Comparison of two 3D scanning software to identify facial features: a prospective instrument to predict difficult airway.

BACKGROUND: Clinical airway assessment has limited predictive ability to anticipate difficult airway. Three-dimensional (3D) technologies have emerged in medicine as valuable tools in different settings including innovation and surgical planning. Three-dimensional facial scanning could add value to clinical measurements and two-dimensional models to assess the airway. However, commonly used high-fidelity scans are expensive. This study aims to compare the accuracy of the measurements made by the Scandy Pro app as a cost-effective alternative to high-fidelity scans made by the Artec Space Spider. We also aim to evaluate the interobserver variability for the measurements performed with Scandy Pro. MATERIALS AND METHODS: We conducted a cross-sectional, comparison study on 10 healthy volunteers. Four observers measured 720 distances and 400 using both Scandy Pro and Artec Space Spider facial scans. Wilcoxon test was used for group-group comparison. RESULTS: Comparison of both instruments showed no difference in angle or distance measurements. The percentage error (measurement difference between the two devices) exhibited by one of the observers was significantly different compared with the other three observers; however, the magnitude of this individual deviation did not affect the overall percentage error. The overall error for Scandy Pro was 5.5% (3.9% and 6.7% for angles and distances, respectively). CONCLUSION: Three-dimensional facial scanning with Scandy Pro is an accurate tool that can be a cost-effective alternative to high-fidelity scans produced by the Artec Space Spider.

Fetal heart rate changes and labor neuraxial analgesia: a machine learning approach.

BACKGROUND: Neuraxial labor analgesia has been associated with fetal heart rate changes. Fetal bradycardia is multifactorial, and predicting it poses a significant challenge to clinicians. Machine learning algorithms may assist the clinician to predict fetal bradycardia and identify predictors associated with its presentation. METHODS: A retrospective analysis of 1077 healthy laboring parturients receiving neuraxial analgesia was conducted. We compared a principal components regression model with tree-based random forest, ridge regression, multiple regression, a general additive model, and elastic net in terms of prediction accuracy and interpretability for inference purposes. RESULTS: Multiple regression identified combined spinal-epidural (CSE) (p = 0.02), interaction between CSE and dose of phenylephrine (p < 0.0001), decelerations (p < 0.001), and the total dose of bupivacaine (p = 0.03) as associated with decrease in fetal heart rate. Random forest exhibited good predictive accuracy (mean standard error of 0.92). CONCLUSION: Use of CSE, presence of decelerations, total dose of bupivacaine, and total dose of vasopressors after CSE are associated with decreases in fetal heart rate in healthy parturients during labor. Prediction of changes in fetal heart rate can be approached with a tree-based random forest model with good accuracy with important variables that are key for the prediction, such as CSE, BMI, duration of stage 1 of labor, and dose of bupivacaine.

Gender Gap: A Qualitative Study of Women and Leadership Acquisition in Anesthesiology.

BACKGROUND: The representation of women among leaders in the field of anesthesia continues to trail that of their male counterparts. This qualitative study was conducted to understand the pathway of leadership acquisition among women in the field of anesthesiology. METHODS: Using constructivist grounded theory, we sought to determine whether there were specific internal or external factors that were common to women in leadership in the specialty field of anesthesiology, and specifically, how they obtained leadership positions. Semistructured interviews were conducted for data collection. A total of 26 women in leadership positions in anesthesiology participated in this study. RESULTS: The analysis of these interviews resulted in the development of 4 common themes related to career pathways for these women in leadership. Each theme was examined in depth to determine the qualities necessary for individuals to advance in the field and the pathway to obtaining leadership positions. The findings of this study showed that early-career, high-value mentorship and sponsorship were important factors in leadership acquisition. Most participants (n = 20; 76%) had early mentors. Of those with early mentorship, 13 (65%) had high-value mentors, who we define as someone with power or authority. Sponsorship was the leading factor contributing to leadership acquisition. CONCLUSIONS: The results of this qualitative study may serve as a guide for encouraging female anesthesiologists with leadership aspirations. We suggest that the specialty field of anesthesiology institute targeted measures to help increase the percentage of women leadership with formal sponsorship programs at the local and national levels.

Effect of table inclination angle on videolaryngoscopy and direct laryngoscopy: Operator's muscle activation and laryngeal exposure analysis.

