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Use of concatemers of ligand-gated ion channel subunits to study mechanisms of steroid potentiation | Synaptic receptors of the nicotinic receptor gene family are pentamers of subunits. This modular structure creates problems in studies of drug actions, related to the number of copies of a subunit that are present and their position. A separate issue concerns the mechanism of action of many anesthetics, which involves potentiation of responses to neurotransmitters. Potentiation requires an interaction between a transmitter and a potentiator, mediated through the target receptor. We have studied the mechanism by which neurosteroids potentiate transmitter responses, using concatemers of covalently linked subunits to control the number and position of subunits in the assembled receptor and to selectively introduce mutations into positionally defined copies of a subunit. We found that the steroid needs to interact with only one site to produce potentiation, that the native sites for steroid interaction have indistinguishable properties, and that steroid potentiation appears to result from a global effect on receptor function. Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Testing the link between sympathetic efferent and sensory afferent fibers in neuropathic pain | Systemic α-adrenergic Blockade with Phentolamine: A Diagnostic Test for Sympathetically Maintained Pain. By S. N. Raja, R. D. Treede, K. D. Davis, and J. N. Campbell. ANESTHESIOLOGY 1991; 74:691-8. Reprinted with permission. ABSTRACT:: The diagnosis of sympathetically maintained pain (SMP) is typically established by assessment of pain relief during local anesthetic blockade of the sympathetic ganglia that innervate the painful body part. To determine if systemic α-adrenergic blockade with phentolamine can be used to diagnose SMP, we compared the effects on pain of local anesthetic sympathetic ganglion blocks (LASB) and phentolamine blocks (PhB) in 20 patients with chronic pain and hyperalgesia that were suspected to be sympathetically maintained. The blocks were done inrandom order on separate days. Patients rated the intensity of ongoing and stimulus-evoked pain every 5 min before, during, and after the LASB and PhB. Patients and the investigator assessing pain levels were blinded to the time of intravenous administration of phentolamine (total dose 25-35 mg). The pain relief achieved by LASB and PhB correlated closely (r = 0.84), and there was no significant difference in the maximum pain relief achieved with the two blocks (t = 0.19, P > 0.8). Nine patients experienced a greater than 50% relief of pain and hyperalgesia from both LASB and PhB and were considered to have a clinically significant component of SMP. We conclude that α-adrenergic blockade with intravenous phentolamine is a sensitive alternative test to identify patients with SMP. © 2012 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
No Silver Medal for Nobel Prize Contenders: Why Anesthesia Pioneers Were Nominated for but Denied the Award | Taking the examples of the pioneers Carl Ludwig Schleich, Carl Koller, and Heinrich Braun, this article provides a first exploratory account of the history of anesthesiology and the Nobel Prize for physiology or medicine. Besides the files collected at the Nobel Archive in Sweden, which are presented here for the first time, this article is based on medical literature of the early 20th century. Using Nobel Prize nominations and Nobel committee reports as points of departure, the authors discuss why no anesthesia pioneer has received this coveted trophy. These documents offer a new perspective to explore and to better understand aspects of the history of anesthesiology in the first half of the 20th century. |
Competency-based education in anesthesiology history and challenges | The Accreditation Council for Graduate Medical Education is transitioning to a competency-based system with milestones to measure progress and define success of residents. The confines of the time-based residency will be relaxed. Curriculum must be redesigned and assessments will need to be precise and in-depth. Core anesthesiology faculty will be identified and will be the "trained observers" of the residents' progress. There will be logistic challenges requiring creative management by program directors. There may be residents who achieve "expert" status earlier than the required 36 months of clinical anesthesia education, whereas others may struggle to achieve acceptable status and will require additional education time. Faculty must accept both extremes without judgment. Innovative new educational opportunities will need to be created for fast learners. Finally, it will be important that residents embrace this change. This will require programs to clearly define the specific aims and measurement endpoints for advancement and success. Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Addressing the mandate for hand-off education: A focused review and recommendations for anesthesia resident curriculum development and evaluation | The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation. © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Oxygen and Life on Earth: An Anesthesiologist's Views on Oxygen Evolution, Discovery, Sensing, and Utilization | The advent of oxygenic photosynthesis and the accumulation of oxygen in our atmosphere opened up new possibilities for the development of life on Earth. The availability of oxygen, the most capable electron acceptor on our planet, allowed the development of highly efficient energy production from oxidative phosphorylation, which shaped the evolutionary development of aerobic life forms from the first multicellular organisms to the vertebrates. Copyright © 2008 The American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. |
The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System | The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system. Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved. |
Practice advisory on anesthetic care for magnetic resonance imaging: An updated report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging | The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Anesthetic Care for Magnetic Resonance Imaging presents an updated report of the Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging. Copyright © 2014, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. |
Senior medical students' knowledge of and attitudes toward anesthesiology in ten medical schools | The American Society of Anesthesiologists has sponsored a national preceptorship program in anesthesiology for medical students since 1966. The purpose of the program is to enhance students' understanding of and interest in anesthesiology. An evaluation of the effectiveness of the first 5 years of the program has been completed. There were no statistically significant differences between students who had and had not participated in the preceptorship program in their correct responses to the 6 knowledge areas over which they were questioned. Significantly more students who had participated in the preceptorship program than students who had not taken a preceptorship considered their skills in endotracheal intubation and positive pressure ventilation more adequate. There was no statistically significant difference between the attitudes of the 2 groups of students toward anesthesiology; 73% of the seniors who had taken a preceptorship said that their attitudes toward anesthesiology were more positive now than they had been in the early years of medical school; 62% of the seniors who had not participated in the program admitted to more positive attitudes toward the specialty as seniors than as preclinical students. |
Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management | The American Society of Anesthesiologists Task Force on Acute Pain Management presents an updated set of recommendations based on the analysis of the current literature and a synthesis of expert opinion. |
Practice guidelines for pulmonary artery catheterization: An updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization | The American Society of Anesthesiologists Task Force on Guidelines for Pulmonary Artery Catheterization presents a systematically developed set of recommendations based on analysis of the current literature and a synthesis of expert opinion. |
Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway | The American Society of Anesthesiologists Task Force on Management of the Difficult Airway presents a systematically developed set of recommendations based on analysis of the current literature and a synthesis of expert opinion. |
Practice guidelines for postanesthetic care: A report by the American Society of Anesthesiologists Task Force on Postanesthetic Care | The American Society of Anesthesiologists Task Force on Postanesthetic Care presents a systematically developed set of recommendations based on analysis of the current literature and a synthesis of expert opinion. |
