Age and anesthetic practice: a regional perspective.

STUDY OBJECTIVE: To obtain information about practitioners' behaviors, perceptions, and perspectives concerning issues related to advancing age and anesthetic practice. DESIGN: Questionnaire survey mailed to 1,208 active and retired American Society of Anesthesiologists (ASA) members in Northern New England. Topics included hours worked, practice policies, stress level of activities, observed in colleagues and personally perceived errors and problems associated with performance, and plans, preparation, and reasons for retirement. SETTING: Practicing respondents worked in academic, community, or federal hospitals, and in ambulatory surgical facilities. MEASUREMENTS AND MAIN RESULTS: For descriptive analysis, counts and frequency distributions were calculated for each question. Statistical methods were used to test differences across age groups and to identify sources of differences. Approximately 40% of respondents in each age group worked an average work week of 50 to 59 hours. Respondents aged 40 to 49 years worked the longest work weeks and duty periods and were more concerned about liability issues than other age groups. Respondents age 60+ tended to work shorter average and maximum work weeks, although 5% of them continued to work 70- to 79-hour weeks. There was no statistically significant difference in hours worked among men and women. Approximately 20% to 30% of respondents relieved older colleagues of late night or call duties, and asked them to restrict or to stop practice out of concern for patient safety. Night call was equally stressful for all age groups. Economic uncertainty, production pressure, and interpersonal relations were more stressful for younger respondents. In preparation for retirement, shifting away from complex cases and phased reduction in clinical activity were increasingly prevalent with each advancing age group. Important reasons for retirement included attitude changes, physical limitations, and declining health. CONCLUSIONS: Despite modest age-associated trends, chronological age per se is not a strong correlate of an individual's practice pattern, behaviors, or perceptions about performance.

Pulmonary edema associated with croup and epiglottitis.

Two children, ages 9 and 2 1/2 years, with clinical diagnoses of laryngotracheitis (croup) and epiglottis, respectively, developed florid pulmonary edema without evidence of cardiac enlargement. Both children responded to vigorous therapy, which included endotracheal intubation, mechanical ventilation with high oxygen concentrations and positive end expiratory pressure, diuretics, and support of the intravascular volume with colloid infusions. Swan-Ganz catheterization was performed in the child with epiglottitis to elucidate any hemodynamic malfunction. Pulmonary artery occluded pressure was found to be normal. We postulate that pulmonary edema may be the result of any of three major physiologic alterations: alveolar hypoxia, increased alveolar-capillary transmural pressure gradient, and a catechol-mediated shift of blood volume from the systemic to the pulmonary circulation. These alterations acting in concert would increase the volume of blood presented to the pulmonary capillaries, the pore size in those capillaries, and the hydrostatic pressure gradient promoting transduation. Failure of pulmonary lymphatics to effectively clear this fluid would result in pulmonary edema. Although pulmonary edema associated with acute upper airway obstruction is unusual, physicians should be altered to its possible appearance and the need for early and vigorous therapeutic measures.

A new approach to congenital posterolateral diaphragmatic hernia.

The theory is advanced that increased pulmonary vascular resistance, resulting in a state of fetal circulation, with right-to-left shunting through the ductus arteriosus, is the main reason that many patients do not survive after repair of a diaphragmatic hernia. Three patients are presented (who, by Raphaely's criteria, were destined for a fatal outcome) in whom the ductus was ligated, and vasodilator drugs were infused into the pulmonary artery. All three demonstrated definite improvement in oxygenation. Two expired after 6 days, one of whom was found at autopsy to have intestinal volvulus and gangrene, and the other multiple plumonary emboli. One case, so managed, survived. The suggestion is made that pulmonary hypoplasia is not the main reason for the high mortality rate after diaphragmatic hernia repair, and that additional laboratory and clinical investigation of the pulmonary circulation may lead to significant improvement in results.