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Career choices for anaesthesia: National surveys of graduates of 1974-2002 from UK medical schools

Background. Knowledge about UK doctors' career intentions and pathways is essential for understanding future workforce requirements. The aim of this study was to report career choices for and career progression in anaesthesia in the UK. Methods. Postal questionnaire surveys were undertaken of qualifiers from all UK medical schools in nine qualification years since 1974. Results. 74% (24623/33417) and 73% (20709/28468) of doctors responded at 1 and 3 yr after qualification. At 1 and 3 yr after qualification, on average, 8% of doctors chose anaesthesia. Between 1974 and 2002 the percentage of doctors choosing anaesthesia, 1 yr after qualification, increased from 5 to 12%. A majority of doctors who chose anaesthesia 1 and 3 yr after qualification were working in anaesthesia 10 yr after qualification. In addition to doctors' enthusiasm for the specialty, career choices for anaesthesia were positively influenced by their perception of working hours, conditions of work, and career and promotion prospects. Conclusions. Anaesthesia has become increasingly popular as a career choice in the UK. Training numbers could be increased in the short term to speed up the process of providing a consultant-delivered service. © The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved.

Consequences of running more operating theatres than anaesthetists to staff them: A stochastic simulation study

Background. Numerous hospitals implement a ratio of one anaesthetist supervising non-medically-qualified anaesthetist practitioners in two or more operating theatres. However, the risk of requiring anaesthetists simultaneously in several theatres due to concurrent critical periods has not been evaluated. It was examined in this simulation study. Methods. Using a Monte Carlo stochastic simulation model, we calculated the risk of a staffing failure (no anaesthetist available when one is needed), in different scenarios of scheduling, staffing ratio, and number of theatres. Results. With a staffing ratio of 0.5 for a two-theatre suite, the simulated risk that at least one failure occurring during a working day varied from 87% if only short operations were performed to 40% if only long operations performed (65% for a 50:50 mixture of short and long operations). Staffing-failure risk was particularly high during the first hour of the workday, and decreased as the number of theatres increased. The decrease was greater for simulations with only long operations than those with only short operations (the risk for 10 theatres declined to 12% and 74%, respectively). With a staffing ratio of 0.33, the staffing-failure risk was markedly higher than for a 0.5 ratio. The availability of a floater for the whole suite to intervene during failure strongly lowered this risk. Conclusions. Scheduling one anaesthetist for two or three theatres exposes patients and staff to high risk of failure. Adequate planning of long and short operations and the presence of a floating anaesthetist are efficient means to optimize site activity and assure safety. © The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved.

Item analysis for the written test of Taiwanese board certification examination in anaesthesiology using the Rasch model

Background. On the written test of board certification examination for anaesthesiology, the probability of a question being answered correctly is subject to two main factors, item difficulty and examinee ability. Thus, item analysis can provide insight into the appropriateness of a particular test, given the ability of examinees. Methods. Study subjects were 36 Taiwanese examinees tested with 100 questions related to anaesthesiology. We used the Rasch model to perform item analysis of questions answered by each examinee to assess the effects of question difficulty and examinee ability using a common logit scale. Additionally, we evaluated test reliability and virtual failure rates under different criteria.Results. The mean examinee ability was higher than the mean item difficulty in this written test by 1.28 (sd=0.57) logit units, which means that the examinees, on average, were able to correctly answer 78% of items. The difficulty of items decreased from 4.25 to -2.43 on the logit scale, corresponding to the probability of having a correct answer from 5% to 98%. There were 60 items with difficulty lower than the least able examinee and seven difficult items beyond the most able one. The agreement of item difficulty between test developers and our Rasch model was poor (weighted κ=0.23).Conclusions. We demonstrated how to assess the construct validity and reliability of the written examination in order to provide useful information for future board certification examinations.The study was approved by the institutional review board with the following trial registered number: VGHIRB No. 97-08-14A. © 2010 The Author.

Detection of awareness in surgical patients with EEG-based indices - Bispectral index and patient state index

Background. Patient state index (PSI) and bispectral index (BIS) are values derived from the EEG, which can measure the hypnotic component of anaesthesia. We measured the ability of PSI and BIS to distinguish consciousness from unconsciousness during induction and emergence from anaesthesia and a period of awareness in surgical patients. Methods. Forty unpremedicated patients were randomized to receive: (1) sevoflurane/remifentanil (≤0.1 μg kg-1 min-1), (2) sevoflurane/remifentanil (≥0.2 μg kg-1 min-1), (3) propofol/remifentanil (≤0.1 μg kg-1 min-1), (4) propofol/remifentanil (≥0.2 μg kg-1 min-1). Every 30 s after the start of the remifentanil, patients were asked to squeeze the investigator's hand. Sevoflurane or propofol were given until loss of consciousness (LOC1). Tunstall's isolated forearm technique was used during neuromuscular block with succinylcholine. After tracheal intubation, propofol or sevoflurane were stopped until return of consciousness (ROC1). Propofol or sevoflurane were re-started to induce LOC2. After surgery, drugs were discontinued and recovery (ROC2) was observed. PSI and BIS at LOC (LOC1 and LOC2) were compared with those at ROC (ROC1 and ROC2) (t-test). Prediction probability (Pk) was calculated from values at the last command before and at LOC and ROC. Values are mean (SD). Results. At non-responsiveness, BIS (66 (17)) and PSI (55 (23)) were significantly less than at responsiveness (BIS, 79 (14); PSI, 77 (18); P<0.05). The wide variation with both BIS and PSI measurements of the 80 'awareness' values led to an erroneous classification as unconscious in some cases (BIS, six patients; PSI, nine patients). Pk was 0.68 (0.03) (BIS) and 0.69 (0.03) (PSI). Conclusions. Despite significant differences between mean values at responsiveness and non-responsiveness for BIS and PSI, neither measure may be sufficient to detect awareness in an individual patient, reflected by a Pk less than below 70%.

Patient Experiences with the Preoperative Assessment Clinic (PEPAC): Validation of an instrument to measure patient experiences

Background. Presently, no comprehensive and validated questionnaire to measure patient experiences of the preoperative assessment clinic (PAC) is available. We developed and validated the Patient Experiences with the Preoperative Assessment Clinic (PEPAC) questionnaire, which can be used for quantitative measurements of patient experiences of the PAC. Methods. We adapted the National Health Service outpatient questionnaire, incorporating questions specific for anaesthesiology. To make the PEPAC appropriate for quantitative measurements, dimensions and single items suitable for statistical analysis were constructed. Each dimension consists of multiple items measuring the same aspect of care. Reliability was established by computing Cronbach's alpha coefficients. Construct validity was assessed by correlating the dimensions with the patient's overall appraisal (Pearson's r). These dimensions should explain a substantial level of variance of the patients' overall appraisal; therefore, regression analysis was performed. Results. After a pilot phase, the questionnaire was sent to 700 consecutive patients (response 74%). Five scales measuring five dimensions of patient experiences were constructed. Cronbach's alpha ranged from 0.56 to 0.84, supporting reliability of the PEPAC. Correlations between the dimensions and patients' overall appraisal ranged from 0.22 to 0.56. Collectively, the five scales explained 51% of patients' overall appraisal. Conclusions. The PEPAC is a comprehensive, reliable, and validated questionnaire to measure patient experiences with the PAC. It might be a useful tool to identify the service areas of the PAC that require improvement and to determine which actions can bring about improvement. © The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved.

Challenge of improving postoperative pain management: Case studies of three acute pain services in the UK National Health Service

Background. Previous national survey research has shown significant deficits in routine postoperative pain management in the UK. This study used an organizational change perspective to explore in detail the organizational challenges faced by three acute pain services in improving postoperative pain management. Methods. Case studies were conducted comprising documentary review and semi-structured interviews (71) with anaesthetists, surgeons, nurses, other health professionals, and managers working in and around three broadly typical acute pain services. Results. Although the precise details differed to some degree, the three acute pain services all faced the same broad range of inter-related challenges identified in the organizational change literature (i.e. structural, political, cultural, educational, emotional, and physical/technological challenges). The services were largely isolated from wider organizational objectives and activities and struggled to engage other health professionals in improving postoperative pain management against a background of limited resources, turbulent organizational change, and inter- and intra-professional politics. Despite considerable efforts they struggled to address these challenges effectively. Conclusions. The literature on organizational change and quality improvement in health care suggests that it is only by addressing the multiple challenges in a comprehensive way across all levels of the organization and health-care system that sustained improvements in patient care can be secured. This helps to explain why the hard work and commitment of acute pain services over the years have not always resulted in significant improvements in routine postoperative pain management for all surgical patients. Using this literature and adopting a whole-organization quality improvement approach tailored to local circumstances may produce a step-change in the quality of routine postoperative pain management.

Reliability of the American Society of Anesthesiologists physical status scale in clinical practice

Background. Previous studies, which relied on hypothetical cases and chart reviews, have questioned the inter-rater reliability of the ASA physical status (ASA-PS) scale. We therefore conducted a retrospective cohort study to evaluate its inter-rater reliability and validity in clinical practice. Methods. The cohort included all adult patients (≥18 yr) who underwent elective non-cardiac surgery at a quaternary-care teaching institution in Toronto, Ontario, Canada, from March 2010 to December 2011. We assessed inter-rater reliability by comparing ASA-PS scores assigned at the preoperative assessment clinic vs the operating theatre. We also assessed the validity of the ASA-PS scale by measuring its association with patients' preoperative characteristics and postoperative outcomes. Results. The cohort included 10 864 patients, of whom 5.5% were classified as ASA I, 42.0% as ASA II, 46.7% as ASA III, and 5.8% as ASA IV. The ASA-PS score had moderate inter-rater reliability (κ 0.61), with 67.0% of patients (n=7279) being assigned to the same ASA-PS class in the clinic and operating theatre, and 98.6% (n=10 712) of paired assessments being within one class of each other. The ASA-PS scale was correlated with patients' age (Spearman's ρ, 0.23), Charlson comorbidity index (ρ=0.24), revised cardiac risk index (ρ=0.40), and hospital length of stay (ρ=0.16). It had moderate ability to predict in-hospital mortality (receiver-operating characteristic curve area 0.69) and cardiac complications (receiver-operating characteristic curve area 0.70). Conclusions. Consistent with its inherent subjectivity, the ASA-PS scale has moderate interrater reliability in clinical practice. It also demonstrates validity as a marker of patients' preoperative health status. © The Author 2014.

Efficacy of high-fidelity simulation debriefing on the performance of practicing anaesthetists in simulated scenarios

Background. Research into adverse events in hospitalized patients suggests that a significant number are preventable. The purpose of this randomized, controlled study was to determine if simulation-based debriefing improved performance of practicing anaesthetists managing high-fidelity simulation scenarios. Methods. The anaesthetists were randomly allocated to Group A: simulation debriefing; Group B: home study; and Group C: no intervention and secondary randomization to one of two scenarios. Six to nine months later, subjects returned to manage the alternate scenario. Facilitators blinded to study group allocation completed the performance checklists (dichotomously scored checklist, DSC) and Global Rating Scale of Performance (GRS). Two non-expert raters were trained, and assessed all videotaped performances. Results. Interim analysis indicated no difference between Groups B and C which were merged into one group. Seventy-four subjects were recruited, with 58 complete data sets available. There was no significant effect of group on pre-test scores. A significant improvement was seen between pre- and post-tests on the DSC in debriefed subjects (pre-test 66.8%, post-test 70.3%; F 1,57=4.18, P=0.046). Both groups showed significant improvement in the GRS over time (F1,57=5.94, P=0.018), but no significant difference between the groups. Conclusions. We found a modest improvement in performance on a DSC in the debriefed group and overall improvement in both control and debriefed groups using a GRS. Whether this improvement translates into clinical practice has yet to be determined.

Implementation of outpatient preoperative evaluation clinics: Facilitating and limiting factors

Background. Several studies have shown that outpatient preoperative evaluation by anaesthetists increases quality of care and is cost-effective. The aim of this study was to gain insight into the factors that positively or negatively influence the implementation of outpatient preoperative evaluation clinics (OPE clinics). Methods. After an extensive literature study and pilot interviews, we constructed written questionnaires that were sent to all Dutch hospitals. The respondents were members of the board of directors, members of the medical staff, anaesthetists, internists, and surgeons. Results. Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of an OPE clinic across all medical specialists interviewed. Lack of finance was most frequently reported as limiting factor in all categories of hospitals (with a complete, partial, or no OPE clinic), but it was significantly more often reported in hospitals without OPE clinic (P<0.01). Perceived benefits and disadvantages, financial rewarding system, and organizational structure played a clear role in the implementation of OPE clinics. Conclusions. A variety of factors play a role in the implementation of an OPE clinic. Besides the more obvious ones, such as financing and cooperation of the professional groups involved underlying factors, such as perceptions of the professionals involved, were found to be related to implementation of an OPE clinic. These underlying factors explain differences between different kinds of hospitals and between professional groups, regarding their resources and motivation to implement an OPE clinic. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

Use of an anaesthesia workstation barrier device to decrease contamination in a simulated operating room

Background. Strategies to achieve reductions in perioperative infections have focused on hand hygiene among anaesthestists but have been of limited efficacy. We performed a study in a simulated operating room to determine whether a barrier covering the anaesthesia workstation during induction and intubation might reduce the risk of contamination of the area and possibly, by extension, the patient. Methods. Forty-two attending and resident anaesthetists unaware of the study design were enrolled in individual simulation sessions in which they were asked to induce and intubate a human simulator that had been prepared with fluorescent marker in its oropharynx as a marker of potentially pathogenic bacteria. Twenty-one participants were assigned to a control group, whereas the other 21 performed the simulation with a barrier device covering the anaesthesia workstation. After the simulation, an investigator examined 14 target sites with an ultraviolet light to assess spread of the fluorescent marker of contamination to those sites. Results. The difference in rates of contamination between the control group and the barrier group was highly significant, with 44.8% (2.5%) of sites contaminated in the control group vs 19.4% (2.6%) of sites in the barrier group (P<0.001). Several key clinical sites showed significant differences in addition to this overall decrement. Conclusions. The results of this study suggest that application of a barrier device to the anaesthesia workstation during induction and intubation might reduce contamination of the intraoperative environment. © 2017 The Author.

