2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade.

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.

Vigilance: the behavioral impact of quantitative monitoring on administration and antagonism of neuromuscular blocking agents.

PURPOSE: The aim of this study was to determine whether use of acceleromyography (1) changes dosing of neuromuscular blocking agents (NMBAs), and (2) increases the time between neostigmine administration and extubation, when compared with subjective assessment of neuromuscular blockade. METHODS: For this retrospective study, data were collected from patient electronic medical records. Patients were included if they had received an NMBA as part of a general anesthetic in 2013 and 2014. Data were analyzed by category of monitoring device: quantitative monitor (acceleromyograph [AMG]) or subjective device (peripheral nerve stimulator [PNS]). Outcomes measured were the total dose of NMBA administered and, the timing of the last dose of NMBA and anticholinesterase relative to tracheal extubation. RESULTS: Results from multivariate models showed that use of acceleromyography was not associated with a change in the total dose of NMBA administered. In contrast, the number of times any monitor was used, as determined by the frequency with which the train-of-four count (TOFC) was recorded, correlated with the administration of greater amounts of rocuronium (P < 0.01) and vecuronium (P < 0.01). The use of acceleromyography did not prolong the time interval between neostigmine administration and tracheal extubation. The number of times any monitor was used during an anesthetic was associated with a decrease in this time interval. The interval decreased an average of 2.7 min each successive time the TOFC was recorded (P < 0.01). CONCLUSIONS: The data presented provides insight about the behavioral engineering inherent to the practice of anesthesiology. Introduction of neuromuscular blockade assessment appeared to increase provider vigilance in dosing of NMBAs-regardless of assessment method. The frequency of intraoperative monitoring (quantitative or subjective) was associated with an increased total dose of NMBA administered and decreased time interval between the last dose of neostigmine and extubation.

First-Year Results of the American Board of Anesthesiology's Objective Structured Clinical Examination for Initial Certification.

In 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate an Objective Structured Clinical Examination (OSCE) into its initial certification examination system. Previously, the ABA's staged examination system consisted of 2 written examinations (the BASIC and ADVANCED examinations) and the Standardized Oral Examination (SOE). The OSCE and the existing SOE are now 2 separate components of the APPLIED Examination. This report presents the results of the first-year OSCE administration. A total of 1410 candidates took both the OSCE and the SOE in 2018. Candidate performance approximated a normal distribution for both the OSCE and the SOE, and was not associated with the timing of the examination, including day of the week, morning versus afternoon session, and order of the OSCE and the SOE. Practice-based Learning and Improvement was the most difficult station, while Application of Ultrasonography was the least difficult. The correlation coefficient between SOE and OSCE scores was 0.35 ([95% confidence interval {CI}, 0.30-0.39]; P < .001). Scores for the written ADVANCED Examination were modestly correlated with scores for the SOE (r = 0.29 [95% CI, 0.25-0.34]; P < .001) and the OSCE (r = 0.15 [95% CI, 0.10-0.20]; P < .001). Most of the candidates who failed the SOE passed the OSCE, and most of the candidates who failed the OSCE passed the SOE. Of the 1410 candidates, 77 (5.5%) failed the OSCE, 155 (11.0%) failed the SOE, and 25 (1.8%) failed both. Thus, 207 (14.7%) failed at least 1 component of the APPLIED Examination. Adding an OSCE to a board certification examination system is feasible. Preliminary evidence indicates that the OSCE measures aspects of candidate abilities distinct from those measured by other examinations used for initial board certification.

Gender distribution in United States anaesthesiology residency programme directors: trends and implications.

The under-representation of women in academic leadership roles, including in anaesthesiology, is a well-documented phenomenon that has persisted for decades despite more women attending medical school, participating in anaesthesiology residencies, and joining academic faculties. The percentage of female anaesthesiologists who hold senior academic ranks or leadership roles, such as chair, lags behind the percentage of female anaesthesiologists overall. Trends towards increasing the numbers of women serving in educational leadership roles, specifically residency programme directors, suggest that there are areas in which academic anaesthesiology has been, and can continue, improving gender imbalance. Continued institutional efforts to recruit women into anaesthesiology, reduce gender bias, and promote interventions that foster gender equity in hiring and promotion will continue to benefit women, academic anaesthesiology departments, and the healthcare system overall.

