Professional news and highlights of December 2011 by Konstantin Lebedinskiy (Website Editor) 12/14/2011 12:00:00 AM

The Checklist Manifesto: To Be Continued!

Young surgeon from Boston, Dr. Atul Gawande, was invited by the American Society of Anesthesiologists to be the 2011 ASA Annual Meeting Opening Session speaker. The author of the New York Times Bestseller “The Checklist Manifesto: How To Get Things Right” (Amazon Best Book of the Month, December 2009), staff writer for the New Yorker magazine, Dr. Gawande was selected by Foreign Policy Magazine and TIME as one of the world’s top 100 influential thinkers.

His opening lecture was also dedicated to the problem of patient safety - from checklist ideology to the Lifebox Program, supported by WHO and WFSA (Dr. Gawande is the Chair of the Lifebox Foundation Board). Very dynamic style saturated with everyday examples and humor makes his speech not only interesting professionally but also pleasant for the listener. Without any doubt, Dr. Gawande is one of the most prominent promoters of contemporary “Patient Safety Movement”, disproving our traditional tale about rigid surgeon…

Some Useful Tools (for the beginning…)

Formula for Body Surface Area (DuBois D, DuBois EF, 1916*):

BSA (m²) = 0.007184 x Height(cm)0.725 x Weight(kg)0.425

Formula for Lean Body Weight:

Lean Body Weight (men) = (1.10 x Weight(kg)) - 128 ( Weight2/(100 x Height(m))2)
Lean Body Weight (women) = (1.07 x Weight(kg)) - 148 ( Weight2/(100 x Height(m))2)

Formula for Body Mass Index (BMI):

Body Mass Index = Weight(kg) / Height(m)2

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* DuBois D; DuBois EF: A formula to estimate the approximate surface area if height and weight be known. Arch Int Med 1916 17: 863-71.
For more details ? see, for example, http://www.halls.md/body-surface-area/refs.htm

The More Data the Better…

Choice of blood pressure monitoring method is usually affected by anaesthesiologist’s expectations of hemodynamic instability: the higher is predicted risk, the more is our attitude to direct arterial pressure monitoring. Common belief is that red pressure trace on the screen is anyway much more reliable than NIBP figures, and after arterial cannulation we often turn non-invasive measurement off or just set very long interval.

It seems, however, that combined use of both methods provides more smooth hemodynamic control, as shown by David B Wax, Hung-Mo Lin and Andrew B Leibowitz in this November issue of “Anesthesiology” (2011; 115(5): 973-8)! NIBP tendency towards underestimate high direct ABP and overestimate low figures could be explained taking into consideration usual position of the cuff in comparison to cannula: in unstable patients figures from brachial artery could be closer to aortic pressure, and therefore more reliable and less “extreme” than those taken from a. radialis.

Certainly, any monitor by itself couldn’t influence the results of treatment, but this difference leads to more moderate anaesthesiologist’s policy, resulting in “decreased use of blood transfusions, vasopressor infusions, and antihypertensive medications compared with the use of ABP alone”. Of course, usually we can’t cancel direct measurement, but these data at least suggest simultaneous use of both methods.
See also comment by Keith Ruskin at “Page 2” Anesthesiology’s blog…

UK National Training Survey 2011: Report Publish

The General Medical Council (GMC) - British independent organization, registering doctors to practise medicine in the UK in order “to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine” - has published the results of its annual survey of junior doctors which provides a comprehensive picture of the views, experience and perceptions of more than 46.000 doctors in training working across the UK.

According to the results, while overall satisfaction of trainees in UK is rather high (79% of the respondents rated their training as excellent or good!), 28% of trainees rarely or never felt feedback from their senior colleagues, 25% did not feel ready to take the next career step and 22% were regularly forced to cope with challenges for which they felt themselves inadequately prepared.

The general list of these problems seems completely similar to the majority of previously published data, in particular concerning anaesthesia residents in various countries - US, Sweden, Russia, etc. Probably, any training system left some of the trainees unsatisfied due to lack of individual approach, and the only quality indicator is simply exact proportion?

Job of Sisyphus or Task for Odysseus?

Evident contradiction between patient safety and methodological strictness is crucial dilemma of many clinical trials, especially those of randomized double-blind design. Dr. Ryan Crowley and co-authors from UCLA David Geffen School of Medicine in the last issue of “Anesthesiology” (2011; 115(5): 1033?43) concluded that continuous central venous oxygen saturation (ScvO2) oximetry could play a significant role in preventing adverse outcomes, but noted certain limitation of their study: it was an observational, unblinded prospective trial, whilst “a prospective trial to evaluate the utility of continuous ScvO2 as a target parameter of goal-directed therapy to improve clinical outcomes is warranted”.

Eckehard AE Stuth and George M Hoffman in the accompanying editorial and Alan J Schwartz in Anesthesiology's blog “Page 2” compared this sophisticated challenge with Sisyphean job: we have to plan our clinical trials considering patient safety as a conditio sine qua non, despite its possible influence on the scientific strength may be evidently deleterious. However, optimistic point of view suggests that the task seems to be more similar not to that of Sisyphus but Odysseus, who has to pass successfully this narrow strait between Scylla of ethics and Charybdis of scientific rigour…

Neuroscientific Foundations of Anesthesiology

Neuroscientific Foundations of Anesthesiology edited by George A. Mashour and Ralph Lydic from Ann Arbor (MI, USA) is available since the last September via the website of Oxford University Press. Since neuroscience is evident basis of all anaesthesiological issues, detailed discussion of this topic, written by the leading specialists from US, Canada, Germany and Uruguay, is essential for both anaesthesia practitioners and researchers.

Twenty chapters are distributed among six main parts of the book covering brain, spinal cord, peripheral and autonomic nervous system, neuromuscular junction and the problem of anaesthetic neurotoxicity. Example pages, giving impressive survey of the whole text, could be explored at Amazon E-bookstore, where the book will be available this December.