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Measuring the anaesthesia clinical learning environment at the department level is feasible and reliable

Background: The learning environment describes the context and culture in which trainees learn. In order to establish the feasibility and reliability of measuring the anaesthetic learning environment in individual departments we implemented a previously developed instrument in hospitals across New South Wales. Methods: We distributed the instrument to trainees from 25 anaesthesia departments and supplied summarized results to individual departments. Exploratory and confirmatory factor analyses were performed to assess internal structure validity and generalizability theory was used to calculate reliability. The number of trainees required for acceptable precision in results was determined using the standard error of measurement. Results: We received 172 responses (59% response rate). Suitable internal structure validity was confirmed. Measured reliability was acceptable (G-coefficient 0.69) with nine trainees per department. Eight trainees were required for a 95% confidence interval of plus or minus 0.25 in the mean total score. Eight trainees as assessors also allow a 95% confidence interval of approximately plus or minus 0.3 in the subscale mean scores. Results for individual departments varied, with scores below the expected level recorded on individual subscales, particularly the ‘teaching’ subscale. Conclusions: Our results confirm that, using this instrument, individual departments can obtain acceptable precision in results with achievable trainee numbers. Additionally, with the exception of departments with few trainees, implementation proved feasible across a training region. Repeated use would allow departments or accrediting bodies to monitor their individual learning environment and the impact of changes such as the introduction of new curricular elements, or local initiatives to improve trainee experience. © 2017 The Author(s)

Mini-clinical evaluation exercise in anaesthesia training

Background: The Mini-Clinical Evaluation Exercise (Mini-CEX) is a workplace-based assessment tool of potential value in anaesthesia to assess and improve clinical performance. Its reliability and positive educational impact have been reported in other specialities, but not, to date, in anaesthesia. In this study, we evaluated the psychometric characteristics, logistics of application, and impact on the quality of supervision of the Mini-CEX in anaesthesia training.MethodsA Mini-CEX encounter consisted of a single specialist anaesthetist observing a trainee over a defined period of time, completing an online Mini-CEX form with the trainee, and providing written and verbal feedback. We sought trainee and supervisor perspectives on its value and ease of use and used Generalizability Theory to estimate reliability.ResultsWe collected 331 assessments from 61 trainees and 58 assessors. Survey responses strongly supported the positive effect of the Mini-CEX on feedback, its relative feasibility, and acceptance as a potential assessment tool. In this cohort, we found variable assessor stringency and low trainee variation. However, a feasible sample of cases and assessors would produce sufficiently precise scores to decide that performance was satisfactory for each trainee with 95 confidence. To generate scores that could discriminate sufficiently between trainees to allow ranking, a much larger sample of cases would be needed.ConclusionsThe Mini-CEX in anaesthesia has strengths and weaknesses. Strengths include: its perceived very positive educational impact and its relative feasibility. Variable assessor stringency means that large numbers of assessors are required to produce reliable scores. © The Author [2009].

Trends in gender distribution among anesthesiology residents: Do they matter?

BACKGROUND: The number of women graduating from United States medical schools progressively increased during the 26 yr period from 1978 to 2004. This change was associated with shifts in the gender distribution of residents training in Accreditation Council for Graduate Medical Education-accredited residency programs. METHODS: We compared trends in the number and gender distribution of residents enrolled in the 10 specialties with the largest national enrollment of residents. RESULTS: The gender distribution of residents training in different specialty programs varies widely. The percentage of women enrolled in anesthesiology training programs is less than the national average, and the rate of increase is less than that of many other specialties. CONCLUSIONS: The reasons for this distribution are multifactorial. Contributing factors may include limited exposure to women role models (including fewer women with senior academic rank and in leadership positions), gender insensitivity leading to an unprofessional work environment, limited involvement of women anesthesiologists in undergraduate medical education, misperceptions of the physician-patient relationship in anesthesiology, and practice scheduling requirements that are inconsistent and inflexible. © 2006 by International Anesthesia Research Society.

The status of women in academic anesthesiology: A progress report

BACKGROUND: The number of women in medicine has increased steadily in the last half century. In this study, we reassessed the status of women in academic anesthesiology departments in the United States in 2006. METHODS: Medical student, resident, and faculty rank gender data were obtained from the Association of American Medical Colleges. Data regarding the make-up and gender of anesthesia subspecialty society leadership, the editorial boards of Anesthesia & Analgesia and Anesthesiology, the awardees of anesthesia research grants, American Board of Anesthesiology examiners, and department chairs were obtained from websites, organization management personnel, and the Wood Library-Museum of Anesthesiology. Anesthesiology data were compared with composite data from medical school departments in other clinical specialties and to data from previous years, beginning in 1985. RESULTS: The percentage of medical school graduates, anesthesiology residents, and anesthesiology faculty members who are women has increased since 1985; however, the rate of increase in the percentage of women is significantly faster for medical school graduates compared with anesthesiology residents (P < 0.001) and faculty (P < 0.05). The percentage of women anesthesiology faculty members who were full professors in 2006 was 6.5% compared with 17.7% of men faculty (P < 0.001) and is not significantly different than in 1986 (P = 0.27). Fourteen percent of full anesthesiology professors were women and this does not differ from all clinical specialties combined (15%). Women comprised 12.7% of academic anesthesiology chairs and 10% of all medical school department chairs in 2006, significantly higher compared with 1993 (P < 0.05). Currently, 8% and 11% of editors and associate editors of Anesthesiology and Anesthesia & Analgesia are women, respectively. Eighteen percent of American Board of Anesthesiology oral board examiners in 2007 were women compared with 8% in 1985 (P < 0.05). The percentage of time in which women have served as anesthesiology society leaders was significantly greater during 1997-2006 compared with 1987-1996 (P < 0.001). The proportion of competitive research grants awarded to women has not changed over several decades. CONCLUSIONS: The status of women in academic anesthesiology in the first decade of the millennium has, by some measures, advanced compared with 20 yr ago. However, by other measures, there has been no change. The task ahead is to identify factors that discourage qualified women medical students, residents, and junior faculty members from pursuing careers in academic anesthesiology and advancing in academic rank. © 2008 International Anesthesia Research Society.

Cardiac Output Assessments in Anesthetized Children: Dynamic Capnography Versus Esophageal Doppler

BACKGROUND: The objective of this study was to compare esophageal Doppler cardiac output (COEDM) against the reference method effective pulmonary blood flow cardiac output (COEPBF), for agreement of absolute values and ability to detect change in cardiac output (CO) in pediatric surgical patients. Furthermore, the relationship between these 2 methods and noninvasive blood pressure (NIBP) parameters was evaluated. METHODS: Fifteen children American Society of Anesthesiology (ASA) I and II (median age, 8 months; median weight, 9 kg) scheduled for surgery were investigated in this prospective observational cohort study. Baseline COEPBF/COEDM/NIBP measurements were made at positive end-expiratory pressure (PEEP) 3 cm H2O. PEEP was increased to 10 cm H2O and COEPBF/COEDM/NIBP was recorded after 1 and 3 minutes. PEEP was then lowered to 3 cm H2O, and all measurements were repeated after 3 minutes. Finally, 20-µg kg-1intravenous atropine was given with the intent to increase CO, and all measurements were recorded again after 5 minutes. Paired recordings of COEDMand COEPBFwere examined for agreement and trending ability, and all parameters were analyzed for their responses to the hemodynamic challenges. RESULTS: Bias between COEDMand COEPBF(COEDM- COEPBF) was -17 mL kg-1min-1(limits of agreement, -67 to +33 mL kg-1min-1) with a mean percentage error of 32% (95% confidence interval [CI], 25-37) and a concordance rate of 71% (95% CI, 63-80). The hemodynamic interventions caused by PEEP manipulations resulted in significant decrease in COEPBFabsolute numbers (155 mL kg-1min-1[95% CI, 151-159] to 127 mL kg-1min-1[95% CI, 113-141]) and a corresponding relative decrease of 18% (95% CI, 14-22) 3 minutes after application of PEEP 10. No corresponding decreases were detected by COEDM. Mean arterial pressure showed a relative decrease with 5 (95% CI, 2-8) and 6% (95% CI, 2-10) 1 and 3 minutes after the application of PEEP 10, respectively. Systolic arterial pressure showed a relative decrease of 5% (95% CI, 2-10) 3 minutes after application of PEEP 10. None of the recorded parameters responded to atropine administration except for heart rate that showed a 4% relative increase (95% CI, 1-7, P =.02) 5 minutes after atropine. CONCLUSIONS: COEDMwas unable to detect the reduction of CO cause by increased PEEP, whereas COEPBFand to a minimal extent NIBP detected these changes in CO. The ability of COEPBFto react to minor reductions in CO, before noticeable changes in NIBP are seen, suggests that COEPBFmay be a potentially useful tool for hemodynamic monitoring in mechanically ventilated children. © 2022 Lippincott Williams and Wilkins. All rights reserved.

Scientific publications in anesthesiology journals from Mainland China, Taiwan, and Hong Kong: A 10-year survey of the literature

Background: The past 20 yr have seen significant growth in China's role in the international community. This same growth and international presence is occurring in the field of anesthesiology. The research status in anesthesiology among Chinese individuals in the 3 major regions of China-mainland China, Hong Kong, and Taiwan-is unknown. We analyzed articles published in peer-reviewed international anesthesiology journals cited by both PubMed and Science Citation Index from these 3 regions. Methods: Articles published in 21 journals in anesthesiology originating from mainland China, Taiwan, and Hong Kong from 1999 to 2008 were retrieved from the PubMed database and the Science Citation Index. The number of total articles, clinical trials, randomized controlled trials, impact factors, citations, and articles published in "high-impact" journals were tabulated to assess both the quantity and quality of research arising from China. Results: From 1999 to 2008 there were 721 articles published in high-impact anesthesiology journals from China, including 204 from mainland China, 317 from Taiwan, and 200 from Hong Kong. The number of articles published each year increased from 50 published in 1999 to 101 published in 2008. From 2005 onward, the number of articles published from mainland China exceeded that from Hong Kong and in 2008 mainland China exceeded Taiwan. The average impact factor of the articles was similar for mainland China (2.84), Taiwan (2.41), and Hong Kong (2.16). The total citations to articles from Taiwan (2376) exceeded citations to articles from mainland China (1143) and Hong Kong (1540). Anesthesia & Analgesia published more articles than any other journal from all 3 regions. Conclusion: The total number of articles from China published in highly cited anesthesiology journals increased markedly from 1999 to 2008, with articles from mainland China increasing substantially after 2004, whereas the number of publications from Hong Kong decreased. The average impact factor was similar for all 3 regions, ranging from 2.2 to 2.8. Anesthesia & Analgesia published more articles from Chinese authors from all 3 regions than any other journal. Copyright © 2010 International Anesthesia Research Society.

Development, Validation, and Results of a Survey of Personal Electronic Device Use Among 299 Anesthesia Providers From a Single Institution

BACKGROUND: The pattern of perioperative use of personal electronic devices (PEDs) among anesthesia providers in the United States is unknown. METHODS: We developed a 31-question anonymous survey of perioperative PED use that was sent to 813 anesthesiologists, anesthesiology residents, and certified registered nurse anesthetists at 3 sites within one health system. The electronic survey assessed patterns of PED use inside the operating room (OR), outside the OR, and observed in others. Questions were designed to explore the various purposes for PED use, the potential impact of specific hospital policies or awareness of medicolegal risk on PED use, and whether PED was a source of perioperative distraction. RESULTS: The overall survey response rate was 36.8% (n = 299). With regard to often/frequent PED activity inside the OR, 24% reported texting, 5% reported talking on the phone, and 11% reported browsing on the Internet. With regard to often/frequent PED activity outside the OR, 88% reported texting, 26% reported talking on the phone, and 63% reported browsing the Internet. With regard to often/frequent PED activity observed in others, 52% reported others texting, 14% reported others talking on the phone, and 34% reported others browsing the Internet. Two percent of respondents self-reported a distraction compared to 15% who had observed a distraction in others. Eighty percent of respondents recognized PED as a potential distraction for patient safety. CONCLUSIONS: Our data reinforce that PED use is prevalent among anesthesia providers. © 2021 International Anesthesia Research Society.

Implementation of a total joint replacement-focused

BACKGROUND: The perioperative setting in the United States is noted for variable and fragmented care that increases the chance for errors and adverse outcomes as well as the overall cost of perioperative care. Recently, the American Society of Anesthesiologists put forward the Perioperative Surgical Home (PSH) concept as a potential solution to this problem. Although the PSH concept has been described previously, "real-life" implementation of this new model has not been reported. METHODS: Members of the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery, in addition to perioperative hospital services, developed and implemented a series of clinical care pathways defining and standardizing preoperative, intraoperative, postoperative, and postdischarge management for patients undergoing elective primary hip (n = 51) and knee (n = 95) arthroplasty. We report on the impact of the Total Joint Replacement PSH on length of hospital stay (LOS), incidence of perioperative blood transfusions, postoperative complications, 30-day readmission rates, emergency department visits, mortality, and patient satisfaction. RESULTS: The incidence of major complication was 0.0 (0.0-7.0)% and of perioperative blood transfusion was 6.2 (2.9-11.4)%. In-hospital mortality was 0.0 (0.0-7.0)% and 30-day readmission was 0.7 (0.0-3.8)%. All Surgical Care Improvements Project measures were at 100.0 (93.0-100.0)%. The median LOS for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95% confidence interval [interquartile range]) 3 (2-3) [2-3] and 3 (2-3) [2-3] days. Approximately half of the patients were discharged to a location other than their customary residence (70 to skilled nursing facility, 1 to rehabilitation, 39 to home with organization health services, and 36 to home). CONCLUSIONS: We believe that our experience with the Total Joint Replacement PSH program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve high patient satisfaction. In the future, the impact of LOS on cost will have to be better quantified. Specifically, future studies comparing PSH to traditional care will have to include consideration of postdischarge care, which are drivers of the perioperative costs. Copyright © 2014 International Anesthesia Research Society.

The Specialist Anesthesiology Workforce in East, Central, and Southern Africa: A Cross-Sectional Study

BACKGROUND: The populations of the East, Central, and Southern African regions receive only a fraction of the surgical procedures they require, and patients are more likely to die after surgery than the global average. An insufficient anesthetic workforce is a key barrier to safe surgery. The anesthetic workforce in this region includes anesthesiologists and nonphysician anesthesia providers. A detailed understanding of the anesthesiologist workforce in East, Central, and Southern Africa is required to devise strategies for the training, retention, and distribution of the workforce. METHODS: A cross-sectional study of the anesthesiologist workforce of the 8 member countries of the College of Anaesthesiologists of East, Central, and Southern Africa (CANECSA) was undertaken. Data collection took place between May 2020 and September 2020 using existing databases and was validated through direct contact with anesthesiologists and other hospital staff. Primary outcomes were: total number of anesthesiologists in the region and their demographics, including gender, age, country of practice, current work location, country of origin, and country where they received their initial anesthesia qualification. RESULTS: Within the CANECSA member countries, 411 qualified anesthesiologists were identified (0.19 per 100,000 population). The median age was 41 years, and one-third were women. The majority (67.5%) were based in urban areas with a population >1 million people, and most are used by government institutions (61.6%). Most anesthesiologists in the region were trained (89.1%) and currently work (95.1%) in their home country. CONCLUSIONS: The numbers of anesthesiologists in CANECSA member countries are extremely low - about 5% of the minimum recommended figures - and poorly distributed relative to the population. Strategies are required to expand the anesthesia workforce and address maldistribution. © 2023 Lippincott Williams and Wilkins. All rights reserved.

Identifying and managing technical faults in the anesthesia machine: Lessons learned from the Israeli board of anesthesiologists

Background: The potential for catastrophe resulting from anesthetic equipment failure and the failure of training programs to adequately prepare residents to detect and manage equipment failure prompted the Israel Board of Anesthesiologists to include simulation-based testing in the Objective Structured Clinical Evaluation component of the Israeli Board Examination in Anesthesiology. Methods: We used simulation-based scenarios to measure the performance of residents while (a) checking the anesthesia machine before the first morning case, (b) checking the anesthesia machine between cases, (c) managing an oxygen pipeline failure, and (d) managing an expiratory valve failure. Results: During board examination, 3 of 28 examinees failed to correctly check at least 70% of the items on the anesthesia machine checkout list before the first morning case and 3 of 30 failed to correctly check 70% of the items between cases. Although all examinees recognized inadequate oxygen cylinder pressure and a malfunctioning valve, 1 of 31 examinees failed to open the O2 cylinder, 6 of 31 did not disconnect the anesthesia machine from the central oxygen supply, 14 of 31 could not explain how to minimize the use of oxygen, 2 of 30 failed to find the faulty valve, and 15 of 30 could not give the correct differential diagnosis. Conclusions: During simulation-based board examination most senior anesthesia residents became aware of equipment failures but many failed to correctly diagnosis and manage the failure. Copyright © 2011 International Anesthesia Research Society.

Motherhood and Anesthesiology: A Survey of the American Society of Anesthesiologists

BACKGROUND: The proportion of women medical school graduates in the United States has grown substantially; however, representation of women in anesthesiology lags behind. We sought to investigate factors associated with women recommending against a career in anesthesiology due to obstacles related to motherhood. METHODS: We surveyed 9525 women anesthesiologist members of the American Society of Anesthesiologists (ASA) with a web-based survey distributed via e-mail. Associations between whether women would counsel against anesthesiology due to obstacles related to motherhood and 34 related categorical variables were estimated. Fisher exact test was used for categorical binary variables, and Wilcoxon-Mann-Whitney test was used for ranked variables. RESULTS: The response rate for the primary question was 19.2%. Among the 1827 respondents to the primary question, 11.6% would counsel a female medical student against a career in anesthesiology due to obstacles pertaining to motherhood. Counseling against an anesthesiology career was not associated with ever being pregnant (P =.16), or whether a woman was pregnant during residency or fellowship training (P =.41) or during practice (P =.16). No association was found between counseling against anesthesiology and training factors: Total number of weeks of maternity leave (P =.18), the percentage of women faculty (P =.96) or residents (P =.34), or the number of pregnant coresidents (P =.66). Counseling against a career in anesthesiology was significantly associated with whether respondents' desired age of childbearing/motherhood and desired number of children were adversely affected by work demands (with Bonferroni adjustment for the 34 comparisons, both P <.0001). The risk ratio of respondents whose desired childbearing age and desired number of children were affected by work demands counseling against a career in anesthesiology was 5.1 compared to women whose desired childbearing age and desired number of children were not affected (99% confidence interval [CI], 3.3-7.9; P <.0001; odds ratio, 6.2). CONCLUSIONS: In this study of 1827 women anesthesiologists, approximately 1 in 10 would counsel a student against a career in anesthesiology due to obstacles pertaining to motherhood, and this was associated with altering one's timing and number of children due to job demands. Further research is needed to understand how women's perception of a career in anesthesiology is related to factors influencing personal choices. Understanding women's perceptions of motherhood in anesthesiology may help leaders support career longevity and personal satisfaction in this growing cohort of anesthesiologists. © 2020 International Anesthesia Research Society.

Gender Gap: A Qualitative Study of Women and Leadership Acquisition in Anesthesiology

BACKGROUND: The representation of women among leaders in the field of anesthesia continues to trail that of their male counterparts. This qualitative study was conducted to understand the pathway of leadership acquisition among women in the field of anesthesiology. METHODS: Using constructivist grounded theory, we sought to determine whether there were specific internal or external factors that were common to women in leadership in the specialty field of anesthesiology, and specifically, how they obtained leadership positions. Semistructured interviews were conducted for data collection. A total of 26 women in leadership positions in anesthesiology participated in this study. RESULTS: The analysis of these interviews resulted in the development of 4 common themes related to career pathways for these women in leadership. Each theme was examined in depth to determine the qualities necessary for individuals to advance in the field and the pathway to obtaining leadership positions. The findings of this study showed that early-career, high-value mentorship and sponsorship were important factors in leadership acquisition. Most participants (n = 20; 76%) had early mentors. Of those with early mentorship, 13 (65%) had high-value mentors, who we define as someone with power or authority. Sponsorship was the leading factor contributing to leadership acquisition. CONCLUSIONS: The results of this qualitative study may serve as a guide for encouraging female anesthesiologists with leadership aspirations. We suggest that the specialty field of anesthesiology institute targeted measures to help increase the percentage of women leadership with formal sponsorship programs at the local and national levels. © 2023 Lippincott Williams and Wilkins. All rights reserved.

The utility of pre-residency standardized tests for anesthesiology resident selection: The place of united states medical licensing examination scores

BACKGROUND: The resident selection process could be improved if United States Medical Licensing Examination (USMLE) scores obtained during residency application were found to predict success on the American Board of Anesthesiology (ABA) written examination (part 1). In this study, we compared USMLE performance during medical school to anesthesiology residency standardized examination performance. METHODS: Sixty-nine anesthesiology residents' USMLE, ABA/American Society of Anesthesiologists (ASA) In-Training Examination, and ABA written board examination (part 1) scores were compared. Linear regression, adjusted Pearson partial correlation, multiple regression, and analysis of variance were used to cross-correlate pre-residency and intra-residency scores. Residents' school of medicine location and year of graduation were noted. RESULTS: Both USMLE step 1 and step 2 Clinical Knowledge examinations correlated significantly with all intra-residency standardized tests. Averaged step 1 and step 2 USMLE score correlated to ABA written examination (part 1) score with a slope of 0.72 and r of 0.48 (P = 0.001). CONCLUSIONS: The USMLE is a significant predictor of residency ABA/ASA In-Training Examination and ABA written examination performance in anesthesiology. Our program has significantly increased its average written board examination performance while increasing the relative importance of USMLE in resident selection. © 2010 International Anesthesia Research Society.

