How well do pediatric anesthesiologists agree when assigning ASA physical status classifications to their patients?1

BACKGROUND: The scope and application of the American Society of Anesthesiologists Physical Status (ASA PS) classification has been called into question and interobserver consistency even by specialist anesthesiologists has been described as only fair. Our purpose was to evaluate the consistency of the application of the ASA PS amongst a group of pediatric anesthesiologists. METHODS: We randomly selected 400 names from the active list of specialist members of the Society for Pediatric Anesthesia. Respondents were asked to rate 10 hypothetical pediatric patients and answer four demographic questions. RESULTS: We received 267 surveys, yielding a response rate of 66.8% and the highest number of responses in any study of this nature. The spread of answers was wide across almost all cases. Only one case had a response spread of only two classifications, with the remaining cases having three or more different ASA PS classifications chosen. The most variability was found for a hypothetical patient with severe trauma, who received five different ASA PS classifications. The Modified Kappa Statistic was 0.5, suggesting moderate agreement. No significant difference between the private and academic anesthesiologists was found (P = 0.26). CONCLUSIONS: We present the largest evaluation of interobserver consistency in ASA PS in pediatric patients by pediatric anesthesiologists. We conclude that agreement between anesthesiologists is only moderate and suggest standardizing assessment, so that it reflects the patient status at the time of anesthesia, including any acute medical or surgical conditions.     

Does the reimbursement of anesthesiologists for intraoperative transesophageal echocardiography promote increased utilization?

OBJECTIVE: To determine whether access to reimbursement increases anesthesiologists' use of intraoperative transesophageal echocardiography (TEE). DESIGN: Survey. SETTING: United States. PARTICIPANTS: Members of the Society of Cardiovascular Anesthesiologists, local Medicare carriers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In year 2000, local Medicare carrier policies specifically allowed some form of reimbursement to the attending anesthesiologist for intraoperative TEE in 15 states, but barred all forms of reimbursement in 16 states and Puerto Rico. Data regarding utilization and billing were available for 702 members of the Society of Cardiovascular Anesthesiologists from these jurisdictions who used TEE in their anesthetic practice. Billing patterns were found to vary significantly according to the local Medicare policy in effect (p = 0.004). Use of intraoperative TEE was found to be unrelated, however, to the reimbursement available from Medicare (p = 0.2 to 0.7). CONCLUSION: The use of intraoperative TEE by anesthesiologists does not seem to be related to the availability of reimbursement from Medicare.     

Awareness during pediatric anesthesia – what is the position of European pediatric anesthesiologists?

BACKGROUND: The incidence of awareness in the pediatric population is reported as high as 1 : 125. An online survey was conducted about the current perception and practice of members of the British and French pediatric anesthesia societies regarding awareness during general anesthesia. METHODS: Following the approval of the executive committees of the British and French pediatric anesthesia societies, members with a valid email contact address were invited to participate in a web-based survey. Perceived risk factors, use of awareness monitors, pre- and postoperative discussions of awareness as well as personal experience were enquired. RESULTS: A total of 302 (51%) responded to the email survey. More than 60% indicated that awareness is a problem in pediatric anesthesia with the majority estimating an incidence of 1 : 1000. Almost half (49%) the respondents believe that awareness is age-dependent and 50% are not concerned below 1 month of age. More than 86% of respondents do not discuss the risk of awareness with the parents or actively look for awareness despite 27% reporting at least one episode in their practice. Intra-operative monitoring almost exclusively consists of clinical signs and endtidal anesthetic concentrations. Bispectral index (BIS) monitoring is routinely used by approximately 10% of the surveyed members. CONCLUSIONS: This survey demonstrates that European pediatric anesthesiologists perceive awareness as a major problem. However, none seems to address the issue openly or looks for its presence routinely. The vast majority of pediatric anesthesiologists rely almost exclusively on clinical monitoring and endtidal anesthetic concentrations for its detection.     

