Supervision Of Anesthesiologist Research Articles

Operational outcomes of propofol sedation versus fentanyl, midazolam and diphenhydramine sedation for endoscopies and colonoscopies at an academic medical center.

On July 1st, 2021, the University of Colorado Hospital (UCH) implemented new sedation protocols in the luminal gastrointestinal (GI) suite. GI proceduralist supervised, Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS) sedation was transitioned to Monitored Anesthesia Care with propofol under physician anesthesiologist supervision (MAC). To determine if there are statistically significant reductions in Sedation-Start to Scope-In time (SSSI) when using Monitored Anesthesia Care with propofol (MAC) versus Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS). Secondary objectives were to determine if statistically significant improvements to other operational times, quality measures, and satisfaction metrics were present. This study was a retrospective analysis of a natural experiment resultant of a change from NAS to MAC sedation protocols. Outcomes for NAS protocols from 1/1/21-6/30/21 were compared to outcomes of MAC protocols from the dates 8/1/21-10/31/21. Results were analyzed using Quasi-Poisson regression analysis and stratified based on upper GI, lower GI, and combined procedures. Patient demographic data including age, biological sex, comorbidities, and BMI, were adjusted for in the analysis. ASA matching was not performed as nursing sedation does not use ASA classifications. Pre-anesthesia co-morbidities were assessed via evaluation of a strict set of comorbidities abstracted from the electronic medical record. Perioperative operational outcomes include Sedation Start to Scope-In (SSSI), In-Room to Scope-In Time (IRSI), Scope Out to Out of Room (SOOR), Total Case Length (TCL), and Post Anesthesia Care Unit Length of Stay (PACU LOS). Quality outcomes include PACU Administered Medications (PAM), and Clinician Satisfaction Scores (CSS). A total of 5,582 gastrointestinal (GI) endoscopic cases (upper, lower, and combined endoscopies) were observed. Statistically significant decreases in SSSI of 2.5, 2.1, and 2.2 minutes for upper, lower, and dual GI procedures were observed when using MAC protocols. A statistically significant increase in satisfaction scores of 47.0 and 19.6 points were observed for nurses and proceduralists, respectively, when using MAC. MAC protocols for endoscopic GI procedures at UCH led to statistically significant decreases in the time required to complete procedures thus increasing operational efficiency.

Influence on the incidence of prolonged times to tracheal extubation from the anesthesia practitioner having completed few prior cases with the surgeon

BackgroundProlonged extubations are defined as an interval ≥15 min between the end of surgery and extubation after general anesthesia when both intubation and extubation occur in the operating room. Earlier studies showed that prolonged extubations are rated poorly by anesthesiologists, and are associated with reintubations, respiratory interventions, longer operating room times, delayed starts of to-follow cases and surgeons, and longer duration workdays. Furthermore, they often are preventable. We test the hypothesis that, at a large teaching hospital with several hundred surgeons, when the anesthesia practitioner who finished a case had finished fewer than five cases previously with the surgeon, there was significantly greater probability of prolonged tracheal extubation. MethodsThis retrospective cohort study included all anesthetics from October 2011 through December 2022 not involving prone positing and where tracheal intubation and extubation occurred in the operating room. The first three years were used for counting earlier cases that the anesthesia practitioner (e.g., nurse anesthetist or resident) had finished with the surgeon to establish their baseline experience. We used the final 53 eight-week periods’ extubations (N = 133,527 cases) in mixed effects logistic regressions with the surgeons treated as random effects. ResultsProlonged extubations occurred in 23% of cases and were associated with a mean of 14.7 min longer time from the end of surgery to operating room exit than cases without prolonged extubations (99% confidence interval 14.7 to 14.8 min, P < 0.0001). The anesthesia practitioner not having finished at least five cases previously with the surgeon over the past 36 months was associated with 16% greater odds of prolonged extubation (99% confidence interval 1.11 to 1.21, P < 0.0001). There was a larger effect on prolonged extubation when the case was finished by a trainee (odds ratio 1.70, 99% confidence interval 1.64–1.76, P < 0.0001). The odds of prolonged extubation was reliably greater for the criterion that the anesthesia practitioner had not finished at least five cases with the surgeon within the previous 36 months versus alternative intervals of within 24 or within 12 months. Pediatric surgeons’ cases had significantly greater odds of prolonged extubations (2.02, 99% confidence interval 1.67–2.44, P < 0.0001). There was negligible effect on the incidences of prolonged extubation from the surgeon having principally an adult ambulatory surgery practice. ConclusionsMultispecialty teaching hospitals can validly monitor their incidence of prolonged extubations as a measure of anesthesia department performance. Consider revising anesthesia assignments and anesthesiologist supervision when frequent.

