Where have all the pediatric anesthesiology fellows gone in the USA? Anesthesiology fellowship trends.

BACKGROUND: Recent consternation over the number of unfilled Pediatric Anesthesiology fellowship positions in the United States compelled us to assess the change in the ratio of Pediatric Anesthesiology fellows to the number of graduating anesthesiology residents over the 14-year period between 2008 and 2022. We also sought to report the total ratio of anesthesiology fellows to graduating residents and trends in the annual number of fellowship applicants relative to the number of Accreditation Council for Graduate Medical Education (ACGME)-accredited anesthesiology fellowship positions by specialty. METHODS: We used publicly available resources, including ACGME Data Resource Books, National Resident Matching Program (NRMP) data, San Francisco (SF) Match data, and American Board of Medical Specialties (ABMS) data, to determine the ratio of anesthesiology fellows to graduating anesthesiology residents and to compare the number of fellowship applicants to fellowship positions for Adult Cardiothoracic Anesthesiology, Critical Care Anesthesiology, Obstetric Anesthesiology, Pain Medicine and Pediatric Anesthesiology. RESULTS: Since 2008, the ratio of ACGME-accredited anesthesiology fellows to graduating residents increased from 0.36 in 2008 (2007 residency graduates) to 0.59 in 2022 (2021 residency graduates) and the ratio of Pediatric Anesthesiology fellows to graduating residents remained relatively stable from 0.10 to 0.11. The number of unmatched positions in Pediatric Anesthesiology increased from 17 in 2017 to 86 in 2023, and all ACGME-accredited fellowships had more positions available than applicants in 2023. CONCLUSION: In the USA, while the ratio of Pediatric Anesthesiology fellowship graduates to anesthesiology residency graduates remained relatively constant from 2008 to 2022, this is likely a lagging indicator that has not yet accounted for the recent decrease in fellowship applicants. These findings refute prior estimates for a surplus in Pediatric Anesthesia supply in the USA and have significant implications for the future.

Racial disparities in postoperative morbidity and mortality among high-risk pediatric surgical patients.

STUDY OBJECTIVE: With increasing improvement in perioperative care, post-surgical complication and mortality rates have continued to decline in the United States. Nonetheless, not all racial groups have benefitted equally from this transformative improvement in postoperative outcomes. We tested the hypothesis that among a cohort of "sick" (ASA physical status 4 or 5) Black and White children, there would be no systematic difference in the incidence of postoperative morbidity and mortality. DESIGN: Retrospective cohort study. SETTING: Institutions participating in the National Surgical Quality Improvement Program-Pediatric (2012-2019). PATIENTS: Black and White children who underwent inpatient operations and were assigned ASA physical status 4 or 5. MEASUREMENTS: risk adjusted odds ratios for 30-day postoperative mortality and complications using multivariable logistic regression models, controlling for various baseline covariates. MAIN RESULTS: There were 16,097 children included in the analytic cohort (77.0% White and 23.0% Black). After adjusting for baseline covariates, Black children were estimated to be 20% more likely than their White counterparts to die within 30 days after surgery (9.3% vs. 7.2%, adjusted-OR: 1.20, 95% CI: 1.05-1.38, P = 0.007). Black children were also more likely to develop pulmonary complications compared to their White peers (52.1% vs. 44.6%, adjusted-OR: 1.13, 95%CI: 1.04, 1.23, P = 0.005). Being Black also conferred an estimated 28% relative greater odds of developing cardiovascular complications (4.6% vs. 3.3%, 95%CI: 1.06, 1.54, P = 0.010). Finally, being Black conferred an estimated 33% relative greater odds of requiring an extended LOS compared to Whites (50.7% vs. 38.7%, adjusted-OR: 1.33, 95% CI: 1.22-1.46, P < 0.001). CONCLUSION: In this cohort of children with high ASA physical status, Black children compared to their White peers experienced significantly higher rates of 30-day postoperative morbidity and mortality. These findings suggest that racial differences in postoperative outcomes among the sickest pediatric surgical patients may not be entirely explained by preoperative health status.

Impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of program directors.

