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ANAESTHESIOLOGY (117 journals)                     

Showing 1 - 117 of 117 Journals sorted alphabetically
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 61)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 6)
Acute Pain     Full-text available via subscription   (Followers: 15)
Advances in Anesthesia     Full-text available via subscription   (Followers: 30)
African Journal of Anaesthesia and Intensive Care     Full-text available via subscription   (Followers: 8)
Ain-Shams Journal of Anaesthesiology     Open Access   (Followers: 2)
Ain-Shams Journal of Anesthesiology     Open Access   (Followers: 1)
Ambulatory Anesthesia     Open Access   (Followers: 9)
Anaesthesia     Hybrid Journal   (Followers: 219)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 67)
Anaesthesia and Intensive Care     Full-text available via subscription   (Followers: 59)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 25)
Anaesthesia Reports     Hybrid Journal  
Anaesthesia, Pain & Intensive Care     Open Access  
Anaesthesiology Intensive Therapy     Open Access   (Followers: 9)
Analgesia & Resuscitation : Current Research     Hybrid Journal   (Followers: 6)
Anesthesia & Analgesia     Hybrid Journal   (Followers: 238)
Anesthesia : Essays and Researches     Open Access   (Followers: 10)
Anesthesia Progress     Hybrid Journal   (Followers: 5)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology     Hybrid Journal   (Followers: 218)
Anesthesiology and Pain Medicine     Open Access   (Followers: 23)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25)
Anesthesiology Research and Practice     Open Access   (Followers: 15)
Angewandte Schmerztherapie und Palliativmedizin     Hybrid Journal  
Annales Françaises d'Anesthésie et de Réanimation     Full-text available via subscription   (Followers: 4)
Annals of Cardiac Anaesthesia     Open Access   (Followers: 14)
BDJ Team     Open Access   (Followers: 1)
Best Practice & Research Clinical Anaesthesiology     Hybrid Journal   (Followers: 15)
BJA : British Journal of Anaesthesia     Hybrid Journal   (Followers: 213)
BJA Education     Hybrid Journal   (Followers: 67)
BMC Anesthesiology     Open Access   (Followers: 17)
BMJ Supportive & Palliative Care     Hybrid Journal   (Followers: 42)
Brazilian Journal of Anesthesiology     Open Access   (Followers: 5)
Brazilian Journal of Anesthesiology (Edicion en espanol)     Open Access  
Brazilian Journal of Anesthesiology (English edition)     Open Access   (Followers: 1)
Brazilian Journal of Pain (BrJP)     Open Access  
British Journal of Pain     Hybrid Journal   (Followers: 25)
Canadian Journal of Anesthesia/Journal canadien d'anesthésie     Hybrid Journal   (Followers: 46)
Case Reports in Anesthesiology     Open Access   (Followers: 11)
Clinical Journal of Pain     Hybrid Journal   (Followers: 15)
Colombian Journal of Anesthesiology : Revista Colombiana de Anestesiología     Hybrid Journal  
Current Anaesthesia & Critical Care     Full-text available via subscription   (Followers: 36)
Current Anesthesiology Reports     Hybrid Journal   (Followers: 4)
Current Opinion in Anaesthesiology     Hybrid Journal   (Followers: 58)
Current Pain and Headache Reports     Hybrid Journal   (Followers: 2)
Der Anaesthesist     Hybrid Journal   (Followers: 8)
Der Schmerz     Hybrid Journal   (Followers: 4)
Der Schmerzpatient     Hybrid Journal  
Douleur et Analgésie     Hybrid Journal  
Egyptian Journal of Anaesthesia     Open Access   (Followers: 2)
Egyptian Journal of Cardiothoracic Anesthesia     Open Access  
EMC - Anestesia-Reanimación     Hybrid Journal  
EMC - Anestesia-Rianimazione     Hybrid Journal  
EMC - Urgenze     Full-text available via subscription  
European Journal of Anaesthesiology     Hybrid Journal   (Followers: 28)
European Journal of Pain     Full-text available via subscription   (Followers: 24)
European Journal of Pain Supplements     Full-text available via subscription   (Followers: 5)
Headache The Journal of Head and Face Pain     Hybrid Journal   (Followers: 5)
Indian Journal of Anaesthesia     Open Access   (Followers: 7)
Indian Journal of Pain     Open Access   (Followers: 2)
Indian Journal of Palliative Care     Open Access   (Followers: 6)
International Anesthesiology Clinics     Hybrid Journal   (Followers: 9)
International Journal of Clinical Anesthesia and Research     Open Access  
Itch & Pain     Open Access   (Followers: 2)
