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Study objective Physician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. Design Time Series of prospectively recorded and historical data. Setting Academic tertiary care medical center and health system. Patients 449 patients undergoing elective primary hip surgery. Interventions For the intervention group we redesigned care with a comprehensive 14–16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. Measurements The intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. Main results Compared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P Conclusions A perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.

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.

PurposeAccording to normative‐rational investment decision models, investors who seek office buildings should select markets which show high employment numbers in office related sectors such as Finance, Insurance, Real Estate (FIRE) and Knowledge Intensive Business Services (KIBS). This view is challenged by behavioural studies, which find that the investors' willingness for analysis and the structure of their decision‐making processes in practice notably limit such an influence. Looking at German office markets, the purpose of this paper is to explore to what extent the aforementioned connection between employment structure and market selection holds.Design/methodology/approachQualitative interviews with German investment experts are analysed in a manner that differentiates between investor types. Behavioural economics form a theoretical basis to identify investor type specific attitudes towards investment markets and the resulting market selection processes. The findings are tested by logistic regressions which connect the spatial structure of office investments with employment data.FindingsA sector‐specific employment structure does not have a direct but an indirect influence on the market selection. The existing theoretical contradiction is resolved by this indirect influence. Investor type specific risk profiles and business models determine varying spatial patterns of market selection.Research limitations/implicationsThe study shows that attitudes towards markets, business logics and decision processes differ between insurance companies and open‐ended funds. Researchers should be aware that empirical results may not always be valid for all institutional investors. In some cases a differentiating research design according to investor type may be necessary.Practical implicationsThe study identifies a set of minimum requirements with regard to building and market characteristics open‐ended funds use for filtering in German secondary/regional markets. Market selection by these funds and insurance companies correlates with relative employment in FIRE‐ and KIBS‐branches.Originality/valueThis paper overcomes decision‐theoretical contradictions and gives empirical evidence for the importance of the employment structure on market selection.

Background The Foundation for Anesthesia Education and Research Medical Student Anesthesia Research Fellowship (MSARF) program is an 8-week program that pairs medical students with anesthesiologists performing anesthesia-related research. This study evaluated the proportion of students who published an article from their work, as well as the percentage of students who entered anesthesiology residency programs. Methods A list of previous MSARF participants (2005 to 2012), site, and project information was obtained. Searches for publications were performed using PubMed. The primary outcome was the publication rate for MSARF projects. The MSARF abstract-to-publication ratio was compared with the percentage of abstracts presented at biomedical meetings that resulted in publication as estimated by a Cochrane review (44%). For students who had graduated from medical school, match lists from the students’ medical schools were reviewed for specialty choice. Results Forty-two percent of the 346 MSARF projects were subsequently published. There was no difference between the MSARF abstract-to-publication ratio and the publication rate of articles from abstracts presented at scientific meetings (P = 0.57). Thirty percent (n = 105; 95% CI, 25 to 35%) of all the MSARF students were authors on a publication. Fifty-eight percent of the students for whom residency match data (n = 255) were available matched into anesthesiology residencies (95% CI, 52 to 64%). Conclusions The MSARF program resulted in many students being included as a co-author on a published article; the majority of these students entered anesthesiology residency programs. Future research should determine whether the program has a long-term impact on the development of academic anesthesiologists.

Background Anesthesiology is among the medical specialties expected to have physician shortage. With little known about older anesthesiologists' work effort and retirement decision making, the American Society of Anesthesiologists participated in a 2006 national survey of physicians aged 50-79 yr. Methods Samples of anesthesiologists and other specialists completed a survey of work activities, professional satisfaction, self-defined health and financial status, retirement plans and perspectives, and demographics. A complex survey design enabled adjustments for sampling and response-rate biases so that respondents' characteristics resembled those in the American Medical Association Physician Masterfile. Retirement decision making was modeled with multivariable ordinal logistic regression. Life-table analysis provided a forecast of likely clinical workforce trends over an ensuing 30 yr. Results Anesthesiologists (N = 3,222; response rate = 37%) reported a mean work week of 49.4 h and a mean retirement age of 62.7 yr, both values similar to those of other older physicians. Work week decreased with age, and part-time work increased. Women worked a shorter work week (mean, 47.9 vs. 49.7 h, P = 0.024), partly due to greater part-time work (20.2 vs. 13.1%, P value less than 0.001). Relative importance of factors reported among those leaving patient care differed by age cohort, subspecialty, and work status. Poor health was cited by 64% of anesthesiologists retiring in their 50s as compared with 43% of those retiring later (P = 0.039). Conclusions This survey lends support for greater attention to potentially modifiable factors, such as workplace wellness and professional satisfaction, to prevent premature retirement. The growing trend in part-time work deserves further study.