The impact of a perceptual and adaptive learning module on transoesophageal echocardiography interpretation by anaesthesiology residents

Background: The role of transoesophageal echocardiography (TOE) in anaesthetic practice is expanding. We evaluated the effect of a TOE perceptual and adaptive learning module (PALM) on first-yr anaesthesiology residents' performance, in diagnosing cardiac pathology by TOE. Methods: First-yr residents were assigned to a group (n = 12) that used a TOE PALM or a control group that did not (n = 12). Both groups received a TOE pretest that measured their accuracy and response times. The PALM group completed the PALM and a posttest within 30 min and a delayed test six months later. The control group received a delayed test six months after their pretest. Accuracy and fluency (accurate responses within 10 s) were measured. Results: The PALM group had statistically significant improvements for both accuracy and fluency (P < 0.0001) in diagnosing cardiac pathology by TOE. After six months, the PALM group's performance remained significantly higher than their pretest values for accuracy (P = 0.0002, d = 2.7) and fluency (P < 0.0001, d = 2.3). Conclusions: In this pilot study, exposure to a PALM significantly improved accuracy and fluency in diagnosing TOE cardiac pathology, in a group of first-year anaesthesiology residents. PALMs can significantly improve learning and pattern recognition in medical education. © 2016 The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Observational study of anaesthesia workflow to evaluate physical workspace design and layout

Background: The safety and efficiency of anaesthesia care depend on the design of the physical workspace. However, little is known about the influence that workspace design has on the ability to perform complex operating theatre (OT) work. The aim of this study was to observe the relationship between task switching and physical layout, and then use the data collected to design and assess different anaesthesia workspace layouts. Methods: In this observational study, six videos of anaesthesia providers were analysed from a single centre in the United States. A task analysis of workflow during the maintenance phase of anaesthesia was performed by categorising tasks. The data supported evaluations of alternative workspace designs. Results: An anaesthesia provider's time was occupied primarily by three tasks: patient (mean: 30.0% of total maintenance duration), electronic medical record (26.6%), and visual display tasks (18.6%). The mean time between task switches was 6.39 s. With the current workspace layout, the anaesthesia provider was centred toward the patient for approximately half of the maintenance duration. Evaluating the alternative layout designs showed how equipment arrangements could improve task switching and increase the provider's focus towards the patient and visual displays. Conclusions: Our study showed that current operating theatre layouts do not fit work demands. We report a simple method that facilitates a quick layout design assessment and showed that the anaesthesia workspace can be improved to better suit workflow and patient care. Overall, this arrangement could reduce anaesthesia workload while improving task flow efficiency and potentially the safety of care. © 2020 British Journal of Anaesthesia

A Remote Surveillance Platform to Monitor General Care Ward Surgical Patients for Acute Physiologic Deterioration

BACKGROUND: The traditional paradigm of hospital surgical ward care consists of episodic bedside visits by providers with periodic perusals of the patient's electronic health record (EHR). Vital signs and laboratory results are directly pushed to the EHR but not to providers themselves. Results that require intervention may not be recognized for hours. Remote surveillance programs continuously monitor electronic data and provide automatic alerts that can be routed to multidisciplinary providers. Such programs have not been explored in surgical general care wards. METHODS: We performed a quality improvement observational study of otolaryngology and ophthalmology patients on a general care ward from October 2017 to March 2019 during nighttime hours (17:00-07:00). The study was initiated due to the loss of on-site anesthesiology resources that historically helped respond to acute physiologic deterioration events. We implemented a remote surveillance software program to continuously monitor patients for severe vital signs and laboratory abnormalities and automatically alert the ward team and a remote critical care anesthesiology team. The primary end point was the true positive rate, defined as the proportion of alerts that were associated with a downstream action that changed the care of the patient. This was determined using systematic chart review. The secondary end point, as a measure of alarm fatigue, was the average number of alerts per clinician shift. RESULTS: The software monitored 3926 hospital visits and analyzed 1,560,999 vitals signs and 16,635 laboratories. It generated 151 alerts, averaging 2.6 alerts per week. Of these, 143 (94.7%) were numerically accurate and 8 (5.3%) were inaccurate. Hypoxemia with oxygen saturation <88% was the most common etiology (92, 63%) followed by tachycardia >130 beats per minute (19, 13.3%). Among the accurate alerts, 133 (88.1%) were true positives with an associated clinical action. Actions included a change in management 113 (67.7%), new diagnostic test 26 (15.6%), change in discharge planning 20 (12.0%), and change in level of care to the intensive care unit (ICU) 8 (4.8%). As a measure of alarm fatigue, there were 0.4 alerts per clinician shift. CONCLUSIONS: In a surgical general care ward, a remote surveillance software program that continually and automatically monitors physiologic data streams from the EHR and alerts multidisciplinary providers for severe derangements provided highly actionable alarms at a rate that is unlikely to cause alarm fatigue. Such programs are feasible and could be used to change the paradigm of monitoring. © 2021 Lippincott Williams and Wilkins. All rights reserved.

Interview Data Highlight Importance of "same-State" on Anesthesiology Residency Match

Background: The US residency application, interview, and match processes are costly and time-intensive. We sought to quantify the importance of an applicant being from the same-state as a residency program in terms of how this impacted the number of interviews needed to match. METHODS: We examined data from interview scheduling software used by 32 programs located in 31 US states and 1300 applicants for the US anesthesiology recruitment cycles from 2015 to 2018. Interviewee data (distance from program, region, numbers of interviews, and program at which interview occurred) were analyzed to quantify the effect of the interviewee being from the same state as the residency program on the odds of matching to that program. Other variables of interest (medical school, current address, US Medical Licensing Exam [USMLE] Step 1 and 2 clinical knowledge [CK] scores, Alpha Omega Alpha [AOA] status, medical school ranking) were also examined as controls. Confidence intervals (CI) were calculated for the ratios of odds ratios. RESULTS: An interviewee living in the same state as the interviewing program could have 5.42 fewer total interviews (97.5% CI, 3.02-7.81) while having the same odds of matching. The same state effect had an equivalent value as an approximately 4.14 USMLE points-difference from the program's mean (97.5% CI was 2.34-5.94 USMLE points). Addition of whether the interviewee belonged to an affiliated medical school did not significantly improve the model; same-state remained significant (P <.0001) while affiliated medical school was not (P =.40). CONCLUSIONS: Our analysis of anesthesiology residency recruitment using previously unstudied interview data shows that same-state locality is a viable predictor of residency matching and should be strongly considered when evaluating whether to interview an applicant. © 2021 Lippincott Williams and Wilkins. All rights reserved.

Emergency Manual Implementation in a Large Academic Anesthesia Practice: Strategy and Improvement in Performance on Critical Steps

BACKGROUND: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps. METHODS: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds. RESULTS: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19–25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16–20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation. CONCLUSIONS: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized. Copyright © 2018 International Anesthesia Research Society

Anesthetic Care in Mozambique

Background: The World Bank and Lancet Commission in 2015 have prioritized surgery in Low-Income Countries (LIC) and Lower-Middle Income Countries (LMICs). This is consistent with the shift in the global burden of disease from communicable to noncommunicable diseases over the past 20 years. Essential surgery must be performed safely, with adequate anesthesia monitoring and intervention. Unfortunately, a huge barrier to providing safe surgery includes the paucity of an anesthesia workforce.1 In this study, we qualitatively evaluated the anesthesia capacity of Mozambique, a LIC in Africa with limited access to anesthesia and safe surgical care. Country-based solutions are suggested that can expand to other LIC and LMICs. Methods: A comprehensive review of the Mozambique anesthesia system was conducted through interviews with personnel in the Ministry of Health (MOH), a school of medicine, a public central referral hospital, a general first referral hospital, a private care hospital, and leaders in the physician anesthesia community. Personnel databases were acquired from the MOH and Maputo Central Hospital. Results: Quantitative results reveal minimal anesthesia capacity (290 anesthesia providers for a population of &gt;25 million or 0.01:10,000). The majority of physician anesthesiologists practice in urban settings, and many work in the private sector. There is minimal capacity for growth given only 1 Mozambique anesthesia residency with inadequate resources. The most commonly perceived barriers to safe anesthesia in this critical shortage are lack of teachers, lack of medical student interest in and exposure to anesthesia, need for more schools, low allocation to anesthesia from the list of available specialist prospects by MOH, and low public payments to anesthesiologists. Qualitative results show assets of a good health system design, a supportive environment for learning in the residency, improvement in anesthetic care in past decades, and a desire for more educational opportunities and teachers. Conclusions: Mozambique has a strong health system design but few resources for surgery and safe anesthesia. At present, similar to other LICs, human resources, access to essential medicines, and safety monitoring limit safe anesthesia in Mozambique. © 2016 International Anesthesia Research Society.

Role of communication systems in coordinating supervising anesthesiologists' activities outside of operating rooms

BACKGROUND: Theoretically, communication systems have the potential to increase the productivity of anesthesiologists supervising anesthesia providers. We evaluated the maximal potential of communication systems to increase the productivity of anesthesia care by enhancing anesthesiologists' coordination of care (activities) among operating rooms (ORs). METHODS: At hospital A, data for 13,368 pages were obtained from files recorded in the internal alphanumeric text paging system. Pages from the postanesthesia care unit were processed through a numeric paging system and thus not included. At hospital B, in a different US state, 3 of the authors categorized each of 898 calls received using the internal wireless audio system (Vocera®). Lower and upper 95% confidence limits for percentages are the values reported. RESULTS: At least 45% of pages originated from outside the ORs (e.g., 20% from holding area) at hospital A and at least 56% of calls (e.g., 30% administrative) at hospital B. In contrast, requests from ORs for urgent presence of the anesthesiologist were at most 0.2% of pages at hospital A and 1.8% of calls at hospital B. CONCLUSIONS: Approximately half of messages to supervising anesthesiologists are for activity originating outside the ORs being supervised. To use communication tools to increase anesthesia productivity on the day of surgery, their use should include a focus on care coordination outside ORs (e.g., holding area) and among ORs (e.g., at the control desk). Copyright © 2013 International Anesthesia Research Society.

The making of an anesthesia historian: Lessons from a worldwide biographical survey

BACKGROUND: There are few, if any, training opportunities for individuals wishing to pursue a career as an anesthesia historian. We surveyed anesthesia historians to learn about their training and experience, with an emphasis on mentoring, obstacles faced, and opportunities for improvement. METHODS: Questionnaires were sent to 34 anesthesia historians in North America, Europe, Asia, and Australia seeking information about demographics, medical training, training related to history, mentoring, research funding, obstacles faced, and suggestions for improvement. RESULTS: The response rate exceeded 90%. The average age of respondents was 70 years, and 85% of the respondents were male. The majority of respondents resided in North America (68%). The rest were from Europe (21%), Australia (9%), and Asia (3%). Graduate training in history was reported by 6%. Thirty-eight percent considered themselves to be self-trained. Thirty-eight percent were recipients of fellowships from the Wood Library-Museum of Anesthesiology. Research guidance was obtained by 74% of respondents. Guidance came from a department chairman (24%), a member of the Wood Library-Museum staff (33%), or another source (43%). The 3 most common obstacles described were difficulty in obtaining funding for research activities (33%), academic recognition (20%), and availability of training and mentoring (18%). Areas identified as needing improvement were research funding (17%), exposure to anesthesia history during residency training (23%), academic recognition (26%), mentoring (17%), and promotion of anesthesia history (17%). CONCLUSIONS: A study of history does not necessarily produce changes in clinical practice, which may limit the perceived value of historical study. The suggestions by these historians should help preserve the history and heritage of anesthesiology. Copyright © 2011 International Anesthesia Research Society.

The Most Influential Publications in Obstetric Anesthesiology, 1998-2017: Utilizing the Delphi Method for Expert Consensus

BACKGROUND: There have been many advances in obstetric anesthesiology in the past 2 decades. We sought to create a list of highly influential publications in the field using the Delphi method among a group of obstetric anesthesiology experts to create an important educational, clinical, and research resource. METHODS: Experts in the field, defined as obstetric anesthesiologists selected to present the Gerard W. Ostheimer Lecture at the Society for Obstetric Anesthesia and Perinatology (SOAP) annual meeting within the past 20 years, were recruited to participate. The Delphi technique was used by administering 3 rounds of surveys. Participants were initially asked to identify the highly influential publications from the year they presented the Ostheimer lecture, in addition to the most influential publications from the time period overall. Highly influential publications were defined as those that changed traditional views, invoked meaningful practices, catalyzed additional research, and fostered ideas or practices that had durability over time. After each round of surveys, responses were collected and used as choices for subsequent surveys with the goal of obtaining group consensus. RESULTS: We determined expert consensus on 22 highly influential publications from 1998 to 2017. The focus of these publications ranged from disease entities, interventions, treatment methodologies, and complications. CONCLUSIONS: Key themes in the publications chosen included the reduction of maternal morbidity and mortality and refinements in the analgesic and anesthetic management of labor and delivery. © 2020 Lippincott Williams and Wilkins. All rights reserved.

New teaching model for practicing ultrasound-guided regional anesthesia techniques: No perishable food products!

Background: There is a pronounced learning curve for the technique of ultrasound-guided regional anesthesia. Practicing with a simulator model has been shown to speed the acquisition of these skills for various ultrasound-guided procedures. However, commercial models for ultrasound-guided regional anesthesia may be too costly or not readily available. Models using turkey breasts or tofu blocks have the disadvantage of containing perishable food products that can be a source for infection. We describe an alternative inexpensive model that is made from nonperishable components readily available in the operating room. Methods: The materials required include 1 clean used 500-mL bag of IV fluids, a bottle of Premisorb (TYCO Healthcare Group, Mansfield, MA), and a piece of foam material approximately 0.3 cm in diameter and 5 cm in length trimmed from operating room foam pads. After filling the IV bag with tap water and inserting the foam into the IV bag from the outlet port of the IV bag, one-third of a bottle of Premisorb (approximately 15 g) is poured into the IV bag. The outlet port of the bag is then sealed by taping the rubber stopper that originally came with the bag. Results: Premisorb, a solidifying agent frequently used to absorb irrigating fluids or blood in operating room suction canisters, produces a gel-like material in the IV bag. The foam inserted into the bag creates a relatively hyperechoic target. This gel-like substance in the bag will seal the holes created after multiple practice needle insertions, resulting in minimal leakage. The semitransparent nature of the gel allows the trainee to visualize the target directly and on the ultrasound screen. Conclusion: The model we describe is inexpensive and easy to make from materials readily available in the operating room with the advantages of being nonperishable, easy to carry, and reusable. Copyright © 2010 International Anesthesia Research Society.

Prior Podcast Experience Moderates Improvement in Electroencephalography Evaluation after Educational Podcast Module

BACKGROUND: There is continued interest in using technology to enhance medical education and the variables that may affect its success. METHODS: Anesthesiology residents and fourth-year medical students participated in an electroencephalography (EEG) educational video podcast module. A 25-item evaluation tool was administered before any EEG education was provided (baseline), and the podcast was then viewed. Another 25-item evaluation tool was administered after podcast viewing (after podcast). Ten EEG interpretations were completed with a neurophysiologist with an additional 25-item evaluation tool administered after the interpretations (after 10 EEG interpretations). Participants were surveyed concerning technology and podcasting experience before the educational module and their responses to the podcast educational model. Multiple analyses were performed (1) to evaluate differences in improvement in EEG evaluation scores between the podcast module and the standard didactics (control group); and (2) to evaluate potential moderation by technology and the podcast experience on the change in mean EEG evaluation scores from after the podcast module to after 10 EEG interpretations. RESULTS: A total of 21 anesthesiology residents and 12 fourth-year medical students participated. Scores on the 25-item evaluation tool increased with each evaluation time (P ≤ 0.001). Moderation analyses revealed that individuals with more podcast experience (≥4 previous podcasts) had greater increases in scores after a podcast and 10 EEG interpretations compared with individuals with less experience (≤3 previous podcasts) (P = 0.027). Furthermore, compared with a control group with similar baseline characteristics that received only standard didactics without a podcast, those in the podcast group had greater increases in mean EEG evaluation scores between baseline and after 10 EEG interpretations. CONCLUSIONS: In reviewing the improvement in EEG evaluation after a podcast education module, those with more podcast experience achieved greater gains in EEG evaluation scores. For EEG education, those receiving the podcast education module showed greater increases in scores compared with those receiving didactic teaching without podcasting, as measured by change in a mean EEG evaluation scores. Copyright © 2015 International Anesthesia Research Society.

Multicentre analysis of practice patterns regarding benzodiazepine use in cardiac surgery

Background: There is controversy regarding optimal use of benzodiazepines during cardiac surgery, and it is unknown whether and to what extent there is variation in practice. We sought to describe benzodiazepine use and sources of variation during cardiac surgeries across patients, clinicians, and institutions. Methods: We conducted an analysis of adult cardiac surgeries across a multicentre consortium of USA academic and private hospitals from 2014 to 2019. The primary outcome was administration of a benzodiazepine from 2 h before anaesthesia start until anaesthesia end. Institutional-, clinician-, and patient-level variables were analysed via multilevel mixed-effects models. Results: Of 65 508 patients cared for by 825 anaesthesiology attending clinicians (consultants) at 33 institutions, 58 004 patients (88.5%) received benzodiazepines with a median midazolam-equivalent dose of 4.0 mg (inter-quartile range [IQR], 2.0–6.0 mg). Variation in benzodiazepine dosage administration was 54.7% attributable to institution, 14.7% to primary attending anaesthesiology clinician, and 30.5% to patient factors. The adjusted median odds ratio for two similar patients receiving a benzodiazepine was 2.68 between two randomly selected clinicians and 4.19 between two randomly selected institutions. Factors strongly associated (adjusted odds ratio, <0.75, or >1.25) with significantly decreased likelihoods of benzodiazepine administration included older age (>80 vs ≤50 yr; adjusted odds ratio=0.04; 95% CI, 0.04–0.05), university affiliation (0.08, 0.02–0.35), recent year of surgery (0.42, 0.37–0.49), and low clinician case volume (0.44, 0.25–0.75). Factors strongly associated with significantly increased likelihoods of benzodiazepine administration included cardiopulmonary bypass (2.26, 1.99–2.55), and drug use history (1.29, 1.02–1.65). Conclusions: Two-thirds of the variation in benzodiazepine administration during cardiac surgery are associated with institutions and attending anaesthesiology clinicians (consultants). These data, showing wide variations in administration, suggest that rigorous research is needed to guide evidence-based and patient-centred benzodiazepine administration. © 2021 British Journal of Anaesthesia

The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution

BACKGROUND: There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States. METHODS: We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists' demographics. Pediatric anesthesiologists' locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA). RESULTS: We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40-57 years), and the majority (56.4%) were men. Approximately two-Thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering. CONCLUSIONS: This description of pediatric anesthesiologists' demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care. © Copyright 2016 International Anesthesia Research Society.

Critical Care Medicine Practice: A Pilot Survey of US Anesthesia Critical Care Medicine-Trained Physicians

BACKGROUND: This survey assessed satisfaction with the practice environment among physicians who have completed fellowship training in critical care medicine (CCM) as recognized by the American Board of Anesthesiology (and are members of the American Society of Anesthesiology) and evaluated the perceived effectiveness of training programs in preparing fellows for critical care practice. METHODS: A cross-sectional online survey composed of 39 multiple choice and open-ended questions was administered between August and December 2018 to all members of the American Society of Anesthesiologists (ASA) who self-identified as being CCM trained. The survey instrument was developed and revised in an iterative fashion by ASA committee on CCM and the Society for Education in Anesthesia (SEA). Survey results were analyzed using a mixed-method approach. RESULTS: Three hundred fifty-three of the 1400 anesthesiologists who self-identified to the ASA as having CCM training (25.2%) completed the survey. Most were men (72.3%), board certified in CCM (98.7%), and had practiced a median of 5 years. Half of the respondents rated their training as "excellent." A total of 70.6% described currently working in academic centers with 53.6% providing care in open surgical intensive care units (ICUs). Most anesthesiologist intensivists (75%) spend at least 25% of their clinical time providing ICU care (versus clinical anesthesia). A total of 89% of the respondents were involved in educational activities, 60% reported being in administrative leadership roles, and 37% engaged in scholarly activity. Areas of dissatisfaction included fatigue, lack of collegiality or respect, lack of research training, decreased job satisfaction, and burnout. Analysis suggested moderate levels of job satisfaction (49%), work-life balance (52%), and high levels of burnout (74%). A significant contributor to burnout was with a perception of lack of respect (P =.005) in the work environment. Burnout was not significantly associated with gender or duration of practice. Qualitative analysis of the open-ended responses also identified these 3 variables as major themes. CONCLUSIONS: This survey of CCM-trained anesthesiologists described a high rate of board certification, practice in academic settings, and participation in resident education. Areas of dissatisfaction with an anesthesia/critical care practice included burnout, work/life balance, and lack of respect. These results may increase recruitment of anesthesiologists into critical care and inform strategies to improve satisfaction with anesthesia critical care practice, fellowship training. © 2021 Lippincott Williams and Wilkins. All rights reserved.