JA Clinical Reports     Open Access  
Journal Club Schmerzmedizin     Hybrid Journal  
Journal of Anesthesia & Clinical Research     Open Access   (Followers: 10)
Journal of Anaesthesiology Clinical Pharmacology     Open Access   (Followers: 8)
Journal of Anesthesia     Hybrid Journal   (Followers: 12)
Journal of Anesthesia History     Full-text available via subscription   (Followers: 1)
Journal of Anesthesiology and Clinical Science     Open Access   (Followers: 1)
Journal of Cellular and Molecular Anesthesia     Open Access  
Journal of Clinical Anesthesia     Hybrid Journal   (Followers: 13)
Journal of Critical Care     Hybrid Journal   (Followers: 39)
Journal of Headache and Pain     Open Access   (Followers: 3)
Journal of Neuroanaesthesiology and Critical Care     Open Access   (Followers: 3)
Journal of Neurosurgical Anesthesiology     Hybrid Journal   (Followers: 8)
Journal of Obstetric Anaesthesia and Critical Care     Open Access   (Followers: 22)
Journal of Pain     Hybrid Journal   (Followers: 17)
Journal of Pain and Symptom Management     Hybrid Journal   (Followers: 39)
Journal of Pain Research     Open Access   (Followers: 10)
Journal of Society of Anesthesiologists of Nepal     Open Access   (Followers: 2)
Journal of the Bangladesh Society of Anaesthesiologists     Open Access  
Jurnal Anestesi Perioperatif     Open Access  
Jurnal Anestesiologi Indonesia     Open Access  
Karnataka Anaesthesia Journal     Open Access   (Followers: 2)
Le Praticien en Anesthésie Réanimation     Full-text available via subscription   (Followers: 2)
Local and Regional Anesthesia     Open Access   (Followers: 8)
Medical Gas Research     Open Access   (Followers: 3)
Medycyna Paliatywna w Praktyce     Open Access   (Followers: 1)
OA Anaesthetics     Open Access   (Followers: 3)
Open Anesthesia Journal     Open Access  
Open Journal of Anesthesiology     Open Access   (Followers: 10)
Pain     Hybrid Journal   (Followers: 54)
Pain Clinic     Hybrid Journal   (Followers: 1)
Pain Management     Hybrid Journal   (Followers: 17)
Pain Medicine     Hybrid Journal   (Followers: 13)
Pain Research and Management     Open Access   (Followers: 8)
Pain Research and Treatment     Open Access   (Followers: 2)
Pain Studies and Treatment     Open Access   (Followers: 2)
Research and Opinion in Anesthesia and Intensive Care     Open Access   (Followers: 3)
Revista Chilena de Anestesia     Open Access   (Followers: 1)
Revista Colombiana de Anestesiología     Open Access   (Followers: 1)
Revista Cubana de Anestesiología y Reanimación     Open Access   (Followers: 1)
Revista da Sociedade Portuguesa de Anestesiologia     Open Access  
Revista Española de Anestesiología y Reanimación     Hybrid Journal  
Revista Española de Anestesiología y Reanimación (English Edition)     Full-text available via subscription   (Followers: 2)
Romanian Journal of Anaesthesia and Intensive Care     Open Access   (Followers: 1)
Saudi Journal of Anaesthesia     Open Access   (Followers: 7)
Scandinavian Journal of Pain     Hybrid Journal  
Southern African Journal of Anaesthesia and Analgesia     Open Access   (Followers: 8)
Sri Lankan Journal of Anaesthesiology     Open Access   (Followers: 2)
Survey of Anesthesiology     Full-text available via subscription   (Followers: 12)
Techniques in Regional Anesthesia and Pain Management     Hybrid Journal   (Followers: 11)
Topics in Pain Management     Full-text available via subscription   (Followers: 2)
Trends in Anaesthesia and Critical Care     Full-text available via subscription   (Followers: 23)


Similar Journals
Journal Cover
Anesthesia & Analgesia
Journal Prestige (SJR): 1.472
Citation Impact (citeScore): 3
Number of Followers: 238  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0003-2999 - ISSN (Online) 1526-7598
Published by LWW Wolters Kluwer Homepage  [300 journals]
  • All Hands On Deck: Evolving Best Practices for Optimal Intraoperative Hand
    • Authors: Nathan; Naveen
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Hocus, PoCUS: OSA Diagnosis'
    • Authors: Wanderer; Jonathan P.; Nathan, Naveen
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Descriptive Statistics in Medical Research
    • Authors: Schober; Patrick; Vetter, Thomas R.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Hand Hygiene and Relearning Lessons From the Past
    • Authors: Riutort; Kevin T.; Brull, Sorin J.; Prielipp, Richard C.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Untapped Potential of Dexmedetomidine
