The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices.

Intubation research on both direct laryngoscopy and alternative intubation devices has focused on laryngeal exposure and not the mechanics of actual endotracheal tube delivery or insertion. Although there are subtleties to tracheal intubation with direct laryngoscopy, the path of tube insertion and the direct line of sight are relatively congruent. With alternative intubation devices, this is not the case. Video or optical elements in alternative intubation devices permit looking around the curve of the tongue, without a direct line of sight to the glottic opening. With these devices, laryngeal exposure is generally the simple part of the procedure, and conversely, tube delivery to the glottic opening and advancement into the trachea are sometimes not straightforward. This article presents the mechanical and optical complexities of endotracheal tube insertion in both direct laryngoscopy and alternative devices. An understanding of these complexities is critical to facilitate rapid tracheal intubation and to minimize unsuccessful attempts.

The design and implementation of an automated system for logging clinical experiences using an anesthesia information management system.

BACKGROUND: Residents in anesthesia training programs throughout the world are required to document their clinical cases to help ensure that they receive adequate training. Current systems involve self-reporting, are subject to delayed updates and misreported data, and do not provide a practicable method of validation. Anesthesia information management systems (AIMS) are being used increasingly in training programs and are a logical source for verifiable documentation. We hypothesized that case logs generated automatically from an AIMS would be sufficiently accurate to replace the current manual process. We based our analysis on the data reporting requirements of the American College of Graduate Medical Education (ACGME). METHODS: We conducted a systematic review of ACGME requirements and our AIMS record, and made modifications after identifying data element and attribution issues. We studied 2 methods (parsing of free text procedure descriptions and CPT4 procedure code mapping) to automatically determine ACGME case categories and generated AIMS-based case logs and compared these to assignments made by manual inspection of the anesthesia records. We also assessed under- and overreporting of cases entered manually by our residents into the ACGME website. RESULTS: The parsing and mapping methods assigned cases to a majority of the ACGME categories with accuracies of 95% and 97%, respectively, as compared with determinations made by 2 residents and 1 attending who manually reviewed all procedure descriptions. Comparison of AIMS-based case logs with reports from the ACGME Resident Case Log System website showed that >50% of residents either underreported or overreported their total case counts by at least 5%. CONCLUSION: The AIMS database is a source of contemporaneous documentation of resident experience that can be queried to generate valid, verifiable case logs. The extent of AIMS adoption by academic anesthesia departments should encourage accreditation organizations to support uploading of AIMS-based case log files to improve accuracy and to decrease the clerical burden on anesthesia residents.

New and emerging analgesics and analgesic technologies for acute pain management.

PURPOSE OF REVIEW: Recent advances in drug delivery technology have provided new means of delivering medications with improved efficacy and safety. This review details developments in drug delivery recently made available or in development with the potential to better deliver analgesia. RECENT FINDINGS: Patient-controlled analgesia of intravenous medications was a major advance in drug delivery technology that allowed opioids to be administered more effectively and more safely. Extension of this technology to medications not administered intravenously has further broadened therapeutic options in the treatment of acute pain. Improvements in sustained-release formulations and patient-controlled analgesia modalities that are not catheter-based confer the potential to deliver analgesia less invasively. Receptor-specific antagonists allow opioids to be administered with fewer untoward side effects. SUMMARY: New routes of administration allow familiar medications to be utilized with greater clinical efficacy. Elimination of the need for indwelling catheters may reduce both the frequency of analgesic gaps and catheter-related complications. Physicians need to be familiar with developments in drug delivery technologies to be able to effectively utilize analgesics as part of well designed multimodal regimens to bring effective and well tolerated analgesia to patients with acute pain.

Academic faculty demonstrate higher well-being than residents: Pennsylvania anesthesiology programs' results of the 2017-2018 ACGME well-being survey.

