M. Christine Stock

Surgical Duration and Risk of Venous Thromboembolism

IMPORTANCE There is a paucity of data assessing the effect of increased surgical duration on the incidence of venous thromboembolism (VTE). OBJECTIVE To examine the association between surgical duration and the incidence of VTE. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective cohort of 1,432,855 patients undergoing surgery under general anesthesia at 315 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011. EXPOSURE Duration of surgery. MAIN OUTCOMES AND MEASURES The rates of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE within 30 days of the index operation. Surgical duration was standardized across Current Procedural Terminology codes using a z score. Outcomes were compared across quintiles of the z score. Multiple logistic regression models were developed to examine the association while adjusting for patient demographics, clinical characteristics, and comorbidities. RESULTS The overall VTE rate was 0.96% (n = 13,809); the rates of DVT and PE were 0.71% (n = 10,198) and 0.33% (n = 4772), respectively. The association between surgical duration and VTE increased in a stepwise fashion. Compared with a procedure of average duration, patients undergoing the longest procedures experienced a 1.27-fold (95% CI, 1.21-1.34; adjusted risk difference [ARD], 0.23%) increase in the odds of developing a VTE; the shortest procedures demonstrated an odds ratio of 0.86 (95% CI, 0.83-0.88; ARD, -0.12%). The robustness of these results was substantiated with several sensitivity analyses attempting to minimize the effect of outliers, concurrent complications, procedural differences, and unmeasured confounding variables. CONCLUSIONS AND RELEVANCE Among patients undergoing surgery, an increase in surgical duration was directly associated with an increase in the risk for VTE. These findings may help inform preoperative and postoperative decision making related to surgery.

High incidence of burnout in academic chairpersons of anesthesiology: Should we be taking better care of our leaders?

Background: Burnout is a work-related psychologic syndrome characterized by emotional exhaustion, low personal accomplishment, and depersonalization. Methods: By using an instrument that included the MBI-HHS Burnout Inventory, we surveyed academic anesthesiology chairpersons in the United States. Current level of job satisfaction compared with 1 and 5 yr before the survey, likelihood of stepping down as chair in the next 2 yr, and a high risk of burnout were the primary outcomes. Results: Of the 117 chairs surveyed, 102 (87%) responded. Nine surveys had insufficient responses for assessment of burnout. Of 93 chairs, 32 (34%) reported high current job satisfaction, which represented a significant decline compared with that reported for 1 yr (P = 0.009) and 5 yr (P = 0.001) before the survey. Of 93 chairs, 26 (28%) reported extreme likelihood of stepping down as a chair in 1–2 yr. There was no association of age (P = 0.16), sex (P = 0.82), or self-reported effectiveness (P = 0.63) with anticipated likelihood of stepping down, but there was a negative association between the modified efficacy scale sco&rgr;rgr; = −0.303, P = 0.003) and likelihood of stepping down. Of 93 chairs, 26 (28%) met the criteria for high burnout and an additional 29 (31%) met the criteria for moderately high burnout. Decreased current job satisfaction and low self-reported spousal/significant other support were independent predictors of high burnout risk. Conclusion: Fifty-one percent of academic anesthesiology chairs exhibit a high incidence/risk of burnout. Age, sex, time as a chair, hours worked, and perceived effectiveness were not associated with high burnout; however, low job satisfaction and reduced self-reported spousal/significant other support significantly increased the risk.

Effect of Pleurotomy on Pulmonary Function After Median Sternotomy

To determine whether pleurotomy during median sternotomy worsens postoperative pulmonary function, patients whose pleurae remained intact (N = 7) were compared with those whose pleural spaces were entered during median sternotomy (N = 31). Thirty-eight adults performed spirometry and N2 washout to determine functional residual capacity preoperatively and 2, 24, 48, and 72 hours after extubation. Two mediastinal drainage tubes were placed in every patient; no pleural drainage tubes were inserted. Chest roentgenograms were performed preoperatively and 24 and 72 hours after extubation. Preoperatively, functional residual capacity, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC did not differ between groups. Postoperatively, in all patients developed a restrictive pulmonary defect, but mean functional residual capacity, FVC, FEV1 and FEV1/FVC did not differ between groups. In contrast to earlier reports, entering the pleural space did not worsen the restrictive pulmonary defect that results from median sternotomy when direct pleural drainage was avoided.

Performance Outcomes in Anesthesiology Residents Completing Categorical (Anesthesia) or Advanced (Nonspecific) Internship Training

Background: The internship or first year (PGY 1) of anesthesiology training may be categorical (within anesthesiology), or obtained in more diverse settings. Revisions recently proposed in the training requirements incorporated the PGY 1 into the existing curriculum. Purposes: We studied whether this change improved measurable outcomes. Methods: There were 518 residents studied retrospectively from four institutions that offered entry following both “Categorical” and “Other” internships. Thus the training in clinical anesthesia was identical. Results: No differences were observed in percentile scores on the Anesthesiology In-Service Training Examination during clinical anesthesia training, the receipt of awards, board certification or time to certification, or in reports of unsatisfactory performance to the American Board of Anesthesiology. “Categorical” residents were more frequently appointed chief resident. Conclusions: Easily accessible performance measures may function as valuable aids in decision making, particularly when significant changes in curricula are contemplated. Data do not support the proposed changes in anesthesiology.

An innovative textbook: design and implementation

The ‘flipped classroom’ instructional strategy has gained much momentum in educational discourse, yet no single educational offering exists in postgraduate medical education (PME) to systematically replace the lecture element of didactic sessions. This article describes the design and implementation of Clinical Anesthesia Fundamentals, the first known textbook in PME addressing this gap in resources through the integration of full‐length interactive multimedia‐enhanced video lectures.