BACKGROUND: Optimal vocal cord visualization depends on the patient's anatomical factors, characteristics of the laryngoscope, and the operator's muscle action. This study evaluated the effect of table inclination and three different laryngoscopic methods on procedural variables. The primary aim of this study is to compare differences in laryngoscopic view among clinicians based on the instrument used and table orientation. The secondary aim is to determine differences in upper extremity muscle activity based on laryngoscope use and table inclination. METHODS: Fifty-five anesthesia providers with different experience levels performed intubations on a manikin using three angles of table inclination and three laryngoscopy methods. Time to intubation, use of optimization maneuvers, glottic view, operator's comfort level, and upper extremity muscle activation measured by surface electromyography were evaluated. RESULTS: Table inclination of 15° and 30° significantly reduced intubation time and the need for optimization maneuvers. Fifteen degrees inclination gave the highest comfort level. Anterior deltoid muscle intensity was decreased when table inclination at 15° and 30° was compared to a flat position. CONCLUSION: Table inclination of 15° reduces intubation time and the need to use optimization maneuvers and is associated with higher operator's comfort levels than 0° and 30° inclination in a simulated scenario using a manikin. Different upper extremity muscle groups are activated during laryngoscopy, with the anterior deltoid muscle exhibiting significantly higher activation levels with direct laryngoscopy at zero-degree table inclination.

Operating room relay strategy for turnover time improvement: a quality improvement project.

INTRODUCTION: Operating room (OR) management plays a pivotal role in the healthcare system due to the high cash flow it yields. Enhancing communication in the OR, which is the common root problem for delays, might improve OR efficiency and revenues for healthcare. This study aims to evaluate the impact of an OR relay strategy on turnover time (TOT). METHODS: A quality improvement project was conducted. In the intervention group, a certified registered nurse anaesthetist (CRNA) remained outside of the OR, coordinating the steps to get the next patient ready. This CRNA communicated with the anaesthesia providers within the OR via a Microsoft Team chat. The TOT for the control group was recorded from the electronic anaesthesia record system. RESULTS/DATA ANALYSIS: Analysis of 636 turnovers was performed with non-parametric tests. The OR relay strategy decreased TOT for most ORs, with statistically significant results for three of the ORs and the overall ORs system. A decreased in variability between TOTs was evidenced for the overall OR and the majority of the ORs evaluated individually. CONCLUSION: The OR relay strategy has a positive impact on TOT.

Anxiety in anesthesia providers during coronavirus disease 19 pandemic: Insights into perception of harm a cross-sectional study.

Background: The influence of Coronavirus disease 2019 (COVID-19) pandemic on mental health has been widely studied; however, literature evaluating the mental health effects of the pandemic on small groups of people is scarce. We aim to evaluate the impact of the COVID-19 pandemic on anxiety levels of anesthesiology providers in an academic institution. Materials and methods: We conducted a cross-sectional study including one hundred and five participants (Faculty anesthesiologists, anesthesia residents, certified registered and student nurse anesthetists). The generalized anxiety disorder questionnaire (GAD-7) was administered to participants. Results: Approximately half of the 105 participants experienced various degrees of anxiety, with only 14.3% exhibiting moderate to severe symptoms of anxiety. Anxiety interfering with daily activities was reported in 54.9% of the participants. Anxiety-generating factors such as access to protective equipment and transmitting the disease to family members were identified. Conclusion: The COVID-19 pandemic is associated with different degrees of anxiety. The prevalence of severe anxiety is relatively low, probably due to differential individual perceptions, feelings of invulnerability, and resilience of anesthesia providers.

Understanding the cycles of COVID-19 incidence: Principal Component Analysis and interaction of biological and socio-economic factors.

The incidence curve of coronavirus disease 19 (COVID-19) shows cyclical patterns over time. We examine the cyclical properties of the incidence curves in various countries and use principal components analysis to shed light on the underlying dynamics that are common to all countries. We find that the cyclical series of 37 countries can be summarized in four principal components which explain over 90% of the variation. We also discuss the influence of complex interactions between biological viral natural history and socio-political reactions and measures adopted by different countries on the cyclical patterns exhibited by COVID-19 around the globe.

Supra-massive transfusion and interdisciplinary approach to cesarean hysterectomy due to complex placenta percreta: Case report.