Economics of operating room use at auniversity eye hospital

In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of auniversity eye hospital. The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on atheoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated. With atotal of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8days, would result in an additional revenue of about 2.4times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit marginII: 701,389 €) for the considered surgical patient collective in 2021. An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for alarge hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

Deep sedation with dexmedetomidine administered by electrophysiologists during COVID-19 pandemic compared with propofol administered by anesthesiologists for ablation of atrial fibrillation

Funding AcknowledgementsType of funding sources: None.BackgroundCOVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation.PurposeWe compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol.MethodsWe retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (< 90%) or need for assisted ventilation/intubation, bradycardia (heart rate < 45 bpm) and persistent hypotension (systolic blood pressure < 90 mmHg).ResultsBaseline characteristics and hemodynamic variables did not differ between the two groups (all p > 0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine.Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine; p = 0.057).ConclusionDeep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.

Neinvazivna ventilacija pacijenta sa akutnom respiratornom insuficijencijom izazvanom COVID-19 pneumonijom - prikaz slučaja

Introduction: Since the beginning of the COVID-19 pandemic, the healthcare system has reorganized, created, and implemented protocols on triage, treatment, indications for hospitalization in intensive care units, and indications for non-invasive and mechanical ventilation. This case report aimed to demonstrate the successful treatment with noninvasive ventilation of a patient with acute respiratory failure in COVID19 pneumonia. Case Report: A 57-year-old patient with comorbidities was admitted to the COVID-19 intensive care unit due to weakness, dry cough, shortness of breath, and difficulty breathing. On admission, SpO2 64%, blood pressure 120/80 mmHg, frequency 160/min., respirations 25/min., temperature 38.6oC, with signs of acute respiratory insufficiency and laboratory-confirmed cytokine storm. Bilateral interstitial pneumonia was radiologically verified. He was treated according to the protocol for COVID-19, with non-invasive ventilation that was applied for 35 days, with constant supervision by an anesthesiologist. Complications, intubation, and mechanical ventilation were prevented. The patient was discharged to home treatment after 62 days in a stable general health condition. Conclusion: The role, knowledge, experience, and constant supervision of anesthesiologists in the intensive care unit during the coronavirus pandemic are significant. Successful treatment using noninvasive ventilation in the presented case contributed to a positive outcome of the disease.

No harm found when the scope of practice of nurse anesthetists is expanded to the whole process of anesthetic care and under indirect supervision of anesthesiologists: A time series study

BackgroundMore and more countries utilize nurse anesthetists as an anesthetic care provider to make up for the insufficiency of anesthesiologists. ObjectiveTo examine whether introducing nurse anesthetists with expanded scope of practice to anesthetic care would jeopardize the safety of patients and quality of anesthetic care. DesignThis observational study used an interrupted time series design. Setting(s)A metropolitan teaching cancer hospital located in Southwest China. Participants24290 patients with surgical procedures under general anesthesia from January 2015 to December 2017 were included. MethodsIn May 2016, nurse anesthetists with expanded scope of practice were introduced to anesthetic care. Administrative and medical record data were accessed to identify the occurrence of anesthetic outcomes including failed tracheal intubation and inability to ventilate with mask, aspiration, problem with airway in the post-anesthesia care room, hypothermia (temperature ≤ 35°C or chills), unplanned stay in the post-anesthesia care room longer than 3 hours, unexpected intensive care unit admission, reintubation, vascular and cardiopulmonary disorders and death. Statistical process control analysis was conducted to test special cause variation in outcomes over time. ResultsFindings demonstrated significant decrease in the proportion of patients staying in the post-anesthesia care room longer than 3 hours and with hypothermia following nurse anesthetists introduced to anesthetic care. Other anesthetic outcomes were not significantly changed. ConclusionsThe results demonstrate that involvement of nurse anesthetists with expanded scope of practice in anesthetic care did not jeopardize patients’ safety or quality of anesthesia. Moreover, it may have beneficial impact in preventing prolonged stay in the post-anesthesia care room and hypothermia. Further research is required to examine the impact of involvement of nurse anesthetists in anesthetic care across all clinical contexts.