An array of clinical events may lead to perioperative neurological injury. We first review the general cellular mechanisms leading to brain tissue injury and death. The genesis and mechanisms of injury after cerebral aneurysm surgery, traumatic brain injury, postoperative vascular insult in patients with severe cerebrovascular disease are discussed, as are strategies for prevention and treatment. More has become known about the epidemiology, risk factors and potential preventive strategies in postoperative delirium, and, to a lesser extent, postoperative cognitive dysfunction. Finally, emerging concepts in clinical brain protection are discussed, including preconditioning, gene therapy and stem cells.

The purpose of this review is to present a comprehensive assessment of the anesthesia workforce during the past decade and attempt forecasting the future based on present knowledge. The supply of anesthesiologists has gradually recovered from a deficit in the mid to late 1990 s. Current entry rates into our specialty are the highest in more than a decade, but are still below the level they were in 1993. These factors along with slower surgical growth and less capital available for expanding anesthetizing locations have resulted in greater availability of anesthesiologists in the labor market. Despite these recent events, the intermediate-term outlook of a rapidly aging population and greater access of previously uninsured patients portends the need to accommodate increasing medical and surgical procedures requiring anesthesia, barring disruptive industry innovations. Late in the decade, nationwide surveys found shortages of anesthesiologists and certified registered nurse anesthetists to persist. In response to increasing training program output with stagnant surgical growth, compensation increases for these allied health professionals have moderated in the present. Future projections anticipate increased personnel availability and, possibly, less compensation for this group. It is important to understand that many of the factors constraining current demand for anesthesia personnel are temporary. Anesthesiologist supply constrained by small graduation growth combined with generation- and gender-based decrements in workforce contribution is unlikely to keep pace with the substantial population and public policy-generated growth in demand for service, even in the face of productivity improvements and innovation.

Background Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing the activity of sympathetic nervous system, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. Methods The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 degrees +/- 0.8 degrees C) or normothermia (n = 501, 36.7 degrees +/- 0.5 degrees C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, and others) were prospectively followed until 3-month follow-up and were compared in hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. Results There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups, and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in postoperative versus preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 microg/l), whereas normothermic patients had a small postoperative increase (median change + 0.01 microg/l, P = 0.038). Conclusion In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.

Background Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. Methods A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Results Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. Conclusion In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

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.

We randomized 74 patients to either a lower Bispectral Index (BIS) regimen (median BIS, 38.9) or a higher BIS regimen (mean BIS, 50.7) during the surgical procedure. Preoperatively and 4-6 wk after surgery, the patients' cognitive status was assessed with a cognitive test battery consisting of processing speed index, working memory index, and verbal memory index. Processing speed index was 113.7 +/- 1.5 (mean +/- se) in the lower BIS group versus 107.9 +/- 1.4 in the higher BIS group (P = 0.006). No difference was observed in the other two test battery components. Somewhat deeper levels of anesthesia were therefore associated with better cognitive function 4-6 wk postoperatively, particularly with respect to the ability to process information.

Verification of appropriate precordial Doppler probe position over the anterior chest wall is crucial for early detection of venous air embolism. We studied responses to normal saline (NS) and carbon dioxide (CO2) test injections at various probe locations during elective craniotomy. All patients received four IV injections (10 mL of NS and 1 mL of CO2 via central and peripheral venous catheters). Doppler sounds were simultaneously recorded with two separate probes. In Group A, probes were placed in left and right parasternal positions. In Group B, the left probe was intentionally malpositioned as far laterally over the left precordium as was compatible with an audible signal. In Group A (n = 23), a left parasternal Doppler signal was easily obtainable in 23 of 23 patients, versus 18 of 23 patients for the right parasternal probe (P < 0.05). In Group B (n = 17), central CO2 injection yielded a positive right parasternal response rate of 88% compared with 29% over the far left precordium (P < 0.015), where central NS injections yielded a 76% response rate (P < 0.015 versus central CO2 injection). Left parasternal placement is at least as sensitive to clinical venous air embolism events as right parasternal placement. Peripheral saline injection represents a viable alternative (83% response rate). Vigorous central injection of 10 mL of NS however, risks false positive verification of left lateral precordial probe placement.