    • Authors: Kleiman; Amanda M.; Johnson, Ken B.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Perioperative Screening for Sleep Apnea: The New Frontier of Point-of-Care
    • Authors: Memtsoudis; Stavros G.; Auckley, Dennis H.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Methadone: New Indications for an Old Drug'
    • Authors: Murphy; Glenn S.; Wu, Christopher L.; Mascha, Edward J.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Tranexamic Acid for Acute Hemorrhage: When Is Enough Evidence Enough'
    • Authors: Faraoni; David; Levy, Jerrold H.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Guidelines, Practice Parameters, and Consensus Statements in
    • Authors: Coombs; Alice A. Tolbert; Butterworth, John F. IV
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Methylprednisolone Does Not Reduce Acute Postoperative Pain After Cardiac
           Surgery: Subanalysis of a Randomized Clinical Trial
    • Authors: Turan; Alparslan; Cohen, Barak; Whitlock, Richard P.; Essber, Hani; Niazi, Azfar; Makarova, Natalya; Saasouh, Wael; Alfirevic, Andrej; Marciniak, Donn; Sessler, Daniel I.
      Abstract: imageBACKGROUND: Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery.METHODS: We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management).RESULTS: Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of −0.25 (−0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64–1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction.CONCLUSIONS: In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Vascular Adhesion Protein-1 Is Associated With Acute Kidney Injury in
           High-Risk Patients After Cardiac Surgery
    • Authors: Meersch; Melanie; Küllmar, Mira; Renfurm, Ronny; Margraf, Andreas; Bormann, Eike; Zarbock, Alexander
      Abstract: imageBACKGROUND: Acute kidney injury is a common complication after cardiac surgery, with a high impact on morbidity and mortality. Vascular adhesion protein-1 is involved in inflammation, which, in turn, is part of the development of acute kidney injury after cardiac surgery.METHODS: In this ancillary study to the RENal effects of Remote Ischemic Preconditioning in cardiac surgery trial, we investigated whether vascular adhesion protein-1 might be associated with the development of acute kidney injury in high-risk patients after cardiac surgery. In total, 114 patients were included in this data set. Acute kidney injury was defined by the Kidney Disease: Improving Global Outcomes criteria serum creatinine and/or urine output. Vascular adhesion protein-1 concentrations were measured at baseline (before surgery), 4 hours, and 12 hours after cardiopulmonary bypass.RESULTS: Vascular adhesion protein-1 levels at 12 hours were significantly higher in patients with acute kidney injury (no acute kidney injury, 271 ng/mL [Q1, Q3, 179, 364 ng/mL] versus acute kidney injury, 384 ng/mL [Q1, Q3, 311, 478 ng/mL]; P < .001). Moreover, patients developing acute kidney injury had higher differences in vascular adhesion protein-1 levels between 12 hours and baseline (P < .001) and between 12 and 4 hours (P < .001) after cardiopulmonary bypass. At a cut point difference value of 99 ng/mL (95% CI, 63–133) between 12 hours and baseline, patients with differences>99 ng/mL showed a higher occurrence rate of acute kidney injury (acute kidney injury, 78.6% versus no acute kidney injury, 31.5%; P < .001). Receiver-operating characteristic curve analyses demonstrated best performance for vascular adhesion protein-1 levels at 12 hours for acute kidney injury within 72 hours after surgery, especially in the subgroup of patients with chronic kidney disease (area under the receiver-operating characteristic curve, 0.78; P < .001).CONCLUSIONS: Vascular adhesion protein-1 is elevated in patients developing acute kidney injury assuming that vascular adhesion protein-1 plays a crucial role in the development of acute kidney injury in high-risk patients after cardiac surgery.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Viscoelastic Signals for Optimal Resuscitation in Trauma: Kaolin
           Thrombelastography Cutoffs for Diagnosing Hypofibrinogenemia (VISOR Study)
    • Authors: Chow; Jonathan H.; Richards, Justin E.; Morrison, Jonathan J.; Galvagno, Samuel M. Jr; Tanaka, Kenichi A.; Madurska, Marta J.; Rock, Peter; Scalea, Thomas M.; Mazzeffi, Michael A.
