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Purpose To address an aging anesthesia workforce, we review the relevant changes and implications associated with age in order to stimulate discussion at the individual, local, and national levels regarding appropriate changes in practice aimed at protecting patient safety. Principal findings In a 2013 survey of Canadian Anesthesiologists, 22% were aged 55-64 yr, 7% were aged 65-74 yr, and 3% were older than 74 yr. Clinical abilities decline with age, making older anesthesiologists more likely than their younger colleagues to be associated with adverse patient events. Anesthesiologists older than 65 yr in Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury compared with anesthesiologists younger than 51 yr of age. In the absence of overt deterioration in skills, decisions about reducing activities and retirement are left largely to individuals despite their limited ability to self-assess competence. This state of affairs may contribute to the increased incidence of adverse events and poor patient outcomes. Conclusions Provincial regulatory bodies have peer assessment programs to evaluate physicians at random, following a complaint, and at certain ages, but all have limitations. Simulation has been used widely for training and assessment in the aviation industry as well as in automobile driving exams. Simulation can assess crisis recognition and management, which is crucial in anesthesiology and not well assessed by other methods, and could assist elderly anesthesiologists during the pre-retirement phase of their careers. A standardized schedule for winding down would have advantages for physicians, their department, and their patients. A suggested schedule might include no further on-call duties for those aged 60 yr and older, no further high-acuity cases for those aged 65 yr and older, and retirement from operating room (OR) clinical practice (with possible continuation of non-OR clinical or other non-clinical activities, if desired) at age 70 yr. These timelines could be extended with satisfactory performance in annual simulation sessions involving assessment and practice in crisis management.

Purpose: Medical emergency teams (MET) merge earlier-thanconventional treatment of worrisome vital signs with a skilled resuscitation response team, and may possibly reduce cardiac arrests, postoperative complications, and hospital mortality. Methods: At the two sites of The Ottawa Hospital, MET was introduced in January 2005. We reviewed call diagnoses, interventions, and outcomes from MET activity, and examined outcomes [cardiac arrests, intensive care unit (ICU) admissions, and readmissions] from Health Records and the ICU database. We compared the first fully operational year, 2006, with pre-MET years, 2003–4. Results: In 5,741 patient encounters, the teams (nurse, respiratory therapist, and intensivist) responded to 1,931 calls over two years, predominantly for high-risk in-patients. As well, there were 3,810 follow-up visits to these patients and to recently discharged ICU patients. In 2006, there were 40.3 calls/team/1,000 hospital admissions, with 71.2% of in-patient ICU admissions preceded by MET calls. Patient illness severity scores decreased from 4.9±2.6 (mean ± SD) before implementing MET to 2.9±2.3 ( P <0.0001) after MET interventions. Intervention on the respiratory system was performed on 72% of patients. Admission to the ICU occurred in 27% of MET patients. Compared with the pre-MET period, we observed decreases in: cardiac arrests (from 2.53±0.8 to 1.3±0.4/1,000 admissions, P <0.001); ICU admissions from in-patient nursing units/month (42.3±7.3 to 37.6±5.1, P =0.05); readmissions after ICU discharge/month (13.5±5.1 to 8.8±4.5, P =0.01); and readmissions within 48 hr of ICU discharge/ month (4.4±2.4 to 2.8±1.0 ICU readmissions/month, P =0.01). Conclusions: Successful implementation of MET reduces patient morbidity and ICU resource utilization.

The concept of a critical care outreach or medical emergency team (MET) was conceived in Australia in 1990, and has since become popular there and in the United Kingdom. Its key components are twofold: earlier recognition of a deteriorating patient based on vital signs, and subsequent response and evaluation by a designated team with expertise, experience and resources.

