Liposomal bupivacaine (LB) has been the subject of a great deal of study, and some degree of controversy, since its development in the late 1990s. While some published studies are supportive of its efficacy, many others are not or demonstrate only marginal improvement in analgesia. This variable efficacy occurs in the face of markedly increased costs when compared with plain local anesthetics. In this education article, we trace the development of LB, summarize the important aspects of its pharmacology, and explore possible causes of its failure to fulfill the promise that the drug held when it was developed and approved. Finally, we discuss some aspects of perineural anatomy that might impact the potential of this drug to provide long-lasting analgesia.

Introduction The use of artificial intelligence (AI) in the scientific process is advancing at a remarkable speed, thanks to continued innovations in large language models. While AI provides widespread benefits, including editing for fluency and clarity, it also has drawbacks, including fabricated content, perpetuation of bias, and lack of accountability. The editorial board of Regional Anesthesia & Pain Medicine (RAPM) therefore sought to develop best practices for AI usage and disclosure.Methods A steering committee from the American Society of Regional Anesthesia and Pain Medicine used a modified Delphi process to address definitions, disclosure requirements, authorship standards, and editorial oversight for AI use in publishing. The committee reviewed existing publication guidelines and identified areas of ambiguity, which were translated into questions and distributed to an expert workgroup of authors, reviewers, editors, and AI researchers.Results Two survey rounds, with 91% and 87% response rates, were followed by focused discussion and clarification to identify consensus recommendations. The workgroup achieved consensus on recommendations to authors about definitions of AI, required items to report, disclosure locations, authorship stipulations, and AI use during manuscript preparation. The workgroup formulated recommendations to reviewers about monitoring and evaluating the responsible use of AI in the review process, including the endorsement of AI-detection software, identification of concerns about undisclosed AI use, situations where AI use may necessitate the rejection of a manuscript, and use of checklists in the review process. Finally, there was consensus about AI-driven work, including required and optional disclosures and the use of checklists for AI-associated research.Discussion Our modified Delphi study identified practical recommendations on AI use during the scientific writing and editorial process. The workgroup highlighted the need for transparency, human accountability, protection of patient confidentiality, editorial oversight, and the need for iterative updates. The proposed framework enables authors and editors to harness AI's efficiencies while maintaining the fundamental principles of responsible scientific communication and may serve as an example for other journals.

The American Society of Regional Anesthesia 2015 guidelines suggest that pre-existing nerve damage constitutes a relative contraindication to peripheral nerve blocks (PNBs), although these guidelines emphasize systemic neuropathies rather than distal compressive neuropathies.[1][1] Cubital tunnel

ABSTRACTBackgroundIn the context of the current opioid crisis, there is a growing interest in evaluating non-pharmacological solutions to manage post-operative pain. Evidence supports the concept that auriculotherapy may provide significant analgesiaObjectiveInvestigating the efficacy of cryo-auriculotherapy to reduce postoperative opioid consumption following a rotator cuff surgery.SettingsAcademic medical center, USAMethodsThis trial was registered to Clinicaltrials.gov (NCT03860259). A total of 39 subjects undergoing rotator cuff surgery and randomized to receive either an active cryo-auriculotherapy treatment (Auriculotherapy; n=20) or a placebo treatment (placebo; n=19) were included in the analysis. For each cryo-auriculotherapy subject, the treatment was performed in the recovery room. The primary endpoint was overall opioid consumption (oral morphine equivalent = OME). Secondary endpoints included pain and overall non-narcotic analgesic consumption on postoperative day 5, patient satisfaction and function recovery using the 12-Item Short Form Health Survey (SF-12), time to discharge from the recovery room and the hospital and patient satisfaction, as well as the number of subjects from each group readmitted because of pain-related issues.ResultsThe use of cryo-auriculotherapy was associated with a 35% decrease in total opioid requirement over the first five-day recovery period and a 15% decrease in pain with movement. Pain with movement in the auriculotherapy group remained lower compared to the placebo group for at least 14 days (4.47 ± 2.12 vs 5.84 ± 2.39, respectively; p=0.0394).ConclusionsOur data suggests that cryo-auriculotherapy represents an alternative to opioids in patients undergoing rotator-cuff surgery.

