 0.59). Autopsy identified a significant nonanesthetic contribution in 61% (κ = 0.64) of these 288 claims. Autopsy helped in the defense of the anesthesiologist in 55% of claims and harmed the defense in 27% (κ = 0.58) of claims with evaluable autopsy information. Conclusions: Autopsy findings were more often helpful than harmful in the medicolegal defense of anesthesiologists. Autopsy identified a significant nonanesthetic contribution to death in two thirds of claims with evaluable autopsy information. © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Prolonged central venous desaturation measured by continuous oximetry is associated with adverse outcomes in pediatric cardiac surgery

Background: The role of continuous central venous oxygen saturation (ScvO2) oximetry during pediatric cardiac surgery for predicting adverse outcomes is not known. Using a recently available continuous ScvO2 oximetry catheter, we examined the association between venous oxygen desaturations and patient outcomes. We hypothesized that central venous oxygen desaturations are associated with adverse clinical outcomes. Methods: Fifty-four pediatric patients undergoing cardiac surgery were prospectively enrolled in an unblinded observational study. ScvO2 was measured continuously in the operating room and for up to 24 h post-Intensive Care Unit admission. The relationships between ScvO2 desaturations, clinical outcomes, and major adverse events were determined. RESULTS:: More than 18 min of venous saturations less than 40% were associated with major adverse events with 100% sensitivity and 97.6% specificity. Significant correlations resulted between the ScvO2 area under the curve less than 40% and creatinine clearance at 12 h in the Intensive Care Unit (r =-0.58), Intensive Care Unit length of stay (r = 0.56), max inotrope use (r = 0.52), inotrope use at 24 h (r = 0.40), inotrope index score (r = 0.39), hospital length of stay (r = 0.36), and length of intubation (r = 0.32). Conclusions: We demonstrate that ScvO2 desaturations by continuous oximetry are associated with major adverse events in pediatric patients undergoing cardiac surgery. The most significant associations with major adverse events are seen in patients with greater than 18 min of central venous saturations less than 40%. Our results support the further investigation of ScvO2 as a potential target parameter in high-risk pediatric patients to minimize the risk of major adverse events. © 2011 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Effects of an Innovative Psychotherapy Program for Surgical Patients: Bridging Intervention in Anesthesiology - A Randomized Controlled Trial

Background: The stepped care program Bridging Intervention in Anesthesiology (BRIA) aims at motivating and supporting surgical patients with comorbid mental disorders to engage in psychosocial mental healthcare options. This study examined the efficacy of BRIA. Methods: This randomized, parallel-group, open-label, controlled trial was conducted in the preoperative anesthesiological assessment clinics and surgical wards of a large university hospital in Germany. A total of 220 surgical patients with comorbid mental disorders were randomized by using the computer-generated lists to one of two intervention groups: BRIA psychotherapy sessions up to 3 months postoperatively (BRIA) versus no psychotherapy/computerized brief written advice (BWA) only. Primary outcome was participation in psychosocial mental healthcare options at month 6. Secondary outcome was change of self-reported general psychological distress (Global Severity Index of the Brief Symptom Inventory) between baseline and month 6. Results: At 6-month follow-up, the rate of patients who engaged in psychosocial mental healthcare options was 30% (33 of 110) in BRIA compared with 11.8% (13 of 110) in BWA (P = 0.001). Number needed to treat and relative risk reduction were 6 (95% CI, 4 to 13) and 0.21 (0.09 to 0.31), respectively. In BRIA, Global Severity Index decreased between baseline and month 6 (P < 0.001), whereas it did not change significantly in BWA (P = 0.197). Conclusions: Among surgical patients with comorbid mental disorders, BRIA results in an increased engagement in subsequent therapy options and a decrease of general psychological distress. These data suggest that it is reasonable to integrate innovative psychotherapy programs into the context of interdisciplinary surgical care.

Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period

Background: The subjective experience of residual neuromuscular blockade after emergence from anesthesia has not been examined systematically during postanesthesia care unit (PACU) stays. The authors hypothesized that acceleromyography monitoring would diminish unpleasant symptoms of residual paresis during recovery from anesthesia by reducing the percentage of patients with train-of-four ratios less than 0.9. Methods: One hundred fifty-five patients were randomized to receive intraoperative acceleromyography monitoring (acceleromyography group) or conventional qualitative train-of-four monitoring (control group). Neuromuscular management was standardized, and extubation was performed when defined criteria were achieved. Immediately upon a patient's arrival to the PACU, the patient's train-of-four ratios were measured using acceleromyography, and a standardized examination was used to assess 16 symptoms and 11 signs of residual paresis. This examination was repeated 20, 40, and 60 min after PACU admission. RESULTS:: The incidence of residual blockade (train-of-four ratios less than 0.9) was reduced in the acceleromyography group (14.5% vs. 50.0% control group, with the 99% confidence interval for this 35.5% difference being 16.4-52.6%, P < 0.0001). Generalized linear models revealed the acceleromyography group had less overall weakness (graded on a 0-10 scale) and fewer symptoms of muscle weakness across all time points (P < 0.0001 for both analyses), but the number of signs of muscle weakness was small from the time of arrival in the PACU and did not differ between the groups at any time. CONCLUSION:: Acceleromyography monitoring reduces the incidence of residual blockade and associated unpleasant symptoms of muscle weakness in the PACU and improves the overall quality of recovery. © 2011 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Influence of the type of anesthesia provider on costs of labor analgesia to the Texas Medicaid Program

Background: The Texas Medicaid Program (Medicaid) defines billable time for labor analgesia as face-to-face time; therefore, anesthesia providers determine billed time. The authors' goal was to determine the influence of anesthesia providers on labor analgesia costs billed to Medicaid. Methods: Under the Freedom of Information Act, Medicaid provided data on claims paid for 6 months in 2001 for labor analgesia administered during the course of a vaginal delivery. Claims were either time based (codes 00946 or 00955) or a flat fee (codes 26311 or 26319). Using modifiers, the authors grouped time-based claims as either anesthesiologist group or certified registered nurse anesthetist (CRNA) group. The cost to Medicaid was based on the 2001 fee schedule. The conversion factor was $18.21 per American Society of Anesthesiologists unit. The flat-fee reimbursement was $152.50. CRNA services were paid at 85% of the fee schedule. Average time per time claim, percent of providers with more than 4 h of billed time, and cost per claim were determined for each group. Providers with more than 120 claims (> 20 claims/month) were considered high-volume. Results: The database included 21,378 claims (anesthesiologist group: 12,698 claims from 219 providers; CRNA group: 8,680 claims from 117 providers). For time-based claims, the average time per case was significantly higher in the CRNA group (146 min) than in the anesthesiologist group (105 min). The CRNA group cost to Medicaid ($225.11) was 19% more per claim than the anesthesiologist group ($189.26). The difference in cost per claim was greater among high-volume providers-$213.10 for the CRNA group versus $168.76 for the anesthesiologist group. If a flat-fee program were instituted using the average cost per claim for all groups ($203.81), the Texas Medicaid program would save more than $500,000 annually. Conclusions: The costs of labor analgesia billed to Texas Medicaid were 19% to 26% less per patient when provided by anesthesiologists than by CRNAs, despite lower per-unit reimbursement of CRNAs.

Association between anesthesiologist age and litigation

Background: The threat of being sued is a concern for many anesthesiologists. This paper asks whether litigation brought against anesthesiologists is associated with the age of the anesthesiologist. Methods: Institutional research ethics approval was granted. We obtained billing data for all procedures performed by specialist anesthesiologists stratified into three age groups (less than 51, 51-64, and 65 and older) from British Columbia, Quebec, and Ontario for the 10-yr period from Jan. 1, 1993 to Dec. 31, 2002. We also obtained all litigations (including disability weighted claims) handled by the Canadian Medical Protective Association during the same time period in which the Canadian Medical Protective Association experts considered the anesthesiologist cited to be at least partially responsible for the adverse event leading to the complaint. Results: In univariate analysis with the less than 51 age group as the reference category, the litigation rate ratio for the 51-64 age group was 1.14 (95% CI: 0.99-1.32) and for the 65 and older age group was 1.50 (95% CI: 1.14-1.97). Our analyses using disability weighted claims showed the 51-64 group to have 1.31 (95% CI: 0.95-1.80) and 65 and older group to have 1.94 (95% CI: 1.41-2.67) relative increase in disability compared to the less than 51 age group. Conclusions: We found a higher frequency of litigation and a greater severity of injury in patients treated by anesthesiologists in the 65 and older group. The reasons for these findings should become an active field of research. Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.

Evolution of the inflammatory and fibroproliferative responses during resolution and repair after ventilator-induced lung injury in the rat

Background: The time course and mechanisms of resolution and repair, and the potential for fibrosis following ventilation-induced lung injury (VILI), are unclear. We sought to examine the pattern of inflammation, injury, repair, and fibrosis following VILI. Methods: Sixty anesthetized rats were subject to high-stretch; low-stretch, or sham ventilation, and randomly allocated to undergo periods of recovery of 6, 24, 48, and 96 h, and 7 and 14 days. Animals were then reanesthetized, and the extent of lung injury, inflammation, and repair determined. RESULTS:: No injury was seen following low-stretch or sham ventilation. VILI caused severe lung injury, maximal at 24 h, but largely resolved by 96 h. Arterial oxygen tension decreased from a mean (SD) of 144.8 (4.1) mmHg to 96.2 (10.3) mmHg 6 h after VILI, before gradually recovering to 131.2 (14.3) mmHg at 96 h. VILI induced an early neutrophilic alveolitis and a later lymphocytic alveolitis, followed by a monocyte/macrophage infiltration. Alveolar tumor necrosis factor-α, interleukin-1β, and transforming growth factor-β1 concentrations peaked at 6 h and returned to baseline within 24 h, while interleukin-10 remained increased for 48 h. VILI generated a marked but transient fibroproliferative response, which restored normal lung architecture. There was no evidence of fibrosis at 7 and 14 days. Conclusions: High-stretch ventilation caused severe lung injury, activating a transient inflammatory and fibroproliferative repair response, which restored normal lung architecture without evidence of fibrosis. © 2011 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Detection of intraoperative incidents by electronic scanning of computerized anesthesia records: Comparison with voluntary reporting

Background: The use of a computerized anesthesia information management system provides an opportunity to scan case records electronically for deviations from specific limits for physiologic variables. Anesthesia department policy may define such deviations as intraoperative incidents and may require anesthesiologists to report their occurrence. The actual incidence of such events is not known. Neither is the level of compliance with voluntary reporting. Methods: Using automated anesthesia record-keeping with long-term storage, physiologic data were recorded every 15 s from 5,454 patients undergoing noncardiothoracic surgery. Recorded measurements of blood pressure, heart rate, arterial oxygen saturation, and temperature were electronically analyzed for deviations from defined limits. The computer system also was used by anesthesiologists to report voluntarily those deviations as intraoperative incidents. For each electronically detected incident: 1) the complete automated anesthesia record was examined by two senior anesthesiologists who, by consensus, eliminated case records with artifact or in which context suggested that the incident was not clinically relevant, and 2) the anesthesia information management system database was checked for voluntary reporting. Results: In 473 automated anesthesia records, 494 incidents were found by electronic scanning of 5,454 automated anesthesia records. Sixty intraoperative incidents were eliminated, 25 due to artifact and 35 due to context. When the remaining 434 intraoperative incidents were checked for voluntary reporting, 18 (4.1%) matching voluntary reports were found. All intraoperative incidents that were reported voluntarily also were detected by electronic scanning. Based on a 10% sample, the sensitivity rate of electronic scanning was 97.2% (35/36), and the specificity rate was 98.4% (427/434). Among 413 cases with electronically detected intraoperative incidents, there were 29 deaths (7.0%), whereas there were only 79 deaths (1.6%) among 5,041 cases without incidents (χ2 = 58.5, P &lt; 0.001). Conclusions: The use of an anesthesia information management system facilitated analysis of intraoperative physiologic data and identified certain intraoperative incidents with high sensitivity and specificity. A low level of compliance with voluntary reporting of defined intraoperative incidents was found for all anesthesiologists studied. Finally, there was a strong association between intraoperative incidents and in-hospital mortality.

An in vivo evaluation of the mycobacterial filtration efficacy of three breathing filters used in anesthesia

Background: The use of breathing filters (BFs) has been recommended to protect the anesthesia apparatus in proven or suspected cases of tuberculosis. Some investigators have also suggested the use of BF to alleviate the need to change anesthesia breathing circuits after each case. This study evaluated the filtration efficacy of three different BFs to prevent mycobacterial contamination of breathing circuits in a model that uses a test animal. Methods: Ten Pall BB25A® (pleated hydrophobic) (Pall Canada Ltd., Mississauga, Ontario, Canada), six DAR Barrierbac S® (felted electrostatic; Mallinckrodt DAR, Mirandola, Italy), and six Baxter Airlife® (felted electrostatic; Baxter Canada, Mississauga, Ontario, Canada) BFs were studied. For each BF tested, 20 ml of a high concentration suspension of Mycobacterium chelonae (range, 2.0 × 107 to 9.0 × 107 colony-forming units/ ml) was nebulized during 2 h at the proximal end of the endotracheal tube of anesthetized pigs. At the end of the nebulization period, the BFs were sampled for culture. The titer reduction value (number of microorganisms challenging the BF divided by the number of microorganisms recovered downstream of the BF) and the removal efficiency (difference between the number of microorganisms challenging the BF and the number of microorganisms recovered downstream of the BF, divided by the number of microorganisms challenging the BF) were calculated. Results: The median titer reduction values were 5.6 × 105, 6.0 × 105, and 8.0 × 108 (P &lt; 0.0005), and the median removal efficiencies were greater than 99.999%, greater than 99.999%, and 100% (P = not significant) for the DAR Barrierbac S®, the Baxter Airlife®, and the Pall BB25A®, respectively. Conclusions: Among the three BFs studied, only the Pall BB25A® completely prevented the passage of M. chelonae, thus protecting the anesthesia breathing circuit from mycobacterial contamination.