Sedation for Brain Magnetic Resonance Imaging in Preterm Infants: Using Propofol under Anesthesiologist Supervision

Purpose We aimed to compare two different sedation protocols for brain magnetic resonance imaging (MRI) in preterm infants. One protocol used chloral hydrate (CH) with monitoring conducted by non-anesthesiologists, and the other used a continuous infusion of propofol (PF) with monitoring by anesthesiologists. Methods A total of 250 preterm infants born between January 2011 and December 2015 who received brain MRI during hospitalization in our neonatal intensive care unit (NICU) were included in this retrospective study. In period 1, sedation for brain MRI was done using a single dose or multiple doses of CH with monitoring conducted by NICU medical staff. In period 2, an anesthesiologist prescribed a continuous infusion of PF and titrated the dosage for minimal and adequate sedation. Data on the adverse events, including desaturation and bradycardia, were collected and compared between periods 1 and 2. Results Despite similar gestational ages of the patients in periods 1 and 2, the infants in period 1 showed a higher risk of developing bradycardia after sedation compared to those in period 2 (30.2% vs. 14.8%; an adjusted odds ratio of 2.35; 95% confidence interval of 1.12 to 4.91). Infants who had an adverse event after sedation had a lower gestational age and corrected age at the time of MRI (26.8 weeks vs. 27.9 weeks, P=0.004; 37.3 weeks vs. 38.3 weeks, P=0.023). The duration of MRI was significantly longer in infants that had an adverse event than those that did not (70.9 minutes vs. 64.3 minutes). After adjusting for various clinical factors, lower gestational age, lower corrected age at the time of MRI, and period 1 increased the risk of developing adverse events after sedation for MRI. Conclusion The use of a continuous PF infusion with dose titration and monitoring by an anesthesiologist is safe and feasible as a sedation protocol for brain MRI in prematurely born infants. Keywords: Magnetic resonance imaging; Anesthesiologists; Propofol; Infant, premature

Introduction of evolving roles of Japanese perianesthesia nurses.

The aim of this special article is to introduce Perianesthesia Nurses (PANs) who play an essential role in assisting anesthesiologists to ensure the safety of patients undergoing anesthesia and to improve the quality of anesthetic care. In Japan, there is no national license for nurse anesthesia providers. Therefore, most of the tasks related to anesthesia are performed by the anesthesiologists. Due to the size and complexity of the aging population, higher quality perioperative care is needed. In search of a solution, PANs were introduced to improve anesthetic care in Japan, enabling anesthesiologists to delegate some of their tasks to PANs who work within the scope of registered nurse's policies. They are a new type of anesthesia care provider in Japan, and different from Certified Registered Nurse Anesthetists in the United States. Currently, six schools provide 2-year master's degree perianesthesia nursing programs, and graduates are now providing anesthetic care both inside and outside of the operating room under the direct supervision of anesthesiologists. PANs not only assist anesthesiologists and help to reduce anesthesiologists' workload, but also contribute to the expansion of anesthesia services. They ensure patient safety and improve the quality of patient care before, during, and after the patient undergoing anesthesia.

Use of an Ultra-slim Gastroscope to Accomplish Endoscopist-Facilitated Rescue Intubation During ERCP: A Novel Approach to Enhance Patient and Staff Safety.

