Search

Competing Interests: The author declares no conflict of interest.

This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Competing Interests: Conflicts of Interest: See Disclosures at the end of the article.

Background: The learning-curve cumulative sum method (LC-CUSUM) and its risk-adjusted form (RA-LC-CUSUM) have been proposed as performance-monitoring methods to assess competency during the learning phase of procedural skills. However, scarce data exist about the method's accuracy. This study aimed to compare the accuracy of LC-CUSUM forms using historical data consisting of sequences of successes and failures in brachial plexus blocks (BPBs) performed by anesthesia residents., Methods: Using historical data from 1713 BPB performed by 32 anesthesia residents, individual learning curves were constructed using the LC-CUSUM and RA-LC-CUSUM methods. A multilevel logistic regression model predicted the procedure-specific risk of failure incorporated in the RA-LC-CUSUM calculations. Competency was defined as a maximum 15% cumulative failure rate and was used as the reference for determining the accuracy of both methods., Results: According to the LC-CUSUM method, 22 residents (84.61%) attained competency after a median of 18.5 blocks (interquartile range [IQR], 14-23), while the RA-LC-CUSUM assigned competency to 20 residents (76.92%) after a median of 17.5 blocks (IQR, 14-25, P = .001). The median failure rate at reaching competency was 6.5% (4%-9.75%) under the LC-CUSUM and 6.5% (4%-9%) for the RA-LC-CUSUM method ( P = .37). The sensitivity of the LC-CUSUM (85%; 95% confidence interval [CI], 71%-98%) was similar to the RA-LC-CUSUM method (77%; 95% CI, 61%-93%; P = .15). Identical specificity values were found for both methods (67%; 95% CI, 29%-100%, P = 1)., Conclusions: The LC-CUSUM and RA-LC-CUSUM methods were associated with substantial false-positive and false-negative rates. Also, small lower limits for the 95% CIs around the accuracy measures were observed, indicating that the methods may be inaccurate for high-stakes decisions about resident competency at BPBs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Large neck circumference and displacement of the trachea due to pathology increase the risk of failed identification of the cricothyroid membrane and cricothyroidotomy. We investigated whether ultrasound aids in the successful identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea., Methods: We developed silicone neck models that were suitable for both palpation and ultrasonography and where the trachea deviated laterally from the midline to either side. After reading a book chapter and participating in a 25-minute lecture and a 15- to 23-minute hands-on demonstration and rehearsal of ultrasonography for identification of the cricothyroid membrane, anesthesiologists and anesthesiology residents randomly performed identification with either ultrasound or palpation on 1 of 2 neck models., Results: We included 57 participants, of whom 29 and 28 were randomized to palpation and ultrasound, respectively. Correct identification of the cricothyroid membrane was achieved by 21 (75.0%) vs 1 (3.5%) of participants in the ultrasound versus palpation groups (risk ratio [RR], 21.8 [95% confidence interval {CI}, 3.1-151.0]). The tracheal midline position in the sagittal plane was identified correctly by 24 (85.7%) vs 16 (55.2%) of participants in the ultrasound versus palpation groups (RR, 1.6 [95% CI, 1.1-2.2])., Conclusions: Identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea was more often successful with ultrasound compared to palpation. Our study supports the potential use of ultrasound before induction of anesthesia and airway management in this group of patients, and it may even be applied in emergency situations when ultrasound is readily available. Further studies in human subjects should be conducted., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Competing Interests: The authors declare no conflicts of interest.

Prompt recognition and management of critical events is pivotal for the provision of safe anesthetic care. This requires a well-functioning team that focuses on effective communication, timely decision-making, and escalation of potential complications. We believe that variation in bedside care leads to "near-misses," adverse outcomes, and serious safety events (SSEs). The principles of an escalation culture have been used successfully in other highly reliable industries such as aviation, military, and manufacturing. We discuss here the introduction of a unique and compelling thought-process for developing an intraoperative escalation protocol that is specifically tailored for our institution. Inspired by a critical intraoperative event, this departmental protocol was developed based on an analysis of multispecialty literature and expert opinion to decrease the incidence of SSEs. It includes a stepwise approach and incorporates patient-specific information to guide team members who encounter dynamic clinical situations. The implementation of the protocol has facilitated continuous quality improvement through iterative education, improving communication, and enhancing decision-making. Concurrently, we have plans to incorporate technology and electronic decision support tools to enhance real-time communication, monitor performance, and foster a culture of safety., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 International Anesthesia Research Society.)

