Background: Pulse oximetry is ubiquitous in anesthesia and is generally a reliable noninvasive measure of arterial oxygen saturation. Concerns regarding the impact of skin pigmentation and race/ethnicity on the accuracy of pulse oximeter accuracy exist. The authors hypothesized a greater prevalence of occult hypoxemia (arterial oxygen saturation [Sao ₂] less than 88% despite oxygen saturation measured by pulse oximetry [Spo2 ] greater than 92%) in patients undergoing anesthesia who self-reported a race/ethnicity other than White. Methods: Demographic and physiologic data, including self-reported race/ethnicity, were extracted from a departmental data warehouse for patients receiving an anesthetic that included at least one arterial blood gas between January 2008 and December 2019. Calculated Sao ₂ values were paired with concurrent Spo2 values for each patient. Analysis to determine whether Black, Hispanic, Asian, or Other race/ethnicities were associated with occult hypoxemia relative to White race/ethnicity within the Spo2 range of 92 to 100% was completed. Results: In total, 151,070 paired Sao ₂–Spo2 readings (70,722 White; 16,011 Black; 21,223 Hispanic; 8,121 Asian; 34,993 Other) from 46,253 unique patients were analyzed. The prevalence of occult hypoxemia was significantly higher in Black (339 of 16,011 [2.1%]) and Hispanic (383 of 21,223 [1.8%]) versus White (791 of 70,722 [1.1%]) paired Sao ₂–Spo2 readings (P < 0.001 for both). In the multivariable analysis, Black (odds ratio, 1.44 [95% CI, 1.11 to 1.87]; P = 0.006) and Hispanic (odds ratio, 1.31 [95% CI, 1.03 to 1.68]; P = 0.031) race/ethnicity were associated with occult hypoxemia. Asian and Other race/ethnicity were not associated with occult hypoxemia. Conclusions: Self-reported Black and Hispanic race/ethnicity are associated with a greater prevalence of intraoperative occult hypoxemia in the Spo2 range of 92 to 100% when compared with self-reported White race/ethnicity. Editor’s Perspective: What We Already Know about This Topic: What This Article Tells Us That Is New:

Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR based environments at scale.

Fibre-optic intubation (FOI) is an advanced technical skill, which anaesthesia residents must frequently perform under pressure. In surgical subspecialties, a virtual ‘warm-up’ has been used to prime a practitioner's skill set immediately before performance of challenging procedures. This study examined whether a virtual warm-up improved the performance of elective live patient FOI by anaesthesia residents. Clinical anaesthesia yr 1 and 2 (CA1 and CA2) residents were recruited to perform elective asleep oral FOI. Residents either underwent a 5 min, guided warm-up (using a bronchoscopy simulator) immediately before live FOI on patients with predicted normal airways or performed live FOI on similar patients without the warm-up. Subjects were timed performing FOI (from scope passing teeth to viewing the carina) and were graded on a 45-point skill scale by attending anaesthetists. After a washout period, all subjects were resampled as members of the opposite cohort. Multivariate analysis was performed to control for variations in previous FOI experience of the residents. Thirty-three anaesthesia residents were recruited, of whom 22 were CA1 and 11 were CA2. Virtual warm-up conferred a 37% reduction in time for CA1s (mean 35.8 ( sd 3.2) s vs . 57 ( sd 3.2) s, P <0.0002) and a 26% decrease for CA2s (mean 23 ( sd 1.7) s vs . 31 ( sd 1.7) s, P =0.0118). Global skill score increased with warm-up by 4.8 points for CA1s (mean 32.8 ( sd 1.2) vs . 37.6 ( sd 1.2), P =0.0079) and 5.1 points for CA2s (37.7 ( sd 1.1) vs . 42.8 ( sd 1.1), P =0.0125). Crossover period and sequence did not show a statistically significant association with performance. Virtual warm-up significantly improved performance by residents of FOI in live patients with normal airway anatomy, as measured both by speed and by a scaled evaluation of skills.

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.