A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist

BACKGROUND: The use of propofol to sedate patients for colonoscopy, generally administered by an anesthesiologist in North America, is increasingly popular. In the United States, regional use of anesthesiologist-assisted endoscopy appears to correlate with local payor policy. This study's objective was to identify nonpayor factors (patient, physician, institution) associated with anesthesiologist assistance at colonoscopy. METHODS: The authors performed a population-based cross-sectional analysis using Ontario health administrative data, 1993-2005. All outpatient colonoscopies performed on adults were identified. Hierarchical multivariable modeling was used to identify patient (age, sex, income quintile, comorbidity), physician (specialty, colonoscopy volume), and institution (type, volume) factors associated with receipt of anesthesiologist-assisted colonoscopy. RESULTS: During the study period, 1,838,879 colonoscopies were performed on 1,202,548 patients. The proportion of anesthesiologist-assisted colonoscopies rose from 8.4% in 1993 to 19.1% in 2005 (P < 0.0001). In the hierarchical model, patients in low-volume community hospitals were five times more likely to receive anesthesiologist-assisted colonoscopy than patients in high-volume community hospitals (odds ration 4.9; 95% confidence interval 4.4-5.5). Less than 1% of colonoscopies in academic hospitals were anesthesiologist-assisted. Compared to gastroenterologists, surgeons were more likely to perform anesthesiologist-associated colonoscopy (odds ratio 1.7; 95% confidence interval 1.1-2.6). CONCLUSIONS: In Ontario, rates of anesthesiologist-assisted colonoscopy have risen dramatically. Institution type was most strongly associated with this practice. Further investigation is needed to determine the most appropriate criteria for the use of anesthesiology services during colonoscopy. © 2009, the American Society of Anesthesiologists, Inc.

Caffeine Accelerates Emergence from Isoflurane Anesthesia in Humans A Randomized, Double-blind, Crossover Study

Background: There are currently no drugs clinically available to reverse general anesthesia. We previously reported that caffeine is able to accelerate emergence from anesthesia in rodents. This study was carried out to test the hypothesis that caffeine accelerates emergence from anesthesia in humans. Methods: We conducted a single-center, randomized, double-blind crossover study with eight healthy males. Each subject was anesthetized twice with 1.2% isoflurane for 1 h. During the final 10 min of each session, participants received an IV infusion of either caffeine citrate (15 mg/kg, equivalent to 7.5 mg/kg of caffeine base) or saline placebo. The primary outcome was the average difference in time to emergence after isoflurane discontinuation between caffeine and saline sessions. Secondary outcomes included the end-tidal isoflurane concentration at emergence, vital signs, and Bispectral Index values measured throughout anesthesia and emergence. Additional endpoints related to data gathered from postanesthesia psychomotor testing. Results: All randomized participants were included in the analysis. The mean time to emergence with saline was 16.5 ± 3.9 (SD) min compared to 9.6 ± 5.1 (SD) min with caffeine (P = 0.002), a difference of 6.9 min (99% CI, 1.8 to 12), a 42% reduction. Participants emerged at a higher expired isoflurane concentration, manifested more rapid return to baseline Bispectral Index values, and were able to participate in psychomotor testing sooner when receiving caffeine. There were no statistically significant differences in vital signs with caffeine administration and caffeine-related adverse events. Conclusions: Intravenous caffeine is able to accelerate emergence from isoflurane anesthesia in healthy males without any apparent adverse effects. Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Fiberoptic Intubation Using Anesthetized, Paralyzed, Apneic Patients Results of a Resident Training Program

Background: There is no consensus about the best way to teach fiberoptic intubation. This study assesses the effectiveness of a training program in which novice anesthetic residents routinely were taught fiberoptic tracheal intubation of anesthetized, paralyzed, apneic patients. Methods: Eight inexperienced anesthetic residents learned fiberoptic and conventional tracheal intubation simultaneously during their first 4 months of training. All intubations were performed using general anesthesia and muscle paralysis. Of these intubations, 223 (23%) were fiberoptic and 743 (77%) were laryngoscopic. Subsequently, their intubation skills with the two techniques were studied in a prospective, single-blind randomized trial involving 131 elective patients. Intubation times, SpO2, ETCO2, hemodynamic changes on intubation, and complications were recorded for 71 fiberoptic and 57 laryngoscopic intubations. Results: There were two failures of the rigid and one failure of the fiberoptic technique due to inability to intubate within 180 s. In cases of failure, the tracheas were intubated successfully after mask ventilation by the alternative technique. No hypoxemia or hypercarbia occurred in any patient. There were no differences in hemodynamic indexes nor incidence of sore throat or hoarseness between the two groups. Mean intubation times were 56 ± 24 s (mean ± SD) for fiberoptic and 34 ± 10 s (mean ± SD) for laryngoscopic (P &lt; 0.001). Conclusions: Novices taught fiberoptic intubation and rigid laryngoscopic intubation under similar conditions, with similar volumes of experience, learn both techniques well. The safety and effectiveness of this training regimen commend it for inclusion in any residency program.

Effect of Performance Deficiencies on Graduation and Board Certification Rates: A 10-yr Multicenter Study of Anesthesiology Residents

Background: This multicenter, retrospective study was conducted to determine how resident performance deficiencies affect graduation and board certification. Methods: Primary documents pertaining to resident performance were examined over a 10-yr period at four academic anesthesiology residencies. Residents entering training between 2000 and 2009 were included, with follow-up through February 2016. Residents receiving actions by the programs' Clinical Competency Committee were categorized by the area of deficiency and compared to peers without deficiencies. Results: A total of 865 residents were studied (range: 127 to 275 per program). Of these, 215 residents received a total of 405 actions from their respective Clinical Competency Committee. Among those who received an action compared to those who did not, the proportion graduating differed (93 vs. 99%, respectively, P < 0.001), as did the proportion achieving board certification (89 vs. 99%, respectively, P < 0.001). When a single deficiency in an Essential Attribute (e.g., ethical, honest, respectful behavior; absence of impairment) was identified, the proportion graduating dropped to 55%. When more than three Accreditation Council for Graduate Medical Education Core Competencies were deficient, the proportion graduating also dropped significantly. Conclusions: Overall graduation and board certification rates were consistently high in residents with no, or isolated, deficiencies. Residents deficient in an Essential Attribute, or multiple competencies, are at high risk of not graduating or achieving board certification. More research is needed on the effectiveness and selective deployment of remediation efforts, particularly for high-risk groups.

Clinical assessment of the ultrasonographic measurement of antral area for estimating preoperative gastric content and volume

Background: This prospective observational study aimed to assess the feasibility and performance of the ultrasonographic measurement of antral cross-sectional area (CSA) for the preoperative assessment of gastric contents and volume in adult patients and for the diagnosis of risk stomach (defined by the presence of solid particles and/or gastric fluid volume >0.8 ml/kg). Methods: A preoperative ultrasonographic measurement of the antral CSA was performed for each patient by a physician (L.B.) blinded to the history of the patient. Immediately after tracheal intubation, an 18-French multiorifice Salem tube was inserted and gastric contents were aspirated in five different patient positions; during this time, the patient's epigastrium was massaged and the tube was moved backward and forward in the stomach. The relationship between the antral area and the volume of aspirated gastric contents was analyzed, as was the performance of ultrasonographic measurement of antral area for the diagnosis of risk stomach. Results: The measurement of antral CSA was performed on 180 of 183 patients. A significant positive relationship between antral CSA and aspirated fluid volume was found. The cutoff value of antral CSA of 340 mm for the diagnosis of risk stomach was associated with a sensitivity of 91% and a specificity of 71%. The area under the receiver operating characteristic curve for the diagnosis of risk stomach was 90%. Conclusions: The ultrasonographic measurement of antral CSA could be an important help for the anesthesiologist in minimizing the risk of pulmonary aspiration of gastric contents due to general anesthesia. Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block

BACKGROUND: This prospective, randomized, blinded study tested the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block as compared with nerve stimulation guidance when using a multiple injection technique. METHODS: Sixty American Society of Anesthesiology physical status I-III patients receiving axillary brachial plexus block with 20 ml ropivacaine, 0.75%, using a multiple injection technique, were randomly allocated to receive either nerve stimulation (group NS, n = 30), or ultrasound guidance (group US, n = 30) for nerve location. A blinded observer recorded the onset of sensory and motor blocks, the need for general anesthesia (failed block) or greater than 100 μg fentanyl (insufficient block) to complete surgery, procedure-related pain, success rate, and patient satisfaction. RESULTS: The median (range) number of needle passes was 4 (3-8) in group US and 8 (5-13) in group NS (P = 0.002). The onset of sensory block was shorter in group US (14 ± 6 min) than in group NS (18 ± 6 min) (P = 0.01), whereas no differences were observed in onset of motor block (24 ± 8 min in group US and 25 ± 8 min in group NS; P = 0.33) and readiness to surgery (26 ± 8 min in group US and 28 ± 9 min in group NS; P = 0.48). No failed block was reported in either group. Insufficient block was observed in 1 patient (3%) of group US and 2 patients (6%) of group NS (P = 0.61). Procedure-related pain was reported in 6 patients (20%) of group US and 14 patients (48%) of group NS (P = 0.028); patient acceptance was similarly good in the two groups. CONCLUSION: Multiple injection axillary block with ultrasound guidance provided similar success rates and comparable incidence of complication as compared with nerve stimulation guidance. © 2007 American Society of Anesthesiologists, Inc.

Repeated cross-sectional surveys of burnout, distress, and depression among anesthesiology residents and first-year graduates

Background: This repeated cross-sectional survey study was conducted to determine the prevalence of, and factors associated with, burnout, distress, and depression among anesthesiology residents and first-year graduates. We hypothesized that heavy workload and student debt burden were associated with a higher risk of physician burnout, distress, and depression, and that perception of having adequate workplace resources, work-life balance, and social support were associated with a lower risk. Methods: Physicians beginning U.S. anesthesiology residency between 2013 and 2016 were invited to take online surveys annually from their clinical anesthesia year 1 to 1 yr after residency graduation. The Maslach Burnout Inventory, the Physician Well-Being Index, and the Harvard Department of Psychiatry/National Depression Screening Day Scale were used to measure burnout, distress, and depression, respectively. Logistic regression analyses were conducted to examine whether self-reported demographics, personal, and professional factors were associated with the risk of burnout, distress, and depression. Results: The response rate was 36% (5,295 of 14,529). The prevalence of burnout, distress, and depression was 51% (2,531 of 4,966), 32% (1,575 of 4,941), and 12% (565 of 4,840), respectively. Factors associated with a lower risk of all three outcomes included respondents' perceived workplace resource availability, (odds ratio = 0.51 [95% CI, 0.45 to 0.57] for burnout; 0.51 [95% CI, 0.45 to 0.56] for distress; 0.52 [95% CI, 0.45 to 0.60] for depression) and perceived ability to maintain work-life balance (0.61 [95% CI, 0.56 to 0.67] for burnout; 0.50 [95% CI, 0.46 to 0.55] for distress; 0.58 [95% CI, 0.51 to 0.65] for depression). A greater number of hours worked per week and a higher amount of student debt were associated with a higher risk of distress and depression, but not burnout. conclusions: Burnout, distress, and depression are notable among anesthesiology residents. Perceived institutional support, work-life balance, strength of social support, workload, and student debt impact physician well-being. © 2019, the American Society of Anesthesiologists, Inc. All Rights Reserved. Anesthesiology 2019; 131:668-77. DOI: 10.1097/ALN.00000000000027

Practice Improvements Based on Participation in Simulation for the Maintenance of Certification in Anesthesiology Program

Background: This study describes anesthesiologists' practice improvements undertaken during the first 3 yr of simulation activities for the Maintenance of Certification in Anesthesiology Program. Methods: A stratified sampling of 3 yr (2010-2012) of participants' practice improvement plans was coded, categorized, and analyzed. Results: Using the sampling scheme, 634 of 1,275 participants in Maintenance of Certification in Anesthesiology Program simulation courses were evaluated from the following practice settings: 41% (262) academic, 54% (339) community, and 5% (33) military/other. A total of 1,982 plans were analyzed for completion, target audience, and topic. On follow-up, 79% (1,558) were fully completed, 16% (310) were partially completed, and 6% (114) were not completed within the 90-day reporting period. Plans targeted the reporting individual (89% of plans) and others (78% of plans): anesthesia providers (50%), non-anesthesia physicians (16%), and non-anesthesia non-physician providers (26%). From the plans, 2,453 improvements were categorized as work environment or systems changes (33% of improvements), teamwork skills (30%), personal knowledge (29%), handoff (4%), procedural skills (3%), or patient communication (1%). The median word count was 63 (interquartile range, 30 to 126) for each participant's combined plans and 147 (interquartile range, 52 to 257) for improvement follow-up reports. Conclusions: After making a commitment to change, 94% of anesthesiologists participating in a Maintenance of Certification in Anesthesiology Program simulation course successfully implemented some or all of their planned practice improvements. This compares favorably to rates in other studies. Simulation experiences stimulate active learning and motivate personal and collaborative practice improvement changes. Further evaluation will assess the impact of the improvements and further refine the program. © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Toll-like receptor 4 inhibitor TAK-242 attenuates acute kidney injury in endotoxemic sheep

Background: This study was conducted to investigate the role of toll-like receptor 4 (TLR4) in mediating acute kidney injury in endotoxemic sheep using the selective TLR4 inhibitor TAK-242. Methods: A randomized, controlled, experimental study was performed with 20 adult Texel crossbred sheep. Before an Escherichia coli lipopolysaccharide infusion (3 μg • kg -1• h-1 for 24 h), sheep were randomized to receive a bolus dose (2 mg/kg-1), followed by a continuous infusion (4 mg • kg-1 • 24 h-1) of either TAK-242 (n = 7) or vehicle (n = 7). A third group of lipopolysaccharide-treated sheep (n = 6) received norepinephrine, titrated to maintain baseline arterial blood pressure. Results: Endotoxin infusion established a state of hyperdynamic circulation, with an increased cardiac index, hypotension, and tachycardia. Urine output and creatinine clearance decreased throughout the experiment, together with increasing plasma creatinine, blood urea nitrogen, and arterial lactate concentrations. After 24 h, TLR4 inhibition had significantly (P ≤ 0.001) attenuated the mean ± SEM decrease in arterial pressure (97 ± 3 vs. 71 ± 4 mmHg), urine output (1.16 ± 0.15 vs. 0.13 ± 0.05 ml • kg • h), and creatinine clearance (126 ± 13 vs. 20 ± 7 ml/min) compared with vehicle-treated animals. Furthermore, arterial lactate, plasma creatinine, and blood urea nitrogen concentrations were significantly lower in the TAK-242 group versus the vehicle-treated animals. Compared with TLR4 inhibition, norepinephrine caused similar effects on arterial pressure, cardiac index, and heart rate; however, it did not attenuate the decrease in urine output or creatinine clearance. Conclusions: These results indicate a critical role for TLR4 in impairing renal function during ovine endotoxemia that is independent of changes in central hemodynamics. Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams &amp; Wilkins. Anesthesiology.

