Effect of Carbohydrate Mouth Rinse on Resistance Exercise Performance.

ABSTRACT: Green, MS, Kimmel, CS, Martin, TD, Mouser, JG, and Brune, MP. Effect of carbohydrate mouth rinse on resistance exercise performance. J Strength Cond Res 36(7): 1916-1921, 2022-A carbohydrate mouth rinse (CMR) has been shown to enhance short duration endurance performance and raises the possibility that a similar strategy could improve performance during resistance exercise. Eighteen male and female (N = 36) resistance trained subjects (mean values ± SD; age: 21.5 ± 1.6 years, height: 1.72 ± 0.09 m, body mass: 72.8 ± 13.4 kg, and body fat: 16.7 ± 5.8%) performed 3 experimental visits during which bench press resistance exercise (4 × 10 repetitions at 65% of 1 repetition maximum [1RM] with 120 seconds recovery) and repetitions to failure at 60% 1RM were performed. Subjects rinsed 25 ml of water (WAT), noncaloric placebo (PLA), or 6.4% maltodextrin (CHO) solution for 10 seconds during exercise in a crossover, counter-balanced manner. Rating of perceived exertion (RPE), pleasure-displeasure (FS), number of repetitions to fatigue (REPS), and postexercise blood glucose (GLU) and lactate (LA) were measured. Compared to WAT (17.7 ± 0.8), PLA (19.0 ± 0.7; p = 0.025), and CHO (18.7 ± 0.8; p = 0.039) treatments resulted in higher REPS, with no difference between PLA and CHO treatments (p = 0.310). Rating of perceived exertion progressively increased each set (p < 0.0001), but was not affected by treatment (p = 0.897). Pleasure-displeasure declined during recovery from sets 3 and 4 (p < 0.05) but was also not affected by treatment (p = 0.692). Postexercise GLU (p = 0.103) and LA (p = 0.620) were not different between treatments. Although a placebo effect was present for REPS, this study failed to detect an effect of CMR on REPS, RPE, FS, GLU, or LA on upper-body resistance exercise.

[Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report]. / Sepse aguda pós­operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso.

BACKGROUND: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. OBJECTIVE: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. CASE REPORT: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. CONCLUSIONS: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.

Six weeks of oral Echinacea purpurea supplementation does not enhance the production of serum erythropoietin or erythropoietic status in recreationally active males with above-average aerobic fitness.

The purpose of this study was to investigate the effect of 6 weeks of oral Echinacea purpurea supplementation on serum erythropoietin (EPO) and erythropoietic status. Twenty-four males (mean ± SE; age = 25.2 ± 1.4 years, height = 178.1 ± 1.4 cm, body mass = 78.1 ± 1.6 kg, body fat = 12.7 ± 0.9%, maximal oxygen uptake = 52.9 ± 0.9 mL·kg-1·min-1) were randomly grouped using a matched-pair, double-blind design and self-administered 8000 mg·day-1 of either E. purpurea (n = 12) or placebo (n = 12) for 42 consecutive days. Blood samples were collected prior to supplementation (day 0) and every 2 weeks during the supplementation period (days 14, 28, and 42) and were analyzed for EPO, red blood cell count, hemoglobin concentration, hematocrit, mean corpuscular volume, and mean corpuscular hemoglobin concentration. Separate 2 × 4 (group × time) factorial ANOVA with repeated measures on time were used to determine statistical differences with significance set at p ≤ 0.05. There were no significant interaction, group, or time effects observed for EPO or erythropoietic status markers for any of the measurement points (p ≤ 0.05). The present study indicated that 6 weeks of oral E. purpurea supplementation in recreationally active males with above average aerobic fitness did not enhance EPO or erythropoietic status. These findings are in contrast with previous reports of E. purpurea supplementation in untrained participants with average fitness levels, but consistent with observations in trained endurance athletes.

Success and Challenge When Returning to Clinical Practice: A Case Series in Anesthesiologist Re-Entry.