The field of minimally invasive neurosurgery has evolved rapidly in its indications and applications over the last few years. New, less invasive techniques with low morbidity and virtually no mortality are replacing conventional neurosurgical procedures. Providing anesthesia for these procedures differs in many ways from conventional neurosurgical operations. Anesthesiologists are faced with the perioperative requirements and risks of newly developed procedures. This review calls attention to the anesthetic issues in various minimally invasive neurosurgical procedures for cranial and spinal indications. Among the procedures specifically discussed are endoscopic third ventriculostomy, endoscopic transsphenoidal hypophysectomy, endoscopic strip craniectomy, deep brain stimulation, video-assisted thorascopic surgery, vertebroplasty and kyphoplasty, cervical discectomy and foraminectomy, and laparoscopically assisted lumbar spine surgery.

§§Departments of *General Anesthesiology, †Department of Orthopedic Surgery, ‡Department of Urology, §Department ofBiostatistics & Epidemiology, The Cleveland Clinic Foundation; Cleveland Clinic Foundation Health Science Center of theOhio State University; ¶Department of Pathology, Ohio State University, Cleveland; #Department of Medicine, University ofWisconsin, Madison; **Division of Vascular Surgery, University of Arkansas for Medical Sciences, Little Rock; ††BaxterHemoglobin Therapeutics, Boulder, Colorado; ‡‡Pfizer Global Research and Development, New York City; and §§RichardPrielipp, MD, Bowman Gray School of Medicine; Gerald Fulda, MD, Christiana Health Care Services; Irwin Gratz, DO, CooperHospital/UMC; Michael Salem, MD, George Washington University Medical Center; Ronald Kline, MD, Harper Hospital;Benjamin Guslits, MD, Henry Ford Hospital; Michael Pasquale, MD, Lehigh Valley Hospital; Lauraine Stewart, MD, McGuireVA Medical Center; Larry Hollier, MD, Mt. Sinai Medical Center; Bhatar Desai, MD, St. Anthony Hospital; Marc J. Shapiro,MD, St. Louis University Hospital; Ronald Pearl, MD, Stanford University Medical Center; Michael J. Williams, MD, ThomasJefferson University; Dennis Doblar, PhD, MD, University of Alabama-Birmingham; Marc Hudson, MD, University of PittsburghMedical Center; Michael P. Eaton, MD, University of Rochester Medical Center; Lewis Gottschalk, MB, University of Texas-HoustonHealth Sciences Center; Mali Mathru, MD, University of Texas Medical Branch; Daniel Herr, MD, Washington Hospital CenterIn this randomized, prospective, double-blinded clinicaltrial, we sought to investigate whether diaspirin-crosslinked hemoglobin (DCLHb) can reduce the periop-erativeuseofallogeneicbloodtransfusion.One-hundred-eighty-one elective surgical patients were enrolled at 19clinical sites from 1996 to 1998. Selection criteria includedanticipated transfusion of 2–4 blood units, aortic repair,and major joint or abdomino-pelvic surgery. Once a deci-sion to transfuse had been made, patients received ini-tially up to 3 250-mL infusions of 10% DCLHb (

UNLABELLED Reports of anesthesia personnel shortages in 2001 led to the first comprehensive analysis of labor supply and demand for anesthesiologists since 1993. We now update this analysis and forecast, incorporating newly available data about residency composition, American Board of Anesthesiology and Certified Registered Nurse Anesthetist certification, the 2002 residency match, surgical facilities, and the US physician workforce. In addition, US residency programs were surveyed; national health care utilization and economic data were reviewed. Adjusted for the new information, our model still shows an anesthesiologist shortfall in 2002, projected to continue through 2005. We now estimate a current shortage of 1100-3800 anesthesiologists in 2002, on the basis of past service demand growth assumptions of 2%-3%, respectively. By 2005 this number is expected to be 500-3900, depending on a future service demand growth of 1.5%-2%, respectively. To avoid a surplus of anesthesiologists in 2006-2010, our model suggests that the number of graduates should level out at 1600 yearly, with a 1.5% service demand growth. To forecast the anesthesia personnel market more accurately, thereby helping supply match demand, substantially better quantification of future demand for anesthesia services is needed. If sustained growth in service demand >1.5% is likely, entry into the specialty should be encouraged beyond the current level. IMPLICATIONS With updates from training programs, surgical activity, and other sources, our previously described model estimates a continuing shortfall of 1000-3800 anesthesiologists in 2002 and 500-3900 in 2005, assuming that service demand growth is 1.5% or 2% annually. If service growth >1.5% is likely, entry into the specialty should be encouraged beyond current levels.