Nerve block (NB) procedures are essential interventions for managing pain by disrupting pain signal transmission along specific nerves. This paper introduces a virtual reality (VR) ultrasound-guided peripheral NB simulation, NBSim, designed for Meta Quest 2 and 3 VR headsets. The simulation aims to evaluate the usability of VR controllers versus hand tracking for manipulating the ultrasound probe and injection needle during NB procedures. A study involving 19 anesthesiology residents randomized into two groups was conducted to assess participant performance and perceptions. Results indicate that while VR controllers may offer slight advantages in ease of use, hand tracking provides a significantly more realistic experience for controlling the needle, crucial for simulating the precision required in NB procedures. Limitations include the small sample size and the need for further research to evaluate long-term skill retention and transferability to clinical practice. Overall, NBSim presents a promising platform for enhancing training in ultrasound-guided NB procedures, with implications for improving clinical outcomes and patient safety.

To the Editor, The investigation by McLeod et al , in October RAPM , makes a strong argument that pressure monitoring does not reliably differentiate needle tip position among different tissues in peripheral nerve blockade.[1][1] However, the authors note in the discussion that "regional block

Background Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. Methods We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as >= 75% agreement and weak consensus as 50%-74% agreement. Results A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. Conclusions We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Purpose: The C4 dermatome anesthesia holds significance for arthroscopic shoulder surgery. However, the reliability of achieving C4 dermatome anesthesia with the current low-dose ultrasound-guided interscalene block (ISB) and supraclavicular block (SCB) remains uncertain. This prospective, single-center study examined the effects of ultrasound-guided interscalene block (ISB) and supraclavicular block (SCB) on the C4 sensory dermatome in patients undergoing shoulder, hand, or wrist surgery. Patients and Methods: Patients undergoing outpatient shoulder, hand, or wrist surgeries received ultrasound-guided ISB (for shoulder surgeries) with 12-15 mL of 0.5% bupivacaine or ultrasound-guided SCB (for hand and wrist surgeries) with 20-24 mL of 0.5% bupivacaine. The primary objective of the study was to investigate the sensory effect on the C4 dermatome after ISB and SCB. The secondary outcomes included the sensory effect on the C5 dermatome after performing ISB and SCB, pain scores upon arrival at the post-anesthesia care unit (PACU), and the incidence of adverse effects. Results: Sixty-one patients were recruited: 30 for ISB and 31 for SCB. C4 dermatome coverage was achieved in 53% and 29% of patients in the ISB and SCB groups, respectively (p=0.0268). Additionally, C5 dermatome coverage was achieved in 97% and 68% of patients in the ISB and SCB groups, respectively (p=0.0034). A moderate correlation coefficient (r=0.47) was observed between C4 sensory scores and postoperative pain scores. Conclusion: Ultrasound-guided ISB successfully provided C4 coverage in 53% of cases, suggesting that performing an additional C4 block alongside ISB could be advantageous when aiming for complete surgical anesthesia. SCB may not be the primary choice for shoulder surgeries as it often fails to achieve satisfactory sensory blocks at the C4 and C5 levels. Plain language summary: This study examined how the interscalene block and supraclavicular block work for numbing the C4 area in patients undergoing shoulder, hand, or wrist surgery. We found that the interscalene block provided C4 coverage in only 53% of cases, suggesting performing an additional C4 block might help achieve complete surgical anesthesia. The supraclavicular block is not the best option for shoulder surgeries because it often fails to provide adequate anesthesia at the C4 and C5 levels.

From the *Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania †School of Population and Global Health, University of Melbourne, Melbourne, Australia. Accepted for publication November 18, 2022. Funding: None. The authors declare no conflicts of interest. Address correspondence to Steven L. Orebaugh, MD, Department of Anesthesiology, University of Pittsburgh School of Medicine, 3440 Terrace St, Suite 1310, Pittsburgh, PA 15260.