Magnetic resonance imaging analysis of the spread of local anesthetic solution after ultrasound-guided lateral thoracic paravertebral blockade: A volunteer study

Background: This study was designed to examine the spread of local anesthetic (LA) via magnetic resonance imaging after a standardized ultrasound-guided thoracic paravertebral blockade. Methods: Ten volunteers were enrolled in the study. We performed ultrasound-guided single-shot paravertebral blocks with 20 ml mepivacaine 1% at the thoracic six level at both sides on two consecutive days. After each paravertebral blockade, a magnetic resonance imaging investigation was performed to investigate the three-dimensional spread of the LA. In addition, sensory spread of blockade was evaluated via pinprick testing. Results: The median (interquartile range) cranial and caudal distribution of the LA relative to the thoracic six puncture level was 1.0 (2.5) and 3.0 (0.75) [=4.0 vertebral levels] for the left and 0.5 (1.0) and 3.0 (0.75) [=3.5 vertebral levels] for the right side. Accordingly, the LA distributed more caudally than cranially. The median (interquartile range) number of sensory dermatomes which were affected by the thoracic paravertebral blockade was 9.8 (6.5) for the left and 10.7 (8.8) for the right side. The sensory distribution of thoracic paravertebral blockade was significantly larger compared with the spread of LA. Conclusions: Although the spread of LA was reproducible, the anesthetic effect was unpredictable, even with a standardized ultrasound-guided technique in volunteers. While it can be assumed that approximately 4 vertebral levels are covered by 20 ml LA, the somatic distribution of the thoracic paravertebral blockade remains unpredictable. In a significant percentage, the LA distributes into the epidural space, prevertebral, or to the contralateral side. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Operating room fires: A closed claims analysis

Background: To assess patterns of injury and liability associated with operating room (OR) fires, closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1985 were reviewed. Methods: All claims related to fires in the OR were compared with nonfire-related surgical anesthesia claims. An analysis of fire-related claims was performed to identify causative factors. Results: There were 103 OR fire claims (1.9% of 5,297 surgical claims). Electrocautery was the ignition source in 90% of fire claims. OR fire claims more frequently involved older outpatients compared with other surgical anesthesia claims (P < 0.01). Payments to patients were more often made in fire claims (P < 0.01), but payment amounts were lower (median $120,166) compared to nonfire surgical claims (median $250,000, P < 0.01). Electrocautery-induced fires (n = 93) increased over time (P < 0.01) to 4.4% claims between 2000 and 2009. Most (85%) electrocautery fires occurred during head, neck, or upper chest procedures (high-fire-risk procedures). Oxygen served as the oxidizer in 95% of electrocautery-induced OR fires (84% with open delivery system). Most electrocautery-induced fires (n = 75, 81%) occurred during monitored anesthesia care. Oxygen was administered via an open delivery system in all high-risk procedures during monitored anesthesia care. In contrast, alcohol-containing prep solutions and volatile compounds were present in only 15% of OR fires during monitored anesthesia care. Conclusions: Electrocautery-induced fires during monitored anesthesia care were the most common cause of OR fires claims. Recognition of the fire triad (oxidizer, fuel, and ignition source), particularly the critical role of supplemental oxygen by an open delivery system during use of the electrocautery, is crucial to prevent OR fires. Continuing education and communication among OR personnel along with fire prevention protocols in high-fire-risk procedures may reduce the occurrence of OR fires. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Injury and liability associated with monitored anesthesia care: A closed claims analysis

Background: To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990. Methods: All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns. Results: MAC claims involved older and sicker patients compared with general anesthesia claims (P < 0.025), often undergoing elective eye surgery (21%) or facial plastic surgery (26%). More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims. In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%, n = 25) specific damaging mechanism in MAC claims. Nearly half of these claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms. On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%). Conclusions: Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires. © 2006 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Development and validation of the questionnaire of satisfaction with perioperative anesthetic care for general and regional anesthesia in taiwanese patients

Background: To fulfill the increasing demand of service quality improvement in recent years, it is imperative to develop a proper instrument to evaluate patient satisfaction with perioperative anesthetic care for many institutes in Taiwan. Methods: We used a six-factor 32-item pilot questionnaire developed in our previous study as our starting point in this study. Exploratory factor analysis of the pilot questionnaire for factor structure generation was performed in general anesthesia patients (group 1, n = 320) and resulted in the generation of the Patient Satisfaction with Perioperative Anesthetic Care questionnaire (PSPACq). Confirmatory factor analysis of the PSPACq in general anesthesia (group 2, n = 565) and regional anesthesia (group 3, n = 225) patients was performed for validation and cross-validation of the PSPACq model, respectively. The confounding variables and the patient loyalty effects on PSPACq scores were analyzed to evaluate the nomological validity of the PSPACq. Result: Exploratory factor analysis of the pilot questionnaire in group 1 resulted in the development of the PSPACq (a seven-factor 30-item model). The standardized coefficients and indexes for the assessment of fit of the PSPACq model in group 2 (validation) and group 3 (cross-validation) patients revealed a well-fitting model. The results of the loyalty scores and confounding variables support the nomological validity of the PSPACq. Conclusions: A valid and reliable questionnaire (PSPACq) with Taiwanese culture characteristics was developed and is suitable for testing of patient satisfaction with perioperative anesthesia care for patients receiving general or regional anesthesia for their surgery. Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

French survey of anesthesia in 1996

Background: To identify the growth in the number of anesthetic procedures since 1980 and the changes in the practice of anesthesia, the present survey was designed to collect and analyze the anesthetic activity performed in France in 1996, from a representative sample collected in all French hospitals and clinics. Methods: This study, initiated by the French Society of Anesthesia and Intensive Care, collected information that included the characteristics of patients (age, sex, American Society of Anesthesiologists status), the techniques of anesthesia, and the nature of the procedure for which anesthesia was required. All French private, public, and military hospitals were asked to participate in the survey. In each hospital in the country, all anesthetic procedures were documented and collected during 3 consecutive days, chosen at random during a 12-month period, to obtain a representative sample of the annual activity. All data were analyzed at the INSERM (National Institute of Health and Medical Research). At the conclusion of the study, 5% of hospitals were randomly assigned to be audited to check for missing data and errors. The rate of anesthetic activity was calculated as the ratio between the annual number of anesthetic procedures and the number of the general population in the same age group. Results: The participation rate of hospitals was 98%. The analysis of the 62,415 collected questionnaires allowed extrapolation of the anesthetic activity to 7,937,000 anesthetic procedures (95% confidence interval, ± 387,000) performed in France in 1996. Thus, the annual rate of anesthetic procedures was 13.5 per 100 population, varying between 5.4 per 100 in girls aged 5-14 yr and 30.2 per 100 in men aged 75-84 yr. Surgery was involved in 71% of anesthesia cases. Regional anesthesia alone was performed in 20% of all surgical cases and was combined with general anesthesia in 3% of additional cases. Anesthesia for obstetric procedures represented 9% of all cases. Seventy-six percent of all anesthetic procedures started between 12:00 A.M. and 7:00 A.M. were related to obstetric activities. Conclusion: In comparison with a previous study, the present survey shows that the number of anesthetic procedures has increased by 120% since 1980, and the rate of anesthetic procedures increased from 6.6 to 13.5 per 100 population, the major changes being observed in patients aged ≥ 75 yr and in those with an American Society of Anesthesiologists physical status of 3. In the same time period, the number of regional anesthetic procedures increased 14-fold. In obstetrics, the practice of epidural analgesia extended from 1.5% to 51% of all deliveries of the country.

Retrograde light-guided laryngoscopy for tracheal intubation: Clinical practice and comparison with conventional direct laryngoscopy

Background: Tracheal intubation with conventional laryngoscopy requires many trials until beginners are sufficiently skilled in intubating patients safely. To facilitate intubation, the authors used retrograde light-guided laryngoscopy (RLGL) and compared its feasibility with conventional direct laryngoscopy (DL). Methods: Twenty operators participated in a prospective, randomized, open-label, parallel-arm study. These operators intubated 205 patients randomly according to a computer-generated procedure by using either DL or RLGL (five intubations with each technique). The primary outcome was the success rate of tracheal intubation. The authors evaluated the success rate of tracheal intubation, the time to glottic exposure and tracheal intubation, and the Cormack and Lehane grades. Results: Compared with DL, the success rate was greater in the RLGL group for all five intubations (72% vs. 47%; rate difference, 25%; 95% CI [11.84-38.16%], P < 0.001). This was associated with a shorter time to glottic exposure (median [25th and 75th percentile]; 27 [15; 42] vs. 45 [30; 73] s, P < 0.001), shorter intubation time (66 [44; 120] vs. 120 [69; 120] s, P < 0.001), and decreased throat soreness (mean ± SD; visual analog scale, 2.1 ± 0.9 vs. 3.7 ± 1.0 cm, P = 0.001) in the RLGL group compared to the DL group. Conclusion: RLGL is an alternative intubation technique. In our study, it enables beginners to intubate patients more successfully and quickly than conventional DL. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Activation of triggering receptor expressed on myeloid cells-1 protects monocyte from apoptosis through regulation of myeloid cell leukemia-1

Background: Triggering receptor expressed on myeloid cells-1 (TREM-1) can amplify the proinflammatory response and may contribute to the pathogenesis of inflammatory disease such as sepsis. However, the role of TREM-1 in monocyte fate and the detailed molecular mechanisms evoked by TREM-1 are unknown. Methods: Adenoviruses overexpressing TREM-1 were constructed and transfected into a monocytic cell line. After activation of TREM-1 by agonist antibody with or without lipopolysaccharide, apoptosis was induced and assayed using flow cytometry. The signaling pathways downstream of TREM-1 were illustrated by inhibitory experiments. Proapoptotic/antiapoptotic protein levels were measured using immunoblot. In addition, the relationship between the expression levels of TREM-1 in monocytes and the magnitude of monocyte apoptosis were analyzed in septic patients. Results: Activation of TREM-1 protected monocytes from staurosporine-induced apoptosis. This characteristic was also obtained under lipopolysaccharide stimulation. The protection of TREM-1 against monocyte apoptosis was abrogated after inhibition of extracellular signal-regulated kinase or v-akt murine thymoma viral oncogene homologue signaling. Cross-linking of TREM-1 remarkably up-regulated myeloid cell leukemia-1 protein level, and inhibition of extracellular signal-regulated kinase or v-akt murine thymoma viral oncogene homologue resulted in the reduction of myeloid cell leukemia-1 expression. Inhibition of myeloid cell leukemia-1 abolished the antiapoptotic effect of TREM-1. Furthermore, in septic patients, TREM-1 levels were inversely correlated to the magnitude of apoptosis in monocyte. Conclusions: TREM-1 played an important role in apoptosis in monocytes. Activation of TREM-1 protected monocytic cells from apoptosis through activation of both extracellular signal-regulated kinase and v-akt murine thymoma viral oncogene homologue pathways and increased expression of myeloid cell leukemia-1 protein. These findings provide a novel additional mechanism for TREM-1-mediated hyperinflammatory response in monocytes. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Involvement of the tyr kinase/JNK pathway in carbachol-induced bronchial smooth muscle contraction in the rat

Background: Tyrosine (Tyr) kinases and mitogen-activated protein kinases have been thought to participate in the contractile response in various smooth muscles. The aim of the current study was to investigate the involvement of the Tyr kinase pathway in the contraction of bronchial smooth muscle. Methods: Ring preparations of bronchi isolated from rats were suspended in an organ bath. Isometric contraction of circular smooth muscle was measured. Immunoblotting was used to examine the phosphorylation of c-Jun N-terminal kinasess (JNKs) in bronchial smooth muscle. Results: To examine the role of mitogen-activated protein kinase(s) in bronchial smooth muscle contraction, the effects of MPAK inhibitors were investigated in this study. The contraction induced by carbachol (CCh) was significantly inhibited by pretreatment with selective Tyr kinase inhibitors (genistein and ST638, n = 6, respectively), and a JNK inhibitor (SP600125, n = 6). The contractions induced by high K depolarization (n = 4), orthovanadate (a potent Tyr phosphatase inhibitor) and sodium fluoride (a G protein activator; NaF) were also significantly inhibited by selective Tyr kinase inhibitors and a JNK inhibitor (n = 4, respectively). However, the contraction induced by calyculin-A was not affected by SP600125. On the other hand, JNKs were phosphorylated by CCh (2.2 ± 0,4 [mean±SEM] fold increase). The JNK phosphorylation induced by CCh was significantly inhibited by SP600125 (n = 4). Conclusion: These findings suggest that the Tyr kinase/JNK pathway may play a role in bronchial smooth muscle contraction. Strategies to inhibit JNK activation may represent a novel therapeutic approach for diseases involving airway obstruction, such as asthma and chronic obstructive pulmonary disease. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Formal instruction in difficult airway management: A survey of anesthesiology residency programs

Background: Up to 30% of all deaths attributable to anesthesia are related to difficulties with airway management. The purpose of this study was to determine whether anesthesiology residents are receiving specialized instruction in the various techniques and mechanical devices currently recommended for airway management in patients with anticipated or unanticipated difficult airways. Methods: A single anonymous questionnaire about resident instruction in the area of difficult airway management was mailed to the directors of 169 American anesthesiology programs. Results: Twenty-seven percent of the 143 programs from which there were responses require residents to participate in a rotation dedicated to management of the difficult airway. As they currently exist, rotations tend to be of short duration. Many are limited to lectures only and infrequently employ state- of-the-art teaching systems. In some programs, recognized airway management techniques such as the Bullard laryngoscope and esophageal-tracheal combitube are not taught at all. Conclusions: Based on the data obtained by the authors, formal instruction in difficult airway management is not offered by most residency programs. It is commonly taught as difficult clinical situations arise. Because these difficulties occur sporadically, opportunities for teaching are occasional. Learning based on sporadic and occasional occurrences risks incomplete and nonuniform training of residents.

