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Background Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. Methods In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa. Results Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. Conclusions Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Background High-quality shared decision-making for patients undergoing elective surgical procedures includes eliciting patient goals and treatment preferences. This is particularly important, should complications occur and life-sustaining therapies be considered. Our objective was to determine the preoperative care preferences of older higher-risk patients undergoing elective procedures and to determine any factors associated with a preference for limitations to life-sustaining treatments. Methods Cross-sectional survey conducted between May and December 2018. Patients ≥55 years of age presenting for a preprocedural evaluation in a high-risk anesthesia clinic were queried on their desire for life-sustaining treatments (cardiopulmonary resuscitation, mechanical ventilation, dialysis, and artificial nutrition) as well as tolerance for declines in health states (physical disability, cognitive disability, and daily severe pain). Results One hundred patients completed the survey. The median patient age was 68. Most patients were Caucasian (87%) and had an American Society of Anesthesiologists (ASA) score of III (88%). The majority of patients (89%) desired cardiopulmonary resuscitation. However, most patients would not accept mechanical ventilation, dialysis, or artificial nutrition for an indefinite period of time. Similarly, most patients (67%-81%) indicated they would not desire treatments to sustain life in the event of permanent physical disability, cognitive disability, or daily severe pain. Conclusions Among older, higher-risk patients presenting for elective procedures, most patients chose limitations to life-sustaining treatments. This work highlights the need for an in-depth goals of care discussion and establishment of advance care preferences before a procedure or operative intervention.

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields.

BACKGROUND Do-not-resuscitate (DNR) orders instruct medical personnel to forego cardiopulmonary resuscitation in the event of cardiopulmonary arrest, but they do not preclude surgical management. Several studies have reported that DNR status is an independent predictor of 30-day mortality; however, the etiology of increased mortality remains unclear. We hypothesized that DNR patients would demonstrate increased postoperative mortality, but not morbidity, relative to non-DNR patients undergoing the same procedures. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database for 2007-2013, we performed a retrospective analysis to compare DNR and non-DNR cohorts matched by the most common procedures performed in DNR patients. We employed univariable and multivariable logistic regression to characterize patterns of care in the perioperative period as well as identify independent risk factors for increased mortality and assess for the presence of "failure to rescue." RESULTS The most common procedures performed on DNR patients were emergent and centered on immediate symptom relief. When adjusting for preoperative factors, DNR patients were still found to have increased incidence of postoperative mortality (odds ratio 2.54 [2.29-2.82], P < .001) but not postoperative morbidity at 30 days. In addition, cardiopulmonary resuscitative measures and unplanned intubation were found to be less frequent in the DNR cohort. CONCLUSIONS These findings suggest that increased mortality is the result of adherence to goals of care rather than "failure to rescue."

Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discussion on critical clinical information. During 100 clinic days on which 8122 patients were evaluated, 606 triggered e-mails, with a potential impact on 19 elements across the perioperative care spectrum. Four cases were canceled, and 42 cases were rescheduled. By fostering information exchange, these communications could advance patient-centered, value-enhanced quality and safety outcomes.

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

Preoperative Assessment Testing Clinics (PATCs) coordinate preoperative surgical, anesthesia, nursing, and laboratory care. Although such clinics have been noted to lead to efficiencies in perioperative care, patient experience and satisfaction with PATCs has not been evaluated. We distributed a one-page questionnaire consisting of satisfaction with clinical and nonclinical providers to patients presenting to our PATC over three different time periods. Eighteen different questions had five Likert scale options that ranged from excellent (5) to poor (1). We achieved a 71.4% collection rate. The average for the subscale that indicated overall satisfaction was 4.48 +/- 0.67 and the average for the total instrument was 4.46 +/- 0.55. Although the highest scores were given for subscales describing the anesthesia, nurse, and lab, only the anesthesia subscale improved with time (P = 0.007). The subscale that involved information and communication had the highest correlation with the overall satisfaction subscale (r = 0.76; P0.0001). The satisfaction with the total duration of the clinic visit (3.71 +/- 1.26) was significantly less (P0.0001) than the satisfaction to the other items. The authors conclude that the practitioner and functional aspects of the preoperative visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time spent being the most positive and negative components, respectively.Patient satisfaction can serve as an important indicator of the quality of preoperative care delivered in Preoperative Assessment Testing Clinics (PATC). Information and communication, both from clinical and nonclinical service providers, remain the most important positive components, and the total duration of the clinic visit represents the most negative component, of patient satisfaction in a PATC.

Although preoperative assessment testing clinics (PATCs) can produce efficiency in the evaluation of surgical candidates, their effect on the use of consultants has not been studied. We hypothesized that changes in PATC procedures, education, and staffing could affect the use and yield of cardiology consultations. All PATC anesthesiologist-requested cardiology consultations for patients undergoing elective noncardiac surgery from 1993 to 1999 were reviewed. This period corresponded to 3 yr before and after a change in the PATC leadership, which resulted in more stringent consultation algorithms, a cardiac assessment and electrocardiogram interpretation educational program, and altered staffing of anesthesiologists and ancillary personnel. A single senior cardiologist completed all consultations. Data including age, sex, reason for consultation, resultant testing, consultant conclusions, cancellations, and surgical procedure and outcomes were collected. In the PRE and POST groups, respectively, 917 and 279 consultations (1.46% versus 0.49% [P = 0.0001] of noncardiovascular surgeries) were ordered despite an increase in the surgical case-mix acuity. In the POST group, significantly fewer consultations were ordered and significantly more required further testing to assess cardiac status. We conclude that changes in PATC consultation algorithms, education, and staffing can significantly decrease the use and yield of preoperative cardiology consultations.Alterations in preoperative assessment testing clinic consultation algorithms, education, and staffing can significantly reduce the use of preoperative cardiology consultations while improving their overall yield.