“Where’s Gina?” I asked one of our CRNAs, inquiring after a colleague that I’d worked with for nearly a decade, a skilled nurse anesthetist whom I considered a good friend. I hadn’t seen her for over a week at our ambulatory surgical center. My inquiry was met with a puzzled expression. “You didn’t hear?” That question suggests many things, few of them good. I suddenly had a feeling of foreboding, and I regarded the anesthetist, trying to brace myself for what was coming. “She’s gone. Terminated. They caught her stealing fentanyl in the eye rooms.” I was crestfallen. What a terrible loss, I thought. I’d had no clue this was occurring, and I had doubtless supervised some of those cases myself. This was one of a half-dozen such episodes in which I learned that one of my health care colleagues was using opioids or another addictive substance, and had been relieved of his or her duties, then dismissed from employment. Each revelation was chilling and stupefying—How? Why? What could possibly prompt such impetuous behavior? My favorite nurse anesthetist, in line to be our chief at some point. A respected academic mentor. No less than 3 anesthesiology residents, 1 of whom died, and another found in a coma on the bathroom floor. And, most recently, a dutiful, amiable acute pain nurse. These were just the people that I KNEW about. How many others, I have often wondered? Six years ago, after learning of the downfall of our anesthetist, I decided that I needed to contribute to the swelling tide of education about opioid misuse, to somehow provide a warning that could help others to comprehend just how insidious these drugs are. Since I spend most of my days providing nerve blocks to reduce the need for opioids in the perioperative period, it seemed a natural thing to do. And, like most anesthesiologists, l have an understanding of these drugs—we provide opioids for analgesia every day or closely supervise those who do. In addition, I have experienced the effects of fentanyl several times myself, for surgery and for GI procedures. I remember thinking, in my euphoric state, that this rapture could explain why a susceptible and perhaps naive person might ceaselessly pursue the thrill of narcotics until they completely consumed him or her. I settled on the idea of writing a novel depicting the fall from grace of a respected anesthesiologist, hoping that this could help to educate doctors, nurses, pharmacists, and perhaps the population at large. And so, in my mind, the story began to emerge: a beautiful, accomplished woman with a penchant for forbidden pleasures enters the life of our young hero…and after a night of passion, he grudgingly agrees to traverse the boundaries of both good practice and his own integrity. The slope proves very slippery and treacherously steep; as he embraces both the woman and the drugs, his life begins to unravel and then completely implodes. He discovers a road to redemption, but it is arduous and will test him severely. The crumbling stairways that lead down to the teeming, drug-ridden neighborhood below the hill on which he lives emphasize the downward arc of his existence, but they lead back upward as well. Will Kurt be able to re-establish his practice, his good name, and the relationships he values? As the dedication suggests, the book is written in tribute to, and sympathy for, those who have fallen prey to opioids. The crisis has only deepened since the pandemic began, with 100,000 deaths last year in the United States attributed to opioid overdose. My hope is that this novel can be part of a sustained effort by physicians to quell what has become an epidemic that is eroding the very core of our society.Figure.: Cover of “The Stairs On Billy Buck Hill.”

To cite: Yin J, Yin W, Kairis E, et al. Reg Anesth Pain Med Epub ahead of print: [please include Day Month Year]. doi:10.1136/rapm-2022103734 Department of Anesthesiology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA

Background:Ultrasound imaging is increasingly used in medical practice, but many institutions have room for growth regarding its incorporation into medical education. An elective hands-on course was developed for preclinical medical students using ultrasound to review and enhance their understanding of anatomy as well as to teach ultrasound-guided nerve blocks on cadaver extremities. The hypothesis was that after 3 instructional sessions students would be able to identify 6 anatomic structures, representing 3 types of tissue, in cadaver upper extremities.Methods:Students received didactic instruction on ultrasound and regional anatomy at the beginning of each class, followed by hands-on practice, including ultrasound use with phantom task trainers, live models, and fresh cadaver limbs. The primary outcome was the students' ability to correctly identify anatomic structures using ultrasound. Secondary outcomes included their ability to perform a simulated nerve block in the cadaver extremities in comparison with a standardized checklist, as well as their response to a post-course survey.Results:Overall, the students had a 91% success rate in identifying anatomic structures and showed capability of performing simulated nerve block with occasional instructor prompting. The post-course survey revealed that the students felt strongly that both the ultrasound and cadaveric components of the course were beneficial to their education.Conclusion:Ultrasound instruction with live models and fresh cadaver extremities in a medical student elective course resulted in a high degree of recognition of anatomic structures, as well as permitted a valued clinical correlation in the form of simulated peripheral nerve blockade.

