Point-of-care ultrasound in pediatric anesthesiology and critical care medicine

Ultrasound has increasingly become a clinical asset in the hands of the anesthesiologist and intensivist who cares for children. Though many applications for ultrasound parallel adult modalities, children as always are not simply small adults and benefit from the application of ultrasound to their management in various ways. Body composition and size are important factors that affect ultrasound performance in the child, as are the pathologies that may uniquely afflict children and aspects of procedures unique to this patient population. Ultrasound simplifies vascular access and other procedures by visualizing structures smaller than those in adults. Maturation of the thoracic cage presents challenges for the clinician performing pulmonary ultrasound though a greater proportion of the thorax can be seen. Moreover, ultrasound may provide unique solutions to sizing the airway and assessing it for cricothyroidotomy. Though cardiac ultrasound and neurosonology have historically been performed by well-developed diagnostic imaging services, emerging literature stresses the utility of clinician ultrasound in screening for pathology and providing serial observations for monitoring clinical status. Use of ultrasound is growing in clinical areas where time and diagnostic accuracy are crucial. Implementation of ultrasound at the bedside will require institutional support of education and credentialing. It is only natural that the pediatric anesthesiologist and intensivist will lead the incorporation of ultrasound in the future practice of these specialties.     

Review article: New directions in medical education related to anesthesiology and perioperative medicine

Purpose

We aim to provide a broad overview of current key issues in anesthesiology education to encourage both ??clinician teachers?? and ??clinician educators?? in academic health centres to consider how medical educational theory can inform their own practice.

Principal findings

Evolving contextual issues, such as work-hour reform and the patient safety movement, necessitate innovative approaches to anesthesiology education. There is a substantial amount of relevant literature from other disciplines, such as sociology, psychology, and human factors research, using methodologies that are often unfamiliar to most clinicians. Recurring themes include the increasing use of simulation-based education, the importance of faculty development, challenges in teaching and assessing the non-medical expert roles, and the promise of team training and interprofessional education. Interdisciplinary collaborations are likely key to answering pressing questions in anesthesiology education, and a greater understanding of qualitative and mixed methods research will allow a broader range of questions to be answered. Simulation offers the opportunity to learn from failures without exposing patients to risk and brings the challenge of integrating innovations into existing curricula. Interprofessional education allows learning in the teams that will work together; even so, it needs to be prioritized to overcome logistical barriers. The challenges of introducing a competency-based curriculum have resulted in hybrid systems where elements of competency-based medical education have been combined with traditional apprenticeship curricula. The value of faculty development to encourage even simple measures, such as establishing learning objectives and discussing these with trainees, cannot be over-emphasized. Key issues in assessment include the need to evaluate multiple levels of performance in a cohesive system of assessment and the need to identify the unintended consequences of assessment.

Conclusions

We have identified a number of key themes and challenges for anesthesiology education. This discussion will continue in greater depth in individual articles in this issue so as to promote further interest in a growing body of literature that is relevant to anesthesiology education.     

The use of computers for perioperative simulation in anesthesia, critical care, and pain medicine

Simulation in perioperative anesthesia training is a field of considerable interest, with an urgent need for tools that reliably train and facilitate objective assessment of performance. This article reviews the available simulation technologies, their evolution, and the current evidence base for their use. The future directions for research in the field and potential applications of simulation technology in anesthesia, critical care, and pain medicine are discussed.     

Molecular medicine--perspectives for anesthesiology and intensive care medicine

The past few decades have seen a profound development in biological sciences. The great progress in molecular biology has provided an enormous potential of new instruments for highly specific and sensitive insights into the etiology and therapy of human disease. Among these first the prototype technique "polymerase chain reaction" (PCR) results in improved diagnostic procedures. The contributions of recombinant DNA technology in defining the molecular pathology of common disorders and of diagnostic molecular techniques for risk stratification are used as examples to reveal the clinical relevance of this innovative tool and its modifications. In addition, the potential use of modified nucleic acid fragments as a therapeutic drug (gene therapy) is mentioned.     

