Anesthesia & Analgesia

This month's issue of Anesthesia & Analgesia considers the historical trajectory of clinical pharmacology in the domain of chronic pain management. It is recognized that patients are largely served with the same medication classes developed in a bygone era. Why the stagnation? A variety of mechanisms are highlighted that attempt to answer this question. The authors of these special articles consider the endless loop of scientific methodology that has yet to evolve our pharmacologic armamentarium. Accordingly, this month's cover art evokes four major therapeutic classes in the backdrop: local anesthetics, NMDA antagonists, non-steroidal anti-inflammatory drugs and opioids. But at center stage lies a rudimentary molecular structure that has yet to be realized. If the methodology of pain therapeutics research is willing to undergo a sea change, perhaps the identity of this next pharmacologic breakthrough will emerge.

Avery Tung, MD, FCCM
Cover Editor and Illustrator:
Naveen Nathan MD

This month’s cover article contains several perspectives on the critical care anesthesiology response to the COVID pandemic. The focus of the article is not on the response per se, as much has already been written, but rather on what COVID has taught us that might improve our response to the next pandemic. In the article, 6 SOCCA members who each contributed to the COVID response in different ways provide a set of diverse viewpoints on what they learned from their experience. The perspectives range from organizational to innovative and highlight the many different contributions of critical care intensivists to the COVID effort. Among the narratives are the remarkable story of how operating rooms were transformed into multiperson ICUs to avoid running out of room, a description of how ICU leaders developed strategies to share clinical information to optimize care when little evidence was available, the innovative and relentless optimization of ECMO and advanced intubation strategies for end-stage COVID patients, and a thoughtful look at effects of the pandemic on intensivist burnout and satisfaction. Taken together, these stories showcase how the COVID pandemic has given critical care anesthesiologists an opportunity to show their value. Please take a look!"

Avery Tung, MD, FCCM
Cover Editor and Illustrator:
Naveen Nathan MD

This month's featured article defines a future frontier for critical care and perioperative medicine: "systems anesthesiology." This dynamic approach to patient care incorporates emerging methods and information from the diverse disciplines of molecular, cellular, and computational sciences. We highlight the utilization of novel molecular markers for disease diagnosis and phenotyping, the incorporation of predictive models for perioperative risk stratification, and the extended reach of anesthesiologist- intensivists using virtual care and remote continuous monitoring. The ability to understand the mechanisms of pathology and to devise therapies with personalized molecular investigations, to use realtime data to predict perioperative risk, and to reach patients and providers on a larger geographic scale will transform the field of anesthesiology. The systems anesthesiologist will use and integrate advanced data to develop a personalized plan for each individual patient. This integration of multidisciplinary insights will allow us to deliver superior patient care.

Katarina J. Ruscic, MD, PhD
Dusan Hanidziar, MD, PhD
Kendrick M. Shaw, MD, PhD
Jeanine Wiener-Kronish, MD
Kenneth T. Shelton, MD

Cover Editor and Illustrator:
Naveen Nathan MD

The focus of this special themed issue of Anesthesia & Analgesia is Patient Blood Management (PBM). PBM is a new global standard of care to optimize a patient's blood health. PBM involves the timely, multidisciplinary application of evidence-based multimodal medical and surgical concepts aimed at screening for, diagnosing, and treating anemia; minimizing surgical, procedural, and iatrogenic blood losses; and managing coagulopathic bleeding to improve health outcomes through patient-centered care. The global definition of PBM is introduced as a "patient-centered, systematic, evidencebased approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." Herein are 14 contemporary papers and 2 editorials, authored by international experts, presenting current aspects of PBM critical thinking and research. The elegance of PBM is personalized patient-centered care and lies in the equity offered to all patients, compelling health care providers, administrators, and governing agencies to implement PBM based on robust data-driven evidence to improve patient outcomes and best utilize precious resources. The anesthesiologist, being a perioperative expert, plays a central role. Anesthesiology as a specialty of perioperative medicine can and must lead the PBM effort to close the gap between knowledge, evidence, guidelines, practice and standards. It is time to transform PBM vision into action.
Guest Editors:
Susan M. Goobie, MD, FRCPC
Nicole R. Guinn, MD
Aryeh Shander, MD


