End-Tidal Control Versus Manual Control of Inhalational Anesthesia Delivery: A Randomized Controlled Noninferiority Trial.

BACKGROUND: Precise anesthesia delivery helps ensure amnesia, analgesia, and immobility. Conventionally, the end-tidal anesthetic concentration is maintained through manual adjustment of the fresh gas flow and anesthetic vaporizer output. Some anesthesia delivery systems can deliver and maintain clinician-selected end-tidal anesthetic agent (EtAA) concentration using a modified closed-loop system. We evaluated the performance of an End-tidal Control (EtC) system on the Aisys CS 2 anesthesia machine (GE HealthCare). We hypothesized EtC anesthetic delivery would be noninferior to manually controlled anesthetic delivery. METHODS: The Multi-site Anesthesia randomized controlled STudy of End-tidal control compared to conventional Results (MASTER) Trial evaluated anesthetic delivery in 210 adult patients receiving inhaled anesthesia. Patients were randomized to either EtC or manual control (MC) anesthetic delivery. The primary objective was to determine whether, compared to conventional anesthesia practice, EtC achieves and maintains clinician-specified EtAA and end-tidal oxygen (Et o2 ) concentrations within defined noninferiority limits. Noninferiority was concluded if the lower limit of the 95% confidence interval (CI) of the difference between the percent duration within the acceptable range (5% of steady state or a margin of ~10% of each agent's minimum alveolar concentration) for EtC and MC was ≥ -5% for both EtAA and Et o2 . Secondary objectives included performance measures: response time: time required to attain 90% of the first desired EtAA, overshoot: amount the controller (or vaporizer delivery) exceeded the desired EtAA, and accuracy: average deviation from the desired EtAA. RESULTS: EtC achieved and sustained targeted EtAA and Et o2 concentrations within the noninferiority threshold. The EtAA was within 5% of the desired value 98% ± 2.05% of the time with EtC compared to 45.7% ± 31.7% of the time with MC (difference 52.3% [95% CI, 45.9%-58.6%], P < .0001). For Et o2 , EtC was within the noninferiority limit 86.3% ± 22.8% of the time compared with MC at 41% ± 33.3% ( P < .0001, difference 45.3% [95% CI, 36.1%-54.5%]). The median response time for achieving 90% of the initial EtAA desired value was 75 seconds with EtC and 158 seconds with MC ( P = .0013). EtC exhibited a median overshoot of 6.64% of the selected EtAA concentration, whereas MC often failed to reach the clinician's desired value. The difference in median percent deviation from desired EtAA value was 15.7% ([95% CI, 13.5%-19.0%], P < 0001). CONCLUSIONS: EtC achieves and maintains the EtAA and Et o2 concentration in a manner that is noninferior to manually controlled anesthesia delivery.

Diversity, Equity, and Inclusion in US Anesthesiology Residency Matching.

BACKGROUND: Patient outcomes are improved with physician-patient gender, racial, and ethnic concordance. However, female, Black, Hispanic or Latino, Native Hawaiian-Pacific Islander (NH-PI), and American Indian-Native Alaskan (AI-AN) physicians are underrepresented in anesthesiology. The American Association of Medical Colleges 2018 Diversity in Medicine Report revealed that women comprise only 35% of anesthesiologists yet nearly half of medical school graduates are women. More than 77% of anesthesiologists are White or Asian. Anesthesiology applicant and match trends may provide insights needed to address underrepresentation within anesthesiology. We hypothesized that proportionally fewer women and racially and ethnically minoritized applicants apply and match into anesthesiology. METHODS: This retrospective observational study identified 47,117 anesthesiology applicants among the 546,298 residency applicants in the Electronic Residency Application Service (ERAS) system between 2011 and 2022 and stratified applicants by self-reported gender, race, and ethnicity. The demographics of anesthesiology trainees reported in the 2014 to 2015, 2018 to 2019, and 2022 to 2023 Accreditation Counsel of Graduate Medical Education (ACGME) Data Resource Books were used as surrogates for matched applicants as demographics are not reported by the National Residency Match Program. To facilitate comparisons, ERAS applicants were grouped into 4-year epochs to align with consolidated ACGME reports corresponding to the application years. Odds ratios (OR); 95% confidence interval of applying to and matching into anesthesiology were analyzed. RESULTS: Women had lower odds of applying to anesthesiology compared to men overall (OR, 0.55; 95% CI, 0.54-0.56, P < .0001) and maintained significantly lowered odds of applying within each epoch. Women had similar odds of matching into anesthesiology residency compared to men (OR, 1.10; 95% CI, 1.06-1.14, P < .0001). Black, Hispanic or Latino, Asian and NH-PI, and AI-AN applicants had similar odds to White applicants of applying to anesthesiology but odds of matching were significantly lower overall (P < .0001) for Asian and NH-PI (OR, 0.66; 95% CI, 0.63-0.70), Black (OR, 0.49; 95% CI, 0.45-0.53), Hispanic or Latino (OR, 0.50; 95% CI, 0.46-0.54), and AI-AN (OR, 0.20; 95% CI, 0.15-0.28) applicants. The odds of matching among some minoritized applicants increased in the ACGME 2022 to 2023 report year. CONCLUSIONS: From 2011 to 2022, women had lower odds of applying to anesthesiology residency than men yet had similar odds of matching. Racial and ethnic minoritized groups had significantly lower odds of matching compared to White applicants despite similar odds of applying. These findings highlight disparities in the anesthesiology match and may help identify opportunities to promote workforce diversity within the field. More detailed reporting of gender, race, and ethnicity in annual match data may better define barriers to entry and identify opportunities for improvement.