ERCP is often performed under monitored anesthesia care (MAC) rather than general anesthesia (GA), with patients positioned semi-prone on the fluoroscopy table. Rarely, a MAC ERCP must be converted to GA due to hypoxia or retained food in the stomach. In these circumstances, standard intubation is associated with a significant delay and potential for patient/staff injury during repositioning. We report a novel endoscopist-driven approach to intubation during ERCP using an ultra-slim, flexible gastroscope with an endotracheal tube backloaded onto it. We identified patients who underwent ERCP from 2014 to 2019, and MAC to GA conversion events. Mode of intubation (standard vs. endoscopist-facilitated) and patient/procedure characteristics were evaluated. All endoscopist-facilitated intubations were performed under anesthesiologist supervision. A total of 3409 patients underwent ERCP; 1568 (46%) GA and 1841 (54%) MAC. Of these, 42 (2.3%) required intubation during ERCP and 16 underwent endoscopist-facilitated intubation due to retained food in the stomach and/or hypoxia. In 3 patients, aspirated material was suctioned from the trachea and bronchi using the ultra-slim gastroscope. Immediate post-procedure extubation was successful in all endoscopist-facilitated intubation patients and none exhibited radiographic evidence of aspiration pneumonia. Endoscopist-facilitated intubation using an ultra-slim flexible gastroscope is feasible and expeditious for MAC to GA conversion during ERCP. This technique is readily accomplished in the semi-prone position, while standard intubation requires patient transfer from fluoroscopy table to gurney, with associated delay/risks. These data suggest that further study of this approach is warranted, and this may be the most favorable approach for intubation during ERCP.

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

The Safety and Effectiveness of Superficial Cervical Plexus Block in Oral and Maxillofacial Surgery as an Alternative to General Anesthesia in Selective Cases: A Clinical Study.

To assess the safety and effectiveness of superficial cervical plexus (SCP) block in oral and maxillofacial surgical (OMFS) practice as an alternative to general anesthesia in selective cases. The total number of patients was 10, out of which 6 were male and 4 were female patients. Five patients had incision and drainage of perimandibular space infections, two patients had enucleation of cyst in the body of mandible, one patient had open reduction and internal fixation isolated angle fracture, and two patients had submandibular lymph node biopsies. Informed& written consent were obtained from the patients after they had the procedure explained to them. Medically compromised patients and those who were excessively anxious and apprehensive, patient who did not want the procedure to be done under regional anesthesia, and patients with a history of allergy to local anesthetic were excluded. All patients had their surgical procedures under regional anesthesia (SCP block with supplemental nerve blocks) performed by the same surgeon under the supervision of anesthesiologist with continuous monitoring. SCP block with concomitant mandibular nerve and long buccal nerve block has a high success rate, low complication rate, and high patient acceptability as shown in the study. Superficial cervical plexus block anesthesia is a safe and useful anesthetic technique with the low risk of accidents and complications, thus a good alternative for regional anesthesia in selected cases in oral and maxillofacial surgery.

Operating Room Personnel Viewpoints About Certified Registered Nurse Anesthetists.

The purpose of this project was to explore what attitudes physicians, nurses, and operating room technicians had about working with Certified Registered Nurse Anesthetists (CRNAs) to better understand practice barriers and facilitators. This Q methodology study used a purposive sample of operating room personnel from four institutions in the Midwestern United States. Participants completed a -4 to +4 rank-ordering of their level of agreement with 34 attitude statements representing a wide range of beliefs about nurse anesthetists. Centroid factor analysis with varimax rotation was used to analyze 24 returned Q sorts. Three distinct viewpoints emerged that explained 66% of the variance: favoring unrestricted practice, favoring anesthesiologist supervision, and favoring anesthesiologist practice. Research is needed on how to develop workplace attitudes that support autonomous nurse anesthetist practice and to understand preferences for restricted practice in team members other than physicians.

Reliability and validity of the anesthesiologist supervision instrument when certified registered nurse anesthetists provide scores.

