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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.

Purpose of Review: The integration of artificial intelligence (AI) in nonoperating room anesthesia (NORA) represents a timely and significant advancement. As the demand for NORA services expands, the application of AI is poised to improve patient selection, perioperative care, and anesthesia delivery. This review examines AI's growing impact on NORA and how it can optimize our clinical practice in the near future., Recent Findings: AI has already improved various aspects of anesthesia, including preoperative assessment, intraoperative management, and postoperative care. Studies highlight AI's role in patient risk stratification, real-time decision support, and predictive modeling for patient outcomes. Notably, AI applications can be used to target patients at risk of complications, alert clinicians to the upcoming occurrence of an intraoperative adverse event such as hypotension or hypoxemia, or predict their tolerance of anesthesia after the procedure. Despite these advances, challenges persist, including ethical considerations, algorithmic bias, data security, and the need for transparent decision-making processes within AI systems., Summary: The findings underscore the substantial benefits of AI in NORA, which include improved safety, efficiency, and personalized care. AI's predictive capabilities in assessing hypoxemia risk and other perioperative events, have demonstrated potential to exceed human prognostic accuracy. The implications of these findings advocate for a careful yet progressive adoption of AI in clinical practice, encouraging the development of robust ethical guidelines, continual professional training, and comprehensive data management strategies. Furthermore, AI's role in anesthesia underscores the need for multidisciplinary research to address the limitations and fully leverage AI's capabilities for patient-centered anesthesia care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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: We report adherence to 6 Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) quality metrics (QMs) relevant to patients undergoing decompressive craniectomy or endoscopic clot evacuation after spontaneous supratentorial intracerebral hemorrhage (sICH)., Methods: In this retrospective observational study, we describe adherence to the following ASPIRE QMs: acute kidney injury (AKI-01); mean arterial pressure < 65 mm Hg for less than 15 minutes (BP-03); myocardial injury (CARD-02); treatment of high glucose (> 200 mg/dL, GLU-03); reversal of neuromuscular blockade (NMB-02); and perioperative hypothermia (TEMP-03)., Result: The study included 95 patients (70% male) with median (interquartile range) age 55 (47 to 66) years and ICH score 2 (1 to 3) undergoing craniectomy (n=55) or endoscopic clot evacuation (n=40) after sICH. In-hospital mortality attributable to sICH was 23% (n=22). Patients with American Society of Anesthesiologists physical status class 5 (n=16), preoperative reduced glomerular filtration rate (n=5), elevated cardiac troponin (n=21) and no intraoperative labs with high glucose (n=71), those who were not extubated at the end of the case (n=62) or did not receive a neuromuscular blocker given (n=3), and patients having emergent surgery (n=64) were excluded from the analysis for their respective ASPIRE QM based on predetermined ASPIRE exclusion criteria. For the remaining patients, the adherence to ASPIRE QMs were: AKI-01, craniectomy 34%, endoscopic clot evacuation 1%; BP-03, craniectomy 72%, clot evacuation 73%; CARD-02, 100% for both groups; GLU-03, craniectomy 67%, clot evacuation 100%; NMB-02, clot evacuation 79%, and; TEMP-03, clot evacuation 0% with hypothermia., Conclusion: This study found variable adherence to ASPIRE QMs in sICH patients undergoing decompressive craniectomy or endoscopic clot evacuation. The relatively high number of patients excluded from individual ASPIRE metrics is a major limitation., Competing Interests: A.V.L. reports receiving salary support from LifeCenter Northwest, which is not relevant to this study. M.R.L. reports receiving research support from Medtronic and Stryker, Consulting for Medtronic, Metis Innovative, and Aegean Advisers, and equity interest in Proprio, Cerebrotech, Synchron, Fluid Biomed, and Hyperion Surgical, none of which are relevant to this study. M.J.S. reports salary support to the University of Washington from Life Center Northwest and consulting for Teleflex Medical, neither of which are relevant to this study. The remaining authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Purpose of Review: Regional anaesthesia is increasingly prominent within anaesthesia, offering alternative analgesic options amidst concerns over opioid-based analgesia. Since Halsted's initial description, the field has burgeoned, with ultrasound visualization revolutionizing local anaesthetic spread assessment, leading to the development of numerous novel techniques. The benefits of regional anaesthesia have gained increasing evidence to support their application, leading to changes within training curricula. Consequently, regional anaesthesia is at a defining moment, embracing the development of core skills for the general anaesthesiologist, whilst also continuing the advancement of the specialty., Recent Findings: Recent priority setting projects have focussed attention on key aspects of regional anaesthesia delivery, including pain management, conduct and efficacy, education, and technological innovation. Developments in our current understanding of anatomy and pharmacology, combined with strategies for optimizing the conduct and maximizing efficacy of techniques, minimizing complications, and enhancing outcomes are explored. In addition, advancements in education and training methodologies and the integration of progress in novel technologies will be reviewed., Summary: This review highlights recent scientific advances in optimizing both single-shot and continuous peripheral regional anaesthesia techniques. By synthesizing these developments, this review offers valuable insights into the evolving landscape of regional anaesthesia, aiming to improve clinical practice and patient care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The author declares no conflicts of interest.