2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway | The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway. © 2022 Lippincott Williams and Wilkins. All rights reserved. |
Status of women in academic anesthesiology | The authors compared anesthesia faculties with the rest of medical school faculties at each of four academic ranks and found a significant difference in proportion of men and women anesthesia faculty members at the assistant professor rank only (P < 0.001). When the faculty status of women and men academic anesthesiologists was examined a significant difference was found in rank distribution in age groups 40 to 44 (P < 0.005) and 45 to 49 (P < 0.001), where there was a deficit of professors and a surfeit of instructors among women. Significant differences in distribution continued at age 50-54 (P < 0.01), 55-59 (P < 0.001), and 60-64 (P < 0.005), primarily at professor and assistant professor ranks. In addition, there was significantly lower prevalence of board certification (P < 0.001) and level of responsibilities for women (P < 0.001). There was no significant difference in tenure status. |
Bacterial interaction between anesthesiologists, their patients, and equipment | The authors examine the following: liberation of organisms from the airway of an infected patient; inoculum size needed to infect a subsequent patient; effect of aerosols (including droplet size and evaporation) on the viability of microorganisms; effect of relative humidity on microorganism viability; effect of anesthesia and oxygen on microorganism viability; effect of metallic ions on microorganism viability; effect of plastics on microorganism viability; clinical investigations - transmission of bacteria from infected patients to the anesthesia machine; and problems associated with acid-fast bacillary infections. Fifty two references are cited. |
Respiratory excretion of halothane after clinical and occupational exposure | The authors have demonstrated measurable levels of halothane in patients for as long as 20 days following anesthesia. Significant accumulations of halothane in operating room personnel following occupational exposure was also observed. Toxicity studies of chronic exposure to low concentrations of anesthetic gases are lacking. Recent reports suggest a possible relationship between health problems and chronic exposure to low concentrations of anesthetic gases. Although no relationship has as yet been established, exhaustion of waste anesthetic gases from the operating room through the use of effective gas scavenging devices on anesthesia machines is suggested. |
Erratum: Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery: A Multicenter Randomized Trial (Anesthesiology (2020) 132 (839-853) DOI: 10.1097/ALN.0000000000003132) | The authors of an article published in the April 2020 issue, “Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery: A Multicenter Randomized Trial,”1 note two errors in their published article and present below the relevant corrections. 1. The description of the area under the curve in the “Sample Size” section expresses this outcome as “units per measurement” and “units/24-hr interval.” This description can be misleading, as multiplication (and not division) is usually used to express this outcome. To avoid any ambiguity, the authors have modified the reporting in this section to “units for each measurement” and “units during a 24-h interval.” “U/24-h interval” has also been corrected to “units during 24-h interval” in the first row of table 2. 2. To estimate the area under the curve, the authors used the “trapezoid rule,” and not the “trapezoid role” as incorrectly described in the penultimate paragraph of the “Statistical Analysis” section on page 844. The authors regret and apologize for these errors. The online version and PDF of the article have been corrected. © 2005 IEEE Computer Society. All rights reserved. |
Erratum: Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients (Anesthesiology (2009) 110 (284-294) DOI: 10.1097/ALN.0b013e318194caaa) | The authors of the article beginning on page 284 in the February 2009 issue wish to add the following ClinicalTrials.gov identifier to their article: NCT00421148. © Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. |
Erratum: Reversal of neuromuscular blockade by sugammadex after continuous infusion of rocuronium in patients randomized to sevoflurane or propofol maintenance anesthesia (Anesthesiology (2009) 111 (30-35) DOI: 10.1097/ALN.0b013e3181a51cb0) | The authors of the article beginning on page 30 in the July 2009 issue wish to add the following ClinicalTrials.gov identifier to their article: NCT00559468. © Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. |
Erratum: Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients (Anesthesiology (2011) 114 (318-329) DOI: 10.1097/ALN.0b013e3182065c36) | The authors of the article beginning on page 318 in the February 2011 issue wish to add the following ClinicalTrials.gov identifier to their article: NCT00474617. © Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. |
Erratum: Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review (Anesthesiology (2020) 133 (1283-1305) DOI: 10.1097/ALN.0000000000003558) | The authors regret this error. The online version and PDF of the article have been corrected. © 2021, the American Society of Anesthesiologists, Inc. |
A study of decision making: how faculty define competence | The authors studied decision making in evaluation of residents by 34 faculty members in a university training program by simulating the evaluation process. Twenty-seven hypothetical residents were described in terms of six criteria used by the American Board of Anesthesiology: Pre-operative Evaluation, Anesthetic Management, Technical Ability, Scholarship, Conduct in Stress, and Relationships with Others. Each criterion was studied at three performance levels: poor, average, and outstanding. A factorial design dictated how each resident was portrayed on an evaluation form familiar to the faculty. Each faculty member ranked the residents in order of clinical competence. His ranking was transformed by conjoint measurement into the percentage contribution of each criterion to the evaluation decision. Mean values (in percentages) were Pre-operative Evaluation 21, Anesthetic Management 22, Technical Ability 14, Scholarship 16, Conduct in Stress 18, and Relationships with Others 9. Underlying these values were four decision-making patterns differing in the perceived importances of the criteria. Although one pattern (41 per cent of faculty members) used all performance data supplied, the others used only three or five criteria. Only Pre-operative Evaluation and Anesthetic Management were part of all four patterns; three of the four patterns, used by 59 per cent of faculty members, apparently ignored Relationships with Others in their evaluations. Faculty age and subspecialty interest did not discriminate among evaluative patterns. This study suggests that there is no consensus on the operational definition of competence and that conjoint measurement is particularly appropriate for the analysis of complex decisions like the evaluation of competence. |
Calcium entry blockers: Uses and implications for anesthesiologists | The Ca++ entry blockers are valuable new drugs in the treatment of many cardiovascular diseases. Because of the prevalence of these diseases, anesthesiologists will anesthetize many patients maintained on Ca++ antagonists and will wish to administer them to some patients under their care. Verapamil and nifedipine are available for use in the United States. Verapamil is useful for the treatment of supraventricular arrhythmias, whereas nifedipine and verapamil are indicated in the treatment of coronary vasospasm. There is no good information regarding whether or not the drugs need to be discontinued for a specific interval before anesthesia. Our clinical experience with both compounds is that they may be continued safely right up to the morning of surgery. Both nifedipine and verapamil are potent vasodilators and must be administered with caution during anesthesia and in the perioperative period, especially in patients with impaired ventricular function and/or hypovolemia. Additionally, verapamil may produce varying degrees of A-V block and must be given very carefully in patients anesthetized with enflurane, isoflurane, and halothane, in patients with A-V nodal block, or in patients maintained on beta-adrenergic blocking drugs. There is little experience to guide the anesthesiologist in the perioperative use of these drugs, but their potential uses are great. The calcium channel blockers are an important addition to our formulary, with many of their uses in anesthesiology yet to be confirmed or discovered. |
