Duke Anesthesiology has made huge strides in research over the past 50 years, thanks to an environment that fosters growth, brilliant academics and a strong focus on the future of patient care. The accomplishments of current and former faculty, clinical and research post-doctoral fellows, research staff, and residents have largely defined the department’s research program. Our current success can be credited to a spirit of teamwork and interdisciplinary collaboration.
Our research program began in the F.G. Hall Laboratory, where studies were focused almost entirely on human physiology. The work conducted here brought Duke Anesthesiology research to national and international prominence, and set an early precedent for successful peer-reviewed extramural funding. The F.G. Hall Laboratory was critical not only in defining modern hyperbaric medicine, but also in developing the department’s basic science component.
A formal process for organizing basic science research, which strives to further our understanding of cellular function, its response to stress and drugs, and translational significance, was established in 1994 when David S. Warner, MD, came to Duke to serve as chief of experimental anesthesiology. By 1998, basic science was considered a division within the department with Warner serving as chief. The Basic Science Division also encompasses translational research—an essential bridge between basic and clinical research that enables physician scientists to apply the information obtained from experimental disease models to human subjects.
At the time, translational research was a relatively new concept in academic anesthesia. This important area was often overlooked by major extramural funding sources, such as the National Institutes of Health (NIH), until about 15 years ago. A stronger emphasis on translational research has enabled our clinical research program to thrive.
Research enables us to better understand a complex phenomenon, predict the probable outcomes of interventions, control the occurrence of undesirable outcomes, and initiate interventions to promote desired results.
The development, application, and proper dissemination of knowledge acquired from research is essential for continued improvement in patient care. As perioperative physicians, anesthesiologists are expected to adopt a research-based practice, and use research findings to assist them in making informed decisions about interventions in the operating room.
After the research project is designed, the next step is to formulate a research proposal and conduct a pilot study. A pilot study is a small-scale trial run of the research study, which is necessary to obtain preliminary data before a full-scale research study can be conducted. Researchers usually have to fund their own pilot study.
Approval from the federal government and the Institutional Review Board (IRB) are necessary to ensure that ethical and safety guidelines are followed. After approval, the research team can screen for patients who fit the subject criteria. Patients are then asked to participate in the research study. With their consent, patients are enrolled in the study and the data collection process begins. Afterwards, the data is analyzed, results are interpreted, and a report of the findings is published.
After a pilot study is conducted, researchers can use the data to apply for a government grant to support a full-scale research study. They can apply to the National Institutes of Health (NIH) and other such funding agencies. Each step of the research project requires a great deal of time and resources, therefore, funding is crucial to the successful completion of a research project. A research study, depending on the protocol, can last anywhere from two to 15 years with an average study lasting about five years. Unfortunately for researchers, support from the government has decreased over the years. So it is imperative for researcher like us to broaden our base of donors who can support our efforts in brain and organ protection research.
Research can sometimes be conducted within the context of previous knowledge. More often than not, the maturity of the concept will spark other questions and give rise to a different research approach. In order to change clinical practice based on research findings, data has to be supported by multiple sources of evidence. The Duke Dream Team takes pride in its substantial accomplishments as a pioneer in brain protection research. Its impact can be seen worldwide as more and more physicians alter their clinical practice as a result of our research findings.
The team comprises physicians, nurses, statisticians, and other professionals who understand the challenging problems associated with major surgery. All those involved focus their efforts on interventions that can protect the brain, kidney, heart, and other organs from injury during surgery. The medical director oversees the wide spectrum of research focused on mechanisms of brain and organ protection during surgery. Physician researchers provide care for patients in the operating room and in the intensive care units. They understand the problems that can occur during and after surgery. They design studies to evaluate, prevent, and treat significant problems, such as changes in mental function and stroke. Clinical research coordinators are nurses or other medical professionals who help the physician carry out the research. They often supervise the research specialist and technicians who collect data. The statisticians help to ensure the integrity of the study design and evaluate results. Our patients are the most vital team members who help us answer important questions.
The earliest high-impact clinical research in anesthesiology at Duke was conducted by Sarah J. Dent, MD, and focused on postoperative nausea and vomiting (PONV). The study of PONV remains an active area of research in the department today. Former Duke Anesthesiology vice chair for faculty development, Tong Joo “TJ” Gan, MD, MHS, FRCA, played an influential role in proving the efficacy of antiemetics and establishing PONV consensus guidelines, which are now an international standard of care. In addition to using acupuncture for the prevention of PONV and postoperative pain, Gan found acupuncture to be highly effective in reducing the severity and frequency of chronic headache. Gan and Peter S.A. Glass, MB ChB, who later went on to become chair of the Department of Anesthesiology at the State University of New York at Stony Brook, also conducted pioneering work in the concept of perioperative goal-directed therapy and the use of bispectral index to monitor the depth of anesthesia—a technology now used around the world.
