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Health care reform has brought an unprecedented emphasis on attaining greater value for patients from treatment managed by individual providers and health care facilities. The value is defined as the relationship of the outcome achieved over an episode of care compared to the effort and resources employed to achieve this outcome. It is delivered when patients recover faster with fewer expensive resources, such as hospital, skilled nursing, or rehab facility stays. It is assessed by considering longer episodes of care, such as 30-180 days after performance of a procedure; and by assessing functional recovery, independence, and reintegration as a productive member of society. We review the evidence that suggests that peripheral nerve analgesia may favorably influence the value relationships described. Where insufficient or no evidence exists, we point out the need for further improvements in the pipeline of evidence for evidence-based medicine.

In North America and Europe, a spectrum of anesthesia personnel exists to deliver anesthesia care. The common transatlantic features, however, are increasing demand for and shortage of anesthesia caregivers. Mechanisms counteracting this shortage include increased entry into practice from higher numbers of anesthesia residents and changes in the delivery of anesthesia care by extension of the role of nonphysician anesthesia providers. The training, professional and technical roles, and workforce contribution of anesthesiologists, anesthetists, and various support personnel in Europe and the United States are described. Current and future factors influencing the relationship between provider availability, use, and demand differ across the Atlantic and within Europe.

SIGNIFICANCE AND INCIDENCE Anesthesia professionals, operating room (OR) nurses, and surgeons worry about injury to skin and other organs when positioning the anesthetized patient. The true incidence of all perioperative position-related injury is subject to conjecture. An important type of position-related injury is peripheral nerve injury. The incidence varies with surgical procedure and positioning. For example, ulnar neuropathy has been found in as many as 26% of patients undergoing open-heart surgery [1], whereas lower extremity neuropathy occurred in 1.5% of patients in the lithotomy position [2]. The incidence of ulnar neuropathy is estimated at 0.46% after noncardiac surgery [3]. According to data from the American Society of Anesthesiologists (ASA) Closed Claims Database, peripheral nerve injuries represent the second largest class of adverse outcomes and account for 16% of all claims [4].

The causes of postoperative cardiovascular disturbances in neurosurgical patients include direct cardiac neurogenic effects, clinical situations where brain tissue is underperfused, and hyperdynamic states. EKG and echographic abnormalities are common in subarachnoid hemorrhage where cardiac troponin I is the most useful predictor of cardiac risk after SAH. Neurogenic pulmonary edema is short lived and often resolves with resolution of the neurologic problem. In traumatic brain injury, where areas of ischemia co-exist with luxury perfusion, advanced hemodynamic monitoring and prevention of jugular venous desaturation best avoid secondary brain injury and achieve optimal neurologic outcome. Induced hypertension improves blood flow through vessels compromised by cerebral stenting, angioplasty, microcatheters, thrombolysis, carotid clamping, intracranial bypass and cerebral vasospasm. Hyperdynamic lesions include vascular breakthrough after elimination of cerebral arteriovenous malformations, but also emergence hypertension and hyperemia. Pharmacologic agents and adjunctive measures are effective in controlling both the systemic and the cerebral circulation.