Competing Interests: The author declares no conflicts of interest.

Competing Interests: The authors declare no conflicts of interest.

Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 International Anesthesia Research Society.)

While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Background: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh., Methods: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data., Results: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria., Conclusions: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Epidermolysis bullosa (EB) is a group of rare, inherited diseases characterized by skin fragility and multiorgan system involvement that presents many anesthetic challenges. Although the literature regarding anesthetic management focuses primarily on the pediatric population, as life expectancy improves, adult patients with EB are more frequently undergoing anesthesia in nonpediatric hospital settings. Safe anesthetic management of adult patients with EB requires familiarity with the complex and heterogeneous nature of this disease, especially with regard to complications that may worsen during adulthood. General, neuraxial, and regional anesthetics have all been used safely in patients with EB. A thorough preoperative evaluation is essential. Preoperative testing should be guided by EB subtype, clinical manifestations, and extracutaneous complications. Advanced planning and multidisciplinary coordination are necessary with regard to timing and operative plan. Meticulous preparation of the operating room and education of all perioperative staff members is critical. Intraoperatively, utmost care must be taken to avoid all adhesives, shear forces, and friction to the skin and mucosa. Special precautions must be taken with patient positioning, and standard anesthesia monitors must be modified. Airway management is often difficult, and progressive airway deterioration can occur in adults with EB over time. A smooth induction, emergence, and postoperative course are necessary to minimize blister formation from excess patient movement. With careful planning, preparation, and precautions, adult patients with EB can safely undergo anesthesia., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: In children, the use of actual weight or predicted weight from various estimation methods is essential to reduce harm associated with dosing errors. This study aimed to validate the new locally derived Lusaka formula on an independent cohort of children undergoing surgery at the University Teaching Hospital in Lusaka, Zambia, to compare the Lusaka formula's performance to commonly used weight prediction tools and to assess the nutritional status of this population., Methods: The Lusaka formula (weight = [age in months/2] + 3.5 if under 1 year; weight = 2×[age in years] + 7 if older than 1 year) was derived from a previously published data set. We aimed to validate this formula in a new data set. Weights, heights, and ages of 330 children up to 14 years were measured before surgery. Accuracy was examined by comparing the (1) mean percentage error and (2) the percentage of actual weights that fell between 10% and 20% of the estimated weight for the Lusaka formula, and for other existing tools. World Health Organization (WHO) growth charts, mid upper arm circumference (MUAC), and body mass index (BMI) were used to assess nutritional status., Results: The Lusaka formula had similar precision to the Broselow tape: 160 (48.5%) vs 158 (51.6%) children were within 10% of the estimated weight, 241 (73.0%) vs 245 (79.5%) children were within 20% of the estimated weight. The Lusaka formula slightly underestimated weight (mean bias, -0.5 kg) in contrast to all other predictive tools, which overestimated on average. Twenty-two percent of children had moderate or severe chronic malnutrition (stunting) and 4.7% of children had moderate or severe acute malnutrition (wasting)., Conclusions: The Lusaka formula is comparable to, or better than, other age-based weight prediction tools in children presenting for surgery at the University Teaching Hospital in Lusaka, Zambia, and has the advantage that it covers a wider age range than tools with comparable accuracy. In this population, commonly used aged-based prediction tools significantly overestimate weights., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Modern consumer electronic devices and automobiles are often controlled by interfaces that sense physical gestures and spoken commands. In contrast, patient monitors and anesthesia devices are typically equipped with panel-mounted buttons, dials, and keyboards. The increased use of noncontact gesture-based interfaces in anesthesia may improve patient safety through more intuitive and prompter control of equipment and also through reduced rates of surface contamination. A novel gesture-based controller was designed and retrofitted to a standard GE Solar 8000M patient monitor. This type of technical innovation is rare, due to closely held proprietary input control systems on commercially produced clinical equipment. Nevertheless, we hypothesized that anesthesiologists would find a contactless gesture interface straightforward to use., Methods: A gesture-based interface system was developed to control a Solar 8000M patient monitor using a millimeter-wave radar sensor. The system was programmed to detect noncontact "rotate" and "press" gestures to control the patient monitor by implementing a virtual trim knob for interface control. Fifty anesthesiologists tested a prototype interface and evaluated usability by completing a short questionnaire incorporating modified Likert scales. These evaluations were performed in a nonpatient care environment so that respondents were not adversely task loaded during assessment, also allaying any ethical or safety concerns regarding use of this novel interface for patient management., Results: Anesthesia hardware was controlled reliably with 2 distinct gestures above the gesture sensor. The gesture-based interface generally was well received by anesthesiologists (8.09; confidence interval, 8.06-8.12 on a 10-point scale), who preferred the simpler "press" gesture to the "rotate" gesture (8.45; 8.39-8.51 vs 7.73; 7.67-7.79 on a 10-point scale; P = .005). The correlation between the preference scores for the 2 gestures from each anesthesiologist was strong (Pearson r = 0.49; 0.25-0.68; P < .001). Advancing level of training (resident, fellow, attending 1-10 years, attending >10 years) was not correlated with preference scores for either gesture (Spearman ρ = -0.02; -0.30 to 0.26; P = .87 for "press" and Spearman ρ = 0.08; -0.20 to 0.35; P = .58 for "rotate")., Conclusions: The use of gesture sensing for controlling anesthesia equipment was well received by a cohort of anesthesiologists. Even though the simpler "press" gesture was preferred over the "rotate" gesture, the intrarespondent correlation indicates that the preference for gestures as a whole is the stronger effect. No adverse relationship was found between acceptability and anesthesia experience level. Gesture sensing is a promising new area to simplify and improve the interaction between the anesthesiologist and the anesthesia workstation., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2020 International Anesthesia Research Society.)

