Volume 10, No. 4 • Winter 1995

APSF Awards Five Research Grants for 1996

Ira J. Rampil, M.S., M.D.

Interest in APSF research grants reached an all-time high in 1995. For the first time, five grants were awarded. Perhaps in response to multiple different forces, there were an astounding 47 applications for grant support, well beyond the prior high of 27 in 1992. The five projects are:

Are Object Displays Superior to Alphanumeric Displays?

Dr. George T. Blike of the Dartmouth-Hitchcock Medical Center will test the hypothesis that patient monitor displays can be engineered to improve anesthesiologist performance during simulated critical incidents.

In nuclear power control rooms, airplane flight decks and the anesthesia environment, human error is the major cause of accidents. Human factor experts have long recognized the crucial impact that instrumentation panels and displays have on the human performance in these environments. Displays are a central component in any information-processing system as they are the link between man and machine. Displays are of two general types, graphical and alphanumeric. Research in applied human factors has focused on using graphical displays in high-risk environments to reduce human error. Modern research in cognitive psychology and visual information-processing has shown that many of the tasks required of nuclear controllers and pilots are better supported by graphical rather than alphanumeric displays. The anesthesia environment presents similar tasks to its human operators (i.e., anesthesiologists); therefore, graphical displays should be superior to alpha-numeric displays in assisting anesthesiologists in the provision of safe anesthesia. This research investigates the development and validation of an innovative graphical display as an instrument to help combat human error in anesthesia care.

Cognitive Analysis of Intraoperative Critical Events

Dr. Robert G. Loeb at the University of California at Davis is a repeat grant winner. Dr. Loeb plans to take the necessary first step in designing ecological displays of patient and anesthesia system data in an investigation of the cognitive demands of intraoperative critical events and of how anesthesiologists currently utilize their resources and equipment to meet these demands. This work stems from the thesis that physician error is an important factor in patient morbidity and mortality. Medical decision-making during intraoperative critical events imposes high cognitive demands on physicians. Cognitive errors result when the physician’s resources are insufficient for these demands. The ability to meet imposed demands also depends on the external displays through which physicians experience system state. Ecological displays can reduce human error by displaying data in a format that is adjusted for human information processing limitations and task-specific demands.

Managing intraoperative ventilation is a primary anesthesia task. Ventilation-related events (VRE) impose high cognitive demands on anesthesiologists. The comparatively high rate of VRE during anesthesia care indicates that these demands may exceed anesthesiologists’ abilities. This study is a cognitive analysis of VRE during anesthesia in order to reveal the nature of their demands and to better understand how anesthesiologists utilize their resources to meet these demands using current information displays. The hypothesis is that the current displays contribute to anesthesiologists’ errors during VRE.

Research methodology will include verbal protocols and video recording of anesthesiologists during simulated VRE. The results will be used in future projects to design ecological displays that support intraoperative physician decision making.

Perioperative Hypothermia and Surgical Wound Healing

Dr. Daniel I. Sessler of the University of California in San Francisco will study the relationship of hypothermia to wound healing. Surgical wound infections are common and serious complications. Mild perioperative hypothermia is also common. Hypothermia decreases resistance to infections by triggering thermoregulatory vasoconstriction which decreases subcutaneous oxygen availability and directly impairing oxidative killing by neutrophils.

Management and Reporting of Critical Events

Evaluation of Airway Edema in Patients Operated on in the Prone Position

Dr. Michele D. Szabo of the Massachusetts General Hospital will conduct an investigation to determine prospectively whether major operative procedures performed upon patients in the prone as compared to the supine position predisposes to the development of potentially life-threatening airway edema and edema-induced impairment of pulmonary function. Multiple measures, including grading of changes in glottic edema obtained by blinded review of videotapes of fiberoptic endoscopy before and after surgery; determination of changes in glottic area by computerized image analysis; grading of the difficulty of laryngoscopy by an experienced anesthesiologist; and evaluation of the incidence of a cuff leak around the endotracheal tube at the conclusion of surgery, will be compared between the two patient positions. Furthermore, the functional consequences of this edema will be evaluated in the immediate postoperative period with spirometry, and especially, flow-volume loops. To identify predictors of position-dependent airway edema, variables thought to contribute to the formation of edema (i.e., duration of procedure, blood loss, fluid replacement) will also be recorded and analyzed. Consequently, this study will, for the first time, systematically investigate the severity and significance of airway edema after anesthesia and surgery in the prone position. As such, this work should provide a rational foundation for managing and avoiding potentially serious airway complications after surgery in the prone position.

New Process Accommodates Increased Applications

The unprecedented interest in applying for APSF grant support placed an increased burden on the Scientific Evaluation Committee, which fortunately had expanded its ranks and altered the review process to lessen the already large task of reviewing applications during the summer months. The first part of the process was the same – each reviewer studied and judged about half of the grants. The applications receiving the highest scores were reviewed in the second round. In past years, all reviewers voted on these and the top three were selected after a brief discussion at the committee’s meeting just prior to the annual meeting of the ASA. This year, the approach taken was more similar to that employed at the NIH. Each grant in the second round was assigned to two reviewers who were the primary discussants at the committee’s meeting. It was only after these presentations and discussions that votes were taken. A different kind of result was produced. Instead of fully funding the top three grants, the committee decided to fund five grants, each at a reduced amount based on a critical analysis of the budgets. The total amount awarded was $153,922, only slightly above the usual annual limit of $150,000. As shown above, the five projects chosen include two studies of clinical complications and three investigating issues related to studying and enhancing provider performance with human factors analysis and simulator-based training.

The committee confronted another anomaly: The chairman of the committee, Dr. Jeffrey Cooper, had been involved with one of the applications as a consultant. It has been the custom of the committee that a member neither review nor vote on an application in which the member had any involvement or if it was from the member’s home institution. To maintain even more objectivity, Dr. Cooper chose to recuse himself from the entire review process and appointed an interim chairman, Ira Rampil, M.D.

Having some extra time available this past summer, Dr. Cooper has reviewed the results of the first nine years of the APSF grant program. A report of his analysis will be published in an upcoming issue of the APSF Newsletter. It includes a list of the titles of all grants awarded, the results of a survey of investigators whose applications were not approved and an analysis of the impact of all of this effort. A list of all publications deriving from APSF support has been compiled and will become available on the APSF World Wide Web home-page. Once again, the APSF Committee on Scientific Evaluation thanks all of those investigators who worked so hard to prepare their applications.

Dr. Rampil is Associate Professor, Department of Anesthesia, University of California at San Francisco. He served as interim chairman of the Scientific Evaluation Committee this year.