Multiple sclerosis remains prevalent among young women in the United States of America. It is a disease of the central nervous system that possesses many anesthetic implications. Anesthesia providers need to understand this disorder and its multiple anesthetic ramifications.Recent work has provided more insight into the etiology of multiple sclerosis, its pathogenesis, diagnosis and natural history. A number of new medications have also been added to the therapeutic armamentarium. Optimal anesthetic care entails a thorough preoperative evaluation, medication history and neurologic examination, intraoperative awareness of conditions that may precipitate attacks and lead to potentially life-threatening complications, as well as postoperative attention to respiratory and other risks. Recommendations for management are based on information from small retrospective studies and anecdotal reports.In summary, our aim is to provide an updated view of multiple sclerosis from the perspective of perioperative care, emphasizing interactions between the disease, surgery and anesthesia.

The built environment of several international airports does not anymore just include facilities for logistical purposes. Instead, several utilisations are typical for city centres, such as offices, shopping venues or conference centres. This has evoked the image of the ‘Airport City’. With regard to the spatial delineation of an Airport City, this chapter follows a narrow understanding of the term. This means that an Airport City is supposed to consist of the airport platform with its terminals and adjacent sites, which are functionally and organisationally closely connected with the airport (Schubert and Conventz 2011: 19).

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.

Background Oral practice examinations (OPEs) are used extensively in many anesthesiology programs for various reasons, including assessment of clinical judgment. Yet oral examinations have been criticized for their subjectivity. The authors studied the reliability, consistency, and validity of their OPE program to determine if it was a useful assessment tool. Methods From 1989 through 1993, we prospectively studied 441 OPEs given to 190 residents. The examination format closely approximated that used by the American Board of Anesthesiology. Pass-fail grade and an overall numerical score were the OPE results of interest. Internal consistency and inter-rater reliability were determined using agreement measures. To assess their validity in describing competence, OPE results were correlated with in-training examination results and faculty evaluations. Furthermore, we analyzed the relationship of OPE with implicit indicators of resident preparation such as length of training. Results The internal consistency coefficient for the overall numerical score was 0.82, indicating good correlation among component scores. The interexaminer agreement was 0.68, indicating moderate or good agreement beyond that expected by chance. The actual agreement among examiners on pass-fail was 84%. Correlation of overall numerical score with in-training examination scores and faculty evaluations was moderate (r = 0.47 and 0.41, respectively; P < 0.01). OPE results were significantly (P < 0.01) associated with training duration, previous OPE experience, trainee preparedness, and trainee anxiety. Conclusion Our results show the substantial internal consistency and reliability of OPE results at a single institution. The positive correlation of OPE scores with in-training examination scores, faculty evaluations, and other indicators of preparation suggest that OPEs are a reasonably valid tool for assessment of resident performance.

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.

After craniotomy, hypertension may contribute to intracerebral hemorrhage.We studied whether scalp infiltration with bupivacaine during craniotomy reduces postoperative pain and hypertension. In a double-blind fashion, 36 adult patients (ASA physical status II or III) undergoing elective craniotomy were randomly assigned to receive scalp infiltration with either bupivacaine (0.25%) and epinephrine (1:200,000) or saline/epinephrine (1:200,000) for skeletal fixation, skin incision, and wound closure. Heart rate (HR) and mean arterial pressure (MAP) were measured after anesthesia induction, after skull-pin insertion, after scalp infiltration, during dural closure, during skin closure, on admission to postanesthesia care unit (PACU), and 1 h after admission. Visual analog pain scores were recorded in the PACU. MAP was significantly greater in the saline group at scalp infiltration. HR was significantly faster in the saline group at dural and skin closure. The bupivacaine group reported significantly less pain than the saline group at PACU admission and 1 h after admission. Pain scores did not correlate with hemodynamic measurements. We conclude that scalp infiltration with 0.25% bupivacaine with 1:200,000 epinephrine blunts certain intraoperative hemodynamic responses and reduces postoperative pain but has no effect on postoperative hemodynamics. Implications: We sought to evaluate whether scalp infiltration with bupivacaine and epinephrine at the beginning and end of craniotomy would afford more intra- and postoperative hemodynamic stability and influence immediate postoperative pain. We found that intraoperative hemodynamics were not influenced greatly; however, craniotomy patients do have significant postoperative pain, which does not seem to have an influence on hemodynamics in the postanesthesia care unit. (Anesth Analg 1998;87:579-82)