Cover Editor and Illustrator:
Naveen Nathan, MD

This month celebrates a century of scholarly publication for Anesthesia & Analgesia. Serving as the mainstream journal in our specialty in these one hundred years, it has addressed the full range of scientific exploration from fundamental bench research to clinical trials and beyond. A series of thematic issues of Anesthesia & Analgesia have recently entertained future trajectories of our field with respect to health care leadership, translational science, and global patient safety. Accordingly, the centenary issue this August focuses on the singular aspect of our field that will define how we practice clinical anesthesia for generations to come: educating future anesthesiologists. Articles contained herein discuss how training models have undergone dogmatic shifts towards competency-based assessment in an effort to ensure greater patient safety. Additionally, advances in digital technology have incorporated impressive virtual and augmented platforms to enhance simulation education and create global, collaborative access to training. This month's cover art reflects the passage of time and the change that it brings. A physical printed copy of Anesthesia & Analgesia, the very first page of the 1922 maiden issue no less, gives way to a digital tablet, allowing a learner to manipulate a virtual molecule of ketamine. Readers are encouraged to reflect on just how far we have come as a specialty and look to the horizon of our destiny in decades to cNaveen Nathan MD Cover Editor and Illustrator

Cover art composed by
Naveen Nathan, MD

Background photograph provided by istock.com, tablet image provided by pixabay.com

The focus of this month's featured article is anesthesia patient safety around the world. Anesthesia professionals in all countries face unique challenges to providing safe perioperative care. Leaders of anesthesia societies from 13 countries around the globe provide insights into the major issues they encounter that impact perioperative patient safety. The countries range from low-middle income to high-income countries. The issues range from a simple lack of basic anesthetic drugs and monitors to complex concerns about maldistribution of qualified anesthesia professionals and an increasing trend towards criminalization of medical errors. Despite the significant resource differences between these 13 countries, they all share common issues. These include challenges related to implementation of national standards of intraoperative care and surgical checklists, establishment of cultures of safety and teamwork, extension of safety efforts into the perioperative period, and initiatives to detect and prevent death from perioperative deterioration from infection, cardiac dysfunction, and respiratory complications. These challenges provide a roadmap for national societies and members of global collaborations to use when prioritizing resources to address opportunities to improve anesthesia patient safety in the coming decade.

Mark A. Warner, MD, Daniel Arnal, MD, Daniel J. Cole, MD, Rola Hammoud, MD, Carolina Haylock-Loor, MD, Pedro Ibarra, Acad, MD, MSc, Muralidhar Joshi, MBBS, MD, Fauzia A. Khan, FRCA, Konstantin M. Lebedinskii, DSc Med, Jannicke Mellin-Olsen, MD, DPH, Katsuyuki Miyasaka, MD, PhD, Wayne W. Morriss, MBChB, Bisola Onajin-Obembe, FWACS, PhD, Robinson Toukoune, MMed, and Patricia Yazbeck, MD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

The mechanism of consciousness and its disruption during physiologic, pharmacologic, and pathologic states of unconsciousness is of fundamental importance. Anesthesiologists, who manipulate conscious states hundreds of millions of times each year in operating rooms around the world, are uniquely positioned to provide key insights into how the electrical and chemical activities of the brain are translated to the subjective experiences of the mind. This month's featured article discusses key outstanding questions related to consciousness—including theoretical foundations, measurement of neural information, and the relationship of conscious experience to the physical world—and provides recommendations for how anesthesiologists can advance this foundational science. Additional empirical articles demonstrate how general anesthetics can be used to experimentally probe both level and content of consciousness. Current investigations and data support the hypothesis that both consciousness and unconsciousness reflect events at the scale of networks, as depicted in the cover art.
George A. Mashour, MD, PhD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

The focus of this month's feature article is the future of perioperative precision medicine. Science is undergoing a reproducibility crisis. Several clinical trials have not been replicable. One of the several reasons is the lack of in-depth mechanistic aspects of diseases and therapies. Disease state happens not only from derangements at the molecular level, but also from the surrounding milieu. "Perioptome" is the terminology that integrates the perioperative genomics, metabolomics, and biomarkers with the clinically manifesting phenomics that we experience as practitioners. Perioperative precision medicine is a broad-based concept that incorporates identification, modulation, and management of the perioptome, to devise better predictive pathways for patient care after surgery. The technological revolution has offered us the best chance to obtain in-depth granularity into delineating these clinical phenotypes with the help of electronic health records, portable personal devices, and individual patient-reported outcomes. Although it may not be easy, it is time is to move beyond clinical statistical significance to individualized trials whenever and wherever feasible.
Miklos D Kertai, MD, PhD, and Pal Nirvik, MBBS, MD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