Development of an Objective Structured Clinical Examination as a Component of Assessment for Initial Board Certification in Anesthesiology.

With its first administration of an Objective Structured Clinical Examination (OSCE) in 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate this type of assessment into its high-stakes certification examination system. The fundamental rationale for the ABA's introduction of the OSCE is to include an assessment that allows candidates for board certification to demonstrate what they actually "do" in domains relevant to clinical practice. Inherent in this rationale is that the OSCE will capture competencies not well assessed in the current written and oral examinations-competencies that will allow the ABA to judge whether a candidate meets the standards expected for board certification more properly. This special article describes the ABA's journey from initial conceptualization through first administration of the OSCE, including the format of the OSCE, the process for scenario development, the standardized patient program that supports OSCE administration, examiner training, scoring, and future assessment of reliability, validity, and impact of the OSCE. This information will be beneficial to both those involved in the initial certification process, such as residency graduate candidates and program directors, and others contemplating the use of high-stakes summative OSCE assessments.

Gender Composition and Trends of Journal of Cardiothoracic and Vascular Anesthesia Editorial Board Membership: A 33-Year Analysis, 1987-2019.

OBJECTIVE: Gender disparities in editorial board composition exist in the vast majority of specialties including anesthesiology. If a similar lack of gender parity exists in cardiothoracic anesthesiology is unknown. The authors examined the gender composition and trends of the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) editorial board from the initial year of its publication (1987) to 2019. The authors tested the hypothesis that the proportion of women serving on the JCVA editorial board has steadily increased over the journal's history, but women are underrepresented compared with the percentage of those currently practicing academic cardiothoracic anesthesia in the United States (US). DESIGN: Observational study. SETTING: Internet analysis. PARTICIPANTS: All members of the JCVA editorial board, 1987-2019. INTERVENTIONS: The JCVA editor-in-chief, the associate editor-in-chief, associate editors, section editors, and general editors on the board were extracted from the masthead of a single issue from each calendar year. The years were divided into quartiles (1987-1995, 1996-2003, 2004-2011, and 2012-2019) to collect representative samples of editorial board composition for analysis. MEASUREMENTS AND MAIN RESULTS: A total of 2,797 members of the JCVA editorial board were positively identified (2,477 [88.6%] men; 310 [11.1%] women); 10 (0.3%) editors could not be identified. Four hundred and fourteen associate and section editors were recorded (men 360 [87.0%], women 54 [13.0%]). There were also 2,353 general editors (2,087 [88.7%] men; 256 [10.9%] women). The total number of JCVA board members, associate and section editors, and general editors progressively increased from 1987 to 1995 to 2012 to 2019. The percentage of women serving on the editorial board increased from 2.5% to 15.8%. Increases in the proportion of female general editors from 2.9% to 16.2% were responsible for this overall increase. A gender gap between the percentage of female first authors (data obtained from a previous publication) and editorial board members was observed in each quartile. Editorial board composition was also different than last author distribution in 1987 to 1995 and 2012 to 2019, but not the other 2 time periods. CONCLUSIONS: The results demonstrate that the proportion of women serving on the JCVA editorial board has steadily increased over the journal's history. Nevertheless, women continue to be underrepresented on the JCVA board compared with the percentage of US female academic cardiothoracic anesthesiologists, and gender gaps between first and last authorship and board composition also persist.

Gender Differences in Authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-Year Analysis of Publications Originating From the United States, 1990-2017.