Labor analgesia using continuous epidural infusions of low-dose bupivacaine and fentanyl may be maintained for many hours. We examined the potential for drug accumulation in both mother and neonate after these long-term infusions. Pregnant women receiving a 10-mL/h continuous infusion of labor analgesia with 0.125% bupivacaine and 2 micrograms/mL of fentanyl were evaluated. Maternal venous and umbilical venous drug concentrations were measured at delivery. Umbilical artery blood gases were obtained. Scanlon neurobehavioral testing was performed on all infants. Length of infusion times varied from 1 to 15 h. Maternal and neonatal drug concentrations remained relatively constant throughout the infusion period. All umbilical blood gas values and neurobehavioral scores were within normal limits. In conclusion, even when maintained for many hours, continuous infusion labor analgesia does not appear to result in significant fetal drug accumulation. No adverse neonatal effects were seen.

UNLABELLED: Pregnancy-related decreases in protein binding may contribute to altered effects of local anesthetics in the parturient. Previous studies have measured protein binding of bupivacaine in term parturients; the current study defines the ratio of bound-to-free bupivacaine throughout gestation at both therapeutic and toxic systemic concentrations of bupivacaine. Venous samples were obtained from 81 women, including 70 parturients, ranging from 7 to 42 wk of gestation and 11 nonpregnant controls. The percent bound bupivacaine at a fixed concentration was determined for each sample at both therapeutic (1 microg/mL) and toxic (5 microg/mL) concentrations using an ultrafiltration technique. Albumin and alpha-1-glycoprotein levels were also measured. Linear regression analysis showed a significant increase in concentration of free bupivacaine throughout gestation at the 5-microg/mL concentration, corresponding to a decrease demonstrated in both albumin and alpha-1-glycoprotein levels. A similar correlation was not found at the 1-microg/mL concentration. Although the relative magnitude of these changes is small, the relative change in free drug throughout gestation is large. Protein binding is only one of several mechanisms that may influence the susceptibility to local anesthetic toxicity in the parturient; however, its relative importance remains unclear. IMPLICATIONS: When venous samples taken from pregnant women were mixed with 5 microg/ml bupivacaine and analyzed, an increase in the free fraction of drug was seen with increasing gestational age, corresponding to decreases in alpha-1-glycoprotein and albumin.

Pregnancy-related anatomic and physiologic changes result in altered pharmacologic and toxicologic responses to local anesthetics. Reductions in serum protein binding have been implicated in enhanced toxic effects. Previous studies have demonstrated these reductions in protein binding only in the term parturient. The present study defines the pattern of protein binding changes of lidocaine throughout gestation. Venous samples were obtained from pregnant patients of varying gestational age, as well as from nonpregnant control patients. The percent free drug at a fixed concentration (2 micrograms/mL) was determined for each sample using an ultrafiltration technique. The free concentration of lidocaine increased significantly throughout gestation, reflecting a corresponding decrease in protein binding. However, these changes were small compared to those in the nonparturient, which suggests that toxicity to lidocaine should not vary during pregnancy.

Pregnancy decreases anesthetic requirements during regional anesthesia. Using an in vitro animal model, this study attempts to elucidate the mechanism of hormonal effects on nerve conduction in desheathed rabbit vagus nerve. The acute effects of progesterone administration on neural blockade induced by bupivacaine were investigated in terms of changes in compound action potentials of A, B, and C fibers. No change in baseline compound action potential was found after 30 min of perfusion of the nerve with progesterone. Exposure of the nerve to progesterone before exposure to bupivacaine did not significantly increase the degree of conduction blockade produced by bupivacaine, and a radioactive assay demonstrated that progesterone was taken up acutely by neural tissue over a 45-min measurement period. These results indicate that although progesterone was taken up in significant amounts by neural tissue, an acute exposure does not increase the sensitivity of the nerves to bupivacaine. Hence, the increased sensitivity of nerves to local anesthetics seen with pregnancy or with chronic progesterone treatment requires some period of time to occur. The mechanism is therefore unlikely to be a direct effect of progesterone on the cell membrane but may involve hormonal effects on protein synthesis.

Ropivacaine (LEA-103) is a new amino-amide local anesthetic agent the chemical structure and anesthetic properties of which are similar to bupivacaine. Preliminary studies in animals indicate that the CNS toxicities of ropivacaine and bupivacaine are similar, but that ropivacaine may have less arrhythmogenic effects than bupivacaine. The current study arrhythmogenic effects than bupivacaine. The current study was designed to compare the in vitro potency, onset and recovery from block of ropivacaine and bupivacaine using an isolated rabbit vagus nerve model. The effect of varying concentrations of ropivacaine and bupivacaine on the compound action potential of A and C nerve fibers was assessed to determine whether motor and sensory fibers have different sensitivities to the two agents. The results showed that the depressant effect of bupivacaine was 16% greater than that of ropivacaine on motor fibers, but only 3% greater on sensory fibers. An analysis of variance indicated that this was a statistically significant difference (P = 0.028). Thus, at the concentrations tested, ropivacaine appears to produce relatively less blockade of motor fibers than does bupivacaine but with similar sensory blockade. The onset of this difference became significant as early as five minutes after the drug exposure was begun. No significant differences in recovery times were observed.