What will anesthesiologists be anesthetizing? trends in neurosurgical procedure usage

BACKGROUND: To anticipate future changes to the practice of neuroanesthesia, we examined the nationwide trends in frequently performed operative neurosurgery. METHODS: We used the Nationwide Inpatient Sample, a random sampling of approximately 20% of United States hospitals from 1993 to 2007. Eight categories of operative neurosurgery were developed, based on procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We tabulated total volume, mean length of stay, and inhospital mortality and calculated growth rates over the entire period, the most recent 5-year period, and the most recent 2-year period. We examined annual volumes from 1993 to 2007 for each neurosurgical category for the most common ICD-9-CM procedure code within each category. RESULTS: Intracranial endovascular procedures had the highest compound annual growth rate over the entire study period (32%), the most recent 4 years (29%), and the most recent 2 years (12%). Craniotomy for vascular surgery decreased over the entire period (-4.2%). Spinal fusion had the largest absolute increase over the study period (from 54,000 in 1993 to 350,000 in 2007). All categories except craniotomy for vascular surgery had decreased length of stay across the study period, with compound annual growth rates of -1.2% (ventricular and thecal shunt) to -6.6% (deep brain stimulation). Intracranial endovascular procedures had a much higher growth rate of length of stay than vascular surgery over the most recent 2-year (14% vs 1.0%) and 5-year periods (5.6% vs 1.5%). CONCLUSIONS: The highest volume trends in operative neurosurgery are for spinal fusion (increasing at a rate of approximately 12,000 procedures/y), craniotomy for tumors and other purposes (increasing at a rate of approximately 2,700 procedures/y), and a decrease in shunts (decreasing at a rate of approximately 3,000 per year). The data suggest that intracranial endovascular treatment remains relatively rare, but it is growing exponentially, and lengths of stay are increasing, whereas inhospital deaths are decreasing. The conclusions of this study are limited by the imprecise nature of the ICD-9-CM procedure codes, the categorization scheme we used, and by the sampling methods of the National Inpatient Sample. Copyright © 2010 International Anesthesia Research Society.

Hypercapnic hyperventilation shortens emergence time from isoflurane anesthesia

BACKGROUND: To shorten emergence time after a procedure using volatile anesthesia, 78% of anesthesiologists recently surveyed used hyperventilation to rapidly clear the anesthetic from the lungs. Hyperventilation has not been universally adapted into clinical practice because it also decreases the Paco2, which decreases cerebral bloodflow and depresses respiratory drive. Adding deadspace to the patient's airway may be a simple and safe method of maintaining a normal or slightly increased Paco2 during hyperventilation. METHODS: We evaluated the differences in emergence time in 20 surgical patients undergoing 1 MAC of isoflurane under mild hypocapnia (ETco2 approximately 28 mmHg) and mild hypercapnia (ETco2 approximately 55 mmHg). The minute ventilation in half the patients was doubled during emergence, and hypercapnia was maintained by insertion of additional airway deadspace to keep the ETco2 close to 55 mmHg during hyperventilation. A charcoal canister adsorbed the volatile anesthetic from the deadspace. Fresh gas flows were increased to 10 L/min during emergence in all patients. RESULTS: The time between turning off the vaporizer and the time when the patients opened their eyes and mouths, the time of tracheal extubation, and the time for normalized bispectral index to increase to 0.95 were faster whenever hypercapnic hyperventilation was maintained using rebreathing and anesthetic adsorption (P < 0.001). The time to tracheal extubation was shortened by an average of 59%. CONCLUSIONS: The emergence time after isoflurane anesthesia can be shortened significantly by using hyperventilation to rapidly clear the anesthetic from the lungs and CO2 rebreathing to induce hypercapnia during hyperventilation. The device should be considered when it is important to provide a rapid emergence, especially after surgical procedures where a high concentration of the volatile anesthetic was maintained right up to the end of the procedure, or where surgery ends abruptly and without warning. © 2007 by International Anesthesia Research Society.

Conventional versus video laryngoscopy for tracheal tube exchange: Glottic visualization, success rates, complications, and rescue alternatives in the high-risk difficult airway patient

BACKGROUND: Tracheal tube exchange is a simple concept but not a simple procedure because hypoxemia, esophageal intubation, and loss of airway may occur with life-threatening ramifications. Combining laryngoscopy with an airway exchange catheter (AEC) may lessen the exchange risk. Laryngoscopy is useful for a pre-exchange examination and to open a pathway for endotracheal tube (ETT) passage. Direct laryngoscopy (DL) is hampered by a restricted "line of sight"; thus, airway assessment and exchange may proceed blindly and contribute to difficulty and complications. We hypothesized that video laryngoscopy (VL), when compared with DL, will improve glottic viewing for airway assessment, and the VL-AEC method of ETT exchange will result in a reduction in airway and hemodynamic complications in high-risk patients when compared with a historical group of patients who underwent DL + AEC-assisted exchange. METHODS: Critically ill patients requiring an ETT exchange underwent DL-assisted pre-exchange airway assessment. If the DL-assisted pre-exchange assessment rendered a "poor view," these patients underwent a VL-based airway assessment followed by a VL-assisted ETT exchange procedure. The DL and VL pre-exchange assessments were compared. The attempts, complications, and rescue devices required for ETT exchange were analyzed. These exchange results were then compared with a historical control group of patients who (1) were classified as a poor view on DL-assisted pre-exchange airway assessment; and (2) underwent a DL + AEC-assisted exchange. The airway assessment and ETT exchange were performed by a board-certified anesthesiologist from the Department of Anesthesiology alone or with anesthesia resident assistance. RESULTS: Three hundred twenty-eight patients with a poor view on initial DL examination underwent a subsequent VL with comparison of views with the 337 patients in the historical control group (DL + AEC). A majority (88%) had a "full or near-full view" on VL examination. The first-pass success rate for ETT exchange was greater in the VL group (91.5% vs 67.7% with DL; P = 0.0001) and the number of patients requiring 3+ attempts was lower (1.2% vs 6.8% with DL; P = 0.0003). A commensurate difference in the incidence of mild and severe hypoxemia, esophageal intubation, bradycardia, and the need for rescue airway device intervention was also observed with VL exchange procedures when compared with the historical DL + AEC group. CONCLUSIONS: These findings support the hypothesis that VL may result in better glottic viewing for airway assessment and may permit the ETT exchange procedure to be performed with fewer airway and hemodynamic complications. Execution of the ETT exchange over an AEC was augmented by improved glottic visualization to allow more efficient and timely ETT passage. Multiple attempts to resecure the airway increased the number of exchange complications. VL + AEC exchange led to fewer attempts and is consistent with the recommendation of the American Society of Anesthesiologists Difficult Airway Task Force to limit laryngoscopic attempts and, as a consequence, decrease complications. A VL-based pre-exchange airway assessment may be a valuable procedure for both planning the exchange and uncovering unrecognized airway maladies, for example, partial or complete self-extubation. © 2015 International Anesthesia Research Society.

Generative retrieval improves learning and retention of cardiac anatomy using transesophageal echocardiography

BACKGROUND: Transesophageal echocardiography (TEE) is a valuable monitor for patients undergoing cardiac and noncardiac surgery as it allows for evaluation of cardiovascular compromise in the perioperative period. It is challenging for anesthesiology residents and medical students to learn to use and interpret TEE in the clinical environment. A critical component of learning to use and interpret TEE is a strong grasp of normal cardiovascular ultrasound anatomy. METHODS: Fifteen fourth-year medical students and 15 post-graduate year (PGY) 1 and 2 anesthesiology residents without prior training in cardiac anesthesia or TEE viewed normal cardiovascular anatomy TEE video clips; participants were randomized to learning cardiac anatomy in generative retrieval (GR) and standard practice (SP) groups. GR participants were required to verbally identify each unlabeled cardiac anatomical structure within 10 seconds of the TEE video appearing on the screen. Then a correctly labeled TEE video clip was shown to the GR participant for 5 more seconds. SP participants viewed the same TEE video clips as GR but there was no requirement for SP participants to generate an answer; for the SP group, each TEE video image was labeled with the correctly identified anatomical structure for the 15 second period. All participants were tested for intermediate (1 week) and late (1 month) retention of normal TEE cardiovascular anatomy. Improvement of intermediate and late retention of TEE cardiovascular anatomy was evaluated using a linear mixed effects model with random intercepts and random slopes. RESULTS: There was no statistically significant difference in baseline score between GR (49% ± 11) and SP (50% ± 12), with mean difference (95% CI) -1.1% (-9.5, 7.3%). At 1 week following the educational intervention, GR (90% ± 5) performed significantly better than SP (82% ± 11), with mean difference (95% CI) 8.1% (1.9, 14.2%); P = .012. This significant increase in scores persisted in the late posttest session at one month (GR: 83% ± 12; SP: 72% ± 12), with mean difference (95% CI) 10.2% (1.3 to 19.1%); P = .026. Mixed effects analysis showed significant improvements in TEE cardiovascular anatomy over time, at 5.9% and 3.5% per week for GR and SP groups respectively (P = .0003), and GR improved marginally faster than SP (P = .065). CONCLUSIONS: Medical students and anesthesiology residents inexperienced in the use of TEE showed both improved learning and retention of basic cardiovascular ultrasound anatomy with the incorporation of GR into the educational experience. © 2017 International Anesthesia Research Society.

Intraoperative transfusion practices in Europe

Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl-1 and increased to 9.8 (1.8) g dl-1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusions: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl-1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold. © 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

I Tweet, Therefore I Learn: An Analysis of Twitter Use Across Anesthesiology Conferences

BACKGROUND: Twitter in anesthesiology conferences promotes rapid science dissemination, global audience participation, and real-time updates of simultaneous sessions. We designed this study to determine if an association exists between conference attendance/registration and 4 defined Twitter metrics. METHODS: Using publicly available data through the Symplur Healthcare Hashtags Project and the Symplur Signals, we collected data on total tweets, impressions, retweets, and replies as 4 primary outcome metrics for all registered anesthesiology conferences occurring from May 1, 2016 to April 30, 2017. The number of Twitter participants, defined as users who contributed a tweet, retweet, or reply 3 days before through 3 days after the conference, was collected. We also collected influencer data as determined by mentions (number of times a user is referenced). Two authors independently verified the categories for influencers assigned by Symplur. Conference demographic data were obtained by e-mail inquiries. Associations between meeting attendees/registrants and Twitter metrics, between Twitter participants and the metrics, and between physician influencers and Twitter participants were tested using Spearman rho. RESULTS: Fourteen conferences with 63,180 tweets were included. With the American Society of Anesthesiologists annual meeting included, the correlations between meeting attendance/registration and total tweets (rs= 0.588; P =.074), impressions (rs= 0.527; P =.117), and retweets (rs= 0.539; P =.108) were not statistically significant; for replies, it was moderately positive (rs= 0.648; P =.043). Without the American Society of Anesthesiologists annual meeting, total tweets (rs= 0.433; P =.244), impressions (rs= 0.350; P =.356), retweets (rs= 0.367; P =.332), and replies (rs= 0.517; P =.154) were not statistically significant. Secondary outcomes include a highly positive correlation between Twitter participation and total tweets (rs= 0.855; P &lt;.001), very highly positive correlations between Twitter participation and impressions (rs= 0.938; P &lt;.001), retweets (rs= 0.925; P &lt;.001), and a moderately positive correlation between Twitter participation and replies (rs= 0.652; P =.044). Doctors were top influencers in 8 of 14 conferences, and the number of physician influencers in the top 10 influencers list at each conference had a moderately positive correlation with Twitter participation (rs= 0.602; P =.023). CONCLUSIONS: We observed that the number of Twitter participants for a conference is positively associated with Twitter activity metrics. No relationship between conference size and Twitter metrics was observed. Physician influencers may be an important driver of participants. © 2020 Lippincott Williams and Wilkins. All rights reserved.

Dissemination of Anesthesia Information during the Coronavirus Disease 2019 Pandemic Through Twitter: An Infodemiology Study

BACKGROUND: Twitter is a web-based social media platform that allows instantaneous sharing of user-generated messages (tweets). We performed an infodemiology study of the coronavirus disease 2019 (COVID-19) Twitter conversation related to anesthesiology to describe how Twitter has been used during the pandemic and ways to optimize Twitter use by anesthesiologists. METHODS: This was a cross-sectional study of tweets related to the specialty of anesthesiology and COVID-19 tweeted between January 21 and October 13, 2020. A publicly available COVID-19 Twitter dataset was filtered for tweets meeting inclusion criteria (tweets including anesthesiology keywords). Using descriptive statistics, tweets were reviewed for tweet and account characteristics. Tweets were filtered for specific topics of interest likely to be impactful or informative to anesthesiologists of COVID-19 practice (airway management, personal protective equipment, ventilators, COVID testing, and pain management). Tweet activity was also summarized descriptively to show temporal profiles over the pandemic. RESULTS: Between January 21 and October 13, 2020, 23,270 of 241,732,881 tweets (0.01%) met inclusion criteria and were generated by 15,770 accounts. The majority (51.9%) of accounts were from the United States. Seven hundred forty-nine (4.8%) of all users self-reported as anesthesiologists. 33.8% of all tweets included at least one word or phrase preceded by the symbol (hashtag), which functions as a label to search for all tweets including a specific hashtag, with the most frequently used being #anesthesia. About half (52.2%) of all tweets included at least one hyperlink, most frequently linked to other social media, news organizations, medical organizations, or scientific publications. The majority of tweets (67%) were not retweeted. COVID-19 anesthesia tweet activity started before the pandemic was declared. The trend of daily tweet activity was similar to, and preceded, the US daily death count by about 2 weeks. CONCLUSIONS: The toll of the pandemic has been reflected in the anesthesiology conversation on Twitter, representing 0.01% of all COVID-19 tweets. Daily tweet activity showed how the Twitter community used the platform to learn about important topics impacting anesthesiology practice during a global pandemic. Twitter is a relevant platform through which to communicate about anesthesiology topics, but further research is required to delineate its effectiveness, benefits, and limitations for anesthesiology discussions. © 2021 Lippincott Williams and Wilkins. All rights reserved.

A prospective observational study of anesthesia- related adverse events and postoperative complications occurring during a surgical mission in Madagascar

BACKGROUND: Two-thirds of the world's population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesiarelated and postoperative complications during a 2-year surgical mission in Madagascar. METHODS: As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification. RESULTS: Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4-2.6). The majority (85% CI, 74-96) of adverse events occurred intraoperatively with 15% (CI, 3-26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3-12.0) per surgery and 9.4% (CI, 8.1-10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0-41.3 and 33.2%; CI, 31.1-35.3 of all complications, respectively). The most common (42.9%; CI, 40.7-45.1) grade of complication was grade II. There was 1 death. CONCLUSIONS: This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia. Copyright © 2018 International Anesthesia Research Society.

Practice of ultrasound-guided palpation of neck landmarks improves accuracy of external palpation of the cricothyroid membrane

BACKGROUND: Ultrasonography can accurately identify the cricothyroid membrane; however, its impact on the subsequent accuracy of external palpation is not known. In this study, we tested the ability of anesthesia participants to identify the midpoint of the cricothyroid membrane using external palpation with and without ultrasound (US)-guided practice. METHODS: Following institutional ethics approval and informed consent, anesthesia participants consisting of anesthesia residents, fellows, and practicing anesthesia assistants underwent didactic teaching on neck landmarks. The participants were then randomized to practice palpation of neck landmarks with US guidance (US group) or without ultrasonography (non-US [NUS] group). After the practice session, each participant identified the cricothyroid membrane using external palpation on the neck of 10 volunteers and marked the anticipated entry point for device insertion (palpation point [PT]). The midpoint of the cricothyroid membrane of each volunteer had been premarked with invisible ink using ultrasonography (US point) by a separate member of the research team. The primary outcome was the accuracy rate defined as the percentage of the attempts with the distance ≤5 mm measured from the PT to US point for the participant. The primary outcome was compared between NUS and US groups using Wilcoxon rank sum test. A mixed-effect logistic regression or mixed-effect linear model was also conducted for outcomes accounting for the clustering and adjusting for potential confounders. RESULTS: Fifteen anesthesia participants were randomized to US (n = 8) and NUS (n = 7) groups. A total of 80 and 61 attempts were performed by the US and NUS groups, respectively. The median accuracy rate in the US group was higher than the NUS group (65% vs 30%; P = .025), and the median PT-US distance in the US group was shorter than in the NUS group (4.0 vs 8.0 mm; P = .04). The adjusted mean PT-US distance in the US group was shorter compared to the NUS group (adjusted mean [95% CI], 3.6 [2.9-4.6] vs 6.8 [5.2-8.9] mm; P < .001). CONCLUSIONS: Anesthesia participants exposed to practice with US-guided palpation of the cricothyroid membrane location were better able to identify the cricothyroid membrane using only blind palpation than participants without US-guided practice. Practice with US-guided palpation of neck landmarks improves subsequent blind localization of the cricothyroid membrane using palpation alone. Copyright © 2018 International Anesthesia Research Society.

Adultification of Black Children in Pediatric Anesthesia

BACKGROUND: Unconscious racial bias in anesthesia care has been shown to exist. We hypothesized that black children may undergo inhalation induction less often, receive less support from child life, have fewer opportunities to have a family member present for induction, and receive premedication with oral midazolam less often. METHODS: We retrospectively collected data on those <18 years of age from January 1, 2012 to January 1, 2018 including age, sex, race, height, weight, American Society of Anesthesiologists (ASA) physical status, surgical service, and deidentified anesthesiology attending physician. Outcome data included mask versus intravenous induction, midazolam premedication, child life consultation, and family member presence. Racial differences between all outcomes were assessed in the cohort using a multivariable logistic regression model. RESULTS: A total of 33,717 Caucasian and 3901 black children were eligible for the study. For the primary outcome, black children 10–14 years were 1.3 times more likely than Caucasian children to receive mask induction (adjusted odds ratio [AOR], 1.3; 95% confidence interval [CI], 1.1–1.6; P = .001). Child life consultation was poorly documented (<0.5%) and not analyzed. Black children <15 years of age were at least 31% less likely than Caucasians to have a family member present for induction (AOR range, 0.4–0.6; 95% CI range, 0.31–0.84; P < .010). Black children <5 years of age were 13% less likely than Caucasians to have midazolam given preoperatively (AOR, 0.9; 95% CI, 0.8–0.9; P = .012). CONCLUSIONS: This study suggests that disparities in strategies for mitigating anxiety in the peri-induction period exist and adultification may be 1 cause for this bias. Black children 10 to 14 years of age are 1.3 times as likely as their Caucasian peers to be offered inhalation induction to reduce anxiety. However, black children are less likely to receive premedication with midazolam in the perioperative period or to have family members present at induction. The cause of this difference is unclear, and further prospective studies are needed to fully understand this difference. Copyright © 2019 International Anesthesia Research Society

Antiemetic prophylaxis as a marker of health care disparities in the national anesthesia clinical outcomes registry

BACKGROUND: US health care disparities persist despite repeated countermeasures. Research identified race, ethnicity, gender, and socioeconomic status as factors, mediated through individual provider and/or systemic biases; little research exists in anesthesiology. We investigated antiemetic prophylaxis as a surrogate marker for anesthesia quality by individual providers because antiemetics are universally available, indicated contingent on patient characteristics (gender, age, etc), but independent of comorbidities and not yet impacted by regulatory or financial constraints. We hypothesized that socioeconomic indicators (measured as insurance status or median income in the patients' home zip code area) are associated with the utilization of antiemetic prophylaxis (as a marker of anesthesia quality). METHODS: We tested our hypothesis in several subsets of electronic anesthesia records from the National Anesthesia Clinical Outcomes Registry (NACOR), fitting frequentist and novel Bayesian multilevel logistic regression models. RESULTS: NACOR contained 12 million cases in 2013. Six institutions reported on antiemetic prophylaxis for 441,645 anesthesia cases. Only 173,133 cases included details on insurance information. Even fewer (n = 92,683) contained complete data on procedure codes and provider identifiers. Bivariate analysis, multivariable logistic regression, and our Bayesian hierarchical model all showed a large and statistically significant association between socioeconomic markers and antiemetic prophylaxis (ondansetron and dexamethasone). For Medicaid versus commercially insured patients, the odds ratio of receiving the antiemetic ondansetron is 0.85 in our Bayesian hierarchical mixed regression model, with a 95% Bayesian credible interval of 0.81-0.89 with similar inferences in classical (frequentist) regression models. CONCLUSIONS: Our analyses of NACOR anesthesia records raise concerns that patients with lower socioeconomic status may receive inferior anesthesia care provided by individual anesthesiologists, as indicated by less antiemetics administered. Effects persisted after we controlled for important patient characteristics and for procedure and provider influences. Findings were robust to sensitivity analyses. Our results challenge the notion that anesthesia providers do not contribute to health care disparities. © 2017 International Anesthesia Research Society.