Background Knowing which neurosurgical patients are at risk for delayed awakening may lead to better utilization of intensive care resources and avoid the risk and cost of pharmacologic reversal and diagnostic tests. Methods The authors compared anesthetic emergence from complex spinal surgery (spine; n = 47) with that from craniotomy for supratentorial nonfrontal (n = 22), frontal (n = 34), or posterior fossa tumor (n = 28). A further comparison involved patients with small versus large (diameter > 30 mm, mass effect) tumors. The standardized anesthetic regimen consisted of induction with 2-4 mg/kg-1 thiopental and 1-2 micrograms/kg-1 sufentanil, followed by maintenance with nitrous oxide, 0.2-0.5 micrograms.kg-1.h-1 sufentanil and < or = 0.5% isoflurane. Sufentanil administration was terminated on dural or spinal muscle closure, isoflurane during skin closure, and nitrous oxide during dressing application. After discontinuing nitrous oxide, a minineurologic examination was performed every 15 min for 1 h, then hourly for 4 h and at 24 h. Results Craniotomy patients performed less well than spinal surgery patients on the minineurologic examination 15 and 30 min after discontinuing nitrous oxide. At 15 min, fewer patients with large (vs. small) tumors were oriented to time (58% vs. 87%; P < 0.01) or place (67% vs. 90%; P < 0.01). Forty-two percent of patients with large tumors still had an abnormal minineurologic examination score versus 15% of patients with small tumors. At 30 min, these values were 28% and 8%, respectively (P < 0.05). Seventy-one percent of patients with large tumors were oriented to time compared to 97% for small lesions (P < 0.01). Emergence from anesthesia was similar for spinal surgery patients and patients with small brain tumors. Conclusion Patients undergoing craniotomy for large intracranial mass lesions awaken more slowly than patients after spinal surgery or craniotomy for small brain tumor.

Our overall goal was to investigate the mechanism by which fentanyl attenuates acetylcholine-induced contraction in porcine coronary artery. We tested the hypothesis that fentanyl attenuates muscarinic coronary contraction via sigma receptor activation. Left coronary artery vascular rings were isolated from porcine hearts and were suspended in organ chambers for isometric tension recording. In untreated coronary vascular rings, acetylcholine administration resulted in dose-dependent contraction. Fentanyl attenuated acetylcholine-induced contraction. The sigma ligands--(+)-pentazocine, (+)-cyclazocine, haloperidol, and 1,3-di-o-tolylguanidine--also inhibited acetylcholine-induced contraction. In contrast, the selective sigma ligand, (+)-3-(3-hydroxyphenyl)-N-(1-propyl) piperidine failed to have an inhibitory effect on acetylcholine-induced contraction. Moreover, metaphit (1-[1(3-isothiocyanatophenyl)cyclohexyl]piperidine), which causes irreversible acylation of sigma receptors, only inhibited acetylcholine-induced contraction when it was present in the organ chamber. We also assessed the effects of inhibiting various points in the signal transduction pathway distal to naloxone-sensitive opioid receptor activation on acetylcholine-induced contraction. Selective (glybenclamide) and nonselective (tetraethylammonium) K(+)-channel inhibition, guanosine triphosphate-binding protein inactivation (pertussis toxin), and Type 1 and Type 2 dopamine receptor inhibition all failed to alter the attenuating effect of fentanyl on acetylcholine-induced contraction. Thus, neither sigma or opioid receptor activation is a prerequisite for fentanyl-induced inhibition of muscarinic coronary contraction.

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.

