American Society of Anesthesiologists

In response to the COVID-19 pandemic, the American Board of Anesthesiology transitioned from in-person to virtual administration of its APPLIED Examination, assessing more than 3000 candidates for certification purposes remotely in 2021. Four hundred examiners were involved in delivering and scoring Standardized Oral Examinations (SOEs) and Objective Structured Clinical Examinations (OSCEs). More than 80% of candidates started their exams on time and stayed connected throughout the exam without any problems. Only 74 (2.5%) SOE and 45 (1.5%) OSCE candidates required rescheduling due to technical difficulties. Of those who experienced “significant issues”, concerns with OSCE technical stations (interpretation of monitors and interpretation of echocardiograms) were reported most frequently (6% of candidates). In contrast, 23% of examiners “sometimes” lost connectivity during their multiple exam sessions, on a continuum from minor inconvenience to inability to continue. 84% of SOE candidates and 89% of OSCE candidates described “smooth” interactions with examiners and standardized patients/standardized clinicians, respectively. However, only 71% of SOE candidates and 75% of OSCE candidates considered themselves to be able to demonstrate their knowledge and skills without obstacles. When compared with their in-person experiences, approximately 40% of SOE examiners considered virtual evaluation to be more difficult than in-person evaluation and believed the remote format negatively affected their development as an examiner. The virtual format was considered to be less secure by 56% and 40% of SOE and OSCE examiners, respectively. The retirement of exam materials used virtually due to concern for compromise had implications for subsequent exam development. The return to in-person exams in 2022 was prompted by multiple factors, especially concerns regarding standardization and security. The technology is not yet perfect, especially for testing in-person communication skills and displaying dynamic exam materials. Nevertheless, the American Board of Anesthesiology’s experience demonstrated the feasibility of conducting large-scale, high-stakes oral and performance exams in a virtual format and highlighted the adaptability and dedication of candidates, examiners, and administering board staff.

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

To determine the 90% effective dose (ED90) of intrathecal hyperbaric bupivacaine for Cesarean delivery under combined spinal-epidural anesthesia (CSE) in parturients with super obesity (body mass index [BMI] ≥ 50 kg·m-2). We enrolled parturients with BMI ≥ 50 kg·m-2 with term, singleton vertex pregnancies undergoing elective Cesarean delivery under CSE. An independent statistician generated the 0.75% hyperbaric bupivacaine dosing regimen in increments of 0.75 mg using a biased-coin up-down sequential allocation technique. This was combined with 15 μg fentanyl, 150 μg morphine, and normal saline to a volume of 2.05 mL. The initial and maximum doses were 9.75 mg and 12 mg, respectively. Participants, clinical team, and outcome assessors were blinded to the dose. The primary outcome was block success, defined as T6 block to pinprick within ten minutes and no intraoperative analgesic supplementation within 90 min of spinal injection. We determined the ED90 using logistic regression. We enrolled 45 parturients and included 42 in the analysis. All doses achieved a T6 level within ten minutes, and the primary outcome occurred in 0/1 (0%) of the 9.75-mg doses, 2/3 (67%) of the 10.5-mg doses, 21/27 (78%) of the 11.25-mg doses, and 11/11 (100%) of the 12-mg doses. The ED90 of hyperbaric bupivacaine was 11.56 mg (95% confidence interval, 11.16 to 11.99). Four parturients (9.5%) had sensory level higher than T2, but none was symptomatic or required general anesthesia. The estimated ED90 of hyperbaric bupivacaine with fentanyl and morphine in parturients with super obesity undergoing Cesarean delivery under CSE was approximately 11.5 mg. ClinicalTrials.gov (NCT03781388); first submitted 18 December 2018.

BackgroundThe purpose of this study was to evaluate relationships between demographics, professional characteristics, and perceived challenges facing the specialty of anesthesiology among physicians who entered a fellowship and those who started independent practice immediately after finishing a U.S. anesthesiology residency.MethodsAnesthesiologists in the year after their residency graduation were invited to take an online survey during the academic years of 2016–2017, 2017–2018, and 2018–2019, with questions about their personal characteristics, the nature of their professional lives, and their perceptions of the greatest challenge facing the profession of anesthesiology.ResultsA total of 884 fellows-in-training and 735 anesthesiologists starting independent practice right after the completion of their residency responded. Fellows were slightly younger (mean = 33.2 vs. 34.0 years old, p < 0.001), were more likely to have a spouse who works outside the home (63.9% vs. 57.0%, p = 0.002), had fewer children (mean = 0.69 vs. 0.88, p < 0.001), worked more hours per week (mean = 56.2 vs. 52.4, p < 0.001), and were less likely to report a personal and professional life balance (66.4% vs. 72.3% positive, p = 0.005) than direct-entry anesthesiologists. Fellows and direct-entry anesthesiologists identified similar challenges in three broad themes – workforce competition (80.3% and 71.8%), healthcare system changes (30.0% and 37.9%), and personal challenges (6.4% and 8.8%). Employment security issues posed by non-physician anesthesia providers and perceived lack of appreciation of anesthesiologists’ value were commonly cited. Relative weighting of challenge concerns varied between fellows and direct-entry physicians, as well as within these groups based on gender, fellowship subspecialty, location or size of practice, and frequency of supervisory roles.ConclusionsAnesthesiology fellows and direct-entry anesthesiologists had largely similar demographics and perspectives on the challenges facing anesthesiology in the United States. Group differences found in some demographics and perspectives may reflect different motivations for choosing their professional paths and their diverse professional experiences.

