Anesthesiology

Pediatric anesthesiology is a deeply rewarding specialty, and the job market remains favorable for the trainees who choose it. However, the U.S. pediatric anesthesiology workforce is facing a convergence of challenges, including declining fellowship recruitment, increasing nonoperating room anesthesia (NORA) and complex surgical volume, expanding clinical demands, and migration of physicians from academic hospitals to ambulatory and contract-based practice models. These trends threaten access to specialized pediatric perioperative care, weaken educational and research missions, and strain the ability of children's hospitals to care for medically complex patients. This article examines the drivers of current U.S. workforce instability and proposes a framework for recruitment, retention, and long-term sustainability. Key recommendations include improving work-life integration through flexible scheduling, aligning compensation with clinical and academic contributions, investing in physician wellness, strengthening leadership engagement, leveraging technology to optimize staffing, and expanding mentorship and pipeline development initiatives. Sustaining the pediatric anesthesiology workforce will require deliberate institutional investment to ensure continued access to high-quality care for children.

Critical care demand in the United States continues to rise, driven by an aging population, increasing comorbidities, and longer hospitalizations. Despite ample capacity and need for anesthesiology critical care medicine (ACCM) training, anesthesiologists account for less than 10% of U.S. intensivists, and recent fellowship match data consistently show underfilled ACCM positions. Structural factors, including perceived compensation, workload, and competing clinical demands, contribute to lower resident interest in ACCM. However, these concerns may not reflect current market and practice patterns. Initiatives aimed at generating accurate data and educating potential candidates on the actual, rather than the perceived, ACCM lifestyle are key. Strengthening anesthesiologist representation requires early mentorship, structured scholarly experiences, and personalized training pathways. Combined and tailored ACCM tracks, modeled after successful approaches in other subspecialties, can align training with career interests while supporting physician retention. As intensive care unit demand grows, anesthesiologists are primed to expand their critical care leadership and meet national workforce needs.

BACKGROUND:The association between narrow pulse pressure and acute kidney injury (AKI) remains controversial. We hypothesized that normal mean arterial pressure (MAP) with narrow pulse pressure is independently associated with postoperative AKI. METHODS:This retrospective cohort study analyzed adult noncardiac surgeries at a single academic medical center in South Korea (2011 to 2020). Patients were stratified by median intraoperative pulse pressure: narrow (less than 40 mmHg), reference (40 to 70 mmHg), and wide (greater than 70 mmHg). Entropy balancing adjusted for covariates, including cumulative vasopressor load and hypotension duration. A two-by-two risk matrix evaluated the interaction between MAP (less than 65 vs . 65 mmHg or greater) and pulse pressure. A mechanistic substudy correlated pulse pressure with stroke volume index. RESULTS:Among 30,039 patients (median age 60 yr; 54.6% male), AKI incidence was 6.7%. Compared to reference pulse pressure, narrow pulse pressure was independently associated with AKI (odds ratio, 1.66; 95% CI, 1.42 to 1.94; P < 0.001). Hypotension with reference pulse pressure did not significantly increase risk (odds ratio, 1.09; 95% CI, 0.86 to 1.38; P = 0.475). Conversely, normotension with narrow pulse pressure elevated AKI risk (odds ratio, 1.56; 95% CI, 1.27 to 1.89; P < 0.001). Patients experiencing a "double hit" of concurrent hypotension and narrow pulse pressure exhibited the highest risk (odds ratio, 1.85; 95% CI, 1.21 to 2.81). Mechanistically, stroke volume index was significantly lower in the normotensive narrow pulse pressure group than the hypotensive reference group (27 vs . 47 ml/m 2 ). Risk became significant after 40 min of exposure. CONCLUSIONS:Narrow pulse pressure is independently associated with postoperative AKI, even when MAP is maintained above 65 mmHg. A MAP-centric approach may obscure low-flow states, highlighting the potential value of incorporating pulse pressure into perioperative assessments.