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., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: Use of anesthesia machines as improvised intensive care unit (ICU) ventilators may occur in locations where waste anesthesia gas suction (WAGS) is unavailable. Anecdotal reports suggest as much as 18 cm H2O positive end-expiratory pressure (PEEP) being inadvertently applied under these circumstances, accompanied by inaccurate pressure readings by the anesthesia machine. We hypothesized that resistance within closed anesthesia gas scavenging systems (AGSS) disconnected from WAGS may inadvertently increase circuit pressures., Methods: An anesthesia machine was connected to an anesthesia breathing circuit, a reference manometer, and a standard bag reservoir to simulate a lung. Ventilation was initiated as follows: volume control, tidal volume (TV) 500 mL, respiratory rate 12, ratio of inspiration to expiration times (I:E) 1:1.9, fraction of inspired oxygen (Fio2) 1.0, fresh gas flow (FGF) rate 2.0 liters per minute (LPM), and PEEP 0 cm H2O. After engaging the ventilator, PEEP and peak inspiratory pressure (PIP) were measured by the reference manometer and the anesthesia machine display simultaneously. The process was repeated using prescribed PEEP levels of 5, 10, 15, and 20 cm H2O. Measurements were repeated with the WAGS disconnected and then were performed again at FGF of 4, 6, 8, 10, and 15 LPM. This process was completed on 3 anesthesia machines: Dräger Perseus A500, Dräger Apollo, and the GE Avance CS2. Simple linear regression was used to assess differences., Results: Utilizing nonparametric Bland-Altman analysis, the reference and machine manometer measurements of PIP demonstrated median differences of -0.40 cm H2O (95% limits of agreement [LOA], -1.00 to 0.55) for the Dräger Apollo, -0.40 cm H2O (95% LOA, -1.10 to 0.41) for the Dräger Perseus, and 1.70 cm H2O (95% LOA, 0.80-3.00) for the GE Avance CS2. At FGF 2 LPM and PEEP 0 cm H2O with the WAGS disconnected, the Dräger Apollo had a difference in PEEP of 0.02 cm H2O (95% confidence interval [CI], -0.04 to 0.08; P = .53); the Dräger Perseus A500, <0.0001 cm H2O (95% CI, -0.11 to 0.11; P = 1.00); and the GE Avance CS2, 8.62 cm H2O (95% CI, 8.55-8.69; P < .0001). After removing the hose connected to the AGSS and the visual indicator bag on the GE Avance CS2, the PEEP difference was 0.12 cm H2O (95% CI, 0.059-0.181; P = .0002)., Conclusions: Displayed airway pressure measurements are clinically accurate in the setting of disconnected WAGS. The Dräger Perseus A500 and Apollo with open scavenging systems do not deliver inadvertent continuous positive airway pressure (CPAP) with WAGS disconnected, but the GE Avance CS2 with a closed AGSS does. This increase in airway pressure can be mitigated by the manufacturer's recommended alterations. Anesthesiologists should be aware of the potential clinically important increases in pressure that may be inadvertently delivered on some anesthesia machines, should the WAGS not be properly connected., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis of unprecedented proportions that has altered the practice of medicine. The pandemic has required pain clinics to transition from in-person visits to telemedicine, postpone procedures, and cancel face-to-face educational sessions. There are no data on how fellowship programs have adapted., Methods: A 17-question survey was developed covering topics including changes in education, clinical care, and psychological stress due to the COVID pandemic. The initial survey was hosted by Qualtrics Inc and disseminated by the Association of Pain Program Directors on April 10, 2020, to program directors at Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowships. Results are reported descriptively and stratified by COVID infection rate, which was calculated from Centers for Disease Control and Prevention data on state infections, and census data., Results: Among 107 surveys distributed, 70 (65%) programs responded. Twenty-nine programs were located in states in the upper tertile for per capita infection rates, 17 in the middle third, and 23 in the lowest tertile. Nearly all programs (93%) reported a decreased workload, with 11 (16%) reporting a dramatic decrease (only urgent or emergent cases). Just more than half of programs had either already deployed (14%) or credentialed (39%) fellows to provide nonpain care. Higher state infection rates were significantly associated with reduced clinical demand (Rs = 0.31, 95% confidence interval [CI], 0.08-0.51; P = .011) and redeployment of fellows to nonpain areas (Rs = 0.30, 95% CI, 0.07-0.50; P = .013). Larger program size but not infection rate was associated with increased perceived anxiety level of trainees., Conclusions: We found a shift to online alternatives for clinical care and education, with correlations between per capita infection rates, and clinical care demands and redeployment, but not with overall trainee anxiety levels. It is likely that medicine in general, and pain medicine in particular, will change after COVID-19, with greater emphasis on telemedicine, virtual education, and greater national and international cooperation. Physicians should be prepared for these changes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