Coronavirus Disease 2019: Anesthesia Machine Circuit Pressure during Use as an Improvised Intensive Care Unit Ventilator

BACKGROUND: Use of anesthesia machines as improvised intensive care unit (ICU) ventilators may occur in locations where waste anesthesia gas suction (WAGS) is unavailable. Anecdotal reports suggest as much as 18 cm H2O positive end-expiratory pressure (PEEP) being inadvertently applied under these circumstances, accompanied by inaccurate pressure readings by the anesthesia machine. We hypothesized that resistance within closed anesthesia gas scavenging systems (AGSS) disconnected from WAGS may inadvertently increase circuit pressures. METHODS: An anesthesia machine was connected to an anesthesia breathing circuit, a reference manometer, and a standard bag reservoir to simulate a lung. Ventilation was initiated as follows: volume control, tidal volume (TV) 500 mL, respiratory rate 12, ratio of inspiration to expiration times (I:E) 1:1.9, fraction of inspired oxygen (Fio2) 1.0, fresh gas flow (FGF) rate 2.0 liters per minute (LPM), and PEEP 0 cm H2O. After engaging the ventilator, PEEP and peak inspiratory pressure (PIP) were measured by the reference manometer and the anesthesia machine display simultaneously. The process was repeated using prescribed PEEP levels of 5, 10, 15, and 20 cm H2O. Measurements were repeated with the WAGS disconnected and then were performed again at FGF of 4, 6, 8, 10, and 15 LPM. This process was completed on 3 anesthesia machines: Dräger Perseus A500, Dräger Apollo, and the GE Avance CS2. Simple linear regression was used to assess differences. RESULTS: Utilizing nonparametric Bland-Altman analysis, the reference and machine manometer measurements of PIP demonstrated median differences of -0.40 cm H2O (95% limits of agreement [LOA], -1.00 to 0.55) for the Dräger Apollo, -0.40 cm H2O (95% LOA, -1.10 to 0.41) for the Dräger Perseus, and 1.70 cm H2O (95% LOA, 0.80-3.00) for the GE Avance CS2. At FGF 2 LPM and PEEP 0 cm H2O with the WAGS disconnected, the Dräger Apollo had a difference in PEEP of 0.02 cm H2O (95% confidence interval [CI], -0.04 to 0.08; P =.53); the Dräger Perseus A500, &lt;0.0001 cm H2O (95% CI, -0.11 to 0.11; P = 1.00); and the GE Avance CS2, 8.62 cm H2O (95% CI, 8.55-8.69; P &lt;.0001). After removing the hose connected to the AGSS and the visual indicator bag on the GE Avance CS2, the PEEP difference was 0.12 cm H2O (95% CI, 0.059-0.181; P =.0002). CONCLUSIONS: Displayed airway pressure measurements are clinically accurate in the setting of disconnected WAGS. The Dräger Perseus A500 and Apollo with open scavenging systems do not deliver inadvertent continuous positive airway pressure (CPAP) with WAGS disconnected, but the GE Avance CS2with a closed AGSS does. This increase in airway pressure can be mitigated by the manufacturer's recommended alterations. Anesthesiologists should be aware of the potential clinically important increases in pressure that may be inadvertently delivered on some anesthesia machines, should the WAGS not be properly connected. © 2021 Lippincott Williams and Wilkins. All rights reserved.

Large heterogeneity in mean durations of labor Analgesia among hospitals reporting to the American Society of anesthesiologists' anesthesia quality Institute

BACKGROUND: Variability in the mean durations of labor analgesia for vaginal delivery among hospitals is unknown. Such differences in means among hospitals would influence appropriate equitable fee-for-service payment to US anesthesia groups. Equitable payment is the foundational principle of relative value unit payment, which, for anesthesia in the United States, means use of the American Society of Anesthesiologist's Relative Value Guide. METHODS: We analyzed data from the American Society of Anesthesiologists' Anesthesia Quality Institute to test whether there are large differences in mean durations of labor analgesia for vaginal delivery among US hospitals. We choose the statistical methodology for that analysis using detailed data from 2 individual hospitals. Analyses of the means were performed for the 172 hospitals reporting a total of at least 200 durations; having no greater than 5.0% of durations 1.0 hour or less; and at least 5 four-week periods each having a mean of at least one epidural every couple of days. The 172 hospitals provided for n = 5671 combinations of hospital and 4-week period and 551,707 labor epidurals, with an overall mean duration of 6.12 hours (SE, 0.001 hour). RESULTS: 55.2% of the 172 hospitals had mean durations of labor analgesia for vaginal delivery that each differed (P < 0.001) from the overall mean. Among those 55.2% were the 9.9% of hospitals with means ≤5.12 hours. Those mean durations on the low end ranged from 2.68 (SE, 0.17) to 5.10 (SE, 0.07) hours. Also, among the 55.2% were the 12.2% of hospitals with means ≥7.12 hours. Those mean durations at the high end ranged from 7.13 (SE, 0.08) to 12.03 (SE, 0.23) hours. The heterogeneity in the mean durations among hospitals would have been greater had the inclusion criteria not been applied. CONCLUSIONS: Our results show that the number of labor epidurals alone is not a valid measure to quantify obstetrical anesthesia productivity. In addition, payment to US anesthesia groups for labor analgesia based solely on the number of labor epidurals initiated is not equitable. Previous work showed lack of validity and equality of payment based on face-to-face time with the patient (i.e., like a surgical anesthetic). The use of base and time units, with one time unit per hour, is a suitable payment system. (Anesth Analg 2015;121:1283-9) Copyright © 2015 International Anesthesia Research Society.

Physician-directed versus computerized closed-loop control of blood pressure using phenylephrine in a swine model

BACKGROUND: Vasopressors provide a rapid and effective approach to correct hypotension in the perioperative setting. Our group developed a closed-loop control (CLC) system that titrates phenylephrine (PHP) based on the mean arterial pressure (MAP) during general anesthesia. As a means of evaluating system competence, we compared the performance of the automated CLC with physicians. We hypothesized that our CLC algorithm more effectively maintains blood pressure at a specified target with less blood pressure variability and reduces the dose of PHP required. METHODS: In a crossover study design, 6 swine under general anesthesia were subjected to a normovolemic hypotensive challenge induced by sodium nitroprusside. The physicians (MD) manually changed the PHP infusion rate, and the CLC system performed this task autonomously, adjusted every 3 seconds to achieve a predetermined MAP. RESULTS: The CLC maintained MAP within 5 mm Hg of the target for (mean ± standard deviation) 93.5% ± 3.9% of the time versus 72.4% ± 26.8% for the MD treatment (P =.054). The mean (standard deviation) percentage of time that the CLC and MD interventions were above target range was 2.1% ± 3.3% and 25.8% ± 27.4% (P =.06), respectively. Control statistics, performance error, median performance error, and median absolute performance error were not different between CLC and MD interventions. PHP infusion rate adjustments by the physician were performed 12 to 80 times in individual studies over a 60-minute period. The total dose of PHP used was not different between the 2 interventions. CONCLUSIONS: The CLC system performed as well as an anesthesiologist totally focused on MAP control by infusing PHP. Computerized CLC infusion of PHP provided tight blood pressure control under conditions of experimental vasodilation. © 2017 International Anesthesia Research Society.

A vibro-tactile display for clinical monitoring: Real-time evaluation

Background: Vibro-tactile displays use human skin to convey information from physiological monitors to anesthesiologists, providing cues about changes in the status of the patient. In this investigation, we evaluated, in a real-time clinical environment, the usability and wearability of a novel vibro-tactile display belt recently developed by our group, and determined its accuracy in identifying events when used by anesthesiologists. Methods: A prospective observational study design was used. During routine anesthesia, a standard physiological monitor was connected to a software tool that used algorithms to automatically identify changing trends in mean noninvasive arterial blood pressure, expired minute ventilation, peak airway pressure, and end-tidal carbon dioxide partial pressure. The software was wirelessly interfaced to a vibro-tactile belt worn by the anesthesiologist. Each physiological variable was mapped to 1 of 4 tactor locations within the belt. The direction (increase/decrease) and 2 levels of change (small/large) were encoded in the stimulation patterns. A training session was completed by each anesthesiologist. The system was activated in real-time during anesthesia alongside routine physiological monitors. When the algorithms detected changes in the patient, the belt vibrated at the appropriate location with the pattern corresponding to the level and direction of change. Using a touch screen monitor the anesthesiologist was to enter the vibro-tactile message by first identifying the variable, then identifying the level and direction of change. Usability and wearability questionnaires were to be completed. The percentage of correct identification of the physiological trend, the direction of change, and the level of change were primary outcome variables. The mean usability score and wearability results were secondary outcome variables. We hypothesized that anesthesiologists would correctly identify the events communicated to them through the vibro-tactile belt 90% of the time, and that anesthesiologists would find the vibro-tactile belt usable and wearable. Results: Seventeen anesthesiologists evaluated the display during 57 cases. The belt was operational for a mean (SD) duration of 75 (41) minutes per case. Seven cases were excluded from analysis because of technical failures. Eighty-one percent (confidence interval [CI], 77% to 84%) of all stimuli were decoded. The physiological trend, the direction of change, and the level of change were correctly identified for 97.7% (CI 96%-99%), 94.9% (CI 92%-97%), and 93.5% of these stimuli (CI, 91%-96%), respectively. Fourteen anesthesiologists completed the usability and wearability questionnaires. The mean usability score was 4.8 of a maximum usability score of 7. Conclusions: Anesthesiologists found a vibro-tactile belt to be wearable and usable and could accurately decode vibro-tactile messages in a real-time clinical environment. © 2012 International Anesthesia Research Society.

Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department

Background: Videolaryngoscopy (VL) is increasingly used, but not yet routine practice, for tracheal intubation. Few departments formally trial equipment before adopting it into practice. We describe the decision-making and implementation processes that our department used when introducing universal VL, with the C-MAC© (Karl Storz, Germany), throughout our anaesthesia and intensive care departments. Methods: We used a structured process to assess the feasibility of a change to universal VL. After departmental training, we undertook a 2 month trial period of mandating VL for all adult in-theatre intubations. Thereafter, VL remained widely available, but not mandated. We regularly surveyed anaesthetists and anaesthetic assistants to evaluate departmental opinion regarding the introduction of universal VL. Results: Before the trial period, one-third of anaesthetists judged that universal VL would be of overall benefit to patient safety, team dynamics, and quality of care. Reservations from both junior and senior anaesthetists focused on training concerns. Support for a changeover to VL, amongst both anaesthetists and anaesthetic assistants, increased throughout the trial period. Six months after the 2 month trial, support had grown further and was almost unanimous. Anaesthetists reported significant benefits in clinical performance, teaching, and human factors, especially teamwork and situation awareness. Conclusions: Performing a formal and prolonged trial of mandatory VL in theatre led to changes in perceptions and departmental consensus. As a result of the trial, the department agreed to the use of C-MAC© videolaryngoscopy as the default intubation technique throughout theatres and intensive care, with removal of standard Macintosh laryngoscopes from routine use. © 2017

Frequency of Operative Anesthesia Care after Traumatic Injury

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database - the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P <.01), increasing injury severity score (P <.01) and higher emergency department Glasgow Coma Score (P <.01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours. CONCLUSIONS: This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question. © 2018 International Anesthesia Research Society.

Visual Analytics to Leverage Anesthesia Electronic Health Record

BACKGROUND: Visual analytics is the science of analytical reasoning supported by interactive visual interfaces called dashboards. In this report, we describe our experience addressing the challenges in visual analytics of anesthesia electronic health record (EHR) data using a commercially available business intelligence (BI) platform. As a primary outcome, we discuss some performance metrics of the dashboards, and as a secondary outcome, we outline some operational enhancements and financial savings associated with deploying the dashboards. METHODS: Data were transferred from the EHR to our departmental servers using several parallel processes. A custom structured query language (SQL) query was written to extract the relevant data fields and to clean the data. Tableau was used to design multiple dashboards for clinical operation, performance improvement, and business management. RESULTS: Before deployment of the dashboards, detailed case counts and attributions were available for the operating rooms (ORs) from perioperative services; however, the same level of detail was not available for non-OR locations. Deployment of the yearly case count dashboards provided near-real–time case count information from both central and non-OR locations among multiple campuses, which was not previously available. The visual presentation of monthly data for each year allowed us to recognize seasonality in case volumes and adjust our supply chain to prevent shortages. The dashboards highlighted the systemwide volume of cases in our endoscopy suites, which allowed us to target these supplies for pricing negotiations, with an estimated annual cost savings of $250,000. Our central venous pressure (CVP) dashboard enabled us to provide individual practitioner feedback, thus increasing our monthly CVP checklist compliance from approximately 92% to 99%. CONCLUSIONS: The customization and visualization of EHR data are both possible and worthwhile for the leveraging of information into easily comprehensible and actionable data for the improvement of health care provision and practice management. Limitations inherent to EHR data presentation make this customization necessary, and continued open access to the underlying data set is essential. Copyright © 2022 International Anesthesia Research Society.

Assessing the association between blood loss and postoperative hemoglobin after cesarean delivery: A prospective study of 4 blood loss measurement modalities

BACKGROUND: Visual estimation and gravimetric methods are commonly used to quantify the volume of blood loss during cesarean delivery (CD). However, the correlation between blood loss and post-CD hemoglobin (Hb) is poorly studied, and it is unclear whether the correlation varies according to how blood loss is measured. METHODS: After obtaining Institutional Review Board approval, we performed a prospective study of 61 women undergoing CD to assess the relations between post-CD Hb and blood loss measured using 4 modalities: gravimetric blood loss measurement (gBL), visual blood loss estimation by a blinded obstetrician (oBL) and anesthesiologist (aBL), and the Triton System (tBL). Hb was measured preoperatively and within 10 minutes after CD. gBL was quantified as blood volume in a suction canister in addition to the weight of blood-soaked sponges. tBL was measured with the Triton System by photographing blood-soaked sponges and suction canister contents. To assess the relation between blood loss and post-CD Hb, we performed correlation analyses and compared the magnitude of the correlations across the 4 measurement modalities using William t test. A Bonferroni correction was set to identify a statistically significant correlation (P <.0125) and statistically significant differences between correlation coefficients (P <.008). RESULTS: The mean (standard deviation) preoperative Hb was 12 (1.1) g/dL and post-CD Hb was 11.3 (1.0) g/dL. Median (interquartile range) values for gBL, oBL, aBL, and tBL were 672 mL (266-970), 700 mL (600-800), 750 mL (600-1000), and 496 mL (374-729), respectively. A statistically significant but weak correlation was observed between tBL and post-CD Hb (r = -0.33; P =.01). No statistically significant correlations were observed among aBL (r = -0.25; P =.06), oBL (r = -0.2; P =.13), and gBL (r = -0.3; P =.03) with post-CD Hb. We did not detect any significant differences between any 2 correlation coefficients across the 4 modalities. CONCLUSIONS: Given that we observed only weak correlations between each modality with post-CD Hb and no significant differences in the magnitude of the correlations across the 4 modalities, there may be limited clinical utility in estimating post-CD Hb from blood loss values measured with any of the 4 modalities. © 2020 Royal Society of Chemistry. All rights reserved.

Interprofessional handover and patient safety in anaesthesia: Observational study of handovers in the recovery room

Background: We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room. Methods: We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts. Results: We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an 'audit point' in care where the patient's intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists' practice than might be expected. Conclusions: Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

The relationship of learning environment, quality of life, and study strategies measures to anesthesiology resident academic performance

BACKGROUND: We designed this study to determine the academic performance of anesthesia residents as related to their differential characteristics on some affective-motivational variables, represented by perceptions about their educational environment, subjective quality of life, and learning and study strategies. METHODS: The study sample consisted of 63 anesthesia residents who completed the World Health Organization Quality of Life Inventory, the Dundee Ready Educational Environment Measure, the Learning and Study Strategies Inventory, and a progress test on basic sciences on two to four measurement occasions during a 2-year period. A growth curve model was fit to the academic performance. Mantel-Haenszel tests identified independent predictors of academic performance on progress tests. RESULTS: Mean rating at the first measuring occasion was 41%. There was a statistically significant improvement over time (slope = 7% per 6-m period; P < 0.01). Analysis of the random effects showed significant individual differences in the intercept. The residents' scores improved at an equivalent rate over the course of the residency. The independent predictors of academic performance were anxiety, motivation, and ability in selecting main ideas. CONCLUSIONS: Knowledge growth on basic sciences during anesthesia residency is significantly associated to the level of anxiety related to study and achievement, to the motivation for learning and for personal improvement, and to the ability in selecting main ideas from subject matters to which residents are exposed during learning episodes. © 2007 by International Anesthesia Research Society.

Analgesic effects of oxycodone relative to those of sufentanil, in the presence of midazolam, during endoscopic injection sclerotherapy for patients with cirrhosis and esophageal varices

BACKGROUND: We evaluated the efficacy and gastroenterologist/patient satisfaction of midazolam combined with oxycodone, relative to that of midazolam combined with sufentanil, for anesthesia during endoscopic injection sclerotherapy (EIS) in patients with cirrhosis and esophageal varices. METHODS: Patients with cirrhosis (20-69 years of age), body mass index, 18-25 kg/m2, American Society of Anesthesiology patient classification physical status I-II who underwent elective EIS were randomly assigned to 1 of 2 groups. In this prospective, double-blinded, randomized controlled trial, 1 group received midazolam and oxycodone (n = 64), and the other group received midazolam and sufentanil (n = 63). Primary and secondary outcome measures were compared between groups. The primary outcome measure was the incidence of hypoxia. Secondary outcome measures included perioperative limb movement, need for rescue analgesics, need for additional sedative propofol, specified adverse reactions (postoperative myoclonus, nausea, vomiting, dizziness, and drowsiness), gastroenterologist satisfaction, and patient satisfaction with postoperative analgesia. RESULTS: Patients in the midazolam-oxycodone group had 32% fewer episodes of hypoxia than did those in the midazolam-sufentanil group (95% confidence interval [CI], -45% to -18%; P &lt; .001), 36.73% fewer perioperative limb movements (95% CI, -51.73% to -21.73%; P &lt; .001), 19.12% fewer required rescue analgesics (95% CI, -30.85% to -7.40%; P = .002), and less propofol requirement in the perioperative period (before EIS, -17.83%; 95% CI, -33.82% to -1.85%; P = .003; throughout EIS, -36.73%; 95% CI, -51.73% to -21.73%; P &lt; .001). The incidence rates for adverse reactions were similar between groups. Both the gastroenterologist and patients reported higher degrees of satisfaction with oxycodone than with sufentanil. CONCLUSIONS: Oxycodone in combination with midazolam may provide an anesthetic technique that results in fewer episodes of hypoxia and other adverse conditions during EIS. Copyright © 2018 International Anesthesia Research Society.

Supraglottic airway device versus tracheal intubation and the risk of emergent postoperative intubation after general anaesthesia in adults: a retrospective cohort study

Background: We examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes. Methods: We included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used. Results: Use of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64–0.97; P&lt;0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4–4.4; P&lt;0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4–43.4%; P&lt;0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99–6.67 vs aOR=1.68, 95% CI, 1.29–2.18 [P&lt;0.001], respectively). Conclusions: In patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation. © 2020 British Journal of Anaesthesia

Visualization improves supraclavicular access to the subclavian vein in a mixed reality simulator

BACKGROUND: We investigated whether visual augmentation (3D, real-time, color visualization) of a procedural simulator improved performance during training in the supraclavicular approach to the subclavian vein, not as widely known or used as its infraclavicular counterpart. METHODS: To train anesthesiology residents to access a central vein, a mixed reality simulator with emulated ultrasound imaging was created using an anatomically authentic, 3D-printed, physical mannequin based on a computed tomographic scan of an actual human. The simulator has a corresponding 3D virtual model of the neck and upper chest anatomy. Hand-held instruments such as a needle, an ultrasound probe, and a virtual camera controller are directly manipulated by the trainee and tracked and recorded with submillimeter resolution via miniature, 6 degrees of freedom magnetic sensors. After Institutional Review Board approval, 69 anesthesiology residents and faculty were enrolled and received scripted instructions on how to perform subclavian venous access using the supraclavicular approach based on anatomic landmarks. The volunteers were randomized into 2 cohorts. The first used real-time 3D visualization concurrently with trial 1, but not during trial 2. The second did not use real-time 3D visualization concurrently with trial 1 or 2. However, after trial 2, they observed a 3D visualization playback of trial 2 before performing trial 3 without visualization. An automated scoring system based on time, success, and errors/complications generated objective performance scores. Nonparametric statistical methods were used to compare the scores between subsequent trials, differences between groups (real-time visualization versus no visualization versus delayed visualization), and improvement in scores between trials within groups. RESULTS: Although the real-time visualization group demonstrated significantly better performance than the delayed visualization group on trial 1 (P = .01), there was no difference in gain scores, between performance on the first trial and performance on the final trial, that were dependent on group (P = .13). In the delayed visualization group, the difference in performance between trial 1 and trial 2 was not significant (P = .09); reviewing performance on trial 2 before trial 3 resulted in improved performance when compared to trial 1 (P < .0001). There was no significant difference in median scores (P = .13) between the real-time visualization and delayed visualization groups for the last trial after both groups had received visualization. Participants reported a significant improvement in confidence in performing supraclavicular access to the subclavian vein. Standard deviations of scores, a measure of performance variability, decreased in the delayed visualization group after viewing the visualization. CONCLUSIONS: Real-time visual augmentation (3D visualization) in the mixed reality simulator improved performance during supraclavicular access to the subclavian vein. No difference was seen in the final trial of the group that received real-time visualization compared to the group that had delayed visualization playback of their prior attempt. Training with the mixed reality simulator improved participant confidence in performing an unfamiliar technique. Copyright © 2017 International Anesthesia Research Society.

A psychological basis for anesthesiologists' operating room managerial decision-making on the day of surgery

BACKGROUND: We investigated whether, without prompting, anesthesiologists tend to make managerial decisions to increase the clinical work per unit time of the sites to which they are assigned during their scheduled time present. Although a sound basis for decision-making involving individual ORs, the heuristic is often suboptimal economically when applied to decisions involving multiple ORs. METHODS: Two studies were performed at one hospital. 1) A retrospective analysis was made of anesthesiologists' managerial decisions when caring for sequential lists of patients. 2) Patients' and surgeons' waiting on nights and weekends were studied before/after education on optimal decision-making. RESULTS: 1) Anesthesiologists' decisions resulted in an increase in their clinical work per unit time, not a reduction in patient waiting. 2) Paradoxically, such efforts on nights and weekends caused increased patient and surgeon waiting. Decisions were unchanged after education on a different way to assign cases. CONCLUSIONS: In a companion article, we showed that clinicians tended to make decisions that increased the clinical work per unit time at each moment in each OR, even when doing so resulted in an increase in overutilized OR time, higher staffing costs, unpredictable work hours, and/or mandatory overtime. The current studies show that such efforts to work fast cannot be explained as a consequence of efforts to reduce surgeon and patient waiting. Rather, the heuristic followed is consistent with increasing one's personal clinical work per unit time at one's assigned anesthetizing location. © 2007 by International Anesthesia Research Society.