Competing Interests: The authors declare no conflicts of interest.

Purpose of Review: Simulation is a well established practice in medicine. This review reflects upon the role of simulation in pediatric anesthesiology in three parts: training anesthesiologists to care for pediatric patients safely and effectively; evaluating and improving systems of care for children; and visions for the future., Recent Findings: Simulation continues to prove a useful modality to educate both novice and experienced clinicians in the perioperative care of infants and children. It is also a powerful tool to help analyze and improve upon how care is provided to infants and children. Advances in technology and computational power now allow for a greater than ever degree of innovation, accessibility, and focused reflection and debriefing, with an exciting outlook for promising advances in the near future., Summary: Simulation plays a key role in developing and achieving peak performance in the perioperative care of infants and children. Although simulation already has a great impact, its full potential is yet to be harnessed., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of This Review: This article explores how artificial intelligence (AI) can be used to evaluate risks in pediatric perioperative care. It will also describe potential future applications of AI, such as models for airway device selection, controlling anesthetic depth and nociception during surgery, and contributing to the training of pediatric anesthesia providers., Recent Findings: The use of AI in healthcare has increased in recent years, largely due to the accessibility of large datasets, such as those gathered from electronic health records. Although there has been less focus on pediatric anesthesia compared to adult anesthesia, research is on- going, especially for applications focused on risk factor identification for adverse perioperative events. Despite these advances, the lack of formal external validation or feasibility testing results in uncertainty surrounding the clinical applicability of these tools., Summary: The goal of using AI in pediatric anesthesia is to assist clinicians in providing safe and efficient care. Given that children are a vulnerable population, it is crucial to ensure that both clinicians and families have confidence in the clinical tools used to inform medical decision- making. While not yet a reality, the eventual incorporation of AI-based tools holds great potential to contribute to the safe and efficient care of our patients., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Purpose of Review: The incorporation of point of care ultrasound into the field of anesthesiology and perioperative medicine is growing at rapid pace. The benefits of this modality align with the acuity of patient care and decision-making in anesthetic care of a trauma patient., Recent Findings: Cardiac ultrasound can be used to diagnose cardiac tamponade or investigate the inferior vena cava to assess volume status in patients who may suffer from hemorrhagic shock. Thoracic ultrasound may be used to rapidly identify pneumothorax or hemothorax in a patient suffering chest wall trauma. In addition, investigators are exploring the utility of ultrasonography in traumatic airway management and elevated intracranial pressure. In addition, the utility of gastric ultrasound on trauma patients is briefly discussed., Summary: Incorporation of point of care ultrasound techniques into the practice of trauma anesthesiology is important for noninvasive, mobile and expeditious assessment of trauma patients. In addition, further large-scale studies are needed to investigate how point of care ultrasound impacts outcomes in trauma patients., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system., (Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved.)

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.)

Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients., (Copyright © 2021, the American Society of Anesthesiologists, Inc. All Rights Reserved.)

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.