The coronavirus disease 2019 (COVID-19) pandemic has infected millions of individuals and posed unprecedented challenges to health care systems. Acute care hospitals have been forced to expand hospital and intensive care capacity and deal with shortages in personal protective equipment. This guide will review 2 areas where the anesthesiologists will be caring for COVID-19 patients: the operating room and on airway teams. General principles for COVID-19 preparation and hospital procedures will be reviewed to serve as a resource for anesthesia departments to manage COVID-19 or future pandemics., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

The coronavirus disease 2019 (COVID-19) pandemic has altered approaches to anesthesiology education by shifting educational paradigms. This vision article discusses pre-COVID-19 educational methodologies and best evidence, adaptations required under COVID-19, and evidence for these modifications, and suggests future directions for anesthesiology education. Learning management systems provide structure to online learning. They have been increasingly utilized to improve access to didactic materials asynchronously. Despite some historic reservations, the pandemic has necessitated a rapid uptake across programs. Commercially available systems offer a wide range of peer-reviewed curricular options. The flipped classroom promotes learning foundational knowledge before teaching sessions with a focus on application during structured didactics. There is growing evidence that this approach is preferred by learners and may increase knowledge gain. The flipped classroom works well with learning management systems to disseminate focused preclass work. Care must be taken to keep virtual sessions interactive. Simulation, already used in anesthesiology, has been critical in preparation for the care of COVID-19 patients. Multidisciplinary, in situ simulations allow for rapid dissemination of new team workflows. Physical distancing and reduced availability of providers have required more sessions. Early pandemic decreases in operating volumes have allowed for this; future planning will have to incorporate smaller groups, sanitizing of equipment, and attention to use of personal protective equipment. Effective technical skills training requires instruction to mastery levels, use of deliberate practice, and high-quality feedback. Reduced sizes of skill-training workshops and approaches for feedback that are not in-person will be required. Mock oral and objective structured clinical examination (OSCE) allow for training and assessment of competencies often not addressed otherwise. They provide formative and summative data and objective measurements of Accreditation Council for Graduate Medical Education (ACGME) milestones. They also allow for preparation for the American Board of Anesthesiology (ABA) APPLIED examination. Adaptations to teleconferencing or videoconferencing can allow for continued use. Benefits of teaching in this new era include enhanced availability of asynchronous learning and opportunities to apply universal, expert-driven curricula. Burdens include decreased social interactions and potential need for an increased amount of smaller, live sessions. Acquiring learning management systems and holding more frequent simulation and skills sessions with fewer learners may increase cost. With the increasing dependency on multimedia and technology support for teaching and learning, one important focus of educational research is on the development and evaluation of strategies that reduce extraneous processing and manage essential and generative processing in virtual learning environments. Collaboration to identify and implement best practices has the potential to improve education for all learners., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

