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Currently, perioperative health care is undergoing transformative changes. One prospect for the specialty of anesthesiology is a reorientation of resident education to focus more on the entire spectrum of perioperative care as exemplified by the perioperative surgical home (PSH). To advance this novel paradigm for patients and anesthesiologists, one must also consider further incorporating the competencies fundamental to the PSH during residency training. As such, the purpose of this case report is to outline the successful implementation of a comprehensive PSH curriculum for anesthesiology residents.

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

ObjectiveDetermine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients' symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters.DesignProspective study of proxy reporters of symptoms in seriously ill patients.SettingsTwo intensive care units in a tertiary medical center in the Western United States.PatientsTwo hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians.InterventionsNone.Measurements and main resultsOn the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients' and family members' ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients' and physicians' ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients' and nurses' ratings. Two symptoms had symptom-distress correlation coefficients between patients' and physicians' ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively.ConclusionsPatient-family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients' symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians' and patients' symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients' symptoms. Proxy overestimation of patients' symptom scores warrants further study because this may influence decisions about treating patients' symptoms.

Hemoglobin values (Hb) can facilitate decisions regarding perioperative transfusion management. Currently, Hb can be determined invasively by analyzing blood via laboratory Co-Oximetry (tHb) or by point-of-care HemoCue (HCue). Recently, a new noninvasive, continuous spectrophotometric sensor (Masimo SpHb) was introduced into clinical practice. We compared the accuracy of the SpHb and HCue with tHb.Twenty patients, ages 40 to 80 years, were studied. They received general anesthesia and underwent spine surgery in the prone position. All blood samples were obtained from a radial artery catheter. SpHb, tHb, and HCue were determined immediately after induction of anesthesia, but before the start of surgery and approximately every hour thereafter. Primary outcomes were defined on the basis of the following differences between measures: SpHb - tHb or HCue - tHb. All patients had 3 to 5 observations taken on each measure. Differences and absolute differences were analyzed by several techniques to assess accuracy. We also investigated the relationship between observed differences and the following variables: tHb level, duration of surgery, age, weight, and perfusion index.Data consisted of 78 measurements of SpHb, tHb, and HCue made on the 20 patients. Absolute differences between SpHb and tHb were1.5 g/dL for 61% of observations, between 1.6 to 2.0 g/dL for 16% and2.0 g/dL for 22% of the observations. Observed differences displayed significant decreases with time and higher perfusion index values. No systematic relationships were observed with age or weight. Except for 1 value, all of the HCue values were1.0 g/dL of tHb.Although HCue was consistently accurate, our data confirm that SpHb often correlated well with tHb values. Yet our study indicates that SpHb may not be as accurate as clinically necessary in some patients. Improved refinement of continuous, noninvasive technology, such as SpHb, could address important clinical requirements.

In this review, we discuss issues of privacy and personal choice in end-of-life decision-making and existing options for directing end-of-life care, and highlight important differences between living wills, advance directives and other forms of healthcare proxies.The events surrounding the death of Terri Schiavo raise many ethical, legal and moral issues that warrant discussion. In that context, we examine the implications associated with family disagreement over end-of-life care, the ramifications for healthcare providers and the role played by politicians, the courts and the media in galvanizing the debate. Groups promoting a variety of causes seized the opportunity to further their own agenda by using the internet and other methods to rapidly disseminate often false information, fueling arguments over misdiagnosis of persistent vegetative state and raising false hopes for neurological recovery.It is incumbent upon the medical community, political and religious leaders and the media to educate the public appropriately about options regarding end-of-life issues and to foster open discourse and encourage the execution of advance directives or healthcare proxies. Although the content of this article deals with a specific case and legal rulings pertaining to the USA, the issues and questions raised are pertinent to healthcare providers and individuals around the world.

In industry and academic anesthesia departments, incentives and bonus payments based on productivity are accounting for an increasing proportion of a total compensation. When incentives are primarily based on clinical productivity, the impact on the distribution of total compensation to the faculty is not known. We compared a pure salary-based compensation methodology based entirely on academic rank to salary plus incentives and/or clinical productivity compensation (i.e., billable hours). The change in compensation methodology resulted in two major findings. First, the productivity-based compensation resulted in a large increase in the variability of total compensation among faculty, especially at the Assistant Professor rank. Second, the mean difference in total compensation between Assistant and Full Professors decreased. The authors conclude that this particular incentive plan, primarily directed toward clinical productivity, dramatically changed the distribution of total compensation in favor of junior faculty. Although not analytically investigated, the potential impact of these changes on faculty morale and distribution of faculty activities is discussed.

Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care.A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine.Physician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization.Relevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline.Guidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.

Objectives : To determine the clinical variables that affect the prognosis of critically ill patients with sustained unexplained hypotension. A further goal was to develop a prognostic scoring system based on clinical data available at the onset of hypotension. Design : Prospective cohort study. Setting : The intensive care units (ICUs) of an academic medical center. Patients : One hundred one adult ICU patients with sustained (>60 mins) unexplained hypotension. Using the initial 50 patients (derivation set), a prognostic score was developed that was then tested in the next 51 patients (validation set). Interventions : None. Measurements and Main Results : The main outcome variable was death or hospital discharge. The overall hospital mortality in the combined sets was 58%. Using a multivariable model we identified three independent (p

Previous reports have described prolonged paralysis after the administration of muscle relaxants in critically ill patients. The purpose of this study was to examine possible pathophysiologic causes for this paralysis by measuring muscle-type, nicotinic acetylcholine receptor number in necropsy muscle specimens from patients who had received muscle relaxants to facilitate mechanical ventilation before death.Prospective laboratory study of human muscle collected at autopsy.Medical and surgical intensive care units (ICUs) at a university hospital and a research laboratory.Fourteen critically ill patients, with a variety of diagnoses, all of whom required mechanical ventilatory support before their deaths in the ICU and who underwent post mortem examination. Patients were arbitrarily divided into three groups, according to their total vecuronium dose and number of days mechanically ventilated before death. Three patients were in the control group (defined as dying within 72 hrs of initiation of ventilatory support and receiving a total dose of5 mg of vecuronium). Six patients were in the low-dose group (defined as requiring ventilatory support for3 days before death and receiving a total vecuronium dose ofor = 200 mg). Five patients were in the high-dose group (defined as requiring ventilatory support for3 days before death and receiving a total vecuronium dose of200 mg).None.Nicotinic acetylcholine receptor numbers as measured by specific 125I-alpha-bungarotoxin binding to human rectus abdominis muscle obtained at autopsy were determined. In general, receptor number reflected the clinical requirements for the muscle relaxants of each patient. Patients who had increasing requirements for muscle relaxants before death had increases in receptor number, as compared with control values.The increase in nicotinic acetylcholine receptor number in muscle from patients with an increasing requirement for muscle relaxants before death suggests that nicotinic acetylcholine receptor up-regulation may underlie the increased requirements for muscle relaxants seen in some patients. Furthermore, these findings suggest that muscle relaxant-induced, denervation-like changes may at least be partially responsible for prolonged muscle paralysis after the long-term administration of muscle relaxants. This study may provide the first information into the molecular mechanisms underlying prolonged paralysis.

Background Hospitalized patients outside of the operating room frequently require emergency airway management. This study investigates complications of emergency airway management in critically ill adults, including: (1) the incidence of difficult and failed intubation; (2) the frequency of esophageal intubation; (3) the incidence of pneumothorax and pulmonary aspiration; (4) the hemodynamic consequences of emergent intubation, including death, during and immediately following intubation; and (5) the relationship, if any, between the occurrence of complications and supervision of the intubation by an attending physician. Methods Data were collected on consecutive tracheal intubations carried out by the intensive care unit team over a 10-month period. Non-anesthesia residents were supervised by anesthesia residents, critical care attending physicians, or anesthesia attending physicians. Results Two hundred ninety-seven consecutive intubations were carried out in 238 adult patients. Translaryngeal tracheal intubation was accomplished in all patients. Intubation was difficult in 8% of cases (requiring more than two attempts at laryngoscopy by a physician skilled in airway management). Esophageal intubation occurred in 25 (8%) of the attempts but all were recognized before any adverse sequelae resulted. New infiltrates suggestive of pulmonary aspiration were present on chest radiography after 4% of intubations. Seven patients (3%) died during or within 30 min of the procedure. Five of the seven patients had systemic hypotension (systolic blood pressure < or = 90 mmHg), and four of the five were receiving vasopressors to support systolic blood pressure. Patients with systolic hypotension were more likely to die after intubation than were normotensive patients (P < 0.001). There was no relationship between supervision by an attending physician and the occurrence of complications. Conclusions In critically ill patients, emergency tracheal intubation is associated with a significant frequency of major complications. In this study, complications were not increased when intubations were accomplished without the supervision of an attending physician as long as the intubation was carried out or supervised by an individual skilled in airway management. Mortality associated with emergent tracheal intubation is highest in patients who are hemodynamically unstable and receiving vasopressor therapy before intubation.