Corresponding minimum alveolar concentrations of isoflurane and isoflurane/nitrous oxide have divergent effects on thalamic nociceptive signalling

Background. Suppression of nociceptive signalling in the thalamus is considered to contribute significantly to the anaesthetic state. Assuming additivity of anaesthetic mixtures, our study assessed the effects of corresponding minimum alveolar concentrations (MACs) of isoflurane and isoflurane/nitrous oxide on thalamic nociceptive signalling. Methods. Nociceptive response activity (elicited by controlled radiant heat stimuli applied to cutaneous receptive fields) of single thalamic neurons was compared in rats anaesthetized at ∼1.1 and ∼1.4 MAC isoflurane with that at ∼1.1 and ∼1.4 MAC isoflurane/nitrous oxide. Results. Under baseline anaesthesia (∼0.9 MAC isoflurane), noxious stimulation elicited excitatory responses in all neurons (n = 19). These responses were uniformly suppressed at ∼1.1 and ∼1.4 MAC isoflurane. In contrast, at ∼1.1 and ∼1.4 MAC isoflurane/nitrous oxide, excitatory responses no different to baseline were still present in 64 and 37% of the neurons, respectively. Conclusions. These data demonstrate a pronounced nitrous oxide-induced response variability. It appears that, with respect to thalamic transfer of nociceptive information, the interaction of isoflurane and nitrous oxide may not be compatible with the concept of additivity and that the antinociceptive potency of nitrous oxide is considerably less than previously reported. © The Board of Management and Trustees of the British Journal of Anaesthesia 2007.

Comparison of Alaris AEP index and bispectral index during propofol-remifentanil anaesthesia

Background. The Alaris AEP monitor™ (Alaris, UK, version 1.4) is the first commercially available auditory evoked potential (AEP) monitor designed to estimate the depth of anaesthesia. It generates an 'Alaris AEP index' (AAI), which is a dimensionless number scaled from 100 (awake) to 0. This study was designed to compare AAI and BIS™ (Aspect, USA, version XP) values at different levels of anaesthesia. Methods. Adult female patients were premedicated with diazepam 0.15 mg kg-1 orally on the morning of surgery. Electrodes for BIS and Alaris AEP monitoring and a headphone to give auditory stimuli were applied as recommended by the manufacturers. Anaesthesia was induced with remifentanil (0.4 μg kg-1 min-1) and a propofol target-controlled infusion (Diprifusor™ TCI, AstraZeneca, Germany) to obtain a predicted concentration of initially 3.5 μg ml-1. After loss of consciousness the patients were given 0.5 mg kg-1 of atracurium. After tracheal intubation, remifentanil was given at 0.2 μg kg-1 min-1 and the propofol infusion was adjusted to obtain BIS target values of 30, 40, 50, and 60. AAI and BIS values were recorded and matched with the predicted propofol effect-site concentrations. Prediction probability was calculated for consciousness vs unconsciousness. Values are mean (SD). Results. Fifty female patients, 53 (15), range 18-78 yr, ASA I or II were studied. Mean values before induction of anaesthesia were 95 (4), range 99-82 for BIS and 85 (12), range 99-55 for AAI. With loss of eyelash reflex both values were significantly reduced to 64 (13), range 83-39 for BIS (P&lt;0.05) and 61 (22), range 99-15 for AAI (P&lt;0.05). The prediction probability PK for consciousness vs unconsciousness (i.e. loss of eyelash reflex) was better for BIS (PK=0-99) than for AAI (PK=0.79). At a BIS of 30, 40, 50, and 60 the corresponding AAI values were 15 (6), 20 (8), 28 (11), and 40 (16), and these were significantly different. Conclusions. During propofol-remifentanil anaesthesia a decrease of the depth of anaesthesia as indicated by BIS monitoring is accompanied by corresponding effects shown by the AAI. However, wide variation in the awake values and considerable overlap of AAI values between consciousness and unconsciousness, suggests further improvement of the AAI system is required.

Integration of academic and clinical performance-Based faculty compensation plans: A system and its impact on an anaesthesiology department

Background. The current economic environmentmakes it difficult foracademic institutions to maintain academic activities with necessary clinical coverage. Productivity-based faculty compensation is reported to improve clinical work output; however, the impact on academic productivity has not been fully described. Methods. An academic anaesthesiology department has used a comprehensive clinical and academic performance-based faculty compensation programme as fiscal year (FY) 2004. Faculty choosing to pursue an academic track can devote up to 80% of their time to non-clinical activities. Payment for this time is 'salary at risk', which is earned through a merit matrix system, which was newly developed to award points for various academic activities. Unclaimed portions of the salary at risk are absorbed into the department budget at the conclusion of the FY. Clinical activities are measured chiefly based on total hours of anaesthetic care. Results. Academic full-time equivalents (FTEs) decreased by 12.0% in FY2005 (FTE of 16.0-14.1) but recovered to the baseline level in FY2006 and remained stable. Clinical FTE also decreased by 6.6% in FY2005 (FTE of 109.1-101.9), then increased in FY2006-FY2010. Increased clinical work output was observed among the clinical and academic faculty members. Each academic faculty member successfully earned their salary at risk in each FY. The annual number of peer-reviewed publications per academic FTE in original research increased from 0.31 (0.18) (FY2001-FY2003) to 0.73 (0.14) (FY2006-FY2011), P=0.024. Conclusions. Integration of clinical and academic performance-based faculty compensation systems is feasible and can be efficacious in a large academic anaesthesiology department. © The Author [2013].Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

Influence of resident training on anaesthesia induction times

Background. The effect of resident training in anaesthesiology on operating room (OR) economics is an issue of debate. Comparisons of anaesthesia process times between residents and consultants might be systematically skewed by interactions of anaesthesia technique and patient factors. Methods. In this prospective, observational study, we analysed anaesthesia process times in 599 cases performed for four different surgical services in a University hospital. The following factors were recorded for each case and used in multivariate analyses of process times: age, American Society of Anesthesiologist (ASA) status, BMI, emergency status, the educational level of the anaesthetist, and the anaesthesia technique. Results. In the non-adjusted comparison, only for two of seven anaesthetic techniques did resident cases have statistically significant longer induction times than consultant cases: general anaesthesia with placement of a central venous catheter [mean (sd) anaesthesia time for resident cases 38.2 (17.0) vs 22.3 (10.0) min for consultant cases, P=0.001] and general anaesthesia with a laryngeal mask airway [resident cases 11.3 (5.5) vs consultant cases 7.3 (5.0) min, P=0.003]. Anaesthetic technique had the greatest effect on anaesthesia induction time. Educational level of the anaesthetist and age of the patients had small, but significant effects. Conclusions. Anaesthesia cases performed by residents have in some, but not in all, anaesthesia techniques increased process times compared with cases performed by consultants. This limits a possible negative impact on OR economics by resident education. Patient-based factors including ASA status, BMI, and emergency status have minimal or no effect on anaesthesia process times. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

Training and the European working time directive: A 7 year review of paediatric anaesthetic trainee caseload data

Background. The implementation of the European Working Time Directive (WTD) has reduced the hours worked by trainees in the UK to a maximum of 56 h per week. With a further and final reduction to 48 h per week scheduled for August 2009, there is concern amongst doctors about the impact on training and on patient care. Paediatric anaesthesia is one of the specialist areas of anaesthesia for which the Royal College of Anaesthetists (RCoA) recommends a minimum caseload during the period of advanced training. Methods. We conducted a retrospective analysis of theatre logbook data from 62 Specialist Registrars (SpRs) who had completed a 12 month period of advanced training in paediatric anaesthesia in our institution between 2000 and 2007. Results. After the implementation of the WTD 56 h week in 2004, the mean total number of cases performed by SpRs per year decreased from 441 to 336, a 24% reduction. We found a statistically significant reduction across all age groups with the largest reduction in the under 1 month of age group. The post-WTD group did not meet the RCoA recommended total minimum caseload or the minimum number of cases of <1 yr of age. Conclusions. Since the implementation of the WTD, there has been a significant reduction in the number of cases performed by SpRs in paediatric anaesthesia and they are no longer achieving the RCoA recommended minimum numbers for advanced training.

Upper limb muscular activity and perceived workload during laryngoscopy: Comparison of Glidescope® and Macintosh laryngoscopy in manikin: An observational study

Background. The interaction between operators and their working environment during laryngoscopy is poorly understood. Numerous studies have focused on the forces applied to the patient's airway during laryngoscopy, but only a few authors have addressed operator muscle activity and workload. We tested whether different devices (Glidescope® and Macintosh) use different muscles and how these differences affect the perceived workload.MethodsTen staff anaesthetists performed three intubations with each device on a manikin. Surface electromyography was recorded for eight single muscles of the left upper limb. The NASA Task Load Index (TLX) was administered after each experimental session to evaluate perceived workload.ResultsA consistent reduction in muscular activation occurred with Glidescope® compared with Macintosh for all muscles tested (mean effect size d=3.28), and significant differences for the upper trapezius (P=0.002), anterior deltoid (P=0.001), posterior deltoid (P=0.000), and brachioradialis (P=0.001) were observed. The overall NASA-TLX workload score was significantly lower for Glidescope® than for Macintosh (P=0.006), and the factors of physical demand (P=0.008) and effort (P=0.006) decreased significantly. Conclusions. Greater muscular activity and workload were observed with the Macintosh laryngoscope. Augmented vision and related postural adjustments related to using the Glidescope® may reduce activation of the operator's muscles and task workload. © 2013 © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Investigation of trainee and specialist reactions to the mini-Clinical Evaluation Exercise in anaesthesia: Implications for implementation

Background. The mini-Clinical Evaluation Exercise (mini-CEX) is a workplace-based assessment which may be useful in anaesthesia training. However, its value depends on how supervisors use it with their trainees. This study analyses experience with the mini-CEX after its introduction into anaesthesia departments in our institution. Methods. We conducted surveys, focus groups, and interviews with trainees and specialists. Data were recorded, transcribed, and entered into NVivo 8. Themes were identified and data coded into these themes. Results. We identified six themes: assessor factors included skills needed to perform the assessments, influences on scoring decisions, and effects on the specialist-trainee relationship; trainee factors related to impact on trainee performance and value at the different training levels; teaching and learning included the effect of focused observation on structuring workplace learning; feedback described how the mini-CEX changed feedback and what was considered useful; mini-CEX process included implementation, initiation of assessments and case selection; and use in assessment included comparisons with existing assessments and the ability to identify poor performers. Conclusions. Mini-CEX formalized the supervisory relationship, promoting educational interactions. During the observation period, trainees took responsibility for decisions, and specialists learnt more about their abilities. The structured format broadened the scope of feedback and made it easier to address performance gaps. We identified factors that facilitated or hindered implementation, or limited effective feedback and the ability to address poor performance. From this analysis, we propose strategies for the implementation of mini-CEX, and recommendations for assessor training to improve the quality and value of the assessments.

Comparison of the Glidescope®, the Pentax AWS®, and the Truview EVO2® with the Macintosh laryngoscope in experienced anaesthetists: A manikin study

Background. The Pentax Airwayscope®, the Glidescope®, and the Truview EVO2® constitute three novel laryngoscopes that facilitate visualization of the vocal cords without alignment of the oral, pharyngeal, and tracheal axes. We compared these devices with the Macintosh laryngoscope in a simulated easy and difficult laryngoscopy. Methods. Thirty-five experienced anaesthetists were allowed up to three attempts to intubate in each of four laryngoscopy scenarios in a Laerdal® SimMan® manikin. The time required to perform tracheal intubation, the success rate, number of intubation attempts and of optimization manoeuvres, and the severity of dental compression were recorded. Results. In the simulated easy laryngoscopy scenarios, there was no difference between the study devices and the Macintosh in success of tracheal intubation. In more difficult tracheal intubation scenarios, the Glidescope® and Pentax AWS®, and to a lesser extent the Truview EVO2® laryngoscope demonstrated advantages over the Macintosh laryngoscope including a better view of the glottis, greater success of tracheal intubation, and ease of device use. The Pentax AWS® was more successful in achieving tracheal intubation, required less time to successfully perform tracheal intubation, caused less dental trauma, and was considered by the anaesthetists to be easier to use. Conclusions. The Pentax AWS® laryngoscope demonstrated more advantages over the Macintosh laryngoscope than either the Truview EVO2® or the Glidescope® laryngoscope, when used by experienced anaesthetists in difficult tracheal intubation scenarios. © The Board of Management and Trustees of the British Journal of Anaesthesia 2009. All rights reserved.

Predictive performance of computer-controlled infusion of remifentanil during propofol/remifentanil anaesthesia

Background. The predictive performance of the available pharmacokinetic parameter sets for remifentanil, when used for target-controlled infusion (TCI) during total i.v. anaesthesia, has not been determined in a clinical setting. We studied the predictive performance of five parameter sets of remifentanil when used for TCI of remifentanil during propofol anaesthesia in surgical patients. Methods. Remifentanil concentration-time data that had been collected during a previous pharmacodynamic interaction study in 30 female patients (ASA physical status 1, aged 20-65 yr) who received a TCI of remifentanil and propofol during lower abdominal surgery were used in this evaluation. The remifentanil concentrations predicted by the five parameter sets were calculated on the basis of the TCI device record of the infusion rate-time profile that had actually been administered to each individual. The individual and pooled bias [median performance error (MDPE)], inaccuracy [median absolute performance error (MDAPE)], divergence and wobble of the remifentanil TCI device were determined from the pooled and intrasubject performance errors. Results. A total of 444 remifentanil blood samples were analysed. Blood propofol and remifentanil concentrations ranged from 0.5 to 11 μg ml-1 and 0.1 to 19.6 ng ml-1 respectively. Pooled MDPE and MDAPE of the remifentanil TCI device were -15 and 20% for the parameter set of Minto and colleagues (Anesthesiology 1997; 86: 10-23), 1 and 21%, -6 and 21%, and -6 and 19% for the three parameter sets described by Egan and colleagues (Anesthesiology 1996; 84: 821-33, Anesthesiology 1993; 79: 881-92, Anesthesiology 1998; 89: 562-73), and -24 and 30% for the parameter set described by Drover and Lemmens (Anesthesiology 1998; 89: 869-77). Conclusions. Remifentanil can be administered by TCI with acceptable bias and inaccuracy. The three pharmacokinetic parameter sets described by Egan and colleagues resulted in the least bias and best accuracy.

