670 Impact Assessment of Perioperative Point-of-Care Ultrasound Training on Anesthesiology Residents (Original Investigations in Education)
The goals of this project were to develop a novel perioperative point-of-care ultrasonography curriculum (FORESIGHT: Focused periOperative Risk Evaluation Sonography Involving Gastro-abdominal Hemodynamic and Transthoracic ultrasound) for resident training and assess the utility of a model/simulation-based education strategy for training them. For 2 yr 42 anesthesiology residents received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Use of a model/simulation learning strategy effectively trained residents on the FORESIGHT exam topics and additional pathology training improved their knowledge. Residents obtained adequate image quality/identified anatomy after 1 yr of training. Application of the perioperative FORESIGHT examination had some clinical impact, a substantial portion of which was secondary to new diagnoses. See the accompanying Editorial View on page 499.
683 Scholarly Productivity and National Institutes of Health Funding of Foundation for Anesthesia Education and Research Grant Recipients: Insights from a Bibliometric Analysis (Original Investigations in Education)
The Foundation for Anesthesia Education and Research (FAER) grant program provides fellows and junior faculty members interested in pursuing research with financial support as they begin their academic careers with the expectation that many of them will become productive independent investigators capable of obtaining competitive awards from the National Institutes of Health. A bibliometric analysis of 397 recipients of FAER grants since the FAER began funding research in 1987 found the recipients produced nearly 20,000 peer-reviewed publications that have been cited more than one half million times. They received 391 National Institutes of Health grants totaling nearly $450 million. More than three fourths of FAER grant recipients remain in academic anesthesiology and many of them have become national leaders.
507 No Significant Association between Anesthesia Group Concentration and Private Insurer Payments in the United States
Physician practices in the United States have become increasingly concentrated. The association between anesthesia group concentration and payments from private insurers to anesthesiologists was examined to determine whether larger practices lead to higher payments for physician services. Data on average payments for five commonly used anesthesia Current Procedure Terminology codes were obtained for physicians in 229 counties between 2002 and 2010. A measure of market concentration for anesthesiologists in each county was calculated using Medicare claims data. The association between market concentration and private insurer payment was then estimated using an approach that minimizes confounding. Payments in more highly concentrated markets were not significantly different from those in less concentrated markets.
524 Ability of the Nociception Level, a Multiparameter Composite of Autonomic Signals, to Detect Noxious Stimuli during Propofol–Remifentanil Anesthesia
The Nociception Level (NoL) index is a multiparameter nonlinear combination of heart rate, heart rate variability, finger photoplethysmogram amplitude, skin conductance, skin conductance fluctuations, and their time derivatives. Seventy-two patients were randomly assigned to receive total intravenous anesthesia with a propofol infusion targeted to maintain the bispectral index at 45 and one of six remifentanil target concentrations between 0 and 5 ng/ml. NoL, heart rate, and arterial blood pressure were measured during nonnoxious, moderately noxious, and intensely noxious stimulation. The NoL outperformed heart rate and mean arterial pressure in terms of sensitivity and specificity and positive and negative predictive values for detection of noxious stimulation. NoL was significantly correlated with target remifentanil concentrations following noxious stimulation and was not affected by nonnoxious events.
535 A Randomized Crossover Study Comparing a Novel Needle Guidance Technology for Simulated Internal Jugular Vein Cannulation
Despite ultrasound guidance for central venous catheter placement, complications persist. A randomized, crossover study of 100 physicians compared needle tip positioning under ultrasound with and without a novel free-hand electronic needle guidance technology that displays needle location in real-time using a simulated gel model with a low pressure venous system and a high pressure arterial system. The incidence of posterior vessel wall puncture, the primary outcome variable, without needle navigation technology was 49% while that with it was 13%. The rate of carotid artery puncture was 21% without needle guidance and 2% with it. Although posterior vessel wall puncture has not been specifically associated with acute complications, it is a surrogate for needle accuracy for ultrasound needle guidance studies.
548 Malignant Hyperthermia Testing in Probands without Adverse Anesthetic Reaction
Reports detailing nonanesthetic-induced malignant hyperthermia–like reactions, or a positive caffeine halothane contracture test (CHCT), in individuals suffering from various disorders have led to referrals of patients with no personal or family history of anesthesia-related malignant hyperthermia reaction to testing facilities. The significance of a positive CHCT in patients without such a history is unclear. Eighty-seven of 136 patients with no personal or familial history of adverse anesthetic reactions who underwent CHCT between 1992 and 2014 were CHCT positive. Reasons for referral include elevated creatine kinase (CK), postexercise rhabdomyolysis or exercise intolerance, postviral chronic fatigue, and muscle weakness of unknown etiology. Oral dantrolene improved musculoskeletal symptoms in 28 of 34 CHCT-positive patients; responders had a higher pretreatment CK and a larger reduction in CK.
557 Brain Maturation in Neonatal Rodents Is Impeded by Sevoflurane Anesthesia
N-acetylaspartate (NAA) is located and synthesized in neurons and is involved in myelin synthesis. Its concentration increases during early postnatal brain development. Proton magnetic resonance spectroscopy can be used to measure brain NAA concentrations noninvasively. The rate of rise of the concentration of NAA from postnatal day 8 to day 9 was less in neonatal rats exposed to 5 h of sevoflurane anesthesia on postnatal day 7 than it was in age-matched unexposed rat pups. The rate of rise of the concentration of NAA from postnatal day 16 to day 17 was unaffected by the same anesthesia regimen. These metabolomics findings support histological evidence that postnatal day 7 rats exposed to anesthesia undergo increased apoptosis but older rats are not as sensitive. See the accompanying Editorial View on page 497.
692 Intraoperative Protective Mechanical Ventilation for Prevention of Postoperative Pulmonary Complications: A Comprehensive Review of the Role of Tidal Volume, Positive End-expiratory Pressure, and Lung Recruitment Maneuvers (Review Article)
Intraoperative lung-protective mechanical ventilation using low tidal volumes, with or without high positive end-expiratory pressure and recruitment maneuvers, has the potential to prevent postoperative pulmonary complications. This review begins with a summary of current definitions of postoperative pulmonary complications and methods to predict their development. Putative mechanisms of ventilator-induced lung injury, including barotrauma, volutrauma, and atelectrauma, are then presented as are mechanical ventilation strategies to protect lungs during surgery. Recent evidence from randomized controlled trials of the effect of protective intraoperative mechanical ventilation on both nonclinical and clinical primary outcome measures is critically reviewed. An algorithm for protective mechanical ventilation in nonobese patients during open abdominal surgery based on the utmost recent evidence is proposed and further research needs are identified. See the accompanying Editorial View on page 501.