We investigated decisions to withhold or withdraw life support from patients in the medical-surgical intensive care units at the Moffitt-Long Hospital of the University of California and San Francisco General Hospital, from July 1987 through June 1988. Among 1719 patients admitted to the two intensive care units, life support was withheld from 22 (1 percent) and withdrawn from 93 (5 percent). The reason for limiting care was poor prognosis. Of these 115 patients (18 of whom were considered brain-dead), 89 died in the intensive care unit (accounting for 45 percent of all deaths there), and all but 1 of the remaining patients died after transfer from the intensive care unit. Thirteen (11 percent) had earlier expressed the wish that their terminal care be limited, but this affected care in only four cases. Only 5 of the 115 patients made the actual decision to limit care; the others were incompetent at the time. Of the latter, 102 had families who participated in the decision; family members of the other 8 incompetent patients could not be found, and the decisions were made by physicians. Only 10 families initially disagreed with the recommendations to limit care, and they later agreed. The median duration of intensive care among the patients from whom life support was withheld or withdrawn was eight days at Moffitt-Long Hospital and four days at San Francisco General, as compared with medians of three and one days, respectively, for other patients who died in the intensive care units. We conclude that although life-sustaining care is withheld or withdrawn relatively infrequently from patients in the intensive care unit, such decisions precipitate about half of all deaths in the intensive care units of the hospitals we studied. In most of these cases the patients are incompetent, but physicians and families usually agree to limit care.

Washin and washout of a volatile anesthetic given through the oxygenator during hypothermic (23.4 +/- 2.1 degrees C) cardiopulmonary bypass were studied in nine patients. The authors administered isoflurane and measured its partial pressure in arterial (Pa) and venous (Pv) blood and the gas exhausted from the oxygenator (PE) at 1, 2, 4, 8, 16, 32, and 48 min during washin. These measurements were repeated during washout, which coincided with rewarming. During washin, PE, Pa, and Pv progressively rose toward inlet gas partial pressure (PI). Equilibration of Pa with PI was 41% after 16 min, 51% after 32 min, and 57% after 48 min of washin. During washout, Pa declined to 24% of its peak after 16 min and to 13% after 32 min. Washin and washout were considerably slower in mixed venous blood. Washin of isoflurane appeared to occur more slowly during cardiopulmonary bypass than during administration via the lungs in normothermic patients, presumably because hypothermia increases tissue capacity, compensating for the effect of hemodilution that otherwise would decrease the blood/gas partition coefficient. During rewarming, washout appeared to occur as rapidly as from the lungs of normothermic patients. This may have resulted from the declining blood/gas partition coefficient (due to rewarming) and relatively limited tissue stores of isoflurane. The relationship between exhaust and arterial partial pressures was reasonably consistent; for clinical purposes, measurement of PE can be used to estimate Pa.

The uptake and elimination of volatile anesthetic agents administered to patients under conditions of hemodilution and hypothermia during cardiopulmonary bypass have not been determined. To define the limitations imposed by oxygenators, we defined washin and washout curves for volatile anesthetic agents administered to bubble oxygenators primed with diluted blood (without connection to a patient). There was rapid equilibration of anesthetic partial pressure between delivered gas and blood (85-90% within 16 minutes). Increasing the gas inflow to the oxygenator from 3 to 12 L/min hastened washin and washout slightly, while increasing the pump blood flow from 3 to 5 L/min had no effect. Rates of washin and washout of anesthetics differed as a function of their blood/gas solubilities: enflurane greater than isoflurane greater than halothane during washin; isoflurane greater than enflurane greater than halothane during washout. However, these differences were small. Oxygenator exhaust partial pressures of anesthetic correlated with simultaneously obtained blood partial pressures, suggesting that monitoring exhaust gas may be useful clinically.

We studied the contribution of pancuronium to anesthetic requirement in man by comparing MAC for halothane alone in 18 patients, with that after intravenous administration of pancuronium, 0.1 mg/kg, in 17 patients. In each group, movement was observed in limbs isolated from the circulation by tourniquet. In patients receiving pancuronium, halothane MAC was 0.55%, whereas the control value was 0.73%. Thus pancuronium reduces halothane MAC by 25%.