Setting priorities for improving the preoperative assessment clinic: The patients' and the professionals' perspective

Background. The quality of the preoperative assessment clinic (PAC) is determined by many factors. Patients' experiences are important indicators, but often overlooked. We prepare to set priorities to improve the PAC by obtaining detailed patients' feedback on the quality of the PAC, and establishing the value patients and professionals attach to different care aspects, using the Patient Experiences with the Preoperative Assessment Clinic questionnaire. Methods. The PAC's standard of service was determined for five care aspects (dimensions), using patients' feedback. The importance of a dimension to patients was determined by calculating the effects of the dimensions on patients' overall appraisal. In addition, professionals were asked to rate the importance of the different care aspects. Results. Patients had the most positive experiences with the nurse, and the least positive experiences with waiting. However, waiting was least important to patients. When combining the PAC's standard of service with the value given to the dimensions by patients and professionals separately, we found in both instances that waiting was in greatest need of improvement. This was followed by reception, the anaesthetist, remaining experiences, and finally the nurse. Conclusions. Quality improvement of the PAC can be achieved by obtaining patients' feedback on the quality, determine a PAC's standard of service, recognize service areas that require improvement, and identify actions appropriate to bring about improvement. The value patients and professionals attach to different aspects of care can then be used to prioritize improvements. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

Supervision and responsibility: The Royal College of Anaesthetists National Audit

Background. The Royal College of Anaesthetists audited consultant supervision and responsibility in anaesthesia in the UK during 2003. Methods. Consultants (supervising) and non-consultants (supervised) were surveyed on their attitudes to supervision, experience of their own hospital system for supervision and of induction for new starters. Local coordination was achieved through anaesthesia audit coordinators who provided information on local policies, induction programmes and anaesthesia charts. Supervision was audited over a 5-day period. Results. 135 departments of anaesthesia took part (43% of 315 departments), questionnaires being returned by 2297 anaesthetists. Anaesthesia record charts in use do not meet criteria considered desirable locally. Most trainees, but less than half staff grade/ associate specialists, received an induction programme, often not supported by written documentation. Consultants find conflicting demands of service and supervision difficult. Many work in systems which do not permit providing direct, immediate support to those supervised. Most anaesthetists think supervision is very important. Around half disagree with national guidance that every NHS patient should have a named consultant. Two per cent of non-consultants during the audit period reported assistance from consultants not being obtainable soon enough. Conclusions. This audit found departure from standards and the potential for risk and failure. New standards may be needed regarding anaesthesia record sheets, induction, accountability, when to seek help and care of sick patients. Supervision systems in over 40% of hospitals need review to ensure they provide a named consultant and immediate direct support for elective lists. © The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved.

Virtual reality-based simulator for training in regional anaesthesia

Background. The safe performance of regional anaesthesia (RA) requires theoretical knowledge and good manual skills. Virtual reality (VR)-based simulators may offer trainees a safe environment to learn and practice different techniques. However, currently available VR simulators do not consider individual anatomy, which limits their use for realistic training. We have developed a VR-based simulator that can be used for individual anatomy and for different anatomical regions. Methods. Individual data were obtained from magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) without contrast agent to represent morphology and the vascular system, respectively. For data handling, registration, and segmentation, an application based on the Medical Imaging Interaction Toolkit was developed. Suitable segmentation algorithms such as the fuzzy c-means clustering approach were integrated, and a hierarchical tree data structure was created to model the flexible anatomical structures of peripheral nerve cords. The simulator was implemented in the VR toolkit ViSTA using modules for collision detection, virtual humanoids, interaction, and visualization. A novel algorithm for electric impulse transmission is the core of the simulation. Results. In a feasibility study, MRI morphology and MRA were acquired from five subjects for the inguinal region. From these sources, three-dimensional anatomical data sets were created and nerves modelled. The resolution obtained from both MRI and MRA was sufficient for realistic simulations. Our high-fidelity simulator application allows trainees to perform virtual peripheral nerve blocks based on these data sets and models. Conclusions. Subject-specific training of RA is supported in a virtual environment. We have adapted segmentation algorithms and developed a VR-based simulator for the inguinal region for use in training for different peripheral nerve blocks. In contrast to available VR-based simulators, our simulation offers anatomical variety.

Failure of simulation training to change residents' management of oesophageal intubation

Background. There are few scientific reports documenting the effects of simulation training on learning. Issues of scientific validity challenge investigators who measure such outcomes. We perceived a failure of residents to change their technical management of oesophageal intubation after simulation training and sought clarification of this observation. Methods. Twenty-one residents were randomly exposed to two deliberate oesophageal intubation scenarios, first as a junior assistant (JS group) or as a senior managing resident (SS group), and secondly as a senior managing resident. After the first episode, residents were given an explanation and demonstration of the suggested technical management strategy, including: (i) confirmation of oesophageal intubation with a second direct laryngoscopy; and (ii) concurrent insertion of a second tube into the trachea. After the second episode, we retrospectively sought to confirm improvement in technical management within the SS group by measuring videotaped performances. Questionnaires were sent to the residents before and after reporting their performance results. Results. There were 14 SS and seven JS subjects. Within SS, there was no improvement in 'confirmation of oesophageal intubation with direct laryngoscopy' (8/14 vs 9/14) or any improvement in 'concurrent insertion of a second ETT (tracheal) tube' (1/14 vs 2/14). Questionnaire responses offered considerable insight into these negative results. Conclusions. This failure to change may have been secondary to a lack of criterion validity, lack of repetition or a long duration between episodes. The expectations for management were not regarded as being advantageous in simulation, but they were successfully adopted in actual clinical emergencies.

Influence of transactive memory on perceived performance, job satisfaction and identification in anaesthesia teams

Background. There is an increasing awareness in the medical community that human factors are involved in effectiveness of anaesthesia teams. Communication and coordination between physicians and nurses seems to play a crucial role in maintaining a good level of performance under time pressure, particularly for anaesthesia teams, who are confronted with uncertainty, rapid changes in the environment, and multi-tasking. The aim of this study was to examine the relationship between a specific form of implicit coordination - the transactive memory system - and perceptions of team effectiveness and work attitudes such as job satisfaction and team identification. Methods. A cross-sectional study was conducted among 193 nurse and physician anaesthetists from eight French public hospitals. The questionnaire included some measures of transactive memory system (coordination, specialization, and credibility components), perception of team effectiveness, and work attitudes (Minnesota Job Satisfaction Questionnaire, team identification scale). The questionnaire was designed to be filled anonymously, asking only biographical data relating to sex, age, status, and tenure. Results. Hierarchical multiple regression analyses revealed as predicted that transactive memory system predicted members' perceptions of team effectiveness, and also affective outcomes such as job satisfaction and team identification. Moreover, the results demonstrated that transactive memory processes, and especially the coordination component, were a better predictor of teamwork perceptions than socio-demographic (i.e. gender or status) or contextual variables (i.e. tenure and size of team). Conclusions. These findings provided empirical evidence of the existence of a transactive memory system among real anaesthesia teams, and highlight the need to investigate whether transactive memory is actually linked with objective measures of performance. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

Evaluation of high patient simulator in assessment of performance of anaesthetists

Background. There is increasing emphasis on performance-based assessment of clinical competence. The High Fidelity Patient Simulator (HPS) may be useful for assessment of clinical practice in anaesthesia, but needs formal evaluation of validity, reliability, feasibility and effect on learning. We set out to assess the reliability of a global rating scale for scoring simulator performance in crisis management. Methods. Using a global rating scale, three judges independently rated videotapes of anaesthetists in simulated crises in the operating theatre. Five anaesthetists then independently rated subsets of these videotapes. Results. There was good agreement between raters for medical management, behavioural attributes and overall performance. Agreement was high for both the initial judges and the five additional raters. Conclusions. Using a global scale to assess simulator performance, we found good inter-rater reliability for scoring performance in a crisis. We estimate that two judges should provide a reliable assessment. High fidelity simulation should be studied further for assessing clinical performance.

Teaching antiarrhythmic therapy and ECG in simulator-based interdisciplinary undergraduate medical education

Background. Third-year students in the Dresden Medical School Programme undergo a 6 week course 'Basics of Drug Therapy' in a problem-based learning curriculum. As part of this course a practical seminar about antiarrhythmic drugs and ECG was set up. This study was conducted to evaluate the use of a simulator in this course. Methods. A total of 234 students were randomly allocated to receive instructions with (Group S) or without (Group C [control]) the use of a simulator. After a lecture on antiarrhythmic drugs, arrhythmias were presented to Group S using an advanced life support (ALS) manikin. The students were asked to administer a drug or to defibrillate, and the outcome was shown on the monitor. The students in Group C were presented with ECG charts without a simulator. The course was evaluated by a questionnaire and multiple-choice questions (MCQ) about arrhythmias. Results. We received 222 questionnaires. The content-time ratio was rated almost perfect in both groups, but the students in Group S rated the course better suited to link theory and practice. Students in Group S considered the simulator helpful and a good tool for teaching, and the extra effort to be worthwhile. A significantly higher number of students in Group S preferred electric cardioversion as therapy for ventricular tachycardia. Conclusions. An ALS manikin can be an effective tool in teaching clinical pharmacology. © The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved.

Perioperative tobacco use interventions in Japan: A survey of thoracic surgeons and anaesthesiologists

Background. Tobacco use interventions in surgical patients who smoke could benefit both their short-term outcome and long-term health. Anaesthesiologists and surgeons can play key roles in delivering these interventions. This study determined the practices, attitudes, and beliefs of these physicians regarding tobacco use interventions in Japan. Methods. Questionnaires were mailed to a national random sampling of Japanese anaesthesiologists and thoracic surgeons (1000 in each group). Results. The survey response rate was 62%. More than 80% of respondents agreed or strongly agreed with the statements affirming the benefits of abstinence to surgical patients. However, only 26% of surgeons and 6% of anaesthesiologists reported almost always providing help to their patients to quit smoking. Compared with anaesthesiologists, surgeons were more likely to perform the elements of current recommendations for brief intervention, and to have attitudes favourable to tobacco use interventions. The most significant barrier to intervention identified by both groups was a lack of time to perform counselling. Compared with non-smokers, physicians who smoked were less likely to perform each of the recommended tobacco interventions. Conclusions. Although current rates of intervention provided by anaesthesiologists and surgeons are low, there is considerable interest among these physicians in learning more about interventions. Given the relatively high prevalence of smoking in Japan and the potential for surgery to serve as a 'teachable moment' to promote abstinence from smoking, leadership by these specialists in the area of tobacco control could have a major impact on public health in Japan. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

Video-assisted instruction improves the success rate for tracheal intubation by novices

Background. Tracheal intubation via laryngoscopy is a fundamental skill, particularly for anaesthesiologists. However, teaching this skill is difficult since direct laryngoscopy allows only one individual to view the larynx during the procedure. The purpose of this study was to determine if video-assisted laryngoscopy improves the effectiveness of tracheal intubation training. Methods. In this prospective, randomized, crossover study, 37 novices with less than six prior intubation attempts were randomized into two groups, video-assisted followed by traditional instruction (Group V/T) and traditional instruction followed by video-assisted instruction (Group T/V). Novices performed intubations on three patients, switched groups, and performed three more intubations. All trainees received feedback during the procedure from an attending anaesthesiologist based on standard cues. Additionally, during the video-assisted part of the study, the supervising anaesthesiologist incorporated feedback based on the video images obtained from the fibreoptic camera located in the laryngoscope. Results. During video-assisted instruction, novices were successful at 69% of their intubation attempts whereas those trained during the non-video-assisted portion were successful in 55% of their attempts (P=0.04). Oesophageal intubations occurred in 3% of video-assisted intubation attempts and in 17% of traditional attempts (P<0.01). Conclusions. The improved rate of successful intubation and the decreased rate of oesophageal intubation support the use of video laryngoscopy for tracheal intubation training. © The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved.

Trainee anaesthetists understand their work in different ways: Implications for specialist education

Background. Traditionally, programmes for specialist education in anaesthesia and intensive care have been based on lists of attributes such as skills and knowledge. However, modern research in the science of teaching has shown that competence development is linked to changes in the way professionals understand their work. The aim of this study was to define the different ways in which trainee anaesthetists understand their work. Methods. Nineteen Swedish trainee anaesthetists were interviewed. The interviews sought the answers to three open-ended questions. (i) When do you feel you have been successful in your work? (ii) What is difficult or what hinders you in your work? (iii) What is the core of your anaesthesia work? Transcripts of the interviews were analysed by a phenomenographic approach, a research method aiming to determine the various ways a group of people understand a phenomenon. Results. Six ways of understanding their work were defined: giving anaesthesia according to a standard plan; taking responsibility for the patient's vital functions; minimizing the patient's suffering and making them feel safe; giving service to specialist doctors to facilitate their care of patients; organizing and leading the operating theatre and team; and developing one's own competence, using the experience gained from every new patient for learning. Conclusions. Trainee anaesthetists understand their work in different ways. The trainee's understanding affects both his/her way of performing work tasks and how he/she develops new competences. A major task for teachers of anaesthesia is to create learning situations whereby trainees can focus on new aspects of their professional work and thus develop new ways of understanding it. © The Board of Management and Trustees of the British Journal of Anaesthesia 2004.

In-theatre training of anaesthetists in a teaching hospital: Has it changed over 10 years?

Background. We wished to ascertain in what way recent changes such as Modernising Medical Careers (MMC) and the implementation of the Working Time Directive (WTD) have affected clinical training and experience for anaesthetists in a teaching centre, in particular the provision of training in specialized fields of anaesthesia provided in the teaching hospital. Methods. Data were extracted from the computerized system for every operating theatre in this Trust. This provided a continuous record of all operations undertaken, and has previously been validated as an accurate record against individual anaesthetists' personal logbooks. We compared recent data with that of 10 yr ago. Results. Comparing data for 1997 and 2008 showed that registrars and post-fellowship senior registrars (SRs) in anaesthesia continue to be well supervised directly by consultants (49% and 39%) and subspeciality training has been protected in our department. Average case numbers for SRs increased from 442 to 623 yr-1, including an increase in emergency workload and theatre cases undertaken during the evening and at night. Although average case numbers for both SRs and consultants increased, we detected a small decrease in average case numbers from 394 to 353 yr-1 for pre-fellowship registrars. Conclusions. In spite of many pressures on training in the clinical setting, the number of cases and senior supervision in specialist modules for trainee anaesthetists in our teaching hospital has been maintained. Continuous monitoring of in-theatre supervision is one way of confirming that training is not compromised as changes occur in hospital workload.