OBJECTIVE: Gender-based differences in scholarship among cardiothoracic anesthesiologists have not been studied. The authors examined the gender distribution of authorship of original research articles, case reports, review articles, and editorials in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) originating from the United States during four 3-year intervals to determine temporal changes in productivity of women in cardiothoracic anesthesiology. The authors tested the hypothesis that scholarly output of women has increased progressively in JCVA over time concomitant with greater participation in first, last, and corresponding author roles. DESIGN: Observational study. SETTING: Internet analysis. PARTICIPANTS: Authors of research articles, case reports, review articles, and editorials published in JCVA in 1990-92, 1999-2001, 2008-10, and 2015-17. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The gender of each author was determined by inspection of the first name. If gender could not be established easily, the author's institutional website was examined or an internet search using the Google search engine was conducted. First, last, and corresponding authors as well as coauthors were noted for each article. A total of 1,195 publications with 4,982 authors (1,032 women; 20.7%) were examined. Gender was identified positively in 98.5% of authors. Women were first, last, and corresponding authors on 22.4%, 10.3%, and 14.6% of publications, respectively. The percentage of women who were authors increased from 12.1% in 1990-92 to 20.9% in 1999-2001 (p < 0.05), but plateaued in 2008 to 2010 (22.3%) and 2015 to 2017 (22.9%). Greater percentages of women were first authors (26.2%), senior authors (11.8%), and corresponding authors (16.6%) in 2015 to 2017 compared with 1990 to 1992 (9.6%, 7.0%, and 8.7%, respectively; p < 0.05 for each). The contributions of women to research articles and case reports were primarily responsible for these observed increases, although women also made a substantial impact with review articles in 2015 to 2017. The percentage of publications that included at least 1 female author in any capacity increased in a time-dependent manner (p < 0.05) from 31.0% (1990-1992) to 74.4% (2015-2017). The proportion of female first or last authors (35.0%) appearing in JCVA during 2015 to 2017 was modestly higher than the current percentage of female cardiothoracic anesthesiologists practicing in departments with accredited fellowship programs (29.1%). CONCLUSION: The results indicate that scholarly output of women rose in JCVA over time, but gains in productivity have plateaued more recently. These findings are encouraging, but women continue to be underrepresented in corresponding and last author roles.

Optimizing Patient Access During an Emergency While Using Intraoperative Computed Tomography.

BACKGROUND: As minimally invasive spine surgery evolves, spine surgeons increasingly rely on advanced intraoperative computed tomography (iCT). iCT provides rapid acquisition of high-resolution images, reduces radiation exposure, improves surgical accuracy, and decreases operative time. However, all iCT systems currently available pose a patient safety risk as their physical space requirements limit patient access in the event of an emergency, particularly when patients are in the prone position. After a near-cardiac arrest at our institution during posterior cervical spine surgery, it was apparent that the presence of the iCT complicated the ability to rapidly reposition the patient in order to provide appropriate resuscitation. METHODS: To ensure our ability to provide timely care during an emergency, we determined that a process which included all members of the operating room (OR) team was required. We held an initial planning meeting where a detailed plan-of-action was created, reviewed, and revised in response to feedback from all stakeholders. We then simulated a cardiac arrest to test our resuscitation plan with all members of the neurosurgery team. A mannequin was positioned prone on an OR table within the iCT, and a resuscitation plan was created. RESULTS: The team orchestrated the mock resuscitation, and the time of cardiac arrest in the prone position to supine repositioning required 110 seconds. The simulation was recorded for post-"code" performance review. Application of the protocol during an actual cardiac arrest was associated with successful restoration of spontaneous circulation and full recovery. CONCLUSIONS: The development and rehearsal of an emergency plan of action greatly facilitated the timely responsiveness of the neurosurgical OR team during a simulated cardiac arrest and was an effective way to identify and address key logistical issues regarding the use of an iCT system.

Teaching a Point-of-Care Ultrasound Curriculum to Anesthesiology Trainees With Traditional Didactic Lectures or an Online E-Learning Platform: A Pilot Study.