Development and evaluation of a graphical anesthesia drug display

Background: Usable real-time displays of intravenous anesthetic concentrations and effects could significantly enhance intraoperative clinical decision-making. Pharmacokinetic models are available to estimate past, present, and future drug effectsite concentrations, and pharmacodynamic models are available to predict the drug's associated physiologic effects. Methods: An interdisciplinary research team (bioengineering, architecture, anesthesiology, computer engineering, and cognitive psychology) developed a graphic display that presents the real-time effect-site concentrations, normalized to the drugs' EC 95, of intravenous drugs. Graphical metaphors were created to show the drugs' pharmacodynamics. To evaluate the effect of the display on the management of total intravenous anesthesia, 15 anesthesiologists participated in a computer-based simulation study. The participants cared for patients during two experimental conditions: with and without the drug display. Results: With the drug display, clinicians administered more bolus doses of remifentanil during anesthesia maintenance. There was a significantly lower variation in the predicted effect-site concentrations for remifentanil and propofol, and effect-site concentrations were maintained closer to the drugs' EC 95. There was no significant difference in the simulated patient heart rate and blood pressure with respect to experimental condition. The perceived performance for the participants was increased with the drug display, whereas mental demand, effort, and frustration level were reduced. In a postsimulation questionnaire, participants rated the display to be a useful addition to anesthesia monitoring. Conclusions: The drug display altered simulated clinical practice. These results, which will inform the next iteration of designs and evaluations, suggest promise for this approach to drug data visualization.

Postoperative recovery with bispectral index versus anesthetic concentration-guided protocols

Background: Use of the bispectral index (BIS) monitor has been suggested to decrease excessive anesthetic drug administration, leading to improved recovery from general anesthesia. The purpose of this substudy of the B-Unawareand BAG-RECALL trials was to assess whether a BIS-based anesthetic protocol was superior to an end-tidal anesthetic concentration-based protocol in decreasing recovery time and postoperative complications. Methods: Patients at high risk for awareness were randomized to either BIS-guided or end-tidal anesthetic concentration-guided general anesthesia in the original trials. Outcomes included time to postanesthesia care unit discharge readiness, time to achieve a postoperative Aldrete score of 9-10, intensive care unit length of stay, postoperative nausea and vomiting, and severe postoperative pain. Univariate Cox regression and chi-square tests were used for statistical analyses. Results: The BIS cohort was not superior in time to postanesthesia care unit discharge readiness (hazard ratio, 1.0; 95% CI, 1.0-1.1; n = 2,949), time to achieve an Aldrete score of 9-10 (hazard ratio, 1.2; 95% CI, 1.0-1.4; n = 706), intensive care unit length of stay (hazard ratio, 1.0; 95% CI, 0.9-1.1; n = 2,074), incidence of postoperative nausea and vomiting (absolute risk reduction,-0.5%; 95% CI,-5.8 to 4.8%; n = 789), or incidence of severe postoperative pain (absolute risk reduction, 4.4%; 95% CI,-2.3 to 11.1%; n = 759). Conclusions: In patients at high risk for awareness, the BIS-guided protocol is not superior to an anesthetic concentration-guided protocol in time needed for postoperative recovery or in the incidences of common postoperative complications. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Determining resident clinical performance: Getting beyond the noise

Background: Valid and reliable (dependable) assessment of resident clinical skills is essential for learning, promotion, and remediation. Competency is defined as what a physician can do, whereas performance is what a physician does in everyday practice. There is an ongoing need for valid and reliable measures of resident clinical performance. Methods: Anesthesia residents were evaluated confidentially on a weekly basis by faculty members who supervised them. The electronic evaluation form had five sections, including a rating section for absolute and relative-to-peers performance under each of the six Accreditation Council for Graduate Medical Education core competencies, clinical competency committee questions, rater confidence in having the resident perform cases of increasing difficulty, and comment sections. Residents and their faculty mentors were provided with the resident's formative comments on a biweekly basis. Results: From July 2008 to June 2010, 140 faculty members returned 14,469 evaluations on 108 residents. Faculty scores were pervasively positively biased and affected by idiosyncratic score range usage. These effects were eliminated by normalizing each performance score to the unique scoring characteristics of each faculty member (Z-scores). Individual Z-scores had low amounts of performance information, but signal averaging allowed determination of reliable performance scores. Average Z-scores were stable over time, related to external measures of medical knowledge, identified residents referred to the clinical competency committee, and increased when performance improved because of an intervention. Conclusions: This study demonstrates a reliable and valid clinical performance assessment system for residents at all levels of training. © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Simulation-based assessment to identify critical gaps in safe anesthesia resident performance

Background: Valid methods are needed to identify anesthesia resident performance gaps early in training. However, many assessment tools in medicine have not been properly validated. The authors designed and tested use of a behaviorally anchored scale, as part of a multiscenario simulation-based assessment system, to identify high- and low-performing residents with regard to domains of greatest concern to expert anesthesiology faculty. © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.

Multimodal Analgesic Regimen for Spine Surgery A Randomized Placebo-controlled Trial

Background: Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores. Methods: Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 μg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h. Results: The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI,-6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being-9 (97.5% CI,-23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being-0.4 (97.5% CI;-0.8, 0.1, P = 0.094). Conclusions: An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery. (ANESTHESIOLOGY 2020; 132:992-1002). © 2020, the American Society of Anesthesiologists, Inc. All Rights Reserved.

Isoflurane regulates atypical type-a γ-aminobutyric acid receptors in alveolar type II epithelial cells

Background: Volatile anesthetics act primarily through upregulating the activity of γ-aminobutyric acid type A (GABAA) receptors. They also exhibit antiinflammatory actions in the lung. Rodent alveolar type II (ATII) epithelial cells express GABAA receptors and the inflammatory factor cyclooxygenase-2 (COX-2). The goal of this study was to determine whether human ATII cells also express GABAA receptors and whether volatile anesthetics upregulate GABAA receptor activity, thereby reducing the expression of COX-2 in ATII cells. Methods: The expression of GABAA receptor subunits and COX-2 in ATII cells of human lung tissue and in the human ATII cell line A549 was studied with immunostaining and immunoblot analyses. Patch clamp recordings were used to study the functional and pharmacological properties of GABAA receptors in cultured A549 cells. Results: ATII cells in human lungs and cultured A549 cells expressed GABAA receptor subunits and COX-2. GABA induced currents in A549 cells, with half-maximal effective concentration of 2.5 μM. Isoflurane (0.1-250 μM) enhanced the GABA currents, which were partially inhibited by bicuculline. Treating A549 cells with muscimol or with isoflurane (250 μM) reduced the expression of COX-2, an effect that was attenuated by cotreatment with bicuculline. Conclusions: GABAA receptors expressed by human ATII cells differ pharmacologically from those in neurons, exhibiting a higher affinity for GABA and lower sensitivity to bicuculline. Clinically relevant concentrations of isoflurane increased the activity of GABAA receptors and reduced the expression of COX-2 in ATII cells. These findings reveal a novel mechanism that could contribute to the antiinflammatory effect of isoflurane in the human lung. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists

Background: We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods: A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant's technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results: Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions: Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated. © Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Mandibular Advancement Improves the Laryngeal View during Direct Laryngoscopy Performed by Inexperienced Physicians

Background: When oral or nasal fiberoptic laryngoscopy is attempted, mandibular advancement has been reported to improve the laryngeal view. The authors hypothesized that mandibular advancement may also improve the laryngeal view during direct laryngoscopy. Methods: Forty patients undergoing elective surgery under general anesthesia were included in this study. After establishment of an adequate level of anesthesia and muscle relaxation, direct laryngoscopy was performed by inexperienced physicians. Four different maneuvers-simple direct laryngoscopy without any assistance (C), simple direct laryngoscopy with mandibular advancement (M), simple direct laryngoscopy with the BURP maneuver (backward, upward, rightward pressure maneuver of the larynx; B), and simple direct laryngoscopy with both mandibular advancement and the BURP maneuver (BM)-were attempted in each subject, and the laryngeal aperture was videotaped with each procedure. An instructor in anesthesiology who was blinded to the procedure evaluated the visualization by reviewing videotape off-line, using the Cormack-Lehane classification system (grades I-IV) and a rating score within each subject (1 = best view; 4 = poorest view). The Friedman test followed by the Student-Newman-Keuls test was performed for statistical comparison. P < 0.05 was considered significant. Results: The laryngeal view was improved with M and B when compared with C (P < 0.05 by both rating and Cormack-Lehane evaluation). BM was the most effective method to visualize the laryngeal aperture (P < 0.05, vs. B and M by rating evaluation), whereas B and M were the second and the third most effective methods, respectively. No statistical difference was observed between B and M with the Cormack-Lehane classification. Conclusion: Mandibular advancement improves the laryngeal view during direct laryngoscopy performed by inexperienced physicians.

Continuous femoral nerve blocks: Varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block

Background: Whether the method of local anesthetic administration for continuous femoral nerve blocks-basal infusion versus repeated hourly bolus doses-influences block effects remains unknown. Methods: Bilateral femoral perineural catheters were inserted in volunteers (n = 11). Ropivacaine 0.1% was concurrently administered through both catheters: a 6-h continuous 5 ml/h basal infusion on one side and 6 hourly bolus doses on the contralateral side. The primary endpoint was the maximum voluntary isometric contraction (MVIC) of the quadriceps femoris muscle at hour 6. Secondary endpoints included quadriceps MVIC at other time points, hip adductor MVIC, and cutaneous sensation 2 cm medial to the distal quadriceps tendon in the 22 h after initiation of local anesthetic administration. Results: Quadriceps MVIC for limbs receiving 0.1% ropivacaine as a basal infusion declined by a mean (SD) of 84% (19) compared with 83% (24) for those receiving 0.1% ropivacaine as repeated bolus doses between baseline and hour 6 (paired t test P = 0.91). Intrasubject comparisons (left vs. right) also reflected a lack of difference: the mean basal-bolus difference in quadriceps MVIC at hour 6 was-1.1% (95% CI-22.0-19.8%). The similarity did not reach the a priori threshold for concluding equivalence, which was the 95% CI decreasing within ± 20%. There were similar minimal differences in the secondary endpoints during local anesthetic administration. Conclusions: This study did not find evidence to support the hypothesis that varying the method of local anesthetic administration-basal infusion versus repeated bolus doses-influences continuous femoral nerve block effects to a clinically significant degree. © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

A systems theoretic process analysis of the medication use process in the operating room

Background: While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room. Methods: The authors completed a systems theoretic process analysis for the medication use process in the operating room at their institution. First, the authors defined medication-related accidents (adverse medication events) and hazards and created a hierarchical control structure (a schematic representation of the operating room medication use system). Then the authors analyzed this structure for unsafe control actions and causal scenarios that could lead to medication errors, incorporating input from surgeons, anesthesiologists, and pharmacists. The authors studied the entire medication use process, including requesting medications, dispensing, preparing, administering, documenting, and monitoring patients for the effects. Results were reported using descriptive statistics. Results: The hierarchical control structure involved three tiers of controllers: perioperative leadership; management of patient care by the attending anesthesiologist, surgeon, and pharmacist; and execution of patient care by the anesthesia clinician in the operating room. The authors identified 66 unsafe control actions linked to 342 causal scenarios that could lead to medication errors. Eighty-two (24.0%) scenarios came from perioperative leadership, 103 (30.1%) from management of patient care, and 157 (45.9%) from execution of patient care. Conclusions: In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives. © 2020 Lippincott Williams and Wilkins. All rights reserved.

Adaptive support ventilation may deliver unwanted respiratory rate-tidal volume combinations in patients with acute lung injury ventilated according to an open lung concept

Background: With adaptive support ventilation, respiratory rate and tidal volume (VT) are a function of the Otis least work of breathing formula. We hypothesized that adaptive support ventilation in an open lung ventilator strategy would deliver higher VTs to patients with acute lung injury. Methods: Patients with acute lung injury were ventilated according to a local guideline advising the use of lower VT (6-8 ml/kg predicted body weight), high concentrations of positive end-expiratory pressure, and recruitment maneuvers. Ventilation parameters were recorded when the ventilator was switched to adaptive support ventilation, and after recruitment maneuvers. If VT increased more than 8 ml/kg predicted body weight, airway pressure was limited to correct for the rise of VT. Results: Ten patients with a mean (±SD) Pao2/Fio2 of 171 ± 86 mmHg were included. After a switch from pressure-controlled ventilation to adaptive support ventilation, respiratory rate declined (from 31 ± 5 to 21 ± 6 breaths/min; difference = 10 breaths/min, 95% CI 3-17 breaths/min, P = 0.008) and VT increased (from 6.5 ± 0.8 to 9.0 ± 1.6 ml/kg predicted body weight; difference = 2.5 ml, 95% CI 0.4-4.6 ml/kg predicted body weight, P = 0.02). Pressure limitation corrected for the rise of VT, but minute ventilation declined, forcing the user to switch back to pressure-controlled ventilation. Conclusions: Adaptive support ventilation, compared with pressure-controlled ventilation in an open lung strategy setting, delivers a lower respiratory rate-higher VT combination. Pressure limitation does correct for the rise of VT, but leads to a decline in minute ventilation. Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

Fiberoptic orotracheal intubation on anesthetized patients: Do manipulation skills learned on a simple model transfer into the operating room?

Background: With increasing pressure to use operating room time efficiently, opportunities for residents to learn fiberoptic orotracheal intubation in the operating room have declined. The purpose of this study was to determine whether fiberoptic orotracheal intubation skills learned outside the operating room on a simple model could be transferred into the clinical setting. Methods: First-year anesthesiology residents and first- and second-year internal medicine residents were recruited. Subjects were randomized to a didactic-teaching-only group (n = 12) or a model-training group (n = 12). The didactic-teaching group received a detailed lecture from an expert bronchoscopist. The model-training group was guided, by experts, through tasks performed on a simple model designed to refine fiberoptic manipulation skills. After the training session, subjects performed a fiberoptic orotracheal intubation on healthy, consenting, anesthetized, paralyzed female patients undergoing elective surgery with predicted "easy" laryngoscopic intubations. Two blinded anesthesiologists evaluated each subject. Results: After the training session, the model group significantly outperformed the didactic group in the operating room when evaluated with a global rating scale (P < 0.01) and checklist (P < 0.05). Model-trained subjects completed the fiberoptic orotracheal intubation significantly faster than didactic-trained subjects (P < 0.01). Model-trained subjects were also more successful at achieving tracheal intubation than the didactic group (P < 0.005). Conclusion: Fiberoptic orotracheal intubation skills training on a simple model is more effective than conventional didactic instruction for transfer to the clinical setting. Incorporating an extraoperative model into the training of fiberoptic orotracheal intubation may greatly reduce the time and pressures that accompany teaching this skill in the operating room.