STUDY OBJECTIVE: Physician burnout and suicide are at epidemic proportions. There is very little data directly comparing resident versus faculty well-being. The 2017-2018 ACGME resident and faculty surveys mark the first time that well-being questions were included. The purpose of this study was to determine whether responses to ACGME well-being questions would differ significantly between anesthesiology residents and academic anesthesiology faculty. DESIGN: 2017-2018 ACGME well-being survey responses. SETTING: All eight Pennsylvania anesthesiology residency programs. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS: The authors compared the 5-point Likert scale responses (1 = Never through 5 = Very Often) between residents (371/384 responses, 97%) and faculty (277/297 responses, 93%) for each of the twelve well-being questions. Responses were also dichotomized as being ≥4 versus <4 for categorical comparisons. MAIN RESULTS: Faculty responded higher than residents both by mean scores and percent of scores ≥ 4 for 6/12 questions (questions 1 (p < 0.001), 2 (p < 0.001), 4 (p < 0.001), 5 (p < 0.001), 8 (p < 0.001), and 11 (p = 0.001)). Residents responded categorically higher for question 9 (p = 0.022) although this was not considered statistically significant. Residents responded lowest for "Reflected on how your work helps make the world a better place" (question 1), whereas the lowest faculty responses were for questions 1, 9, and 10. Both had high responses for "Had an enjoyable interaction with a patient" (question 11). CONCLUSIONS: Pennsylvania academic anesthesiology faculty survey responses demonstrated a higher level of well-being compared to their residents. The variation in scoring suggests that anesthesiology residents and faculty have differing perceptions of various well-being domains. Information from well-being surveys can help provide programs with focus areas that they can intervene on to improve physician well-being.

Acute pain management in the postanesthesia care unit.

Pain management in the postanesthesia care unit (PACU) is continually evolving, with several new nonopioids expanding the list of available agents. Pain in the PACU is not an inevitable outcome of surgery. With careful planning, multimodal analgesic techniques instituted preoperatively will reduce pain in the PACU. Accurate assessment of the characteristics of pain will direct rational drug choices while minimizing side effects. Better management of pain in the PACU setting will likely improve patient satisfaction and facilitate shorter PACU stays.

Challenges in acute pain management.

The management of acute pain remains challenging, with many patients suffering inadequate pain control following surgery. Certain populations are at unique risk for unrelieved pain. Evidence-based approaches taking into account patients' specific needs and problems will likely substantially improve their perioperative experience. These patients must be identified in the preoperative process, and an anesthetic/analgesic plan discussed and formulated. A targeted multimodal approach to pain management should be considered the best clinical practice. The most challenging patients may benefit most from the surveillance of an acute pain service that is able to monitor and coordinate care into the postoperative period.

Use of a tracheoscopic ventilation tube for endotracheal intubation in the difficult airway.

Difficult endotracheal intubation is a clinical challenge for anesthesiologists and other practitioners of airway management. The use of a tracheoscopic ventilation tube, a novel airway device, for endotracheal intubation during general anesthesia in two patients with difficult airways after unsuccessful direct laryngoscopy is presented.

An evidence-based approach to medication preparation for the surgical patient at risk for latex allergy: is it time to stop being stopper poppers?

The prevalence of latex allergy is increasing in surgical patient populations. Avoidance of exposure to the allergen is essential to minimizing perioperative complications in patients suspected to be at risk. Natural rubber latex has historically been ubiquitous in medical devices containing rubber. In 1998, the Food and Drug Administration (FDA) began to require the labeling of medical devices made from natural rubber latex; since that time substantial progress has been made in identifying latex-free alternatives. However, the rubber stoppers commonly found in pharmaceutical vial closures are exempt from FDA labeling requirements. Examination of the clinical and basic science literature regarding pharmaceutical vial closures supports limiting the rubber stopper to a single needle puncture as a safer practice, with the caveat that no strategy exists for the complete elimination of risk as long as stoppers made from natural rubber latex are used in pharmaceutical vials intended for human use.

The evolving role of spinal agents in acute pain.

Local anesthetics and opioids were among the earliest pharmacologic agents used for intrathecal injection. Side-effect profiles have limited the use of additional agents and, after a century of clinical use, local anesthetics and opioids remain the most widely used intrathecal or epidural medications.