How do we define the condition ‘recurrent low back pain’? A systematic review

Recurrent low back pain (recurrent LBP) is a common condition, however, it is unclear if uniform definitions are used in studies investigating the prevalence and management of this condition. The aim of this systematic review was to identify how recurrent LBP is defined in the literature. A literature search was performed on MEDLINE, EMBASE, CINAHL, AMED, and PEDro. Studies were considered eligible if they investigated a cohort of subjects with recurrent LBP or if they were measuring the prevalence of recurrent LBP. Two independent reviewers assessed inclusion of studies and extracted definitions of recurrent LBP. Forty-three studies met the inclusion criteria. The majority of studies (63%) gave an explicit definition of recurrent LBP; however, the definitions varied greatly and only three definitions for recurrent LBP were used by more than one study. The most common feature given as part of the definition was the frequency of previous episodes of low back pain. Only 8% (3/36) of studies used previously recommended definitions for recurrent LBP. Large variation exists in definitions of recurrent LBP used in the literature, making interpretation of prevalence rates and treatment outcomes very difficult. Achieving consensus among experts in this area is required.     

What do French anesthesiologists choose when they are patients themselves?

To determine whether, as patients, French anaesthesiologists prefer regional anaesthesia, like their North American colleagues, they were all mailed a questionnaire which submitted 2 different scenarios. Scenario A concerned emergency surgery for an open fracture to the right tibia, the patient-cum-anaesthetist having a full stomach. Scenario B was the elective removal of the plate a year later. Response rate was 15% (1,187 answers). For scenario A 89% of physicians preferred regional anaesthesia, while 57% preferred regional anaesthesia for scenario B. Epidural anaesthesia was twice as popular as spinal anaesthesia. Lower limb blocks were only chosen by a minority (A:5%; B:6%). Statistically significant differences were found between selected techniques, according to respondent's age, sex, medical school and type of practice, especially for scenario B. The fear of complications like regurgitation, allergic reaction, or postdural puncture headache seemed to be of less influence in the choice than the experience of the anaesthetist to carry out the anaesthetic in each scenario. It can therefore be concluded that French anaesthesiologists prefer regional anaesthesia for lower limb surgery required for themselves. However, experience of the "operator" with the technique seems to be as important as the technique itself.     

Management of pregnancy-related emergencies: What do Polish anesthesiologists know?

BackgroundEmergencies can occur at any time during pregnancy. In addition to obstetricians and midwives, anesthesiologists should also be familiar with pregnancy-related emergencies. The aim of this study was to assess the basic and advanced knowledge regarding the management of pregnancy-related emergencies of anesthesiologists.MethodsAn anonymous questionnaire was distributed to anesthesiologists at two conferences (S1, n = 87; S2, n = 35), and to other groups comprising doctors during specialization (DS, n = 28) and postgraduate doctors (PD, n = 130). Ultimately, 280 doctors were included in the survey. The first part of the questionnaire collected demographics, and a second one evaluated both their basic and advanced knowledge by taxonomy.ResultsBasic knowledge regarding the management of pregnancy-related emergencies of the tested group was poorer compared with advanced knowledge. The DS group had better basic management skills than anesthesiology specialists and the PD group. Significantly worse results of the tested group were obtained on the questions about maneuvers for choking pregnant women and time to cesarean section during cardiopulmonary resuscitation. The specialists and the DS group had results on advanced level questions better than the PD group.ConclusionsOlder specialists in anesthesiology did not know how to properly manage pregnancy-related emergencies at the basic level; however, anesthesiologists were familiar with advanced management. No relationship between recalling and using such knowledge in difficult situations was observed. The teaching process of acute obstetric emergencies must be improved through implementation of compulsory nationwide courses and verification of knowledge every few years.     

Accidental needlesticks: do anesthesiologists practice proper infection control precautions?

