CUTE LUNG INJURY AND ACUTE respiratory distress syndrome (ARDS, the most severe form of acute lung injury), are potentially devastating complications of critical illness. 1 Arising in response to direct lung injury (eg, pneumonia) or intense systemic inflammation (eg, sepsis), 2 the pathogenesis involves pulmonary edema, diffuse cellular destruction, alveolar collapse, and disordered repair. Mortality and health care costs are high, 3 and long-term survivors experience serious morbidity. 4 See also pp 646, 691, and 693.

Purpose: Medical emergency teams (MET) merge earlier-thanconventional treatment of worrisome vital signs with a skilled resuscitation response team, and may possibly reduce cardiac arrests, postoperative complications, and hospital mortality. Methods:At the two sites of The Ottawa Hospital, MET was introduced in January 2005. We reviewed call diagnoses, interventions, and outcomes from MET activity, and examined outcomes [cardiac arrests, intensive care unit (ICU) admissions, and readmissions] from Health Records and the ICU database. We compared the first fully operational year, 2006, with pre-MET years, 2003-4. Results:In 5,741 patient encounters, the teams (nurse, respiratory therapist, and intensivist) responded to 1,931 calls over two years, predominantly for high-risk in-patients. As well, there were 3,810 follow-up visits to these patients and to recently discharged ICU patients. In 2006, there were 40.3 calls/team/1,000 hospital admissions, with 71.2% of in-patient ICU admissions preceded by MET calls. Patient illness severity scores decreased from 4.9 ± 2.6 (mean ± SD) before implementing MET to 2.9 ± 2.3 (P < 0.0001) after MET interventions. Intervention on the respiratory system was performed on 72% of patients. Admission to the ICU occurred in 27% of MET patients. Compared with the pre-MET period, we observed decreases in: cardiac arrests (from 2.53 ± 0.8 to 1.3 ± 0.4 /1,000 admissions, P < 0.001); ICU admissions from in-patient nursing units/month (42.3 ± 7.3 to 37.6 ± 5.1, P = 0.05); readmissions after ICU discharge/month (13.5 ± 5.1 to 8.8 ± 4.5, P = 0.01); and readmissions within 48 hr of ICU discharge/month (4.4 ± 2.4 to 2.8 ± 1.0 ICU readmissions/month, P = 0.01). Conclusions: Successful implementation of MET reduces patient morbidity and ICU resource utilization. (42,3 ± 7,3 à 37,6 ± 5,1, P = 0,05) ; réadmissi-ons après congé des USI/mois (13,5 ± 5,1 à 8,8 ± 4,5, P = 0,01)

Low and minimal flow inhalational anaesthesiaPurpose: To describe the pharmacokinetic behaviour and practical aspects of low (0.5-I l.min ~) and minimal (0.25-0.5 l.min i) flow anaesthesia. Methods: A Medline search located articles on low flow anaesthesia, and computer simulated anaesthetic uptake models are used. Principal findings: Host, 85-9096, of anaesthetists use high fresh gas flow rates during inhalational anaesthesia. Low/minimal flow anaesthesia with a circle circuit may avoid the need for in-circuit humidifiers, raise the temperature of inspired gases by up to 6~ reduce cost by about 2596 by reduction of fresh gas flows to 1.5 l.min -~ , and reduce environmental pollution with scavenged gas. Knowledge of volatile anaesthetic pharmacokinetic behaviour facilitates the use of minimalllow flow rates. Small amounts of nitrogen or minute amounts of methane, acetone, carbon monoxide, and inert gases in the circuit are of no concern, but the degradation of desflurane (to carbon monoxide by dry absorbent) and sevoflurane (to compound A by using a fresh gas flow of >2 l-rain-') must be avoided. With modem gas monitoring technology, safety should be no more of a concern than with high flow techniques. Conclusion: The use of fresh gas flow rates of < I l-min -~ for maintenance of anaesthesia has many advantages, and should be encouraged for inhalational anaesthesia with most modem volatile anaesthetics.

PurposeTo address an aging anesthesia workforce, we review the relevant changes and implications associated with age in order to stimulate discussion at the individual, local, and national levels regarding appropriate changes in practice aimed at protecting patient safety.Principal findingsIn a 2013 survey of Canadian Anesthesiologists, 22% were aged 55-64 yr, 7% were aged 65-74 yr, and 3% were older than 74 yr. Clinical abilities decline with age, making older anesthesiologists more likely than their younger colleagues to be associated with adverse patient events. Anesthesiologists older than 65 yr in Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury compared with anesthesiologists younger than 51 yr of age. In the absence of overt deterioration in skills, decisions about reducing activities and retirement are left largely to individuals despite their limited ability to self-assess competence. This state of affairs may contribute to the increased incidence of adverse events and poor patient outcomes.ConclusionsProvincial regulatory bodies have peer assessment programs to evaluate physicians at random, following a complaint, and at certain ages, but all have limitations. Simulation has been used widely for training and assessment in the aviation industry as well as in automobile driving exams. Simulation can assess crisis recognition and management, which is crucial in anesthesiology and not well assessed by other methods, and could assist elderly anesthesiologists during the pre-retirement phase of their careers. A standardized schedule for winding down would have advantages for physicians, their department, and their patients. A suggested schedule might include no further on-call duties for those aged 60 yr and older, no further high-acuity cases for those aged 65 yr and older, and retirement from operating room (OR) clinical practice (with possible continuation of non-OR clinical or other non-clinical activities, if desired) at age 70 yr. These timelines could be extended with satisfactory performance in annual simulation sessions involving assessment and practice in crisis management.