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Background: Anesthesiologists provide crucial anesthesiology services in the operating room and non-operating room locations. Combined with an aging and growing Israeli population, there is an increasing demand for anesthesiology services. A previous study performed in 2005 showed that most anesthesiologists are immigrant physicians with few Israeli medical school graduates. Since then, physician immigration decreased, many have retired and demand for anesthesia services has increased while insufficient numbers of new anesthesiologists were trained, leading to a shortage, limiting surgeries and other procedures in many hospitals. The present study examined the composition of the Israeli anesthesiology workforce in 2021and compared it to the 2005 workforce., Methods: A cross-sectional survey of demographic and professional information about each Israeli hospital anesthesiologists was solicited from 34 anesthesiology department chairs responsible for 36 Israeli acute care hospitals., Results: There are 1313 anesthesiologists in the 36 hospitals, resulting in a ratio of 14.2 anesthesiologists per 100,000 population. 22.6% of anesthesiologists will reach retirement age over the next ten years. The proportion of female anesthesiologists was 28.7%. While Israeli medical school graduates increased to 18.1% from 12.2% in 2005, non-Israeli citizens and non-permanent residents comprised 8.5% of the workforce., Conclusions: Despite growth in the ratio of anesthesiologists per population, a workforce shortage is expected to worsen over the next ten years due to retirements, shortened call hours, and the Yatziv reform which bans graduates of certain overseas medical schools from obtaining Israeli Medical Licenses. The current workforce has compensated for the existing shortage of anesthesiologists by enlisting non-Israeli trainees from overseas. Yet, it is crucial to maintain and enlarge the local Israeli workforce to forestall a worsening shortage., (© 2024. The Author(s).)

The imbalance in anesthesia workforce supply and demand has been exacerbated post-COVID due to a surge in demand for anesthesia care, especially in non-operating room anesthetizing sites, at a faster rate than the increase in anesthesia clinicians. The consequences of this imbalance or labor shortage compromise healthcare facilities, adversely affect the cost of care, worsen anesthesia workforce burnout, disrupt procedural and surgical schedules, and threaten academic missions and the ability to educate future anesthesiologists. In developing possible solutions, one must examine emerging trends that are affecting the anesthesia workforce, new technologies that will transform anesthesia care and the workforce, and financial considerations, including governmental payment policies. Possible practice solutions to this imbalance will require both short- and long-term multifactorial approaches that include increasing training positions and retention policies, improving capacity through innovations, leveraging technology, and addressing financial constraints., (Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.)

Background: Gender imbalance and poor representation of women complicate the anesthesiology workforce crisis in sub-Saharan Africa (SSA). This study was performed to obtain a better understanding of gender disparity among medical graduates and anesthesiologists in SSA., Methods: Using a quantitative, participatory, insider research study, led by female anesthesiologists as the national coordinators in SSA, we collected data from academic or national health authorities and agencies. National coordinators were nominees of anesthesiology societies that responded to our email invitations. Data gathered from 13 countries included information on medical graduates, anesthesiologists graduating between 1998 and 2021, and number of anesthesiologists licensed to practice in 2018. We compared data between Francophone and Anglophone countries, and between countries in East Africa and West Africa/Central Africa. We calculated anesthesiology workforce densities and compared representation of women among graduating anesthesiologists and medical graduates.Data analysis was performed using linear regression. We used F-tests on regression slopes to assess the trends in representation of women over the years and the differences between the slopes. A value of P < .050 was considered statistically significant., Results: Over a 20-year period, the representation of female medical graduates in SSA increased from 29% (1998) to 41% (2017), whereas representation of female anesthesiologists was inconsistent, with an average of 25%, and lagged behind. Growth and gender disparity patterns were different between West Africa/Central Africa and East Africa. Representation of female anesthesiologists was higher in East Africa (39.4%) than West Africa/Central Africa (19.7%); and the representation of female medical graduates in East Africa (42.5%) was also higher that West Africa/Central Africa (33.1%)., Conclusions: On average, in SSA, female medical graduates (36.9%), female anesthesiologists (24.9%), and female anesthesiology residents projected to graduate between 2018 and 2022 (25.2%) were underrepresented when compared to their male counterparts. Women were underrepresented in SSA, despite evidence that their representation in medicine and anesthesiology in East African countries was rising., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Background: There is a large global deficit of anesthesia providers. In 2016, the World Federation of Societies of Anaesthesiologists (WFSA) conducted a survey to count the number of anesthesia providers worldwide. Much work has taken place since then to strengthen the anesthesia health workforce. This study updates the global count of anesthesia providers., Methods: Between 2021 and 2023, an electronic survey was sent to national professional societies of physician anesthesia providers (PAPs), nurse anesthetists, and other nonphysician anesthesia providers (NPAPs). Data included number of providers and trainees, proportion of females, and limited intensive care unit (ICU) capacity data. Descriptive statistics were calculated by country, World Bank income group, and World Health Organization (WHO) region. Provider density is reported as the number of providers per 100,000 population., Results: Responses were obtained for 172 of 193 United Nations (UN) member countries. The global provider density was 8.8 (PAP 6.6 NPAP 2.3). Seventy-six countries had a PAP density <5, whereas 66 countries had a total provider density <5. PAP density increased everywhere except for high- and low-income countries and the African region., Conclusions: The overall size of the global anesthesia workforce has increased over time, although some countries have experienced a decrease. Population growth and differences in which provider types that are counted can have an important impact on provider density. More work is needed to define appropriate metrics for measuring changes in density, to describe anesthesia cadres, and to improve workforce data collection processes. Effort to scale up anesthesia provider training must urgently continue., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

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.)

Competing Interests: The authors declare no conflicts of interest.