At many facilities in the United States, supervision of Certified Registered Nurse Anesthetists (CRNAs) is a major daily responsibility of anesthesiologists. We use the term "supervision" to include clinical oversight functions directed toward assuring the quality of clinical care whenever the anesthesiologist is not the sole anesthesia care provider. In our department, the supervision provided by each anesthesiologist working in operating rooms is evaluated each day by the CRNA(s) and anesthesiology resident(s) with whom they worked the previous day. The evaluations utilize the 9 questions developed by de Oliveira Filho for residents to assess anesthesiologist supervision. Each question is answered on a 4-point Likert scale (1 = never, 2 = rarely, 3 = frequently, and 4 = always). We evaluated the reliability and validity of the instrument when used in daily practice by CRNAs. The data set included all 7273 daily supervision scores and 1088 comments of 77 anesthesiologists provided by 49 CRNAs, as well as the 6246 scores and 681 comments provided by 62 residents, for dates of service between July 1, 2013, and June 30, 2014. Reliability of the instrument was assessed using its internal consistency. Content analysis was used to associate supervision scores (i.e., mean of the 9 answers) and presence of the verbs "see" or "saw" combined with negation in comments (e.g., "I did not see the anesthesiologist during the case(s) together"). Results are reported as the mean ± SE from among the 6 two-month periods. Supervision scores <2 were provided for 7.2% ± 0.4% of assessments and scores <3 were provided for 36.6% ± 1.1% of assessments, by 18.2 ± 0.9 and 34.0 ± 0.6 CRNAs, respectively (i.e., low scores were not attributable to just a few CRNAs or anesthesiologists). These frequencies were greater than for trainees (anesthesiology residents) (both P < 0.0001). No single question among the 9 questions in the supervision instrument explained CRNA supervision scores <2 (or <3) because of substantial (expected) interquestion correlation. Cronbach's alpha equaled 0.895 ± 0.003 among the 6 two-month periods. Among the CRNA evaluations that included a written comment, the Cronbach's alpha was 0.907 ± 0.003. Thus, like for anesthesiology residents, when used by CRNAs, the questions measured a one-dimensional attribute. The presence of a comment containing the action verb "see" or "saw," with the focus theme ("I did not see …"), increased the odds of a CRNA providing a supervision score <2 (odds ratio = 74.2, P = 0.0003) and supervision score <3 (odds ratio = 48.2, P < 0.0001). Limiting consideration to scores with comments, there too was an association between these words and a score <2 (odds ratio = 19.4, P = 0.0003) and a score <3 (odds ratio = 31.5, P < 0.0001). In Iowa, substantial anesthesiologist presence is not required for CRNA billing. More comments containing "see" or "saw" were made by CRNAs rather than residents (n = 75 [97.4%] versus n = 2 [2.6%], respectively, P < 0.0001), indicating face validity of the analysis. If some of the 9 questions were not perceived by the CRNAs as relevant to their interprofessional interactions, Cronbach's alpha would be low, not the 0.907 ± 0.003, above. Similarly, one or more of the individual questions would also not routinely be scored at its upper boundary of 4.0 ("always"). This was not so, being as the score was 4.0 for 24.9% ± 0.3% of the CRNA evaluations, and that score of 4.0 was more common than even the next most common combination of scores (P < 0.0001). The de Oliveira Filho supervision instrument was designed for use by residents. Our results show that the instrument also is reliable and valid when used by CRNAs. This is important given our previous finding that the CRNA:MD ratio had no correlation with the level of supervision provided.

The Training and Performance of Emergency Physicians as Anesthetists for International Medical Surgical Response Teams: The Emergency Physician’s General Anesthesia Syllabus (EP GAS)

Background: The availability of an anesthesiologist is often a limiting factor in the number of operations that can be performed by International Medical Surgical Response Teams (IMSuRT). Because emergency physicians (EPs) possess skills in airway control, management of moderate and deep sedation, and ventilator management, we propose that with proper training in general anesthesia, EPs can serve as anesthetists for IMSuRT with anesthesiologist supervision. Methods: During a 10-week period, a board-certified EP administered general anesthesia to 60 patients prior to a surgical medical mission trip. The breakdown of surgical cases was: 11 orthopedic, 2 genitourinary, 20 ear, nose, and throat, 8 obstetrics and gynecological, 13 general surgery, and 6 vascular. A simplified protocol for induction, maintenance, and emergence was adhered to for all cases. Results: Fourteen orthopedic cases using general anesthesia were performed in a one-week period in Haiti. These cases involved open reduction and internal fixation (ORIF), hemiarthoplasty, hardware removal, tendon transfer and external fixation of fractured bone. Conclusion: We demonstrate the feasibility of a model curriculum to train EPs in the basics of anesthesia. The EP can safely and effectively deliver general anesthesia for major cases on surgical medical mission trips under the auspices of an anesthesiologist in an austere environment.