Technologies to shape the future: proteomics applications in anesthesiology and critical care medicine

Broadly speaking, proteomics is concerned with the simultaneous characterization of the features (for example, the concentration or activity) of the many different proteins that are typically found in biological or clinical specimens. The field is being driven forward both by innovative biotechnology companies and by academicians who are introducing the technology required for the parallel identification of individual proteins. The technology currently relies heavily on two-dimensional gel electrophoresis combined with mass spectrometry, but protein microarray chips are rapidly becoming a reality. Protein biomarkers are increasingly being recognized as crucially important for the study of disease processes, both from diagnostic and prognostic points of view. Proteome level studies will therefore be used increasingly both to identify and follow the course of various pathological conditions. In the specialty of anesthesiology, this technology will allow an improved understanding of the mechanisms of action of many of the drugs that are routinely administered in the operating room and also the effects of these therapeutic drugs on protein expression. In addition, proteomic studies will increasingly be used for both diagnostic and prognostic purposes in the intensive care unit and the chronic pain clinic.     

Outcomes in perioperative medicine and anesthesiology. Into the next millennium

Although the development of outcomes research in perioperative medicine and anesthesiology has focused on traditional clinical outcomes, there seems to be a transition toward more global assessments of patient-related outcomes. Present trends in outcomes research and EBM may promise an improvement in individual patient and overall quality of care. New roles and opportunities in perioperative medicine and anesthesiology provide additional venues for outcomes research in this millennium.     

Assessing the relative quality of anesthesiology and critical care medicine Internet mailing lists.

We studied the relative quality of a subset of anesthesiology and critical care medicine Internet mailing lists regarding the publishing capacity of their members to compare them with the major journals and conferences regarding these specialties. Using systematic searches on MEDLINE and according to the Science Citation Index 1995, we investigated the impact factor of mailing list subscribers, of the first authors of the selected articles, and of the first authors of published abstracts from conferences. We studied six mailing lists, seven journals, and four conferences. Journals and conferences showed a higher percentage of published authors and higher average impact factor among their first authors than the mailing lists did per subscriber. However, when only the subset of publishing authors from the three media was considered, no significant differences were found. We conclude that qualified authors may be found among the subscribers of Internet medical mailing lists on anesthesiology and critical care medicine. These professional discussion groups could complement peer-reviewed publications and conferences in professional information exchange and continuing medical education. Implications: Internet publishing is not governed by rules that assure certain basic quality standards. Methods for assessing these standards are needed. We compared discussion groups with medical journals and conferences on anesthesiology and critical care medicine by calculating the impact factor of their members and first authors, respectively. Our study shows that qualified authors may be found in all three media.     

Up-to-date medical care for perioperative venous thromboembolism in Japan--standardization of care for perioperative venous thromboembolism in Japan: preface

New era in the prevention of venous thromboembolism (VTE) in Japan started in 2004 when the Japanese guideline for prevention of VTE was released by the editorial committee on the Japanese guideline for prevention of VTE and Japanese public health system began to cover the cost of physical prevention of VTE for hospitalized patients. The incidence of perioperative symptomatic pulmonary thromboembolism (PTE) significantly decreased in 2004 compared with 2003 and 2002 according to the results of the annual research for perioperative PTE by the Japanese Society of Anesthesiologists (3.62/10,000 cases in 2004, 4.41/10,000 cases in 2002, 4.76/10,000 cases in 2003). However, there has been no change in the mortality rate of perioperative PTE during these three years. This special issue was planned to introduce the panel discussion titled as "Up-to-date medical care for perioperative venous thromboembolism in Japan-Standardization of care for perioperative venous thromboembolism in Japan" in the 53rd annual scientific meeting of the Japanese Society of Anesthesiologists at Kobe in 2006.