Background: The coronavirus disease 2019 (COVID-19) pandemic has affected the personal and professional lives of all health care workers. Anesthesiologists frequently perform virus-aerosolizing procedures (eg, intubation and extubation) that place them at increased risk of infection. We sought to determine how the initial COVID-19 outbreak affected members of the Society for Pediatric Anesthesia (SPA) on both personal and professional levels. Specifically, we examined the potential effects of gender and age on personal stress, burnout, sleep deprivation, anxiety, depression, assessed job satisfaction, and explored financial impact., Methods: After receiving approval from the SPA Committees for Research and Quality and Safety and the Colorado Multiple Institutional Review Board, we e-mailed a questionnaire to all 3245 SPA members. The survey included 22 questions related to well-being and 13 questions related to effects of COVID-19 on current and future practice, finances, retirement planning, academic time and productivity, and clinical and home responsibilities. To address low initial response rates and quantify nonresponse bias, we sent a shortened follow-up survey to a randomly selected subsample (n = 100) of SPA members who did not respond to the initial survey. Response differences between the 2 cohorts were determined., Results: A total of 561 (17%) members responded to the initial questionnaire. Because of COVID-19, 21.7% of respondents said they would change their clinical responsibilities, and 10.6% would decrease their professional working time. Women were more likely than men to anticipate a future COVID-19-related job change (odds ratio [OR] = 1.92, 95% confidence interval [CI], 1.12-2.63; P = .011), perhaps because of increased home responsibilities (OR = 2.63, 95% CI, 1.74-4.00; P < .001). Additionally, 14.2% of respondents planned to retire early, and 11.9% planned to retire later. Women and non-White respondents had higher likelihoods of burnout on univariate analysis (OR = 1.75, 95% CI, 1.06-2.94, P = .026 and OR = 1.82, 95% CI, 1.08-3.04, P = .017, respectively), and 25.1% of all respondents felt socially isolated. In addition, both changes in retirement planning and future occupational planning were strongly associated with total job satisfaction scores (both P < .001)., Conclusions: The COVID-19 pandemic has affected the personal and professional lives of pediatric anesthesiologists, albeit not equally, as women and non-Whites have been disproportionately impacted. The pandemic has significantly affected personal finances, home responsibilities, and retirement planning; reduced clinical and academic practice time and responsibilities; and increased feelings of social isolation, stress, burnout, and depression/anxiety., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