Objectives To prove the existence of a current anesthesiologist shortage and to project the balance of labor supply and demand in the future. Methods To quantify the current supply we used published health personnel data from federal agencies and the American Medical Association, as well as membership data from the American Society of Anesthesiologists. We estimated anesthesiologist supply in 2001 based on the number of graduating residents and fellows, taking into account the loss of a portion of graduating residents due to temporary visa status. We assumed that neither a shortage nor an oversupply existed in 1994 and that demand for anesthesiologists was approximated by the number of surgical procedures reported by federal agencies. In modeling future supply and demand for anesthesiologists, we assumed that the current health care policy and economic climates will continue. We extrapolated demand using 1.5% to 3% yearly growth rates based on a synthesis of recent and projected procedure growth rates, procedure rates for the elderly, and population aging trends. We estimated the supply for 2001 through 2003 based on the current resident cohort modified by their projected graduation rate. Accounting for attrition during residency and the effect of fellowship training, we assumed that after 2003 the number of American medical graduates will initially increase by 15% annually and that the number of international medical graduates will decrease to a stable level of 500 trained each year. We assumed an average retirement age of 65 years. Results Our model suggests that there is currently a 3.6% to 10.9% shortage of anesthesiologists nationwide, depending on the assumption of a 2% or 3% increase in annual demand since 1994 and a constant pattern of work distribution by anesthesia providers. This amounts to approximately 1200 to 3800 anesthesiologists. If projected demand continues to increase at the rate of 1.5% to 2% annually, the shortfall will amount to 2.6% to 12.0% of the labor supply by 2005, representing a deficit of 1000 to 4500 anesthesiologists. By 2010, this shortfall is projected to disappear or continue to amount to about 11% of the anesthesiologist supply, depending on the assumptions about the rate of demand for anesthesiologists. Compared with the expected graduating class of 1100 anesthesiology residents in 2001, our model calls for nearly 1600 graduates by 2005 and 2000 by 2010. Conclusion A substantive shortfall of anesthesia personnel exists in 2001 and will continue for years to come, fueled by changing population demographics, population health trends, and accelerating advancements in surgical technology, as well as growth in ambulatory and office-based surgery, pain medicine, and intensive care. In addition to focusing on financing, national health policy needs to address the adequacy of health care personnel resources for an aging population, in particular when they require surgery, are afflicted by painful conditions, or become critically ill.

T ECHNICALLY, a blood substitute is a substance that can effectively replace most functions of human blood. However, oxygen-carrying modified hemoglobin solutions and perfluorocarbons have also been referred to as "blood substitutes." Because these recently developed solutions can perform only selected functions of blood, they are more accurately referred to as "oxygen-carrying volume expanders." Hemoglobin-based oxygen carriers (HBOCs) are modified hemoglobin solutions or hemoglobin packaged into liposomes, which are able to deliver oxygen to tissues. A hemoglobin therapeutic is a hemoglobin solution optimized through chemical modification to bring about certain pharmacological and therapeutic effects. Hemoglobin therapeutics may possess a combination of therapeutically active properties such as oxygen-carrying capacity, favorable theologic properties, and pressor action.

Study Objective: To describe the planning, structure, startup, administration, growth, and evaluation of a comprehensive oral practice examination (OPE) program. Setting: Midwest U.S. anesthesiology residency training program. Measurements and Main Results: Committee planning involved consideration of format and frequency of administration, timing for best resident and faculty availability, communication, forms design, clerical support, record keeping, and quality monitoring. OPE format was deliberately constructed to resemble that used by the American Board of Anesthesiology (ABA) to enhance resident familiarity with ABA style oral examination. Quality improvement tools consisted of regular examiner and examinee inservice sessions, liaison with ABA associate examiners, and review of examinee exit questionnaires. A set of OPE databases was constructed to facilitate quality monitoring and educational research efforts. A semiannual administration schedule on three to four consecutive Mondays optimally accommodated resident rotations and faculty work schedules. Continued administration of the OPE program required ongoing construction of a pool of guided case-oriented questions, selection of appropriate questions based on examinee training exposure, examination calendar publication, and scheduling of recurring examiner and examinee activities. Important issues that required action by the governing committee were examination timing, conflict with clinical demands, use of OPE results, and procurement of training resources. The OPE program grew from 56 examinations in the first year to 120 exams by year 3. It was perceived positively by the majority of residents. There were 90.2% of exit questionnaires that acknowledged specific learning about oral examination technique, while only 0.3% indicated lack of meaningful information exchange. Fewer than 10% of responses indicated misleading questions or badgering by examiners. Resident preparedness increased with repeat OPE exposure. Conclusions: A comprehensive mock oral examination program was successfully planned, initiated, and developed. It is well accepted by residents and faculty. Its inception was associated with an increase in resident preparedness. Now in its tenth year of existence it continues to be an asset and essential component of our training program.