Occupational disease among operating room personnel | The conclusions of the Ad Hoc Committee on occupational disease, appointed by the American Society of Anesthesiologists, based on questionnaires sent to 73,496 individuals, are critically discussed. The authors come to the conclusion that so far no proof is given of the existence of occupational disease in operating room personnel. |
Response of Chinese Anesthesiologists to the COVID-19 Outbreak | The coronavirus disease 2019, named COVID-19 officially by the World Health Organization (Geneva, Switzerland) on February 12, 2020, has spread at unprecedented speed. After the first outbreak in Wuhan, China, Chinese anesthesiologists encountered increasing numbers of infected patients since December 2019. Because the main route of transmission is via respiratory droplets and close contact, anesthesia providers are at a high risk when responding to the devastating mass emergency. So far, actions have been taken including but not limited to nationwide actions and online education regarding special procedures of airway management, oxygen therapy, ventilation support, hemodynamic management, sedation, and analgesia. As the epidemic situation has lasted for months (thus far), special platforms have also been set up to provide free mental health care to all anesthesia providers participating in acute and critical caring for COVID-19 patients. The current article documents the actions taken, lesson learned, and future work needed. © 2020, the American Society of Anesthesiologists, Inc. |
Erratum: Population volume kinetics in Volunteers: Comment:(Anesthesiology DOI: 10.1097/ALN.0000000000003210) | The correspondence published Online First on February 20, 2020, "Population Volume Kinetics in Volunteers: Comment"1 has been retracted because the original article being discussed, "Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and Isoflurane-anesthetized Volunteers,"2 has been retracted at the request of the authors. © 2020 Lippincott Williams and Wilkins. All rights reserved. |
Erratum: Population Volume Kinetics in Volunteers: Reply: (Anesthesiology DOI: 10.1097/ALN.0000000000003211) | The correspondence published Online First on February 20, 2020, "Population Volume Kinetics in Volunteers: Reply"1 has been retracted because the original article being discussed, "Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and Isoflurane-anesthetized Volunteers,"2 has been retracted at the request of the authors. © 2020 Lippincott Williams and Wilkins. All rights reserved. |
The American Society of Anesthesiologist's efforts in developing guidelines for sedation and analgesia for nonanesthesiologists: The 40th rovenstine lecture | The current shortage of anesthesiologists exceeds their capacity to administer all sedation in hospitals, ambulatory care facilities, and offices. The American Society of Anesthesiologists must take the lead in developing evidence-based research to quantify the risks of anesthesia administration by nonanesthesiologists. |
Ca2+ uptake and Ca2+ release by skeletal muscle sarcoplasmic reticulum: Differing sensitivity to inhalational anesthetics | The effects of halothane, enflurane, and isoflurane were measured on two different mechanisms of Ca2+ regulation by isolated skeletal muscle sarcoplasmic reticulum (SR) membranes. A 100,000-dalton Ca2+-ATPase protein transports Ca2+ from outside to inside the SR membrane. At concentration ranges representing anesthetic levels of 0.06 to 2.3 times MAC, halothane, enflurane, and isoflurane each increased rate of Ca2+ uptake by SR. Each concentration of isoflurane produced a greater rate of Ca2+ uptake, whereas halothane and enflurane produced maximum stimulation of Ca2+ uptake at 1 and 1.6 times MAC, respectively. The second Ca2+ regulation mechanism studied was a Ca2+ release channel in the SR membrane. The release of Ca2+ via this mechanism requires a critical threshold Ca2+ load (nmol Ca2+/mg SR protein) for Ca2+-induced Ca2+ release to occur. Each anesthetic tested effectively lowered the critical Ca2+ load threshold for Ca2+ release, i.e., the Ca2+ channel was more readily induced to an open state in the presence of anesthetic. The concentrations of anesthetics having this effect on the putative Ca2+ channel were between 0.0026 and 0.078 MAC equivalents for each agent, and these concentrations are much lower than the anesthetic concentrations affecting Ca2+ uptake. These data show that in isolated skeletal muscle SR membranes a Ca2+ channel release function is altered at anesthetic concentrations far below those that change Ca2+ uptake function by a Ca2+-ATPase and below concentrations of the volatile agents producing clinical anesthesia. The Ca2+ channel effect may represent protein-anesthetic interaction, whereas the Ca2+-ATPase effect may occur by a generalized SR membrane perturbation by the anesthetics. |
Potential hazards and applications of lithium in anesthesiology | The element lithium (Li) is ubiquitous in nature, yet only in the last decade has its use as a therapeutic agent been approved in the United States. Although it is a simple element Li's pharmacologic mechanism of action remains to be fully understood, and as its therapeutic use becomes more widespread, it poses particular hazards for the anesthesiologist. This short review is meant to inform, as well as to help guide the anesthesiologist in his approach to a patient receiving Li treatment. Moreover, possible new applications for Li in anesthesiology are discussed. |
Military anesthesia trainees in WWII at the University of Wisconsin: Their training, careers, and contributions | The emerging medical specialty of anesthesiology experienced significant advances in the decade prior to World War II but had limited numbers of formally trained practitioners. With war looming, a subcommittee of the National Research Council, chaired by Ralph M. Waters, MD., was charged with ensuring sufficient numbers of anesthesiologists for military service. A 12-week course was developed to train military physicians at academic institutions across the country, including the Wisconsin General Hospital. A total of 17 officers were trained in Madison between September 1942 and December 1943. Notably, Virgil K. Stoelting, the future chair of anesthesiology at Indiana University, was a member of this group.A rigorous schedule of study and clinical work ensured the officers learned to administer anesthesia safely while using a variety of techniques. Their leadership and contributions in the military and after the war contributed significantly to the further growth of anesthesiology. © 2013 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology. |
Foregger 705® malfunction resulting in loss of gas flow | The Foregger 705® has an indexing key pin-plunger that is subject to damage by regular use, possibly because it is brazed rather than welded. In our situation, as this pin developed a greater 'wobble', it allowed damage of a common outlet poppet valve, damaging that valve in such a way that no flow could pass through either DRV. Diluent gas will flow via an alternate route when the Copper Kettle ® is used. The abrupt cutoff of all gas flow has obvious potential hazard and should be brought to the attention of anesthesia personnel using this machine. |
Nitrate-nitrite-nitric oxide pathway: Implications for anesthesiology and intensive care | The gaseous radical nitric oxide is involved in numerous physiologic and pathophysiological events important in anesthesiology and intensive care. Nitric oxide is endogenously generated from the amino acid l-arginine and molecular oxygen in reactions catalyzed by complex nitric oxide synthases. Recently, an alternative pathway for nitric oxide generation was discovered, wherein the inorganic anions nitrate (NO3) and nitrite (NO2), most often considered inert end products from nitric oxide generation, can be reduced back to nitric oxide and other bioactive nitrogen oxide species. This nitrate-nitrite-nitric oxide pathway is regulated differently than the classic l-arginine-nitric oxide synthase nitric oxide pathway, and it is greatly enhanced during hypoxia and acidosis. Several lines of research now indicate that the nitrate-nitrite-nitric oxide pathway is involved in regulation of blood flow, cell metabolism, and signaling, as well as in tissue protection during hypoxia. The fact that nitrate is abundant in our diet gives rise to interesting nutritional aspects in health and disease. In this article, we present an overview of this field of research with emphasis on relevance in anesthesiology and intensive care. © 2010, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Erratum: Pregnancy and labor epidural effects on gastric emptying: A prospective comparative study (Anesthesiology (2022) 136 (542-550) DOI: 10.1097/ALN.0000000000004133) | The gastric emptying rate referenced throughout the article is not a true “rate,” but is rather a fraction.Accordingly, gastric emptying “rate” has been changed to gastric emptying “fraction” throughout the article. The authors regret this error.The online version and PDF of the article have been corrected. Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. |