Improvement in the quality of randomized controlled trials among general anesthesiology journals 2000 to 2006: A 6-year follow-up

BACKGROUND: We previously assessed all randomized controlled trials (RCTs) from four anesthesiology journals from January 2000 to December 2000. We identified key areas for improvement in the study protocol design and implementation and in data analyses. This study was repeated for the year 2006 to determine if improvements have occurred during the 6-yr interval. METHODS: All RCTs published in 2006 in four anesthesiology journals (Anesthesiology, Anesthesia & Analgesia, Anaesthesia, and Canadian Journal of Anesthesia) were retrieved using a MEDLINE search. Of 2164 articles published in 2006, 200 papers met these search criteria and were considered valid for analysis. We completed a 14-item, validated assessment tool used in our previous study to determine a quality score for each article. Four clinical reviewers each assessed 50 articles, and one reviewer assessed all 200 articles. Points were assigned by consensus. Scores were weighted and compared with the results from the year 2000. RESULTS: Quality scores improved from the year 2000 to 2006, from a mean overall quality score of 44% (95% CI = 42, 46) to a mean score of 58% (95% CI = 55, 60). Specific areas of study, quality assessment demonstrating improvement, included sample size estimates (52% vs 86%, P < 0.0001), major end-points (44% vs 99%, P < 0.0001), and discussion of side effects (68% vs 82%, P = 0.0019). Low quality scores remained for randomization blinding (4% vs 19% P < 0.0001), observer blinding to continuing studies (1% vs 5% P = 0.116), and post-β estimates in trials with negative outcomes (16% vs 18%, P < 0.87). CONCLUSIONS: There appears to have been a general improvement in the overall quality of RCT reporting among the major anesthesiology journals from the year 2000 to 2006. However, many articles could be improved with respect to randomization blinding, observer blinding to continuing study results (i.e., no unplanned interim data analysis), and a full discussion of Type II error in negative trials. Responsibility to improve the quality of the anesthesiology literature rests with investigators to design, implement and report high quality RCTs, and with peer reviewers and journal editors to set the standard for manuscript reporting. Periodic reassessments of the literature can serve to improve and maintain the quality of clinical trials reporting. © 2009 International Anesthesia Research Society.

Forecasting and perception of average and latest hours worked by on-call anesthesiologists

BACKGROUND: We studied the value of providing information to anesthesia providers about the length of time typically worked during on-call shifts. The mean time at which a shift ends can be used for purposes of trades, payments, or reverse auctions, because the mean is proportional to the total time. The 80th percentile (with a suitable upper confidence limit for uncertainty due to limited sample sizes) can be used for judging the earliest time by which after-work activities reasonably can be planned. METHODS: (A) Three years of operating room (OR) information system data were analyzed. Dependent variables were the earliest times when the numbers of ORs running were always ≤6 ORs, ≤4 ORs, and ≤2 ORs. We progressively built linear regression models for each of the three dependent variables using day of the week, scheduled number of cases, scheduled hours of cases (including turnovers), and linear time trend. Calculations were repeated after excluding residuals. Calculations were repeated using regression trees. (B) Anesthesiologists were surveyed about their perceptions of the mean and 80th percentiles. RESULTS: (A) For the three thresholds and two end points (mean and 80th percentile), differences among days of the week were as large as 45 min. Differences between end points for the same weekdays were as large as 245 min. Comparatively, additional knowledge about the number or hours of cases provided in the late afternoon on the working day before surgery reduced the mean absolute error by only 4.1-6.0 min. Results were insensitive to a variety of analytic methods. Information available more days before the day of surgery (e.g., 1 wk) would have had even less incremental predictive value. (B) The mean absolute error of anesthesiologists' estimates for 80th percentiles was 60 min, principally because of underestimation of the 80th percentiles. More than half (69%, P = 0.0003) of anesthesiologists' estimates for 80th percentiles had error >30 min, whereas errors of this magnitude were less for the mean (44%, P = 0.0004). CONCLUSIONS: Historical data from OR or anesthesia information management systems, or from anesthesia billing systems, can be used months before staff scheduling to provide insight to anesthesia providers on respective calls. The data are useful because experience provides limited intuition. Updates on scheduled workload available closer to the day of surgery provided only marginal increases in knowledge over the use of historical data. © 2009 by International Anesthesia Research Society.

The Pediatric-Specific American Society of Anesthesiologists Physical Status Score: A Multicenter Study

BACKGROUND: When applied to the pediatric population, the American Society of Anesthesiologists physical status (ASA-PS) classification has exhibited poor reliability due to its subjective and adult-focused definitions. This study was done to measure interrater agreement of a pediatric-adapted ASA-PS classification and to solicit multicenter perspectives to optimize the pediatric ASA-PS classification. METHODS: A prospective, mixed-methods study of 197 pediatric anesthesiologists from 13 academic pediatric hospitals in the United States, Europe, and Australia surveyed in May and July 2019. Participants assigned ASA-PS scores (I to V) for 15 pediatric cases with a heterogeneous mix of acute and chronic health conditions undergoing a variety of surgical and related procedures. Pediatric-adapted definitions of ASA-PS were provided. The intraclass correlation coefficient (ICC) was used to assess interrater reliability of ASA-PS scores. The ICC was estimated using 2-way mixed-effects modeling, accounting for multiple raters assigning scores for the same set of cases. Qualitative feedback on the pediatric-adapted ASA-PS classification was analyzed with line-by-line coding. RESULTS: The survey response rate was 83.8% (165 of 197). The ICC agreement among participants on ASA-PS scoring across all 15 clinical cases was 0.58 (95% confidence interval [CI], 0.42-0.77). ICC did not vary significantly by years of anesthesiology practice. ICC varied across hospitals (range: 0.34; 95% CI, 0.12-0.63 to 0.79; 95% CI, 0.66-0.91). The highest level of agreement occurred with cases most often scored as ASA-PS I, IV, and V; the lowest agreement occurred with cases most often scored ASA-PS II and III. Clarification of how well a chronic condition was controlled and presence of an acute illness were 2 common themes suggested to optimize the validity of the pediatric-adapted ASA-PS definitions. CONCLUSIONS: The pediatric-adapted ASA-PS classification had moderate interrater reliability among pediatric anesthesiologists. The lower reliability of scoring for ASA-PS II and III cases, in particular, supports the need for further ASA-PS definition refinement for pediatric populations. © 2021 Lippincott Williams and Wilkins. All rights reserved.

Is compliance with surgical care improvement project cardiac (SCIP-Card-2) measures for perioperative β-blockers associated with reduced incidence of mortality and cardiovascular-related critical quality indicators after noncardiac surgery?

BACKGROUND: While continuation of β-blockers (BBs) perioperatively has become a national quality improvement measure, the relationship between BB withdrawal and mortality and cardiovascular-related critical quality indicators has not been studied in a contemporary cohort of patients undergoing noncardiac surgery. METHODS: For this retrospective study, the quality assurance database of a large community-based anesthesiology group practice was used to identify 410,288 surgical cases, 18 years of age or older, who underwent elective or emergent noncardiac surgical procedures between January 1, 2009, and December 31, 2014. Each surgical case that was withdrawn from BBs perioperatively was propensity matched by clinical and surgical characteristics to 4 cases that continued BBs perioperatively. Subsequently, multivariable conditional logistic regression analyses were performed in the matched cohort to determine the extent to which withdrawal of perioperative BBs was independently associated with mortality as the primary outcome and cardiovascular-related critical quality indicators as the secondary outcome (need for vasopressor, electrocardiographic changes requiring treatment, unplanned admission to intensive care unit, postanesthesia care unit stay >2 hours, and a combination of cardiac arrest and myocardial infarction) within 48 hours postoperatively. RESULTS: Of the 66,755 (16%) cases in the cohort admitted on BB therapy, BBs were withdrawn in 3829 (6%) and continued in 62,926 (94%). Propensity score matching resulted in an analysis cohort of 19,145 cases. Withdrawal of perioperative BBs in the multivariable conditional logistic regression analysis was significantly associated with an increased risk for mortality (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.75–7.35; P = .0003), but a significantly decreased risk for need of blood pressure support requiring vasopressor initiation (OR, 0.84; 95% CI, 0.76–0.92; P = .0003) and extended postanesthesia care unit stay (OR, 0.69; 95% CI, 0.54–0.88; P = .004) within 48 hours after noncardiac surgery. CONCLUSIONS: Perioperative withdrawal of BBs was associated with increased risk for mortality within 48 hours after noncardiac surgery and with decreased risk for need of vasopressor during the early postoperative period and a shorter stay in the postanesthesia care unit. Copyright © 2017 International Anesthesia Research Society.

Anaesthesia provider volume and perioperative outcomes in total joint arthroplasty surgery

Background: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume–outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties. Methods: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported. Results: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50–149; OR: 0.80; CI: 0.66–0.98) and prolonged length of stay (OR: 0.69; CI: 0.60–0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75–0.95). Conclusions: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings. © 2019 British Journal of Anaesthesia

Evaluation of Open Access Websites for Anesthesia Education

BACKGROUND: While the prevalence of free, open access medical education resources for health professionals has expanded over the past 10 years, many educational resources for health care professionals are not publicly available or require fees for access. This lack of open access creates global inequities in the availability and sharing of information and may have the most significant impact on health care providers with the greatest need. The extent of open access online educational websites aimed for clinicians and trainees in anesthesiology worldwide is unknown. In this study, we aimed to identify and evaluate the quality of websites designed to provide open access educational resources for anesthesia trainees and clinicians. METHODS: A PubMed search of articles published between 2009 and 2020, and a Startpage search engine web search was conducted in May 2021 to identify websites using the following inclusion criteria: (1) contain educational content relevant for anesthesia providers or trainees, (2) offer content free of charge, and (3) are written in the English language. Websites were each scored by 2 independent reviewers using a website quality evaluation tool with previous validity evidence that was modified for anesthesia (the Anesthesia Medical Education Website Quality Evaluation Tool). RESULTS: Seventy-five articles and 175 websites were identified; 37 websites met inclusion criteria. The most common types of educational content contained in the websites included videos (66%, 25/37), text-based resources (51%, 19/37), podcasts (35%, 13/37), and interactive learning resources (32%, 12/37). Few websites described an editorial review process (24%, 9/37) or included opportunities for active engagement or interaction by learners (30%,11/37). Scores by tertile differed significantly across multiple domains, including disclosure of author/webmaster/website institution; description of an editorial review process; relevancy to residents, fellows, and faculty; comprehensiveness; accuracy; disclosure of content creation or revision; ease of access to information; interactivity; clear and professional presentation of information; and links to external information. CONCLUSIONS: We found 37 open access websites for anesthesia education available on the Internet. Many of these websites may serve as a valuable resource for anesthesia clinicians looking for self-directed learning resources and for educators seeking to curate resources into thoughtfully integrated learning experiences. Ongoing efforts are needed to expand the number and improve the existing open access websites, especially with interactivity, to support the education and training of anesthesia providers in even the most resource-limited areas of the world. Our findings may provide recommendations for those educators and organizations seeking to fill this needed gap to create new high-quality educational websites. © 2022 Lippincott Williams and Wilkins. All rights reserved.

The Practice of Pediatric Cardiac Anesthesiology in the United States

BACKGROUND: With advances in surgical and catheter-based interventions and technologies in patients with congenital heart disease (CHD), the practice of pediatric cardiac anesthesiology has evolved in parallel with pediatric cardiac surgery and pediatric cardiology as a distinct subspecialty over the past 80 years. To date, there has not been an analysis of the distribution of pediatric cardiac anesthesiologists relative to cardiac and noncardiac procedures in the pediatric population. The primary aim is to report the results of a survey and its subsequent analysis to describe the distribution of pediatric cardiac anesthesiologists relative to pediatric cardiac procedures that include surgical interventions, cardiac catheterization procedures, imaging studies (echocardiography, magnetic resonance, computed tomography, positron emission tomography), and noncardiac procedures. METHODS: A survey developed in Research Electronic Data Capture (REDcap) was sent to the identifiable division chiefs/cardiac directors of 113 pediatric cardiac anesthesia programs in the United States. Data regarding cardiac surgical patients and procedures were collected from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHD). RESULTS: This analysis reveals that only 38% (117 of 307) of pediatric cardiac anesthesiologists caring for patients with CHD pursued additional training in pediatric cardiac anesthesiology, while 44% (136 of 307) have gained experience during their clinical practice. Other providers have pursued different training pathways such as adult cardiac anesthesiology or pediatric critical care. Based on this survey, pediatric cardiac anesthesiologists devote 35% (interquartile range [IQR], 20%-50%) of clinical time to the care of patients in the cardiac operating room, 25% (20%-35%) of time to the care of patients in the cardiac catheterization laboratory, 10% (5%-10%) to patient care in imaging locations, and 15% covering general pediatric, adult, or cardiac patients undergoing noncardiac procedures. Attempts to actively recruit pediatric cardiac anesthesiologists were reported by 49.2% (29 of 59) of the institutions surveyed. Impending retirement of staff was anticipated in 17% (10 of 59) of the institutions, while loss of staff to relocation was anticipated in 3.4% (2 of 59) of institutions. Thirty-seven percent of institutions reported that they anticipated no immediate changes in current staffing levels. CONCLUSIONS: The majority of currently practicing pediatric cardiac anesthesiologists have not completed a fellowship training in the subspecialty. There is, and will continue to be, a need for subspecialty training to meet increasing demand for services especially with increase survival of this patient population and to replace retiring members of the workforce. © 2022 Lippincott Williams and Wilkins. All rights reserved.

Should Objective Structured Clinical Examinations Assist the Clinical Competency Committee in Assigning Anesthesiology Milestones Competency?

BACKGROUND: With the integration of Objective Structured Clinical Examinations into the Anesthesiology primary board certification process, residency programs may choose to implement Objective Structured Clinical Examinations for resident skill assessment. The aim of this study was to evaluate Objective Structured Clinical Examination-based milestone assessment and compare with Clinical Competency Committee milestone assessment that is based purely on clinical evaluations. METHODS: An annual Objective Structured Clinical Examination event was used to obtain milestone assessment of clinical anesthesia year 0-clinical anesthesia year 3 residents for selected milestones in patient care, professionalism, and interpersonal/communication skills. The Objective Structured Clinical Examination scenarios were different for each training level. The Clinical Competency Committee evaluated each resident semiannually based on clinical evaluations of resident performance. The Clinical Competency Committee milestone assessments from 2014 to 2016 that were recorded closest to the Objective Structured Clinical Examination event (±3 months) were compared to the Objective Structured Clinical Examination milestone assessments. A total of 35 residents were included in this analysis in 3 different training cohorts: A (graduates 2016, n = 12); B (graduates 2017, n = 10); and C (graduates 2018, n = 13). All residents participated in Objective Structured Clinical Examinations because their clinical anesthesia year 0 year and Clinical Competency Committee milestone data had been reported since December 2014. RESULTS: Both assessment techniques indicated a competency growth proportional to the length in training. Despite limited cumulative statistics in this study, average trends in the Objective Structured Clinical Examination-Clinical Competency Committee relationship indicated: (1) a good proportionality in reflecting competency growth; (2) a grade enhancement associated with Clinical Competency Committee assessment, dominated by evaluations of junior residents (clinical anesthesia year 0-clinical anesthesia year 1); and (3) an expectation bias in Clinical Competency Committee assessment, dominated by evaluation of senior residents (clinical anesthesia year 2-clinical anesthesia year 3). CONCLUSIONS: Our analysis confirms the compatibility of the 2 evaluation methods in reflecting longitudinal growth. The deviation of Objective Structured Clinical Examination assessments versus Clinical Competency Committee assessments suggests that Objective Structured Clinical Examinations may be providing additional or different information on resident performance. Educators might consider using both assessment methods to provide the most reliable and valid competency assessments during residency. © 2018 International Anesthesia Research Society.

Gender effects in anaesthesia training in Australia and New Zealand

Background: Women face gender-based challenges in their medical education and career. Inequitable access to procedural training, a confidence gap, and professional identity deficit have been shown. We made a gender comparison of procedural case volume, confidence for independent practice, perceived gender and ethnic bias, and professional identity in Australasian anaesthesia trainees. Methods: An online, voluntary, anonymous survey using SurveyMonkey® was delivered to Australasian anaesthesia trainees. Information collected included demographics, experience and confidence in 12 anaesthetic procedures, assessments relating to confidence and professional identity, and perceived gender and ethnic bias. Gender differences were evaluated. Results: Three hundred and fifty-six trainees (22.2%) of the Australian and New Zealand College of Anaesthetists (ANZCA) responded. Male trainees reported a higher number (standard deviation) of procedures performed greater than 10 times (men 4.45 [2.55], women 3.78 [1.95]; P<0.001 adjusted for training level). Men were more likely to rate themselves at a training competency above their actual training level (men 18.6%, women 7.8%; P=0.004) and exaggerate procedural experience to supervisors (men 30.8%, women 11.8%; P<0.001). Final-year male trainees felt significantly more prepared for independent practice (P=0.021, trend across ordered responses). Women reported significantly higher levels of gender bias exhibited by patients (men 1.1%, women 84.5%; P<0.001) and in training overall (men 10.3%, women 55.3%; P<0.001), which was compounded in women with an ethnic minority background. Conclusions: A discrepancy exists between the number of procedures performed by male and female anaesthesia trainees in Australia and New Zealand. Relative male overconfidence may be a major contributing factor to the gender confidence gap. © 2020 British Journal of Anaesthesia

Perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11 781 anaesthesiologists

Background: Women make up an increasing proportion of the physician workforce in anaesthesia, but they are consistently under-represented in leadership and governance. Methods: We performed an internet-based survey to investigate career opportunities in leadership and research amongst anaesthesiologists. We also explored gender bias attributable to workplace attitudes and economic factors. The survey instrument was piloted, translated into seven languages, and uploaded to the SurveyMonkey® platform. We aimed to collect between 7800 and 13 700 responses from at least 100 countries. Participant consent and ethical approval were obtained. A quantitative analysis was done with χ2 and Cramer's V as a measure of strength of associations. We used an inductive approach and a thematic content analysis for qualitative data on current barriers to leadership and research. Results: The 11 746 respondents, 51.3% women and 48.7% men, represented 148 countries; 35 respondents identified their gender as non-binary. Women were less driven to achieve leadership positions (P&lt;0.001; Cramer's V: 0.11). Being a woman was reported as a disadvantage for leadership and research (P&lt;0.001 for both; Cramer's V: 0.47 and 0.34, respectively). Women were also more likely to be mistreated in the workplace (odds ratio: 10.6; 95% confidence interval: 9.4–11.9; P&lt;0.001), most commonly by surgeons. Several personal, departmental, institutional, and societal barriers in leadership and research were identified, and strategies to overcome them were suggested. Lower-income countries were associated with a significantly smaller gender gap (P&lt;0.001). Conclusions: Whilst certain trends suggest improvements in the workplace, barriers to promotion of women in key leadership and research positions continue within anaesthesiology internationally. © 2019 British Journal of Anaesthesia

Eye tracking for assessment of workload: a pilot study in an anaesthesia simulator environment

Background: Workload assessment is an important tool for improving patient safety in anaesthesia. We tested the hypothesis that heart rate, pupil size, and duration of fixation increase, whereas saccade amplitude decreases with increased workload during simulated critical incidents. Methods: Fifteen trainee anaesthetists participated in this randomized cross-over trial. Each participant used a head-mounted eye-tracking device (EyeSeeCam) during induction of general anaesthesia in a full-scale simulation during three different sessions. No critical incident was simulated in the first session. In a randomized order, workload was increased by simulation of a critical incident in the second or third session. Pupil size, duration of fixations, saccadic amplitude, and heart rate of each participant and the simulator conditions were recorded continuously and synchronized. The data were analysed by paired sample t-tests and mixed-effects regression analysis. Results: The findings of the second and third sessions of 11 participants were analysed. Pupil diameter and heart rate increased simultaneously as the severity of the simulated critical incident increased. Allowing for individual effects, the simulator conditions explained 92.6% of the variance in pupil diameter and 93.6% of the variance in heart rate (both P<0.001). The duration of fixation decreased with increased workload. The saccadic amplitude remained unaffected by workload changes. Conclusions: Pupil size and heart rate reflect workload increase within simulator sessions, but they do not permit overall workload comparisons between individuals or sessions. Contrary to our assumption, the duration of fixation decreased with increased workload. Saccade amplitude did not reflect workload fluctuations. © 2011 The Author(s)

Validity evidence for the Anesthesia Clinical Encounter Assessment (ACEA) tool to support competency-based medical education