Hearing acuity of anesthesiologists and alarm detection

Background: With rapid technological advances in anesthesiology, we are acquiring an ever increasing number of auditory alarm systems in the operating room the value of which depend on the hearing acuity of the anesthesiologist monitoring the patient. Presbycusis, the effect of aging on the auditory system, characteristically results in a bilaterally symmetric neurosensory high-frequency hearing loss (>2,000 Hz). In this study we attempt to assess the impact of this common hearing disorder on alarm detection. Methods: We measured air conduction hearing acuities of 188 anesthesiologists who volunteered to participate. Subjects were divided into six age groups (25-34, 35-44, 45-54, 55-64, and 75 yr of age). Abnormal audiograms were compared to the intensity and frequency of alarms in our operating room to determine which alarms were out of hearing range. Subjects with a history of chronic or excessive noise exposure were excluded from the study. The median hearing threshold for each age group of study subjects was compared to the median hearing threshold of similar age groups in the general population. Results: Overall, 66% of the subjects had an abnormal audiogram, and 7% had one or more alarm intensities less than their detectability threshold (14% unilateral, 86% bilateral). Median hearing threshold was worse than the general population for men and women less than 55 yr of age. Hearing acuity worse than the general population occurred at the lower frequencies while acuity at the higher frequencies was equal or slightly better. However, inability to hear alarms occurred only with those alarms that have frequencies of 4,000 Hz or greater. Conclusions: Although high-frequency hearing acuity of individuals in our study was better than that of the general population, hearing deficits at high frequencies were of the magnitude to interfere with alarm detection. Also background noise levels vary greatly in different operating rooms. These two problems create a hindrance to alarm detection for certain anesthesiologists. From our data we conclude that the aging human ear may not be capable of accurately detecting some auditory alarms in the operating room. Alarm design should consider hearing acuity because high-frequency alarms may go undetected.

Opioid Fills for Lumbar Facet Radiofrequency Ablation Associated with New Persistent Opioid Use

Background: Zygapophyseal (facet) joint interventions are the second most common interventional procedure in pain medicine. Opioid exposure after surgery is a significant risk factor for chronic opioid use. The aim of this study was to determine the incidence of new persistent use of opioids after lumbar facet radiofrequency ablation and to assess the effect of postprocedural opioid prescribing on the development of new persistent opioid use. Methods: The authors conducted a retrospective cohort study using claims from the Clinformatics Data Mart Database (OptumInsight, USA) to identify opioid-naïve patients between 18 and 64 yr old who had lumbar radiofrequency ablation. Patients who had either subsequent radiofrequency ablation 15 to 180 days or subsequent surgery within 180 days after the primary procedure were excluded from the analysis. The primary outcome was new persistent opioid use, defined as opioid prescription fulfillment within the 8 to 90 and 91 to 180 day periods after radiofrequency ablation. The authors then assessed patient-level risk factors for new persistent opioid use. Results: A total of 2,887 patients met the inclusion criteria. Of those patients, 2,277 (78.9%) had radiofrequency ablation without a perioperative opioid fill, and 610 (21.1%) patients had the procedure with a perioperative opioid fill. The unadjusted rate of new persistent opioid use was 5.6% (34 patients) in the group with a perioperative opioid fill versus 2.8% (63 patients) for those without an opioid fill. Periprocedural opioid prescription fill was independently associated with increased odds of new persistent use (adjusted odds ratio, 2.35; 95% CI, 1.51 to 3.66; P < 0.001). Conclusions: Periprocedural opioid use after lumbar radiofrequency ablation was associated with new persistent use in previously opioid-naïve patients, suggesting that new exposure to opioids is an independent risk factor for persistent use in patients having radiofrequency ablation for chronic back pain. Opioid prescribing after radiofrequency ablation should be reevaluated and likely discontinued in this population. (ANESTHESIOLOGY 2020; 132:1165-74). © 2020, the American Society of Anesthesiologists, Inc. All Rights Reserved.

Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation

BACKGROUND:: Emergent intubation is associated with a high complication rate. These intubations are often performed by resident physicians in teaching hospitals. The authors evaluated whether supervision by an anesthesia-trained intensivist decreases complications of emergent intubations. METHODS:: The authors performed a prospective cohort study in an Academic Tertiary Care Hospital. They enrolled 322 consecutive patients who required emergent intubation between November 1, 2006, and April 15, 008. Emergency intubations are performed by anesthesia residents during their surgical intensive care unit rotation. An attending anesthesiologist was assigned to supervise these intubations at predetermined periods. A respiratory therapist assisted with airway management and ventilation. Information related to the intubation, detailing patient demographics, indication for intubation, attending anesthesiologist presence, medications used, and immediate complications, was recorded. Disposition and duration of mechanical ventilation were also recorded. RESULTS:: There were no differences in demographics, clinical characteristics, or illness severity among patients intubated with and without attending supervision. Attending physician supervision was associated with a significant decrease in complications (6.1% vs. 21.7%; P = 0.0001). There was no difference in ventilator-free days or 30-day mortality. CONCLUSION:: Supervision by an attending anesthesiologist was associated with a decreased incidence of complications during emergent intubations. © 2008, the American Society of Anesthesiologists, Inc.

Spontaneous breathing with biphasic positive airway pressure attenuates lung injury in hydrochloric acid-induced acute respiratory distress syndrome

BACKGROUND:: It has been proved that spontaneous breathing (SB) with biphasic positive airway pressure (BIPAP) can improve lung aeration in acute respiratory distress syndrome compared with controlled mechanical ventilation. The authors hypothesized that SB with BIPAP would attenuate lung injury in acute respiratory distress syndrome compared with pressure-controlled ventilation. METHODS:: Twenty male New Zealand white rabbits with hydrochloric acid aspiration-induced acute respiratory distress syndrome were randomly ventilated using the BIPAP either with SB (BIPAP plus SB group) or without SB (BIPAP minus SB group) for 5 h. Inspiration pressure was adjusted to maintain the tidal volume at 6 ml/kg. Both groups received the same positive end-expiratory pressure level at 5 cm H2O for hemodynamic goals. Eight healthy animals without ventilatory support served as the control group. RESULTS:: The BIPAP plus SB group presented a lower ratio of dead space ventilation to tidal volume, a lower respiratory rate, and lower minute ventilation. No significant difference in the protein levels of interleukin-6 and interleukin-8 in plasma, bronchoalveolar lavage fluid, and lung tissue were measured between the two experimental groups. However, SB resulted in lower messenger ribonucleic acid levels of interleukin-6 (mean ± SD; 1.8 ± 0.7 vs. 2.6 ± 0.5; P = 0.008) and interleukin-8 (2.2 ± 0.5 vs. 2.9 ± 0.6; P = 0.014) in lung tissues. In addition, lung histopathology revealed less injury in the BIPAP plus SB group (lung injury score, 13.8 ± 4.6 vs. 21.8 ± 5.7; P < 0.05). CONCLUSION:: In hydrochloric acid-induced acute respiratory distress syndrome, SB with BIPAP attenuated lung injury and improved respiratory function compared with controlled ventilation with low tidal volume. (Anesthesiology 2014; 120:1441-9) © 2014 The American Society of Anesthesiologists, Inc.

Should anesthesia groups advocate funding of clinics and scheduling systems to increase operating room workload?

BACKGROUND:: Knowledge of patterns related to patient visits in a multispecialty group is important for helping anesthesia groups make strategic and tactical decisions relevant to increasing anesthesia workload. METHODS:: The authors studied surgery at an outpatient surgery center over 6 months and analyzed every clinic visit that preceded surgery by 2 yr. They also studied surgery that occurred at either the outpatient center or a tertiary surgical suite over 3 months, including all preceding clinic visits. RESULTS:: Results were similar whether data were analyzed by number of cases or by American Society of Anesthesiologists' Relative Value Guide units. The median number of visits to the surgeon before surgery was 2 (95% confidence interval 2-2). Most patients have one visit with the surgeon, decide to have surgery, and then have one preoperative visit. Fewer than 20% of American Society of Anesthesiologists' Relative Value Guide units for outpatient surgery arose from patients seen by a primary care or nonsurgical specialist before referral to the surgeon. Patients with more than one previous surgery at the facility accounted for less than 6% of American Society of Anesthesiologists' Relative Value Guide units. CONCLUSION:: Investment in outpatient primary care clinics, nonsurgical specialty clinics, or scheduling systems to facilitate patient appointments would not materially affect anesthesia workload. The workload of the anesthesia department depends on facilitating surgeon-dependent processes: (1) open access to operating room time on any future workday, (2) well-calculated blocks to permit high surgeon productivity, and (3) open access to surgeon clinics to reduce days from referral to first appointment. © 2009 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Comparison of the effects of 0.03 and 0.05 mg/kg midazolam with placebo on prevention of emergence agitation in children having strabismus surgery

BACKGROUND:: Midazolam has been widely studied for preventing emergence agitation. The authors previously reported that in children with sevoflurane anesthesia, intravenous administration of midazolam (0.05 mg/kg) before the end of surgery reduced the incidence of emergence agitation but prolonged the emergence time. This study was designed to test the hypothesis that a lower midazolam dose could suppress emergence agitation with minimal disturbance of the emergence time in children with sevoflurane anesthesia. METHODS:: In this randomized, double-blind, placebo-controlled trial, 90 children (1 to 13 yr of age) having strabismus surgery were randomized to 1:1:1 to receive 0.03 mg/kg of midazolam, 0.05 mg/kg of midazolam, or saline just before the end of surgery. The primary outcome, the incidence of emergence agitation, was evaluated by using the pediatric anesthesia emergence delirium scale and the four-point agitation scale. The secondary outcome was time to emergence, defined as the time from sevoflurane discontinuation to the time to extubation. RESULTS:: The incidence of emergence agitation was lower in patients given 0.03 mg/kg of midazolam (5 of 30, 16.7%) and patients given 0.05 mg/kg of midazolam (5 of 30, 16.7%) compared with that in patients given saline (13/of 30, 43.3%; P = 0.036 each). The emergence time was longer in patients given 0.05 mg/kg of midazolam (17.1 ± 3.4 min, mean ± SD) compared with that in patients given 0.03 mg/kg of midazolam (14.1 ± 3.6 min; P = 0.0009) or saline (12.8 ± 4.1 min; P = 0.0003). CONCLUSION:: Intravenous administration of 0.03 mg/kg of midazolam just before the end of surgery reduces emergence agitation without delaying the emergence time in children having strabismus surgery with sevoflurane anesthesia. (Anesthesiology 2014; 120:1354-61) © 2014 The American Society of Anesthesiologists, Inc.

Reversal of monoarthritis-induced affective disorders by diclofenac in rats

BACKGROUND:: Nonsteroidal anti-inflammatory drugs are effective for arthritic pain, but it is unknown whether they also benefit anxiety and depression that frequently coexist with pain. Using the monoarthritis model, the authors evaluated the activation of extracellular signal-regulated kinases 1 and 2 (ERK1/2) in structures implicated in both sensorial and emotional pain spheres, and it was verified whether analgesia can reverse monoarthritis- mediated affective responses. METHODS:: Monoarthritis was induced in male rats by complete Freund's adjuvant injection. Allodynia (ankle-bend test), mechanical hyperalgesia (paw-pinch test), anxiety-and depression-like behaviors (elevated zero maze and forced swimming tests, respectively), and ERK1/2 phosphorylation (Western blot) in the spinal cord, paragigantocellularis nucleus, locus coeruleus, and prefrontal cortex were evaluated at 4, 14, and 28 days postinoculation (n = 6 per group). Changes in these parameters were evaluated after induction of analgesia by topical diclofenac (n = 5 to 6 per group). RESULTS:: Despite the pain hypersensitivity and inflammation throughout the testing period, chronic monoarthritis (28 days) also resulted in depressive-(control [mean ± SEM]: 38.3 ± 3.7 vs. monoarthritis: 51.3 ± 2.0; P < 0.05) and anxiogenic-like behaviors (control: 36.8 ± 3.7 vs. monoarthritis: 13.2 ± 2.9; P < 0.001). These changes coincided with increased ERK1/2 activation in the spinal cord, paragigantocellularis, locus coeruleus, and prefrontal cortex (control vs. monoarthritis: 1.0 ± 0.0 vs. 5.1 ± 20.8, P < 0.001; 0.9 ± 0.0 vs. 1.9 ± 0.4, P < 0.05; 1.0 ± 0.3 vs. 2.9 ± 0.6, P < 0.01; and 1.0 ± 0.0 vs. 1.8 ± 0.1, P < 0.05, respectively). Diclofenac decreased the pain threshold of the inflamed paw and reversed the anxio-depressive state, restoring ERK1/2 activation levels in the regions analyzed. CONCLUSION:: Chronic monoarthritis induces affective disorders associated with ERK1/2 phosphorylation in paragigantocellularis, locus coeruleus, and prefrontal cortex which are reversed by diclofenac analgesia. (Anesthesiology 2014; 120:1476-90) © 2014 The American Society of Anesthesiologists, Inc.

Characterization of acute and chronic neuropathies induced by oxaliplatin in mice and differential effects of a novel mitochondria-targeted antioxidant on the neuropathies

BACKGROUND:: Oxaliplatin, a chemotherapeutic agent used for the treatment of colorectal cancer, induces dose-limiting neuropathy that compromises quality of life. This study aimed to reproduce, in mice, patients' symptoms of oxaliplatin-induced neuropathy and to observe effects of SS-31, a mitochondria-targeted antioxidant on the neuropathy. METHODS:: Neuropathy was induced by single or repeated injections of oxaliplatin. Cold and mechanical hypersensitivities were assessed by 15 C-cold plate, temperature preference, and von Frey tests. Morphology of peripheral nerves and dorsal root ganglions, expression of spinal cord c-Fos, density of intraepidermal nerve fibers, and levels of dorsal root ganglion-reactive oxygen/nitrogen species were examined. SS-31 was administered concomitantly or after oxaliplatin injections. RESULTS:: Single injection of oxaliplatin induced cold hypersensitivity in forepaws but not in hind paws which resolved within days (maximal forepaw shakes: 28 ± 1.5 vs. 9.3 ± 1.6/150 s, mean ± SEM, P < 0.001, n = 6 per group). Oxaliplatin-administered mice disfavored 10 and 15 C plates more than control. Paw stimulation at 15 C induced c-Fos-positive cells within superficial laminae of the dorsal horn in C7-T1 segments. Weekly administrations induced gradual development of persistent mechanical allodynia in the hind paws (minimal mechanical threshold: 0.19 ± 0.08 vs. 0.93 ± 0.11 g, P < 0.001, n = 10 per group). Microscopy revealed no overt morphological changes in peripheral nerves and dorsal root ganglions. Concomitant SS-31 administration with repeated oxaliplatin administration attenuated both cold and mechanical hypersensitivity. Decrease in intraepidermal nerve fibers and increase in dorsal root ganglion-reactive oxygen/nitrogen species were also attenuated. Acute SS-31 administration after symptoms were established reversed only cold hypersensitivity. CONCLUSION:: This model of oxaliplatin-induced neuropathy mimicked patients' conditions. SS-31 has potentials to prevent both acute and chronic neuropathies but is only helpful in treatment of acute neuropathy. (Anesthesiology 2014; 120:459-73) Copyright © 2013, the American Society of Anesthesiologists, Inc.