INTRODUCTION: Anesthesiologists returning to clinical practice pose unique challenges for licensing and credentialing boards. Few institutions provide re-education. We describe the physician refresher/re-entry program at our College of Medicine. METHODS: We launched the physician re-entry program in 2006. This individualized program re-educates physicians who left clinical practice for any reason and are seeking to return. We report results achieved for 12 anesthesiologists who successfully completed the course between August 2012 and February 2018. RESULTS: Seven men and five women left their practices for various reasons, which included relocation, family or medical reasons, substance use, and burnout. None left practice for medical negligence. Range away from clinical activity was 0-10 years. Five had active licenses. Seven were US graduates and five were international. Nine of 12 achieved their goals. Of the 3 others, 1 did not pursue her goal, another did not obtain a residency, and the other just finished the program. Seven out of 9 (78%) achieved their goal within 1 year of course completion. DISCUSSION: Despite our small sample size, our experience to successfully return inactive physicians to the workforce adds to the scant literature and experience in refreshing inactive physicians. Our trainees return to practice serving communities across the country and are now a pivotal part of the anesthesiology workforce. Thus, this program not only services individual physicians, but the whole community affected by their absence.

Sclerosing mesenteritis: a comprehensive clinical review.

Sclerosing mesenteritis is a rare disease entity initially described in 1924 with a prevalence reported to be less than 1%. Sclerosing mesenteritis is a comprehensive term used to describe three almost similar clinical entities including mesenteric panniculitis, retractile mesenteritis, and mesenteric lipodystrophy which only differ by their histology. The etiology of sclerosing mesenteritis is uncertain, but the disease has been associated with trauma, autoimmune disease, surgery, and malignancy. The typical presenting symptom is the abdominal pain, but sclerosing mesenteritis has a broad constellation of presenting symptoms which often makes consideration of the diagnosis unlikely. Treatment for this little-understood disease ranges from surgical intervention for patients presenting with obstructive symptoms to immunosuppressive medical therapy for patients presenting with pain. The purpose of this article is to provide an overview of the literature relevant to the diagnosis, etiology, and management of this condition in hopes of making physicians aware of this unique condition.

Effect of Mouthguard Use on Metabolic and Cardiorespiratory Responses to Aerobic Exercise in Males.

PURPOSE: This study investigated the physiological effects of wearing a mouthguard during submaximal treadmill exercise. METHOD: Twenty-four recreationally active males (Mage = 21.3 ± 2.4 years, Mheight = 1.78 ± 0.06 m, Mweight = 81.9 ± 10.6 kg, Mbody mass index = 25.8 ± 3.4 kg·m-2) performed incremental, continuous exercise at 2, 4, 6, and 8 mph (3.2, 6.4, 9.7, 12.9 kph) for 5 min at each speed on a motor-driven treadmill on 2 separate occasions in a randomized, crossover, counterbalanced design while wearing or not wearing a self-adaptable "boil and bite" mouthguard. Respiratory rate (RR), tidal volume (VT), ventilation (VE), oxygen consumption (VO2), respiratory exchange ratio (RER), and heart rate (HR) data were averaged during the last 60 s of each exercise stage; blood lactate (LA) was measured before exercise and 3 min and 10 min following exercise. RESULTS: Repeated-measures analysis of variance revealed that mouthguard use failed to alter the response of RR, VT, VE, VO2, RER, and HR to treadmill exercise (p > .05), although each variable did increase in magnitude as a result of increasing treadmill speed (p < .001). Although increasing to above resting values at both 3 min and 10 min (p < .001) after cessation of exercise, LA levels also displayed no differences with mouthguard use (p > .05). CONCLUSION: Despite predictable increases in respiratory, metabolic, and cardiovascular variables in response to incremental exercise, the presence of a mouthguard failed to affect the magnitude or nature of these physiological responses.

Utilization of Smartphone Applications by Anesthesia Providers.

