THIS MONTH IN Anesthesiology

Medical management of abnormal placentation is reviewed.

Rapid eye movement sleep rebound occurs following 6 h of general anesthesia. See the accompanying Editorial View on  page 683 

Basal infusion versus  repeated bolus doses did not influence continuous femoral nerve block effects.

Two different cognitive strategies that modulate chronic pain are studied.

Management of predisposing risk factors and early detection of perioperative stroke are reviewed.

There is an essential need for valid measures of clinical performance in order to provide feedback for learning and determine promotions for all residents. Anesthesia residents were anonymously evaluated weekly using an electronic evaluation form based on a “relative to peers” performance scale and the Accreditation Council for Graduate Medical Education core competencies. Nearly 15,000 evaluations of 108 residents were reviewed, and all were generally positively biased (blue ) versus  unbiased faculty (red ). A normalization process for each performance score based on individual faculty members allowed for determination of reliable performance scores. Average scores remained stable over time, were related to external measures of knowledge, and identified residents who required interventions. This study demonstrates the utility of a clinical performance assessment system for anesthesia residents. See the accompanying Editorial View on  page 681 

Due to high costs and the use of other modern diagnostics, the rate of autopsy for in-hospital deaths has declined dramatically. This retrospective study compared the cause of death findings using the American Society of Anesthesiologists Closed Claims Project Database after autopsy was (n = 551) or was not (n = 429) performed. In the 288 evaluable claims with autopsy, patients were younger and healthier than those for whom autopsy was not performed (P < 0.001). In cases with autopsy, an unexpected pathological diagnosis was determined in half of all claims. A significant nonanesthetic contribution was found in the majority of claims (61%), which resulted in a positive outcome for the defense of the anesthesiologists in 55% of claims. Autopsy results were harmful in only 27% of cases. Despite the decline in utilization, autopsy findings remain more helpful than harmful in the medicolegal defense of anesthesiologists. See the accompanying Editorial View on  page 685 

Currently, pharmacologic agents are not used to actively induce emergence from general anesthesia. This study tested the effects of methylphenidate, a dopamine/norepinephrine transporter inhibitor, on time to emergence from isoflurane anesthesia in rodents. Time to emergence was reduced by nearly 200 s by methylphenidate. Methylphenidate also dose-dependently induced the return of righting reflex and an increase in minute ventilation. Methylphenidate may be clinically useful as an agent to reverse general anesthetic-induced unconsciousness and respiratory depression at the end of surgery.