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Anesthetic agents are known greenhouse gases with hundreds to thousands of times the global warming impact compared with carbon dioxide. We sought to mitigate the negative environmental and financial impacts of our practice in the perioperative setting through multidisciplinary staff engagement and provider education on flow rate reduction and volatile agent choice. These efforts led to a 64% per case reduction in carbon dioxide equivalent emissions (163 kg in Fiscal Year 2012, compared with 58 kg in Fiscal Year 2015), as well as a cost savings estimate of $25,000 per month.

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BACKGROUND: Between 2011 and 2013, medical students at a large, tertiary academic hospital reported a lower-than-expected perception of direct observation and feedback during their third- and fourth-year clinical clerkships. The anesthesiology clerkship is a team-based care model that involves an anesthesiologist, resident or anesthetist, and student. This model allows for direct supervision of all patient interactions and procedures. Despite this structure, medical students reported an acceptable but lower-than-anticipated perception of direct observation and feedback taking place during a 2-week anesthesiology clerkship. METHODS: Interventions were proposed to improve student awareness of the supervision, teaching, and feedback taking place. A skills checklist for intravenous (IV) line placement that an anesthesia provider completed while observing the student was chosen as a meaningful intervention to improve the students' perception of observation and feedback. This checklist required direct observation of the IV line placement clinical skill, and the evaluator was directed to give oral feedback to the student. Students were surveyed regarding their perceptions of direct observation and feedback during a 4-year period, 2 years prior to and 2 years after implementation of the IV checklist. RESULTS: No statistically significant difference was noted between the preintervention and postintervention groups. CONCLUSION: While formal observation of and feedback on an IV placement did not change student perception, the intervention showed that a more in-depth analysis of the "educational alliance" desired during an anesthesiology clerkship is warranted, especially as medical education continues to evolve.

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Tracheal extubation in children with known difficult airways is associated with an increased risk of adverse events. Currently, there is no reliable measure to predict the need for emergent reintubation due to airway inadequacy. Airway exchange catheter-assisted extubation has been shown to be a useful adjunct in decreasing the risk of adverse events due to failed extubation. We report a case of using an airway exchange catheter-assisted extubation with continuous end-tidal carbon dioxide monitoring for a pediatric patient with a known difficult airway.

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High-dose radiation brachytherapy is a treatment for inoperable cervical and endometrial carcinoma. A general anesthetic is often utilized for patient comfort, facilitating patient transport to imaging resources, and allowing rapid discharge home after the procedure. Patient comorbidities, however, must be considered for every anesthetic performed. We describe a successful surgical epidural anesthetic for a patient with challenging comorbidities, including cardiac, pulmonary, and hematologic body systems.

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Age-related tongue weakness may contribute to swallowing deficits in the elderly. One contributing factor may be an alteration in muscle-fiber-type properties with aging. However, it is not clear how muscle fiber types within the aged tongue may vary from those found in young adults, or how fiber types may vary across the anteroposterior axis of the extrinsic tongue muscles. We examined the myosin heavy chain (MHC) composition of anterior, medial, and posterior sections of the genioglossus muscle (GG) in ten old male Fischer 344/Brown Norway rats and compared findings to previously reported data from young adult male rats. Significant differences (p < 0.01) between young adult and old rats were found in the distribution of MHC isoforms along the anteroposterior axis of the muscle. In the anterior, medial, and posterior regions, there was a significantly smaller proportion of type IIb MHC in the old rat GG muscles, while the proportion of type IIx MHC was significantly greater. In the medial region, the proportion of type I MHC was found to be significantly greater in the old rats. Thus, we found a shift to more slowly contracting muscle fibers in the aged rat tongue.

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The tongue plays a vital role in swallowing actions. However, tongue muscles have been understudied, and it is unclear if tongue muscles are homogeneous with respect to muscle fiber-type distribution. We examined myosin heavy chain (MHC) composition of anterior, medial, and posterior sections of the genioglossus muscle (GG) using sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) in ten adult (9 months old) male Fischer 344/Brown Norway hybrid rats. We found that Type IIx MHC predominated in the anterior, medial, and posterior regions of the GG muscle (p=0.002), followed by IIa, then IIb. The anterior GG contained a significantly greater (p=0.004) proportion of Type IIa than did the medial or posterior regions, while the posterior GG contained a significantly greater (p=0.002) proportion of Type IIb MHC than did the medial or anterior GG. Accordingly, we found variable expression of MHC isoforms across anterior, medial, and posterior portions of the GG muscle, with more fast-contracting isoforms found posteriorly. Because motor control of the tongue requires precise and rapid movements for bolus manipulation and airway protection, variable expression of MHC isoforms along the anteroposterior axis of the GG muscle may be required to efficiently achieve deglutition and maintenance of airway patency.

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