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

Background: Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition., Methods: We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey., Results: Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again., Conclusions: The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

We investigated the history of Resusci Anne, the well-known cardiopulmonary resuscitation (CPR) simulation trainer. The creation of Resusci Anne began with Peter J. Safar, an accomplished anesthesiologist who experimented with resuscitation of respiration and cardiac function. He collaborated with Asmund S. Laerdal, whose early experimentation with soft plastics allowed him to create a human simulator that could be used to teach the skills of resuscitation to both medical care practitioners and individuals of all walks of life. A special face was chosen for the simulation mannequin, one based on a mysterious death mask of a beautiful woman from the late 19th century. The success of Resusci Anne led to the widespread acceptance of CPR and simulation use in medical training.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Frailty is a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors. People with frailty are vulnerable to stressors, and exposure to the stress of surgery is associated with increased risk of adverse outcomes and higher levels of resource use. As Western populations age rapidly, older people with frailty are presenting for surgery with increasing frequency. This means that anesthesiologists and other perioperative clinicians need to be familiar with frailty, its assessment, manifestations, and strategies for optimization. We present a narrative review of frailty aimed at perioperative clinicians. The review will familiarize readers with the concept of frailty, will discuss common and feasible approaches to frailty assessment before surgery, and will describe the relative and absolute associations of frailty with commonly measured adverse outcomes, including morbidity and mortality, as well as patient-centered and reported outcomes related to function, disability, and quality of life. A proposed approach to optimization before surgery is presented, which includes frailty assessment followed by recommendations for identification of underlying physical disability, malnutrition, cognitive dysfunction, and mental health diagnoses. Overall, 30%-50% of older patients presenting for major surgery will be living with frailty, which results in a more than 2-fold increase in risk of morbidity, mortality, and development of new patient-reported disability. The Clinical Frailty Scale appears to be the most feasible frailty instrument for use before surgery; however, evidence suggests that predictive accuracy does not differ significantly between frailty instruments such as the Fried Phenotype, Edmonton Frail Scale, and Frailty Index. Identification of physical dysfunction may allow for optimization via exercise prehabilitation, while nutritional supplementation could be considered with a positive screen for malnutrition. The Hospital Elder Life Program shows promise for delirium prevention, while individuals with mental health and or other psychosocial stressors may derive particular benefit from multidisciplinary care and preadmission discharge planning. Robust trials are still required to provide definitive evidence supporting these interventions and minimal data are available to guide management during the intra- and postoperative phases. Improving the care and outcomes of older people with frailty represents a key opportunity for anesthesiologists and perioperative scientists.

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

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.

