Looking Ahead to the Frontier of Anesthesiology Education.

In this issue of Anesthesia & Analgesia, a series of articles focus on the elemental changes to anesthesia training and education. Kealey and Naik review the status of competency-based medical training, a method through which learners are deliberately observed for progression to mastery in clinical management. This is contrast to the assumption that trainees will presumably reach the same intended endpoint merely by spending a pre-specified amount of time in post-graduate residency training. The advantages and disadvantages of the competency-based approach are reviewed. Alam and Matava describe how education has also changed to incorporate digital technology by way of immersive simulation. They detail the use of virtual and augmented reality to offer trainees the opportunity to engage in clinical exercises that are infrequently encountered in real practice, increase the exposure to challenging scenarios and foster real-time collaborations on a global scale. An accompanying editorial offers further perspective on the future of training in our specialty. The reader is strongly encouraged to review the cited articles for an in-depth appreciation of the concepts discussed.

Ketamine and the At-Risk Brain.

Postoperative cognitive dysfunction and delirium are undesirable consequences of surgery and anesthesia that regrettably do not have consistent predictive markers. Nor do they have reliable prophylactic or treatment methodologies. In an effort to better understand how anesthetic drugs alter the rate of postoperative delirium, Chang et al explore how patients with preoperative cognitive impairment respond to the influence of intraoperative ketamine. Patients aged 65 or older presenting for spine surgery lasting over three hours were assessed and divided into those with and without baseline cognitive impairment. Both groups either received intraoperative ketamine or did not. All patients who received intraoperative ketamine demonstrated an increase in power spectral density via electroencephalographic assessment. However, patients with preoperatively established cognitive impairment displayed a significantly diminished electroencephalographic response to ketamine. Furthermore, this subgroup also suffered an increased incidence of postoperative delirium. What is the interpretation of this finding? An accompanying editorial elegantly describes how disorders of cognition result from both predisposing and precipitating factors. In this case, patients with known cognitive impairment were more likely to endure delirium when exposed to ketamine. Is it possible that ketamine and other drugs could be used as agents to stratify cognitive risk? Should we definitively avoid such drugs as potentiators of cognitive dysfunction? A variety of contextual limitations must be entertained when interpreting the results of this study as summarized in this infographic. These are also elaborated in greater detail in both the primary article as well as its attendant editorial. The reader is encouraged to review both in their entirety for an in-depth scope of understanding.

A Growing Transparency in Medicine.

The provision of health services has been transforming from a largely top-down, paternalistic model into a construct in which patients play a substantive role in decision making over their care. Two articles in this month's issue of Anesthesia & Analgesia and an accompanying editorial address the growing momentum behind transparency in health care. Firstly, Quinonez et al consider the increasing expectation of family presence during surgical procedures and resuscitation of loved ones. They entertain the valid merits of family presence, such as the anxiolytic effect it may have as well as increased understanding of procedural goals and enhanced staff professionalism. Conversely, family members may not be psychologically prepared to bear witness to more invasive clinical environments and may serve as a source of distraction to providers. The impact of family presence on medical litigation is unclear. There have been long standing precedents set by way of obstetric and pediatric populations as seen in this infographic. In conjunction with the increased desire for physical presence of loved ones during clinical procedures, so too is there a demand for complete access to all medical records, including even the arcane hieroglyphics of an anesthesia record as detailed by Ramaswamy et al. As federal law now mandates such access, questions naturally arise as to their utility and medicolegal implications. The reader is strongly encouraged to review the concepts elaborated in these articles for in depth appreciation of their considerations.

Moving Beyond the Pandemic: Insights from a Shared Experience.

For over two years the resilience of humanity was tested with the coronavirus outbreak. At its outset the scientific community rallied and did its very best to disseminate accumulating knowledge in real time to contain the outbreak. Sobering lessons were learned in managing such a global crisis. Critical care anesthesiologists in particular were instrumental as decision makers and their insight is reflected in a review of how we may be better prepared in the future should another virus spread with such scale and severity. Members of the Society of Critical Care Anesthesiologists contribute to a special article in this issue that focuses on several broad themes that emerged from managing the pandemic. These include large scale decision making in health care systems, clinical management of a new disease, resource management with conversion of operating rooms to intensive care units, and health care provider well-being. These considerations are summarized in this infographic. It is heartening to see an article and an accompanying editorial in this issue that address what we have learned from our collective experience. It is a testament to the will of the scientific community and health care providers to evolve and overcome, to move beyond discouragement and prevail.

Opioid Use Disorder in Pregnant Patients.

In this issue of Anesthesia & Analgesia, Lim and colleagues offer a scoping review of the available literature encompassing opioid use disorder (OUD) in pregnant patients. As discussed in their review, opioid use and abuse in pregnant patients have increased four-fold in the past decade. As such, these patients can present significant challenges with respect to pain management during labor and delivery. A baseline habituation to opioids can render patients resistant to conventional pain management plans. Those who are additionally prescribed opioid agonist-antagonists or other maintenance medications for OUD such as buprenorphine or methadone have even more complex pharmacologic considerations that make pain management unpredictable. As detailed in their analysis, there is a paucity of literature surrounding optimal management strategies in this population of patients. Reports are increasing over time, however, most publications are of lower tier evidence, with very few randomized trials and systematic reviews to inform practitioners. It becomes plainly evident that this is an area of clinical science that demands greater attention. Specific areas of focus elaborated by the authors include: better characterization of opioid selection and dosing in managing labor analgesia, effectiveness of different regional anesthetic techniques, non-pharmacologic management, and psycho-social support for these patients. The reader is strongly encouraged to review the cited article for an in-depth understanding of the concepts summarized in this infographic.