Phase 1 safety assessment of intrathecal oxytocin

BACKGROUND:: Preclinical data suggest that oxytocin reduces hypersensitivity by actions in the spinal cord, but whether it produces antinociception to acute stimuli is unclear. In this article, the authors examined the safety of intrathecal oxytocin and screened its effects on acute noxious stimuli. METHODS:: After institutional review board and Food and Drug Administration approval, healthy adult volunteers received 5, 15, 50, or 150 μg intrathecal oxytocin in a dose-escalating manner in cohorts of five subjects. Hemodynamic and neurologic assessments were performed for 4 h after injections and 24 h later, at which time serum sodium was also measured. Cerebrospinal fluid was obtained 60 min after injection, and responses to noxious heat stimuli in arm and leg as well as temporal summation to repeated application of a von Frey filament were obtained. RESULTS:: One subject receiving the highest dose experienced transient hypotension and bradycardia as well as subjective numbness in a lumbo-sacral distribution. No other subject experienced subjective or objective neurologic symptoms. Overall, blood pressure and heart rate increased 1 to 4 h after injection by less than 15% with no dose dependency. There was no effect on serum sodium, and cerebrospinal fluid oxytocin increased in a dose-dependent manner after injection. Pain scores to noxious heat stimuli were unaffected by oxytocin, and the temporal summation protocol failed to show summation before or after drug treatment. CONCLUSION:: This small study supports further investigation on oxytocin for analgesia for hypersensitivity states, with continued systematic surveillance for possible effects on blood pressure, heart rate, and neurologic function. (ANESTHESIOLOGY 2015; 122:407-13).

Effect of a cognitive aid on adherence to perioperative assessment and management guidelines for the cardiac evaluation of noncardiac surgical patients

BACKGROUND:: The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. METHODS:: Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. RESULTS:: All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). CONCLUSIONS:: Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs. © 2014 The American Society of Anesthesiologists, Inc.

Accuracy of transthoracic lung ultrasound for diagnosing anesthesia-induced atelectasis in children

BACKGROUND:: The aim of this study was to test the accuracy of lung sonography (LUS) to diagnose anesthesia-induced atelectasis in children undergoing magnetic resonance imaging (MRI). METHODS:: Fifteen children with American Society of Anesthesiology's physical status classification I and aged 1 to 7 yr old were studied. Sevoflurane anesthesia was performed with the patients breathing spontaneously during the study period. After taking the reference lung MRI images, LUS was carried out using a linear probe of 6 to 12 MHz. Atelectasis was documented in MRI and LUS segmenting the chest into 12 similar anatomical regions. Images were analyzed by four blinded radiologists, two for LUS and two for MRI. The level of agreement for the diagnosis of atelectasis among observers was tested using the κ reliability index. RESULTS:: Fourteen patients developed atelectasis mainly in the most dependent parts of the lungs. LUS showed 88% of sensitivity (95% CI, 74 to 96%), 89% of specificity (95% CI, 83 to 94%), and 88% of accuracy (95% CI, 83 to 92%) for the diagnosis of atelectasis taking MRI as reference. The agreement between the two radiologists for diagnosing atelectasis by MRI was very good (κ, 0.87; 95% CI, 0.72 to 1; P < 0.0001) as was the agreement between the two radiologists for detecting atelectasis by LUS (κ, 0.90; 95% CI, 0.75 to 1; P < 0.0001). MRI and LUS also showed good agreement when data from the four radiologists were pooled and examined together (κ, 0.75; 95% CI, 0.69 to 0.81; P < 0.0001). CONCLUSION:: LUS is an accurate, safe, and simple bedside method for diagnosing anesthesia-induced atelectasis in children. © 2014 The American Society of Anesthesiologists, Inc.

Real-time detection of gastric insufflation related to facemask pressure-controlled ventilation using ultrasonography of the antrum and epigastric auscultation in nonparalyzed patients

BACKGROUND:: The authors sought to determine the level of inspiratory pressure minimizing the risk of gastric insufflation while providing adequate pulmonary ventilation. The primary endpoint was the increase in incidence of gastric insufflation detected by ultrasonography of the antrum while inspiratory pressure for facemask pressure-controlled ventilation increased from 10 to 25 cm H2O. METHODS:: In this prospective, randomized, double-blind study, patients were allocated to one of the four groups (P10, P15, P20, and P25) defined by the inspiratory pressure applied during controlled-pressure ventilation: 10, 15, 20, and 25 cm H2O. Anesthesia was induced using propofol and remifentanil; no neuromuscular-blocking agent was administered. Once loss of eyelash reflex occurred, facemask ventilation was started for a 2-min period while gastric insufflation was detected by auscultation and by real-time ultrasonography of the antrum. The cross-sectional antral area was measured using ultrasonography before and after facemask ventilation. Respiratory parameters were recorded. RESULTS:: Sixty-seven patients were analyzed. The authors registered statistically significant increases in incidences of gastric insufflation with inspiratory pressure, from 0% (group P10) to 41% (group P25) according to auscultation, and from 19 to 59% according to ultrasonography. In groups P20 and P25, detection of gastric insufflation by ultrasonography was associated with a statistically significant increase in the antral area. Lung ventilation was insufficient for group P10. CONCLUSION:: Inspiratory pressure of 15 cm H2O allowed for reduced occurrence of gastric insufflation with proper lung ventilation during induction of anesthesia with remifentanil and propofol in nonparalyzed and nonobese patients. (Anesthesiology 2014; 120:326-34) Copyright © 2013, the American Society of Anesthesiologists, Inc.

A response surface model approach for continuous measures of hypnotic and analgesic effect during sevoflurane-remifentanil interaction: Quantifying the pharmacodynamic shift evoked by stimulation

BACKGROUND:: The authors studied the interaction between sevoflurane and remifentanil on bispectral index (BIS), state entropy (SE), response entropy (RE), Composite Variability Index, and Surgical Pleth Index, by using a response surface methodology. The authors also studied the influence of stimulation on this interaction. METHODS:: Forty patients received combined concentrations of remifentanil (0 to 12 ng/ml) and sevoflurane (0.5 to 3.5 vol%) according to a crisscross design (160 concentration pairs). During pseudo-steady-state anesthesia, the pharmacodynamic measures were obtained before and after a series of noxious and nonnoxious stimulations. For the "prestimulation" and "poststimulation" BIS, SE, RE, Composite Variability Index, and Surgical Pleth Index, interaction models were applied to find the best fit, by using NONMEM 7.2.0. (Icon Development Solutions, Hanover, MD). RESULTS:: The authors found an additive interaction between sevoflurane and remifentanil on BIS, SE, and RE. For Composite Variability Index, a moderate synergism was found. The comparison of pre-and poststimulation data revealed a shift of C50SEVO for BIS, SE, and RE, with a consistent increase of 0.3 vol%. The Surgical Pleth Index data did not result in plausible parameter estimates, neither before nor after stimulation. CONCLUSIONS:: By combining pre-and poststimulation data, interaction models for BIS, SE, and RE demonstrate a consistent influence of "stimulation" on the pharmacodynamic relationship between sevoflurane and remifentanil. Significant population variability exists for Composite Variability Index and Surgical Pleth Index. (Anesthesiology 2014; 120:1390-9) © 2014 The American Society of Anesthesiologists, Inc.

Simulator-based transesophageal echocardiographic training with motion analysis: A curriculum-based approach

BACKGROUND:: Transesophageal echocardiography (TEE) is a complex endeavor involving both motor and cognitive skills. Current training requires extended time in the clinical setting. Application of an integrated approach for TEE training including simulation could facilitate acquisition of skills and knowledge. METHODS:: Echo-naive nonattending anesthesia physicians were offered Web-based echo didactics and biweekly hands-on sessions with a TEE simulator for 4 weeks. Manual skills were assessed weekly with kinematic analysis of TEE probe motion and compared with that of experts. Simulator-acquired skills were assessed clinically with the performance of intraoperative TEE examinations after training. Data were presented as median (interquartile range). RESULTS:: The manual skills of 18 trainees were evaluated with kinematic analysis. Peak movements and path length were found to be independent predictors of proficiency (P < 0.01) by multiple regression analysis. Week 1 trainees had longer path length (637 mm [312 to 1,210]) than that of experts (349 mm [179 to 516]); P < 0.01. Week 1 trainees also had more peak movements (17 [9 to 29]) than that of experts (8 [2 to 12]); P < 0.01. Skills acquired from simulator training were assessed clinically with eight additional trainees during intraoperative TEE examinations. Compared with the experts, novice trainees required more time (199 s [193 to 208] vs. 87 s [83 to 16]; P = 0.002) and performed more transitions throughout the examination (43 [36 to 53] vs. 21 [20 to 23]; P = 0.004). CONCLUSIONS:: A simulation-based TEE curriculum can teach knowledge and technical skills to echo-naive learners. Kinematic measures can objectively evaluate the progression of manual TEE skills. Copyright © 2014, the American Society of Anesthesiologists, Inc.

Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis

Background. Anesthesia gas delivery equipment is a potentially important source of patient injury. To better define the contribution of gas delivery equipment to professional liability in anesthesia, the authors conducted an in-depth analysis of cases from the database of the American Society of Anesthesiologists Closed Claims Project. Methods: The database of the Closed Claims Project is composed of closed US malpractice claims that have been collected in a standardized manner. All claims resulting from the use of gas delivery equipment were reviewed for recurrent patterns of injury. Results: Gas delivery equipment was associated with 72 (2%) of 3,791 claims in the database. Death and permanent brain damage accounted for almost all adverse outcomes (n = 55, 76%) Equipment misuse was defined as fault or human error associated with the preparation, maintenance, or deployment of a medical device. Equipment failure was defined as unexpected malfunction of a medical device, despite routine maintenance mid previous uneventful use. Misuse of equipment (n = 54, 75%) was three times more common than equipment failure (n = 17, 24%). Misconnects and disconnects of the breathing circuit made the largest contribution to injury (n = 25, 35%). Reviewers judged that 38 of 72 claims (53%) could have been prevented by pulse oximetry, capnography, or a combination of these two monitors. Overall, 56 of 72 gas delivery claims (78%)were deemed preventable with the use or better use of monitors. The year of occurrence for claims involving gas delivery equipment ranged from 1962 to 1991 and did not differ significantly from claims involving other adverse respiratory events. Conclusions: Claims associated with gas delivery equipment are infrequent but severe and continue to occur in the 1990s. Educational and preventive strategies that focus on equipment misuse and breathing circuit configuration may have the greatest potential for enhancing the safety of anesthesia gas delivery equipment.

Target-Controlled Drug Delivery: Progress Toward an Intravenous "Vaporizer" and Automated Anesthetic Administration

Based on a drug's typical pharmacokinetic behavior, target-controlled infusion systems calculate and deliver the infusion rate that is necessary to achieve and maintain a user-designated drug concentration in the blood or theoretical effect site. Employed in both clinical and research settings, target-controlled infusion technology represents an important advance in the delivery of intravenous anesthetics.

An Anesthesiologist's Perspective on the History of Basic Airway Management: The "preanesthetic" Era-1700 to 1846

Basic airway management modern history starts in the early 18th century in the context of resuscitation of the apparently dead. History saw the rise and fall of the mouth-to-mouth and then of the instrumental positive-pressure ventilation generated by bellows. Pulmonary ventilation had a secondary role to external and internal organ stimulation in resuscitation of the apparently dead. Airway access for the extraglottic technique was to the victim's nose. The bellows-to-nose technique was the "basic airway management technique" applicable by both medical and nonmedical personnel. Although the techniques had been described at the time, very few physicians practiced glottic (intubation) and subglottic (tracheotomy) techniques. Before the anesthetic era, positive-pressure ventilation was discredited and replaced by manual negative-pressure techniques. In the middle of the 19th century, physicians who would soon administer anesthetic gases were unfamiliar with the positive-pressure ventilation concept. © 2015 the American Society of Anesthesiologists, Inc.

Measuring Clinical Productivity of Anesthesiology Groups: Surgical Anesthesia at the Facility Level

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent. © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Succinylcholine and intracranial pressure

Bolus injections of succinylcholine (1.5mg/kg) signifcantly increased intracranial pressure (ICP) in cats under normal conditions from control levels of 8 +/-1 mmHg to 16 +/-3 mmHg (+/-SEM, P less than 0.01), and in the presence of artifcially increased ICP from control levels of 27 +/-1 mmHg to 47 +/-4 mmHg (P less than 0.01). Tese approximately 100% increases in ICP were accompanied by a transitory decrease in mean arterial pressure (approximately 10 s), followed by a 15 to 20% increase (P less than 0.05). Pulmonary arterial pressure increased 20 to 30% (P less than 0.05). Tese results, when considered in conjunction with results previously obtained in humans, suggest that succinylcholine may be contraindicated in neurosurgical patients. © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Modulation of Cerebral Function by Muscle Afferent Activity, with Reference to Intravenous Succinylcholine

Cerebral Function and Muscle Afferent Activity Following Intravenous Succinylcholine in Dogs Anesthetized with Halothane: The Effects of Pretreatment with a Defasciculating Dose of Pancuronium. By WL Lanier, PA Iaizzo, and JH Milde. Anesthesiology 1989; 71:87-95. Reprinted with permission. By the mid-1980s, it was widely assumed that if the depolarizing muscle relaxant, succinylcholine, given IV, produced increases in intracranial pressure, it did so because fasciculations produced increases in intrathoracic and central venous pressures that were transferred to the brain; however, there was no direct evidence that this was true. In contrast, we explored the possibility that the succinylcholine effect on the brain was explained by the afferentation theory of cerebral arousal, which predicts that agents or maneuvers that stimulate muscle stretch receptors will tend to stimulate the brain. Our research in tracheally intubated, lightly anesthetized dogs discovered that IV succinylcholine (which does not cross the blood-brain barrier) produced a doubling of cerebral blood flow that lasted for 30 min and corresponded to activation of the electroencephalogram and increases in intracranial pressure. Later, in our Classic Paper, we were able to assess simultaneously cerebral physiology and afferent nerve traffic emanating from muscle stretch receptors (primarily muscle spindles). We affirmed that the cerebral arousal response to succinylcholine was indeed driven by muscle afferent traffic and was independent of fasciculations or increases in intrathoracic or central venous pressures. Later research in complementary models demonstrated that endogenous movement (e.g., coughing, hiccups) produced a cerebral response very similar to IV succinylcholine, apparently as a result of the same muscle afferent mechanisms, independent of intrathoracic and central venous pressures. Thus, the importance of afferentation theory as a driver of the cerebral state of arousal and cerebral physiology during anesthesia was affirmed. © 2023 Lippincott Williams and Wilkins. All rights reserved.