The Earth's mean surface temperature is already approximately 1.1°C higher than pre-industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three-stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high-, middle- and low-income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists' education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re-evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references., (© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: The pattern of perioperative use of personal electronic devices (PEDs) among anesthesia providers in the United States is unknown., Methods: We developed a 31-question anonymous survey of perioperative PED use that was sent to 813 anesthesiologists, anesthesiology residents, and certified registered nurse anesthetists at 3 sites within one health system. The electronic survey assessed patterns of PED use inside the operating room (OR), outside the OR, and observed in others. Questions were designed to explore the various purposes for PED use, the potential impact of specific hospital policies or awareness of medicolegal risk on PED use, and whether PED was a source of perioperative distraction., Results: The overall survey response rate was 36.8% (n = 299). With regard to often/frequent PED activity inside the OR, 24% reported texting, 5% reported talking on the phone, and 11% reported browsing on the Internet. With regard to often/frequent PED activity outside the OR, 88% reported texting, 26% reported talking on the phone, and 63% reported browsing the Internet. With regard to often/frequent PED activity observed in others, 52% reported others texting, 14% reported others talking on the phone, and 34% reported others browsing the Internet. Two percent of respondents self-reported a distraction compared to 15% who had observed a distraction in others. Eighty percent of respondents recognized PED as a potential distraction for patient safety., Conclusions: Our data reinforce that PED use is prevalent among anesthesia providers., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Ensuring a productive clinical and research workforce requires bringing together physicians and communities to improve health, by strategic targeting of initiatives with clear and significant public health relevance. Within anesthesiology, the traditional perspective of the field's health impact has focused on providing safe and effective intraoperative care, managing critical illness, and treating acute and chronic pain. However, there are limitations to such a framework for anesthesiology's public health impact, including the transient nature of acute care episodes such as the intraoperative period and critical illness, and a historical focus on analgesia alone-rather than the complex psychosocial milieu-for pain management. Due to the often episodic nature of anesthesiologists' interactions with patients, it remains challenging for anesthesiologists to achieve their full potential for broad impact and leadership within increasingly integrated health systems. To unlock this potential, anesthesiologists should cultivate new clinical, research, and administrative roles within the health system-transcending traditional missions, seeking interdepartmental collaborations, and taking measures to elevate anesthesiologists as dynamic and trusted leaders. This special article examines 3 core themes for how anesthesiologists can enhance their impact within the health care system and pursue new collaborative health missions with nonanesthesiologist clinicians, researchers, and administrative leaders. These themes include (1) reframing of traditional anesthesiologist missions toward a broader health system-wide context; (2) leveraging departmental and institutional support for professional career development; and (3) strategically prioritizing leadership attributes to enhance system-wide anesthesiologist contributions to improving overall patient health., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: Breast cancer is the most common malignancy in women. Surgery is a mainstay therapy unfortunately burdened by complications as severe postoperative pain. Regional anesthesia may play a role in a multimodal strategy for prevention and treatment of postoperative pain. The main purpose of this survey was to investigate the rate of use of regional anesthesia techniques in patients undergoing breast surgery in the Italian public hospital system., Methods: We designed an online survey that consisted of 22 questions investigating the anesthesia management of breast surgery, particularly focused on regional anesthesia. The survey lasted from November 18, 2019 to February 28, 2020. Directors of anesthesia departments of 168 Italian public health system hospitals were contacted and invited to forward the survey to every anesthesiologist in their unit., Results: A total of 935 anesthesiologists received the survey; among them 460 entered the final analysis. Regional anesthesia was not used by 44.6% of the anesthesiologists and lack of experience/training was the main cause (75.6%). Logistic regression models revealed that anesthesiologists with more than 15 years of experience (odds ratio [OR] = 0.55; 95% confidence interval [CI], 0.33-0.93) or working most of their days in intensive care unit (ICU) compared to operating theater (OR = 0.25; 95% CI, 0.14-0.43) were less likely to perform regional anesthesia techniques., Conclusions: Low implementation of regional anesthesia techniques in breast surgery emerges from our survey and the major reason cited is a lack of proper training. An improved training program in regional anesthesia, especially in residents' curricula, could be useful to increase its rate of use and to standardize its practice., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Twitter is a web-based social media platform that allows instantaneous sharing of user-generated messages (tweets). We performed an infodemiology study of the coronavirus disease 2019 (COVID-19) Twitter conversation related to anesthesiology to describe how Twitter has been used during the pandemic and ways to optimize Twitter use by anesthesiologists., Methods: This was a cross-sectional study of tweets related to the specialty of anesthesiology and COVID-19 tweeted between January 21 and October 13, 2020. A publicly available COVID-19 Twitter dataset was filtered for tweets meeting inclusion criteria (tweets including anesthesiology keywords). Using descriptive statistics, tweets were reviewed for tweet and account characteristics. Tweets were filtered for specific topics of interest likely to be impactful or informative to anesthesiologists of COVID-19 practice (airway management, personal protective equipment, ventilators, COVID testing, and pain management). Tweet activity was also summarized descriptively to show temporal profiles over the pandemic., Results: Between January 21 and October 13, 2020, 23,270 of 241,732,881 tweets (0.01%) met inclusion criteria and were generated by 15,770 accounts. The majority (51.9%) of accounts were from the United States. Seven hundred forty-nine (4.8%) of all users self-reported as anesthesiologists. 33.8% of all tweets included at least one word or phrase preceded by the # symbol (hashtag), which functions as a label to search for all tweets including a specific hashtag, with the most frequently used being #anesthesia. About half (52.2%) of all tweets included at least one hyperlink, most frequently linked to other social media, news organizations, medical organizations, or scientific publications. The majority of tweets (67%) were not retweeted. COVID-19 anesthesia tweet activity started before the pandemic was declared. The trend of daily tweet activity was similar to, and preceded, the US daily death count by about 2 weeks., Conclusions: The toll of the pandemic has been reflected in the anesthesiology conversation on Twitter, representing 0.01% of all COVID-19 tweets. Daily tweet activity showed how the Twitter community used the platform to learn about important topics impacting anesthesiology practice during a global pandemic. Twitter is a relevant platform through which to communicate about anesthesiology topics, but further research is required to delineate its effectiveness, benefits, and limitations for anesthesiology discussions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Although the package insert clearly states that "the safety and efficacy of sugammadex in pediatric patients have not been established," we hypothesized that sugammadex is used widely in pediatric anesthetic practice supplanting neostigmine as the primary drug for antagonizing neuromuscular blockade (NMB). Additionally, we sought to identify the determinants by which pediatric anesthesiologists choose reversal agents and if and how they assess NMB in their practice. Finally, because of sugammadex's effects on hormonal contraception, we sought to determine whether pediatric anesthesiologists counseled postmenarchal patients on the need for additional or alternative forms of contraception and the risk of unintended pregnancy in the perioperative period., Methods: We e-mailed a questionnaire to all 3245 members of the Society of Pediatric Anesthesia (SPA) requesting demographic data and attitudes regarding use of NMB agents, monitoring, and antagonism practices. To address low initial response rates and quantify nonresponse bias, we sent a shortened follow-up survey to a randomly selected subsample (n = 75) of SPA members who did not initially respond. Response differences between the 2 cohorts were determined., Results: Initial questionnaire response rate was 13% (419 of 3245). Overall, 163 respondents (38.9%; 95% confidence interval [CI], 34.2-43.8) used sugammadex as their primary reversal agent, and 106 (25.2%; 95% CI, 21.2-30.0) used it exclusively. Respondents with ≤5 years of practice used sugammadex as their primary reversal agent more often than those with ≥6 years of practice (odds ratio [OR]: 2.08; 95% CI, 1.31-3.31; P = .001). This increased utilization remained after controlling for institutional restriction and practice type (adjusted OR [aOR]: 2.20; 95% CI, 1.38-3.54; P = .001). Only 40% of practitioners always assess NMB (train-of-four), and use was inversely correlated with years of practice (Spearman ρ = -0.11, P = .04). Anesthesiologists who primarily used sugammadex assess NMB less routinely (OR: 0.56; 95% CI, 0.34-0.90; P = .01). A slim majority (52.8%) used sugammadex for pediatric postmenarchal girls; those with less experience used it more commonly (P < .001). Thirty-eight percent did not discuss its effects on hormonal contraception with the patient and/or family, independent of anesthesiologist experience (P = .33) and practice location (P = .38). No significant differences were seen in demographics or practice responses between initial and follow-up survey respondents., Conclusions: Sugammadex is commonly used in pediatric anesthesia, particularly among anesthesiologists with fewer years of practice. Failure to warn postmenarchal adolescents of its consequences may result in unintended pregnancies. Finally, pediatric anesthesia training programs should emphasize objective monitoring of NMB, particularly with sugammadex use., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: A temporary decrease in anesthesiology residency graduates that occurred around the turn of the millennium may have workforce implications. The aims of this study are to describe, between 2005 and 2015, (1) demographic changes in the workforce of physicians trained as anesthesiologists; (2) national and state densities of these physicians, as well as temporal changes in the densities; and (3) retention of medical licenses by mid- and later-career anesthesiologists., Methods: Using records from the American Board of Anesthesiology and state medical and osteopathic boards, the numbers of licensed physicians aged 30-59 years who had completed Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training were calculated cross-sectionally for 2005, 2010, and 2015. Demographic trends were then described. Census data were used to calculate national and state densities of licensed physicians. Individual longitudinal data were used to describe retention of medical licenses among older physicians., Results: The number of licensed physicians trained as anesthesiologists aged 30-59 years increased from 32,644 in 2005 to 36,543 in 2010 and 36,624 in 2015, representing a national density of 1.10, 1.18, and 1.14 per 10,000 population in those years, respectively. The density of anesthesiologists among states ranged from 0.37 to 3.10 per 10,000 population. The age distribution differed across the years. For example, anesthesiologists aged 40-49 years predominated in 2005 (47%), but by 2015, only 31% of anesthesiologists were aged 40-49 years. The proportion of female anesthesiologists grew from 22% in 2005, to 24% in 2010, and to 28% in 2015, particularly among early-career anesthesiologists. For anesthesiologists with licenses in 2005, the number who still had active licenses in 2015 decreased by 9.6% for those aged 45-49 years, by 14.1% for those aged 50-54 years, and by 19.7% for those aged 55-59 years., Conclusions: The temporary decrease in anesthesiology residency graduates around the turn of the 21st century decreased the proportion of anesthesiologists who were midcareer as of 2015. This may affect the future availability of senior leaders as well as the future overall workforce in the specialty as older anesthesiologists retire. National efforts to plan for workforce needs should recognize the geographical variability in the distribution of anesthesiologists., (Copyright © 2021 International Anesthesia Research Society.)