BACKGROUND: Point-of-care ultrasonography (PoCUS) provides real-time, dynamic clinical evidence for providers to make potentially lifesaving medical decisions; however, these tools cannot be used effectively without appropriate training. Although there is always the option of traditional didactic methods, there has been a recent trend toward a "reverse classroom" web-based model using online e-learning modules. Our objective was to collect pilot data that would justify a future randomized controlled trial, comparing traditional didactics to an e-learning PoCUS curriculum for lung ultrasonography (LUS) and the focused assessment with sonography in trauma (FAST) exam. METHODS: Anesthesiology interns, residents (CA 1-3), and fellow trainees enrolled in a LUS and FAST exam course and were randomized to receive didactic lectures or e-learning. Trainees completed knowledge pre- and posttests. Surveys were administered to gauge learning satisfaction. All trainees completed a hands-on-training (HOT) workshop. Image acquisition was assessed through practical tests before HOT, immediately after HOT, and 5 months later. RESULTS: Eighteen trainees completed the study. There was no evidence of a difference in change in LUS knowledge test score from baseline to posttest between the e-learning and didactic groups (difference in median percentage point change [95 % CI]: 6.6 [-10.0, 23.2]; P = .411). There was no evidence of a difference in LUS knowledge posttest scores (difference in median percentage points [95% CI]: -0.9 [-4.8, 3.0]; P = .629), FAST knowledge posttest score (0 [incalculable]; P = .999), or post-HOT practical test score (-4.2 [-24.6, 16.3]; P = .672) between groups. There was no evidence of a difference in degree of satisfaction with learning experience between groups (odds ratios [95% CI]: 1.75 [0.31, 9.94]; P = .528). CONCLUSIONS: There was no evidence of a difference between the e-learning and traditional didactic groups in learning or satisfaction outcomes. These results justify establishing an adequately powered, randomized controlled trial assessing the noninferiority of e-learning to traditional didactics for teaching LUS and FAST.

Gender Distribution of the American Board of Anesthesiology Diplomates, Examiners, and Directors (1985-2015).

To understand the potential role of women in leadership positions, data from the American Board of Anesthesiology (ABA) were analyzed to explore the impact of women in the specialty of anesthesiology. The number of newly certified ABA diplomates, oral examiners, and directors from 1985 to 2015 was obtained from the ABA database. The percentages of women in each group were calculated for each year. Because it took an average of 10 years for a diplomate to become an oral examiner and an average of 7 years for an oral examiner to be elected as a director during the study period, the following percentages were compared: women oral examiners versus newly certified women diplomates 10 years prior and women directors versus women oral examiners 7 years prior. The correlation coefficients between the percentages of women oral examiners and of newly certified women diplomates 10 years prior and between the percentages of women directors and women oral examiners 7 years prior were calculated. From 1985 to 2015, the percentage of newly certified women diplomates increased from 15% to 38% with an average annual increase of 0.74%, percentage of women oral examiners increased from 8% to 26% with an average annual increase of 0.63%, and percentage of women directors increased from 8% to 25% with an average annual increase of 0.56%. The percentage of women examiners consistently lagged behind the percentage of women diplomates who were certified 10 years earlier; the average difference over 21 years from 1995 to 2015 was -3.7% with a standard deviation of 2.1%. The correlation coefficient between the percentages of women examiners and newly certified women diplomates 10 years earlier from 1995 to 2015 was 0.86 (P < .001). However, the percentage of women directors was generally higher than that of women examiners 7 years earlier; the average difference over 24 years from 1992 to 2015 was 3.5% with a standard deviation of 4.0%. The correlation coefficient between the percentages of women directors and women examiners 7 years prior from 1992 to 2015 was 0.86 (P < .001). The percentage of newly certified women diplomates, examiners, and directors increased steadily from 1985 to 2015. The percentage of women examiners lagged behind that of women diplomates 10 years prior from 1995 to 2015; however, the percentage of women directors was, on average, higher than that of the women examiners 7 years prior from 1992 to 2015.

Pharmacokinetic/Pharmacodynamic Model of CW002, an Investigational Intermediate Neuromuscular Blocking Agent, in Healthy Volunteers.