Background The interscalene brachial plexus block has been used effectively for intraoperative and postoperative analgesia in patients undergoing shoulder surgery, but it is associated with high rates of diaphragmatic dysfunction. Performing the block more distally, at the level of the superior trunk, may reduce the incidence of phrenic nerve palsy. We hypothesized that superior trunk block would result in diaphragmatic paralysis rate of less than 20%. Methods 30 patients undergoing arthroscopic shoulder surgery received superior trunk block under ultrasound guidance. Measurements of diaphragm excursion were determined with ultrasound prior to the block, 15 min after the block, and postoperatively in phase II of postanesthesia care unit, in conjunction with clinical parameters of respiratory function. Results 10 patients (33.3%, 95% CI 17.3% to 52.8%) developed complete hemidiaphragmatic paralysis at the postoperative assessment. An additional eight patients (26.7%) developed paresis without paralysis. Of the 18 patients with diaphragm effects, seven (38.9%) reported dyspnea. 83.3% of patients with abnormal diaphragm motion (56.7% of the total sample) had audibly reduced breath sounds on auscultation. Oxygen saturation measurements did not correlate with diaphragm effect and were not significantly reduced by the postoperative assessment. Conclusion Although injection of local anesthetic at the superior trunk level is associated with less diaphragmatic paralysis compared with traditional interscalene block, a significant portion of patients will continue to have ultrasonographic and clinical evidence of diaphragmatic weakness or paralysis.

Background and objectivesWhile there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists.MethodsThis anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items were defined as highest importance (score ≥8) by ≥70% of all participants.Results469 participants/586 invitations (80.0% response) scored in round 1, and 402/469 participants (85.7% response) scored in round 2. Participants represented 66 countries. Strong consensus was reached for 8 core peripheral and neuraxial blocks and 17 items describing learning objectives and skills assessment. Volume of practice for peripheral blocks was uniformly 16–20 blocks per anatomical region, while ≥50 neuraxial blocks were considered minimum.ConclusionsThis international consensus study provides specific information for designing a non-fellowship regional anesthesia curriculum. Implementation of a standardized curriculum has benefits for patient care through improving quality of training and quality of nerve blocks.

