Simulation in pediatric anesthesiology: current state and visions for the future.

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.

Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists.

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.

Development, Validation, and Results of a Survey of Personal Electronic Device Use Among 299 Anesthesia Providers From a Single Institution.

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.

The Effects of Coronavirus Disease 2019 on Pediatric Anesthesiologists: A Survey of the Members of the Society for Pediatric Anesthesia.

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.

Opportunities Beyond the Anesthesiology Department: Broader Impact Through Broader Thinking.

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.

Breast Regional Anesthesia Practice in the Italian Public Health System (BRA-SURVEY): A Survey-Based National Study.

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.

Dissemination of Anesthesia Information During the Coronavirus Disease 2019 Pandemic Through Twitter: An Infodemiology Study.

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.

Improving Tolerance to Snorkel Mask Use as Alternative Personal Protective Equipment.

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.

A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade.

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.

Demographic Trends From 2005 to 2015 Among Physicians With Accreditation Council for Graduate Medical Education-Accredited Anesthesiology Training and Active Medical Licenses.

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.

Association of Anesthesiologist Handovers With Short-term Outcomes for Patients Undergoing Cardiac Surgery.

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.

Interruption of the European Association of Cardiothoracic Anaesthesiology (EACTA) Fellowship Program During the Coronavirus Disease 2019 Pandemic: Consequences and Solutions.

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.

Shared decision-making - Creating pathways and models of care.

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.

Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective.

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.

Retention and Migration of Rwandan Anesthesiologists: A Qualitative Study.

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 Most Influential Publications in Obstetric Anesthesiology, 1998-2017: Utilizing the Delphi Method for Expert Consensus.

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.