Health care-related apps provide valuable facts and have added a new dimension to knowledge sharing. The purpose of this study is to understand the pattern of utilization of mobile apps specifically created for anesthesia providers. Smartphone app stores were searched, and a survey was sent to 416 anesthesia providers at 136 anesthesiology residency programs querying specific facets of application use. Among respondents, 11.4% never used, 12.4% used less than once per month, 6.0% used once per month, 12.1% used 2-3 times per month, 13.6% used once per week, 21% used 2-3 times per week, and 23.5% used daily. Dosage/pharmaceutical apps were rated the highest as most useful. 24.6% of the participants would pay less than $2.00, 25.1% would pay $5.00, 30.3% would pay $5-$10.00, 9.6% would pay $10-$25.00, 5.1% would pay $25-$50.00, and 5.1% would pay more than $50.00 if an app saves 5-10 minutes per day or 30 minutes/week. The use of mobile phone apps is not limited to reiterating information from textbooks but provides opportunities to further the ever-changing field of anesthesiology. Our survey illustrates the convenience of apps for health care professionals. Providers must exercise caution when selecting apps to ensure best evidence-based medicine.

Effect of Caffeine Supplementation on Quadriceps Performance After Eccentric Exercise.

Green, MS, Martin, TD, and Corona, BT. Effect of caffeine supplementation on quadriceps performance after eccentric exercise. J Strength Cond Res 32(10): 2863-2871, 2018-Caffeine use is common among athletes seeking to capitalize on its potential ergogenic effects. Limited research has examined caffeine's effects when used after activities that resulted in exercise-induced muscle damage (EIMD). This study examined the effect of caffeine supplementation on uninjured and injured muscle. Eight men and women (N = 16) who were physically active individuals participated in this study (age: 24.3 ± 4.3 years; height: 173.0 ± 7.0 cm, mass: 75.2 ± 11.5 kg; body fat: 18.2 ± 15.9%). One leg was assessed under uninjured and injured (100 eccentric quadriceps contractions) conditions after caffeine supplementation (6 mg·kg), with the other leg assessed under both conditions after placebo supplementation. Compared with the placebo, caffeine increased peak isokinetic torque by 6.8 ± 2.3 and 9.4 ± 2.5% in uninjured and injured muscle, respectively, but had no effect on maximal voluntary isometric torque or fatigue index in uninjured or injured muscle, with treatments exhibiting similar (p > 0.05) alterations in isometric torque (-11.9 ± 2.2%), fatigue index (-13.9 ± 3.4%), and soreness (+44.0 ± 4.7) after eccentric contractions. The results of this study suggest that caffeine possesses a similar ergogenic effect on isokinetic torque in both uninjured and injured states, but no effect on the production of isometric torque, perception of soreness, or degree of relative fatigue. Athletes should consider the potential caffeine supplementation possesses during recovery from activities that resulted in EIMD.

Vasoplegic syndrome: An update on perioperative considerations.

Vasoplegic syndrome (VS) is increasingly recognized as an important clinical entity in perioperative medicine. VS is characterized by significant arterial hypotension, normal or high cardiac output, low systemic vascular resistance, and increased requirements for intravenous volume and vasopressors. Tremendous variations exist regarding incidence reported in the literature and management at different institutions; and the incidence of VS is likely significantly higher than many anesthesiologists believe. Thus the aims of this article are to review the pertinent aspects related to VS and alert clinical anesthesiologists to this under-recognized yet very challenging clinical condition. The potential risk factors include blood transfusion, cardiopulmonary bypass, organ transplantation, trauma and sepsis, and use of specific medications such as angiotensin-converting enzyme inhibitors, Angiotensin-II antagonist, heparin, amiodarone, aprotinin, and protamine. The pathogenesis of VS may have several mechanistic pathways, overproduction of inducible nitric oxide, activation of ATP-dependent K channels, vasopressin V1A-receptor down-regulation, and nuclear factor-κB activation. Current management strategies include intravenous administration of volume and catecholamines, vasopressin, methylene blue and high dose hydroxocobalamin. Other treatment could include ATP-sensitive K channel blocker, nuclear factor-κB inhibitor, indigo carmine, and hyperbaric oxygen therapy. VS is still associated with significantly increased perioperative morbidity and mortality.