To the Editor We congratulate and thank the Fourth Consensus Conference addressing Guidelines for the Management of Postoperative Nausea and Vomiting (PONV).1 We wholeheartedly agree with its "one major change in this iteration of the guideline…that in adults, the panel consensus is now to implement multimodal PONV prophylaxis in patients with 1 or 2 risk factors, in an attempt to reduce risk of inadequate prophylaxis." However, since patients with 0 risk factors still have a 10% PONV risk, and because at least 3 nonsedating off-patent inexpensive antiemetics are easily available with minimal side effect burden, we endorse 2 integrated approaches that differ from those presented by the current or previous Consensus Guidelines. First, and principally, we endorse that oral perphenazine 8 mg (OP8) is a low-cost and efficacious tool for prevention of PONV. Second, we will demonstrate the theoretical value of "the perphenazine-dexamethasone-ondansetron (P-D-O) technique" (OP8, dexamethasone 4 mg intravenous [IV], and ondansetron 4 mg IV), applied to every PONV risk category in such a way that the patient may receive a greater number of PONV-prophylactic agents than what the Consensus Guidelines recommend. Specifically, Consensus "wait and see" patients get 3 antiemetics (P-D-O); those for whom 2 agents are recommended receive 3 agents (P-D-O); and those for whom 3 or 4 agents are recommended all get 4 (P-D-O and an neurokinin-1 receptor-antagonist such as aprepitant [40 mg orally, per os]). Perphenazine, a phenothiazine with antihistamine properties, at 5 mg IV, was included in the Consensus manuscript's Table 4, but the IV preparation has not been commercially available in the United States since the early 2000s. We have had extensive experience with OP8 in adults as part of a multimodal antiemetic plan, with its cost at the undersigned authors' institutions ranging from 50 cents to 2 dollars per dose (US currency). For this low cost per patient, we have previously reported2 a 27.2% reduction in the need for IV ondansetron rescue in the postanesthesia care unit (PACU) in nearly 9500 patients from 2002 to 2006. The implications of a routinely applied P-D-O technique, including for "zero risk factor" patients, is illustrated in a scenario analysis given in the Table. In the classic factorial trial by Apfel et al,3 ondansetron 4 mg, dexamethasone 4 mg, and droperidol 1.25 mg each reduced the risk of PONV by approximately 25%. Based on our 2002–2006 aforementioned2 ~25% reduction in need-for-rescue when OP8 was used preoperatively, the Table illustrates that the 3-drug low-cost P-D-O reduces the theoretical risk from 20/200 (10%) to 8/200 (4%) in patients that the Consensus-recommended prophylaxis plan would entail rescue-only without prophylaxis. With the sequential 25% risk reduction per each prophylactic drug, OP8 reduces 20/200 to 15/200, dexamethasone reduces 15/200 to 11/200, and ondansetron reduces 11/200 to 8/200. For patients with 20%–40% risk, we assume 2-agent antiemetic prophylaxis in the Consensus-treated group with ondansetron-dexamethasone (4 mg each IV), and the P-D-O technique-treated group having a 25% further risk reduction than the Consensus-treated group. Finally, for the 60%–80% risk groups where the Consensus guideline is for 3 or 4 antiemetics, we assume half of the Consensus-treated group gets ondansetron-dexamethasone-droperidol 1.25 mg IV for "3 antiemetics," and the other half of the Consensus-treated group gets ondansetron-dexamethasone-droperidol-aprepitant 40 mg po for "4 antiemetics"; meanwhile, we recommend that P-D-O-aprepitant be given for the 60%–80% risk P-D-O–treated groups. Table. - Scenario Analysis of Side-by-Side Estimated Incidences of PONV When the Consensus Guidelines Are Followed Versus the Proposed P-D-O Technique Baseline PONV risk Consensus-recommended intervention1 Consensus-dosed, PONV cases per 2001 P-D-O technique, PONV cases per 2002,3 PONV prevented with P-D-O, cases per 2002 10% Wait and see 20 8 12 20% 2 antiemetics 22 16 6 40% 2 antiemetics 45 32 13 60% 3 or 4 antiemetics 25 + 19 = 44 38* 6 80% 3 or 4 antiemetics 34 + 25 = 59 51* 8 Difference in incidence (column total) 190 per 1000 145 per 1000 45 cases per 1000 prevented P-D-O technique: perphenazine (8 mg orally before surgery) plus dexamethasone (4 mg IV after induction) plus ondansetron (4 mg IV before emergence). When the Consensus-recommended intervention involves a range of options (eg, 3 or 4 antiemetics), the Consensus-dosed PONV cases per 200 represents a weighted average (half receiving 3, the other half receiving 4), *but for the P-D-O technique, a fourth agent (eg, aprepitant) is what we recommend (and assume) for all cases to have a 25% further risk