Snorkel masks have become an option for personal protective equipment (PPE) due to the shortage of air filtration at least 95% of airborne particle (N95) masks as a result of the coronavirus disease 2019 (COVID-19) pandemic. We developed a 3D design of a triheaded adapter that connects a snorkel mask to 3 different National Institute for Occupational Safety and Health (NIOSH)-approved air filtration at least 99% of airborne particles (N99) filters with the aim of improving wearer comfort. We measured the resistance of the new triheaded adapter to be one-third the resistance of the single adapter. Interdepartmental survey of anesthesiologists showed an improvement in perceived comfort when using the triheaded adapter as compared to the single adapter., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Complete handover of anesthesia care to a second anesthesiologist has been demonstrated to be associated with worse short-term adverse outcomes among cardiac surgery patients, but little information from multi-institutional studies is available., Methods: New York's cardiac surgery registry was used to identify patients who underwent cardiac surgery in New York between 2010 and 2016 with and without complete handovers of anesthesia care. A retrospective observational study with inverse probability treatment weighting (IPTW) based on the propensity score was used to adjust for differences in preoperative patient characteristics while comparing differences in the primary outcome (in-hospital/30 day mortality), major complications in the index admission or within 30 days of the index surgery, readmissions within 30 days, and length of stay., Results: A total of 8.5% of the 103,102 cardiac surgery procedures involved complete handovers. After adjustment, there was a difference between patients with and without handovers in the primary outcome (2.86% vs 2.48%, adjusted risk ratio [ARR] = 1.15 [1.01-1.31]). There was no difference in readmissions within 30 days (13.7% vs 14.4%, ARR = 0.95 [0.90-1.00]), and the differences in complications and length of stay were not clinically meaningful (adjusted differences of <10%)., Conclusions: Cardiac surgery patients in New York who had complete anesthesia handovers experienced higher short-term mortality rates, but there were no meaningful differences in other outcomes. Unnecessary handovers should be carefully monitored.

This article discusses the impact of the COVID-19 pandemic on the EACTA fellowship program. The authors present three points that in their view are important and give cause for concern because they could make it difficult or impossible to achieve the original goals of the fellowship program. Corresponding points are discussed and possible solutions are presented. An implementation in the fellowship curriculum is planned., Competing Interests: Declaration of Competing Interest All authors are members of EACTA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Substance use disorder among physicians can expose both physicians and their patients to significant risk. Data regarding the epidemiology and outcomes of physician substance use disorder are scarce but could guide policy formulation and individual treatment decisions. This article describes the incidence and outcomes of substance use disorder that resulted in either a report to a certifying body or death in physicians after the completion of anesthesiology training., Methods: Physicians who completed training in U.S. anesthesiology residency programs from 1977 to 2013 and maintained at least one active medical license were included in this retrospective cohort study (n = 44,736). Substance use disorder cases were ascertained through records of the American Board of Anesthesiology and the National Death Index., Results: Six hundred and one physicians had evidence of substance use disorder after completion of training, with an overall incidence of 0.75 per 1,000 physician-years (95% CI, 0.71 to 0.80; 0.84 [0.78 to 0.90] in men, 0.43 [0.35 to 0.52] in women). The highest incidence rate occurred in 1992 (1.79 per 1,000 physician-years [95% CI, 1.12 to 2.59]). The cumulative percentage expected to develop substance use disorder within 30 yr estimated by Kaplan-Meier analysis equaled 1.6% (95% CI, 1.4 to 1.7%). The most common substances used by 353 individuals for whom information was available were opioids (193 [55%]), alcohol (141 [40%]), and anesthetics/hypnotics (69 [20%]). Based on a median of 11.1 (interquartile range, 4.4 to 19.8) yr of follow-up, the cumulative proportion of survivors estimated to experience at least one relapse within 30 yr was 38% (95% CI, 31 to 43%). Of the 601 physicians with substance use disorder, 114 (19%) were dead from a substance use disorder-related cause at last follow-up., Conclusions: A substantial proportion of anesthesiologists who develop substance use disorder after the completion of training die of this condition, and the risk of relapse is high in those who survive.