Quelling the Storm: A Review of the Management of Electrical Storm.

Heightened sympathetic input to the myocardium potentiates cardiac electrical instability and may herald an electrical storm. An electrical storm is characterized by 3 or more episodes of ventricular tachycardia, ventricular fibrillation, or appropriate internal cardiac defibrillator shocks within 24 hours. Management of electrical storms is resource-intensive and inevitably requires careful coordination between multiple subspecialties. Anesthesiologists have an important role in acute, subacute, and long-term management. Identifying the phase of an electrical storm and understanding the characteristics of each morphology may help the anesthesiologist anticipate the management approach. In the acute phase, management of an electrical storm is aimed at providing advanced cardiac life support and identifying reversible causes. After initial stabilization, subacute management focuses on dampening the sympathetic surge with sedation, thoracic epidural, or stellate ganglion blockade. Definitive long-term management with surgical sympathectomy or catheter ablation also may be warranted. Our objective is to provide an overview of electrical storms and the anesthesiologist's role in management.

Automating Anesthesiology Resident Case Logs Reduces Reporting Variability.

Background: The Accreditation Council for Graduate Medical Education (ACGME) case log system for anesthesiology resident training relies on subjective categorization of surgical procedures and lacks clear guidelines for assigning credit roles. Therefore, resident reporting practices likely vary within and between institutions. Our primary aim was to develop a systematic process for generating automated case logs using data elements extracted from the electronic health care record. We hypothesized that automated case log reporting would improve accuracy and reduce reporting variability. Methods: We developed a systematic approach for automating anesthesiology resident case logs from the electronic health care record using a discrete classification system for assigning credit roles and Anesthesia Current Procedure Terminology codes to categorize cases. The median number of cases performed was compared between the automated case log and resident-reported ACGME case log. Results: Case log elements were identified in the electronic health care record and automatically extracted. A total of 42 individual case logs were generated from the extracted data and visualized in an external dashboard. Automated reporting captured a median of 1226.5 (interquartile range: 1097-1366) total anesthetic cases in contrast to 1134.5 (interquartile range: 899-1208) reported to ACGME by residents (P = .0014). Automation also decreased the case count interquartile range and the distribution approached normality, suggesting that automation reduces reporting variability. Conclusions: Automated case log reporting uniformly captures the resident training experience and reduces reporting variability. We hope this work provides a foundation for aggregating graduate medical education data from the electronic health care record and advances adoption of case log automation.

Multidisciplinary Approach to Hemodynamic Management During High-Risk Ventricular Tachycardia Ablation.

Percutaneous ventricular assist devices have been used for high-risk ventricular tachycardia ablation when hemodynamic decompensation is expected. Utilizing a case example, we present our experience with development of a coordinated, team-based approach focused on periprocedural management of patients with high-risk ventricular tachycardia. (Level of Difficulty: Advanced.).

Appropriate Delivery of Antitachyarrhythmia Therapy Despite Magnet Placement Over Implanted Cardioverter-Defibrillator: A Case Report.

The fundamental perioperative concern for patients with implantable cardioverter-defibrillators (ICDs) is the potential for electromagnetic interference (EMI) from monopolar electrosurgery. The ICD may interpret electromagnetic signals as a tachyarrhythmia and deliver an inappropriate shock to the patient. Magnet placement is often used to avoid this problem since a magnet will often deactivate an ICD's tachyarrhythmia therapy. We report a case in which magnet placement over an ICD failed to suspend tachyarrhythmia therapy because of imprecise magnet positioning. This case demonstrates the possibility for error when relying on a magnet to suspend tachyarrhythmia therapies.