BACKGROUND: The COVID-19 pandemic created a situation with an urgent need to produce a virtual system for the 2019-2020 pediatric anesthesiology fellowship cycle. With fellowship interviews beginning in April 2020, there was minimal time for programs to adapt. Each program rapidly developed its own platform, expectations, materials, and process for interviews-all while under the stress of managing the unfolding patient care, financial, and leadership crises of the unfolding pandemic. AIMS: The aim of this survey-based study was to help identify changes compared with previous traditional cycles, obstacles encountered, and program director attitudes toward this, and possible future, virtual application cycles. We separately report the results of an applicant-based survey about the 2020 virtual interview cycle. METHODS: A 50-question survey was developed utilizing Qualtrics. An anonymous survey link was sent to all pediatric anesthesiology program directors with an invitation for one program leader (either the program director or assistant/associate program director but not both) from each program to complete the voluntary survey. RESULT: Thirty respondents completed the survey, for a response rate of 50% based on the 60 ACGME-approved pediatric anesthesiology fellowships. Compared to previous traditional cycles, almost half of respondents (14/29, 48.3%) reported no increase in the number of applications received, and a majority of respondents (16/29, 55.2%) reported that they offered the same number of interview spots for the year. The virtual interview process appears to have gone smoothly, as a majority of programs reported they never or rarely had technical problems across a number of different domains. Importantly, the majority of respondents were either somewhat satisfied or extremely satisfied (21/28, 75%) with the overall virtual interview process. Given the choice of preferred interview format going forward, half of the respondents (14/28) would offer a combination of traditional and virtual interviews. CONCLUSIONS: These results demonstrate that virtual interviews are a viable alternative to traditional interviews and can be completed without many technological complications. PDs were overall satisfied with virtual interviews, despite not having appropriate time to plan and coordinate, and would be interested in continuing this option into the future. There are areas where improvements can be made and with appropriate planning could look to mitigate some of the areas where virtual interviews fall short of traditional interviews. In combination with our previously published survey of applicants (Paediatr Anaesth. 2021;31(9):968-976), these data form a more complete picture of virtual interview best practices going forward.

The impact of the COVID-19 pandemic on the 2020 pediatric anesthesiology fellowship application cycle: A survey of applicants.

BACKGROUND: The COVID-19 pandemic created a situation with an urgent need to produce a virtual system for the 2019-2020 pediatric anesthesiology fellowship cycle. With fellowship interviews beginning in April 2020, there was minimal time to adapt. Each program rapidly developed its own platform, expectations, materials, and process for interviews, and applicants were exposed to a wide array of variability in the process-all while under the stress of interviewing for fellowship positions. AIMS: The aim of this survey-based study was to obtain input from applicants to help guide program decisions about "best practice" for the future for both pediatric anesthesiology and other graduate medical education matches. METHODS: A 28-question survey was developed utilizing Qualtrics. An anonymous link was sent to all pediatric anesthesiology program directors for distribution of the survey link to all recently matched applicants. Incoming fellows who were accepted outside of the match process were also invited to respond. RESULTS: Fifty respondents completed the survey, for a response rate of 30% based on the 167 matched fellowship positions nationwide (50/167). A majority of the respondents reported they felt virtual interviews allowed them to learn the following things equally as well compared with a traditional interview about fellowship programs: salary and benefits, available academic opportunities, available clinical opportunities, clinical schedule of the fellowship, mentorship opportunities, clinical experience and training of the fellowship, and expected work-life balance during fellowship. Respondents report that the most important factors in making their rank list were perceived goodness of fit, desired geographic location, and perception of program leadership. Additionally, respondents ranked the types of information and interactions that they found most helpful to make decisions. All respondents reported the benefit of cost savings compared to a traditional application cycle, with the most commonly reported estimated savings being $3,000-$5,000 per respondent. CONCLUSIONS: These results allow recommendations for "best practices" for virtual interviews to include programs providing an electronic packet of information prior to the interview day, providing dedicated time for applicants to interact with current fellows, providing applicants an understanding of the city/region of the location of the program, and offering a completely optional postinterview visit, when possible. Based on the results of this survey, we recommend that programs continue to offer virtual interviews as a penalty-free option for applicants, even when in-person interviews may be feasible.