BACKGROUND:Dopamine neurons in the ventral tegmental area (VTA), a midbrain structure, have been widely implicated in promoting emergence from general anesthesia. However, most studies have focused on anesthetics that primarily target GABAA receptors. Whether these neurons also facilitate emergence from mechanistically diverse drug-induced unconscious states is not known. Here we examine the specific contribution of VTA dopamine neurons in restoring arousal following sevoflurane-, dexmedetomidine-, fentanyl-, and ketamine-induced unconsciousness. METHODS:Adult Sprague Dawley rats received viral constructs driving selective expression in tyrosine hydroxylase-positive VTA neurons of either channelrhodopsin or the control protein, YFP. Accurate targeting in VTA TH:ChR was confirmed by assessing righting in response to photostimulation during continuous sevoflurane inhalation (1.4-2.0%). In a randomized block design, rats were exposed to dexmedetomidine (15 µg/kg IV bolus), fentanyl (50 µg/kg IV bolus), or ketamine (50 mg/kg IV infusion). Following loss of the righting reflex, behavioral arousal and frontal EEG activity were recorded with or without photostimulation. The proportion of animals righting during the light-on and light-off conditions was assessed in a mixed-effects Cox regression model, and spectral power differences were quantified with effect size estimates. RESULTS:Optogenetic stimulation of VTA dopamine neurons during continuous sevoflurane inhalation restored righting in VTA TH:ChR rats, with a median latency of 4.7 minutes (95%CI[2.6, 6.4]) following the onset of photostimulation. VTA TH:ChR rats were significantly more likely to right during photostimulation following dexmedetomidine (HR = 27.7, 95%CI[2.7, 287.1], p=0.0053), and responders showed attenuated spectral power in low frequencies (<12Hz) in VTA TH:ChR. Optogenetic stimulation did not affect behavioral nor neurophysiological measures of arousal following fentanyl. Finally, optogenetic stimulation in VTA TH:ChR rats modestly delayed emergence from ketamine sedation without altering EEG spectral power. CONCLUSIONS:These data suggest the role of dopamine VTA neurons in anesthetic emergence is agent-specific and likely shaped by distinct, and sometimes opposing, neural pathways.

BACKGROUND:The Hypotension Prediction Index (HPI) was developed to predict intraoperative hypotension several minutes before its occurrence. Although previous randomized trials reported reduced hypotension with HPI-guided management, these findings may partly reflect performance bias from open-label designs and selection bias in algorithm validation. Recent observational evidence suggests that much of HPI's apparent benefit may result from earlier treatment at higher mean arterial pressure (MAP) thresholds, supporting direct randomized comparison with a proactive higher MAP target. METHODS:In this open-label, parallel-group randomized controlled trial at two centers, 100 adults undergoing major noncardiac surgery requiring invasive arterial monitoring were equally randomized to HPI-guided management (treatment triggered when HPI ≥85) or a higher MAP-targeted strategy (treatment triggered when MAP ≤ 73 mmHg), both following the same predefined hemodynamic protocol. The primary endpoint was time-weighted average hypotension (MAP <65 mmHg), used to test superiority of HPI-guided management over a proactive higher MAP target. Secondary outcomes included area under the threshold for hypotension, hypertension burden (MAP >100 mmHg), norepinephrine dose, length of hospital stay, and 30-day mortality. RESULTS:Median (interquartile range) time-weighted average hypotension was 0.07 (0-0.20) mmHg in the HPI group and 0.16 (0.02-0.50) mmHg in the higher MAP target group (P = 0.119). The area under the threshold for hypotension was 22 (0-96) mmHg·min and 59.7 (5.7-119.3) mmHg·min, respectively (P = 0.172). Time-weighted average hypertension did not differ significantly between groups: 0.80 (0.50-1.80) versus 0.70 (0.20-1.98) mmHg (P = 0.555). Pre-specified secondary clinical outcomes, including norepinephrine dose, length of hospital stay and 30-day mortality, did not differ significantly. CONCLUSIONS:HPI-guided management was not superior to a proactive MAP ≤73 mmHg strategy. Because this trial was not designed to test equivalence or noninferiority, the findings indicate no demonstrated superiority rather than clinical equivalence between the trigger strategies.

BACKGROUND:Esophageal pressure (Pes) is the reference standard for monitoring inspiratory effort and lung stress during assisted ventilation, but its routine application is hindered by the lack of specialized equipment and specific training. We aimed to determine whether endotracheal tube cuff pressure (PCUFF) could serve as a more accessible surrogate. METHODS:In this prospective study, Pes and PCUFF were simultaneously recorded in 30 orally intubated adult patients undergoing pressure support ventilation. A downward pressure support titration (15 to 5 cmH2O) was performed. PCUFF was calibrated using occlusion-induced changes in airway pressure. The correlation between tidal swings of PCUFF and Pes was analyzed using a linear mixed-effects model. Agreement between the two parameters was evaluated by Bland-Altman analysis (for repeated measures). Diagnostic performance was analyzed for PCUFF to detect extremes of inspiratory effort, using inspiratory muscle pressure (Pmus) and Pmus-time product per minute (PTPmus/min) as references, alongside high transpulmonary driving pressure (∆PL>20 cmH2O) and high transpulmonary mechanical power (MPL>12 J/min). RESULTS:Across 840 analyzed breaths, PCUFF correlated with Pes (marginal R²=0.772; conditional R²=0.949) with a mean bias (limits-of-agreement) of 0.25 (-5.42-5.92) cmH₂O. For detecting low effort (Pmus<5 cmH2O or PTPmus/min<50 cmH2O·s/min), PCUFF yielded areas under the curves (AUCs) of 0.95 (95% confidence interval: 0.91-0.99) and 0.94 (0.86-1.00), respectively. For identifying high effort (Pmus>10 cmH2O or PTPmus/min>150 cmH2O·s/min), the respective AUCs were 0.93 (0.89-0.97) and 0.82 (0.76-0.88). Utilizing a leave-one-out cross-validation framework to prevent overfitting, PCUFF successfully discriminated high ∆PL and MPL with AUCs of 0.89 (0.83-0.95) and 0.88 (0.82-0.93), respectively. CONCLUSIONS:Although PCUFF cannot entirely replace Pes for precise quantification due to relatively wide limits of agreement, it exhibits excellent diagnostic discrimination. PCUFF holds promise as an accessible, continuous bedside monitor for identifying patients with potentially injurious levels of effort, stress and energy intensity.