Study Objective: To evaluate heart rate (HR) variability in the prone position with power spectral heart rate (PSHR) analysis during spinal and general anesthesia. Design: Prospective, clinical evaluation of HR variability in the prone position. Setting: Tertiary care teaching hospital. Patients: 20 healthy, ASA physical status I and II patients scheduled for elective lumbar spine surgery in the prone position. Interventions: Anesthetic technique was either a standard general anesthetic or spinal anesthetic, based on the preference of the patient. Power spectral heart rate, HR, and blood pressure (BP) readings were determined prior to anesthetic intervention and as soon as a stable PSHR reading was available in the prone position. Measurements and Main Results: Heart rate and BP were recorded at baseline prior to anesthesia and at the time of stable PSHR data in the prone position. Power spectral heart rate data included low-frequency activity (LFa), high-frequency activity (HFa), and the ratio (LFa/HFa). Spinal anesthesia level was recorded by thoracic dermatome at complete onset. Data were collected from 20 patients; 12 patients chose spinal anesthesia and 8 chose general anesthesia. The prone position resulted in significant increase in HR in the spinal group and significant decrease in BP in the general anesthesia group. Low-frequency activity and LFa/HFa ratio were unchanged in the spinal anesthesia group and were significantly decreased in the general anesthesia group. Spinal level was T8.7. Conclusions: The association of less change in LFa activity and preservation of BP on assumption of the prone position in patients during low spinal anesthesia suggests better preservation of autonomic nervous system compensatory mechanisms during low spinal anesthesia than with general anesthesia.

Selective dorsal root rhizotomy is performed for relief of spasticity in children with cerebral palsy. Postoperative pain relief can be provided by intrathecal morphine administered at the time of the procedure. We sought to define an optimal dose of intrathecal morphine in children undergoing selective rhizotomy, through a randomized, double-blinded prospective trial. After institutional approval and parental written informed consent, 27 patients, ages 3-10 years, were randomized to receive 10, 20, or 30 micrograms.kg-1 (Groups A, B, and C, respectively) of preservative-free morphine administered intrathecally by the surgeon after dural closure. Postoperatively, vital signs, pulse oximetry, and pain intensity scores were recorded hourly for 24 hr. Supplemental intravenous morphine was administered postoperatively according to a predetermined schedule based on pain scores. There was considerable individual variability in the time to initial morphine dosing and cumulative supplemental morphine dose. Time to first supplemental morphine dose was not different between groups. When compared to Groups A and B, cumulative 6-hr supplemental morphine dose was significantly lower in Group C (38.6 +/- 47 micrograms versus 79.1 +/- 74 and 189.6 +/- 126 for Groups A and B, respectively). By 12 hr, cumulative supplemental morphine dose was similar in Groups A and C. Group B consistently had a higher supplemental dose requirement than Groups A and C at 6, 12, and 18 hr. By 24 hr, there was no difference in cumulative dose among groups. Postoperative pain scores and the incidence of respiratory events, nausea, vomiting and pruritus were comparable among groups. These data suggest that intrathecal morphine at 30 micrograms.kg-1 provides the most intense analgesia at 6 hr following selective dorsal root rhizotomy, but was otherwise comparable to the 10 micrograms.kg-1 dose.

s Presented at the Spring Meeting of the Society for Education in Anesthesia The following abstracts were presented at the Annual Spring Meeting of the Society for Education in Anesthesia: b2005: The Ins and Outs of Anesthesia, Q co-hosted by the Society for Education in Anesthesia and the Children’s National Medical Center, held in Washington, DC, June 3-5, 2005. Armin Schubert, MD, MBA Editor-in-Chief, The Journal of Education in Perioperative Medicine A mastery learning model for assessing competency of medical students using portfolios L. Henson (MD), T. Dews (MD), M. Lotto (MD), J. Tetzlaff (MD), E. Dannefer (MD) Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH Introduction: Student assessment in most medical schools relies on a combination of multiple-choice examinations to test factual knowledge, objective structured clinical examinations scored by standardized patients, or observing faculty to test clinical skills, and global assessments of knowledge, skills, and professionalism (battitudes Q ) by faculty and 0952-8180/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2005.09.003 Fig. 1 Portfolio process for year 1. Shaded boxes indicate competencies tracked for each block of the year 1 schedule. Journal of Clinical Anesthesia (2005) 17, 663–682