Background: Workplace-based assessment (WBA) is key to a competency-based assessment strategy. Concomitantly with our programme's launch of competency-based medical education, we developed an entrustment-based WBA, the Anesthesia Clinical Encounter Assessment (ACEA), to assess readiness for independent practice of competencies essential to perioperative patient care. This study aimed to examine validity evidence of the ACEA during postgraduate anaesthesiology training. Methods: The ACEA comprises an eight-item global rating scale (GRS), an overall independence rating, an eight-item checklist, and case details. ACEA data were extracted for University of Toronto anaesthesia residents from July 2017 to January 2020 from the programme's online assessment portal. Validity evidence was generated following Messick's validity framework, including response process, internal structure, relations with other variables, and consequences. Results: We analysed 8664 assessments for 137 residents completed by 342 assessors. From generalisability analysis, 10 independent observations (two assessments each from five assessors) were sufficient to achieve a reliability threshold of ≥0.70 for in-training assessments. A composite GRS score of 3.65/5 provided optimal sensitivity (93.6%) and specificity (90.8%) for determining entrustment on receiver operator characteristic curve analysis. Test–retest reliability was high (intraclass correlation coefficient [ICC2,1]=0.81) for matched assessments within 14 days of each other. Composite GRS scores differed significantly between residents based on their training level (P&lt;0.0001) and correlated highly with overall independence (0.91, P&lt;0.001). The internal consistency of the GRS (α=0.96) was excellent. Conclusions: This study supports the validity of the ACEA for assessing the competence of residents performing perioperative care and supports its use in competency-based anaesthesiology training. © 2021 British Journal of Anaesthesia

Closed-circuit xenon delivery using a standard anesthesia workstation

Background: Xenon (Xe) is an anesthetic with minimal side effects, now also showing promise as a neuroprotectant both in vitro and in vivo. Although scarce and expensive, Xe is insoluble and patient uptake is low, making closed circuits the optimum delivery method. Although the future of Xe anesthesia is uncertain, effective neuroprotection is highly desirable even if moderately expensive. A factor limiting Xe research in all these fields may be the perceived need to purchase special Xe anesthesia workstations that are expensive and difficult to service. We investigated the practicality of 1) true closed-circuit Xe delivery using an unmodified anesthesia workstation with gas monitoring/delivery attachments restricted to breathing hoses only, 2) a Xe delivery protocol designed to eliminate wastage, and 3) recovering Xe from exhaled gas. Methods: Sixteen ASA physical status I/II patients were recruited for surgery of >2 h. Denitrogenation with 100% oxygen was started during induction and tracheal intubation under propofol/remifentanil anesthesia. This continued after operating room transfer for 30 min. All fresh gases were then temporarily stopped, metabolic oxygen consumption then being replaced with 250-mL Xe boluses until FIXe = 50%. A basal oxygen fresh gas flow was thereafter restored with additional Xe given as required via the expiratory hose to maintain a FIXe ≥ 50%. At no time, apart from during circle flushes every 90 min, were the bellows allowed to completely fill and spill gas, ensuring the circle remained closed. On termination of anesthesia, the first 10 exhaled breaths were collected as was residual gas from the circle, allowing measurement of the Xe content of each. Results: Total Xe consumption, including initial wash-in and circle flushes, was 12.62 (5.31) L or 4.95 (0.82) L/h, mean (sd). However, consumption during maintenance periods was lower: 3 L/h at 1 h and 2 L/h thereafter. Of the total Xe used, 8.98% (5.94%) could be recovered at the end of the procedure. Conclusions: We report that closed-circuit Xe delivery can be achieved with a modified standard anesthesia workstation with breathing hose alterations only and that the protocol was very gas efficient, especially during the normally wasteful Xe wash-in. A Xe mixture of ≥50% was delivered for up to 341 min (5 h 41 min) and Xe consumption was 4.95 (0.82) L/h, maintenance being achieved with 2-3 L/h. With this degree of efficiency, Xe recovery/recycling at the end of anesthesia may be of little additional benefit. Copyright © 2009 International Anesthesia Research Society.

Perceptions about blood transfusion: A survey of surgical patients and their anesthesiologists and surgeons

BACKGROUND:: Although blood transfusion is a common therapeutic intervention and a mainstay of treating surgical blood loss, it may be perceived by patients and their physicians as having associated risk of adverse events. Practicing patient-centered care necessitates that clinicians have an understanding of an individual patient's perceptions of transfusion practice and incorporate this into shared medical decision-making. METHODS:: A paper survey was completed by patients during routine outpatient preoperative evaluation. An online survey was completed by attending anesthesiologists and surgeons at the same institution. Both surveys evaluated perceptions of the overall risk of transfusions, level of concern regarding 5 specific adverse events with transfusion, and perceptions of the frequency of those adverse events. Group differences were evaluated with conventional inferential biostatistics. RESULTS:: A total of 294 patients and 73 physicians completed the surveys. Among the surveyed patients, 20% (95% confidence interval, 15%-25%) perceived blood transfusions as "very often risky" or "always risky." Greater perceived overall blood transfusion risk was associated with African American race (P = 0.028) and having a high school or less level of education (P = 0.022). Greater perceived risk of allergic reaction (P = 0.001), fever (P < 0.001), and dyspnea (P = 0.001) were associated with African American race. Greater perceived risk of allergic reaction (P = 0.009), fever (P = 0.039), dyspnea (P = 0.004), human immunodeficiency virus/acquired immune deficiency syndrome and hepatitis (P = 0.003), and medical error (P = 0.039) were associated with having a high school or less level of education. Patients and physicians also differed significantly in their survey responses, with physicians reporting greater overall perceived risk with a blood transfusion (P = 0.001). CONCLUSIONS:: Despite improvements in blood transfusion safety in the United States and other developed countries, the results of this study indicate that a sizeable percentage of patients still perceive transfusion as having significant associated risk. Furthermore, patients and their anesthesiologists/surgeons differ in their perceptions about transfusion-related risks and complications. Understanding patients' perceptions of blood transfusion and identifying groups with the greater specific concerns will better enable health care professionals to address risk during the informed consent process and recommend blood management in accordance with the individual patient's values, beliefs, and fears or concerns. Copyright © 2014 International Anesthesia Research Society.

Automated correction of room location errors in anesthesia information management systems

BACKGROUND:: Anesthesia information management systems (AIMS) and operating room information management systems (ORIMS) are both used in operating rooms (OR). Anesthesia providers use AIMS to document their care in near real-time, including milestone events, and these systems automatically record vital signs from patient monitors. Circulating nurses use ORIMS primarily to document procedural information. Because of automatic documentation, AIMS would be ideal platforms for OR managerial decision support if the correct locations of cases in progress were known accurately. Trust is diminished if recommendations are poor. METHODS:: We compiled room location error rates from prior analyses of ORIMS data. Data from 24 consecutive 4-wk periods (45,459 cases) were analyzed from one hospital where both ORIMS and AIMS data were available. The actual location of cases was inferred from the physical location of the workstation recording the majority of pulse oximetry saturations. These were compared to the listed location in the AIMS and the final corrected location in the ORIMS. The scheduled and final ORIMS locations were compared to determine how often location changes were updated before the start of anesthesia. The location of cases was inferred in near real-time by using the identifier of the AIMS workstation transmitting pulse oximetry saturated electrocardiogram heart rate, and end-tidal CO2 partial pressures. RESULTS:: Location error rates ranged from 0% to 7.5% at 42 hospitals. The error rate at the studied hospital was just 0.4%, showing that the hospital was suitable for investigation. The 0.4% error rate was based on cases listed as overlapping in the same OR, and thus under-estimated the actual error rate in the ORIMS (1.0%). With education, there was a decrease in the moved cases in the ORIMS whose location was not changed before the start of anesthesia (9.3%-2.0%, P < 10). Despite the significant improvement (P < 10) in the error rate between the AIMS listed and actual locations, the residual AIMS real-time error rate was 4.1% of cases. Use of vital sign data reduced errors to <0.1%. CONCLUSIONS:: Education can only modestly improve the accuracy of OR locations in ORIMS and AIMS data. The actual location can be inferred, either in near real-time or afterwards, from the AIMS workstation transmitting vital sign data. This addresses the fundamental problem of cases having more than one location during the course of anesthetic care (e.g., holding area, block room, OR, and postanesthesia care unit), which cannot be determined from scheduled ORIMS or listed AIMS locations. © 2008 International Anesthesia Research Society.

Technology diffusion of anesthesia information management systems into Academic Anesthesia Departments in the United States

BACKGROUND:: Anesthesia information management systems (AIMS) are electronic health records that automatically import vital signs from patient monitors and allow for computer-assisted creation of the anesthesia record. When most recently surveyed in 2007, it was estimated that at least 16% of U.S. academic hospitals (i.e., with an anesthesia residency program) had installed an AIMS. At least an additional 28% reported that they were in the process of implementing, or searching for an AIMS. In this study, we updated the adoption figures as of May 2013 and examined the historical trend of AIMS deployment in U.S. anesthesia residency programs from the perspective of the theory of diffusion of technologic innovations. METHODS:: Questionnaires were sent by e-mail to program directors or their identified contact individuals at the 130 U.S. anesthesiology residency programs accredited as of June 30, 2012 by the Accreditation Council for Graduate Medical Education. The questionnaires asked whether the department had an AIMS, the year of installation, and, if not present, whether there were plans to install an AIMS within the next 12 months. Follow-up e-mails and phone calls were made until responses were obtained from all programs. Results were collected between February and May 2013. Implementation percentages were determined using the number of accredited anesthesia residency programs at the start of each academic year between 1987 and 2013 and were fit to a logistic regression curve using data through 2012. RESULTS:: Responses were received from all 130 programs. Eighty-seven (67%) reported that they currently are using an AIMS. Ten programs without a current AIMS responded that they would be installing an AIMS within 12 months of the survey. The rate of AIMS adoption by year was well fit by a logistic regression curve (P = 0.90). CONCLUSIONS:: By the end of 2014, approximately 75% of U.S. academic anesthesiology departments will be using an AIMS, with 84% adoption expected between 2018 and 2020. Historical adoption of AIMS has followed Roger's 1962 formulation of the theory of diffusion of innovation. © 2013 International Anesthesia Research Society.

Preparation of the Dräger Fabius anesthesia machine for the malignant-hyperthermia susceptible patient

BACKGROUND:: Anesthesia machines must be flushed of halogenated anesthetics before use in patients susceptible to malignant hyperthermia. We studied the kinetics of sevoflurane clearance in the Dräger Fabius anesthesia machine and compared them to a conventional anesthesia machine (Dräger Narkomed GS). METHODS:: Before each trial, the anesthesia machine was contaminated for 2 h with 3% sevoflurane and then prepared by changing the CO2 absorbent, removing the vaporizer(s), and mounting a clean circuit and artificial lung. The basic flush procedure consisted of oxygen 10 L/min with the ventilator set to a tidal volume of 600 mL at a rate of 10/min. Residual sevoflurane in the inspiratory limb of the circuit was measured using an ambient air analyzer capable of measuring sevoflurane to <1 ppm. Results were analyzed using log-linear regression of residual concentration as a function of time. This model was used to estimate the time required to achieve a desired residual anesthetic concentration. RESULTS:: Times to achieve 10 and 5 ppm in the Dräger Narkomed GS were 11 and 18 min, respectively. For the Dräger Fabius anesthesia machine, times to 10 and 5 ppm were 75 and 104 min, respectively. Several maneuvers to accelerate clearance of residual sevoflurane from the Dräger Fabius resulted in only modest reductions in these times (10 and 5 ppm times 40-50 min and 60-80 min, respectively). Insertion of an activated charcoal filter (QED®, Anecare Laboratories, Salt Lake City, UT) into the inspiratory limb of the Dräger Fabius circuit reduced the residual anesthetic concentration to <5 ppm within 10 min; this concentration was maintained for >6 h despite a fresh gas flow of only 2 L/min after the first 15 min. DISCUSSION:: Preparation of the Dräger Fabius anesthesia machine using conventional flushing techniques required almost 10 times as long as an older, conventional anesthesia machine. If a prolonged flush is impractical or impossible, we describe a procedure using an activated charcoal filter inserted on the inspiratory limb of the breathing circuit which can effectively scrub residual sevoflurane to a concentration <5 ppm within 10 min. This procedure includes an initial 5 min flush without the activated charcoal filter followed by a 5 min flush with the charcoal filter, after which the machine is ready for use in the malignant hyperthermia-susceptible patient. The charcoal filter must remain on the machine for the remainder of the anesthetic, and the fresh gas flow should be maintained ≥ 10 L/min for the first 5 min, and ≥ 2 L/min thereafter. Copyright © 2008 International Anesthesia Research Society.

Performance of certified registered nurse anesthetists and anesthesiologists in a simulation-based skills assessment

BACKGROUND:: Anesthesiologists and certified registered nurse anesthetists (CRNAs) must acquire the skills to recognize and manage a variety of acute intraoperative emergencies. A simulation-based assessment provides a useful and efficient means to evaluate these skills. In this study, we evaluated and compared the performance of board-certified anesthesiologists and CRNAs managing a set of simulated intraoperative emergencies. METHODS:: We enrolled 26 CRNAs and 35 board-certified anesthesiologists in a prospective, randomized, single-blinded study. These 61 specialists each managed 8 of 12 randomly selected, scripted, intraoperative simulation exercises. Participants were expected to recognize and initiate appropriate therapy for intraoperative events during a 5-min period. Two primary raters scored 488 simulation exercises (61 participants × 8 encounters). RESULTS:: Anesthesiologists achieved a modestly higher mean overall score than CRNAs (66.6% ± 11.7 [range = 41.7%-86.7%] vs 59.9% ± 10.2 [range = 38.3%-80.4%] P < 0.01). There were no significant differences in performance between groups on individual encounters. The raters were consistent in their identification of key actions. The reliability of the eight-scenario assessment, with two raters for each scenario, was 0.80. CONCLUSION:: Although anesthesiologists, on average, achieved a modestly higher overall score, there was marked and similar variability in both groups. This wide range suggests that certification in either discipline may not yield uniform acumen in management of simulated intraoperative emergencies. In both groups, there were practitioners who failed to diagnose and treat simulated emergencies. If this is reflective of clinical practice, it represents a patient safety concern. Simulation-based assessment provides a tool to determine the ability of practitioners to respond appropriately to clinical emergencies. If all practitioners could effectively manage these critical events, the standard of patient care and ultimately patient safety could be improved. Copyright © 2008 International Anesthesia Research Society.

What can the national quality forum tell us about performance measurement in anesthesiology?

BACKGROUND:: Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists. METHODS:: We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearinghouse for all federal performance measures, and classified all measures as follows: (1) anesthesia-specific; (2) surgery-specific; (3) jointly attributable; or (4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome, or efficiency; (2) patients, disease, and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream. RESULTS:: Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. "Anesthesia-specific" measures addressed preoperative antibiotic timing (n = 4), normothermia (n = 1), and protocol use for the placement of central venous catheter (n = 1). Jointly attributable measures included outcome measures (n = 49/67, 73.1%), which were weighted toward mortality alone (n = 24) and cardiac surgery (n = 14). Other jointly attributable measures addressed orthopedic surgery (n = 4), general surgical oncologic resections (n = 12), or nonspecified surgeries (n = 15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n = 33/67, 47%) were frequent measure stewards. CONCLUSIONS:: Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.

Anesthetic agent-specific effects on synaptic inhibition

BACKGROUND:: Anesthetics enhance γ-aminobutyric acid (GABA)-mediated inhibition in the central nervous system. Different agents have been shown to act on tonic versus synaptic GABA receptors to different degrees, but it remains unknown whether different forms of synaptic inhibition are also differentially engaged. With this in mind, we tested the hypothesis that different types of GABA-mediated synapses exhibit different anesthetic sensitivities. The present study compared effects produced by isoflurane, halothane, pentobarbital, thiopental, and propofol on paired-pulse GABAA receptor-mediated synaptic inhibition. Effects on glutamate-mediated facilitation were also studied. METHODS:: Synaptic responses were measured in rat hippocampal brain slices. Orthodromic paired-pulse stimulation was used to assess anesthetic effects on either glutamate-mediated excitatory inputs or GABA-mediated inhibitory inputs to CA1 neurons. Antidromic stimulation was used to assess anesthetic effects on CA1 background excitability. Agents were studied at equieffective concentrations for population spike depression to compare their relative degree of effect on synaptic inhibition. RESULTS:: Differing degrees of anesthetic effect on paired-pulse facilitation at excitatory glutamate synapses were evident, and blocking GABA inhibition revealed a previously unseen presynaptic action for pentobarbital. Although all 5 anesthetics depressed synaptically evoked excitation of CA1 neurons, the involvement of enhanced GABA-mediated inhibition differed considerably among agents. Single-pulse inhibition was enhanced by propofol, thiopental, and pentobarbital, but only marginally by halothane and isoflurane. In contrast, isoflurane enhanced paired-pulse inhibition strongly, as did thiopental, but propofol, pentobarbital, and halothane were less effective. CONCLUSIONS:: These observations support the idea that different GABA synapses use receptors with differing subunit compositions and that anesthetics exhibit differing degrees of selectivity for these receptors. The differing anesthetic sensitivities seen in the present study, at glutamate and GABA synapses, help explain the unique behavioral/clinical profiles produced by different classes of anesthetics and indicate that there are selective targets for new agent development. © 2014 International Anesthesia Research Society.

Influence of provider type (Nurse Anesthetist or Resident Physician), staff assignments, and other covariates on daily evaluations of anesthesiologists' quality of supervision

BACKGROUND:: At many U.S. healthcare facilities, supervision of anesthesiology residents and/or Certified Registered Nurse Anesthetists (CRNAs) is a major daily responsibility of anesthesiologists. Our department implemented a daily process by which the supervision provided by each anesthesiologist working in operating rooms was evaluated by the anesthesiology resident(s) and CRNA(s) with whom they worked the previous day. METHODS:: Requests for evaluation were sent daily via e-mail to each resident and CRNA after working in an operating room. Supervision scores were analyzed after 6 months, and aligned with the cases' American Society of Anesthesiologists Relative Value Guide units. RESULTS:: (1) Mean monthly evaluation completion rates exceeded 85% (residents P = 0.0001, CRNAs P = 0.0005). (2) Pairwise by anesthesiologist, residents and CRNAs mean supervision scores were correlated (P < 0.0001), but residents assigned greater scores than did CRNAs (P < 0.0001). The pairwise differences between residents and CRNAs were heterogeneous among anesthesiologists (P < 0.0001). (3) Anesthesiologist supervision scores provided by residents were: (a) greater when a resident had more units of work that day with the rated anesthesiologist (P < 0.0001), and (b) less when the anesthesiologist had more units of work that same day with other providers (P < 0.0001). However, the relationships were unimportantly small, Kendall τb = +0.083 ± 0.014 (SE) and τb = -0.057 ± 0.014, respectively. The correlations were even less among the CRNAs, τb = -0.029 ± 0.013 and τb = -0.004 ± 0.012, respectively. (4) There also was unimportantly small association between a resident's or CRNA's mean score for an anesthesiologist and the number of days worked together (τb = -0.069 ± 0.023 and τb = +0.038 ± 0.020, respectively). CONCLUSIONS:: Although the attributes that residents and CRNA perceive as constituting "supervision" significantly share commonalities, supervision scores should be analyzed separately for residents and CRNAs. Although mean supervision scores differ markedly among anesthesiologists, supervision scores are influenced negligibly by staff assignments (e.g., how busy the anesthesiologist is with other operating rooms). © 2014 International Anesthesia Research Society.

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: Results from the israeli board of anesthesiologists

BACKGROUND:: Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. The candidates represent a unique national cohort in which we were able to assess competence in the simulated scenario of cardiorespiratory arrest in the parturient. METHODS: A simulated scenario of preeclampsia with magnesium toxicity leading to cardiac arrest in a pregnant patient was performed by 25 senior anesthesiology residents. A unique two-stage simulation examination consisting of high fidelity simulation followed immediately by oral debriefing was conducted. The assessment was scored using a predetermined checklist of key actions and answers to clarifying questions. Simulation performance was compared to debriefing performance. RESULTS: During the board examination, resuscitation not specific to the pregnant patient was performed well (commencing chest compressions, bag-mask ventilation, cardiac defibrillation); however actions specific to the parturient were performed poorly. Left uterine displacement, cricoid pressure during bag-mask ventilation, and instructing preparations to be made for perimortem cesarean delivery within 5 minutes were performed by 68%, 48%, and 40% of candidates respectively (lower 99% confidence limit 42%, 25%, and 19%, respectively). Cricoid pressure during bag-mask ventilation was performed by 48% (25%) but described in debriefing by 80% of candidates (53%) (P = 0.08), and time setting for perimortem cesarean delivery was performed by 40% (29%) but described by 80% (53%) (P = 0.05) of examinees. CONCLUSIONS: Senior anesthesiology residents have poor knowledge of resuscitation of the pregnant patient. The results suggest 2-stage simulation including an oral component may reveal disparities in knowledge not assessed by simulation alone, but definitive conclusions require further study. Copyright © 2012 International Anesthesia Research Society.