Organization and physician education in critical care medicine | The goal of critical care medicine is to improve care for acute life threatening illnesses and injuries, leading to increased salvage of life with human mentation. Recent advances in the knowledge and technology of acute care still await application through regional emergency and critical care medicine systems, all components of which must be upgraded and coordinated. Close cooperation among physicians committed to emergency care and intensive care at the hospital level and for community wide organization of care is essential. The trend for critical care medicine to become a subspecialty of anesthesiology, medicine, pediatrics, or surgery is viable. There is not general agreement at this time concerning the definition and scope of critical care medicine. Combined emergency care and critical care education by interdisciplinary programs should be upgraded for medical students and residents in all clinical disciplines. CCM followship training programs should be expanded to meet manpower needs for ICU leadership, to improve standards in all components of the emergency and critical care medicine system, and to foster acute care related research. All anesthesiologists should be educated to the capability of functioning as consultants in resuscitation and respiratory intensive care. Their full or most time involvement as leaders or team members in critical care medicine will depend on the individual's competence, interest, availability, and financial considerations. (120 references are cited) |
Addiction and anesthesiology | The goal of this article is to describe drug addiction, its adverse consequences on our profession, and what can be done about it. |
Thoughts on a paleoanesthetic | The great importance of the introduction into clinical anesthesia of cyclopropane 40 yr ago is pointed out, and it is argued that even nowadays with many more anesthetics, muscle relaxants and types of equipment available, this general anesthetic, unique in that it does not induce cardiovascular depression, can be of great value. |
Gut Microbiome in Anesthesiology and Pain Medicine | The gut microbiome plays critical roles in human health and disease. Recent studies suggest it may also be associated with chronic pain and postoperative pain outcomes. In animal models, the composition of the gut microbiome changes after general anesthesia and affects the host response to medications, including anesthetics and opioids. In humans, the gut microbiome is associated with the development of postoperative pain and neurocognitive disorders. Additionally, the composition of the gut microbiome has been associated with pain conditions including visceral pain, nociplastic pain, complex regional pain syndrome, and headaches, partly through altered concentration of circulating bacterial-derived metabolites. Furthermore, animal studies demonstrate the critical role of the gut microbiome in neuropathic pain via immunomodulatory mechanisms. This article reviews basic concepts of the human gut microbiome and its interactions with the host and provide a comprehensive overview of the evidence linking the gut microbiome to anesthesiology, critical care, and pain medicine. © 2022 Lippincott Williams and Wilkins. All rights reserved. |
Role of network science in the study of anesthetic state transitions | The heterogeneity of molecular mechanisms, target neural circuits, and neurophysiologic effects of general anesthetics makes it difficult to develop a reliable and drug-invariant index of general anesthesia. No single brain region or mechanism has been identified as the neural correlate of consciousness, suggesting that consciousness might emerge through complex interactions of spatially and temporally distributed brain functions. The goal of this review article is to introduce the basic concepts of networks and explain why the application of network science to general anesthesia could be a pathway to discover a fundamental mechanism of anesthetic-induced unconsciousness. This article reviews data suggesting that reduced network efficiency, constrained network repertoires, and changes in cortical dynamics create inhospitable conditions for information processing and transfer, which lead to unconsciousness. This review proposes that network science is not just a useful tool but a necessary theoretical framework and method to uncover common principles of anesthetic-induced unconsciousness. © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2018; 129:1029-44 |
'There shall be no pain' | The history of the discovery of laughing gas anesthesia by Wells is described. The tendency of the modern anesthesiologist to oocupy himself with critical care medicine (CCM) is discussed. According to the author, CCM is only a detail of anesthesiology and it would be regretted if the anesthesiologist were no longer to use his special knowledge for that which should remain the starting point of the specialty: there shall be no pain. |
Impact of the World Health Organization Surgical Safety Checklist on Patient Safety | The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. Surgical safety checklists may be used as some of the tools to prevent such complications. Use of checklists may reduce critical workload by eliminating issues that are already controlled for. The global introduction of the World Health Organization Surgical Safety Checklist aimed to improve safety in both anesthesia and surgery and to reduce complications and mortality by better teamwork, communication, and consistency of care. This review describes a literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects and using a theoretical framework for quality of provided healthcare (structure-process-outcome) to understand the checklists' possible impact on patient safety. |
Erratum: Interscalene Brachial Plexus Block with Liposomal Bupivacaine versus Standard Bupivacaine with Perineural Dexamethasone: A Noninferiority Trial (Anesthesiology (2022) 136 (434-447) DOI: 10.1097/ALN.0000000000004111) | The last sentence in the Results section paragraph on the primary outcome (page 438) was incorrect as published: "Superiority testing (one-sided t test) demonstrated that the average numerical rating scale pain score over 3 days postoperatively for the liposomal bupivacaine group was not superior to that of the bupivacaine with dexamethasone group (P = 0.998)." There was an error in the P-value calculation as originally published. The corrected sentence should read, "In addition, based on a manuscript peer reviewer request for superiority testing via post hoc analysis, superiority testing (two-tailed two-sample t test) was performed and found that the average numerical rating scale pain score over 72h postoperatively was statistically significantly lower for the liposomal bupivacaine group compared to the bupivacaine with dexamethasone group (P = 0.002). However, the mean average numerical rating scale pain score over 72h difference was 1.1, which is below the predetermined clinically meaningful margin of 1.3." The conclusions of the investigation are unchanged. © 2023 Lippincott Williams and Wilkins. All rights reserved. |
Electrocution in the operating room. | The manner in which a patient sustained an electrical shock injury from improperly wired equipment during the course of an operation was described in order to acquaint others with a potentially hazardous situation. A patient requiring surgical treatment had the ground plate of an electrocautery unit placed under her buttocks and the electrodes of an EKG unit attached to her shoulders and her precordium. During the course of the operation, the EKG monitor was subject to electrical interference. In an effort to correct the problem, the surgeon instructed the nurse to unplug the monitor and reinsert the plug into a 2nd wall receptable. As the plug was reinserted, the physician suffered a minor shock and the patient experienced an intense shock. She became cyanotic and her pulse stopped. The patient was revived and later recovered completely. Inspection of the equipment revealed that the EKG's power plug was incorrectly wired. The chassis ground was connected to the neutral plug instead of the ground plug. Furthermore, the 2nd wall receptacle was wired with reversed polarity. When the plug was inserted into the 2nd receptacle, a 110 volt alternating current developed between the precoidal EKG lead and the ground plate. If the monitor had been plugged into the 2nd receptacle prior to the operation, the monitor would not have functioned. The technician probably would have assumed that the machine was not in working order and would have substitued another machine. In order to minimize electrical shocks, EKG leads should be applied only to the extremities and not to the precordium region. |