Motivational influences on anaesthetists' use of practice guidelines

Background. With the proliferation of practice guidelines in anaesthesia comes the possibility that anaesthetists may, during the course of their work, commit 'violations' (actions that are not intended to cause harm to patients, but that deviate from guidelines). These may have a long-term impact on patient safety, and so there is a need to understand what makes anaesthetists decide to follow or deviate from guidelines. Methods. A questionnaire on the use of guidelines was completed by 629 College Fellows. This presented three anaesthetic scenarios, each of which involved a deviation from a guideline, and asked respondents to rate their beliefs about the likely outcome of the violation, the level of social approval they would have for violating, the amount of control they would have over violating, and the practice of their peers with regard to violating. Results. In all three scenarios, beliefs about the outcome of violating and the amount of control over violating predicted respondents' self-reported likelihood that they would commit the violation. In two scenarios, beliefs about the practice of peers predicted violating. Level of social approval predicted violating in one scenario only. Conclusions. Anaesthetists' decisions to follow or deviate from guidelines are influenced by the beliefs they hold about the consequences of their actions, the direct or indirect influence of others, and the presence of factors that encourage or facilitate particular courses of action.

Making robust assessments of specialist trainees' workplace performance

Background. Workplace-based assessments should provide a reliable measure of trainee performance, but have met with mixed success. We proposed that using an entrustability scale, where supervisors scored trainees on the level of supervision required for the case would improve the utility of compulsory mini-clinical evaluation exercise (CEX) assessments in a large anaesthesia training program. Methods. We analysed mini-CEX scores from all Australian and New Zealand College of Anaesthetists trainees submitted to an online database over a 12-month period. Supervisors' scores were adjusted for the expected supervision requirement for the case for trainees at different stages of training. We used generalisability theory to determine score reliability. Results. 7808 assessments were available for analysis. Supervision requirements decreased significantly (P < 0.05) with increased duration and level of training, supporting validity. We found moderate reliability (G > 0.7) with a feasible number of assessments. Adjusting scores against the expected supervision requirement considerably improved reliability, with G > 0.8 achieved with only nine assessments. Three per cent of trainees generated average mini-CEX scores below the expected standard. Conclusions. Using an entrustment scoring system, where supervisors score trainees on the level of supervision required, mini-CEX scores demonstrated moderate reliability within a feasible number of assessments, and evidence of validity. When scores were adjusted against an expected standard, underperforming trainees could be identified, and reliability much improved. Taken together with other evidence on trainee ability, the mini-CEX is of sufficient reliability for inclusion in high stakes decisions on trainee progression towards independent specialist practice. © 2017 The Author.

Leadership of United States academic anesthesiology programs 2006: Chairperson characteristics and accomplishments

BACKGROUND/METHODS: We conducted an Internet-based survey of all current academic anesthesiology chairpersons to benchmark their characteristics and accomplishments, as well as to gain insights that might be useful to aspirant department chairs. RESULTS: The response rate was 55%; chairs were predominantly male (92%), with a mean age of 55 yr and an average time in post of 6.5 yr. They were American medical graduates (82%), had undergone a research (31%) or a clinical fellowship (57%), were full professors (86%) and practiced most commonly as generalists and in intensive care. Chairs had a significant record of scholarship, including a median of 30 peer-reviewed papers, and an average of 11.0 industry and 2.7 federal grants. Thirty-two percent served as editors of peer-reviewed journals and 42% have served as president/chairman of national committees. Fully 30% of current chairs had previous experience as a chair. Sixty-eight percent of current chairs decided early in their career (at the resident/fellow or assistant professor level) that they wished to be a chair. In advising aspirant chairs, the most helpful experience to being a chair was that of having served as a vice chair, and the highest rated advice was to become a division director. Chairs were predominantly satisfied with their position (median 3 of 10) and 44% would return to clinical anesthesiology after chairmanship. CONCLUSIONS: The survey suggests that anesthesiology chairs value peer-reviewed research, scholarship, and academic achievement, but do not believe that significant research experience is of great benefit to functioning as a chair. © 2007 by International Anesthesia Research Society.

Anticipation of the difficult airway: Preoperative airway assessment, an educational and quality improvement tool

BackgroundAssessment of the potentially difficult airway (DA) is a critical aspect of resident education. We investigated the impact of a new assessment form on airway prediction and management by anaesthesia residents. We hypothesized that residents would demonstrate improvement in evaluation of DAs over the study duration.MethodsAfter IRB approval, anaesthesia residents were randomized into two groups: control (existing form) and experimental (new form). Data were collected prospectively from August 2008 to May 2010 on all non-obstetric adult patients undergoing non-emergent surgery.ResultsEight thousand three hundred and sixty-four independent preoperative assessments were collected and 8075 were analysed. The experimental group had the higher completion rate than the control group (94.3% vs 84.3%, P=0.001). DA prediction was higher for the control group (71.2%) compared with the experimental group (69.1%; P=0.032). A significant improvement in prediction rates was found over time for the experimental group (likelihood estimate=0.00068, P=0.031).ConclusionsThe use of a comprehensive airway assessment did not improve resident ability to predict a DA in an academic, tertiary-based hospital, anaesthesiology residency training programme. © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Anaesthetic management and outcomes in patients with surgically corrected D-transposition of the great arteries undergoing non-cardiac surgery

BackgroundPatients with effective repair of D-transposition of the great arteries (D-TGA) increasingly present for non-cardiac surgery. These patients may be predisposed to heart failure, arrhythmias, and sudden death, especially after the atrial switch repair. This retrospective study was undertaken to review the care and outcomes of patients with D-TGA who presented for non-cardiac surgery.MethodsRecords for patients with surgically corrected D-TGA undergoing general anaesthesia for non-cardiac surgery between October 2000 and April 2008 were reviewed. The anaesthesiology records, operative note, admission history and physical examination records, and discharge summaries of these patients were reviewed and the following data collected: patient characteristics; comorbidities; surgical procedure; anaesthetic and monitoring techniques; intra- and postoperative complications; and admission status.ResultsFifty procedures, including 43 in the paediatric setting and seven in the adult setting, comprised the final sample. The majority of these patients received anaesthesia on an outpatient basis in the paediatric hospital, without invasive monitoring and without complication. There were four adverse events including a significant bradycardia, failed extubation after two of the procedures, and postoperative bleeding requiring return to the operating theatre in another.ConclusionsData suggest that the majority of patients with surgically corrected D-TGA can safely undergo general anaesthesia, often as outpatients, with no invasive monitoring. However, given the incidence of adverse events, it remains imperative that the perioperative care be individualized based on the presence of comorbidities, type of repair, residual cardiac disease, severity of planned surgery, and experience of the provider.

Visual metaphors on anaesthesia monitors do not improve anaesthetists' performance in the operating theatre

BackgroundPrevious research using a metaphorical anaesthesia monitor, where dimensions of rectangles proportionally represent 30 patient variable values, showed improved performance in diagnosing adverse events compared with the standard monitor. Steady-state values were represented by a frame around each rectangle. We developed a similar metaphorical anaesthesia interface, but instead of presenting four relatively simple complications, we presented 10 complications of various levels of difficulty. Our simplified monitor presented variables that anaesthetists and trainees suggested as being essential for diagnosis.MethodsThirty-two anaesthetists and anaesthesia trainees participated in the monitoring task. Three types of monitors were presented: standard monitor, metaphorical monitor, and metaphorical monitor with trend arrows emphasizing the direction of change. The subjects were presented with screenshots of the three monitor types displaying anaesthesia-related complications. They were asked to indicate treatment method and diagnosis for the displayed complication.ResultsNo significant differences were found in time to diagnosis and accuracy between the metaphorical and standard monitor. There were also no differences between trend and no-trend monitors. Forty per cent of the complications were identified incorrectly.ConclusionsVisual metaphors on anaesthesia monitors do not improve anaesthetists' performance in the operating theatre. Since all complications in this study were identifiable based on monitor values alone, it seems feasible to develop a decision support system (DSS) based on these values. We suggest that a DSS could support the anaesthetist by calling attention to diagnoses that may not be considered. © 2013 Author.

Scholarly activity points: A new tool to evaluate resident scholarly productivity

BackgroundScholarly activity is an important aspect of a resident's educational experience; however, evaluation methods have remained underdeveloped despite the increased focus over the last decade. A new scoring system is proposed as a comprehensive evaluation tool.MethodsIn this scoring system, each scholarly activity (i.e. abstracts, manuscripts, book chapters, research protocols, and research grants) are converted into a numerical score, Scholarly Activity Points (SAPs), which reflects the complexity of the project and the degree of resident's involvement. First, a relative weight value is given to each scholarly category based on its complexity (i.e. 50 points to an abstract, 150 to a manuscript). Then SAPs are calculated with modifiers specific to each scholarly activity (i.e. for an abstract, meeting venue, repeated presentation, authorship, abstract category, and awards). To demonstrate how the system works, a list of scholarly activities by anaesthesia residents graduating from a university programme between 2003 and 2010 was obtained. SAP scores of graduating classes were analysed.ResultsDuring the 2003-2010 academic years, a total of 106 residents (the mean of 13 per class, ranging from 9 to 19) graduated from the full 3 yr residency programme. The SAP system allowed statistical comparison among the graduated classes of overall scholarly productivity; significant increases were noted in the average SAPs per resident among the classes of 2009 [154 (204), [mean (sd)]] and 2010 [524 (471)] compared with those by the classes of 2003-2006 [90 (188), 45 (73), 126 (349), 83 (205), respectively].ConclusionsA new scoring system enabled a comprehensive statistical evaluation of residents' scholarly productivity. © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

How excellent anaesthetists perform in the operating theatre: A qualitative study on non-technical skills

BackgroundTeaching trainees to become competent professionals who can keep the complex system of anaesthesia safe is important. From a safety point of view, non-technical skills such as smooth cooperation and good communication deserve as much attention as theoretical knowledge and practical skills, which by tradition have dominated training programmes in anaesthesiology. This study aimed to describe the way excellent anaesthetists act in the operating theatre, as seen by experienced anaesthesia nurses.MethodsThe study had a descriptive and qualitative design. Five focus group interviews with three or four experienced Swedish anaesthesia nurses in each group were conducted. Interviews were analysed by using a qualitative method, looking for common themes.ResultsSix themes were found: (A) structured, responsible, and focused way of approaching work tasks; (B) clear and informative, briefing the team about the action plan before induction; (C) humble to the complexity of anaesthesia, admitting own fallibility; (D) patient-centred, having a personal contact with the patient before induction; (D) fluent in practical work without losing overview; and (F) calm and clear in critical situations, being able to change to a strong leading style.ConclusionsExperienced anaesthesia nurses gave nuanced descriptions of how excellent anaesthetists behave and perform. These aspects of the anaesthetist's work often attract too little attention in specialist training, notwithstanding their importance for safety and fluency at work. Creating role models based on studies like the present one could be one way of increasing safety in anaesthesia. © The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Resistance, reverse flow and opening pressure of unidirectional valves

Based on a new preliminary standard of the‘Comité Européen de Normalisation’, the following unidirectional valves were tested with regard to resistance, opening pressure, reverse flow and dislocation: the Dräger inspiratory and expiratory valves, the Engström inspiratory valve, the Ohmeda valve, the Siemens Ventilator 710 inspiratory and expiratory valves, the Siemens Ventilator 900C unidirectional valve of the absorber and the Megamed 700 inspiratory and expiratory valves of the circle system 219 (Megamed 700 CS 219). The following valves fulfilled all Comité Européen de Normalisation requirements: Dräger inspiratory and expiratory valves, Siemens 900 absorber valve and Megamed 700 CS 219 inspiratory valve. The Siemens 710 valve and the Megamed 700 CS 219 expiratory valve did not meet the requirements for flow resistance. The Ohmeda and Siemens 710 valves and the Engström inspiratory valve did not fulfil the Comité Européen de Normalisation requirements for reverse flow. In addition, the Engström inspiratory valve did not comply with the dislocation test. The requirements for the opening pressure were met by all the valves tested. Valves with the disc in a horizontal position achieved better results than those with the disc in a vertical position. These measurements, showing the differences in the performance of various types of valves confirm the feasibility of the standards proposal. Copyright © 1995, Wiley Blackwell. All rights reserved

Twenty years of collaboration between Belgium and Benin in training anesthesiologists for Africa

Belgium has been collaborating for 20 years with Abomey-Calavi University in Cotonou, Republic of Benin, to train anesthesiologists for Sub-Saharan, French-speaking African countries. With 123 graduates from 15 countries and 46 residents still in training, this program has succeeded in reversing the trend of a decreasing anesthesiology workforce in those countries, thus improving the quality of anesthesia and patient safety. Belgian government sources, as well as hospitals and anesthesia teams, provided most of the financial resources. Reasons for success, positive outcomes, and shortcomings are discussed, as well as future perspectives and threats. Failure to enroll enough female residents (15%) and brain drain (18% of alumni) are of concern. Alumni are capable of importing and adapting modern technology and practice. Graduates increase the impact of the Cotonou program by getting involved in teaching nonphysician anesthesia providers and by supporting new anesthesiology training programs being launched in several countries. Other African countries with training programs, by following this example, could accelerate anesthesiology progress by accepting foreign residents from the region. The role of anesthesiologists as anesthesia team leaders must be better defined, and residency training programs adapted accordingly. Continuing international support remains of critical importance, especially in the form of resident rotations to high-income countries. The development of structured anesthesiology programs should be encouraged by African governments as developing anesthesia is a prerequisite for surgical development in every discipline. © 2018 International Anesthesia Research Society.