The role of Certified Registered Nurse Anesthetists in the United States

Certified Registered Nurse Anesthetists (CRNAs) have been providing anesthesia care in the United States (US) for nearly 150years. Historically, anesthesia care for surgical patients was mainly provided by trained nurses under the supervision of surgeons until the establishment of anesthesiology as a medical specialty in the US. Currently, all 50 US states utilize CRNAs to perform various kinds of anesthesia care, either under the medical supervision of anesthesiologists in most states, or independently without medical supervision in 16 states; the latter has become an on-going source of conflict between anesthesiologists and CRNAs. Understanding the history and current conditions of anesthesia practice in the US is crucial for countries in which the shortage of anesthesia care providers has become a national issue.

Ten Years of Experience Training Non‐Physician Anesthesia Providers in Haiti

Surgery is increasingly recognized as an effective means of treating a proportion of the global burden of disease, especially in resource-limited countries. Often non-physicians, such as nurses, provide the majority of anesthesia; however, their training and formal supervision is often of low priority or even non-existent. To increase the number of safe anesthesia providers in Haiti, Médecins Sans Frontières has trained nurse anesthetists (NAs) for over 10 years. This article describes the challenges, outcomes, and future directions of this training program. From 1998 to 2008, 24 students graduated. Nineteen (79%) continue to work as NAs in Haiti and 5 (21%) have emigrated. In 2008, NAs were critical in providing anesthesia during a post-hurricane emergency where they performed 330 procedures. Mortality was 0.3% and not associated with lack of anesthesiologist supervision. The completion rate of this training program was high and the majority of graduates continue to work as nurse anesthetists in Haiti. Successful training requires a setting with a sufficient volume and diversity of operations, appropriate anesthesia equipment, a structured and comprehensive training program, and recognition of the training program by the national ministry of health and relevant professional bodies. Preliminary outcomes support findings elsewhere that NAs can be a safe and effective alternative where anesthesiologists are scarce. Training non-physician anesthetists is a feasible and important way to scale up surgical services resource limited settings.

Benefits of quantitative gated SPECT in evaluation of perioperative cardiac risk in noncardiac surgery

Gated single-photon emission computed tomography (G-SPECT) was used to evaluate cardiac risk associated with noncardiac surgery and determine the benefits and indications of this technique for this type of surgery. Patients scheduled to undergo noncardiac surgery under the supervision of anesthesiologists and subjected to preoperative cardiac evaluation using G-SPECT during the 26-month period between June 2000 and August 2002 were followed for the presence/absence of cardiac events (i.e., cardiac death, myocardial infarction, unstable angina, congestive heart failure, or fatal arrhythmia) during surgery and the postoperative period until discharged. Relationships between the occurrence of cardiac events and preoperative G-SPECT findings were evaluated. A total of 39 patients underwent G-SPECT; 6 of the 39 exhibited abnormal ejection fraction (left ventricular ejection fraction, LVEF<or=50%) and end-systolic volume (ESV>or=50 ml). Surgery was suspended for three of these six patients and cardiac events developed in the remaining three patients. Both abnormal perfusion images (PI) and abnormal wall thickening (WT) were observed in all six patients. All six patients exhibited abnormal LVEF and/or ESV. Three patients had either abnormal PI or WT, and a cardiac event occurred in one of them. Of the five patients who experienced cardiac events during or after surgery, two exhibited a short run of ventricular tachycardia requiring a continuous administering of antiarrhythmic drugs, whereas the remaining three patients exhibited cardiac failure requiring inotropic support following surgery. The results of this study indicate that the occurrence of perioperative cardiac events can be predicted by considering the severity of expected surgical stress and preoperative G-SPECT findings for LVEF, PI, and WT. We conclude that G-SPECT is quite useful for cardiac risk assessment in patients undergoing noncardiac surgery.

Depression of diaphragm contractility by nitrous oxide in humans.