Background: Health care professional migration continues to challenge countries where the lack of surgical and anesthesia specialists results in being unable to address the global burden of surgical disease in their populations. Medical migration is particularly damaging to health care systems that are just beginning to scale up capacity building of human resources for health. Anesthesiologists are scarce in low-resource settings. Defining reasons why anesthesiologists leave their country of training through in-depth interviews may provide guidance to policy makers and academic organizations on how to retain valuable health professionals., Methods: There were 24 anesthesiologists eligible to participate in this qualitative interview study, 15 of whom are currently practicing in Rwanda and 9 had left the country. From the eligible group, interviews were conducted with 13 currently practicing in Rwanda and 2 who had left to practice elsewhere. In-depth interviews of approximately 60 minutes were used to define themes influencing retention and migration among anesthesiologists in Rwanda. Interviews were conducted using a semistructured guide and continued until theoretical sufficiency was reached. Thematic analysis was done by 4 members of the research team using open coding to inductively identify themes., Results: Interpretation of results used the framework categorizing themes into push, pull, stick, and stay to describe factors that influence migration, or the potential for migration, of anesthesiologists in Rwanda. While adequate salary is essential to retention of anesthesiologists in Rwanda, other factors such as lack of equipment and medication for safe anesthesia, isolation, and demoralization are strong push factors. Conversely, a rich academic life and optimism for the future encourage anesthesiologists to stay., Conclusions: Our study suggests that better clinical resources and equipment, a more supportive community of practice, and advocacy by mentors and academic partners could encourage more staff anesthesiologists to stay and work in Rwanda.

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There have been many advances in obstetric anesthesiology in the past 2 decades. We sought to create a list of highly influential publications in the field using the Delphi method among a group of obstetric anesthesiology experts to create an important educational, clinical, and research resource., Methods: Experts in the field, defined as obstetric anesthesiologists selected to present the Gerard W. Ostheimer Lecture at the Society for Obstetric Anesthesia and Perinatology (SOAP) annual meeting within the past 20 years, were recruited to participate. The Delphi technique was used by administering 3 rounds of surveys. Participants were initially asked to identify the highly influential publications from the year they presented the Ostheimer lecture, in addition to the most influential publications from the time period overall. Highly influential publications were defined as those that changed traditional views, invoked meaningful practices, catalyzed additional research, and fostered ideas or practices that had durability over time. After each round of surveys, responses were collected and used as choices for subsequent surveys with the goal of obtaining group consensus., Results: We determined expert consensus on 22 highly influential publications from 1998 to 2017. The focus of these publications ranged from disease entities, interventions, treatment methodologies, and complications., Conclusions: Key themes in the publications chosen included the reduction of maternal morbidity and mortality and refinements in the analgesic and anesthetic management of labor and delivery.

Shared decision-making (SDM) is an essential element providing patient-centered perioperative care. Newer value-based healthcare models, defined as patient-centered outcomes versus the cost required to achieve these outcomes, will necessitate the use of metrics that reflect the alignment of treatment decisions with patient preferences and goals. The heart of a successful SDM conversation is ensuring this alignment. Accountability for ensuring high quality SDM perioperatively is not clearly assigned. By learning methodologies to successfully incorporate SDM into clinical practice, anesthesiologists can increase the value of care they provide to their patients. The ideal means of achieving SDM within the complexity of modern medicine is not yet certain., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The regional anesthesia community regularly uses social media for advocacy and education. Well-known leaders in the field are willing to share their opinions with colleagues in a public forum. Some visionaries predict that the influence of social media will soon transcend that of the traditional academic journal. While physicians support the use of social media, an trend may exist toward anecdotal information. Does a lack of online regulation along with a bias towards self-promotion cloud meaningful discussion? In order to avoid the pitfalls of social media, thoughtful communication will help regional anesthesiologists promote their subspecialty. Mindful dialog, promotion of academic journals, and professional etiquette will help maintain a collegial environment., Competing Interests: Competing interests: Dr Marc Huntoon is the former editor-in-chief of the Regional Anesthesia and Pain Medicine journal., (© American Society of Regional Anesthesia & Pain Medicine 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Retrospective cohort study., Objective: The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF)., Summary of Background Data: Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF., Methods: This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS., Results: A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001)., Conclusion: ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives., Level of Evidence: 3.

Background: Burnout is a psychological syndrome that results from chronic exposure to job stress. It is defined by a triad of emotional exhaustion, depersonalization, and reduced personal accomplishment. In research, mostly from high-income countries, burnout is common in health care professionals, especially in anesthesiologists. Burnout can negatively impact patient safety, the physical and mental health of the anesthetist, and institutional efficiency. However, data on burnout for anesthesia providers in low- and middle-income countries are poorly described. This study sought to determine the prevalence of burnout syndrome among all anesthesia providers (physician and nonphysician) working in Zambian hospitals and to determine which sociodemographic and occupational factors were associated with burnout., Methods: A questionnaire was sent to all Zambian anesthesia providers working in private and public hospitals. The questionnaire assessed burnout using the Maslach Burnout Inventory Human Services Survey, a validated 22-item survey widely used to measure burnout among health professionals. Sociodemographic and occupational factors postulated to be associated with burnout were also assessed., Results: Surveys were distributed to all 184 anesthesia providers in Zambia; 160 were returned. This resulted in a response rate representing 87% of all anesthesia providers in the country. Eighty-six percentage of respondents were nonphysician anesthesia providers. Burnout was present in 51.3% (95% confidence interval [CI], 43.2-59.2) of participants. Logistic regression analysis revealed that "not having the right team to carry out work to an appropriate standard" (odds ratio, 2.91, 95% CI, 1.33-6.39; P = .008), and "being a nonphysician" (odds ratio, 3.4, 95% CI, 1.25-12.34; P = .019) were significantly associated with burnout in this population., Conclusions: In a cross-sectional survey of anesthesia providers in Zambia, >50% of the respondents met the criteria for burnout. The risk was particularly high among nonphysician providers who typically work in isolated rural practice. Efforts to decrease burnout rates through policy and educational initiatives to increase the quantity and quality of training for anesthesia providers should be considered.