The effect of propofol on the electroencephalogram (EEG) in patients with epilepsy is still unclear. Case reports with electroencephalographic documentation highlight pro- and anticonvulsant effects and beta activation of the EEG. This prospective study sought to determine the effect of propofol in 17 patients undergoing cortical resection for intractable epilepsy. Each patient received 2 mg/kg of propofol intravenously and the EEG was recorded from chronically implanted subdural electrodes placed during a previous craniotomy. Frequency of interictal spikes, time to burst suppression, and appearance of beta activation were recorded. The median frequency of interictal spikes decreased significantly from 2 spikes/min before to 0 spikes/min after propofol (P = 0.001). Seizure activity did not increase after propofol. Profound burst suppression and an increase in beta activity were noted consistently. The use of propofol in patients with epilepsy seems to be safe but may interfere with the recording of EEG spikes.

α(2)-Agonists are a novel class of drugs with mechanisms of action that differ from other commonly used anesthetic drugs. They have neuroprotective, cardioprotective, and sedative effects. These unique characteristics make them potentially useful during neuroanesthesia and intensive care. We review the effects of dexmedetomidine on cerebral blood flow and cerebral metabolism, along with recent advances in using α(2)-agonists in neuroanesthesia and neurointensive care.

The authors present a prospective study of single-agent pediatric sedation regimens for patients older than 2 years of age undergoing magnetic resonance (MR) imaging of the brain and spine. Thirty patients underwent MR imaging after intravenous administration of pentobarbital in successive boluses of 2.5 mg/kg to a maximum of 7.5 mg/kg. Thirty-one patients received an intravenous bolus followed by continuous infusion of propofol. The dosage schedule for propofol was 2 mg/kg (with supplemental 1 mg/kg boluses) followed by continuous infusion of 6 mg/kg per hour. There was no significant difference in the physiologic response to sedation between the two groups, although the magnitude of the drop in pulse was significantly greater in the group receiving propofol. Three patients receiving propofol experienced transient decreases in oxygen saturation, at variable times over the course of the procedure. However, patients recovered significantly faster from sedation with propofol. While propofol may represent a viable alternative to pentobarbital in selected patients, propofol requires constant physician supervision and meticulous technique.

Background Hospitals are increasingly required to publicly report outcomes, yet performance is best interpreted in the context of population and procedural risk. We sought to develop a risk-adjustment method using administrative claims data to assess both national-level and hospital-specific performance. Methods A total of 35,179,507 patient stay records from 2001-2006 Medicare Provider Analysis and Review (MEDPAR) files were randomly divided into development and validation sets. Risk stratification indices (RSIs) for length of stay and mortality endpoints were derived from aggregate risk associated with individual diagnostic and procedure codes. Performance of RSIs were tested prospectively on the validation database, as well as a single institution registry of 103,324 adult surgical patients, and compared with the Charlson comorbidity index, which was designed to predict 1-yr mortality. The primary outcome was the C statistic indicating the discriminatory power of alternative risk-adjustment methods for prediction of outcome measures. Results A single risk-stratification model predicted 30-day and 1-yr postdischarge mortality; separate risk-stratification models predicted length of stay and in-hospital mortality. The RSIs performed well on the national dataset (C statistics for median length of stay and 30-day mortality were 0.86 and 0.84). They performed significantly better than the Charlson comorbidity index on the Cleveland Clinic registry for all outcomes. The C statistics for the RSIs and Charlson comorbidity index were 0.89 versus 0.60 for median length of stay, 0.98 versus 0.65 for in-hospital mortality, 0.85 versus 0.76 for 30-day mortality, and 0.83 versus 0.77 for 1-yr mortality. Addition of demographic information only slightly improved performance of the RSI. Conclusion RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data.

The effect of intrathecal morphine on the minimum alveolar concentration (MAC) of halothane was investigated in 22 patients undergoing elective abdominal surgery. The patients were randomly assigned to the control (CTRL) or intrathecal morphine sulfate (ITMS)-treated groups. Approximately 2.5 h before induction of anesthesia with halothane, the ITMS-treated group received 15 micrograms/kg preservative-free ITMS (Duramorph; Elkins-Sinn, Cherry Hill, NJ) while in the right lateral decubitus position. The CTRL group was treated in an identical fashion except that, after placement of the introducer needle, actual dural puncture was omitted. After inhalational induction with halothane as the sole anesthetic agent, the patients' responses to surgical incision were recorded. MAC was determined with the modified up-down method of Dixon and verified with probit analysis. MAC (+/- SE) after ITMS was 0.76 +/- 0.06, compared with a CTRL MAC of 0.78 +/- 0.15 (not significant). Under the conditions of this study, the MAC of halothane in humans was not significantly affected by ITMS.