Shaw, Andrew D. MB, FRCA, FFICM, FRCPC*,†; Glas, Kathryn MD, MBA*,‡; Shernan, Stanton K. MD*,§ Author Information

Aim: To determine frequency of anesthesiologists practicing pencil- point spinal needles in teaching hospitals of Sindh, Pakistan. Study design: Cross-sectional study. Place and Duration of Study: The Indus Hospital, Aga Khan University Hospital Karachi, Liaquat National Hospital Karachi, Civil Hospital Karachi, Jinnah Postgraduate Medical Centre (JPMC) Karachi, Sindh institute of Urology &amp; Transplantation (SIUT) Karachi, Abbasi Shaheed Hospital Karachi, Ziauddin Hospital Karachi, PNS Shifa Hospital Karachi, Civil Hospital Hyderabad, Chandka Medical College Larkana and Peoples Medical College Nawabshah from 1stJune 2018 to 30thApril 2019. Methodology: Sixty FCPS anesthesiologists or equivalent working in teaching hospitals of Sindh for more than one year, either gender and age 30-70 years were enrolled in the study. MCPS specialists were excluded. Results: Majority anesthesiologists were males 48 (80%). The median working experience was 15 years (IQR): (10-21) with no significant difference between both the genders (mean: 17.2 vs 13.8, p=0.277). Thirty three (55.5%) had professional experience of ≥15 years. Approximately 42% belonged to Aga Khan University hospital. All participants had work experience of general surgery, while 54(90%) worked in Urology, 53(88.3%) participants had experience of Orthopedics, Gynecology and Obstetrics. Conclusion: Although majority of consultants use 25G Pencil Point Needles for spinal anesthesia but still we need to educate more practitioner of government institutes to use smaller gauge spinal needles and the reason of using smaller gauge pencil point needles should be to prevent the chances of PDPH. Key words: Choice, Needle, Spinal anesthesia, Teaching hospitals

Boston dentist William T. G. Morton secured a provisional English patent for etherization in December 1846. The full patent specification was submitted 6 months later, and the patent was sealed on June 18, 1847. The enrolled copies of the provisional and full patents, which are held in The National Archives, London, have not been previously documented in the anesthesia literature. We review the communications between Boston and London regarding the patent for etherization, the possibility that preliminary discussions and trials of etherization may have been conducted in London before the earliest known application of the discovery for a dental extraction on December 19, 1846, and the role of the American lawyer James Augustus Dorr, who was Morton's agent in the United Kingdom.

Objective: The aim of our paper is to answer the question that during the ureteroscopy procedure if ureteral access sheath could facilitate operation, could decrease complication rates,operation time,requirement of additional surgery. Method: The patients were randomly divided into two groups. Group 1 contained 44 patients for whom a UAS was not used and Group 2 consisted of 70 patients for whom a UAS was used during the URS procedure. The operation was continued using the semirigid ureteroscope within the UAS. Results: There were no statistically significant differences between the two groups in terms of the mean age, BMI, ASA score, mean stone density, previous unsuccessful interventions, history of stone disease, mean grade of hydronephrosis in renal pelvis and mean stone size. the mean operation time was 41 minutes for Group 1 and 30 minutes for Group 2, with a statistically significant difference (p < 0.001), consistent with the literature. Similarly, the difference in the mean fluoroscopy time was statistically significant, being determined as six minutes for Group 1 and three minutes for Group 2 (p < 0.001). Conclusions: Use of UAS was statistically significantly superior in terms of many parameters, such as increased stone-free rate, shorter operation time, and reduced requirement of additional surgery. Furthermore, the complication rates did not significantly differ between the UAS and non-UAS groups. We also consider that the advantages of a higher stone-free rate and reduced requirement of secondary interventions make the cost of UAS acceptable.

Estimates for the incidence of difficult intubation in the obstetric population vary widely, although previous studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples. The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery. This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database. The study population included women aged 15 to 44 yr undergoing general anesthesia for cesarean delivery between 2004 and 2019 at 1 of 45 medical centers. Coprimary outcomes included the frequencies of difficult and failed intubation. Difficult intubation was defined as Cormack-Lehane view of 3 or greater, three or more intubation attempts, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway. Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement. The rates of difficult and failed intubation were assessed. Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation. This study identified 14,748 cases of cesarean delivery performed under general anesthesia. There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI, 1:55 to 1:44; n = 14,531). There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI, 1:1,276 to 1:511; n = 14,537). Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid-to-mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations. In this large, multicenter, contemporary study of more than 14,000 general anesthetics for cesarean delivery, an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808 were observed. Most risk factors for difficult intubation were nonobstetric in nature. These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.