Anaphylaxis during anaesthesia. Results of a two-year survey in France

Between January 1, 1997 and December 31, 1998, 467 patients were referred to one of the allergo-anaesthesia centres of the French GERAP (Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques) network and were diagnosed as having anaphylaxis during anaesthesia. Diagnosis was established on the basis of clinical history, skin tests and/or a specific IgE assay. The most frequent cause of anaphylaxis was a neuromuscular blocking agent (69.2%). Latex was less frequently incriminated (12.1%) than in previous reports. A significant difference was observed between the incidence of anaphylactic reactions observed with each neuromuscular blocking agent and the number of patients who received each drug during anaesthesia in France throughout the study period (P<0.0001). Succinylcholine and rocuronium were most frequently incriminated. Clinical reactions to neuromuscular blocking drugs were more severe than to latex. The diagnostic value of specific IgE assays was confirmed. These results are consistent with changes in the epidemiology of anaphylaxis related to anaesthesia and are an incentive for the further development of allergo-anaesthesia clinical networks.

Blood concentrations of nitrous oxide in theatre personnel

Blood concentrations of nitrous oxide were measured in anaesthetists, surgeons and theatre nursus. Comparison of anaesthetists and surgeons working in the same theatre showed that in ENT surgeons concentrations were greater (p≪0.01), while in general surgeons they were smaller (P≪0.003). Blood concentrations of nitrous oxide in the "circulating" nurses were low; with scavenging they were unmeasurable. Atmogpheric concentrations in the breathing zones were usually greater than the correspondmg blood concentrations, but this was not always true. However, a positive correlation between blood and atmospheric concentrations was obrained (r = 0.82). Meticulous use of scavenging devices produced a mean reduction in blood nitrous oxide concentranons of 86% for all groups. The mean blood concentration of nitrous oxide in anaesthetists when scavenging was used was 45 p.p.m. (1.9 μmol litre-1).This figure should be taken into account in establishing maximum permitted exposure to nitrous oxide. © 1980 Macmillan Publishers Ltd.

Book reviews

Book reviewed in this article PRACTICAL ANESTHESIOLOGY J.F.ARTUSIO and V.D.B.MAZZIA ELDERLY PATIENTS, THEIR MEDICAL CARE BEFORE AND AFTER OPERATION KENNETH HAZELL DRUG ADDICTION LAWRENCE KOLB LOCAL ANALGESIA, ABDOMINAL SURGERY SIR ROBERT MACINTOSH and R.BRYCE‐SMITH Copyright © 1963, Wiley Blackwell. All rights reserved

Book reviews

Book reviewed in this article: Anaesthesia at the district hospital M.B. Dobson. A tribute to Professor Sir Robert Macintosh for his 90th birthday Edited by W.D.A. Smith and G.M.C. Paterson. Clinical anatomy for anesthesiologists R.S. Snell and J. Katz. Anesthesiology report Vol. 1. No. 1. Edited by M.C. Rogers, R.C. Wetzel, E.D. Miller Jr. and W.D. Watkins. Copyright © 1989, Wiley Blackwell. All rights reserved

Book reviews

Book reviews in this article: Energy metabolism in trauma. Ciba Foundation symposium Edits R. Porter and J. Knight. Progress in Anaesthesiology: proceedings of the Fourth World Congress of Anaesthesiologists Editors T. B. Boulton, R. Bryce‐Smith, M. K. Sykes, G. B. Gillet, A. L. Revell. The Respiratory Muscles: Mechanics and Neural Control E. J. M. Campbell, E. Agostoni and J. Newsom Davis. Copyright © 1971, Wiley Blackwell. All rights reserved

Book reviews

Books review in this article: A laboratory basis for anesthesiology G. DAL SANTO. Pain relief and anaesthesia in childbirth P. BROWSRIDGE. Psychology, pain and anaesthesia Edited by H.B. GIBSOK. Copyright © 1994, Wiley Blackwell. All rights reserved

Book Reviews

Books reviewed in this article: ESSAYS ON THE FIRST HUNDRED YEARS OF ANESTHESIA. Volume 2&#x2028;W. STANLEY SYKES THE CONQUEST OF PAIN&#x2028;RONALD WOOLMER CONE OF OBLIVION&#x2028;L. J. LUDOVICI CLINICAL ELECTROENCEPHALOGRAPHY&#x2028;L. G. KILOH and J. W. OSSELTON APPRAISAL OF CURRENT CONCEPTS IN ANESTHESIOLOGY&#x2028;Edited by JOHN ADRIANI THE OPERATION&#x2028;LEONARD ENGEL INTRODUCTION TO ANESTHESIA THE PRINCIPLES OF SAFE PRACTICE (Second edition)&#x2028;ROBERT D. DRIPPS, JAMES E. ECKENHOFF and LEROY D. VANDAM AN INTRODUCTION TO ANESTHETICS&#x2028;JOHN D. LAYCOCK Copyright © 1962, Wiley Blackwell. All rights reserved

The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice

Both the American Society of Anesthesiologists and the Difficult Airway Society of the United Kingdom have published guidelines for the management of unanticipated difficult intubation. Both algorithms end with the 'can't intubate, can't ventilate' scenario. This eventuality is rare within elective anaesthetic practice with an estimated incidence of 0.01-2 in 10 000 cases, making the maintenance of skills and knowledge difficult. Over the last four years, the Department of Anaesthetics at the Royal Perth Hospital have developed a didactic airway training programme to ensure staff are appropriately trained to manage difficult and emergency airways. This article discusses our training programme, the evaluation of emergency airway techniques and subsequent development of a 'can't intubate, can't ventilate' algorithm. © 2009 The Authors.

Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: A cohort study of 188 064 patients registered in the Danish Anaesthesia Database

Both the American Society of Anesthesiologists and the UK NAP4 project recommend that an unspecified pre-operative airway assessment be made. However, the choice of assessment is ultimately at the discretion of the individual anaesthesiologist. We retrieved a cohort of 188 064 cases from the Danish Anaesthesia Database, and investigated the diagnostic accuracy of the anaesthesiologists' predictions of difficult tracheal intubation and difficult mask ventilation. Of 3391 difficult intubations, 3154 (93%) were unanticipated. When difficult intubation was anticipated, 229 of 929 (25%) had an actual difficult intubation. Likewise, difficult mask ventilation was unanticipated in 808 of 857 (94%) cases, and when anticipated (218 cases), difficult mask ventilation actually occurred in 49 (22%) cases. We present a previously unpublished estimate of the accuracy of anaesthesiologists' prediction of airway management difficulties in daily routine practice. Prediction of airway difficulties remains a challenging task, and our results underline the importance of being constantly prepared for unexpected difficulties. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Chlorhexidine cleaning of re-usable bougies

Bougies are susceptible to becoming contaminated before or during use. Chlorhexidine wipes may have a residual antibacterial effect, potentially minimising bacterial transmission after bougie use or storage. We evaluated the decontaminant and antibacterial effectiveness of 70% alcohol/2% chlorhexidine wipes in laboratory, clinical and accelerated ageing studies, and conducted a telephone survey of normal practice. In the laboratory tests, chlorhexidine wipes were completely effective against Escherichia coli and methicillin-resistant Staphylococcus aureus, and prevented recontamination for 24 h. Clinical introduction of chlorhexidine wipes reduced bougie contamination from 33% to 0%. Following 150 cleaning episodes, there was no physical or functional damage to the bougies. Eight out of nine hospitals in the East of England Health Region use re-usable bougies. We recommend that following decontamination, bougies should be wiped with 70% alcohol/2% chlorhexidine wipes, to retain antimicrobial activity during handling. © 2013 The Association of Anaesthetists of Great Britain and Ireland.

Assessing the efficacy of HME filters at preventing contamination of breathing systems

Breathing system filters are intended to prevent cross-infection during anaesthesia. However, there is a lack of information on whether filters prevent contamination of the breathing system by the patient. We measured the contamination of 235 used filters of four different types obtained from operating theatres: two pleated hydrophobic (BB25M and BB22/15M, Pall Medical, Portsmouth, UK) used for adult patients and two electrostatic (355/5430 Hygroboy and 355/5427 Hygrobaby, Tyco Healthcare, Gosport, UK) used for paediatric patients. The filters were swabbed over their internal surfaces on both the patient and the machine sides and these were assessed with the use of adenosine triphosphate bioluminescence. Contamination was present on the machine side of 20 (9%) filters. Current standards for testing of filters has no set 'pass' level and is performed in the laboratory setting. Bioluminescence may be used in the clinical setting to elucidate factors that might increase the chance of cross-contamination between patients. © 2007 The Authors Journal compilation © 2007 The Association of Anaesthetists of Great Britain and Ireland.

The effect of ventilation system design on air contamination with halothane in operating theatres

By measuring the halothane concentrations in samples of air from three different operating theatres during routine operating lists the pattern of spread of the waste anaesthetic gases has been demonstrated. The results show that in all the theatres there was a spread of halothane from its point of escape from the anaesthetic circuit to all parts of the theatre air. A turbulent flow ventilation system produced an uneven spread with the greates concentrations in the zone of air breathed by standing personnel. A downward displacement system produced a more even spread throughout the theatre but with a much reduced general level of pollution. © 1974 John Sheratt and Son Ltd.

The World Federation of Societies of Anaesthesiologists Minimum Capnometer Specifications 2021-A Guide for Health Care Decision Makers

Capnometry, the measurement of respiratory carbon dioxide, is regarded as a highly recommended safety technology in intubated and nonintubated sedated and/or anesthetized patients. Its utility includes confirmation of initial and ongoing placement of an airway device as well as in detecting gas exchange, bronchospasm, airway obstruction, reduced cardiac output, and metabolic changes. The utility applies prehospital and throughout all phases of inhospital care. Unfortunately, capnometry devices are not readily available in many countries, especially those that are resource-limited. Constraining factors include cost, durability of devices, availability of consumables, lack of dependable power supply, difficulty with cleaning, and maintenance. There is, thus, an urgent need for all stakeholders to come together to develop, market, and distribute appropriate devices that address costs and other requirements. To foster this process, the World Federation of Societies of Anaesthesiologists (WFSA) has developed the "WFSA-Minimum Capnometer Specifications 2021." The intent of the specifications is to set the minimum that would be acceptable from industry in their attempts to reduce costs while meeting other needs in resource-constrained regions. The document also includes very desirable and preferred options. The intent is to stimulate interest and engagement among industry, clinical providers, professional associations, and ministries of health to address this important patient safety need. The WFSA-Minimum Capnometer Specifications 2021 is based on the International Organization for Standardization (ISO) capnometer specifications. While industry is familiar with such specifications and their presentation format, most clinicians are not; therefore, this article serves to more clearly explain the requirements. In addition, the specifications as described can be used as a purchasing guide by clinicians. Copyright © 2021 International Anesthesia Research Society.

Cardiac anesthesia: Thirty years later-the second annual Arthur E. Weyman lecture

Cardiac anesthesiology has evolved spectacularly over the past 30 yr, changing from a practice focused on the anesthetic management of patients with cardiovascular diseases to a practice of cardiovascular medicine that contributes to the medical and surgical management of cardiovascular patients. The second Weyman lecture reviews this history, the critical role of the Society of Cardiovascular Anesthesiologists in the evolution of the specialty, and the prospects for continued development for the specialty, the society, and the patients they care for. © 2009 International Anesthesia Research Society.

A survey on the intended purposes and perceived utility of preoperative cardiology consultations

Cardiology consultations are often requested by surgeons and anesthesiologists for patients with cardiovascular disease. There can be confusion, however, regarding both the reasons for a consultation and their effect on patient management. This study was designed to determine the attitudes of physicians toward preoperative cardiology consultations and to assess the effect of such consultations on perioperative management. A multiple-choice survey regarding the purposes and utility of cardiology consultations was sent to randomly selected New York metropolitan area anesthesiologists, surgeons, and cardiologists. In addition, the charts of 55 consecutive patients aged >50 yr who received preoperative cardiology consultations were examined to determine the stated purpose of the consult, recommendations made, and concordance by surgeons and anesthesiologists with cardiologists' recommendations. Of the 400 surveys sent to each specialty, 192 were returned from anesthesiologists, 113 were returned from surgeons, and 129 were returned from cardiologists. There was substantial disagreement on the importance and purposes of a cardiology consult:intraoperative monitoring, 'clearing the patient for surgery,' and advising as to the safest type of anesthesia were regarded as important by most cardiologists and surgeons but as unimportant by anesthesiologists (all P < 0.05). Most surgeons (80.2%) felt obligated to follow a cardiologist's recommendations, whereas few anesthesiologists (16.6%) felt so obligated (P < 0.05). The most commonly stated purpose of the 55 cardiology consultations examined was 'preoperative evaluation.' Only 5 of these (9%) were obtained for patients in whom there was a new finding. Of the cardiology consultations, 40% contained no recommendations other than 'proceed with case,' 'cleared for surgery,' or 'continue current medications.' Recommendations regarding intraoperative monitoring or cardiac medications were largely ignored. Implications: We conclude that there seems to be considerable disagreement among anesthesiologists, cardiologists, and surgeons as to the purposes and utility of cardiology consultations. A review of 55 consecutive cardiology consultations suggests that most of them give little advice that truly affects management.

Changing specialties: Do anesthesiologists differ from other physicians?

Career choices of physicians frequently change after senior year in medical school. Although previous studies have documented the magnitude of these changes, they contain no information concerning anesthesiologists. Changes in specialities of 1151 physicians, graduates from the same medical school, between the years 1968 and 1976 were studied. Of these physicians, 35 (3%) are presently engaged in the practice anesthesiology. Of 31 physicians who planned careers in anesthesiology as seniors, 26 (84%) remained in anesthesiology. Nine physicians changed from other specialities to anesthesiology. The ability of anesthesiology to retain physicians who originally planned to specialize in it, or to gain physicians from other fields, was not different from that found in other specialties studied.

Caroline B. Palmer: Pioneer physician anesthetist and first chair of anesthesia at Stanford

Caroline B. Palmer was appointed as Chief of Anesthesia at Cooper Medical College (soon renamed as Stanford Medical School) in 1909. For the next 28 years, she was an innovative leader, a clinical researcher, and a strong advocate for recognition of anesthesiology as a medical specialty. To honor her accomplishments, the operating room suite in the new Stanford Hospital will be named after this pioneering woman anesthesiologist. © 2015 International Anesthesia Research Society.