The convergence of multiple recent developments in health care information technology and monitoring devices has made possible the creation of remote patient surveillance systems that increase the timeliness and quality of patient care. More convenient, less invasive monitoring devices, including patches, wearables, and biosensors, now allow for continuous physiological data to be gleaned from patients in a variety of care settings across the perioperative experience. These data can be bound into a single data repository, creating so-called data lakes. The high volume and diversity of data in these repositories must be processed into standard formats that can be queried in real time. These data can then be used by sophisticated prediction algorithms currently under development, enabling the early recognition of patterns of clinical deterioration otherwise undetectable to humans. Improved predictions can reduce alarm fatigue. In addition, data are now automatically queriable on a real-time basis such that they can be fed back to clinicians in a time frame that allows for meaningful intervention. These advancements are key components of successful remote surveillance systems. Anesthesiologists have the opportunity to be at the forefront of remote surveillance in the care they provide in the operating room, postanesthesia care unit, and intensive care unit, while also expanding their scope to include high-risk preoperative and postoperative patients on the general care wards. These systems hold the promise of enabling anesthesiologists to detect and intervene upon changes in the clinical status of the patient before adverse events have occurred. Importantly, however, significant barriers still exist to the effective deployment of these technologies and their study in impacting patient outcomes. Studies demonstrating the impact of remote surveillance on patient outcomes are limited. Critical to the impact of the technology are strategies of implementation, including who should receive and respond to alerts and how they should respond. Moreover, the lack of cost-effectiveness data and the uncertainty of whether clinical activities surrounding these technologies will be financially reimbursed remain significant challenges to future scale and sustainability. This narrative review will discuss the evolving technical components of remote surveillance systems, the clinical use cases relevant to the anesthesiologist's practice, the existing evidence for their impact on patients, the barriers that exist to their effective implementation and study, and important considerations regarding sustainability and cost-effectiveness.

Background: Detailed reviews of closed malpractice claims have provided insights into the most common events resulting in litigation and helped improve anesthesia care. In the past 10 years, there have been multiple safety advancements in the practice of obstetric anesthesia. We investigated the relationship among contributing factors, patient injuries, and legal outcome by analyzing a contemporary cohort of closed malpractice claims where obstetric anesthesiology was the principal defendant., Methods: The Controlled Risk Insurance Company (CRICO) is the captive medical liability insurer of the Harvard Medical Institutions that, in collaboration with other insurance companies and health care entities, contributes to the Comparative Benchmark System database for research purposes. We reviewed all (N = 106) closed malpractice cases related to obstetric anesthesia between 2005 and 2015 and compared the following classes of injury: maternal death and brain injury, neonatal death and brain injury, maternal nerve injury, and maternal major and minor injury. In addition, settled claims were compared to the cases that did not receive payment. χ, analysis of variance, Student t test, and Kruskal-Wallis tests were used for comparison between the different classes of injury., Results: The largest number of claims, 54.7%, involved maternal nerve injury; 77.6% of these claims did not receive any indemnity payment. Cases involving maternal death or brain injury comprised 15.1% of all cases and were more likely to receive payment, especially in the high range (P = .02). The most common causes of maternal death or brain injury were high neuraxial blocks, embolic events, and failed intubation. Claims for maternal major and minor injury were least likely to receive payment (P = .02) and were most commonly (34.8%) associated with only emotional injury. Compared to the dropped/denied/dismissed claims, settled claims more frequently involved general anesthesia (P = .03), were associated with delays in care (P = .005), and took longer to resolve (3.2 vs 1.3 years; P < .0001)., Conclusions: Obstetric anesthesia remains an area of significant malpractice liability. Opportunities for practice improvement in the area of severe maternal injury include timely recognition of high neuraxial block, availability of adequate resuscitative resources, and the use of advanced airway management techniques. Anesthesiologists should avoid delays in maternal care, establish clear communication, and follow their institutional policy regarding neonatal resuscitation. Prevention of maternal neurological injury should be directed toward performing neuraxial techniques at the lowest lumbar spine level possible and prevention/recognition of retained neuraxial devices.

Background: Apneic oxygenation via the oral route using a buccal device extends the safe apnea time in most but not all obese patients. Apneic oxygenation techniques are most effective when tracheal oxygen concentrations are maintained >90%. It remains unclear whether buccal oxygen administration consistently achieves this goal and whether significant risks of hypercarbia or barotrauma exist., Methods: We conducted a randomized trial of buccal or sham oxygenation in healthy, nonobese patients (n = 20), using prolonged laryngoscopy to maintain apnea with a patent airway until arterial oxygen saturation (SpO2) dropped <95% or 750 seconds elapsed. Tracheal oxygen concentration, tracheal pressure, and transcutaneous carbon dioxide (CO2) were measured throughout. The primary outcome was maintenance of a tracheal oxygen concentration >90% during apnea., Results: Buccal patients were more likely to achieve the primary outcome (P < .0001), had higher tracheal oxygen concentrations throughout apnea (mean difference, 65.9%; 95% confidence interval [CI], 62.6%-69.3%; P < .0001), and had a prolonged median (interquartile range) apnea time with SpO2 >94%; 750 seconds (750-750 seconds) vs 447 seconds (405-525 seconds); P < .001. One patient desaturated to SpO2 <95% despite 100% tracheal oxygen. Mean tracheal pressures were low in the buccal (0.21 cm·H2O; SD = 0.39) and sham (0.56 cm·H2O; SD = 1.25) arms; mean difference, -0.35 cm·H2O; 95% CI, 1.22-0.53; P = .41. CO2 accumulation during early apnea before any study end points were reached was linear and marginally faster in the buccal arm (3.16 vs 2.82 mm Hg/min; mean difference, 0.34; 95% CI, 0.30-0.38; P < .001). Prolonged apnea in the buccal arm revealed nonlinear CO2 accumulation that declined over time and averaged 2.22 mm Hg/min (95% CI, 2.21-2.23)., Conclusions: Buccal oxygen administration reliably maintains high tracheal oxygen concentrations, but early arterial desaturation can still occur through mechanisms other than device failure. Whereas the risk of hypercarbia is similar to that observed with other approaches, the risk of barotrauma is negligible. Continuous measurement of advanced physiological parameters is feasible in an apneic oxygenation trial and can assist with device evaluation.