When David Watkins, MD, PhD, became chair of Duke Anesthesiology in 1983, he launched bench research in the department and oversaw creation of the CRII Laboratory, which served as the department’s first human pharmacology lab. In this lab, which was directed by Glass, numerous important concepts were developed. Examples include the context-sensitive half-time and the bispectral index, which ultimately helped to popularize the use of total intravenous anesthesia as a standard anesthetic technique in clinical anesthesia practice.
Debra A. Schwinn, MD, James B. Duke Professor of Anesthesiology, who served as our department’s director of perioperative genomics and vice chair for research for several years, played a critical role in developing bench research at Duke. Schwinn set a standard for NIH-funded research in the department, made fundamental discoveries in alpha adrenergic receptor signaling, and recruited several NIH-funded faculty members, including Madan Kwatra, PhD, Elliott Bennett-Guerrero, MD, James Reynolds, PhD, and Warner, to expand the department’s research programs. “She set a standard for excellence for research conduct and innovation that continues to permeate the entire department,” says Warner.
Following Schwinn’s lead, Warner has helped to develop the careers of countless world-class physician scientists across a broad range of medical specialties. A world-renowned neuro-anesthesiologist, Warner is known for his work in the mechanisms of stroke and brain protection, acute brain and spinal cord injury, and therapeutic interventions. By establishing a strong foundation in neuroanesthesia basic research at Duke, Warner has created a perfect environment in which to train and mold young physician scientists. In fact, he served as the principal investigator for the department’s formal NIH-funded training grant designed to develop physician scientists at the fellowship level. Duke Anesthesiology has maintained this grant since 1996, when it became one of six anesthesiology departments in the nation to receive this honor. Thanks to former Duke Anesthesiology chairman, Mark F. Newman, MD, Merel H. Harmel Professor, and Catherine M. Kuhn, MD, professor of anesthesiology, this concept has since been extended to the residency with development of a pioneering American Board of Anesthesiology approved physician scientist track (Academic Career Enrichment Scholars) designed to substantively integrate formal research training with combined residency and fellowship clinical training over a five-year period.
The Cardiothoracic Anesthesiology Division has a history of high-impact research related to cognitive dysfunction following cardiac procedures that began with the work of former Duke Anesthesiology chairman, Joseph “Jerry” Reves, MD. He imparted both his knowledge and passion for the study of cognitive dysfunction to Newman, who pioneered the study of cognitive dysfunction following cardiopulmonary bypass. This work opened the concept of perioperative genomics and also led to major changes in bypass conduct now practiced universally.
Joseph P. Mathew, MD, MHSc, MBA, Jerry Reves, MD, Professor of Anesthesiology and current chairman of Duke Anesthesiology, worked with his team to take this research a step further – exploring the effects of extreme hemodilution during cardiac surgery, evaluating the use of lidocaine to prevent cognitive injury, and assessing the utility of functional magnetic resonance imaging to better understand postoperative cognitive dysfunction. Mathew previously served as medical director of NORG (Neurological Outcomes Research Group) and director of CARE (Clinical Anesthesiology Research Endeavors, now named the Clinical Research Unit (CRU)). Currently, Edmund Jooste, MB, serves as director of the CRU, which began as an initiative within the cardiac division and was eventually extended to the entire department. The CRU is focused on quality improvement and clinical research that lead to changes in clinical practice.
For nearly three decades, the department has held an event known as Academic Evening to showcase ongoing research activities. This event has become a model for similar events organized by most leading anesthesiology departments across the nation. Academic Evening was the brainchild of Robert Sladen, MB ChB, and is now led by Dr. Jeffrey Gadsden, chief of the Orthopaedics, Plastics and Regional Anesthesiology Division. The event presents more than 80 research projects each year and has an attendance of 150-200 persons.
The progress that we have made in research over a 50-year period is absolutely astounding. What is even more impressive, however, is the fact that we have seen a snowball effect. In recent years, the rate at which we are making these life-changing discoveries has multiplied. We have witnessed firsthand countless advances in surgical and critical care intervention that were unimaginable just a few years ago. Basic science in particular is exploding. The department has invested heavily in basic science research focused on mechanisms of chronic pain, a common affliction requiring breakthrough science to advance patient care. A rapidly emerging focus is on exploration of neural mechanisms of injury and pain. With a strong translational science program now in place, these discoveries lead to changes in how perioperative patients are managed, improving long-term outcome and quality of life. As the population ages and physicians see a higher number of patients with significant co-morbidities, the importance of anesthesia research will continue to mount.
The department continues to push the limits of modern science through support of original research concepts, recruitment of world-class research faculty, and training the clinical and basic scientists of tomorrow. Together, we are advancing the future of patient care for generations to come.