An audit of intensive care unit (ICU) patients with perioperative myocardial ischemia and/or infarction (PMI/I) suggested under-use of prophylactic beta-adrenergic blocking drugs (ABDs). A multidisciplinary team developed an institutional protocol to identify at-risk patients, to standardize and facilitate prophylactic beta-adrenergic blockade, and to improve management of such patients. We report a retrospective assessment of the efficiency of program implementation. Eligible preanesthesia assessment unit patients received metoprolol for one to four weeks prior to surgery, intraoperatively, and postoperatively. Patients with PMI/I requiring ICU admission were tracked from January 2002 to December 2004. The protocol was implemented in May 2003. The efficiency of program implementation was evaluated during two months of normal operating room activity (September 2003 and February 2004). The use of ABDs increased during the audit. Preoperative use increased from 31% in September 2003 to 39% of eligible patients in February 2004, with a stable surgical population. The incidence of patients with PMI/I admitted to ICU decreased from 2.6/1,000 surgical cases pre-implementation to 1.6/1,000 surgical cases post-implementation (P=0.025). For the whole hospital, implementation was associated with a decrease in PMI/I incidence from 5.9 to 2.0/1,000 surgical cases (P<0.001). Heightened awareness and standardization of perioperative beta-blockade coincided with an increase in metoprolol use in at-risk patients and reduction in PMI/I. There was an increase in at-risk patients receiving prophylactic ABDs, a reduction in PMI/I diagnoses throughout the hospital, and reduced ICU patient admissions with PMI/I.

Several modalities have been shown to be individually effective in reducing the incidence (and hence associated morbidity, mortality, and costs) of ventilator-associated pneumonia, but their implementation into clinical practice is inconsistent. We introduced an intensive care unit protocol and measured its effect on ventilator-associated pneumonia. A multidisciplinary team constructed a multifaceted protocol incorporating low risk and low cost strategies, many of which had independent advantages of their own. Some components were already in use, and their importance was emphasized to improve compliance. New strategies included elevation of the head of the bed, transpyloric enteral feeding, and antiseptic mouthwash. The approach to implementation and maintenance included education, monitoring, audits and feedback to encourage compliance with the protocol. The implementation of this prevention protocol reduced the incidence of ventilator-associated pneumonia from a baseline of 94 cases per year or 26.7 per 1,000 ventilator days to 51.3 per year or 12.5 per 1,000 ventilator days, i.e., about 50% of the pre-protocol rate (P < 0.0001). Adherence to simple and effective measures can reduce the incidence of ventilator-associated pneumonia. The protocol described was inexpensive and effective, and estimated savings are large. Implementation and maintenance of gains require a multidisciplinary approach, with buy-in from all team members, and ongoing monitoring, education, and feedback to the participants.

To describe the pharmacokinetic behaviour and practical aspects of low (0.5-1 l.min-1) and minimal (0.25-0.5 l.min-1) flow anaesthesia. A Medline search located articles on low flow anaesthesia, and computer simulated anaesthetic uptake models are used. Most, 85-90%, of anaesthetists use high fresh gas flow rates during inhalational anaesthesia. Low/minimal flow anaesthesia with a circle circuit may avoid the need for in-circuit humidifiers, raise the temperature of inspired gases by up to 6 degrees C, reduce cost by about 25% by reduction of fresh gas flows to 1.5 l.min-1, and reduce environmental pollution with scavenged gas. Knowledge of volatile anaesthetic pharmacokinetic behaviour facilitates the use of minimal/low flow rates. Small amounts of nitrogen or minute amounts of methane, acetone, carbon monoxide, and inert gases in the circuit are of no concern, but the degradation of desflurane (to carbon monoxide by dry absorbent) and sevoflurane (to compound A by using a fresh gas flow of > 2 l.min-1) must be avoided. With modern gas monitoring technology, safety should be no more of a concern than with high flow techniques. The use of fresh gas flow rates of < 1 l.min-1 for maintenance of anaesthesia has many advantages, and should be encouraged for inhalational anaesthesia with most modern volatile anaesthetics.

Background and Objectives.Until the arrival of microcatheters, continuous spinal anesthesia was mainly restricted to elderly and high-risk patients. The introduction of microcatheters enabled the technique to be used in a wider range of patients. This paper describes the experiences of anesthetists in Canada with these catheters, and the changes in their practice since their withdrawal.Methods.Anesthetists (those known to have experience with continuous spinal anesthesia, or to be regional anesthesia enthusiasts) across Canada were surveyed by telephone or mail.Results.Of a total of 36 respondents, 25 had tried continuous spinal anesthesia with microcatheters. The majority had experience of only a few cases, but a few reported larger series of hundreds of cases. Numerous technical difficulties with catheter insertion occurred, and problems with catheter breakage and neurologic deficit were reported. Some of these problems were reported to the Health Protection Branch, and, as a result of these reports and problems experienced in the United States, microcatheters were recalled in Canada soon after the FDA safety alert in the United States.Conclusions.Various techniques are being used instead of continuous spinal anesthesia with microcatheters, and only a few anesthetists favored their return.