Micropuncture needles combined with ultrasound guidance for unusual central venous cannulation: Desperate times call for desperate measures-A new trick for old anesthesiologists

Central vascular access can be a very challenging task in patients with skeletal deformities such as ankylosing spondylitis, kyphosis, and chin-on-chest deformity. The use of traditional methods of accessing the central venous circulation in these patients can require multiple attempts and may lead to significant complications such as bleeding, pneumothorax, and vascular injury. Ultrasound-guided central venous access has become a very common procedure in the United States and Europe; its efficacy and safety have been demonstrated, and together with the use of micropuncture needles, the technique can facilitate central venous access in complicated cases. © 2012 International Anesthesia Research Society.

Influence of less than full-time or full-time on totality of training and subsequent consultant appointment in anaesthesia

Changes in medical training have increased the popularity of less than full-time training. However, there are no data on the impact on training time or consultant workforce. We reviewed a three-year cohort of trainees via the Royal College of Anaesthetist's training and recruitment databases. Eighty-eight (96%) less than full-time trainees and 677 (95%) full-time trainees were appointed to a substantive consultant post (p = 0.82). Three (3%) less than full-time trainees and 12 (2%) full-time trainees gained part-time consultant posts (p < 0.001). Average length of training (years, months, days) was 8 y, 5 m, 6 d (median (IQR [range]) 5 y, 0 m, 14 d (4 y, 11 m, 29 d - 9 y, 8 m, 3 d [4 y, 2 m, 18 d - 12 y, 0 m, 0 d]) for full-time and 10 y, 8 m, 23 d (median (IQR [range]) 7 y, 3 m, 28 d (6 y, 7 m, 24 d - 11 y, 1 m, 23 d [4 y, 11 m, 29 d - 11 y, 9 m, 10 d]) for less than full-time trainees. The average length of training for both groups is significantly longer than the seven years used in workforce planning. © 2015 The Association of Anaesthetists of Great Britain and Ireland.

Litigation related to airway and respiratory complications of anaesthesia: An analysis of claims against the NHS in England 1995-2007

Claims notified to the NHS Litigation Authority in England between 1995 and 2007 and filed under anaesthesia were analysed to explore patterns of injury and cost related to airway or respiratory events. Of 841 interpretable claims the final dataset contained 96 claims of dental damage, 67 airway-related claims and 24 respiratory claims. Claims of dental damage contributed a numerically important (11%), but financially modest (0.5%) proportion of claims. These claims predominantly described injury during tracheal intubation or extubation; a minority associated with electroconvulsive therapy led to substantial cost per claim. The total cost of (non-dental) airway claims was £4.9 million (84% closed, median cost £30 000) and that of respiratory claims was £3.3 million (81% closed, median £27 000). Airway and respiratory claims account for 12% of anaesthesia-related claims, 53% of deaths, 27% of cost and ten of the 50 most expensive claims in the dataset. Airway claims most frequently described events at induction of anaesthesia, involved airway management with a tracheal tube and typically led to hypoxia and patient death or brain injury. Airway trauma accounted for one third of airway claims and these included deaths from mediastinal injury at intubation. Pulmonary aspiration and tube misplacement, including oesophageal intubation, led to several claims. Among respiratory claims, ventilation problems, combined with hypoxia, were an important source of claims. Although limited clinical details hamper analysis, the data suggest that most airway and respiratory-related claims arise from sentinel events. The absence of clinical detail and denominators limit opportunities to learn from such events; much more could be learnt from a closed claim or sentinel event analysis scheme. © 2010 The Association of Anaesthetists of Great Britain and Ireland.

Action guidance for addressing pollution from inhalational anaesthetics

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well-being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare-related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well-established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action-oriented recommendations, supported by useful resources and success stories. The CODA-hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence-based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia. © 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

The laryngeal mask airway in children: A fibreoptic assessment of positioning

Clinical and fibreoptic assessment of the positioning of the laryngeal mask airway was performed in 100 children. Clinical observation indicated a patent airway in 98% and severe airway obstruction in 2% of cases. Perfect positioning, as judged by fibreoptic laryngoscopy, was found in 49% and the epiglottis was within the mask in 49%. Fibreoptic evidence of partial airway obstruction in 17%, was not detected clinically. Copyright © 1991, Wiley Blackwell. All rights reserved

Development, Reporting, and Evaluation of Clinical Practice Guidelines

Clinical practice parameters have been published with greater frequency by professional societies and groups of experts. These publications run the gamut of practice standards, practice guidelines, consensus statements or practice advisories, position statements, and practice alerts. The definitions of these terms have been clarified in an accompanying article. In this article, we present the criteria for high-quality clinical practice parameters and outline a process for developing them, specifically the Delphi method, which is increasingly being used to build consensus among content experts and stakeholders. Several tools for grading the level of evidence and strength of recommendation are offered and compared. The speciousness of categorizing guidelines as evidence-based or consensus-based will be explained. We examine the recommended checklist for reporting and appraise the tools for evaluating a practice guideline. This article is geared toward developers and reviewers of clinical practice guidelines and consensus statements. © 2019 International Anesthesia Research Society.

A Call to Action: A Specialty-Specific Course to Support the Next Generation of Clinician Scientists in Anesthesiology

Clinical production pressure is a significant problem for faculty of anesthesiology departments who seek to remain involved in research. Lack of protected time to dedicate to research and insufficient external funding add to this long-standing issue. Recent trends in funding to the departments of anesthesiology and their academic output validate these concerns. A 2022 study examining National Institutes of Health (NIH) grant recipients associated with anesthesiology departments across 10 years (2011-2020) outlines total awarded funds at $1,676,482,440, with most of the funds awarded to only 10 departments in the United States. Of note, the total 1-year NIH funding in 2021 for academic internal medicine departments was 3 times higher than the 10-year funding of anesthesiology departments. Additionally, American Board of Anesthesiology (ABA) diplomats represent a minority (37%) of the anesthesiology researchers obtaining grant funding, with a small number of faculty members receiving a prevalence of monies. Overall, the number of publications per academic anesthesiologist across the United States remains modest as does the impact of the scholarly work. Improving environments in which academic anesthesiologists thrive may be paramount to successful academic productivity. In fact, adding to the lack of academic time is the limited bandwidth of senior academic physicians to mentor and support aspiring physician scientists. Given then the challenges for individual departments and notable successes of specialty-specific collaborative efforts (eg, Foundation for Anesthesia Education and Research [FAER]), additional pooled-resource approaches may be necessary to successfully support and develop clinician scientists. It is in this spirit that the leadership of Anesthesia & Analgesia and The Journal of Education in Perioperative Medicine, unified with the Association of University Anesthesiologists, aim to sponsor the Introduction to Clinical Research for Academic Anesthesiologists (ICRAA) Course. Directed toward early career academic anesthesiologists who wish to gain competency specifically in the fundamentals of clinical research and receive mentorship to develop an investigative project, the yearlong course will provide participants with the skills necessary to design research initiatives, ethically direct research teams, successfully communicate ideas with data analysts, and write and submit scientific articles. Additionally, the course, articulated in a series of interactive lectures, mentored activities, and workshops, will teach participants to review articles submitted for publication to medical journals and to critically appraise evidence in published research. It is our hope that this initiative will be of interest to junior faculty of academic anesthesiology departments nationally and internationally. © 2022 Lippincott Williams and Wilkins. All rights reserved.

Publications in Anesthesia Journals: Quality and clinical relevance

Clinicians performing evidence-based anesthesia rely on anesthesia journals for clinically relevant information. The objective of this study was to analyze the proportion of clinically relevant articles in five high impact anesthesia journals. We evaluated all articles published in Anesthesiologiy, Anesthesia & Analgesia, British Journal of Anesthesia, Anesthesia, and Acta Anaesthesiologica Scandinavica from January to June, 2000. Articles were assessed and classified according to type, outcome, and design; 1379 articles consisting of 5468 pages were evaluated and categorized. The most common types of article were animal and laboratory research (31.2%) and randomized clinical trial (20.4%). A clinically relevant article was defined as an article that used a statistically valid method and had a clinically relevant end-point. Altogether 18.6% of the pages had as their subject matter clinically relevant trials. We compared the Journal Impact Factor (a measure of the number of citations per article in a journal) and the proportion of clinically relevant pages and found that they were inversely proportional to each other.

The use of cognitive aids during emergencies in anesthesia: A review of the literature

Cognitive aids are prompts designed to help users complete a task or series of tasks. They may take the form of posters, flowcharts, checklists, or even mnemonics. It has been suggested that the use of cognitive aids improves performance and patient outcomes during anesthetic emergencies; however, a systematic assessment of the evidence is lacking. The aim of this literature review was to determine (1) whether cognitive aids improve performance of individuals and teams and (2) whether recommendations can be made for future cognitive aid design, testing, and implementation. Medical, nursing, and psychology databases were searched using broad criteria to find cognitive aids that have been reported in the literature for use in anesthetic emergencies. The reference lists of the articles selected for review were also screened to identify additional studies. Selected articles that described the evaluation of cognitive aids used in anesthetic emergencies were reviewed to determine how the content of the aid was derived, how the design was evaluated, and the success of the aid in improving technical and team performance. The search yielded 22 cognitive aids developed to support clinicians during anesthetic emergencies that had been evaluated in 23 studies. Ten studies using simulation suggested that technical performance improves with the use of cognitive aids in some anesthetic emergencies such as malignant hyperthermia, cardiopulmonary resuscitation, and airway management. However, in 3 of the simulator-based evaluations, participants had either no improvement or took longer to diagnose and treat and made more incorrect diagnoses. Four studies investigated the effect of the aids on teamwork with differing conclusions. One study suggested improved participants' coordination patterns and one found aids improved their decision-making scores, but 2 other studies indicated that there was no improvement and even provided evidence of reduced levels of team communication when teams used a cognitive aid in simulated conditions. The designs of cognitive aids were rarely considered. Education may compensate for a poorly designed aid, but only by ingraining correct actions for situations in which the aid provides little or no guidance. Cognitive aids should continue to be developed from established clinical guidelines where guidelines exist. They would also benefit from more extensive simulation-based usability testing before use. Further evidence is required to explore the effects of cognitive aids in anesthetic emergencies, how they affect team function, and their design considerations. Copyright © 2013 International Anesthesia Research Society.

State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018

Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were ‘never the same’ prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects. © 2019 British Journal of Anaesthesia

The relationship of cognitive, personality, and academic measures to anesthesiology resident clinical performance

Cognitive skills (including vigilance), personality factors, and standardized academic test performance may be associated with clinical competence in anesthesiology to varying degrees. Sixty-seven anesthesiology residents in training at one center between 1993 and 1995 were administered the modified Vigil (For Thought, Ltd., Nashua, NH), the Paced Auditory Serial Addition Test, the California Personality Inventory, the State-Trait Anxiety Inventory, and five standardized academic performance tests. The clinical performance of anesthesiology residents was rated on a quarterly basis by a clinical competence committee. A growth curve model indicated that there was significant variability in clinical competence at the start of residency and a statistically significant improvement over time, and that the relative ranking of the residents remained stable over the course of training. Of 46 potential variables, 7 were associated (P < 0.10) with poor clinical performance; these were subjected to a multivariate test (Mantel-Haenszel). Cognitive variables predicting poor clinical performance were difficulty performing a rapid mental arithmetic test requiring divided attention and commission errors during complex visual target detection. Personality variables predicting poor clinical performance were introversion and flexibility. A predictive academic variable was poor anesthesia knowledge as measured by using two different tests during the first month of training. There were varying levels of independence among these variables. Implications: Early academic test performance and certain cognitive and personality tests were associated with the clinical performance of anesthesiology residents. The predictive value of these findings should be confirmed in a prospective, multicenter study.

Nominal group technique: A method of decision‐making by committee

Committee‐work which involves decision‐making from a range of alternatives is frequently time‐consuming, inefficient, and frustrating. Nominal Group Technique is a structured method of group decision‐making which allows a rich generation of original ideas, balanced participation of all members of the group, and a rank‐ordered set of decisions based on a mathematical voting method. A brief description of a Nominal Group Technique session is given and its application to decision‐making by committees of anaesthetists is illustrated by an example. Copyright © 1980, Wiley Blackwell. All rights reserved

Customizable Curriculum to Enhance Resident Communication Skills

Communication remains challenging to teach and evaluate. We designed an online patient survey to assess anesthesia residents' communication skills from August 2014 to July 2015. In December 2014, we implemented a customized, simulation-based curriculum. We calculated an overall rating for each survey by averaging the ratings for the individual questions. Based on the Hodges-Lehmann 2-sample aligned rank-sum test, overall ratings, reported as the median (interquartile range) of residents' average overall ratings, differed significantly between the preintervention (3.86 [3.76-3.94]) and postintervention (3.91 [3.84-3.95]) periods (P =.025). Future studies should assess the intervention's effectiveness and generalizability. © 2019 International Anesthesia Research Society.

An evidence-based approach to airway management: Is there a role for clinical practice guidelines?

Complications arising out of airway management represent an important cause of anaesthesia-associated morbidity and mortality. Anaesthetic practice itself can lead to preventable harm, a particular example being persistent attempts at direct laryngoscopy, that results in delay in employing alternative strategies (or devices) when intubation is difficult. When patients are injured, expert review is called upon and often concludes that airway management provided by the anaesthetists was substandard. Many training programmes do not offer their trainees structured or organised teaching in airway management and many trainees probably enter practice with limited skills to deal with difficult airways. The literature on the management of the difficult airway in anaesthesia practice (especially as it relates to new technology and salvage strategies) is expanding rapidly. New technologies and practised response algorithms may be helpful in the management of the difficult airway, reducing the potential for adverse patient outcomes. Specialist societies and national interest groups can play an important role by critically reviewing and then applying the evidence base to generate clinical practice guidelines. The recommendations contained in such guidelines should be based on the most current evidence and they should be reviewed regularly for their content and continued relevance. © 2011 The Association of Anaesthetists of Great Britain and Ireland.