Background: In neuroanesthesia practice, muscle relaxants may at times need to be avoided to facilitate intraoperative motor pathway monitoring. Our study's objective was to determine the optimal dose of remifentanil required to prevent movement after neurosurgical stimulation. Methods: After Institutional Review Board approval and written informed consent, 132 patients undergoing elective craniotomy randomly received one of 12 remifentanil dose regimens (0.10 to 0.21 microg/kg/min). Remifentanil was started before induction with propofol and succinylcholine. Anesthesia was maintained with isoflurane (0.6% end-tidal) in air/oxygen. During the study, movement was assessed on predetermined criteria by the anesthesiology, nursing, and neurosurgical teams. Heart rate and blood pressure were recorded every 5 minutes. We assessed the relationship between movement, hypotension, bradycardia, and dose using probit analysis and logistic regression. Results: Sixty-five percent of the patients moved in response to surgical stimuli [95% confidence interval (CI): 49%-79%] at a remifentanil infusion rate of 0.10 microg/kg/min, and movement decreased to 21% (95% CI: 11-35) at 0.21 microg/kg/min. The probability of movement was 50% at an infusion rate (95% CI) of 0.13 (0.10 to 0.15) microg/kg/min remifentanil and decreased to 25% at an infusion rate of 0.19 (0.17 to 0.29) microg/kg/min. The probability of hypotension and bradycardia was 50% at 0.13 (0.10 to 0.15) microg/kg/min and 0.17 (0.15 to 0.21) microg/kg/min, respectively. Conclusions: Higher doses of remifentanil lessen the risk of movement in the absence of muscle relaxants with surgical stimulation for elective craniotomy. Hypotension and bradycardia were common at higher doses. Even at the maximum dose (0.21 mcg/kg/min) there was a 20% chance of movement. Adjunctive therapy is needed to ablate movement reliably, and to counteract the hypotensive effect of remifentanil. These findings may be helpful for clinicians administering remifentanil and isoflurane during procedures, where muscle relaxants may not be desirable.

Background Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput. Methods The high-throughput parallel processing strategy included neuraxial anesthesia performed in an "induction room" adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time. Results There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 +/- 0.7 (mean +/- SD) to 3.4 +/- 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%. Conclusion Reorganizing the perioperative work process for total joint replacements sustainably increased OR throughput. Because joint arthroplasties generated a positive margin greater than the incremental cost, the high-throughput system improved financial performance.

The effect of ketamine alone and in combination with N2O (70% inspired) on median nerve somatosensory evoked potentials (SSEPs) was investigated in 16 neurologically normal patients undergoing elective abdominopelvic procedures. The anesthetic regimen consisted of ketamine (2 mg/kg iv bolus followed by continuous infusion at a rate of 30 micrograms.kg-1.min-1) [corrected], neuromuscular blockade (atracurium), and mechanical ventilation with 100% oxygen. SSEP recordings were obtained immediately preinduction and at 2, 5, 10, 15, 20, and 30 min postinduction. Thereafter, N2O was added with surgical incision and maintained for 15 min. At 5-min intervals, SSEP recordings were again taken during and after N2O. With minor exceptions, mean cortical and noncortical latencies as well as noncortical-evoked potential amplitude were unaffected by either ketamine or N2O. Ketamine induction increased cortical amplitude significantly with maximal increases occurring within 2-10 min. For example, at 5-min postinduction, mean N1-P1 amplitude increased from 2.58 +/- 1.05 (baseline) to 2.98 +/- 1.20 microV and P1-N2 amplitude increased from 2.12 +/- 1.50 (baseline) to 3.99 +/- 1.76 microV. Throughout the 30-min period after ketamine induction, mean P1-N2 amplitude increased generally by more (57-88%) than did mean N1-P1 amplitude (6-16%). N2O added to the background ketamine anesthetic produced a rapid and consistent reduction in both N1-P1 and P1-N2 amplitude. Thus, at 1 min after N2O, mean N1-P1 amplitude decreased from 2.74 +/- 1.11 to 1.64 +/- 0.63 microV, while P1-N2 amplitude decreased from 3.32 +/- 1.52 to 1.84 +/- 0.87 microV.(ABSTRACT TRUNCATED AT 250 WORDS)