Diagnostic ultrasonography was first utilized in the 1940s. The past 70+ years have seen an explosion in both ultrasound technology and availability of ultrasound technology to more and more clinicians. As ultrasound technology and availability have grown, the utility of ultrasound technology in the clinical setting as only been limited by clinicians' imagination. Due to its lack of radiation, non-invasive nature, and gentle learning curve, medical ultrasonography is now a tremendously useful Point of Care technology in the clinical arena. What follows is a discussion of Point of Care Ultrasound (PoCUS) and how it can be incorporated in the daily practice of any regional anesthesiology. While most regional anesthesiologists usually focus on the interventional aspects of ultrasonography (i.e. nerve blocks), our discussion will center on the diagnostic value of ultrasonography-especially concerning assessment of cardiac physiology and pathophysiology, gastric anatomy, airway anatomy, and intracranial pathophysiology. After reading and reviewing this chapter, the learner will have the knowledge to start training themselves in a variety of PoCUS exams that will allow rapid diagnosis of normal and abnormal patient conditions. Once an accurate diagnosis is established, the anesthesiologist and his/her team can then confidently optimize an anesthetic pain, prevent harm, and/or treat a patient condition. In this day and age, the ability to rapidly establish an accurate diagnosis cannot be overstated-especially in a critical situation. It is the authors' sincerest hope that the following discussion will help regional anesthesiologist to become even better and well-rounded clinical leaders., (Published by Elsevier Ltd.)

The authors queried 9 anesthesiology societies to examine Distinguished Service Award recipients over time by gender. Of the 211 total Distinguished Service Awards given by all 9 societies, women received 25 (11.8%). Comparing pre-2008 data to the most recent decade, there was no statistical difference in the number of women Distinguished Service Award recipients with 8.9% and 17.1% women Distinguished Service Award recipients, respectively (P = .076). Societies varied greatly in their women awardees, from 40% to 0% in the last decade. Low levels of awardees stand in contrast to the increasing number of women in the academic pipeline. The authors recommend that societies collect gender membership data and study their award processes from nomination to selection.

Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose of Review: Nonoperating room anesthesia (NORA) is the fastest growing segment of anesthetic practice. This review provides an overview of knowledge and trends that will need to be introduced to residents as part of their education., Recent Findings: Topics for the future include, but are not limited to, new medications, artificial intelligence and big data, monitoring depth of hypnosis, translational innovation and collaboration, demographic changes, financial driving forces, destination hubs, medical tourism, and new approaches to education training and self-management., Summary: Implementing new medical technologies for anesthesia outside the operating room will help to successfully master this ever evolving subspecialty. Anesthesiologists require specific preparation for the diverse settings that they will encounter during their training. In this rapidly changing field, cognitive fitness must be factored into teaching and evaluation of residents. We describe the most important topics to consider when educating anesthesiology residents, and highlight research that addresses upcoming challenges.

Background: Anesthesiology has a long relationship with critical care medicine (CCM). However, US anesthesiologists are less likely to practice CCM than non-US anesthesiologists. To date, no studies have compared academic contributions in CCM between US anesthesiologists and non-US anesthesiologists. The objective of our study was to use recent trends in critical care publications as a surrogate for academic contribution among US and non-US anesthesiologists., Methods: Research articles published between 2010 and 2015 in 3 anesthesiology journals (Anesthesiology, Anesthesia & Analgesia, and British Journal of Anaesthesia) and 3 multidisciplinary CCM journals (Critical Care Medicine, Intensive Care Medicine, and Journal of Critical Care) were reviewed. Author information, including the primary department appointment and geographic location for the first and senior author(s), and article details, including topic and publication type, were collected. Odds ratios for having a first or senior author from the United States were calculated. Anesthesiologists' contributions in individual journals were summarized, as were trends in anesthesiology CCM publications during the 6-year study period., Results: A total of 3831 articles were reviewed, with 1050 (27.4%) having US authors. Eighty-two and one-half percent of CCM articles in anesthesiology journals had a US anesthesiologist as first author, and 81% had a US anesthesiologist as senior author, while fewer CCM articles in multidisciplinary journals had a US anesthesiologist as first (12.1%) or senior (12.3%) author. When considering all publications, 16.3% and 16.4% of articles had a US anesthesiologist as the first or senior author compared with articles for which non-US anesthesiologists were first (23.8%) or senior (20.9%) authors. The odds of having a US anesthesiologist as first or senior author compared to a non-US anesthesiologist for all publications were 0.6 (0.5-0.7) and 0.7 (0.6-0.9). The number of publications trended downward for both US anesthesiologists and non-US anesthesiologists during the study period., Conclusions: When compared to non-US anesthesiologists, US anesthesiologists had more CCM publications in anesthesiology journals and fewer publications in multidisciplinary CCM journals. The number of anesthesiology CCM publications decreased for both US and non-US anesthesiologists throughout the study period.

Background: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation., Methods: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V., Results: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P < .01), increasing injury severity score (P < .01) and higher emergency department Glasgow Coma Score (P < .01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours., Conclusions: This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.

The American Society of Anesthesiologists (ASA) Annual Meeting is the primary venue for anesthesiologists to present research, share innovations, and build networks. Herein, we describe gender representation for physician speakers at the Annual Meeting relative to the specialty overall. Details of ASA Annual Meeting presentations for individuals and panels were abstracted from the ASA archives for 2011-2016. Observed speaker gender composition was compared to expected composition based on the gender distribution of members of the ASA. There were 5167 speaker slots across 2025 presentations and panels. Of the speaker slots, 3874 were assigned to men and 1293 to women. Speaker slot gender composition was relatively consistent between 2011 and 2016 (annual percentage 22.3%-27.7% women, trend test P = .062). ASA membership composition of women increased slightly over the study period (24%-28%). The overall observed number of women in speaker slots over the study period did not differ significantly from what would be expected based on the ASA membership composition (25.0% observed versus 25.9% expected; P = .153). However, the percentage of single speakers who were women was significantly less than would be expected based on the ASA gender distribution (20.2% observed versus 25.9% expected; P < .001). Interestingly, for panels that included 2-5 anesthesiologists, single-gender panels were more common than would be expected by chance, with all-male panels predominating (all P < .01). The gender composition of speakers at the ASA Annual Meeting largely reflected gender composition within the specialty, although women were not overrepresented at any meeting. The predominance of single-gender panels and underrepresentation of women as single speakers is a potential target to improve gender representation.