Placenta accreta spectrum encompasses a group of conditions of abnormal placental infiltration of the uterine wall and surrounding tissues. It is associated with significant blood loss, perioperative morbidity, and risk of death. A coordinated interdisciplinary approach to these complex cases and early resuscitation with blood products are critical factors in the successful management of patients affected by this disease. We describe the successful management of a patient with placenta percreta who required supra-massive transfusion of blood products and interventions by different specialized teams in a tertiary care center.

Limiting Outward Flow From the Patient's Airways to the Airway Operator: Head Chamber for Intubation of COVID-19 Patients.

We present the prototype of an adjunct to personal protective equipment (PPE) for intubation of patients with coronavirus disease 2019 (COVID-19). Acknowledging the risk of infection for the airway operator and personnel in the room when tracheal intubation is required for a COVID-19 patient, we designed a chamber that creates a microenvironment around the patient's head that limits the outward flow from a patient's airways to the airway operator with a filtered suction system in order to limit viral spread and lower contamination risk during intubation in non-negative-pressure rooms. The device was successfully tested in a simulation setting.

Use of a Triple Prophylactic Strategy to Prevent Post-dural Puncture Headache: An Observational Study.

Objective Post-dural puncture headache (PDPH) after an accidental dural puncture is a very common complication of epidural analgesia/anesthesia. We observed the ability of a triple prophylactic method (epidural saline, morphine, and intravenous (IV) cosyntropin) to prevent PDPH and the need for a blood patch.  Methods We retrospectively evaluated the effect of the combination of epidural saline, IV cosyntropin, and epidural morphine in parturients who had an accidental dural puncture with regard to the PDPH rate and the need for an epidural blood patch. We report a case series of patients with accidental dural puncture who underwent triple prophylaxis and other methods. Results Thirty-one patients were included in the study. Fourteen cases received triple prophylaxis (45%). Three patients in this group developed PDPH (21%), with two of them requiring a blood patch (14%). Nine patients underwent preventive measures other than triple prophylaxis with a PDPH rate of 55% and one needing a blood patch (11%). Conservative management was used in eight patients with PDPH and blood patch rates of 100% and 62%, respectively. Conclusion The triple prophylactic regimen of epidural saline, IV cosyntropin, and epidural morphine used after accidental dural puncture exhibits great potential to reduce the incidence of PDPH and the need for blood patch in obstetric patients.

Utility of color flow Doppler ultrasound to identify peripheral intravenous catheter position in adult surgical patients.

OBJECTIVE: To evaluate color flow Doppler flow ultrasound compared to standard clinical techniques, to detect the intravascular position of peripheral intravenous catheters in adult surgical patients. METHODS: A prospective study was conducted in adult (>18 years old) patients scheduled to undergo elective surgery. Peripheral intravenous catheter position was evaluated with standard clinical techniques (free flow of fluid from a hanging bag, easy saline injection, and aspiration of blood), and with color flow Doppler ultrasound proximal to the insertion site to identify intravascular catheter position. Comparative test performance was carried out. RESULTS: In total, 174 patients were enrolled. The venous catheter was deemed to be intravascular in 92.53% (n = 161) and 90.23% (n = 157) based on clinical evaluation and color flow Doppler, respectively (p = 0.206). Moderate to substantial agreement between the two approaches was found. Cohen's kappa was 0.64 (95% CI 0.43-0.83). Specificity of clinical judgment to detect catheter extravascular position was only 58.82%, when the color flow Doppler technique was set as the gold standard. Free flow from a hanging bag method showed the best agreement with color flow Doppler to determine intravascular position of a catheter (p = 0.3173, kappa = 0.68), with sensitivity of 98.09% and specificity of 64.71%. CONCLUSION: Color flow Doppler is a specific tool complementary to sensitive clinical indicators to detect peripheral venous catheter infiltration. The ability of color flow Doppler to accurately determine the position of a peripheral venous catheter depends on experience and familiarity with the tool by providers, who can master the technique with education and training.

Adaptive optimal target controlled infusion algorithm to prevent hypotension associated with labor epidural: An adaptive dynamic programming approach.