Background: Pediatric anesthesiologists are exposed to ionizing radiation from x-rays on an almost daily basis. Our goal was to determine the culture of safety in which they work and how they adhere to preventative strategies that minimize exposure risk in their daily practice., Methods: After Institutional Review Board waiver and approval of the Society for Pediatric Anesthesia's research and quality and safety committees, an electronic e-mail questionnaire was sent to the Society's physician, nontrainee members and consisted of questions specific to provider use of protective lead shielding, the routine use of dosimeters, and demographic information. Univariate analyses were performed using the Wilcoxon rank sum test for ordinal variables, the Fisher exact test for categorical variables, and the Spearman test to analyze correlation between 2 ordinal variables, while a proportional odds logistic regression was used for a multivariable ordinal outcome analysis. P values of <.05 were considered statistically significant., Results: Twenty-one percent (674/3151) of the surveyed anesthesiologists completed the online questionnaire. Radiation exposure is ubiquitous (98.7%), and regardless of sex, most respondents were either concerned or very concerned about radiation exposure (76.8%); however, women were significantly more concerned than men (proportional odds ratio, 1.66 [95% confidence interval, 1.20-2.31]; P = .002). Despite this and independent of sex, level of concern was not associated with use of a radiation dosimeter (P = .85), lead glasses (odds ratio, 1.07 [95% confidence interval, 0.52-2.39]; P = 1.0), or a thyroid shield (P = .12). Dosimeters were rarely (13%) or never used (52%) and were mandated in only 28.5% of institutions. Virtually none of the respondents had ever taken a radiation safety course, received a personal radiation dose report, notification of their radiation exposure, or knew how many millirem/y was considered safe. Half of the respondents were female, and while pregnant, 73% (151/206) tried to avoid radiation exposure by requesting not to be assigned to cases requiring x-rays. These requests were honored 78% (160/206) of the time., Discussion: Despite universal exposure to ionizing radiation from x-rays, pediatric anesthesiologists do not routinely adhere to strategies designed to limit the intensity of this exposure and rarely work in institutions in which a culture of radiation safety exists. Our study highlights the need to improve radiation safety education, the need to change the safety culture within the operating rooms and imaging suites, and the need to more fully investigate the utility of dosimeters, lead shielding, and eye safety measures in pediatric anesthesia practice.

Background: Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty., Methods: With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution., Results: A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021)., Conclusions: Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.