Forensic anesthesiology? | The members of the health care profession, in assuming responsibility for a patient's medical treatment, not only have an obligation to see that they do no harm to the patient, but also to protect the susceptible patient from harm. In this case, the actions of parents and other visitors must be closely monitored. |
Serendipity: Being in the right place at the right time | The minimum alveolar concentration (MAC) of an inhaled anesthetic preventing movement in response to a surgical incision as a measure of equipotency was “invented” in 1964 at the University of California, San Francisco. The principal advantage of MAC is that it allows the pharmacologic effects of inhaled anesthetics to be compared against each other at a similar anesthetic depth. Thus, if the hemodynamic effect (hypotension, decreased cardiac output) of anesthetic “A” is greater than that of anesthetic “B,” the anesthesiologist may elect to use “A” in patients with myocardial dysfunction. A rare side effect of a volatile anesthetic is that in some patients, malignant hyperthermia may occur with or without succinylcholine use. This phenomenon was detected in a patient in whom halothane MAC was being measured. The availability of the Severinghaus blood gas device allowed for the first ever measurement of the metabolic and respiratory acidemia that accompanies malignant hyperthermia. Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. |
Manipulating neural circuits in anesthesia research | The neural circuits underlying the distinct endpoints that define general anesthesia remain incompletely understood. It is becoming increasingly evident, however, that distinct pathways in the brain that mediate arousal and pain are involved in various endpoints of general anesthesia. To critically evaluate this growing body of literature, familiarity with modern tools and techniques used to study neural circuits is essential. This Readers' Toolbox article describes four such techniques: (1) electrical stimulation, (2) local pharmacology, (3) optogenetics, and (4) chemogenetics. Each technique is explained, including the advantages, disadvantages, and other issues that must be considered when interpreting experimental results. Examples are provided of studies that probe mechanisms of anesthesia using each technique. This information will aid researchers and clinicians alike in interpreting the literature and in evaluating the utility of these techniques in their own research programs. © 2020 Wolters Kluwer Health, Inc. All rights reserved. |
Perioperative Management of Patients Infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists | The outbreak of the new Coronavirus disease, COVID-19, has been involved in 77,262 cases in China as well as in 27 other countries as of February 24, 2020. Because the virus is novel to human beings, and there is no vaccine yet available, every individual is susceptible and can become infected. Healthcare workers are at high risk, and unfortunately, more than 3,000 healthcare workers in China have been infected. Anesthesiologists are among healthcare workers who are at an even higher risk of becoming infected because of their close contact with infected patients and high potential of exposure to respiratory droplets or aerosol from their patients' airways. In order to provide healthcare workers with updated recommendations on the management of patients in the perioperative setting as well as for emergency airway management outside of the operating room, the two largest anesthesia societies, the Chinese Society of Anesthesiology (CSA) and the Chinese Association of Anesthesiologists (CAA) have formed a task force to produce the recommendations. The task force hopes to help healthcare workers, particularly anesthesiologists, optimize the care of their patients and protect patients, healthcare workers, and the public from becoming infected. The recommendations were created mainly based on the practice and experience of anesthesiologists who provide care to patients in China. Therefore, adoption of these recommendations outside of China must be done with caution, and the local environment, culture, uniqueness of the healthcare system, and patients' needs should be considered. The task force will continuously update the recommendations and incorporate new information in future versions. © 2020, the American Society of Anesthesiologists, Inc. |
Anesthesia for cesarean section | The past decade has witnessed a series of major changes in the practice of obstetrics, including a three-to fourfold increase in the incidence of delivery by cesarean section. At the same time, obstetric anesthesia has emerged as a recognized subspecialty of anesthesiology, with increasing attention focused on measuring the impacts on mother, fetus, and newborn of anesthetic interventions. The present review indicates substantial advances in our understanding of the physiology, pharmacology and clinical management of anesthesia for cesarean delivery. At the same time, the need for further studies is clear, particularly in the areas of prevention of the risks of gastric aspiration, management of patients with hypertension and diabetes, and the short- and long-term effects of analgesics and anesthetics on the premature, the compromised, and the full-term fetus and infant. Excellent results are obtained in elective cesarean section at term with well-managed spinal, epidural, or general anesthesia. 245 references are cited. |
Alteration of warfarin kinetics in man associated with exposure to an operating room environment | The plasma half life of warfarin (mean±SE) in five normal, nonmedicated control subjects given a single 40 mg/m2 oral dose of warfarin was 38.8±4.1 hours. It was essentially the same (37.7±2.6 hours) in these subjects when determined again four months later. The effect of the single dose of warfarin on prothrombin complex activity (prothrombin response) was determined by calculating the area under the curve obtained by plotting prothrombin time (seconds) versus time after the warfarin dose (hours). The prothrombin response in control subjects was 1670±64 sec hr initially and essentially the same at the end of the four month interval (1730±96 sec hr). Plasma warfarin half life and prothrombin response in seven anesthesiology residents were 32.1±3.6 hours and 1337±78 sec hr at the start of their training period, i.e., before working in the operating room. Four months later, their plasma warfarin half lives were significantly prolonged (49.3±4.8 hours) and the prothrombin responses were significantly greater (1552±22 sec hr) compared with their initial values. The alteration of warfarin kinetics appeared to be due mainly to inhibition of warfarin metabolism, presumably related to the repeated exposure of these subjects to an operating room environment. |
"Gentlemen! This Is No Humbug": Did John Collins Warren, M.D., proclaim these words on October 16, 1846, at Massachusetts General Hospital, Boston? | The proclamation, "Gentlemen! this is no humbug," attributed to John Collins Warren, M.D., was not identified in any contemporaneous eyewitness report of William T. G. Morton's October 16, 1846, demonstration of ether at Massachusetts General Hospital. The earliest known documentation of the proclamation is in Nathan P. Rice's biography of Morton, first published in 1859. Only three eyewitnesses, Washington Ayer, M.D., Robert Thompson Davis, M.D., and Isaac Francis Galloupe, M.D., reported Warren's alleged proclamation. However, their accounts first appeared in 1896, 50 yr after Morton's demonstration of etherization. Although Warren's alleged proclamation appears plausible, the overall impression from eyewitness statements and publications relating to the October 16, 1846, demonstration of etherization is that it may not have been made. © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. |
Cognitive processes in anesthesiology decision making | The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology. Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame. Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making. Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Anesthesiology in the People's Republic of China | The same drugs that are used in the USA are available in China, local and regional anesthesia are very popular. The author saw 15 operations performed under acupuncture anesthesia. In his opinion the method can be of value in selected cases. There is a great difference in technique for the same operative procedure. Virtually no clinical research is done under acupuncture anesthesia. |