Short stature and later maturation of youth artistic gymnasts are often attributed to the effects of intensive training from a young age. Given limitations of available data, inadequate specification of training, failure to consider other factors affecting growth and maturation, and failure to address epidemiological criteria for causality, it has not been possible thus far to establish cause–effect relationships between training and the growth and maturation of young artistic gymnasts. In response to this ongoing debate, the Scientific Commission of the International Gymnastics Federation (FIG) convened a committee to review the current literature and address four questions: (1) Is there a negative effect of training on attained adult stature? (2) Is there a negative effect of training on growth of body segments? (3) Does training attenuate pubertal growth and maturation, specifically, the rate of growth and/or the timing and tempo of maturation? (4) Does training negatively influence the endocrine system, specifically hormones related to growth and pubertal maturation? The basic information for the review was derived from the active involvement of committee members in research on normal variation and clinical aspects of growth and maturation, and on the growth and maturation of artistic gymnasts and other youth athletes. The committee was thus thoroughly familiar with the literature on growth and maturation in general and of gymnasts and young athletes. Relevant data were more available for females than males. Youth who persisted in the sport were a highly select sample, who tended to be shorter for chronological age but who had appropriate weight-for-height. Data for secondary sex characteristics, skeletal age and age at peak height velocity indicated later maturation, but the maturity status of gymnasts overlapped the normal range of variability observed in the general population. Gymnasts as a group demonstrated a pattern of growth and maturation similar to that observed among short-, normal-, late-maturing individuals who were not athletes. Evidence for endocrine changes in gymnasts was inadequate for inferences relative to potential training effects. Allowing for noted limitations, the following conclusions were deemed acceptable: (1) Adult height or near adult height of female and male artistic gymnasts is not compromised by intensive gymnastics training. (2) Gymnastics training does not appear to attenuate growth of upper (sitting height) or lower (legs) body segment lengths. (3) Gymnastics training does not appear to attenuate pubertal growth and maturation, neither rate of growth nor the timing and tempo of the growth spurt. (4) Available data are inadequate to address the issue of intensive gymnastics training and alterations within the endocrine system.

•Thalamus connectivity with sensory cortical regions decrease during development.•Thalamus connectivity with heteromodal cortical regions increase during development.•Increased thalamus connectivity with visual regions in females.•Increased thalamus connectivity with orbitofrontal regions in males.•Decreased thalamus connectivity with frontal regions in psychosis spectrum youth. The thalamus is composed of multiple nuclei densely connected with the cortex in an organized manner, forming parallel thalamocortical networks critical to sensory, motor, and cognitive functioning. Thalamocortical circuit dysfunction has been implicated in multiple neurodevelopmental disorders, including schizophrenia, which also often exhibit sex differences in prevalence, clinical characteristics, and neuropathology. However, very little is known about developmental and sex effects on thalamocortical networks in youth. The present study characterized the effects of age, sex and psychosis symptomatology in anatomically constrained thalamocortical networks in a large community sample of youth (n = 1100, aged 8–21) from the Philadelphia Neurodevelopmental Cohort (PNC). Cortical functional connectivity of seven anatomically defined thalamic nuclear groups were examined: anterior, mediodorsal, ventral lateral, ventral posterolateral, pulvinar, medial and lateral geniculate nuclear groups. Age and sex effects were characterized using complementary thalamic region-of-interest (ROI) to cortical ROI and voxel-wise analyses. Effects of clinical symptomatology were analyzed by separating youth into three groups based on their clinical symptoms; typically developing youth (n = 298), psychosis spectrum youth (n = 320), and youth with other psychopathologies (n = 482). As an exploratory analysis, association with PRIME scores were used as a dimensional measure of psychopathology. Age effects were broadly characterized by decreasing connectivity with sensory/motor cortical areas, and increasing connectivity with heteromodal prefrontal and parietal cortical areas. This pattern was most pronounced for thalamic motor and sensory nuclei. Females showed greater connectivity between multiple thalamic nuclear groups and the visual cortex compared to males, while males showed greater connectivity with the inferior frontal and orbitofrontal cortices. Youth with psychosis spectrum symptoms showed a subtle decrease in thalamic connectivity with the premotor and prefrontal cortices. Across all youth, greater PRIME scores were associated with lower connectivity between the prefrontal cortex and mediodorsal thalamus. By characterizing typical development in anatomically constrained thalamocortical networks, this study provides an anchor for conceptualizing disruptions to the integrity of these networks observed in neurodevelopmental disorders.