Background: In patients who receive a nondepolarizing neuromuscular blocking drug (NMBD) during anesthesia, undetected postoperative residual neuromuscular block is a common occurrence that carries a risk of potentially serious adverse events, particularly postoperative pulmonary complications. There is abundant evidence that residual block can be prevented when real-time (quantitative) neuromuscular monitoring with measurement of the train-of-four ratio is used to guide NMBD administration and reversal. Nevertheless, a significant percentage of anesthesiologists fail to use quantitative devices or even conventional peripheral nerve stimulators routinely. Our hypothesis was that a contributing factor to the nonutilization of neuromuscular monitoring was anesthesiologists' overconfidence in their knowledge and ability to manage the use of NMBDs without such guidance., Methods: We conducted an Internet-based multilingual survey among anesthesiologists worldwide. We asked respondents to answer 9 true/false questions related to the use of neuromuscular blocking drugs. Participants were also asked to rate their confidence in the accuracy of each of their answers on a scale of 50% (pure guess) to 100% (certain of answer)., Results: Two thousand five hundred sixty persons accessed the website; of these, 1629 anesthesiologists from 80 countries completed the 9-question survey. The respondents correctly answered only 57% of the questions. In contrast, the mean confidence exhibited by the respondents was 84%, which was significantly greater than their accuracy. Of the 1629 respondents, 1496 (92%) were overconfident., Conclusions: The anesthesiologists surveyed expressed overconfidence in their knowledge and ability to manage the use of NMBDs. This overconfidence may be partially responsible for the failure to adopt routine perioperative neuromuscular monitoring. When clinicians are highly confident in their knowledge about a procedure, they are less likely to modify their clinical practice or seek further guidance on its use.

Type 1 diabetes mellitus is a lifelong condition. It requires intensive patient involvement including frequent glucose measurements and subcutaneous insulin dosing to provide optimal glycemic control to decrease short- and long-term complications of diabetes mellitus without causing hypoglycemia. Variations in insulin pharmacokinetics and responsiveness over time in addition to illness, stress, and a myriad of other factors make ideal glucose control a challenge. Control-to-range and control-to-target artificial pancreas devices (closed-loop artificial pancreas devices [C-APDs]) consist of a continuous glucose monitor, response algorithm, and insulin delivery device that work together to automate much of the glycemic management for an individual while continually adjusting insulin dosing toward a glycemic target. In this way, a C-APD can improve glycemic control and decrease the rate of hypoglycemia. The MiniMed 670G (Medtronic, Fridley, MN) system is currently the only Food and Drug Administration-cleared C-APD in the United States. In this system, insulin delivery is continually adjusted to a glucose concentration, and the patient inputs meal-time information to modify insulin delivery as needed. Data thus far suggest improved glycemic control and decreased hypoglycemic events using the system, with decreased need for patient self-management. Thus, the anticipated use of these devices is likely to increase dramatically over time. There are limited case reports of safe intraoperative use of C-APDs, but the Food and Drug Administration has not cleared any device for such use. Nonetheless, C-APDs may offer an opportunity to improve patient safety and outcomes through enhanced intraoperative glycemic control. Anesthesiologists should become familiar with C-APD technology to help develop safe and effective protocols for their intraoperative use. We provide an overview of C-APDs and propose an introductory strategy for intraoperative study of these devices.

Background: Physician educators must balance the need for resident procedural education with clinical time pressures as well as patient safety and comfort. Alternative educational strategies, including e-learning tools, may be beneficial to orient novice learners to new procedures and speed proficiency. We created an e-learning tool (computer-enhanced visual learning [CEVL] neuraxial) to enhance trainee proficiency in combined spinal-epidural catheter placement in obstetric patients and performed a randomized controlled 2-center trial to test the hypothesis that use of the tool improved the initial procedure performed by the anesthesiology residents., Methods: Anesthesiology residents completing their first obstetric anesthesiology rotation were randomized to receive online access to the neuraxial module (CEVL group) or no access (control) 2 weeks before the rotation. On the first day of the rotation, residents completed a neuraxial procedure self-confidence scale and an open-ended medical knowledge test. Blinded raters observed residents performing combined spinal-epidural catheter techniques in laboring parturients using a procedural checklist (0-49 pts); the time required to perform the procedure was recorded. The primary outcome was the duration of the procedure., Results: The CEVL group had significantly shorter mean (±standard deviation) procedure time compared to the control group 22.5 ± 4.9 vs 39.5 ± 7.1 minutes (P < .001) and had higher scores on the overall performance checklist 36.4 ± 6.6 vs 28.8 ± 7.1 (P = .012). The intervention group also had higher scores on the open-ended medical knowledge test (27.83 ± 3.07 vs 22.25 ± 4.67; P = .002), but self-confidence scores were not different between groups (P = .64)., Conclusions: CEVL neuraxial is a novel prerotation teaching tool that may enhance the traditional initial teaching of combined spinal-epidural procedures in obstetric anesthesiology. Future research should examine whether the use of web-based learning tools impacts long-term provider performance or patient outcomes.