Scientific Accuracy Matters | The Solubility of Halothane in Blood and Tissue Homogenates. By Larson CP, Eger EI, Severinghaus JW. Anesthesiology 1962; 23:349-55. Measured samples of human and bovine blood, human hemoglobin, and tissue homogenates from human fat and both human and bovine liver, kidney, muscle, whole brain, and separated gray and white cortex were added to stoppered 2,000-ml Erlenmeyer flasks. To each flask, 0.1 ml of liquid halothane was added under negative pressure using a calibrated micropipette. After the flask was agitated for 2 to 4 h to achieve equilibrium between the gas and blood or tissue contents, a calibrated infrared halothane analyzer was used to measure the concentration of halothane vapor. Calculated partition coefficients ranged from 0.7 for water to 2.3 for blood and from 3.5 for human or bovine kidney to 6 for human whole brain or liver and 8 for human muscle. Human peritoneal fat had a value of 138. The human blood-gas partition coefficient of 2.3 as determined by this equilibration method was well below the previously published value of 3.6. © 2021 Lippincott Williams and Wilkins. All rights reserved. |
Research training in anesthesiology: Expand it now! | The specialty is well served by the questions and proposals raised by the authors of these two important publications. We believe current ACGME program requirements and ABA criteria for entering its examination system, along with ACGME and ABA interests in accommodating well-designed, exceptional curriculums on a case-by-case basis, allow individual residents and program directors to craft personalized curriculums that can provide strong research-oriented training experiences and be integrated throughout anesthesiology training programs. Proposals to further expand research experiences during residency training or to require dedicated research time in anesthesiology subspecialty training programs will be debated further in the coming year. Copyright © 2006, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. |
Should we all have a sympathectomy at birth? Or at least preoperatively? | The sympathetic nervous system appears useful to wild animals in helping to mobilize energy stores and in facilitating escape from threatening situations. But, as the article by Stone et al. in this issue of ANESTHESIOLOGY suggests, such reactions may not be beneficial in anesthetized humans inasmuch as myocardial oxygen requirement may increase beyond supply. Do the adverse effects of stress now outweigh the benefits an intact sympathetic nervous system conveys? Should we ideally all be sympathectomized at birth, or at least preoperatively? Before answering this not so tongue-in-cheek question, we should first consider the details of this study by Stone et al. which has stimulated this question. |
Chronobiology and Anesthesia | The time of day influences physiologic functions, pain, the pharmacologic aspects of drugs used for anesthesia, and the efficacy of many drugs used in the perioperative period. However, information regarding circadian rhythms for general anesthetics and newer analgesic agents remains fragmentary. Introduction of chronobiology in the field of anesthesia has become necessary for the quality of future clinical and experimental research. |
Anesthetic and analgesic drug products advisory committee activity and decisions in the opioid-crisis era | The United States Food and Drug Administration is tasked with ensuring the efficacy and safety of medications marketed in the United States. One of their primary responsibilities is to approve the entry of new drugs into the marketplace, based on the drug's perceived benefit-risk relationship. The Anesthetic and Analgesic Drug Product Advisory Committee is composed of experts in anesthesiology, pain management, and biostatistics, as well as consumer and industry representatives, who meet several times annually to review new anesthetic-related drugs, those seeking new indications, and nearly every opioid-related application for approval. The following report describes noteworthy activities of this committee since 2017, as it has grappled, along with the Food and Drug Administration, to balance the benefit-risk relationships for individual patients along with the overarching public health implications of bringing additional opioids to market. All anesthesia advisory committee meetings since 2017 will be described, and six will be highlighted, each with representative considerations for potential new opioid formulations or local anesthetics. © 2020 Lippincott Williams and Wilkins. All rights reserved. |
Postoperative epidural morphine is safe on surgical wards | The use of epidural morphine for postoperative analgesia outside of intensive care units remains controversial. In this report our anesthesiology-based acute pain service documents experience with 1,106 consecutive postoperative patients treated with epidural morphine on regular surgical wards. This experience involved 4,343 total patient days of care and 11,089 individual epidural morphine injections. On a 0-10 verbal analog scale, patient-reported median pain scores at rest and with coughing or ambulation were 1 (interquartile range 3) and 4 (interquartile range 4), respectively. The incidence of side effects requiring medication were as follows: pruritus 24%, nausea 29%, and respiratory depression 0.2%. There were no deaths, neurologic injuries, or infections associated with the technique. Migration of epidural catheters into the subarachnoid space and into epidural veins each occurred twice. Overall, 1,051 of the 1,106 patients (95%) experienced none of the following problems: catheter obstruction, premature dislodgement, painful injections, catheter migration, infection, or respiratory depression. We conclude that postoperative pain can be safely and effectively treated with epidural morphine on surgical wards. |
Determining Associations and Estimating Effects with Regression Models in Clinical Anesthesia | There are an increasing number of "big data"studies in anesthesia that seek to answer clinical questions by observing the care and outcomes of many patients across a variety of care settings. This Readers' Toolbox will explain how to estimate the influence of patient factors on clinical outcome, addressing bias and confounding. One approach to limit the influence of confounding is to perform a clinical trial. When such a trial is infeasible, observational studies using robust regression techniques may be able to advance knowledge. Logistic regression is used when the outcome is binary (e.g., intracranial hemorrhage: yes or no), by modeling the natural log for the odds of an outcome. Because outcomes are influenced by many factors, we commonly use multivariable logistic regression to estimate the unique influence of each factor. From this tutorial, one should acquire a clearer understanding of how to perform and assess multivariable logistic regression. Copyright © 2020, the American Society of Anesthesiologists, Inc. |
Can simulation help to answer the demand for echocardiography education? | There has been a recent explosion of education and training in echocardiography in the specialties of anesthesiology and critical care. These devices, by their impact on clinical management, are changing the way surgery is performed and critical care is delivered. A number of international bodies have made recommendations for training and developed examinations and accreditations. The challenge to medical educators in this area is to deliver the training needed to achieve competence into already overstretched curricula. The authors found an apparent increase in the use of simulators, with proven efficacy in improving technical skills and knowledge. There is still an absence of evidence on how it should be included in training programs and in the accreditation of certain levels. There is a conviction that this form of simulation can enhance and accelerate the understanding and practice of echocardiography by the anesthesiologist and intensivists, particularly at the beginning of the learning curve. © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Monitoring depth of anesthesia: With emphasis on the application of the Bispectral Index and the middle latency auditory evoked response to the prevention of recall | There is considerable current interest in the issue of awareness. The concern that, in our patients, unnecessary anxiety about the risk of awareness and unrealistic expectations about the ability of the BIS monitor to prevent the phenomenon have developed has already been discussed in ANESTHESIOLOGY.34,35 It has also been asserted that careful, prospective study with subsequent peer-reviewed publication will be necessary to establish the effectiveness of any putative awareness-prevention device.35 The peer-reviewed literature does not support the notion that any commercially available monitor can serve to prevent awareness, although it indicates that useful trend-monitoring of depth of anesthesia and titration of depth of sedation can be accomplished with the BIS.10,11 Furthermore, even in the event of the development of a device that reliably identifies anesthetic states representing a high risk for awareness, episodes of awareness still may occur. The first reason is that depth of anesthesia at any moment is probably the sum of the effects of the anesthetic agents being administered and the prevailing degree of stimulus-related arousal. Even a monitor that meets the stringent specificity conditions suggested above might 'fail,' in the context of light anesthesia with minimal surgical stimulus, in the event of a sudden increase in the intensity of stimulus. The second is that there will continue to be situations in which the clinician is limited by failing hemodynamics from administering the anesthetic agents that are otherwise warranted. It is unrealistic to expect any monitor to be proof-positive against the occurrence of awareness. |