Objective: To perform a comprehensive nationwide survey of more than 90% of all cardiovascular hospitals in China to assess the current 2018 status of transesophageal echocardiography (TEE) equipment, operating physicians, education, impact on surgery, and reimbursement., Design: In this nationwide survey, 716 cardiovascular hospitals in mainland China were included. A 15-question electronic survey was sent to these hospitals and the data were received directly from the questionnaire website for analysis., Setting: Cardiovascular hospitals in mainland China., Participants: Departments of anesthesiology in cardiovascular hospitals in mainland China., Interventions: Answer a 15-question survey., Measurements and Main Results: About 90% of hospitals have acquired machines to perform TEEs with most of the machines controlled by the ultrasound department. Anesthesiologists performed intraoperative TEEs in 45% of the hospitals, but only 15% of the hospitals have anesthesiologists who have met the basic TEE training requirements. Most anesthesiologists (68%) believed TEE significantly contributed to patient care during cardiovascular surgeries. The overwhelming majority of surveyed hospital staff (93%) stated that they were planning to continue or start intraoperative TEE examinations in the future., Conclusion: Many hospitals in China have acquired equipment to perform intraoperative TEE examinations during cardiovascular surgeries. However, the number of anesthesiologists who can perform TEEs independently still is not adequate. Standardized trainings, a formal certification process, and governmental payment model changes must be provided to ensure high-quality TEE services and better surgical outcomes in China., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Females remain under-represented in academic anesthesiology. Our objectives were to investigate gender differences over time in the first and last authors of published articles as well as corresponding citation rates in the Canadian Journal of Anesthesia (CJA)., Methods: We conducted a cross-sectional, retrospective analysis of first and last authors' gender from editorials and original articles published in the CJA in a sample of one calendar year of each decade between 1954 to 2017. We analyzed the relationships between author gender, year of publication, article type, and number of citations., Results: Out of 639 articles identified, 542 (85%) were original investigations and 97 (15%) were editorials. Where gender could be confidently identified, the majority (461/571, 81%) of first authors were male. Although there was an increase in the proportion of female first authors over time, this increase was outpaced by the overall increase in female anesthesiologists in Canada. Original articles received more citations and were more likely to have a female first author than editorial articles were. An original article with a female first author resulted in 0.34 (95% confidence interval, 0.28 to 0.39; P < 0.001) more citations per article than a male first author when adjusting for year of publication., Conclusions: Our study shows that, despite a slow increase over time, female authors are under-represented relative to male authors in the CJA and relative to the changing demographics of anesthesiologists in Canada. The reasons for this disparity are multifactorial and further research is needed to identify effective solutions.

Background: To identify trends in injuries and substandard care associated with anesthesia, we analyzed the Korean Society of Anesthesiologists database for anesthesia-related case files from July 2009 to June 2018., Methods: Case characteristics, injuries, and outcomes were compared between the first part (July 2009-June 2014, n = 105) and the second part (July 2014-June 2018, n = 92) of the analyzed time period., Results: Overall, 132 cases resulted in death. The proportion of fatal cases for sedation was similar to general anesthesia (66.2% vs. 76.3%). The proportion of cases with permanent injury or death decreased significantly in the second part of the period compared with the first part (76.1% vs. 93.3%, P = 0.002). With a growing trend in the proportion of sedation cases, a similar number of sedation and general anesthesia cases were referred during the overall period (77 and 76 cases, respectively). Propofol-based regimens remained the dominant sedation method (89.7% in the first part vs. 78.9% in the second part). The most common adverse event in cases of permanent injury or death was identified as being respiratory in origin (98/182, 53.8%). Permanent injuries or deaths were related to local anesthetic systemic toxicity (LAST) and beach-chair positioning for shoulder surgery, in 8 and 5 cases, respectively., Conclusions: Despite the decreasing trend in injury severity with time, several characteristic injury profiles were identified: lack of vigilance in propofol-based sedation, neurological injuries related to the beach-chair position, and LAST occurring during tumescent anesthesia or brachial plexus block.

The methodology used during the development of American Society of Anesthesiologists evidence-based practice parameters, from conceptualization through final adoption of the documents, is described. Features of the methodology include the literature search, review and analysis, survey development and application, and consolidation of the full body of evidence used for preparing clinical practice recommendations. Anticipated risks of bias, validation of the process, and the importance of the documents for clinical use are discussed.

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields.

Background: Gender inequity is still prevalent in today's medical workforce. Previous studies have investigated the status of women in academic anesthesiology. The objective of this study is to provide a current update on the status of women in academic anesthesiology. We hypothesized that while the number of women in academic anesthesiology has increased in the past 10 years, major gender disparities continue to persist, most notably in leadership roles., Methods: Medical student, resident, and faculty data were obtained from the Association of American Medical Colleges. The number of women in anesthesiology at the resident and faculty level, the distribution of faculty academic rank, and the number of women chairpersons were compared across the period from 2006 to 2016. The gender distribution of major anesthesiology journal editorial boards and data on anesthesiology research grant awards, among other leadership roles, were collected from websites and compared to data from 2005 and 2006., Results: The number (%) of women anesthesiology residents/faculty has increased from 1570 (32%)/1783 (29%) in 2006 to 2145 (35%)/2945 (36%) in 2016 (P = .004 and P < .001, respectively). Since 2006, the odds that an anesthesiology faculty member was a woman increased approximately 2% per year, with an estimated odds ratio of 1.02 (95% confidence interval, 1.014-1.025; P < .001). In 2015, the percentage of women anesthesiology full professors (7.4%) was less than men full professors (17.3%) (difference, -9.9%; 95% confidence interval of the difference, -8.5% to -11.3%; P < .001). The percentage of women anesthesiology department chairs remained unchanged from 2006 to 2016 (12.7% vs 14.0%) (P = .75). To date, neither Anesthesia & Analgesia nor Anesthesiology has had a woman Editor-in-Chief. The percentage of major research grant awards to women has increased significantly from 21.1% in 1997-2007 to 31.5% in 2007-2016 (P = .02)., Conclusions: Gender disparities continue to exist at the upper levels of leadership in academic anesthesiology, most importantly in the roles of full professor, department chair, and journal editors. However, there are some indications that women may be on the path to leadership parity, most notably, the growth of women in anesthesiology residencies and faculty positions and increases in major research grants awarded to women.