BACKGROUND:Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are increasingly prescribed for type 2 diabetes (T2DM) management with demonstrated benefits on glycemic control, cardiac outcomes, and weight reduction but further study is needed to establish the impact of GLP-1 RAs on perioperative outcomes. METHODS:We conducted an observational analysis with data between June 1, 2013, to June 1, 2023, using an electronic health record database (TriNetX Research Network) before the 2023 American Society of Anesthesiologists guidance to hold GLP-1 RAs preoperatively. Adult surgical patients with T2DM having anesthesia were propensity-score matched 1:1 by surgery type, patient characteristics, diabetic biomarkers, and risk factors for postoperative morbidity. We compared GLP-1 RA use with (1) metformin, (2) sodium-glucose cotransporter 2 inhibitors (SGLT2i), or (3) dipeptidyl peptidase-4 inhibitors (DPP4i). Each group did not have concomitant use of the comparator. Outcomes were 14-day postoperative mortality, aspiration pneumonitis, bacterial pneumonia, emergency intubation, acute kidney injury, stroke, acute myocardial infarction (MI), and major adverse cardiovascular events (MACE) as defined by a composite of mortality, MI, or stroke. RESULTS:Preoperative GLP-1 RA use was associated with reduced mortality (0.98% vs. 2.20%, risk ratio (RR) 0.44 [95% confidence interval 0.31-0.64], Padj 0.0002) when compared to metformin use. Compared to SGLT2is, GLP-1 RAs were associated with numerical difference in MACE (3.86% vs. 5.03%, RR 0.77 [0.60-0.98], Padj 0.13). When compared with DPP4is, GLP-1 RAs were associated with decreased postoperative mortality (1.84% vs. 2.89%, RR 0.63 [0.45-0.89], Padj 0.04) and bacterial pneumonia (0.85% vs. 1.80%, RR 0.47 [0.29-0.76], Padj 0.02). CONCLUSIONS:Preoperative GLP-1 RA use was associated with lower short-term postoperative mortality and reduced morbidity compared with metformin and DPP4is, and no increased aspiration risk compared to any other drug class. Although these findings suggest perioperative benefits of GLP-1 RAs, confirmation in prospective studies is needed to guide evidence-based management strategies.

BACKGROUND:Increasingly, protocols have been developed to optimize obstetric anesthesia care. However, there is a paucity of data on adherence to these guidelines. The primary aims of this study were to utilize the Multicenter Perioperative Outcomes Group (MPOG) database to estimate (1) the rate of adherence to best practice guidelines for cesarean delivery (CD) (2) the association of case- and hospital-level factors with adherence, and (3) the percentage of variability in adherence attributable to the patient-, case-, and hospital-level factors. METHODS:We performed a multicenter, observational cohort study utilizing the MPOG database to review all CDs in women aged 15-44. Best practices were defined based on societal guidelines and included timely antibiotic administration, post-spinal SBP maintenance >90 mmHg, general anesthesia (GA) avoidance, prevention of perioperative hypothermia, use of low-dose neuraxial morphine, post-spinal vasopressor infusions, and spinal needles ≥ 25-gauge. Covariates of interest included patient-, case-, and hospital-level factors. RESULTS:We analyzed 289,047 CD cases in the MPOG database from 2015-2022. The following adherence outcomes were observed: timely antibiotic administration, 86.2% (99%CI: 86-86.3%); post-spinal SBP maintenance, 96.7% (99%CI: 96.6-96.8%); avoidance of GA, 97.0% (99%CI: 96.9-97.0%); prevention of perioperative hypothermia, 56.7% (99%CI: 56.5-56.9%); use of low-dose neuraxial morphine, 74.2% (99%CI: 74.0-74.5%); use of post-spinal vasopressor infusion, 55.4% (99%CI: 55.1-55.8%); and use of ≥ 25-gauge needle for spinal anesthesia, 89.0% (99%CI: 88.6-89.4%). Poorer adherence correlated with factors at the patient- (ASA Physical Status ≥ 4), case- (evening or overnight CD), and institution-level (absence of obstetric fellowship or "Center of Excellence" status). CONCLUSIONS:Among our large cohort of CD cases, overall adherence to guideline-supported best practices was variable, with post-spinal vasopressor infusions being the lowest and avoidance of GA being the highest. Targeted interventions addressing these factors may improve quality and promote more optimal care.