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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.

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.

Anesthesiology is at a crossroad, particularly in the USA. We explore the changing and future roles for anesthesiologists, including the implication of new models of care such as the perioperative surgical home, changes in payment methodology, and the impact other refinements in healthcare delivery will have on practice opportunities and training requirements for anesthesiologists.The advances in the practice of anesthesiology are having a significant impact on patient care, allowing a more diverse and complex patient population to benefit from the knowledge, skills and expertise of anesthesiologists. Expanded clinical opportunities, increased utilization of technology and expansion in telemedicine will provide the foundation to care for more patients in diverse settings and to better monitor patients remotely while ensuring immediate intervention as needed. Although the roles of anesthesiologists have been diverse, the scope of practice varies from one country to another. The changing healthcare needs in the USA in particular are creating new opportunities for American anesthesiologists to define expanded roles in healthcare delivery. To fulfill these evolving needs of patients and health systems, resident training, ongoing education and methods to ensure continued competency must incorporate new approaches of education and continued certification to ensure that each anesthesiologist has the full breadth and depth of clinical skills needed to support patient and health system needs.The scope of anesthesia practice has expanded globally, providing anesthesiologists, particularly those in the USA, with unique new opportunities to assume a broader role in perioperative care of surgical patients.

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.

BACKGROUND Blood hemoglobin can be monitored continuously and noninvasively with a noninvasive spectrophotometric sensor (Masimo SpHb). The perfusion index (PI) of the finger is directly related to the clinical accuracy of SpHb. We evaluated those variables that influence PI without the influences of surgery and anesthesia. METHODS Based on our past studies, 12 awake adult volunteers were studied. A SpHb sensor was attached to the same finger of each hand. The temperature of each finger was measured via a skin surface probe. A digital nerve block (DNB) was performed with 1% lidocaine on one finger and 0.25% bupivacaine on the other finger of the opposite hand. SpHb, PI, and finger temperature were monitored continuously 30 minutes before and 3 to 4 hours after placement of the DNB. A random effects spline regression was used to flexibly model the outcomes before and after the DNB and to compare the effects of lidocaine and bupivacaine. RESULTS The DNBs increased the PI for both lidocaine and bupivacaine (P < 0.0001) and finger temperature from both lidocaine (P < 0.0001) and bupivacaine (P = 0.02). The duration of action of bupivacaine was markedly longer than that of lidocaine (P < 0.0001). Between 45 and 75 minutes after insertion of the DNB, the PI with bupivacaine was substantially higher than that of lidocaine. The PI was directly related to changes in finger temperature and SpHb. During this time interval, 11 of the 12 volunteers receiving bupivacaine descriptively had increases in finger temperature ranging from no change to 6.1°C. In contrast, only 6 of the 12 lidocaine volunteers had increases in finger temperature ranging from no change to 4°C. Changes in PI were directly correlated with SpHb values (correlation coefficient = 0.7). CONCLUSIONS A DNB increases PI and finger temperature. These increases lasted 2 to 3 hours longer with bupivacaine than lidocaine. The increases in PI were associated with slightly higher SpHb values. We conclude that the DNB induces increases in PI and temperature of the finger. Because of the close relationship between finger temperature, PI, and SpHb, consistently increasing finger temperature and PI could increase the accuracy of SpHb.

Summary A variety of methods is available to monitor the patient who requires mechanical ventilation. The monitoring techniques include clinical assessment, monitors of gas exchange and a variety of methods to evaluate pulmonary mechanical function. The selection of the most appropriate monitors for each patient depends upon an understanding of the clinical situation, the available monitoring techniques and the information each monitor provides, as well as their limitations. The challenge for the physician is to identify and appropriately use those monitoring techniques that provide the optimum of cost-effective clinical management with minimal morbidity and mortality.

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.

Blood hemoglobin (Hb) can be continuously monitored utilizing noninvasive spectrophotometric finger sensors (Masimo SpHb). SpHb is not a consistently accurate guide to transfusion decisions when compared with laboratory Co-Oximetry (tHb). We evaluated whether a finger digital nerve block (DNB) would increase perfusion and, thereby, improve the accuracy of SpHb.Twenty adult patients undergoing spinal surgery received a DNB with lidocaine to the finger used for the monitoring of SpHb. SpHb-tHb differences were determined immediately following the DNB and approximately every hour thereafter. These differences were compared with those in our previously reported patients (N = 20) with no DNB. The SpHb-tHb difference was defined as "very accurate" if 0.5 g/dL and "inaccurate" if 2.0 g/dL. Perfusion index (PI) values at the time of each SpHb-tHb measurement were compared.There were 57 and 78 data points in this and our previous study, respectively. The presence of a DNB resulted in 37 % of measurements having SpHb values in the "very accurate group" versus 12 % in patients without a DNB. When the PI value was 2.0, only 1 of 57 DNB values was in the "inaccurate" group. The PI values were both higher and less variable in the patients who received a DNB.A DNB significantly increased the number of "very accurate" SpHb values and decreased the number of "inaccurate" values. We conclude that a DNB may facilitate the use of SpHb as a guide to transfusion decisions, particularly when the PI is 2.0.

Transesophageal echocardiography (TEE) has become a commonly used monitor of left ventricular (LV) function and filling during cardiac surgery. Its use is based on the assumption that changes in LV short-axis ID reflect changes in LV volume. To study the ability of TEE to estimate LV volume and ejection immediately following CABG, 10 patients were studied using blood pool scintigraphy, TEE, and thermodilution cardiac output (CO). A single TEE short-axis cross-sectional image of the LV at the midpapillary muscle level was used for area analysis. Between 1 and 5 h postoperatively, simultaneous data sets (scintigraphy, TEE, and CO) were obtained three to five times in each patient. End-diastolic (EDa) and end-systolic (ESa) areas were measured by light pen. Ejection fraction area (EFa) was calculated (EFa = (EDa - ESa)/EDa). When EFa was compared with EF by scintigraphy, correlation was good (r = 0.82 SEE = 0.07). EDa was taken as an indicator of LV volume and compared with LVEDVI which was derived from EF by scintigraphy and CO. Correlation between EDa and LVEDVI was fair (r = 0.74 SEE = 3.75). The authors conclude that immediately following CABG, a single cross-sectional TEE image provides a reasonable estimate of EF but not LVEDVI.

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%.