Patients receiving labor epidurals commonly experience arterial hypotension as a complication of neuraxial block. The purpose of this study was to design an adaptive optimal controller for an infusion system to regulate mean arterial pressure. A state-space model relating mean arterial pressure to Norepinephrine (NE) infusion rate was derived for controller design. A data-driven adaptive optimal control algorithm was developed based on adaptive dynamic programming (ADP). The stability and disturbance rejection ability of the closed-loop system were tested via a simulation model calibrated using available clinical data. Simulation results indicated that the settling time was six minutes and the system showed effective disturbance rejection. The results also demonstrate that the adaptive optimal control algorithm would achieve individualized control of mean arterial pressure in pregnant patients with no prior knowledge of patient parameters.

Ultrasound your NPO: Effect of body mass index on gastric volume in term pregnant women - Retrospective case series.

INTRODUCTION: A common belief has been that obese patients are prone to develop aspiration of gastric contents when general anesthesia is administered. We aimed to determine the correlation between antral cross-sectional area as a surrogate of gastric volume measured by gastric ultrasound, and body mass index (BMI) in term pregnant women scheduled for elective cesarean section. METHODS: A cross-sectional observational study was conducted on forty-two term pregnant patients scheduled for cesarean section. A preoperative qualitative and quantitative ultrasound assessment of the antral area was performed on the day of surgery. Gastric volume as a function of BMI was evaluated. RESULTS: A significant correlation was found between BMI and gastric antral area (p = 0.001), as well as with longitudinal diameter (p < 0.001). This correlation is independent of gravidity and parity. CONCLUSION: BMI is an independent predictor of antral cross sectional area and gastric volume in term pregnant patients scheduled for cesarean section. Perioperative fasting guidelines in pregnancy should be adjusted in obese and morbidly obese pregnant women.

Intrapartum epidural catheter displacement: Comparison of three dressing methods (Migración de catéter epidural intraparto: Comparación de tres métodos de fijación).

AIM: To compare the effect on epidural catheter migration of three different types of dressing used in labor. INTRODUCTION: Failure of labor epidural is due to multiple factors including catheter migration. Epidural catheter migration has been showed to be related to body mass index and patient position. The dressing technique also influences catheter migration and the risk of epidural failure. METHODS: Patients were randomly allocated to one of three groups based on type of dressing of labor epidural: TegadermTM (Group T), TegadermTM with sticky pad (Group P), and TegadermTM with Steri-StripTM (Group S). Measured variables included parity, gestational age, body mass index (BMI), level of puncture and distance of epidural catheter migration. RESULTS: There was an overall difference in epidural catheter migration (ECM) distance among different groups (p<0.05). Pairwise comparison revealed only a significant difference between groups P and T (0.76±1.35 vs. -0.14±1.03, p<0.01). CONCLUSION: Taping the lumbar epidural catheter used for labor analgesia with TegadermTM is inferior to TegadermTM with sticky pad or with Steri-StripTM in terms of catheter migration. There is no association of catheter migration and BMI.

Objetivo: Comparar el efecto de tres diferentes tipos de fijación sobre la migración del catéter epidural durante el trabajo de parto. Introducción: El fallo del bloqueo epidural en el trabajo de parto se debe a múltiples factores incluyendo la migración de catéter. La migración de catéter epidural se ha relacionado con el índice de masa corporal y la posición, así como con movimientos del paciente. La técnica de fijación también afecta la migración de catéter y el riesgo de bloqueo epidural fallido. Método: Las pacientes fueron aleatorizadas y asignadas a uno de tres grupos según el tipo de fijación: TegadermTM (Grupo T), TegadermTM con almohadilla adhesiva (Grupo P) y Tegaderm TM con Steri-StripTM (Grupo S). Las variables evaluadas incluyeron paridad, edad gestacional, índice de masa corporal (IMC), nivel de punción y distancia de migración del catéter epidural. Resultados: Se detectó una diferencia en la distancia de migración de catéter epidural entre los diferentes grupos (p<0.05). La comparación reveló diferencia únicamente entre los grupos P y T (0.76±1.35 vs. -0.14±1.03, p<0.01). Conclusión: TegadermTM como método de fijación de catéter epidural en el trabajo de parto resultó ser inferior al TegadermTM con almohadilla adhesiva o con Steri-StripTM en términos de migración de catéter. No existe una asociación entre migración de catéter epidural e IMC.

Are Anesthesiology Providers Good Guessers? Heart Rate and Oxygen Saturation Estimation in a Simulation Setting.