Nitrous oxide is widely used in anesthesia and critical care medicine. The effect of nitrous oxide on diaphragm contractility in humans is unknown. We evaluated the effect of a 50% nitrous oxide-50% oxygen mixture on diaphragm contractility in healthy adult volunteers. The sniff transdiaphragmatic pressure (Sn Pdi) and the twitch transdiaphragmatic pressure (Tw Pdi) elicited by bilateral supramaximal phrenic nerve stimulation were measured before during and after inhalation of a mixture of 50% nitrous oxide and 50% oxygen. Sn Pdi decreased by 15.4% during nitrous oxide inhalation, with a value of 136 +/- 21 cm H(2)O before nitrous oxide and a value of 115 +/- 27 cm H(2)O during nitrous oxide inhalation (P = 0.03). Similarly, Tw Pdi decreased from 21.2 +/- 1.8 cm H(2)O before nitrous oxide inhalation to 16.9 +/- 4.1 cm H(2)O during nitrous oxide inhalation (P = 0.03). The effect of nitrous oxide was totally abolished 20 min after its discontinuation. Nitrous oxide has a short-acting suppressant effect on the pressure generating capacity of the diaphragm in healthy humans. We investigated whether nitrous oxide (a common component of gas anesthesia) reduces diaphragm strength in humans. Diaphragm strength is reduced by nitrous oxide but the effect wears off within 20 min of administration. Caution is advised when using nitrous oxide without anesthesiologist supervision in patients at risk of ventilatory failure

Practice of ambulatory anesthesia in honduras: The central American experience

H ONDURAS IS A developing country, with scarcely 5 million inhabitants and 112,000 km 2 of territorial extension. The entire country has only 52 anesthesiologists, all of whom completed residency training abroad because it is not available in the educational programs of the local medical schools. What occurs is that the anesthe~ sia specialists train paramedical personnel to be anesthetic technicians who will be working at the public hospitals under the anesthesiologist's supervision. This allows them to meet the needs of the people in the field. Even though Honduras has not suffered the deleterious effects of war, it endures other problems, such as the two clearly separate socioeconomic poles of the miserable poverty (in the largest percentage) and the ostentatious richness, with a very small middle class. The world crisis is more visible in this type of society, which has generated excessive violence, thievery, and misery. Nevertheless, there are some advantages in this ongoing smuggle. Necessity is the mother of invention, and although anesthesiologists in Honduras do not have international fame, they have been obligated to improvise with materials and equipment in their dally practice (adhesive tape has become our number 1 auxiliary). The adoption of a saving policy to face the precarious situation has helped to overcome the necessities. The upper class might not be accustomed to these medical behaviors, but the resources must be well spent and waste avoided i f it is possible. New inventions from the medical engineering field have given us accurate devices to obtain better measurement, precise evaluation, and prompt treatment of the patient. The great activity of pharmaceutical laboratory chemists have launched many new products to the medicine market that make the practice of anesthesiology easier, safer, and more efficient. In developed countries this reality has made a real change because of the lower costs for medical care due to the ability to have patients hospitalized for a shorter period of time. It is economically attractive for the administration of hospitals or health care facilities to treat several patients per day with a short postoperative time rather than to have beds perpetually occupied. The profits are larger with the new methods. In Third World Countries, many things regarding medical service are done backwards (day surgeIaj is no exception) because of the difficulty to obtain expensive modern drugs and devices. There are arguments among the administrations because they would rather give affordable (or inexpensive) health care, believing this is the best solution to the crisis that the health care system faces, without making an effort to understand and compare the cost per day for inpatient care versus the technology investment and the acquisition of new drags that will allow a short hospital stay, which is what makes this kind of practice profitable. What occurs in private practice regarding this matter? Hospital permanency of the postsurgical patient is extended as much as possible because of the profits obtained by them; therefore, we believe that the ambulatory surgery programs are not attractive to these kinds of nonspecific day surgery centers. In the late i940s some ideas of day surgery programs took shape in Latin America, but it was not until 1970 that Honduras began those programs when some procedures were done in long-stay medical centers under ambulatory surgery criteria. In those early days the operations performed were mostly adenotonsillectomy, circumcision, inguinal herniorrhaphy, cystocele correction, hand surgery, and more, but percent-

Practice Guidelines for Cancer Pain Management

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