Design and analysis of studies with binary-event composite endpoints: Guidelines for anesthesia research

Composite endpoints consisting of several binary events, such as distinct perioperative complications, are frequently chosen as the primary outcome in anesthesia studies (and in many other clinical specialties) because (1) no single outcome fully characterizes the disease or outcome of interest, and/or (2) individual outcomes are rare and statistical power would be inadequate for any single one. Interpreting a composite endpoint is challenging because components rarely meet the ideal criteria of having comparable clinical importance, frequency, and treatment effects. We suggest guidelines for forming composite endpoints and show advantages of newer versus conventional statistical methods for analyzing them. Components should be a parsimonious set of outcomes, which when taken together, well represent the disease of interest and are very plausibly related to the intervention. Adding components that are too narrow, redundant, or minimally influenced by the study intervention compromises interpretation of results and reduces power. We show that multivariate (i.e., multiple outcomes per patient) methods of analyzing a binary-event composite provide distinct advantages over standard methods such as any-versus-none, count of events, or evaluation of individual events. Multivariate methods can incorporate clinical importance weights, compensate for events occurring at varying frequencies, assess treatment effect heterogeneity, and are often more powerful than alternative statistical approaches. Methods are illustrated with an American College of Surgeons National Surgical Quality Improvement Program registry study that evaluated the effects of smoking on major perioperative outcomes, and with a clinical trial comparing the effects of crystalloids and colloids on major complications. Sample data files and SAS code are included for convenience. Copyright © 2011 International Anesthesia Research Society.

Performance of computer-controlled infusion of propofol: An evaluation of five pharmacokinetic parameter sets

Computer-controlled infusion of propofol is used with increasing frequency for the induction and maintenance of anesthesia. The performance of computer- controlled infusion devices is highly dependent on how well the implemented pharmacokinetic parameter set matches the pharmacokinetics of the patient. This study examined the performance of a computer-controlled infusion device when provided with five different pharmacokinetic parameter sets of propofol in female patients. The infusion rate-time data that had been stored on a disk from 19 female patients who had been given propofol by computer- controlled infusion, using the pharmacokinetic parameter set from Gepts et al. (Anesth Analg 1987;66:1256-63), were entered into a computer simulation program to recalculate predicted propofol concentrations that would have been obtained with four other pharmacokinetic parameter (Shafer et al., Anesthesiology 1988;69:348-56; Kirkpatrick et al., Br J Anesth 1988;60:146- 50; Cockshott et al., Br J Anesth 1987;59:941P; Tackley et al., Br J Anesth, 1989;62:46-53) sets of propofol, had these been implemented. The performance error (PE) was determined for each measured blood propofol concentration, on the basis of each of the five pharmacokinetic parameter sets. Then, for each of the five pharmacokinetic parameter sets, the performance in the population was determined by the median absolute performance error (MDAPE), the median performance error (MDPE), the wobble (the median absolute deviation of each PE from the MDPE), and the divergence (the percentage change of the absolute PE with time). The MDPE and MDAPE were compared between the parameter sets by the multisample median test. The initially used pharmacokinetic parameter set from Gepts et al. resulted in a MDPE of 24% and MDAPE of 26%. In comparison with this parameter set (Gepts et al.), the computer simulations revealed that the pharmacokinetic parameter set of Kirkpatrick et al. resulted in a significantly worse performance (MDPE, and MDAPE: 106%, P < 0.001), whereas with the three other pharmacokinetic parameter sets the performance did not differ. For all five pharmacokinetic parameters sets the divergence (median and range) in the patients in Group A, who had received a stepwise increasing target propofol concentration, was significantly greater (median 42%; range, 31%-59%) compared to the corresponding divergence in the patients in Group B (median 1%; range -18%-4%; P < 0.05), who had received a single constant target propofol concentration. The PE thus did not increase with time but with increasing target propofol concentration. In conclusion, the pharmacokinetic parameter sets of propofol described by Gepts et al., Shafer et al., Cockshott et al., and Tackley et al. result in an equally clinical acceptable, but not optimal, performance of the computer-controlled infusion of propofol in the type of patients studied above. With all five pharmacokinetic parameter sets, the underprediction of the measured concentration increases with the increasing target concentration.

False individual patient data and zombie randomised controlled trials submitted to Anaesthesia

Concerned that studies contain false data, I analysed the baseline summary data of randomised controlled trials when they were submitted to Anaesthesia from February 2017 to March 2020. I categorised trials with false data as ‘zombie’ if I thought that the trial was fatally flawed. I analysed 526 submitted trials: 73 (14%) had false data and 43 (8%) I categorised zombie. Individual patient data increased detection of false data and categorisation of trials as zombie compared with trials without individual patient data: 67/153 (44%) false vs. 6/373 (2%) false; and 40/153 (26%) zombie vs. 3/373 (1%) zombie, respectively. The analysis of individual patient data was independently associated with false data (odds ratio (95% credible interval) 47 (17–144); p = 1.3 × 10−12) and zombie trials (odds ratio (95% credible interval) 79 (19–384); p = 5.6 × 10−9). Authors from five countries submitted the majority of trials: China 96 (18%); South Korea 87 (17%); India 44 (8%); Japan 35 (7%); and Egypt 32 (6%). I identified trials with false data and in turn categorised trials zombie for: 27/56 (48%) and 20/56 (36%) Chinese trials; 7/22 (32%) and 1/22 (5%) South Korean trials; 8/13 (62%) and 6/13 (46%) Indian trials; 2/11 (18%) and 2/11 (18%) Japanese trials; and 9/10 (90%) and 7/10 (70%) Egyptian trials, respectively. The review of individual patient data of submitted randomised controlled trials revealed false data in 44%. I think journals should assume that all submitted papers are potentially flawed and editors should review individual patient data before publishing randomised controlled trials. © 2020 Association of Anaesthetists

A trial comparing emergency front of neck airway performance in a novel obese-synthetic neck, meat-modified obese neck and conventional slim manikin

Conventional emergency front of neck airway training manikins mimic slim patients and are associated with unrealistic procedural ease. We have described previously a pork belly-modified manikin that more realistically simulated an obese patient's neck. In this study, we compared a novel obese-synthetic manikin (obese-synthetic manikin) with a pork belly-modified manikin (obese-meat manikin) and a conventional slim manikin (slim manikin). Thirty-three experienced anaesthetists undertook simulated emergency front of neck airway procedures on each manikin (total 99 procedures). Time to ventilation was longer on both obese manikins compared with the slim manikin (median (IQR [range]) time to intubation 159 (126–243 [73–647]) s in the obese-synthetic, 105 (72–138 [43–279]) s in the obese-meat and 58 (47–74 [30–370]) s in the slim manikin; p < 0.001 between each manikin). Cricothyroidotomy success rate was similar in the both obese manikins but lower when compared with the slim manikin (15/33 obese-synthetic vs. 14/33 obese-meat vs. 27/33 slim manikin). Participant feedback indicated performance difficulty was similar between both obese manikins, which were both more difficult than the slim manikin. The tissues of the obese-meat manikin were judged more realistic than those of either other manikin. Overall, the obese-synthetic manikin performed broadly similarly to the obese-meat manikin and was technically more difficult than the conventional slim manikin. The novel obese-synthetic manikin maybe useful for training and research in front of neck airway procedures. © 2019 Association of Anaesthetists

Anesthesia Considerations and Infection Precautions for Trauma and Acute Care Cases During the COVID-19 Pandemic: Recommendations From a Task Force of the Chinese Society of Anesthesiology

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide. During the ongoing COVID-19 epidemic, most hospitals have postponed elective surgeries. However, some emergency surgeries, especially for trauma patients, are inevitable. For patients with suspected or confirmed COVID-19, a standard protocol addressing preoperative preparation, intraoperative management, and postoperative surveillance should be implemented to avoid nosocomial infection and ensure the safety of patients and the health care workforce. With reference to the guidelines and recommendations issued by the National Health Commission and Chinese Society of Anesthesiology, this article provides recommendations for anesthesia management of trauma and emergency surgery cases during the COVID-19 pandemic. Copyright © 2020 International Anesthesia Research Society.

A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country

Critical incident monitoring has the advantage of identifying a potential risk to the patient without it necessarily resulting in morbidity. An added advantage in developing countries is the low cost involved in introducing the programme. This paper analyses the incidents reported from the operating room suite in a teaching hospital in a developing country from August 1997 to 31 December 1999. During the period, 20 819 anaesthetics were administered and 329 incidents were reported (1.58% of the cases). Seventy-three per cent of the incidents were reported in patients of ASA grade 1 or 2. Thirty-nine per cent occurred during induction, 51% during maintenance and 10% during emergence. Human error was the cause in 41%, equipment error in 50% and system error in 8.5%. Twenty-two per cent of the incidents resulted in minor, and 13% in major physiological disturbance. The technique has been found useful in identifying trends and selecting issues to be discussed in departmental quality assurance meetings, but requires persistent motivation of the reporting staff.

Definitions in obstetric anaesthesia: How should we measure anaesthetic workload and what is 'epidural rate'?

Crude delivery rate is used to calculate requirements for consultant anaesthetic sessions in the UK, but this calculation is arbitrary and ignores differences in case-mix between units. The term 'epidural rate' is commonly used to indicate regional anaesthetic activity but has never been defined. We challenge both these concepts and illustrate our argument by applying different definitions of obstetric anaesthetic activity to prospectively collected maternity data from 31,211 deliveries over 5 years in two hospitals. Number of anaesthetic interventions is a more accurate reflection of obstetric anaesthetic activity than number of deliveries, with Northwick Park Hospital having about 200-600 more deliveries per year than Chelsea and Westminster Hospital but about 300-400 fewer anaesthetic interventions per year. 'Epidural rate' varied by up to 30% according to the definition used. We conclude that number of anaesthetic interventions should replace crude number of deliveries as a measure of obstetric anaesthetic activity, and that the term 'regional anaesthesia rate' should replace 'epidural rate'.

Anaesthesia - A sedentary specialty? Accelerometer assessment of the activity level of anaesthetists while at work

Current guidance recommends that all adults should take a minimum of 10 000 steps a day to remain healthy. We assessed the activity levels of 45 anaesthetists while at work, using accelerometers. These devices also allowed us to measure sitting, standing and walking time - features of the working day that are also likely to contribute to health and well-being. In addition, each anaesthetist was asked to guess how many steps they had taken and complete a questionnaire assessing current activity levels. Median (IQR [range]) number of steps taken per day at work was 3694 (2435-4646 [1444-7712]). Almost all anaesthetists underestimated the number of steps they had taken. We concluded that no anaesthetists in our study were able to take the recommended 10 000 steps solely during their working day. A concerted effort is required in recreational time to ensure anaesthetists stay fit and healthy. © 2008 The Authors.

A survey of undergraduate teaching in anaesthesia

Currently, no well accepted and clearly defined 'core' curriculum for undergraduate anaesthesia teaching exists. To address this deficiency we surveyed 73 university departments of anaesthesia and intensive care. Sixty-five replied from South-east Asia (12), Australasia (13), the UK and Ireland (28) and Canada (12). A questionnaire containing 37 items ranging from departmental structure to curriculum content was used. We found significant regional differences. Overall, most departments taught pharmacology of anaesthetic drugs (83%), pre-operative assessment (92%) and care of the unconscious patient (77%). Ninety-seven per cent taught airway management and intubation and 80% taught intravenous cannulation. Basic life support was taught by 92% and advanced life support by 71%. Fewer than half taught advanced trauma life support principles (44%). Critical care teaching was less well defined, but a consensus of schools taught respiratory failure and ventilation, management of circulatory shock and principles of sepsis and multi-organ system failure. Practical clinical skills were taught mainly using patients and simulators, 46% had a skills laboratory and six employed a resuscitation officer. However, it should be noted that we did not assess the quality and outcome of teaching.

A novel technique to determine an 'apparent ke0' value for use with the Marsh pharmacokinetic model for propofol

Debate continues over the most appropriate blood-brain equilibration rate constant (ke0) for use with the Marsh pharmacokinetic model for propofol. We aimed to define the optimal ke0 value. Sixty-four patients were sedated with incremental increases in effect-site target concentration of propofol while using six different ke0 values within the range 0.2-1.2 min-1. Depth of sedation was assessed by measuring visual reaction time. A median 'apparent ke0' value of 0.61 min -1 (95% CI 0.37-0.78 min-1) led to the greatest probability of achieving a stable clinical effect when the effect-site target was fixed at the effect-site concentration displayed by the target-controlled infusion system, at the time when a desired depth of sedation had been reached. By utilising a clinically relevant endpoint to derive this value, inter-individual pharmacokinetic and pharmacodynamic variability may be accounted for. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Effects of the European working time directive on anaesthetic training in the United Kingdom

Decreases in the hours worked by trainee anaesthetists are being brought about by both the New Deal for Trainees and the European Working Time Directive. Anticipated improvements in health and safety achieved by a decrease in hours will be at the expense of training time if the amount of night-time work remains constant. This audit examined the effects of a change from a partial to a full shift system on a cohort of trainee anaesthetists working in a large district general hospital in the South-west of England. Logbook and list analyses were performed for two 10-week periods: one before and one after the decrease in hours. An 18% decrease in the number of cases done and an 11% decrease in the number of weekly training lists were found for specialist registrars. A 22% decrease in the number of cases done and a 14% decrease in the number of weekly training lists were found for senior house officers. Furthermore, a decrease of one service list per specialist registrar per week was seen, which will have implications for consultant manpower requirements. © 2004 Blackwell Publishing Ltd.

Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team

Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations. © 2020 The Authors

Physician well-being in practice

Despite a recent surge of interest in physician well-being, the discussion remains diffuse and often scattered. Lingering questions of what wellness entails, how it is personally applicable, and what can be done, remain pervasive. In this review, we focus on policy-level, institutional and personal factors that are both obstacles to wellness and interventions for potential remedy. We outline clear obstacles to physician wellness that include dehumanization in medicine, environments and cultures of negativity, barriers to wellness resources, and the effect of second victim syndrome. This is followed by proven and proposed interventions to support physicians in need and foster cultures of sustained well-being from policy, institutional, and personal levels. These include medical liability and licensure policy, peer support constructs, electronic health record optimization, and personal wellness strategies. Where sufficient data exists, we highlight areas specific to anesthesiology. Overall, we offer a pragmatic framework for addressing this critical concern at every level. Copyright © 2020 International Anesthesia Research Society

Trends in Authorship in Anesthesiology Journals

Despite increasing representation in medicine, women continue to be a minority in academic practice and leadership, especially in male-dominated fields like anesthesiology. Differences in compensation and participation in leadership may represent barriers to career advancement for women in anesthesiology. Key factors for promotion in academic anesthesiology are research, funding, and publication. As such, designation as a first or senior author on a publication in a professional journal may act as currency for promotion. Here, we examine the prevalence of female first and senior authorship of original research articles published in Anesthesiology and Anesthesia & Analgesia during the years 2002, 2007, 2012, and 2017. Other manuscript characteristics assessed in relation to author gender included study type, subspecialty topic, and total number of authors. Of 2600 manuscripts studied, analysis of authorship by year demonstrated an increase in female first authorship, senior authorship, and editorial board membership by 10%, 9%, and 6%, respectively. Women made up a higher percentage of first authors on manuscripts with female senior authors. More nonexperimental studies had female senior authors than experimental studies. Female first authors had greater representation in the subspecialties of neuroanesthesia, obstetrical anesthesia, pain management, and pediatric anesthesia. Median number of authors was unrelated to senior author gender. This study shows increasing female first and senior authorship, as well as editorial board composition in 2 popular, high-impact anesthesiology journals. Recognizing gender-based trends in publications is important to develop strategies for the recruitment, retention, and advancement of women in anesthesiology. © 2018 International Anesthesia Research Society.

Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency

Determination of operating room (OR) block allocation and case scheduling is often not based on maximizing OR efficiency, but rather on tradition and surgeon convenience. As a result, anesthesiology groups often incur additional labor costs. When negotiating financial support, heads of anesthesiology departments are often challenged to justify the subsidy necessary to offset these additional labor costs. In this study, we describe a method for calculating a statistically sound estimate of the excess labor costs incurred by an anesthesiology group because of inefficient OR allocation and case scheduling. OR information system and anesthesia staffing data for 1 yr were obtained from two university hospitals. Optimal OR allocation for each surgical service was determined by maximizing the efficiency of use of the OR staff. Hourly costs were converted to dollar amounts by using the nationwide median compensation for academic and private-practice anesthesia providers. Differences between actual costs and the optimal OR allocation were determined. For Hospital A, estimated annual excess labor costs were $1.6 million (95% confidence interval, $1.5-$1.7 million) and $2.0 million ($1.89-$2.05 million) when academic and private-practice compensation, respectively, was calculated. For Hospital B, excess labor costs were $1.0 million ($1.08-$1.17 million) and $1.4 million ($1.32-1.43 million) for academic and private-practice compensation, respectively. This study demonstrates a methodology for an anesthesiology group to estimate its excess labor costs. The group can then use these estimates when negotiating for subsidies with its hospital, medical school, or multispecialty medical group.

Theoretic significance of pH dependence of narcotics and narcotic antagonists in clinical anesthesia

Determination of the effect of pH and temperature on pK(a) partition, and drug distribution coefficients in a series of common narcotics and their antagonists has shown that within the range of blood pH (7.1 to 7.7) encountered in the practice of anesthesiology, marked differences of distribution of the drugs between a model lipid (octanol) and water can occur. When these data are considered in the light of clinical experience with narcotics used in patients undergoing or recovering from surgical procedures, a correlation between the depth and duration of narcosis or the efficacy of narcotic antidotes and ventilatory status is seen. This correlation can be explained in part if the influence of blood pH on the probable CNS/blood distribution of a given drug is taken into consideration. Support is given to this proposal by representative studies in the literature. The very different drug distribution coefficients of two closely related narcotic antagonists, naloxone and naltrexone, correctly predicted the faster onset and shorter duration of the former, which was confirmed by reported clinical observations.

Effective standards and regulatory tools for respiratory gas monitors and pulse oximeters: The role of the engineer and clinician

Developing safe and effective medical devices involves understanding the hazardous situations that can arise in clinical practice and implementing appropriate risk control measures. The hazardous situations may have their roots in the design or in the use of the device. Risk control measures may be engineering or clinically based. A multidisciplinary team of engineers and clinicians is needed to fully identify and assess the risks and implement and evaluate the effectiveness of the control measures. In this paper, I use three issues, calibration/accuracy, response time, and protective measures/alarms, to highlight the contributions of these groups. This important information is captured in standards and regulatory tools to control risk for respiratory gas monitors and pulse oximeters. This paper begins with a discussion of the framework of safety, explaining how voluntary standards and regulatory tools work. The discussion is followed by an examination of how engineering and clinical knowledge are used to support the assurance of safety. Copyright © 2007 International Anesthesia Research Society.

Analysis of a national difficult airway database

Difficult airway management continues to adversely affect patient care and clinical outcomes and is poorly predicted. Previous difficult airway management is the most accurate predictor of future difficulty. The Difficult Airway Society initiated a national airway database to allow clinicians to access details of previous difficult airway episodes in patients issued with a difficult airway alert card. We aimed to analyse this database, reporting patient characteristics, airway management and patient outcomes. We included all living adult patients reported in the first 5 years of the database (n = 675). Clinical airway assessment was reported in 634 (94%) patients, with three or more parameters assessed in 488 (72%). A history of difficult airway was known in 136 (20%) patients and difficult airway management was anticipated in 391 (58%). In all, 75 (11%) patients had an airway-related critical incident, with 1 in 29 being awoken from anaesthesia, 1 in 34 requiring unplanned or prolonged stay in the intensive care unit and 1 in 225 needing an emergency front-of-neck airway or had a cardiac arrest/peri-arrest episode. Airway-related critical incidents were associated with out-of-hours airway management, but no other associations were apparent. Our data report the first analysis of a national difficult airway database, finding that unanticipated difficult airway management continues to occur despite airway assessment, and the rate of critical incidents in this cohort of patients is high. This database has the potential to improve airway management for patients in the future. © 2022 Association of Anaesthetists.

Difficult tracheal intubation in obstetrics

Difficult intubation has been classified into four grades, according to the view obtainable at laryngoscopy. Frequency analysis suggests that, in obstetrics, the main cause of trouble is grade 3, in which the epiglottis can be seen, but not the cords. This group is fairly rare so that a proportion of anaesthetists will not meet the problem in their first few years and may thus be unprepared for it in obstetrics. However the problem can be simulated in routine anaesthesia, so that a drill for managing it can be practised. Laryngoscopy is carried out as usual, then the blade is lowered so that the epiglottis descends and hides the cords. Intubation has to be done blind, using the Macintosh method. This can be helpful as part of the training before starting in the maternity department, supplementing the Aberdeen drill. Copyright © 1984, Wiley Blackwell. All rights reserved

Laryngeal mask airway intracuff pressure estimation by digital palpation of the pilot balloon: A comparison of reusable and disposable masks

Digital palpation of the pilot balloon provides information about the intracuff pressure of tile laryngeal mask airway. The purpose of this in vitro, study was to evaluate this technique for the reusable and disposable laryngeal mask airway. Ten anaesthetists and 10 recovery-unit nurses estimated intracuff pressures from low/high initial pressures before/after training. In the pretraining phase, the mean (95% CI) pressure was 99 (94-105) cmH2O, but this was significantly lower for the reusable laryngeal mask airway (91 vs. 103 cmH2O) and if the initial pressure was low (81 vs. 112 cmH2O). In the post-training phase, there was a significant overall improvement to 75 (66-85) cmH2O, but target pressures remained more accurate if the initial pressure was low. Subjects in the training group could estimate 95% of pressures for both devices to within ± 10 cmH2O of the target if the initial pressure was low. We conclude that anaesthetists and recovery-unit nurses are capable of accurate estimation of intracuff pressures using the digital palpation technique following a brief period of training.

Retention of tracheal intubation skills by novice personnel: A comparison of the Airtraq® and Macintosh laryngoscopes

Direct laryngoscopic tracheal intubation is a potentially lifesaving manoeuvre, but it is a difficult skill to acquire and to maintain. These difficulties are exacerbated if the opportunities to utilise this skill are infrequent, and by the fact that the consequences of poorly performed intubation attempts may be severe. Novice users find the Airtraq® laryngoscope easier to use than the conventional Macintosh laryngoscope. We therefore wished to determine whether novice users would have greater retention of intubation skills with the Airtraq® rather than the Macintosh laryngoscope. Twenty medical students who had no prior airway management experience participated in this study. Following brief didactic instruction, each took turns performing laryngoscopy and intubation using the Macintosh and Airtraq® devices in easy and simulated difficult laryngoscopy scenarios. The degree of success with each device, the time taken to perform intubation and the assistance required, and the potential for complications were then assessed. Six months later, the assessment process was repeated. No didactic instruction or practice attempts were provided on this latter occasion. Tracheal intubation skills declined markedly with both devices. However, the Airtraq® continued to provide better intubating conditions, resulting in greater success of intubation, with fewer optimisation manoeuvres required, and reduced potential for dental trauma, particularly in the difficult laryngoscopy scenarios. The substantial decline in direct laryngoscopy skills over time emphasise the need for continued reinforcement of this complex skill. © 2007 The Authors Journal compilation 2007 The Association of Anaesthetists of Great Britain and Ireland.

Learning and performance of tracheal intubation by novice personnel: A comparison of the Airtraq® and Mancintosh laryngoscope

Direct laryngoscopic tracheal intubation is taught to many healthcare professionals as it is a potentially lifesaving procedure. However, it is a difficult skill to acquire and maintain, and, of concern, the consequences of poorly performed intubation attempts are potentially serious. The Airtraq® Laryngoscope is a novel intubation device which may possess advantages over conventional direct laryngoscopes for use by novice personnel. We conducted a prospective trial with 40 medical students who had no prior airway management experience. Following brief didactic instruction, each participant took turns in performing laryngoscopy and intubation using the Macintosh and Airtraq devices under direct supervision. Each student was allowed up to three attempts to intubate in three laryngoscopy scenarios using a Laerdal® Intubation Trainer and one scenario in a Laerdal® SimMan® Manikin. They then performed tracheal intubation of the normal airway a second time to characterise the learning curve for each device. The Airtraq provided superior intubating conditions, resulting in greater success of intubation, particularly in the difficult laryngoscopy scenarios. In both easy and simulated difficult laryngoscopy scenarios, the Airtraq decreased the duration of intubation attempts, reduced the number of optimisation manoeuvres required, and reduced the potential for dental trauma. The Airtraq device showed a rapid learning curve and the students found it significantly easier to use. The Airtraq appears to be a superior device for novice personnel to acquire the skills of tracheal intubation. © 2006 The Authors Journal compilation © 2006 Association of Anaesthetists of Great Britain and Ireland.

A comparison of McGrath and Macintosh laryngoscopes in novice users: A manikin study

Direct laryngoscopy using the Macintosh laryngoscope is a difficult skill to acquire. Videolaryngoscopy is a widely accepted airway management technique that may be easier for novices to learn. We compared the McGrath® videolaryngoscope and Macintosh laryngoscope by studying the performance of 25 medical students with no previous experience of performing tracheal intubation using an easy intubation scenario in a manikin. The order of device use was randomised for each student. After brief instruction each participant performed eight tracheal intubations with one device and then eight tracheal intubations with the other laryngoscope. Novices achieved a higher overall rate of successful tracheal intubation, avoided oesophageal intubation and produced less dental trauma when using the McGrath. The view at laryngoscopy was significantly better with the McGrath. Intubation times were similar for both laryngoscopes and became shorter with practice. There was no difference in participants' rating of overall ease of use for each laryngoscope. © 2009 The Authors.

The medicolegal importance of enhancing timeliness of documentation when using an anesthesia information system and the response to automated feedback in an academic practice

Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had ≤2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained. Copyright © 2006 International Anesthesia Research Society.

Zebulon Mennell: A pioneer of neurosurgical anaesthesia

Dr Zebulon Mennell, the first anaesthetist to devote himself largely to anaesthesia for neurosurgery, was horn on 15 June 1876. He graduated at St Thomas's Hospital in London, where he was an anaesthetist. He was also an anaesthetist at the Royal National Hospital for Nervous Diseases, Queen Square, London, a post which he held until 1945. His writings indicate that he appreciated the problems of neurosurgical anaesthesia and he was the first individual to work in this field as a specialist. Copyright © 1983, Wiley Blackwell. All rights reserved

A tribute to Dr. Paul A. J. Janssen: entrepreneur extraordinaire, innovative scientist, and significant contributor to anesthesiology.

Dr. Paul Janssen was the founder of Janssen Pharmaceutica and the developer of over 80 pharmaceutical compounds that proved useful in human, botanical, and veterinary medicine. He and his coworkers synthesized the fentanyl family of drugs, many other potent analgesics, droperidol, etomidate, and numerous other important medicines that were extremely useful in psychiatry, parasitology, gastroenterology, cardiology, virology, and immunology. Anesthesiology and medicine as a whole have benefited a great deal from his resourcefulness, creativity, and entrepreneurial spirit.

Special article: T. H. Seldon (1905-1991).

Dr. Seldon was Editor of Anesthesia & Analgesia from 1954 to 1977. We examined how he led the effort to transform this journal into a clinically relevant and vital publication for the specialty.

Drug metabolizing ability in operating theatre personnel

Drug metabolizing ability was determined in a group of anesthetists and other operating theatre personnel. Two indices were used: plasma antipyrine half life and plasma γ glutamyl transpeptidase activity (γ GPT). The plasma clearance of antipyrine (2.93 ± 0.79 l./hr mean ± SD) was significantly faster (21%) in the operating theatre exposed group than in the matched controls (2.46 ± 0.76 l./hr).

Drug metabolizing ability in operating theatre personnel

Drug-metabolizing ability was determined in a group of anaesthetists and other operating theatre personnel. A slightly increased rate of plasma antipyrine clearance was observed in the subjects studied. The extent of the increase was considerably less than that brought about by hypnotic doses of barbiturates or by occupational exposure to insecticides. Therefore marked changes in the ability to metabolize drugs are unlikely in this group of subjects. However, if the aetiology of halothane hepatitis involves the formation of halothane metabolites, the risk may be increased by regular exposure to operating theatre contaminants. © 1974 John Sherratt and Son Ltd.