Management of Residual Neuromuscular Blockade Recovery: Age-Old Problem with a New Solution.

Neostigmine has been traditionally used as the agent of choice to reverse Neuromuscular Blockade (NMB) after muscle paralysis during general anesthesia. However, the use of neostigmine has not been without untoward events. Sugammadex is a novel drug that selectively binds to aminosteroid nondepolarizing muscle relaxants and reverses even a deep level of NMB. Controversy exists regarding the optimal dose of sugammadex that is effective in reversing the NMB after the incomplete reversal with neostigmine and glycopyrrolate. We discuss a case where sugammadex reduced the time of the recovery from NMB in a patient who had incomplete antagonisms following adequate treatment with neostigmine, aiding timely extubation without persistent residual NMB, and hence prevented the requirement of postoperative ventilation and the improvement in patient care. More randomized control studies are needed in order to conclude the appropriate dose of sugammadex in cases of incomplete reversal.

Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients.

INTRODUCTION: An acquired Tracheoesophageal fistula (TEF) is commonly caused by a malignancy or trauma, with pulmonary infection or aspiration being the presenting symptom. However, in the critical care setting the presentation can be subtle and may present with difficult ventilation. High endotracheal tube cuff pressures can lead to tracheal erosions and thus increasing the chances for developing a TEF. Prolonged intubation in the presence of other risk factors like poor general state of health, episodic hypotension, nasogastric tubes, and repeated intubations can increase the likelihood of developing an acquired TEF. Angioedema of the airway is a rare but potentially devastating complication of angiotensin converting enzyme inhibitors (ACE-I) that could further add insult to the tracheal mucosa, predisposing to an acquired TEF. CASE PRESENTATION: An elderly woman with multiple comorbidities and requiring mechanical ventilation, developed angioedema following intake of ACE inhibitor for hypertension. The ensuing airway edema made weaning off mechanical ventilation difficult. After repeated attempts at extubation, tracheostomy was performed. With the loss of airway after tracheostomy, the possibility of TEF was considered given her multiple risk factors and intra-operative findings of the tracheal mucosa. CONCLUSIONS: While it may be difficult to predict who will actually develop a TEF, it is prudent to identify those at risk and take precautionary measures to prevent one. Emphasis should be placed on daily endotracheal cuff manometric pressure check to prevent ischemic changes of the tracheal mucosa resulting from high cuff pressures. Also, bronchoscopy could be used after extubating susceptible patients to detect an acquired TEF.

Unusual Case of Severe Lactic Acidosis in a Liver Transplant Patient.

Lactic acidosis is a standard indicator for oxygen debt and some other very significant causes. We describe a case of liver transplant patient presenting with vague abdominal pain and lactic acidosis without any liver dysfunction/failure/ischemia/rejection or sepsis. The imaging studies showed vague bowel edema and normal hepatic perfusion. The patient continued to deteriorate with rising lactic acidosis when a repeat CT abdomen eventually showed signs of lymphomatosis peritonei. Biopsy revealed the unusual diagnosis of posttransplant lymphoproliferative disorder. Immediate discontinuation of immunosuppression and initiation of chemotherapy led to clinical improvement. Our intention of presenting this case is to increase awareness of posttransplant lymphoma and propose lactic acidosis as not only an indicator of liver dysfunction or rejection but also an aid for diagnosis of this unusual but fatal and potentially curable condition.

A Case of Arterial and Venous Tear during Single Lead Extraction.

Transcutaneous lead extraction can be associated with significant morbidity and mortality. The risk of causing concomitant arterial and venous injury is rare. We report a case of marginal artery rupture with coronary sinus rupture after a CS lead extraction. A 71-year-old male was admitted for extraction of a 6-year-old implantable cardioverter-defibrillator lead due to fracture from insulation break. During the lead extraction, blood pressure fell precipitously and echocardiographic findings were consistent with pericardial effusion. After unsuccessful pericardiocentesis, open chest sternotomy and evacuation of hematoma was performed. Subsequent surgical repair of several injuries was completed including the distal coronary sinus, a large degloving injury of posterior portion of the heart, and first obtuse marginal branch bleed. This case demonstrates that when performing transcutaneous lead extraction (TLE) with laser sheath, a degloving injury can cause arterial rupture with concomitant coronary sinus injury. A multidisciplinary team-based approach can ensure patient safety. Learning Objective. Implantable cardioverter-defibrillator leads will falter over time. With the advancement of new technology for extraction more frequent and serious complications will occur. Active fixation CS leads present unique challenges. In the presence of hemodynamic changes during extraction the occurrence of both an arterial and venous injury must be considered.

