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Background Modern medical education requires frequent competency assessment. The Accreditation Council for Graduate Medical Education (ACGME) provides a descriptive framework of competencies and milestones but does not provide standardized instruments to assess and track trainee competency over time. Entrustable professional activities (EPAs) represent a workplace-based method to assess the achievement of competency milestones at the point-of-care that can be applied to anesthesiology training in the United States. Methods Experts in education and competency assessment were recruited to participate in a 6-step process using a modified Delphi method with iterative rounds to reach consensus on an entrustment scale, a list of EPAs and procedural skills, detailed definitions for each EPA, a mapping of the EPAs to the ACGME milestones, and a target level of entrustment for graduating US anesthesiology residents for each EPA and procedural skill. The defined EPAs and procedural skills were implemented using a website and mobile app. The assessment system was piloted at 7 anesthesiology residency programs. After 2 months, faculty were surveyed on their attitudes on usability and utility of the assessment system. The number of evaluations submitted per month was collected for 1 year. Results Participants in EPA development included 18 education experts from 11 different programs. The Delphi rounds produced a final list of 20 EPAs, each differentiated as simple or complex, a defined entrustment scale, mapping of the EPAs to milestones, and graduation entrustment targets. A list of 159 procedural skills was similarly developed. Results of the faculty survey demonstrated favorable ratings on all questions regarding app usability as well as the utility of the app and EPA assessments. Over the 2-month pilot period, 1636 EPA and 1427 procedure assessments were submitted. All programs continued to use the app for the remainder of the academic year resulting in 12,641 submitted assessments. Conclusions A list of 20 anesthesiology EPAs and 159 procedural skills assessments were developed using a rigorous methodology to reach consensus among education experts. The assessments were pilot tested at 7 US anesthesiology residency programs demonstrating the feasibility of implementation using a mobile app and the ability to collect assessment data. Adoption at the pilot sites was variable; however, the use of the system was not mandatory for faculty or trainees at any site.

Background: This multicenter study was undertaken to compare the effect of sevoflurane with that of isoflurane on renal function in 26 patients with pre-existing renal insufficiency. Sevoflurane undergoes hepatic metabolism, with release of inorganic fluoride. Elevated flu oride levels have been associated with renal impairment in patients undergoing methoxyflu rane anesthesia raising concerns about the nephrotoxic potential of sevoflurane. Methods : Patients were ASA II or III class, with renal insufficiency defined by a preopera tive serum creatinine concentration of 1.5-3.0 mg/dl. A standardized anesthetic regimen was used consisting of intravenous induction with propofol, vecuronium for muscle relax ation, and fentanyl for analgesia. Patients were randomized to receive either isoflurane or sevoflurane with 100% oxygen. Blood samples were obtained preoperatively and at 24, 48, and 72 h postoperativety for renal/electrolyte determinations. Blood samples for plasma flu oride measurement were obtained preoperatively. Results: Plasma fluoride levels were significantly higher in patients receiving sevoflurane at all measurement points from 0 to 72 h postanesthesia. Mean peak fluoride concentration was 33.4 μM. The maximum fluoride value measured was 51.2 μM. There were no signifi cant differences in postoperative serum creatinine values at any time between patients receiving sevoflurane or isoflurane. Conclusions: Sevoflurane metabolism produces elevations in plasma fluoride concentra tions relative to isoflurane. Despite the increase in plasma fluoride levels, the administration of sevoflurane to patients with renal insufficiency did not produce any adverse effects on renal function as measured by serum creatinine concentration when compared with isoflurane.

o Not Resuscitate (DNR) orders are established by competent patients or appropriate surro- gates to provide a mechanism for withholding specific resuscitative therapies in the event of a car- diopulmonary arrest. It is important for health care institutions to develop policies to deal with DNR or- ders in the setting of anesthesia and surgery as it is estimated that 15% of patients with DNR orders un- dergo a surgical procedure (1) and the frequency of DNR orders is increasing as the population becomes better informed about the Patient Self-Determination Act and advanced directives (2). Several surveys have documented confusion on the part of individual prac- titioners and have demonstrated that only a small percentage of institutions have specific policies re- garding perioperative DNR orders (3-6). This lack of consistency stems in part from the fact that surgery and anesthesia routinely involve physiologic stresses and suppression of vital signs far different from those experienced outside the operating room. The unique aspects of anesthesia create potential practical and ethical barriers to the implementation of perioperative DNR orders. In this paper, the complex medial and ethical issues surrounding the perioperative DNR or- ders are discussed, and the rationale for the recently introduced American Society of Anesthesiologists (ASA) guidelines is highlighted. Most of the surgery performed in patients with DNR orders is palliative and designed to improve patient comfort or simplify care. For many practitio- ners the definition of anesthesia includes routine sup- pression of respiration and performance of procedures such as endotracheal intubation and volume or drug infusion, which in other settings are often refused as

Pulmonary arteriovenous malformation (PAVM) is an uncommon congenital anomaly. As PAVM is a direct communication between branches of the pulmonary artery and vein, major disturbances in gas exchange can result. We present a patient with an unsuspected PAVM who came to our institution for drainage of a brain abscess. Arterial blood gas analysis during and after surgery demonstrated a large alveolar-arterial gradient for oxygen in the absence of any obvious pulmonary pathology while the patient was receiving positive pressure ventilation (PPV). Oxygenation improved considerably upon resumption of spontaneous ventilation. A diagnosis of PAVM was made subsequently. We conclude that positive pressure ventilation can worsen right to left shunting in patients with PAVM.

We report a case of suspected carbon dioxide embolism occurring during laparoscopy. Among the sequelae was neurological dysfunction felt to be secondary to paradoxical embolization. The patient was treated with hyperbaric oxygen therapy. Hyperbaric oxygen should be considered when confronted with a clinically important gas embolism.