BACKGROUND: Anesthesia providers may need to interpret the output of vital sign monitors based on auditory cues, in the context of multitasking in the operating room. This study aims to evaluate the ability of different anesthesia providers to estimate heart rate and oxygen saturation in a simulation setting. METHODS: Sixty anesthesia providers (residents, nurse anesthetics, and anesthesiologists) were studied. Four scenarios were arranged in a simulation context. Two baseline scenarios with and without waveform visual aid, and two scenarios with variation of heart rate and/or oxygen saturation were used to assess the accuracy of the estimation made by the participants. RESULTS: When the accurate threshold for the heart rate was set at less than 5 beats per minute, the providers only had a correct estimation at two baseline settings with visual aids (p=0.22 and 0.2237). Anesthesia providers tend to underestimate the heart rate when it increases. Providers failed to accurately estimate oxygen saturation with or without visual aid (p=0.0276 and 0.0105, respectively). Change in recording settings significantly affected the accuracy of heart rate estimation (p < 0.0001), and different experience levels affected the estimation accuracy (p=0.041). CONCLUSION: The ability of anesthesia providers with different levels of experience to assess baseline and variations of heart rate and oxygen saturation is unsatisfactory, especially when oxygen desaturation and bradycardia coexist, and when the subject has less years of experience.

Evaluation of Anesthesiology Residents' Supervision Skills: A Tool to Assess Transition Towards Independent Practice.

Problem Anesthesiologists are often expected to supervise residents, nurse anesthetists, and anesthesiologist assistants in their practice. Development of a supervisory skill set is important during anesthesiology training and has a potential impact on the quality of patient care. During anesthesiology residency training, residents develop different competencies through direct supervision by a staff anesthesiologist. However, there is significant variability among anesthesia residency programs in the United States in terms of the opportunity residents have to supervise other anesthesia providers. The supervisory competency is not routinely evaluated during residency training. Intervention This study aimed at evaluating an educational seminar to foster the competency of supervision in anesthesiology. The 90-minute seminar included a live lecture and a series of workshops. The lecture had a duration of 45 minutes followed by three workshops of 15 minutes each. The workshops consisted of different simulated case scenarios with the participation of actors and a manikin as a patient. A debriefing session took place after the scenarios. Every resident included in the study participated in the workshops. The workshops were aligned with the learning objectives of the educational strategy. Context The study included 12 junior anesthesiology residents supervised by 24 senior residents during simulated clinical encounters. Quality of supervision, using the nine-item Quality of Supervision Questionnaire validated by De Oliveira Filho, and self-perception were evaluated before and after the educational intervention consisting of a face-to-face seminar and individual workshops administered during each encounter. Impact There was a significant difference between the overall means among senior residents for the quality of supervision measured by a nine-item quality of supervision questionnaire before and after the educational intervention program (3.11 ± 0.29 vs 3.96 ± 0.17, p < 0.01). There was no significant difference between the overall means for the self-perception of the senior residents before and after the intervention program (3.51 ± 0.54 vs. 3.48 ± 0.20). Lessons learned A bimodal educational intervention combining face-to-face seminars and workshops is effective to improve the quality of supervision in senior residents; however, it does not change the self-perception of the supervisory process. Addition of this type of educational intervention to the anesthesiology residency curriculum would add to the development of the supervisory competency and warrants further research in clinical situations.

Association between Blood Viscosity and Cardiovascular Risk Factors in Patients with Arterial Hypertension in a High Altitude Setting.

Background  Blood viscosity is a determinant of vascular resistance, and it is expected to contribute to blood pressure. Arterial hypertension (HTN), in addition to other cardiovascular risk factors, contribute to cardiac morbidity. Our study aimed to establish the association between cardiovascular risk factors including HTN and whole blood viscosity in Ecuadorian patients. Material and methods We studied 132 patients with the diagnosis of HTN. Fifteen cardiovascular risk factors were analyzed. The association between whole blood viscosity (WBV) and the number of cardiovascular risk factors was studied. The association between blood viscosity and risk factors was analyzed. Results  One hundred and thirty-two patients were analyzed. Blood viscosity was associated with a number of cardiovascular risk factors. Creatinine, uric acid, total cholesterol, and low-density lipoprotein (LDL) values were significantly higher in patients with high blood viscosity. Conclusion  Blood viscosity is a physiological variable associated with a number of cardiovascular risk factors in hypertensive patients. Such risk factors are related to renal function and lipid profiles. In high-altitude residents, polycythemia is common, and the consequences of high hematocrit on cardiovascular morbidity in this setting deserve special attention and warrant further research.