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding.

AIM: To determine whether patients hospitalized with gastrointestinal (GI) blood loss anemia are being checked and treated for iron deficiency. METHODS: Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 µg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females. RESULTS: Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those (91.9%) had anemia during their hospital stay. Ninety-five patients (30.9%) had iron studies performed during hospitalization, and 45 of those (47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50 (17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia (IDA), only 22 (48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes. CONCLUSION: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.

Recovery following desflurane versus sevoflurane anesthesia for outpatient urologic surgery in elderly females.

BACKGROUND: An unresolved question is the time required for the ability to return to complex tasks following anesthesia. OBJECTIVES: This study aims to characterize the severity and duration of cognitive impairment following sevoflurane or desfluane anesthesia after brief surgery using tests of cognitive ability to objectively testing performance. PATIENTS AND METHODS: This study is a double blinded randomized controlled trial. Patients were randomized to receive either a desflurane or sevoflurane-based anesthetic. On the morning of the surgery the subjects performed baseline cognitive task tests (Mini Mental Status exam, Trail Making Test Part A and B, Digit Symbol Coding, Hopkins Verbal Learning Test, Stroop Color and Word Test to determine baseline cognitive function. Cognitive testing was repeated 30 minutes and 1 hour after surgery whereas Modified Telephone Interview for Cognitive Status (TICS-M) and Memory Aging Telephone Screen (MATS) was used on the following day of surgery. RESULTS: Trail Making Test Part B cognitive test showed statistically significant in comparison for pre and post exposure of anesthetics. This difference was seen in the desflurane group. Other cognitive tests did not show differences on exposure to the anesthetic gases. CONCLUSIONS: This study questioned the difference between volatile anesthetic agent's effects on patients completing a battery of neurocognitive tests attempting to answer if one agent has a more profound effect. Our study shows no statistically significant cognitive decline except for those in the Trail Making Part B in the Desflurane group. This conclusion is limited by the inherent limitations of the study, but does reinforce that the systemic inflammatory response from the surgery contributes cognitive impairment.

The effect of training level on opioid utilization efficiency.

STUDY OBJECTIVE: This study focuses on residents' ability to predict opioid administration requirements and if improvement is made as learners progress. Residents request opioid from the pharmacy at the start of the day based on clinical assignment. Unused and wasted opioids are returned at the end of the day. The labor and cost associated with this process are not trivial nor is the risk of excess opioid access. We examined if estimation of daily opioid use by residents increased in accuracy as progression through the program occurred. MATERIALS AND METHODS: We conducted a retrospective analysis in the setting of the operating room examining pharmacy opioid usage. The measurements included the number of vials requested, the number of vials dispensed, and the number of vials returned. Information was stratified in our database by the level of training. The set inclusion criterion was any surgery performed in the operating rooms that required the use of opioids. The exclusion criteria included anesthesia that required a regional block, cardiac surgeries, emergent cases, and obstetric cases. MAIN RESULTS: A total of 104 opioid requests were made that met our criteria. Comparing CA-1 and CA-3 residents and CA-2 and CA-3 residents, a statistically significant difference exists between the number of vials requested and the number returned. Our data show a statistically significant difference in efficiency as residents progress from their CA-1 year to CA-3 year. CONCLUSION: In summary, our findings support the idea that residents are able to better predict opioid requirements for cases as they progress through training. Closely monitoring such patterns can serve a useful educational purpose and allow for identification of misuse. Improvement in cost-effective care and limiting waste while working in a complex integrated health care environment are additional benefits.