2007 In review: A dozen steps forward in anesthesiology | These 12 articles represent an inspiring collection of advances in our specialty. Yet another dozen could easily have been chosen, including: • Long-term neuroprotection from isoflurane: Sakai et al. ANESTHESIOLOGY 2007; 106:92-9 • The first human application of a novel local anesthetic: Rodriquez-Navarro et al. ANESTHESIOLOGY 2007; 106: 339-45 • Application of monitoring to measure in real time end-tidal concentrations of systemically administered drugs: Takita et al. ANESTHESIOLOGY 2007; 106:659-64 and Hornuss et al. ANESTHESIOLOGY 2007; 106:665-4 • ASA practice guidelines for obstetric anesthesia: Connis et al. ANESTHESIOLOGY 2007; 106:843-63 • The safety of low dose droperidol in the peri-operative period: Nuttall et al. ANESTHESIOLOGY 2007; 106:531-6 • Moving neuromuscular monitoring electrodes 2 cm medially reduces the incidence of postoperative nausea and vomiting as much as pharmacologic therapy: Arnberger et al. ANESTHESIOLOGY 2007; 107:903-8 • Laboratory studies suggesting a drug used orally to treat Alzheimer's disease might also be used to treat chronic pain: Clayton et al. ANESTHESIOLOGY 2007; 106: 1019-25 • Novel description of an anesthetic site of action on presynaptic targets: Metz et al. ANESTHESIOLOGY 2007; 107:971-82 Just as movie trailers are intended to whet your appetite to see a film, so do we hope this brief review highlighting practical and theoretical advances in the practice of medicine in our specialty will whet your appetite to reread these articles. Stay tuned for 2008! Copyright © 2007, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. |
Research training grants in anesthesia: Seventeen years of NIH support | Thirteen centers were granted a total of $10,709,000 from the National Institutes of Health for research training in anesthesia in fiscal years 1959 to 1975, inclusive. Eighty nine per cent ($9,543,000) of the funds were spent. Of 442 trainees supported, 376 have made career decisions. Two hundred and seventeen (58%) of these pursued academic careers (academicians). Seventy four of the former trainees (20% of those who have chosen a career) received subsequent NIH awards for research projects between fiscal years 1962 and 1974, inclusive, supporting 446 grant years of research. These research investigators are considered 'total successes'. One hundred and forty three (38%) of the former trainees, pursuing academic anesthesia careers, but who have not yet received NIH support for research, are considered to be 'qualified successes' of this training program. After an estimated lag time of 5.5 to 6 yr following completion of training, it is expected that 1/3 of those trained in these programs will receive NIH research support (145 to 150 individuals). The expenditure per postdoctoral trainee per year was $17,400, and the average number of months of support per trainee was 15.1, for an average cost per trainee of $21,600. The cost per academician was $37,400; the cost per research investigator was $96,400. The cost per research investigator is estimated to be $57,000 if 1/3 of the former trainees subsequently obtain NIH research support, as the authors project. Compared with estimated expenditures of $12,600 per year of medical school education, these costs are not unreasonable. Further follow up study of the careers of the graduates of research training grant programs is needed to complete the data collection and to verify the accuracy of the authors' projections. The research training grant program in anesthesia has been beneficial in alleviating the manpower shortage of academic anesthesiologists and research investigators and has also provided 14 chairpersons in academic anesthesia departments. The current and future needs for academicians and research investigators in anesthesia must be determined in order to ascertain whether additional research training support is required in anesthesia. |
Type 2 Perioperative Myocardial Infarction: Can We Close Pandora's Box? | This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue. Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. |
The centennial of spinal anesthesia | This article reviews the life and profession of Dr. August Bier, who performed the first operation under spinal anesthesia on August 16, 1898, at the Royal Surgical Hospital of the University of Kiel, Germany. |
Musings from an Unlikely Clinician-Scientist: 2018 American Society of Anesthesiologists Excellence in Research Award | This article, which stems 2018 American Society of Anesthesiologists Excellence in Research Award Lecture, aims to encourage young investigators, offer advice, and share several early life experiences that have influenced the author's career as an anesthesiologist and clinician-scientist. The article also describes key discoveries that have increased understanding of the role of γ-aminobutyric acid type A (GABAA) receptors in health and disease. The author's research team identified the unique pharmacologic properties of extrasynaptic GABAA receptors and their role in the anesthetic state. The author's team also showed that extrasynaptic GABAA receptors expressed in neuronal and nonneuronal cells contribute to a variety of disorders and are novel drug targets. The author's overarching message is that young investigators must create their own unique narratives, train hard, be relentless in their studies and - most important - enjoy the journey of discovering new truths that will ultimately benefit patients. Copyright © 2019, the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this article is prohibited. |
Obstetric anesthesia for a patient with malignant hyperthermia susceptibility | This is a follow-up on a case report previously published in Anesthesiology concerning a patient with a family history of hyperthermia. The same patient has subsequently had spinal anesthesia for vaginal delivery. Creatine phosphokinase (CPK) levels in her plasma rose from 1,605 IU before labor to 2,390 IU during spinal anesthesia, an alarming increase in a few hours' time. Most of the family members were investigated for creatine phosphokinase levels. |
Assessing the past and shaping the future of anesthesiology: The 43rd Rovenstine Lecture | This lecture, honoring Dr. Emery A. Rovenstine, recounts the accomplishments of anesthesiologists over the past seven decades since he ushered in a new era in anesthesiology discovery and patient care. Dedication to discovery, involvement, commitment, and compassionate service are ecessary for current and future generations if anesthesiology is to continue to flourish. |
An Anesthesiologist's Perspective on the History of Basic Airway Management | This second installment of the history of basic airway management covers the early - artisanal - years of anesthesia from 1846 to 1904. Anesthesia was invented and practiced as a supporting specialty in the context of great surgical and medical advances. The current-day anesthesia provider tends to equate the history of airway management with the history of intubation, but for the first 58 yr after the introduction of ether anesthesia, airway management was provided by basic airway techniques with or without the use of a face mask. The jaw thrust and chin lift were described in the artisanal years and used primarily with inhalation anesthesia in the spontaneously breathing patient and less often with negative-pressure ventilation in the apneic victim. Positive-pressure ventilation and intubation stayed at the fringes of medical practice, and airway techniques and devices were developed by trial and error. At the beginning of the 20th century, airway management and anesthetic techniques lagged behind surgical requirements. © 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. |