Approach to learning and educational environment: time to rethink measurement tools in postgraduate medical training?

OBJECTIVES: To assess the correlation between perception of the learning environment and the approach to learning adopted by anesthesiology residents throughout training in an academic institution in the United States. METHODS: This is a cross-sectional study involving forty-one anesthesiology residents who completed electronic forms of the Revised Two-Factor Study Process Questionnaire to assess learning approaches, and the Dundee Ready Educational Environment Measure questionnaire to assess learning environment. Convenience sampling was used with the current anesthesiology residents. Learning approaches were analyzed with a multiple regression model for correlation between total score, domains, and training level. Analysis of variance was used to assess differences in perception of the learning environment based on training level. Multivariate logistic regression was used to assess the correlation between domains of learning the environment and approaches questionnaires. Cronbach α was used to evaluate the internal consistency of responses within each domain of both questionnaires. RESULTS: Forty-one residents completed the questionnaires. Cronbach α varied between 0.604 and 0.76 among the domains in the Study Process Questionnaire and was greater than 0.60 for the Dundee questionnaire. There was a moderate correlation between total deep approach scores and the total subjective perception of teachers scores (R2= - 0.507, p <0.01). There was no significant association between specific domains of Dundee and study process questionnaires and resident year of training. CONCLUSIONS: The learning approaches adopted by anesthesiology residents and the perception of the educational environment are not correlated with years of training. The DREEM and R-SPQ-2F questionnaires should not be recommended for evaluation of anesthesiology residents.

Color your epidural: color flow Doppler to confirm labor epidural needle position.

BACKGROUND: Labor epidural analgesia success depends on precise needle position placement within the epidural space, with reported failure rates to be as high as 32%. In this study, we describe a novel technique employing color Doppler to aid in the confirmation of the correct position of the epidural needle tip. METHODS: Retrospective evaluation of 35 patients who received labor combined spinal-epidural (CSE) with confirmation of epidural needle position with color flow Doppler (CFD) ultrasonography. Demographic data, intervertebral level of insertion and dermatome sensory level were extracted. Video and image evaluation of CFD patterns were used to confirm epidural needle tip and catheter position. CFD was used to visualize intrathecal injection of local anesthetic in two patients. RESULTS: Three different color flow patterns were visualized after the loss of resistance technique: visualization of a red and blue mosaic adjacent to the posterior complex, a mosaic pattern enveloping the trajectory of the epidural needle, and a linear deeper mosaic color pattern during spinal injection in relation to the posterior complex. Identification of epidural needle tip and epidural catheter tip occurred in 77% and 37.1% of patients, respectively. CONCLUSIONS: CFD is a novel and useful technique to confirm the precise position of the epidural needle tip in the context of labor analgesia. Identification of the epidural catheter with CFD is difficult despite an adequate CSE technique.

Multifaceted remediation program: experience of a residency program to rescue residents who failed the American Board of Anesthesiology basic examination.

PROBLEM: Passing the American Board of Anesthesiology (ABA) basic examination is required to progress through anesthesiology training in USA. Failing the test may be related to medical knowledge gaps, presence of negative psychosocial factors, and/or individual approaches to learning. This article describes the experience of development and implementation of a multifaceted remediation program (MRP) in residents who failed the ABA basic test. INTERVENTION: This is a retrospective analysis of four cases of residents who failed the ABA basic test between 2016 and 2017. The MRP is described. Pedagogical diagnosis, objectives, teaching strategies and assessment, and their constructive alignment are presented. Information regarding test performance is also presented. CONTEXT: This study involves accredited anesthesiology residency program in USA. Outcomes: Four subjects (11% of program residents) failed the ABA basic test. Superficial approach to learning was observed in 100% of cases. The total possible number of participants was 4. The actual number of participants was 4, and the response rate was 100%. Four residents fell under 10th percentile on the first attempt, and 100% passed the test on the second attempt. There was 38% improvement in the number of failed keywords between the two attempts. LESSONS LEARNED: Implementation of the MRP developed at our institution is successful to remediate anesthesiology residents who fail the ABA basic examination. We learned that the deep analysis of learning approaches, psychosocial factors, and medical knowledge gaps can be used to develop a remediation program based on the constructive alignment between objectives, curriculum, and assessment.