Evaluating the long-term retention of a multidisciplinary electroencephalography instructional model

BACKGROUND:: Clinical decision making and problem solving require a core of basic factual knowledge that must be accessed sometimes months or years after it has been learned. We examined whether 10 compared with 20 total electroencephalogram (EEG) interpretations impacted scores for long-term retention with the residents in the 20 total EEG group assessed with additional examinations. METHODS:: Study participants interpreted 10 (10 EEG group) or 20 (20 EEG group) EEGs during a month rotation. Using a 25-item evaluation tool, participants were assessed before any EEG interpretations and were reassessed with another 25-item assessment tool after 10 EEG interpretations with the neurophysiologist. The 20 EEG group also received unique 25-item assessments after 15 and 20 EEG interpretations. Long-term retention was assessed with a 40-item evaluation tool targeted for administration 12 months after the curriculum. The assessments were unique for the specific time points studied (baseline, after 10 EEG interpretations, after 15 EEG interpretations, after 20 EEG interpretations, and long term); all participants completed the same assessment tool for each specific time point assessed during the study. The assessment tools evaluated knowledge of EEG monitoring, anesthetic effects, and clinical EEG interpretation. RESULTS:: Twenty anesthesiology residents completed the study with each group consisting of 10 residents. The mean scores represent the percentage of correct items, and for the 10 EEG group, the mean scores went from 42.8% ± 14.4% at baseline to 63.2% ± 8.0% (P < 0.001) after 10 EEG interpretations; however, there was no statistically significant difference noted from baseline to long-term retention 6.9% ± 9.0% (P = 0.78). Mean scores for the 20 EEG group improved from 34.4% ± 9.7% at baseline to 63.2% ± 6.2% (P < 0.001) after 10 EEGs and 62.3% ± 9.3% (P < 0.001) for long-term retention. Using a mixed model analysis, the only difference between the 10 and 20 EEG groups involved long-term retention with a total of 20 EEG interpretations compared with 10 (P = 0.006); there were no statistical differences between the groups at baseline (P = 0.065) or after 10 EEG interpretations (P = 1.00). DISCUSSION:: Long-term retention was significantly improved after 20 compared with 10 EEG interpretations as evaluated by the assessment tools. Potential reasons for better long-term retention may relate to the total number of EEG interpretations with 2 additional spaced interval opportunities and evaluations reinforcing learning. © 2013 International Anesthesia Research Society.

Rescheduling of previously cancelled surgical cases does not increase variability in operating room workload when cases are scheduled based on maximizing efficiency of use of operating room time

BACKGROUND:: Conceptually, cancelling a case close to the scheduled day of surgery increases variability in operating room (OR) workload (i.e., total hours of scheduled cases plus turnovers), creating managerial problems. However, in our recent study of an OR scheduling office, cancellations (slightly) reduced variability in workload among days. If a relatively low incidence of cancellations does not cause increased variability in workload, this would be a useful finding when focusing strategic OR management initiatives. However, the previous study considered only the effect on the schedule for the day the cancelled case originally was scheduled to be performed, not the future date on which the case was performed. METHODS:: For 90% of cancelled cases, the patient later underwent the same or a similar procedure at the studied hospital. Thus, the OR schedule at 7:00 AM each day over 2 years could be used to study case rescheduling. The primary end point, calculated for each surgeon, was the difference of 2 ratios. The first ratio was the proportion of scheduled workload attributable to previously cancelled cases, among all days for which the surgeon's workload exceeded the surgeon's median workload. The second ratio was that proportion among the other days when the surgeon performed at least 1 case. Means ± SEMs were calculated by random effects analysis, stratified by surgeon. RESULTS:: From 7:00 AM the working day before surgery through the day of surgery, 9.7% ± 0.6% of scheduled OR hours and 9.7% ± 0.5% of cases were cancelled. Among cases performed, 9.5% ± 0.5% of the scheduled hours and 9.5% ± 0.5% of the cases were previously cancelled (i.e., rescheduled to a later date and then performed). Surgeons' median workloads on days with at least 1 case were 8.3 ± 0.2 hours. The percentage of scheduled workload attributable to rescheduled cases was slightly less on days when the surgeon had larger than median workloads (-0.7% ± 0.3%, P = 0.022). CONCLUSIONS:: Rescheduled cancelled cases did not increase variability in OR workload. This finding is useful combined with our recent finding that cancellation slightly reduces variability in OR workload on the date of cancellation. Cancellations should not be interpreted as a system failure that increases variability in surgical workload. We recommend that anesthesiologists aim to reduce cancellation rates if above benchmarked averages, but otherwise focus on more strategically beneficial initiatives. We recommend also that these results be considered if cancellation rates are used in assessing anesthesiology group performance. © 2013 International Anesthesia Research Society.

Oxygen consumption of a pneumatically controlled ventilator in a field anesthesia machine

BACKGROUND:: Field anesthesia machines (FAM) have been developed for remote locations where reliable supplies of compressed medical gases or electricity may be absent. In place of electricity, pneumatically controlled ventilators use compressed gas to power timing circuitry and actuate valves. We sought to determine the total O2 consumption and ventilator gas consumption (drive gas [DG] plus pneumatic control [PC] gas) of a FAM's pneumatically controlled ventilator in mechanical models of high (HC) and low (LC) total thoracic compliance. METHODS:: The amount of total O2 consumed by the Magellan-2200 (Oceanic Medical Products, Atchison, KS) FAM with pneumatically controlled ventilator was calculated using the ideal gas law and the measured mass of O2 consumed from E cylinders. DG to the bellows canister assembly was measured with the Wright Respirometer Mk 8 (Ferraris Respiratory Europe, Hertford, UK). PC gas consumption was calculated by subtracting DG and fresh gas flow (FGF) from the total O2 consumed from the E cylinder. The delivered tidal volume (VT) was measured with a pneumotach (Hans Rudolph, KS City, MO). Three different VT were tested (500, 750, and 1000 mL) with two lung models (HC and LC) using the Vent Aid Training Test Lung (MI Instruments, Grand Rapids, MI). Respiratory variables included an I:E of 1:2, FGF of 1 L/min, and respiratory rate of 10 breaths/min. RESULTS:: Total O2 consumption was directly proportional to VT and inversely proportional to compliance. The smallest total O2 consumption rate (including FGF) was 9.3 ± 0.4 L/min in the HC-500 model and the largest was 15.9 ± 0.5 L/min in the LC-1000 model (P < 0.001). The mean PC circuitry consumption was 3.9 ± 0.24 L/min or 390 mL ± 24 mL/breath. CONCLUSIONS:: To prepare for loss of central DG supply, patient safety will be improved by estimating cylinder duration for low total thoracic compliance. Using data from the smaller compliance and greatest VT model (LC-1000), a full O2 E cylinder would be depleted in <42 min, whereas a full H cylinder would last approximately 433 min. Copyright © 2008 International Anesthesia Research Society.

Operating room nursing directors' influence on anesthesia group operating room productivity

BACKGROUND:: Implementation of initiatives to increase anesthesia group productivity depends not just on anesthesia groups, but on operating room (OR) nursing administration. OR nursing directors may encourage organizational change based on the needs of their hospitals and nurses. These changes may differ from those that would increase the anesthesia group's productivity. We assessed reward structures using (A) letters of nomination for the "OR Manager of the Year" award offered annually by the publication OR Manager, and (B) data from a salary/career survey of OR directors by the same publication. METHODS:: (A) There were 164 nomination letters submitted from 2004 through 2007 for 45 nominees. The letters contained n = 2659 full sentences and n = 50,821 words. We systematically created a list of 36 terms related to finance, profit, and productivity. We also analyzed the frequency of use of these terms relative to the use of the 15 most common relationship-oriented terms (e.g., compassion, encourage, mentor, and respect). (B) The salary/career survey's questions relevant to anesthesia group productivity had responses from 303 US OR directors, 97% of whom were nurses. We tested the strength of the relationship between the budget responsibility of the OR nursing director and his or her annual salary. RESULTS:: (A) 2.6% of sentences in the nomination letters included at least one term related to profit and productivity (95% confidence interval 2.0%-3.2%). Relationship-oriented terms were 9.0 times more prevalent (95% confidence interval 7.1-11.4). (B) There was statistically significant positive proportionality between the OR nursing director's operational budget (including personnel) and his or her salary (Pearson r = 0.64, P < 0.001). The 10th percentile of the operational budget was $1 million and the 90th percentile was $36 million. The budget of $1 million was associated with a salary 22% less than the median and the budget of $36 million was associated with a salary 22% larger than the median. CONCLUSION:: Through (A) organizational constituencies, and (B) compensation, many US OR nursing directors likely are encouraged to enhance relations with nursing staff, not to champion organizational initiatives that would reduce under-utilized OR time and OR nursing labor costs. Resulting decisions can differ from those that would increase the productivity (profit) of the anesthesia group. Anesthesia groups need to champion initiatives to increase anesthesia productivity, while being sensitive to institutional expectations of nursing directors. Copyright © 2008 International Anesthesia Research Society.

Six-year follow-up on work force and finances of the United States anesthesiology training programs: 2000 to 2006

BACKGROUND:: In the mid 1990s, interest in the field of anesthesiology decreased significantly among medical students, resulting in a decreasing resident class size and, subsequently, fewer anesthesiologists entering the United States workforce. This apparent practitioner shortage was associated with increased salary demands, which placed anesthesiology training departments in financial jeopardy. Starting in 1999, a survey was sent to the department chairs of the United States anesthesiology training programs to assess the status of faculty and finances of their departments. Follow-up surveys have been conducted each year thereafter. We present the results of the 2006 survey and 7 yr trend data. METHODS:: Surveys were distributed by e-mail in September 2006 to anesthesiology department chairs of the United States training programs. The responses were received by e-mail. Descriptive statistics were performed on responder data. In addition, a linear regression model to predict institutional support was developed. RESULTS:: One-hundred-eighteen departments were surveyed with a response rate of 61%. There were an average of 4 open faculty positions in the 71% of the departments reporting open faculty positions. This would imply an overall 5% open position rate, down from 10% in 2000. Of the 96% of departments who employ certified registered nurse anesthetists, 70% had an average of 4 open positions, or approximately 11% shortage. The average department received $5,500,000 in total institutional support annually ($120,000/faculty). When the portion of this support provided for certified registered nurse anesthetists was removed, the average amount received was $4,600,000 or $100,000/faculty. This is a 10% increase over the previous year and an approximate 300% increase over the year 2000. Faculty academic time averaged 18% (where 20% is 1 day per week). The departments billed an average of 12,200 U/faculty/year. The average anesthesia unit value collected was $31/unit, while departments would require $46/unit to meet expenses. In a linear regression model, clinical revenue per unit billed minus expenses per unit billed predicted faculty support per fulltime equivalent. CONCLUSION:: This current survey reveals a continuing need for institutional support to keep anesthesiology training departments financially solvent. The amount of support is associated with the reimbursement for anesthesia work. There is also a continuing, but decreasing, number of open faculty anesthesiologist positions nationwide. Copyright © 2008 International Anesthesia Research Society.

Adoption of anesthesia information management systems by academic departments in the United States

BACKGROUND:: Information technology has been promoted as a way to improve patient care and outcomes. Whereas information technology systems for ancillary hospital services (e.g., radiology, pharmacy) are deployed commonly, it has been estimated that anesthesia information management systems (AIMS) are only installed in a small fraction of United States (US) operating rooms. In this study, we assessed the adoption of AIMS at academic anesthesia departments and explored the motivations for and resistance to AIMS adoption. METHODS:: Members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors were solicited by e-mail to participate in an online survey of AIMS adoption. Two months after closing the survey, another e-mail was sent with a single question asking for an update to their AIMS implementation status. RESULTS:: Surveys were fully completed by 48 (34%) of the 140 Society of Academic Anesthesiology Chairs and Association of Anesthesiology Program Directors departments surveyed, with 72 (51%) providing AIMS status information. Twenty of these 72 departments have an AIMS installed, 12 are currently implementing, 11 have selected but not yet installed, and 18 are planning to purchase an AIMS in 2008 or 2009. Therefore, at least 61 (44%) of all 140 US academic anesthesia departments have committed to AIMS. This estimated adoption rate is conservative because the numerator equals the affirmative responses, whereas the denominator equals the total population of academic departments. Among adopters, the top ranked anticipated benefits from installing an AIMS included improved clinical documentation, improved data collection for clinical research, enhancement of quality improvement programs, and compliance with requirements of regulatory authorities. The hospital provided funding in almost all facilities (90%), with co-funding by the anesthesia group in 35%. CONCLUSIONS:: At least 61 or 44% of the 140 US academic departments surveyed in this study have already implemented, are planning to acquire, or are currently searching for an AIMS. Adoption of AIMS technology appears to have reached sufficient momentum within academic anesthesiology departments to result in a fundamental change. © 2008 International Anesthesia Research Society.

Examination of publications from academic anesthesiology faculty in the United States

BACKGROUND:: Leaders in academic anesthesiology in the United States have called for an examination of the state of scholarship within anesthesiology departments. National Institutes of Health funding and publication quality of subsets of U.S anesthesiologists have been examined; however, the publication output of and the demographic characteristics that are associated with academic anesthesiologists, defined as faculty associated with a medical college, are unknown. A database from the American Association of Medical Colleges containing demographic information of all academic anesthesiologists in the United States was used to examine the publication output and demographic characteristics of anesthesiology faculty during a 2-year period from 2006 to 2008. METHOD:: All the publications found in the PubMed database for each faculty member were retrieved and included in a database containing their demographics including institution, gender, academic degree, academic rank, nature of appointment (part versus full-time), status of appointment (joint versus primary), departmental division, subspecialty certification status, and additional graduate medical education training. RESULTS:: Six thousand one hundred forty-three faculty who held positions at the 108 U.S. academic anesthesiology programs published 8521 manuscripts between 2006 and 2008. Thirty-seven percent of faculty published a manuscript, and the overall median publication rate was 0. The proportion of faculty with at least 1 publication was larger among faculty with higher rank (Odds Ratio [OR] for professors versus instructors = 6.4; confidence interval [CI], 4.57-8.49; P < 0.0001), male gender (OR 1.3; CI, 0.14-1.47; P < 0.0001), possessing a courtesy appointment status (OR 2.1; CI, 1.25-3.52; P = 0.0048) and lacking postgraduate training and subspecialty certification (OR for MD versus MD w/training + certification 1.3; CI, 1.11-1.60; P = 0.0020). Those faculty with an MD had lower probablility of publishing when compared with MD/PhD or PhD faculty (OR 0.45; CI, 0.32-0.65; P < 0.0001; OR 0.27; CI, 0.20-0.37; P < 0.0001, respectively). Within the group of faculty who published at least 1 paper, full professor faculty had 3.8 times more publications than instructors (CI, 2.99-4.88; P < 0.0001), and those who lacked postgraduate training had 1.4 times more publications than those who were trained and certified (CI, 1.16-1.78; P = 0.0009). PhD degree (P = 0.006), male gender (P = 0.013), and courtesy anesthesia appointment (P = 0.037) also were associated with higher publication rates. CONCLUSIONS:: The overall publication rate of anesthesiologists associated with medical schools was low in this time period. These data establish the pre-"call to action" baseline of scholarly activity by U.S. academic anesthesiologists for future comparisons. Increased use of structured resident and fellow research education programs as well as recruiting more MD/PhD and PhD scientists to the field may help to improve the publication productivity of academic anesthesiology departments. © 2013 International Anesthesia Research Society.

Noble gas binding to human serum albumin using docking simulation: Nonimmobilizers and anesthetics bind to different sites

BACKGROUND:: Nonimmobilizers are structurally similar to anesthetics, but do not produce anesthesia at clinically relevant concentrations. Xenon, krypton, and argon are anesthetics, whereas neon and helium are nonimmobilizers. The structures of noble gases with anesthetics or nonimmobilizers are similar and their interactions are simple. Whether the binding site of anesthetics differs from that of nonimmobilizers has long been a question in molecular anesthesiology. METHODS:: We investigated the binding sites and energies of anesthetic and nonimmobilizer noble gases in human serum albumin (HSA) because the 3D structure of HSA is well known and it has an anesthetic binding site. The computational docking simulation we used searches for binding sites and calculates the binding energy for small molecules and a template molecule. RESULTS:: Xenon, krypton, and argon were found to bind to the enflurane binding site of HSA, whereas neon and helium were found to bind to sites different from the xenon binding site. Rare gas anesthetic binding was dominated by van der Waals energy, while nonimmobilizer binding was dominated by solvent-effect energy. Binding site preference was determined by the ratios of local binding energy (van der Waals energy) and nonspecific binding energy (solvent-effect energy) to the total binding energy. van der Waals energy dominance is necessary for anesthetic binding. CONCLUSIONS:: This analysis of binding energy components provides a rationale for the binding site difference of anesthetics and nonimmobilizers, reveals the differences between the binding interactions of anesthetics and nonimmobilizers, may explain pharmacological differences between anesthetics and nonimmobilizers, and provide an understanding of anesthetic action at the atomic level. © 2008 International Anesthesia Research Society.

The importance of subjective facial appearance on the ability of anesthesiologists to predict difficult intubation

BACKGROUND:: Previously we demonstrated that a computer algorithm based on bedside airway examinations and facial photographs accurately classified easy and difficult airways. The extent of the ability of anesthesiologists to perform the same task is unknown. We hypothesized that providing photographs would add to the predictive ability of anesthesiologists over that achieved when provided only with the Mallampati (MP) score and the thyromental distance (TMD). We further hypothesized that human observers would implicitly bias their predictions toward more sensitive determination of difficult airways, rather than more specific determination of easy airways. METHODS:: Residents, fellows, and attending anesthesiologists with varying levels of experience (N = 160) were presented with MP and TMD information from 80 Caucasian men subjects. The same subjects' data, accompanied by 3 facial photographs in head-on and right and left profiles, were also presented. Anesthesiologists classified the airways as easy or difficult according to specified criteria ("easy" defined as a single attempt with a Macintosh 3 blade resulting in a grade 1 laryngoscopic view; "difficult" defined as >1 attempt by an operator with at least 12 months anesthesia experience, grade 3 or 4 laryngoscopic view, need for a second operator, or nonelective use of an alternative airway device). Accuracy, sensitivity, and specificity were calculated for each anesthesiologist. We further developed a cost function to quantify a relative bias toward avoiding an unexpectedly difficult intubation versus overpreparing for an easy intubation. RESULTS:: One hundred sixty respondents completed the study. Presenting photographs improved respondents' sensitivity and accuracy in classifying airways, though specificity decreased slightly. Overall accuracy when given photographs was 61.6% (95% confidence interval, 60.8%-62.4%), which was significantly lower than the computer's performance of 87.5% (t test, P < 0.0001). Presentation of photographs, compared with MP and TMD alone, caused anesthesiologists to change their prediction from easy to difficult more frequently if the patients were obese (weight or body mass index), despite not having data on weight or height available. The cost function demonstrated that anesthesiologists strongly preferred to enhance sensitivity (detecting difficult airways) as compared with specificity (detecting easy airways), with a ratio of 6.5:1 (95% confidence interval, 4.9:1-8.4:1). CONCLUSIONS:: Anesthesiologists can derive useful information from facial appearance that enhances the prediction of a difficult airway over that achieved when presented with MP and TMD data alone. Anesthesiologists implicitly bias their predictions toward detection of difficult airways, compared with the true incidence of difficult airways, at the expense of accuracy and specificity. This behavior may be rational for cognitive tasks in which the costs of failure are strongly asymmetric. © 2013 International Anesthesia Research Society.

Academic productivity of directors of ACGME-Accredited residency programs in surgery and anesthesiology

BACKGROUND:: Scholarly activity is expected of program directors of Accreditation Council for Graduate Medical Education (ACGME)-accredited residency training programs. Anesthesiology residency programs are cited more often than surgical programs for deficiencies in academic productivity. We hypothesized that this may in part reflect differences in scholarly activity between program directors of anesthesiology and surgical trainings programs. To test the hypothesis, we examined the career track record of current program directors of ACGME-accredited anesthesiology and surgical residency programs at the same institutions using PubMed citations and funding from the National Institutes of Health (NIH) as metrics of scholarly activity. METHODS:: Between November 1, 2011 and December 31, 2011, we obtained data from publicly available Web sites on program directors at 127 institutions that had ACGME-accredited programs in both anesthesiology and surgery. Information gathered on each individual included year of board certification, year first appointed program director, academic rank, history of NIH grant funding, and number of PubMed citations. We also calculated the h-index for a randomly selected subset of 25 institution-matched program directors. RESULTS:: There were no differences between the groups in number of years since board certification (P = 0.42), academic rank (P = 0.38), or years as a program director (P = 0.22). However, program directors in anesthesiology had less prior or current NIH funding (P = 0.002), fewer total and education-related PubMed citations (both P < 0.001), and a lower h-index (P = 0.001) than surgery program directors. Multivariate analysis revealed that the publication rate for anesthesiology program directors was 43% (95% confidence interval, 0.31-0.58) that of the corresponding program directors of surgical residency programs, holding other variables constant. CONCLUSIONS:: Program directors of anesthesiology residency programs have considerably less scholarly activity in terms of peer-reviewed publications and federal research funding than directors of surgical residency programs. As such, this study provides further evidence for a systemic weakness in the scholarly fabric of academic anesthesiology. © 2013 International Anesthesia Research Society.

The ability of anesthesia providers to visually estimate systolic pressure variability using the "eyeball" technique

BACKGROUND:: Systemic arterial respiratory variation has been shown to be a reliable predictor of changes in cardiac output after fluid administration. Arterial respiratory variation is often estimated from visual examination of the arterial waveform tracing. Our goal in this study was to assess the ability of anesthesia providers to visually estimate systolic pressure variation (SPV) as a percentage of systolic blood pressure (SPV). METHODS:: Fifty anesthesia providers were recruited and asked to visually examine 10 recorded arterial waveform tracings (played in real time), to estimate SPV, and to state whether or not a fluid bolus was indicated. After completion of the examination, the participants were shown the original tracings, the true value for SPV, and their estimate. The percentage of incorrect physician decisions to administer or not administer additional fluid was analyzed using a binomial proportion confidence interval. Clinical utility was also assessed using clinical significance analysis. Limits of agreement were analyzed using the nonparametric approach recommended by Bland and Altman. RESULTS:: The mean bias was +1.2%. The nonparametric limits of agreement were-5.1 and 7.5%, and contained 82% of values. Actual physician decisions were incorrect 4.4% of the time (95% confidence interval [CI] 2.8% to 6.6%). On the basis of the clinical significance analysis, only 1% of treatments based on the visual estimation would have been incorrect. CONCLUSION:: Visual estimates of respiratory variation are within clinically reasonable limits 82% of the time and lead to erroneous management decisions in 4.4% of measurements. Copyright © 2012 International Anesthesia Research Society.

Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills

BACKGROUND:: The clinical utility of focused transthoracic echocardiography (TTE) is increasingly recognized in perioperative medicine. However its use is limited among anesthesiologists because of a lack of training. The most efficient training methods have not been determined. We hypothesized that simulation-based TTE training would be more effective than traditional lecture-based methods for teaching basic TTE skills to the anesthesiology residents. METHODS:: In this prospective randomized study, 61 anesthesiology residents (in anesthesia clinical training years 1 to 3) were randomized to either control (n = 30) or simulation groups (n = 31) for TTE training. A standardized pretest was administered before TTE training sessions of 45 minutes each. The first training session used a lecture-based video didactic in the control group or a TTE simulator in the simulation group. Comprehension in both groups was then assessed using a written posttest and by performing a TTE examination on a volunteer subject. TTE examinations were graded on the ability to acquire the correct image, image quality, anatomy identification, and time required to attain proper imaging by 2 blinded experts. A second training session incorporating "hands-on" training with a volunteer subject was conducted in a subset of 21 residents (n = 11 control, n = 10 simulation). The simulation group included additional simulator training. After the second session, another posttest on a volunteer subject was administered. RESULTS:: Pretest scores revealed similar preintervention knowledge among residents (56.0% ± 11.9% vs 59.3% ± 11.0%, P = 0.25; control versus simulator group, respectively). The simulation group scored higher on all criteria after the first training session: written posttest (57.9% ± 8.8% vs 68.2% ± 10.1%; P < 0.001), volunteer subject posttest image quality scores (0 to 25 scale) (6.4 ± 3.5 vs 12.4 ± 4.2; P = 0.003), anatomy identification scores (0 to 25 scale) (8.3 ± 6.6 vs 17.8 ± 6.6; P = 0.003), and percentage correct views (50 ± 19 vs 78 ± 21; P < 0.001). After the second session, all scores were again improved in the simulation group: volunteer subject posttest image quality scores (9.6 ± 3.3 vs 15.6 ± 2.8; P = 0.002), anatomy identification scores: (17.6 ± 3.8 vs 22.8 2.4; P = 0.003), and percentage correct views (80 ± 16 vs 96 ± 8; P = 0.007). DISCUSSION:: This prospective randomized study demonstrated that anesthesiology residents trained with simulation acquired better skills in TTE image acquisition and anatomy identification on volunteer subjects. The educational benefit of simulation persisted even with introduction of hands-on instruction with volunteer subjects in both groups. The impact of these short-term educational approaches on longer-term retention and actual clinical application warrants further investigation. Copyright © 2012 International Anesthesia Research Society.

Status of anesthesiology resident research education in the United States: Structured education programs increase resident research productivity

BACKGROUND:: The enhancement of resident research education has been proposed to increase the number of academic anesthesiologists with the skills and knowledge to conduct meaningful research. Program directors (PDs) of the U.S. anesthesiology residency programs were surveyed to evaluate the status of research education during residency training and to test the hypothesis that structured programs result in greater resident research productivity based on resident publications. METHODS:: Survey responses were solicited from 131 anesthesiology residency PDs. Seventy-four percent of PDs responded to the survey. Questions evaluated department demographic information, the extent of faculty research activity, research resources and research funding in the department, the characteristics of resident research education and resident research productivity, departmental support for resident research, and perceived barriers to resident research education. RESULTS:: Thirty-two percent of programs had a structured resident research education program. Structured programs were more likely to be curriculum based, require resident participation in a research project, and provide specific training in presentation and writing skills. Productivity expectations were similar between structured and nonstructured programs. Forty percent of structured programs had > 20% of trainees with a publication in the last 2 years compared with 14% of departments with unstructured programs (difference, 26%; 99% confidence interval [CI], 8%-51%; P = 0.01). The percentage of programs that had research rotations for 2 months was not different between the structured and the nonstructured programs. A research rotation of >2 months did not increase the percentage of residents who had published an article within the last 2 months compared with a research rotation of <2 months (difference, 13%; 99% CI, 10%-37%; P = 0.14). There was no difference in the percentage of faculty involved in research in structured compared with unstructured research education. In programs with <20% of faculty involved in research, 15% reported >20% of residents with a publication in the last 2 years compared with 36% in programs with >20% of faculty involvement (difference, 21%; 99% CI, -4% to 46%; P = 0.03). CONCLUSIONS:: Our findings suggest that structured residency research programs are associated with higher resident research productivity. The program duration and the fraction of faculty in resident research education did not significantly increase research productivity. Research training is an integral component of resident education, but the mandatory enhancement of resident research education will require a significant change in the culture of academic anesthesiology leadership and faculty. Copyright © 2012 International Anesthesia Research Society.

The learning curve associated with the epidural technique using the Episure™ AutoDetect™ versus conventional glass syringe: An open-label, randomized, controlled, crossover trial of experienced anesthesiologists in obstetric patients

BACKGROUND:: The Episure™ AutoDetect™ (spring-loaded) syringe has been observed to successfully identify the epidural space in 2 pilot studies. In this study we evaluated the impact of the spring-loaded syringe on the establishment of successful epidural labor analgesia (primary outcome), elapsed time for catheter placement, and learning curve (cumulative summary analysis, i.e., Cusum) of experienced anesthesiologists. METHODS:: Fourteen attending and fellow anesthesiologists were randomized to perform 50 consecutive epidural technique attempts using a spring-loaded or conventional glass syringe. Ten participants completed an additional 50 attempts with the alternate syringe in a crossover design. RESULTS:: A total of 1200 epidural placement attempts were performed. Use of the spring-loaded syringe was associated with a nonsignificant difference of estimated success rate in obtaining analgesia success (absolute difference of 1.0% 95% confidence interval, CI: -8.9% to 10.8%), shorter elapsed mean time to epidural catheter placement (ratio of 0.92 95% CI, 0.89-0.96); P = 0.003) and similar Cusum curves when compared with a conventional glass syringe. Analgesia success was more common with attending versus fellow anesthesiologists (absolute difference of 34.6% 95% CI, 14.9% to 54.3%; P < 0.001), and when the initial preferred technique was loss-of-resistance to continuous saline versus intermittent air (absolute difference of 33.8% 95% CI, 12.6% to 55.0%; P < 0.001). Shorter elapsed mean times were also observed in the group exposed to the spring-loaded syringe first (ratio of 0.65 95% CI, 0.62-0.67; P = 0.02). CONCLUSIONS:: When used by experienced obstetric anesthesiologists, the spring-loaded syringe was associated with a similar overall rate for establishing successful epidural labor analgesia, a shorter elapsed time to epidural catheter insertion, particularly when the anesthesiologist was randomized to use the novel syringe first, and a similar Cusum curve when compared with a conventional glass syringe. Attending versus fellow anesthesiologists and an initial technique preference for loss-of-resistance to continuous saline were associated with greater analgesia success with the novel syringe. Copyright © 2012 International Anesthesia Research Society.

Subspecialty impact factors: The contribution of pediatric anesthesia and pain articles

BACKGROUND:: The Science Citation Index "Journal Impact Factor" (JIF) is widely used to assess journal quality and prestige. The JIFs for the specialty anesthesia are reported annually, however, the impact factors (IFs) for subspecialties in those journals have not been reported. Therefore, we compared the IFs of pediatric anesthesia (Ped IFs) and pain (Pain IFs) articles from four anesthesia journals for two epochs. METHODS:: An article-by-article manual search for "source" pediatric anesthesia and pain articles published in 1998, 1999, 2003, and 2004 in Anesthesiology, Anesthesia & Analgesia, British Journal of Anaesthesia, and Canadian Journal of Anesthesia was performed. The citations for each of these articles in each of the years were surveyed in the ISI Web of Science database. Ped IFs and Pain IFs for the 2000 and 2005 epochs were calculated and compared with the JIF from which they were derived and to those of the journal, Pediatric Anesthesia. RESULTS:: Ped IFs for the four journals in 2005 exceeded those in 2000, whereas the Pain IFs were unchanged. For both the Ped IFs and the Pain IFs, there was a significant effect of the journal. The Pain IFs were 70% greater than the Ped IFs. CONCLUSIONS:: Ped IFs were consistently less than the JIFs in which they were published and the Pain IFs, except for the British Journal of Anaesthesia 2005 in the latter case. The numbers of citations of pediatric anesthesia articles were greater in journals with greater IFs. The implications of subspecialty IFs warrant further consideration. Copyright © 2008 International Anesthesia Research Society.

The influence of head and neck position on the oropharyngeal leak pressure and cuff position of three supraglottic airway devices

BACKGROUND:: With supraglottic airway devices, such as the laryngeal tube suction (LTS), ProSeal laryngeal mask airway (PLMA) and Cobra perilaryngeal airway (CobraPLA), oropharyngeal leak pressure or cuff position may vary according to changes in the position of the head and neck. We evaluated oropharyngeal leak pressure and cuff pressure of the PLMA, LTS, and CobraPLA in different head and neck positions. METHODS:: One-hundred-thirty-nine patients (aged 18-70 yr) scheduled for minor surgical procedures were randomly allocated to one of the supraglottic airway devices. Oropharyngeal leak pressure and cuff pressure were evaluated in four head and neck positions: neutral, 45° of flexion, 45° of extension, and 45° of right rotation. Adverse events (i.e., difficulty in ventilation or gastric insufflation) were assessed during the study. RESULTS:: Leak pressures of the PLMA were lowest in the extension (18.5 vs 23.9 and 26.8 cm H2O of LTS and CobraPLA, respectively; P < 0.001) and in the rotation position (25.0 vs 29.4 and 28.5 cm H2O of LTS and CobraPLA, respectively; P < 0.005). With the CobraPLA, gastric insufflations occurred before the oropharyngeal leak in 37 of 45 patients. There were ventilatory difficulties in seven patients with LTS after neck flexion, which required tracheal intubation. CONCLUSIONS:: The PLMA showed significantly lower oropharyngeal leak pressures than did the LTS or CobraPLA in the neck extension and rotation positions. Caution is warranted when changing the position of the head and neck when using the Cobra-PLA or LTS as gastric insufflation or ventilatory difficulty may occur. Copyright © 2008 International Anesthesia Research Society.

Financial and environmental costs of reusable and single-use anaesthetic equipment

Background. An innovative approach to choosing hospital equipment is to consider the environmental costs in addition to other costs and benefits. Methods. We used life cycle assessment to model the environmental and financial costs of different scenarios of replacing reusable anaesthetic equipment with single-use variants. The primary environmental costs were CO2 emissions (in CO2 equivalents) and water use (in litres). We compared energy source mixes between Australia, the UK/Europe, and the USA. Results. For an Australian hospital with six operating rooms, the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment would be an AUD$32 033 (£19 220), 46% decrease. In Australia, converting from single-use to reusable equipment would result in an increase of CO2 emissions from 5095 (95% CI: 4614-5658) to 5575 kg CO2 eq (95% CI: 5542-5608), a 480 kg CO2 eq (9%) increase. Using the UK/European power mix, converting from single-use (5575 kg CO2 eq) to reusable anaesthetic equipment (802 kg CO2 eq) would result in an 84% reduction (4873 kg CO2 eq) in CO2 emissions, whilst in the USA converting to reusables would have led to a 2427 kg CO2 eq (48%) reduction. In Australia, converting from single-use to reusable equipment would more than double water use from 34.4 to 90.6 kilolitres. Conclusions. For an Australian hospital with six operating rooms, converting from single-use to reusable anaesthetic equipment saved more than AUD$30 000 (£18 000) per annum, but increased the CO2 emissions by almost 10%. The CO2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment. © 2017 The Author.

Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone

Background. Anaesthesia care in developed countries involves sophisticated technology and experienced providers. However, advanced machines may be inoperable or fail frequently when placed into the austere medical environment of a developing country. Failure mode and effects analysis (FMEA) is a method for engaging local staff in identifying real or potential breakdowns in processes or work systems and to develop strategies to mitigate risks. Methods. Nurse anaesthetists from the two tertiary care hospitals in Freetown, Sierra Leone, participated in three sessions moderated by a human factors specialist and an anaesthesiologist. Sessions were audio recorded, and group discussion graphically mapped by the session facilitator for analysis and commentary. These sessions sought to identify potential barriers to implementing an anaesthesia machine designed for austere medical environments-the universal anaesthesia machine (UAM)-and also engaging local nurse anaesthetists in identifying potential solutions to these barriers. Results. Participating Sierra Leonean clinicians identified five main categories of failure modes (resource availability, environmental issues, staff knowledge and attitudes, and workload and staffing issues) and four categories of mitigation strategies (resource management plans, engaging and educating stakeholders, peer support for new machine use, and collectively advocating for needed resources). Conclusions. We identified factors that may limit the impact of a UAM and devised likely effective strategies for mitigating those risks. © The Author 2014.

Predictive validity of a selection centre testing non-technical skills for recruitment to training in anaesthesia

Background. Assessment centres are an accepted method of recruitment in industry and are gaining popularity within medicine. We describe the development and validation of a selection centre for recruitment to speciality training in anaesthesia based on an assessment centre model incorporating the rating of candidate's non-technical skills.MethodsExpert consensus identified non-technical skills suitable for assessment at the point of selection. Four stations - structured interview, portfolio review, presentation, and simulation - were developed, the latter two being realistic scenarios of work-related tasks. Evaluation of the selection centre focused on applicant and assessor feedback ratings, inter-rater agreement, and internal consistency reliability coefficients. Predictive validity was sought via correlations of selection centre scores with subsequent workplace-based ratings of appointed trainees. Two hundred and twenty-four candidates were assessed over two consecutive annual recruitment rounds; 68 were appointed and followed up during training. Candidates and assessors demonstrated strong approval of the selection centre with more than 70 of ratings 'good' or 'excellent'. Mean inter-rater agreement coefficients ranged from 0.62 to 0.77 and internal consistency reliability of the selection centre score was high (Cronbach's α=0.88-0.91). The overall selection centre score was a good predictor of workplace performance during the first year of appointment.ConclusionsAn assessment centre model based on the rating of non-technical skills can produce a reliable and valid selection tool for recruitment to speciality training in anaesthesia. Early results on predictive validity are encouraging and justify further development and evaluation. © 2010 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

National survey of College Tutors in the UK regarding training in medical education

Background. College Tutors are responsible for the organization of training and should possess the pre-requisite knowledge and skills to facilitate this. Methods. An anonymized survey of anaesthetic College Tutors in the UK was conducted with regard to training in medical education. Results. A response rate of 65.54% was achieved. Around 16% had a formal postgraduate teaching qualification and another 27% were interested in attaining one. However, 84% were of the opinion that formal teaching qualifications were not essential for College Tutors. The more recently appointed College Tutors (<2 yr experience) had more formal qualifications and thought these were important. Appraisal and assessment courses were considered the most valuable for professional development of the role of the College Tutor, and were identified as challenging. Conclusions. This survey highlights that training in medical education for College Tutors is inadequate. It is the responsibility of the Colleges and the Postgraduate Deans to ensure College Tutors are supported appropriately to develop the knowledge and skills required for the role. © The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved.

National critical incident reporting systems relevant to anaesthesia: A European survey

Background. Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia. Methods. We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure. Results. Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed. Conclusions. We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level. © 2013 © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Comparative effectiveness and safety of physician and nurse anaesthetists: A narrative systematic review

Background. Despite widespread debate on the merits of different models of anaesthesia care delivery, there are few published data on the relative safety and effectiveness of different anaesthesia providers. Method. We conducted a systematic search for, and critical appraisal of, primary research comparing safety and effectiveness of different anaesthetic providers. Results. Our search of Medline, EMBASE, CINAHL, and HMIC for material published between 1990 and April 2003 yielded four articles of relevance to the question. The studies used a variety of methodologies and all had potential confounding factors limiting the validity of the results. Conclusions. In view of the paucity of high-level primary evidence in this area, it is not possible to draw a conclusion regarding differences in patient safety as a function of provider type. There are difficulties in classifying events as 'anaesthesia-related', and also in the variable definitions of 'supervision' and 'anaesthesia care team'. We suggest that existing attempts to show differences in outcome might usefully be complemented by studies examining measures of anaesthetic process. © The Board of Management and Trustees of the British Journal of Anaesthesia 2004.

The State of UK anaesthesia: A survey of National Health Service activity in 2013

Background. Details of current UK anaesthetic practice are unknown and were needed for interpretation of reports of accidental awareness during general anaesthesia (GA) within the 5th National Audit Project. Methods.We surveyed NHS anaesthetic activity to determine numbers of patients managed by anaesthetists and details of 'who, when, what, and where': activity included GA, local anaesthesia, sedation, or patients managed awake. Anaesthetists in NHS hospitals collected data on all patients for 2 days. Scaling enabled estimation of annual activity. Results. Hospital response rate was 100% with 20 400 returns. The median return rate within departments was 98% (inter-quartile range 0.95'1). Annual numbers (% of total) of general anaesthetics, sedation, and awake cases were 2 766 600 (76.9%), 308 800 (8.6%), and 523 100 (14.5%), respectively. A consultant or career grade anaesthetist was present in more than 87% of cases. Emergency cases accounted for 23.1% of workload, 75% of which were undertaken out of hours. Specialties with the largest workload were orthopaedics/trauma (22.1%), general surgery (16.1%), and gynaecology (9.6%): 6.2% of cases were non-surgical. The survey data describe: who anaesthetized patients according to time of day, urgency, and ASA grade; when anaesthesia took place by day and by weekday; the distribution of patient types, techniques, and monitoring; where patients were anaesthetized. Nine patients out of 15 460 receiving GA died intraoperatively. Conclusions. Anaesthesia in the UK is currently predominantly a consultant-delivered service. The low mortality rate supports the safety of UK anaesthetic care. The survey data should be valuable for planning and monitoring anaesthesia services. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Expertise in practice: An ethnographic study exploring acquisition and use of knowledge in anaesthesia

Background. Expert professional practice in any field is known to rely on both explicit (formal) and tacit (personal) forms of knowledge. Current anaesthetic training programmes appear to favour explicit knowledge and measurable competencies. We aimed to describe and explore the way different types of knowledge are learned and used in anaesthetic practice. Method. Qualitative approach using non-participant observation of, and semi-structured interviews with, anaesthetic staff in two English hospitals. Results. The development of expertise in anaesthesia rests on the ability to reconcile and interpret many sources of knowledge - clinical, social, electronic, and experiential - and formal theoretical learning. Experts have mastered technical skills but are also able to understand the dynamic and uncertain condition of the anaesthetized patient and respond to changes in it. This expertise is acquired by working with colleagues, and, importantly, by working independently, to develop personal routines. Routines mark the successful incorporation of new knowledge but also function as a defence against the inherent uncertainty of anaesthetic practice. The habits seen in experts' routines are preferred ways of working chosen from a larger repertoire of techniques which can also be mobilized as changing circumstances demand. Conclusions. Opportunities for developing expertise are linked to the independent development of personal routines. Evidence-based approaches to professional practice may obscure the role played by the interpretation of knowledge. We suggest that the restriction of apprenticeship-style training threatens the acquisition of anaesthetic expertise as defined in this paper.

Misuse of standard error of the mean (SEM) when reporting variability of a sample. A critical evaluation of four anaesthesia journals

Background. In biomedical research papers, authors often use descriptive statistics to describe the study sample. The standard deviation (SD) describes the variability between individuals in a sample; the standard error of the mean (SEM) describes the uncertainty of how the sample mean represents the population mean. Authors often, inappropriately, report the SEM when describing the sample. As the SEM is always less than the SD, it misleads the reader into underestimating the variability between individuals within the study sample. Methods. The aim of this study was to evaluate the frequency of inappropriate use of the SEM in four leading anaesthesia journals in 2001. The journals were searched manually for descriptive statistics reporting either the mean (SD) or the mean (SEM), and inappropriate use of the SEM was noted. Results. In 2001, all four anaesthesia journals published articles that used the SEM incorrectly: Anesthesia & Analgesia 27.7%, British Journal of Anaesthesia 22.6%, Anesthesiology 18.7% and European Journal of Anaesthesiology 11.5%. Laboratory reports and clinical studies were equally affected, except for Anesthesiology where 90% were basic science reports. Conclusions. One in four articles (n=198/860, 23%) published in four anaesthesia journals in 2001 inappropriately used the SEM in descriptive statistics to describe the variability of the study sample. Anaesthesia journals are encouraged to provide clearer statistical guidelines on how to report data variability in descriptive statistics.

What information do anesthetics provide for patients?

Background. Information on anaesthesia interventions, plans and risks is needed by patients and carers alike and is a key component of the Good Practice In Consent initiative. Existing information materials may under-represent what patients are able to contribute. Method. UK anaesthetic departments were surveyed on provision of written patient information. The response rate was 66% (177/267). Results. Fifty-five per cent of respondents reported providing patient information materials for, planned surgical admission, mainly on general anaesthesia, regional analgesia and pain. A minority provided information for children and for critical care patients. Few (32%) had sought feedback from patients, and few used existing sources of guidance. Most (85%) wanted improvements, with a four-to-one majority favouring central resources developed by The Royal College of Anaesthetists. Conclusions. Working in parallel does not give our hospitals excellent, effective patient information materials. Demand exists for The Royal College of Anaesthetists to lead in this area. Working in partnership with patients and taking into account existing written guidance is important but has often been overlooked.