BACKGROUND: CW002 is an investigational nondepolarizing, neuromuscular blocking agent with a rapid onset and intermediate duration of action in animals. This is a single ascending dose, healthy subject study exploring tolerability, pharmacokinetics, and potency. METHODS: Population pharmacokinetic and pharmacokinetic/pharmacodynamic models were developed using plasma drug concentration data from a previously published dose-response study in 28 healthy subjects receiving single doses of CW002 during sevoflurane anesthesia. Subjects included in the models were from five different dose cohorts (cohorts 3, 4, 5, 6, and 8 receiving 0.04, 0.06, 0.08, 0.10, and 0.14 mg/kg, respectively). Serial arterial plasma concentrations and muscle twitch heights were monitored. RESULTS: A four-compartment model was fit to the concentration-time data, whereas a transit compartment with a sigmoid Emax model was fit to the pharmacokinetic/pharmacodynamic data. The population pharmacokinetics of CW002 was linear with very low interindividual variability in clearance (10.8%). Simulations were conducted to predict the onset and offset of effect at 2×, 3×, and 4× ED95. The time to 80% block was predicted to be 1.5, 0.8, and 0.7 min for 2×, 3×, and 4× ED95 doses, respectively. The simulated 25 to 75% recovery index was independent of dose. CONCLUSIONS: CW002 has predictable pharmacokinetics and is likely to have a rapid onset with an intermediate duration of action at 3× ED95. This model provides information to inform critical decisions (e.g., dose, study design) for continued development of CW002.

Effect of the BASIC Examination on Knowledge Acquisition during Anesthesiology Residency.

BACKGROUND: The American Board of Anesthesiology recently introduced the BASIC Examination, a component of its new staged examinations for primary certification, typically offered to residents at the end of their first year of clinical anesthesiology training. This analysis tested the hypothesis that the introduction of the BASIC Examination was associated with an acceleration of knowledge acquisition during the residency training period, as measured by increments in annual In-Training Examination scores. METHODS: In-Training Examination performance was compared longitudinally among four resident cohorts (n = 6,488) before and after the introduction of the staged system using mixed-effects models that accounted for possible covariates. RESULTS: Compared with previous cohorts in the traditional examination system, the first resident cohort in the staged system had a greater improvement in In-Training Examination scores between the first and second years of clinical anesthesiology training (by an estimated 2.0 points in scaled score on a scale of 1 to 50 [95% CI, 1.7 to 2.3]). By their second year, they had achieved a score similar to that of third-year clinical anesthesiology residents in previous cohorts. The second cohort to enter the staged system had a greater improvement of the scores between the clinical base year and the first clinical anesthesiology year, compared with the previous cohorts. CONCLUSIONS: These results support the hypothesis that the introduction of the BASIC Examination is associated with accelerated knowledge acquisition in residency training and provides evidence for the value of the new staged system in promoting desired educational outcomes of anesthesiology training.

Dose-response and Cardiopulmonary Side Effects of the Novel Neuromuscular-blocking Drug CW002 in Man.

BACKGROUND: CW002 is a benzylisoquinolinium nondepolarizing neuromuscular-blocking drug found to be inactivated by cysteine in preclinical studies. The current study represents a dose escalation clinical trial designed to describe CW002 potency, duration, cardiopulmonary side effects, and histamine release. METHODS: Healthy subjects anesthetized with sevoflurane/nitrous oxide were divided into five groups (n = 6), each receiving a fixed CW002 dose (0.02, 0.04, 0.06, 0.08, or 0.10 mg/kg), and one group (n = 4) receiving 0.14 mg/kg. Blood pressure and heart rate were continuously recorded along with airway dynamic compliance. Neuromuscular blockade was assessed with mechanomyography at the adductor pollicis. Arterial blood was obtained before and after CW002 injection for analysis of plasma histamine concentration. Potency was estimated from a baseline sigmoid Emax model. RESULTS: ED50 was found to be 0.036 mg/kg (95% CI, 0.020 to 0.053 mg/kg) and ED95 0.077 mg/kg (95% CI, 0.044 to 0.114 mg/kg). At 0.14 mg/kg (1.8 × ED95), 80% twitch depression occurred in 94 ± 18 s with complete block in 200 ± 87 s. Clinical recovery (25% of maximum twitch) occurred in 34 ± 3.4 min, with a 5 to 95% recovery interval of 35.0 ± 2.7 min. The time to a train-of-four ratio greater than 0.9 ranged from 59 to 86 min. CW002 did not elicit histamine release or significant (greater than 10%) changes in blood pressure, heart rate, or dynamic airway compliance. CONCLUSIONS: In healthy subjects receiving sevoflurane/nitrous oxide, CW002 at 1.8 × estimated ED95 produces a clinical duration less than 40 min, elicits no histamine release, and has minimal cardiopulmonary side effects.