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STUDY OBJECTIVE: To determine needs, adequacy, types of resources, and challenges in teaching faculty how to provide feedback to residents. DESIGN: Survey instrument. SETTING: Academic medical center. PARTICIPANTS: Of the 115 anesthesia residency program directors surveyed, 69 responses were received (60% response rate). MEASUREMENTS: Percentages of respondents who indicated categories of need, adequacy, and types of resources for teaching faculty to give feedback to residents were recorded, as were narrative descriptions of challenges confronted by respondents. MAIN RESULTS: While the percentage of programs with faculty development resources has increased from 20.2% in 1999 to 48% today, an overwhelming majority of program directors (90%) feel that faculty require more training in providing feedback to residents. The majority of program directors also want more resources to train their faculty in providing feedback. CONCLUSIONS: While the perceived gap in providing training for faculty in giving feedback to anesthesia residents has narrowed, program director responses suggest a substantial unmet need remains. Innovative new approaches are in order.

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Noonan syndrome is a relatively common genetically transmitted disorder characterized by facial, cardiac, and musculoskeletal abnormalities. The management of a 27 year old woman with Noonan syndrome at 23 weeks' gestation, presenting with premature labor, who required an emergent Cesarean section for placental abruption, is discussed. In addition to Noonan syndrome, this patient had bacterial endocarditis involving the mitral and aortic valves. The anesthetic implications of Noonan syndrome and endocarditis during pregnancy are presented.

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STUDY OBJECTIVE: To determine the methods used to teach surgical airway management to residents. DESIGN: Electronic mail survey instrument. SETTING: Academic medical center. PARTICIPANTS: 82 (of a possible 132) United States residency program directors. MEASUREMENTS: Data including whether instruction in surgical airway management was provided, which methods were used, whether these teaching methods have changed since the subject was first examined, were recorded. The number of residents in each program represented by a respondent also was recorded. MAIN RESULTS: The survey response rate was 62% (82 of 132). Seventy-two respondents (88%) reported that education in surgical airway management was part of their curriculum. Practice on a mannequin was the most common form of instruction (57%), followed by traditional didactic teaching (31%), a cadaver workshop or a large animal laboratory (29%), human patient simulator training (24%), and supply of subject-specific reading materials alone (3%). Forty-seven programs (65%) taught surgical airway management using a single method, whereas the remainder (35%) incorporated more than one approach. Training experience was dependent on the program size. The top one quarter of the programs in size (67 ± 10 residents) were more likely to use a multimodal approach (48%) and a cadaver workshop or large animal laboratory (38%). CONCLUSIONS: The majority of anesthesiology training programs accredited by the Accreditation Council for Graduate Medical Education provide some form of skill-based instruction in surgical airway management for their residents.

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Anesthesiology residents in the United States (US) not only must develop the clinical skills needed to provide independent patient care, but also are required to become familiar with the business aspects of the modern health care system. Unfortunately, practice management education may be inadequate during anesthesiology residency training. The authors describe the design and implementation of a weekend retreat curriculum in business-of-medicine education for anesthesiology residents. Experts were recruited to discuss interviewing skills, contract law and negotiation, billing and reimbursement, insurance, malpractice, and financial planning. A strict lecture didactic format was avoided, and presentations were designed to encourage speaker-audience interaction. The program was relatively simple to design and implement, satisfied several Accreditation Council of Graduate Medical Education core competencies for US anesthesiology education, may be altered as practice management evolves, and may be adapted to accommodate the needs of programs in other countries.

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Klippel-Trénaunay syndrome is a rare disorder characterized by the triad of capillary or cavernous hemangiomas, venous varicosities or malformations, and soft tissue or bone hypertrophy. Neuraxial anesthesia in patients with Klippel-Trénaunay syndrome has been infrequently described and has not been previously reported when accompanied by consumptive coagulopathy with thrombocytopenia (Kasabach-Merritt syndrome). The authors describe their clinical management of a 23 year-old woman with Klippel-Trénaunay syndrome who presented for elective total knee arthroplasty. Her past medical history was notable for chronic Kasabach-Merritt syndrome, hypersplenism with pancytopenia, and intermittent lower gastrointestinal bleeding resulting from colonic hemangiomas. The physical examination revealed several large cavernous hemangiomas located on her right face, neck, chest, arm, and leg. No hemangiomas were noted within the dermatomal levels innervated by the upper lumbar spine. The neck hemangioma was very large and filled with blood when the patient assumed a supine position, making it almost impossible for her to breathe. The oropharynx revealed markedly hypertrophied soft tissue, pharyngeal, and hypopharyngeal hemangiomas, and a Mallampati class IV airway. Spinal and epidural hemangiomas were excluded based on a magnetic resonance imaging study before surgery. Kasabach-Merritt coagulopathy was corrected preoperatively by administration of cryoprecipitate. These interventions allowed the authors to safely perform a spinal anesthetic for the operation. The current case illustrates that major conduction anesthesia may be safely performed in patients with Klippel-Trénaunay disease provided that preoperative imaging studies exclude neurovascular involvement and coexisting coagulopathy is appropriately corrected.

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UNLABELLED: Isoflurane, enflurane, sevoflurane, and especially desflurane produce carbon monoxide (CO) during reaction with desiccated absorbents. Of these, sevoflurane is the least studied. We investigated the dependence of CO production from sevoflurane on absorbent temperature, minute ventilation (VE), and fresh gas flow rates. We measured absorbent temperature and in vitro CO concentrations when desiccated Baralyme reacted with 1 minimum alveolar anesthetic concentration of (2.1%) sevoflurane at 2.3-, 5.0-, and 10.0-L VE. Mathematical modeling of carboxyhemoglobin concentrations was performed using an existing iterative method. Rapid breakdown of sevoflurane prevented the attainment of 1 minimum alveolar anesthetic concentration with low fresh gas flow rates. CO concentrations increased with VE and with absorbent temperatures exceeding 80 degrees C, but concentrations decreased with higher fresh gas flow rates. Average CO concentrations were 150 and 600 ppm at 2.3- and 5.0-L VE; however, at 10 L, over 11,000 ppm of CO were produced followed by an explosion and fire. Methanol and formaldehyde were present and may have contributed to the flammable mixture but were not quantitated. Mathematical modeling of exposures indicates that in average cases, only patients < or =25 kg, or severely anemic patients, are at risk of carboxyhemoglobin concentrations >10% during the first 60 min of anesthesia. IMPLICATIONS: Sevoflurane breakdown in desiccated absorbents is expected to result in only mild carbon monoxide (CO) exposure. Completely dry absorbent and high minute ventilation rates may degrade sevoflurane to extremely large CO concentrations. Serious CO poisoning or spontaneous ignition of flammable gases within the breathing circuit are possible in extreme circumstances.

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