An Anesthesiologist's Perspective on the History of Basic Airway Management: The "progressive" Era, 1904 to 1960 | This third installment of the history of basic airway management discusses the transitional-"progressive"-years of anesthesia from 1904 to 1960. During these 56 yr, airway management was provided primarily by basic techniques with or without the use of a face mask. Airway maneuvers were inherited from the artisanal era: head extension and mandibular advancement. The most common maneuver was head extension, also used in bronchoscopy and laryngoscopy. Basic airway management success was essential for traditional inhalation anesthesia (ether, chloroform) and for the use of the new anesthetic agents (cyclopropane, halothane) and intravenous drugs (thiopental, curare, succinylcholine). By the end of the era, the superiority of intermittent positive pressure ventilation to spontaneous ventilation in anesthesia and negative pressure ventilation in resuscitation had been demonstrated and accepted, and the implementation of endotracheal intubation as a routine technique was underway. © 2018 Lippincott Williams and Wilkins. All rights reserved. |
Obstetric anesthesia: A national survey | To assess obstetric anesthesia in the United States, and to determine why more anesthesia personnel are not involved in this subspecialty, a questionnaire was sent to the heads of obstetric and anesthesia services in 1,200 hospitals. Both obstetric and anesthesia respondents agreed on several characteristics of obstetric anesthesia that inhibit more participation by anesthesia personnel. Among others, they identified that: the unpredictability of labor and delivery makes scheduling difficult; obstetricians tend to dictate type and timing of anesthesia; the risk of malpractice claims is increased for obstetric anesthesia; and, finally, larger obstetric services would make it more practical to provide anesthesia services. Regarding availability of personnel and procedures, obstetric units with less than 500 deliveries per year were considerably more understaffed than the larger units in most areas studied. When general anesthesia was used for cesarean section in these units, it was provided by, or given under the direction of, an anesthesiologist only 44% of the time, whereas in the hospitals with more than 1,500 deliveries per year, an anesthesiologist was present 86% of the time, Likewise, in the small units, personnel classified as 'others' were responsible for newborn resuscitation in 24% and 43% of instances after cesarean section and vaginal delivery, respectively. In the hospitals with more than 1,500 deliveries, comparable figures were 4% and 2%, respectively. |
Trust, but verify: The accuracy of references in four anesthesia journals | To determine the accuracy of bibliographic citation in the anesthesia literature, we reviewed all 1988 volumes of Anesthesiology, Anesthesia and Analgesia, British Journal of Anaesthesia, and Canadian Journal of Anaesthesia and sequentially numbered all references appearing in that year (n = 22,748). One hundred references from each of the four journals were randomly selected. After citations to nonjournal articles (i.e., books or book chapters) were excluded, the remaining 348 citations were analyzed in detail. Six standard bibliographic elements-authors' names, article title, journal title, volume number, page numbers, and year-were examined in each selected reference. Primary sources were reviewed, unless our institution did not own the source or could not obtain it through interlibrary loan, in which case standard indexes, abstracting services, and computerized databases were consulted. Each element was checked for accuracy, and references were classified as either correct or incorrect. A reference was correct if each element of the citation was identical to its source. Of the examined references, more than half (50.3%) contained an error in at least one element. The elements most likely to be inaccurate were, in descending order, article title, author, page numbers, journal title, volume number, and year. No significant differences (P = 0.283) existed in the error rates of the four journals; the percentage of citations containing at least one error ranged from 44% (Anesthesia and Analgesia) to 56% (British Journal of Anaesthesia). The citation error rate of anesthesia journals is similar to that reported in other specialties, where error rates ranging from 38% to 54% have been documented. |
Home noninvasive ventilation: What does the anesthesiologist need to know? | Treatment of chronic respiratory failure with noninvasive ventilation (NIV) is standard pediatric practice, and NIV systems are commonly used in the home setting. Although practice guidelines on the perioperative management of children supported with home NIV systems have yet to be published, increasingly these patients are referred for consultation regarding perioperative management. Just as knowledge of pharmacology underlies the safe prescription of medication, so too knowledge of biomedical design is necessary for the safe prescription of NIV therapy. The medical device design requirements developed by the Organization for International Standardization provide a framework to rationalize the safe prescription of NIV for hospitalized patients supported at home with NIV systems. This review article provides an overview of the indications for home NIV therapy, an overview of the medical devices currently available to deliver it, and a specific discussion of the management conundrums confronting anesthesiologists. Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. |
Potential adverse ultrasound-related biological effects: A critical review | Ultrasound energy exerts important cellular, genetic, thermal, and mechanical effects. Concern about the safety of ultrasound prompted several agencies to devise regulatory limits on the machine output intensities. The visual display of thermal and mechanical indices during ultrasound imaging provides an aid to limit the output of the machine. Despite many animal studies, no human investigations conducted to date have documented major physiologic consequences of ultrasound exposed during imaging. To date, ultrasound imaging appears to be safe for use in regional anesthesia and pain medicine interventions, and adherence to limiting the output of ultrasound machines as outlined by the Food and Drug Administration may avoid complications in the future. This article reviews ultrasound-related biologic effects, the role of the regulatory agencies in ensuring safety with the use of ultrasound, and the limitations and implications of ultrasound use in humans. © 2011 the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology. |
Physician payment reform: Anesthesiology as a case study | We examined the effects of Resource-based Relative Value Scale (RBRVS)- and physician diagnosis-related groups (MDDRG)-based payment for anesthesiology services related to surgery by simulating these physician payment reform options. We merged Medicare Part A (hospital) and Part B (anesthesiology) payment data for 7,770 patients for the MDDRGT analysis and examined 10,431 surgical procedures for the RBRVS analysis within 27 diagnosis-related groups (DRGs) during the second half of 1986 in 16 hospitals representing different geographic regions, bed size, and teaching status. Assuming budget neutrality (i.e., constant total expenditure for anesthesiology services) and using the proposed methodologies, we simulated RBRVS and MDDRG payments and compared them to current payments for anesthesiology services. Individual surgical procedures demonstrated a two- to more than four-fold variation in duration, accompanied by a similar variation in anesthesiology payments. Within DRGs, there was a three- to ten-fold variation in duration, and a two- to seven-fold variation in anesthesiology payments. Anesthesiology time was highly correlated with surgical time (r = 0.86-0.96). Compared to the current system, RBRVS and MDDRG systems were associated with systematic variations in payments, such that on average, on each case, anesthesiologists practicing in rural and nonteaching hospitals would gain, whereas those in urban or suburban and teaching facilities would lose. After adjusting for complexity of procedure, the distribution of payment gains and losses was a function of duration of surgery, which is not influenced by the anesthesiologist. Longer cases of a given surgical procedure result in payment decreases. The results document the importance of retaining a time factor in the payment methodology for anesthesiology services to maintain equitable payment across practice settings - an objective of physician payment reform. |
A continuous indicator of the zero level of central venous pressure | When using a U tube to indicate the zero level of central venous pressure, this zero level is lost when the patient is moved upwards and downwards. Therefore, the authors attach a partially filled large syringe barrel (without the plunges) to one end of the U tube and fix this barrel at the site of the right atrium. |
The role of World War II and the European theater of operations in the development of anesthesiology as a physician specialty in the USA | World War II was a juncture in the development of anesthesia asa physician specialty because of the wartime education in anesthesia, the nature of wartime practice, and the impression trained physician-anesthetists made on surgeons and other physicians. |