Anesthesiologists as well as patients are at risk for acquiring blood-borne infections such as hepatitis and AIDS. We surveyed 2,530 anesthesiologists, a 10% random sample of the members of the American Society of Anesthesiologists, with a response rate of 57.1%, to determine the incidence of accidental needlestick exposure among anesthesia personnel and whether anesthesiologists are adhering to infection control guidelines to protect themselves and their patients from exposure to infectious diseases. Eighty-eight percent of respondents reported at least 1 accidental needlestick in the past 10 years; 21% received a needlestick from a high-risk patient and 4.5% a needlestick from a known HIV-positive patients. Residents reported significantly more accidental needlesticks from known HIV-positive patients (8.5%). Mucous membrane, open cut, eye, or other significant exposure to HIV-contaminated blood or body fluids was sustained by 8.34% of respondents in the past 10 years. Sixty percent of respondents reported they almost never reuse common syringes now compared with a 40.8% non-reuse rate (P < 0.001) in a similar survey on infection control practices conducted in 1990. Sixty-three percent reported they almost never reuse a vasopressor syringe compared with the 1990 non-reuse rate of 52.5% (P < 0.001). In the current survey, 39% of anesthesiologists reported reusing syringes from one patient to another and 36% reported reusing the same vasopressor syringes for different patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

How much colorectal surgery do general surgeons do?

BACKGROUND: Surgical subspecialization has croded the traditional domain of the general surgeon. The purpose of this study was to assess the volume and distribution of colon and rectal cases performed by general surgeons. STUDY DESIGN: The American Board of Surgery database was queried to identify and categorize the number of colorectal cases performed yearly by "generalists" (general surgeons) recertified between 1995-1997. RESULTS: There were 2,434 general surgeons (those with a basic certificate only) recertified. The mean number of large bowel cases was 33 (range 0-243). Thirty-one cases represented the 70th percentile and 60 cases represented the 90th percentile. The mean number of anorectal cases was 12.3 (range 0-185). The 70th percentile was 15 cases, and the 90th percentile was 26 cases. Seventy-five percent of general surgeons perform > or = 17 large intestine cases each year, whereas, only 25% perform > 16 total anorectal cases. CONCLUSION: General surgeons perform a substantial number of colon resections and relatively few anorectal cases. It is unclear whether this is an issue of anorectal training in general surgery programs or referral patterns.     

How to define anemia in children with chronic kidney disease?

In a cross-sectional study, we compared the prevalence of anemia based on age- and gender-specific reference intervals for hemoglobin (Hgb) and hematocrit (Hct) with the Kidney Disease Outcomes Quality Initiative (KDOQI) anemia definition (Hgb < 110 g/L) in 351 children with chronic kidney disease (CKD) stages I–V. Cystatin C-based GFRs were 122 ± 36 mL/min/1.73 m² in patients with stage I CKD (n = 196), 76 ± 8 mL/min/1.73 m² for stage II (n = 104), 45 ± 9 mL/min/1.73 m² for stage III (n = 36), and 22 ± 5 mL/min/1.73 m² in patients with stage IV+V CKD (n = 15). Fifty-nine patients received iron therapy and 32 patients were treated with Darbepoetin. For Hgb, a total of 90 patients fit the age and gender derived criteria, compared to only 54 patients identified by the KDOQI guidelines (p = 0.0010). Similarly, for Hct, a total of 78 patients fit the age and gender derived criteria, which was a significantly higher proportion than the 56 identified by the KDOQI guidelines (r = 0.22, p = 0.0435). There was a significant correlation between the GFR and both the Hgb Z-score (p = 0.0068) and the Hct Z-score (p = 0.0128). There was poor agreement between conventional and KDOQI definitions of anemia in children with CKD.     

How do we assess microsurgical skill?

How does one demonstrate competence in microsurgery? This will become an increasingly more important question as further reforms in surgical training and revalidation are implemented. Any assessment of competence should include an assessment of technical skill, but there is presently no validated objective assessment technique to do this. We examine the ideal characteristics of an assessment technique and review the methods currently being validated and which could be applicable to microsurgical skills. © 2005 Wiley‐Liss, Inc. Microsurgery 25:25–29, 2005.