Smoking and pain : Pathophysiology and clinical implications

Cigarette smoke, which serves as a nicotine delivery vehicle in humans, produces profound changes in physiology. Experimental studies suggest that nicotine has analgesic properties. However, epidemiologic evidence shows that smoking is a risk factor for chronic pain. The complex relationship between smoking and pain not only is of scientific interest, but also has clinical relevance in the practice of anesthesiology and pain medicine. This review will examine current knowledge regarding how acute and chronic exposure to nicotine and cigarette smoke affects acute and chronic painful conditions. It will cover the relevant pharmacology of nicotine and other ligands at the nicotinic acetylcholine receptor as related to pain, explore the association of cigarette smoking with chronic painful conditions and potential mechanisms to explain this association, and examine clinical implications for the care of smokers with pain. Copyright © 2010.

Artificial Intelligence and Machine Learning in Anesthesiology

Commercial applications of artificial intelligence and machine learning have made remarkable progress recently, particularly in areas such as image recognition, natural speech processing, language translation, textual analysis, and self-learning. Progress had historically languished in these areas, such that these skills had come to seem ineffably bound to intelligence. However, these commercial advances have performed best at single-Task applications in which imperfect outputs and occasional frank errors can be tolerated. The practice of anesthesiology is different. It embodies a requirement for high reliability, and a pressured cycle of interpretation, physical action, and response rather than any single cognitive act. This review covers the basics of what is meant by artificial intelligence and machine learning for the practicing anesthesiologist, describing how decision-making behaviors can emerge from simple equations. Relevant clinical questions are introduced to illustrate how machine learning might help solve them-perhaps bringing anesthesiology into an era of machine-Assisted discovery. Copyright © 2019, the American Society of Anesthesiologists, Inc. All Rights Reserved.

Controlled substance dispensing and accountability in United States anesthesiology residency programs

Controlled substance dependence (CSD) among anesthesiology personnel, particularly residents, has become a matter of increasing concern. Opinions vary as to the effectiveness of controlled substances (CS) accountability in deterring, identifying, or confirming CSD. A survey of program directors of American anesthesiology training programs was conducted in the summer of 1990 to determine the level of CS dispensing and accountability within their programs. The survey demonstrated that CS dispensing and accountability varied considerably among programs, among hospitals associated with individual programs, and within geographically distinct anesthesia delivery areas within the separate hospitals. Nevertheless, most institutions were moving toward improved methods of CS dispensing and providing more and better CS accountability. The presence of significant CSD, particularly among anesthesiology residents, was reconfirmed. We were unable to correlate the level of accountability of CS with the incidence of CSD. It remains to be seen to what extent CS accountability will continue to develop and whether CSD prevalence will then be changed.

Addiction and substance abuse in anesthesiology

Despite substantial advances in our understanding of addiction and the technology and therapeutic approaches used to fight this disease, addiction still remains a major issue in the anesthesia workplace, and outcomes have not appreciably changed. Although alcoholism and other forms of impairment, such as addiction to other substances and mental illness, impact anesthesiologists at rates similar to those in other professions, as recently as 2005, the drug of choice for anesthesiologists entering treatment was still an opioid. There exists a considerable association between chemical dependence and other psychopathology, and successful treatment for addiction is less likely when comorbid psychopathology is not treated. Individuals under evaluation or treatment for substance abuse should have an evaluation with subsequent management of comorbid psychiatric conditions. Participation in self-help groups is still considered a vital component in the therapy of the impaired physician, along with regular monitoring if the anesthesiologist wishes to attempt reentry into clinical practice. © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Myocardial ischemia revisited.

Does perioperative myocardial ischemia lead to postoperative myocardial infarction? By Stephen Slogoff and Arthur S. Keats. Anesthesiology 1985; 62:107-14. Reprinted with permission.To determine if a relationship exists between perioperative myocardial ischemia (ST segment depression greater than or equal to 0.1 mV) and postoperative myocardial infarction (PMI), nonparticipating observers recorded all electrocardiographic, hemodynamic, and other events between arrival of patients in the operating room and onset of cardiopulmonary bypass during 1,023 elective coronary artery bypass operations (CABG). The roles of preoperative patient characteristics, quality of the operation limited by disease as rated by the surgeon and duration of ischemic cardiac arrest as risk factors for PMI also were quantified. Electrocardiographic ischemia occurred in 36.9% of all patients, with almost half the episodes occurring before induction of anesthesia. PMI was almost three times as frequent in patients with ischemia (6.9% vs. 2.5%) and was independent of when ischemia occurred. Ischemia was related significantly to tachycardia but not hypertension nor hypotension and was frequent in the absence of any hemodynamic abnormalities. The anesthesiologist whose patients had the highest rate of tachycardia and ischemia had the highest rate of PMI. Although neither single nor multiple preoperative patient characteristics related to PMI, suboptimal quality of operation and prolonged ischemic cardiac arrest increased the likelihood of PMI independent of the occurrence of myocardial ischemia. The authors conclude that perioperative myocardial ischemia is common in patients undergoing CABG, occurs randomly as well as in response to hemodynamic abnormalities, and is one of three independent risk factors the authors identified as related to PMI. PMI is unrelated to preoperative patient characteristics such as ejection fraction and left main coronary artery disease, and its frequency will relate primarily to perioperative management rather than patient selection.

Muscarinic signaling in the central nervous system: Recent developments and anesthetic implications

During the last decade, major advances have been made in our understanding of the physiology and pharmacology of CNS muscarinic signaling. It is time to emphasize that the well-known peripheral parasympathetic and cardiovascular actions represent only one component of muscarinic signaling. Interestingly, many new findings have the potential to influence the practice of anesthesiology. Inhibition of muscarinic signaling may explain some of the anesthetic state, and subtype-selective drugs may allow wider perioperative manipulation of CNS muscarinic systems. The next years will doubtlessly see progress in this area, and our specialty may well reap the benefits.

Dynamic Cortical Connectivity during General Anesthesia in Surgical Patients

Editor's Perspective What We Already Know about This Topic Animal data, along with recent human observations (in this issue of Anesthesiology∗), suggest that cortical oscillations and connectivity shift dynamically during what appears to be stable general anesthesia Clinical evidence in the perioperative setting to support these observations is currently lacking What This Article Tells Us That Is New During anesthesia and surgery, cortical networks display a dynamic interplay among brain states, rather than a static equilibrium These findings suggest that a single measure of connectivity may not be a reliable correlate of surgical anesthesia depth Background: Functional connectivity across the cortex has been posited to be important for consciousness and anesthesia, but functional connectivity patterns during the course of surgery and general anesthesia are unknown. The authors tested the hypothesis that disrupted cortical connectivity patterns would correlate with surgical anesthesia. Methods: Surgical patients (n = 53) were recruited for study participation. Whole-scalp (16-channel) wireless electroencephalographic data were prospectively collected throughout the perioperative period. Functional connectivity was assessed using weighted phase lag index. During anesthetic maintenance, the temporal dynamics of connectivity states were characterized via Markov chain analysis, and state transition probabilities were quantified. Results: Compared to baseline (weighted phase lag index, 0.163, ± 0.091), alpha frontal-parietal connectivity was not significantly different across the remaining anesthetic and perioperative epochs, ranging from 0.100 (± 0.041) to 0.218 (± 0.136) (P > 0.05 for all time periods). In contrast, there were significant increases in alpha prefrontal-frontal connectivity (peak = 0.201 [0.154, 0.248]; P < 0.001), theta prefrontal-frontal connectivity (peak = 0.137 [0.091, 0.182]; P < 0.001), and theta frontal-parietal connectivity (peak = 0.128 [0.084, 0.173]; P < 0.001) during anesthetic maintenance. Additionally, shifts occurred between states of high prefrontal-frontal connectivity (alpha, beta) with suppressed frontal-parietal connectivity, and high frontal-parietal connectivity (alpha, theta) with reduced prefrontal-frontal connectivity. These shifts occurred in a nonrandom manner (P < 0.05 compared to random transitions), suggesting structured transitions of connectivity during general anesthesia. Conclusions: Functional connectivity patterns dynamically shift during surgery and general anesthesia but do so in a structured way. Thus, a single measure of functional connectivity will likely not be a reliable correlate of surgical anesthesia. © 2019 the American Society of Anesthesiologists, Inc.

Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event

Editor's Perspective What We Already Know about This Topic Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. What This Article Tells Us That Is New Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief. Background: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors' objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel. Methods: At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings. Results: During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers. Conclusions: Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief. © 2019 the American Society of Anesthesiologists, Inc.

Automated Ambulatory Blood Pressure Measurements and Intraoperative Hypotension in Patients Having Noncardiac Surgery with General Anesthesia: A Prospective Observational Study

Editor's Perspective What We Already Know about This Topic Intraoperative hypotension is associated with significant postoperative complications Intraoperative hypotension has been defined relative to preinduction blood pressure Blood pressure varies during the day, and the relationship between preinduction blood pressure and usual blood pressure over 24 h is incompletely described Similarly the relationship between low blood pressure intraoperatively and 24-h usual blood pressure is unknown What This Article Tells Us That Is New There is a poor correlation between preinduction blood pressure and the usual blood pressure over 24 h In two thirds of patients, the lowest postinduction and intraoperative pressures were lower than the lowest nighttime blood pressure Background: Normal blood pressure varies among individuals and over the circadian cycle. Preinduction blood pressure may not be representative of a patient's normal blood pressure profile and cannot give an indication of a patient's usual range of blood pressures. This study therefore aimed to determine the relationship between ambulatory mean arterial pressure and preinduction, postinduction, and intraoperative mean arterial pressures. Methods: Ambulatory (automated oscillometric measurements at 30-min intervals) and preinduction, postinduction, and intraoperative mean arterial pressures (1-min intervals) were prospectively measured and compared in 370 American Society of Anesthesiology physical status classification I or II patients aged 40 to 65 yr having elective noncardiac surgery with general anesthesia. Results: There was only a weak correlation between the first preinduction and mean daytime mean arterial pressure (r = 0.429, P < 0.001). The difference between the first preinduction and mean daytime mean arterial pressure varied considerably among individuals. In about two thirds of the patients, the lowest postinduction and intraoperative mean arterial pressures were lower than the lowest nighttime mean arterial pressure. The difference between the lowest nighttime mean arterial pressure and a mean arterial pressure of 65 mmHg varied considerably among individuals. The lowest nighttime mean arterial pressure was higher than 65 mmHg in 263 patients (71%). Conclusions: Preinduction mean arterial pressure cannot be used as a surrogate for the normal daytime mean arterial pressure. The lowest postinduction and intraoperative mean arterial pressures are lower than the lowest nighttime mean arterial pressure in most patients. © 2019, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

The Evolution of the Anesthesia Patient Safety Movement in America: Lessons Learned and Considerations to Promote Further Improvement in Patient Safety

Ellison C. Pierce, Jr., M.D., and a small number of specialty leaders and scientists formed a remarkable, diverse team in the mid-1980s to address a dual crisis: a safety crisis for anesthetized patients and a medical malpractice insurance crisis for anesthesiologists. This cohesive team's efforts led to the formation of the Anesthesia Patient Safety Foundation, the American Society of Anesthesiologists's Committees on Standards of Care and on Patient Safety and Risk Management, and the society's Closed Claims Project. The commonality of leaders and members of the Anesthesia Patient Safety Foundation and American Society of Anesthesiologists initiatives provided the strong coordination needed for their efforts to effect change, introduce standards of care and practice parameters, obtain financial support needed to grow patient safety-oriented new knowledge, integrate industry and other relevant leaders outside of anesthesiology, and involve all anesthesia professions. By implementing successful patient safety initiatives, they promoted the recognition that anesthesiology and patient safety are inextricably linked. Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved.

Fatigue in anesthesia: Implications and strategies for patient and provider safety

Fatigue is commonplace in contemporary society and is especially likely in individuals working in industries that must be in continuous operation. This article reviews the physiological challenges that face anesthesia care providers and the safety risks of working while fatigued. Data-based strategies are suggested for individual management of fatigue. The review concludes that the discipline of anesthesiology should take a leadership role in formulating health system-wide approaches for scheduling that are based on evidence rather than tradition.

49 Mathoura road: Geoffrey kaye's letters to Paul M. Wood, 1939-1955

From 1930 to 1955, Geoffrey Kaye, M.B.B.S., was one of the most influential anesthetists in Australia. In 1951, he opened a center of excellence for Australian anesthesia at 49 Mathoura Road, Toorak, Melbourne, which Kaye affectionately called "The Anaesthestists' Castle" and "49." "49" was designed to foster the educational, research, and administrative activities that would allow Australian anesthesia to reach the level of practice and professionalism found in Europe and America. Kaye wholly financed the venture and lived on the second floor of the building. During his world-wide travels, Kaye had developed a friendship with Paul M. Wood, M.D., the originator of the American Library-Museum now known eponymously as the Wood Library-Museum of Anesthesiology. Through the letters Kaye sent to Wood, the authors see Kaye's perception of the events surrounding the rise and fall of "49." Kaye's early letters were optimistic as he discussed the procurements and provisions he made for "49." His later letters exhibit frustration at the lack of participation by members of the Australian Society of Anaesthetists. Kaye was truly a visionary for his time. He believed that the diffusion center which "49" was to become was not only realistic and achievable but also necessary if Australian anesthesia was to gain international prominence comparable to anesthesia in Europe and North America. In the end, the failure of "49" left Kaye estranged from Australian anesthesia for many years. How this estrangement affected Australian anesthesia is unknown. © 2014, the American Society of Anesthesiologists, Inc.

How Can Anesthesiologists Influence Policymaking? Reflections from a Year at the Council of Economic Advisers

From September 2019 to August 2020, the author served as a senior economist on the Council of Economic Advisers, a government agency charged with providing economic analysis and advice to the President of the United States and senior government officials. Working with the Council yielded many useful lessons on how anesthesiologists can influence healthcare policy. First, because the President has wide latitude over many areas of health policy that directly impact patient care and anesthesiologists' working environment, anesthesiologists should focus their efforts on influencing policymakers within the executive branch of government in addition to influencing lawmakers. Second, policymakers are busy and typically do not have a technical background, so anesthesiologists must learn how to communicate with them succinctly and at an appropriate level. Finally, because policymakers often need analysis quickly, anesthesiologists must meet these needs even if the underlying analysis is rougher and less precise that what would normally be needed for peer review. © 2021 Lippincott Williams and Wilkins. All rights reserved.