This article in our series on point-of-care ultrasound (US) for the regional anesthesiologist and pain management specialist describes the emerging role of gastric ultrasonography. Although gastric US is a relatively new point-of-care US application in the perioperative setting, its relevance for the regional anesthesiologist and pain specialist is significant as our clinical practice often involves providing deep sedation without a secured airway. Given that pulmonary aspiration is a well-known cause of perioperative morbidity and mortality, the ability to evaluate for NPO (nil per os) status and risk stratify patients scheduled for anesthesia is a powerful skill set. Gastric US can provide valuable insight into the nature and volume of gastric content before performing a block with sedation or inducing anesthesia for an urgent or emergent procedure where NPO status is unknown. Patients with comorbidities that delay gastric emptying, such as diabetic gastroparesis, neuromuscular disorders, morbid obesity, and advanced hepatic or renal disease, may potentially benefit from additional assessment via gastric US before an elective procedure. Although gastric US should not replace strict adherence to current fasting guidelines or be used routinely in situations when clinical risk is clearly high or low, it can be a useful tool to guide clinical decision making when there is uncertainty about gastric contents.In this review, we will cover the relevant scanning technique and the desired views for gastric US. We provide a methodology for interpretation of findings and for guiding medical management for adult patients. We also summarize the current literature on specific patient populations including obstetrics, pediatrics, and severely obese subjects.

What We Already Know About This Topic: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The incidence of substance use disorders in the United States among residents in anesthesiology is between 1% and 2%. A recent study reported that the incidence of substance use disorders in U.S. anesthesiology residents has been increasing. There are no reports of effective methods to prevent substance use disorder in residents. A comprehensive drug testing program including a random component may reduce the incidence of substance use disorders., Methods: The authors initiated a comprehensive urine drug screening program of residents, fellows, faculty physicians, and certified nurse anesthetists. The authors performed 3,190 tests over 13 yr. The authors determined the incidence of substance use disorders among residents in our large anesthesiology residency program during the decade before (January 1, 1994, to December 31, 2003) and for the 13 yr after (January 1, 2004 to December 31, 2016) instituting a random urine drug testing program. A total of 628 residents trained in the program over these 23 yr; they contributed a total of 1,721 resident years for analysis. Fewer faculty and certified nurse anesthetists were studied, so we do not include them in our analysis., Results: The incidence of substance use disorders among trainees in our department during the 10 yr before initiation of urine drug screening was four incidents in 719 resident years or 0.0056 incidents per resident-year. In the 13 yr after the introduction of urine drug screening, there have been zero incidents in 1,002 resident years in our residency program (P = 0.0305)., Conclusions: This single-center, comprehensive program including preplacement and random drug testing was associated with a reduction of the incidence of substance use disorders among our residents in anesthesiology. There were no instances of substance use disorders in our residents over the recent 13 yr. A large, multicenter trial of a more diverse sample of academic, government, and community institutions is needed to determine if such a program can predictably reduce the incidence of substance use disorders in a larger group of anesthesiology residents.

Ensuring adequate ventilation and oxygenation and delivering inhaled anesthetic agent to the patient remain core responsibilities of the anesthesia provider during general anesthesia. Because of the emphasis placed on physiology, pharmacology, clinical sciences, and administrative duties, the stellar anesthesia workstation technology may be underutilized by the anesthesia community. Target-controlled O2 and agent delivery and automated end-expired CO2 control have entered the clinical arena, with only cost, luddism, and administrative hurdles preventing their more widespread use. This narrative review will explain technological aspects of existing and recently introduced anesthesia workstations. Concepts rather than particular anesthesia machines will be addressed, but examples will mostly pertain to the more recently introduced workstations. The anesthesia workstation consists of a ventilator, a carrier gas and agent delivery system, a scavenging system, and monitors. Mainly, the circle breathing circuit configuration, ventilator, and carrier gas and agent delivery technology are discussed. Occasionally, technical details are provided to give the reader a taste of the modern technology.

Administration of preoperative antimicrobial prophylaxis, often with a cephalosporin, is the mainstay of surgical site infection prevention guidelines. Unfortunately, due to prevalent misconceptions, patients labeled as having a penicillin allergy often receive alternate and less-effective antibiotics, placing them at risk of a variety of adverse effects including increased morbidity and higher risk of surgical site infection. The perioperative physician should ascertain the nature of previous reactions to aid in determining the probability of the prevalence of a true allergy. Penicillin allergy testing may be performed but may not be feasible in the perioperative setting. Current evidence on the structural determinants of penicillin and cephalosporin allergies refutes the misconception of cross-reactivity between penicillins and cefazolin, and there is no clear evidence of an increased risk of anaphylaxis in cefazolin-naive, penicillin-allergic patients. A clinical practice algorithm for the perioperative evaluation and management of patients reporting a history of penicillin allergy is presented, concluding that cephalosporins can be safely administered to a majority of such patients.