reduction. Further prospective study is needed to confirm this clinical impression. In this illustration, oral perphenazine 8 mg2 is assumed to be a viable substitute to IV droperidol 1.25 mg3, with a ~25% risk reduction. Further prospective study is needed to confirm this clinical impression. No other multimodal techniques are assumed to have been given in either treatment arm (eg, regional or total IV anesthesia). Based on this estimate, 45 fewer patients per 1000 would encounter PONV with the P-D-O technique, representing a 24% risk reduction when compared with the Consensus guideline prophylaxis scheme using ondansetron-dexamethasone, with or without droperidol, and with or without aprepitant, based on the risk estimate category given above.Abbreviations: IV, intravenous; P-D-O, perphenazine-dexamethasone-ondansetron; PONV, postoperative nausea and vomiting We previously2 encouraged prospective, randomized research with OP8, especially in light of nonsedating benefits in the setting of ambulatory anesthesia fast-tracking and phase 1 PACU bypass, but (13 years after that recommendation) do not anticipate the costs of this research to be underwritten by industry sponsors due to its long-standing availability as a generic preparation, and the implications of a generic medication showing equal efficacy to branded medications. We have found OP8 useful as follows: (1) as a nonsedating antiemetic; (2) as a preventative measure similar to the antihistamine promethazine4 against ketamine-induced psychotomimetic effects; and (3) as a safe single-dose drug (only 1.3 extrapyramidal events per 10,000 patients receiving 4–8 mg oral dose, with all events easily treated).5 We have published a case series/review2 and a randomized trial6 of emetic outcomes after the use of OP8 and dexamethasone, with6 or not necessarily with2 ondansetron (ie, before ondansetron became available as a generic medication). Additionally, we evaluated the efficacy of single-dose OP8 to a single 40 mg dose of aprepitant given preoperatively in colorectal surgery patients at our academic center within an enhanced recovery protocol, which was designed to mitigate opioid utilization, reduce PONV, and optimize patient recovery.7 In this retrospective study, no differences were noted in antiemetic requirement on postoperative days 0 and 1 between patients receiving OP8 versus aprepitant. In addition, when patients were matched for preoperative, procedural, and anesthesia characteristics, no differences were noted in late PONV between patients receiving OP8 versus aprepitant. As enhanced recovery protocols become more widespread and continue to be applied to other surgical specialties, effective PONV prevention is imperative for improving patient outcomes. OP8 deserves to be properly evaluated (by clinical study, and/or in routine clinical practice) as a part of a cost-effective multimodal enhanced recovery strategy. As a reminder, metoclopramide should be considered contraindicated for perioperative use if perphenazine is used preoperatively, due to drug interaction risk. According to the Consensus Guideline, "Metoclopramide may be useful in institutions where other dopamine antagonists are not available, but otherwise may not be very efficacious."1 CONCLUSIONS The search for the best, cost-effective approach to PONV is far from complete. We recommend that anesthesiology/surgery departments and hospital clinicians on Pharmacy & Therapeutics committees consider in earnest the value of routine preoperative, single-dose OP8, as part of the described P-D-O technique, for patients who have (1) no history of extrapyramidal reactions to similar drugs, (2) no concomitant current long-term prescriptions for antidopaminergic psychiatric drugs, including aripiprazole, and (3) no coexisting Parkinson Disease or cerebral palsy. Our threshold age for dose reduction (0–4 mg instead of 8 mg) is 70 years, if there is no plan for concomitant ketamine use. Brian A. Williams, MD, MBADepartment of Anesthesiology and Perioperative MedicineUniversity of PittsburghPittsburgh, Pennsylvania[email protected] Jennifer M. Holder-Murray, MDDepartment of SurgeryUniversity of PittsburghPittsburgh, Pennsylvania Stephen A. Esper, MD, MBAKathirvel Subramaniam, MDDepartment of Anesthesiology and Perioperative MedicineUniversity of PittsburghPittsburgh, Pennsylvania Susan J. Skledar, BS Pharm, MPH, FASHPDepartment of Pharmacy and TherapeuticsUniversity of PittsburghPittsburgh, Pennsylvania Michael L. Kentor, MDSteven L. Orebaugh, MDMichael P. Mangione, MDJames W. Ibinson, MD, PhDJonathan H. Waters, MDJohn P. Williams, MDJacques E. Chelly, MD, PhD, MBADepartment of Anesthesiology and Perioperative MedicineUniversity of PittsburghPittsburgh, Pennsylvania