49 Mathoura Road: Geoffrey Kaye's center of excellence for the Australian Society of Anaesthetists

Geoffrey Kaye, M.B.B.S. (1903 to 1986), was a prominent Australian anesthetist, researcher, and educator who envisioned that anesthesia practice in Australia would be comparable to European and American anesthesia practice during the 1940s and 1950s. Kaye's close relationship with Francis Hoeffer McMechan, M.D., F.I.C.A. (1879 to 1939), which began when Kaye left a favorable impression on McMechan at a meeting of the Australasian Medical Congress in 1929, eventually led Kaye to establish an educational center for the Australian Society of Anaesthetists at 49 Mathoura Road, Toorak, Melbourne, Australia, in 1951. The center served as the "Scientific Headquarters" and the Australian Society of Anaesthetists' official headquarters from 1951 to 1955. Although anesthesia's recognition as a specialty was at the heart of the center, Kaye hoped that this "experiment in medical education" - equipped with a library, museum, laboratory, workshop, darkroom, and meeting space - would "bring anaesthetists of all lands together" in Australia. The lack of member participation in Kaye's center, however, led Kaye to dissolve the center by 1955. Previous research has documented the history of Kaye's center from correspondence between Kaye and influential American anesthesiologist Paul M. Wood, M.D. (1894 to 1953), from 1939 to 1955. Through letters Kaye sent to American anesthesiologist Paul M. Wood, M.D. (1894 to 1963), the authors see Kaye's detailed plans, design, and intent for the center at 49 Mathoura Road. Comparisons of Kaye's letters to Wood during the 1950s with his letters to Gwenifer Wilson, M.D., M.B.B.S. (1916 to 1988), during the 1980s illustrate a change in Kaye's perceptions regarding the failure of the center. © 2016, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

Anesthesiologists' Role in Value-based Perioperative Care and Healthcare Transformation

Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients. © 2021 Lippincott Williams and Wilkins. All rights reserved.

COVID-19 Infection: Implications for Perioperative and Critical Care Physicians

Healthcare systems worldwide are responding to Coronavirus Disease 2019 (COVID-19), an emerging infectious syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus. Patients with COVID-19 can progress from asymptomatic or mild illness to hypoxemic respiratory failure or multisystem organ failure, necessitating intubation and intensive care management. Healthcare providers, and particularly anesthesiologists, are at the frontline of this epidemic, and they need to be aware of the best available evidence to guide therapeutic management of patients with COVID-19 and to keep themselves safe while doing so. Here, the authors review COVID-19 pathogenesis, presentation, diagnosis, and potential therapeutics, with a focus on management of COVID-19-associated respiratory failure. The authors draw on literature from other viral epidemics, treatment of acute respiratory distress syndrome, and recent publications on COVID-19, as well as guidelines from major health organizations. This review provides a comprehensive summary of the evidence currently available to guide management of critically ill patients with COVID-19. © 2020, the American Society of Anesthesiologists, Inc. All Rights Reserved.

High-volume hemofiltration in the intensive care unit: A blood purification therapy

High-volume hemofiltration is an extracorporeal therapy that has been available in the intensive care unit for more than 10 yr. Recent improvements in technology have made its clinical application easier and safer. However, the definition, indications, and management of this technique are still unclear, and considerable controversy and confusion remain. The aim of this review is to analyze the available data while taking into account the distinction between two very different clinical situations: acute kidney injury requiring renal support, and severe inflammatory states where blood purification has been suggested as an adjuvant therapy. For patients with acute kidney injury requiring renal replacement therapy, the two largest multicenter studies performed to date established that high ultrafiltration flow rates are not necessary. Conversely, much experimental and some clinical evidence suggest that high-volume hemofiltration can be beneficial for the subset of critically ill patients with severe inflammatory states such as septic shock. © 2012 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology.

The Apgar score has survived the test of time.

In 1953, Virginia Apgar, M.D. published her proposal for a new method of evaluation of the newborn infant. The avowed purpose of this paper was to establish a simple and clear classification of newborn infants which can be used to compare the results of obstetric practices, types of maternal pain relief and the results of resuscitation. Having considered several objective signs pertaining to the condition of the infant at birth she selected five that could be evaluated and taught to the delivery room personnel without difficulty. These signs were heart rate, respiratory effort, reflex irritability, muscle tone and color. Sixty seconds after the complete birth of the baby a rating of zero, one or two was given to each sign, depending on whether it was absent or present.Virginia Apgar reviewed anesthesia records of 1025 infants born alive at Columbia Presbyterian Medical Center during the period of this report. All had been rated by her method. Infants in poor condition scored 0-2, infants in fair condition scored 3-7, while scores 8-10 were achieved by infants in good condition. The most favorable score 1 min after birth was obtained by infants delivered vaginally with the occiput the presenting part (average 8.4). Newborns delivered by version and breech extraction had the lowest score (average 6.3). Infants delivered by cesarean section were more vigorous (average score 8.0) when spinal was the method of anesthesia versus an average score of 5.0 when general anesthesia was used. Correlating the 60 s score with neonatal mortality, Virginia found that mature infants receiving 0, 1 or 2 scores had a neonatal death rate of 14%; those scoring 3, 4, 5, 6 or 7 had a death rate of 1.1%; and those in the 8-10 score group had a death rate of 0.13%. She concluded that the prognosis of an infant is excellent if he receives one of the upper three scores, and poor if one of the lowest three scores.

A modification in the training requirements in anesthesiology: Requirements for the third clinical anesthesia year

In order to continue to enhance the educational quality of residency training in anesthesiology and ultimately to improve patient care, the American Board of Anesthesiology has adopted a modification in the curriculum for the 4-year Continuum of Education in Anesthesiology to provide for a CA-3 year replacing the Specialized Year and the Alternate Pathways. This CA-3 year will be required for residents beginning the CA-1 year of training on or after May 1, 1986. There will be a 2-year transition period beginning May 1, 1984, to facilitate its implementation.

Development of an anesthesiology-based postoperative pain management service

In recent years, two new therapeutic modalities for treatment of postoperative pain have become available: epidural opiate analgesia (EOA) and patient-controlled analgesia (PCA). Several factors have limited the wide-spread use of these techniques: the cost of PCA machines, the time required by anesthesiologists to manage epidural analgesia, fear of respiratory depression with EOA, and lack of structured programs for the provision of PCA and EOA. In this paper, we describe our approach for dealing with these issues so as to extend the advantages of EOA and PCA to greater numbers of postsurgical patients.

Erratum: Nebulization of antiinfective agents in invasively mechanically ventilated adults: A systematic review and meta-analysis (Anesthesiology (2017) 126 (890-908) DOI: 10.1097/ALN.0000000000001570)

In th article beginning on page 890 in the May 2017 issue, the first sentence of the Competing Interests section is incorrect due to a publisher error. The correct sentence is "Dr. Rello received research grants and consulting fees from Bayer (Leverkusen, Germany) and Genentech (San Francisco, California)." This error has been corrected in the online version of the article. Copyright © 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Survey of residency training in preoperative evaluation

In the academic year 1998 to 1999, the majority of accredited anesthesiology residency training programs did not have a formal curriculum addressing preoperative assessment, and nearly 40% provided no clinical training in preoperative evaluation.

Erratum: Comparison of tracheal intubation conditions in operating room and intensive care unit: A prospective, observational study (Anesthesiology (2018) 129 (321–328) DOI: 10.1097/ALN.0000000000002269)

In the article "Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit: A Prospective, Observational Study" (Taboada M, Doldan P, Calvo A, Almeida X, Ferreiroa E, Baluja A, Cariñena A, Otero P, Caruezo V, Naveira A, Otero P, Alvarez J: Anesthesiology 2018; 129:321-8), there was a mistake in table 2. The complication of hypoxia less than 80% was 29 patients (14%) in the intensive care unit, but table 2 mistakenly shows 19 patients (14%). The authors regret this error. © 2019, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

Erratum: Disruption of Rapid Eye Movement Sleep Homeostasis in Adolescent Rats after Neonatal Anesthesia (Anesthesiology (2019) 130 (981-194) DOI: 10.1097/ALN.0000000000002660)

In the article "Disruption of Rapid Eye Movement Sleep Homeostasis in Adolescent Rats after Neonatal Anesthesia" (Lunardi N, Sica R, Atluri N, Salvati KA, Keller C, Beenhakker MP, Goodkin HP, Zuo Z: Anesthesiology 2019; 130:981-94), the figure 2 image and legend were incorrect. They should have appeared as follows. The authors regret these errors. The article has been corrected online and in the PDF. (Figure Presented). © 2019, the American Society of Anesthesiologists, Inc.

Erratum: Limb remote ischemic preconditioning attenuates lung injury after pulmonary resection under propofol-remifentanil anesthesia: A randomized controlled study (Anesthesiology (2014) 121 (249-259) DOI: 10.1097/ALN.0000000000000266)

In the article "Limb Remote Ischemic Preconditioning Attenuates Lung Injury after Pulmonary Resection under PropofolRemifentanil Anesthesia: A Randomized Controlled Study" (Li C, Xu M, Wu Y, Li YS, Huang WQ, Liu KX: Anesthesiology 2014; 121:249-59), the P values in tables 1 and 2 are systematically incorrect, given the descriptive statistics. The authors are unable to locate the primary data to recalculate the P values in these tables. They located the primary data for table 3 and verified that the descriptive data presented in the article are correct. The authors believe that the reported descriptive statistics, including tables 1 and 2, are correct, and that the reported P values are incorrect due to a systematic error. The authors regret these errors. © 2019, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

Erratum: Limb remote ischemic preconditioning for intestinal and pulmonary protection during elective open infrarenal abdominal aortic aneurysm repair: A randomized controlled trial (Anesthesiology (2013) 118 (842–852) DOI: 10.1097/ALN.0b013e3182850da5)

In the article "Limb Remote Ischemic Preconditioning for Intestinal and Pulmonary Protection during Elective Open Infrarenal Abdominal Aortic Aneurysm Repair: A Randomized Controlled Trial" (Li C, Li YS, Xu M, Wen SH, Yao X, Wu Y, Huang CY, Huang WQ, Liu KX: Anesthesiology 2013; 118:842-52), the P values in table 2 are systematically incorrect, given the descriptive statistics. The authors are unable to locate the primary data to recalculate the P values in these tables. The authors believe that the reported descriptive statistics, including tables 1 and 2, are correct, and that the reported P values are incorrect due to a systematic error. The authors regret these errors. © 2019, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

Erratum: Lung ultrasound in emergency and critically ill patients: Number of supervised exams to reach basic competence (Anesthesiology (2020) 132 (899−907) DOI: 10.1097/ALN.0000000000003096)

In the article "Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence" published in the April 2020 issue, there is an error in the Methods section. In the third paragraph under "Lung Ultrasound Curriculum and the APECHO Study" on page 902, the sentence "⋯ (3) interstitial syndrome, defined as the presence of more than two spaced B lines or coalescent B lines, detected in a limited portion of the intercostal space and issued from the pleural line or subpleural consolidations of at least 5 mm;⋯" should be replaced by "⋯ (3) interstitial syndrome, defined as the presence of more than two spaced B lines;⋯". The authors regret the error. The online version and PDF of the article have been corrected. © 2020 Lippincott Williams and Wilkins. All rights reserved.

Erratum: Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: A study of 92,881 patients (Anesthesiology (2007) 106 (226-237))

In the article "Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center" (Flick RP, Sprung J, Harrison TE, Gleich SJ, Schroeder DR, Hanson AC, Buenvenida SL, Warner DO: Anesthesiology 2007; 106:226-37) there is an error in the following sentence: "Of the 26 noncardiac patients who experienced CA, 7 had congenital heart disease, such that 87.5% of all patients who experienced perioperative CA had underlying heart disease." This sentence should have read "76% of all patients," not "87.5% of all patients." The authors regret this error. © 2019, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

Erratum: Prophylactic intrathecal morphine and prevention of post-dural puncture headache: A randomized double-blind trial (Anesthesiology (2020) 132 (1045−1052) DOI: 10.1097/ALN.0000000000003206)

In the article "Prophylactic Intrathecal Morphine and Prevention of Post-Dural Puncture Headache: A Randomized Double-blind Trial" published in the May 2020 issue, the terms intrathecal morphine and intrathecal saline are reversed in the Abstract and Results section. The results section of the Abstract currently reads: "Epidural blood patch was administered to 10 of 27 (37%) of subjects in the intrathecal morphine and 11 of 21 (52%) of the intrathecal saline group (difference 15%; 95% CI, -18% to 48%)." The correct statement should read: "Epidural blood patch was administered to 11 of 21 (52%) of the intrathecal morphine group and 10 of 27 (37%) of subjects in the intrathecal saline and (difference 15%; 95% CI, -18% to 48%)." This statement is consistent with what is reported in Table 2. The same error is found in the Results section. It currently reads: "Epidural blood patch was administered to 36% of subjects in the intrathecal morphine and 52% of the intrathecal saline group (difference, 16%; 95% CI, -17% to 49%)." The correct statement should be: "Epidural blood patch was administered to 52% of subjects in the intrathecal morphine and 37% of the intrathecal saline group (difference 15%; 95% CI, -18% to 48%)." The authors regret the error. The online version and PDF of the article have been corrected. © 2020 Lippincott Williams and Wilkins. All rights reserved.

Erratum: "Protective Ventilation" during Anesthesia: Is It Meaningful? (Anesthesiology (2016) 125 (1079-82))

In the article beginning on page 1079 of the December 2016 issue, an incorrect reference appears in the References list. Reference 25 is incorrect, and should instead be listed as: "Edmark L, Auner U, Hallen J, Lassinantti-Olowsson L, Hedenstierna G, Enlund M: A ventilation strategy during general anaesthesia to reduce postoperative atelectasis. Upsala Journal of Medical Sciences 2014; 55:75-81.". © Copyright 2016, the American Society of Anesthesiologists Inc Wolters Kluwer Health Inc. Unauthorized reproduction of this article is prohibited.

Erratum: Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure (Anesthesiology (2014) 120 (1137-1145))

In the article beginning on page 1137 of the May 2014 issue, typographic data errors exist in table 1, in the two right-most columns. The correct data are as follows: (Table presented).