This month's featured article considers the challenges of designing, conducting, and interpreting clinical trials. Better still, solutions and a pathway forward are provided. Most would agree that clinical research is essential to the progress of knowledge and the practice of medicine. However, large, definitive randomized trials—the accepted gold standard and currency of evidence-based medicine—are expensive, and most take too long to complete. Anesthesia clinical trial networks have been created across the world, providing shared expertise, centralized data management and statistical analysis, infrastructure, and other resources to improve the efficiency and value of clinical trials. Innovations in clinical trial design, digital technologies, consumer engagement, and implementation science are also changing how we design and conduct clinical trials. This month's art cover depicts the value of digital health and global collaborations for the future of clinical trials.
Paul S. Myles, MD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

This month's cover art depicts the various categories of Health Services Research (HSR), which is defined as a multidisciplinary field that studies how economic systems, organizational structures and processes, emerging health technologies, and personal behaviors affect the delivery of care in the "real world" and ultimately, overall health of our patients. The cover specifically depicts the research continuum from basic research to translational research to clinical research to health services research. If we accept that the ultimate goal of this research continuum is to improve the health of our patients, it is clear that it's not enough (for example) to develop a new treatment and then show its clinical superiority over existing treatment. In fact, we would go so far as to call this a surrogate outcome that is easy to measure but does not reflect the real goal of the research continuum. Indeed, HSR measures (for example) effective execution of knowledge translation, and this construct is frequently difficult because of the silo mentality that is embedded in our health care system. Knowledge translation requires a fully integrated system to execute the care, and that is difficult when various specialties "compete" rather than "collaborate." Surgeons have already embraced HSR—we hope that this themed issue will contribute to the development of perioperative HSR in anesthesiology, foster more consideration of how we effectively translate the knowledge from scientific endeavors into high-quality care, and act as an impetus for the development of grant mechanisms directed at this area.


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

This month's cover art depicts teamwork in action and is emphasized in two lead articles. As anesthesiologists, our practice of medicine requires us to be collaborators, communicators, and consensus builders. As accentuated by stresses imposed by the ongoing global pandemic, our value proposition as resilient, skilled, dynamic, and trusted leaders in healthcare has gained new public attention. These qualities uniquely poise anesthesiologists to rise to leadership positions within increasingly integrated health systems. At the same time, as leaders, we need to keep our balance, especially in the current turbulent times as we care for our patients, our colleagues, and our communities. The best health system CEOs are able to listen, delegate, mentor and celebrate the successes of others. As anesthesiologists and health system leaders, we have learned the important lesson that it's not about "winning" but about finding solutions. Effective leadership frequently avoids the use of "command and control" that is an externalized and often rigid, coercive, and non-collaborative leadership style. Rather, we see ourselves as servant leaders, those who deemphasize self and prioritize the needs of others as part of a larger healthcare team. You may wonder which of the 5 individuals on the cover art might represent the health system leader...a worthy conversation topic!

Joanne M. Conroy, MD
Michael R. Mathis, MD

Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

The focus of this month's featured article is the intersection of one of the key foundational practices of anesthesia care, intraoperative opioid administration, and administration practice patterns. Using a large dataset from the Multicenter Perioperative Outcomes Group (MPOG), the authors have characterized and quantified variability in intraoperative opioid practice patterns using a Bayesian analysis. Their work demonstrates the significant variability in practice between institutions and forms a strong foundational background for future research in this area. This month's art cover depicts this complex intersection, visually conveying distributions and variability of practice patterns, opioid formulations, and patients.

Bhiken I. Naik, Kai Kuck, Leif Saager,
Sachin Kheterpal, Karen B. Domino,
Karen L. Posner, Anik Sinha, Ami Stuart,
Chad M. Brummett, Marcel E.
Durieux, Michelle T. Vaughn, and
Nathan L. Pace, and the MPOG EOS
Investigator Group

Cover art composed by
Naveen Nathan, MD