Race and major pulmonary complications following inpatient pediatric otolaryngology surgery.

BACKGROUND: Compared to their white peers, black children are more likely to experience serious respiratory complications in the perioperative period. Whether a racial difference exists in the occurrence of late postoperative respiratory complications is largely unknown. Here, we evaluated a multi-institutional cohort of children who underwent various elective otolaryngology procedures to examine the racial differences in major postoperative pulmonary complications. METHODS: We performed a retrospective analysis of elective inpatient otolaryngology cases from the National Surgical Quality Improvement Program (2012-2018). We used propensity score matching of black to white patients to compare the risk of postoperative pulmonary complications, defined as the occurrence of either pneumonia, unplanned reintubation, or prolonged postoperative mechanical ventilation. RESULTS: The matched cohort was comprised of 4786 black and white patients (2 393 of each race). Black children were more likely to develop postoperative pulmonary complications compared to white peers (29.3% vs. 24.2%; odds ratio: 1.38; 95% confidence interval: 1.20, 1.59; P-value < .001). Furthermore, black children were almost two times more likely to require unplanned postoperative reintubation, relative to their white peers (2.6% vs. 1.3%; odds ratio: 2.07; 95% confidence interval: 1.33, 3.22; P-value < .001). Similarly, black children were estimated to have 37% relative greater odds of requiring prolonged mechanical ventilation (28.6% vs. 23.7%; 95% confidence interval: 1.19, 1.58; P-value < .001). Finally, being of black race conferred greater odds of requiring prolonged hospital length of stay, relative to being of white race (38.6% vs. 34.5%; odds ratio:1.24; 95% confidence interval: 1.09, 1.42; P-value = .004). CONCLUSION: Black children undergoing elective otolaryngological surgery are more likely to develop major postoperative pulmonary complications.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review.

BACKGROUND: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Exome analysis identifies Brody myopathy in a family diagnosed with malignant hyperthermia susceptibility.

Whole exome sequencing (WES) was used to determine the primary cause of muscle disorder in a family diagnosed with a mild, undetermined myopathy and malignant hyperthermia (MH) susceptibility (MHS). WES revealed the compound heterozygous mutations, p.Ile235Asn and p.Glu982Lys, in ATP2A1, encoding the sarco(endo)plasmic reticulum Ca(2+) ATPase type 1 (SERCA1), a calcium pump, expressed in fast-twitch muscles. Recessive mutations in ATP2A1 are known to cause Brody myopathy, a rare muscle disorder characterized by exercise-induced impairment of muscle relaxation and stiffness. Analyses of affected muscles showed the absence of SERCA1, but SERCA2 upregulation in slow and fast myofibers, suggesting a compensatory mechanism that partially restores the diminished Ca(2+) transport in Brody myopathy. This compensatory adaptation to the lack of SERCA1 Ca(2+) pumping activity within the muscle explains, in part, the mild course of disease in our patient. Diagnosis of MHS in this family was secondary to a loss of SERCA1 due to disease-associated mutations. Although there are obvious differences in clinical expression and molecular mechanisms between MH and Brody myopathy, a feature common to both conditions is elevated myoplasmic Ca(2+) content. Prolonged intracellular Ca(2+) elevation is likely to have led to MHS diagnosis in vitro and postoperative MH-like symptoms in Brody patient.

Review of the efficacy and safety of remifentanil for the prevention and treatment of pain during and after procedures and surgery.

Remifentanil is an ultrashort-acting synthetic opioid. It is metabolized by nonspecific tissue and plasma esterases. Remifentanil's metabolism is responsible for its unique pharmacokinetic profile and flat, context-sensitive half-time. Since its introduction into clinical practice, remifentanil has been used for a variety of anesthetic and analgesic applications; however, concerns regarding a potential for rapid induction of tolerance and/or induced hyperalgesia, coupled with an ultrarapid offset of effect, make the drug less than optimal for use in the pharmacologic management of pain.