      Abstract: imageBACKGROUND: Acute traumatic coagulopathy is common in trauma patients. Prompt diagnosis of hypofibrinogenemia allows for early treatment with cryoprecipitate or fibrinogen concentrate. At present, optimal cutoffs for diagnosing hypofibrinogenemia with kaolin thrombelastography (TEG) have not been established. We hypothesized that kaolin kaolin-TEG parameters, such as kinetic time (K-time), α-angle, and maximum amplitude (MA), would accurately diagnose hypofibrinogenemia (fibrinogen .05 for all comparisons). The estimated optimal cutoffs for diagnosing hypofibrinogenemia were 1.5 minutes for K-time (95% CI, 1.4–1.6), 70.0° for α-angle (95% CI, 69.8–71.0), and 60.9 mm for MA (95% CI, 59.2–61.8). The estimated optimal cutoffs for diagnosing severe hypofibrinogenemia were 2.4 minutes for K-time (95% CI, 1.7–2.8), 60.6° for α-angle (95% CI, 57.2–67.3), and 51.2 mm for MA (95% CI, 49.0–56.2). Currently recommended K-time and α-angle cutoffs from the American College of Surgeons had low sensitivity for diagnosing hypofibrinogenemia (3%–29%), but sensitivity improved to 74% when using optimal cutoffs.CONCLUSIONS: Kaolin-TEG parameters can accurately diagnose hypofibrinogenemia and severe hypofibrinogenemia in trauma patients. Currently recommended cutoffs for the treatment of hypofibrinogenemia are skewed toward high specificity and low sensitivity. Many patients are likely to be undertreated for hypofibrinogenemia using current national guidelines.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Association of Preoperative Serum Chloride Levels With Mortality and
           Morbidity After Noncardiac Surgery: A Retrospective Cohort Study
    • Authors: Oh; Tak Kyu; Do, Sang-Hwan; Jeon, Young-Tae; Kim, Jinhee; Na, Hyo-Seok; Hwang, Jung-Won
      Abstract: imageBACKGROUND: Postoperative hyperchloremia is known to be related to increases in mortality and morbidity after surgery. However, the relationship between preoperative hyperchloremia and hypochloremia and postoperative mortality and morbidity is not well established. Our aim was to evaluate the relationship between preoperative hyperchloremia or hypochloremia, as assessed using preoperative serum chloride tests, and 90-day mortality and morbidity after noncardiac surgery.METHODS: In this retrospective cohort study, we reviewed the medical records of patients>20 years of age who underwent noncardiac surgery between January 2010 and December 2016. Patients were categorized into one of the following groups on the basis of the results of serum chloride testing performed within 1 month before surgery: normochloremia, 97–110 mmol·L−1; hyperchloremia,>110 mmol·L−1; and hypochloremia,
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Dexmedetomidine for Improved Quality of Emergence From General Anesthesia:
           A Dose-Finding Study
    • Authors: Aouad; Marie T.; Zeeni, Carine; Al Nawwar, Rony; Siddik-Sayyid, Sahar M.; Barakat, Hanane B.; Elias, Sandra; Yazbeck Karam, Vanda G.
      Abstract: imageBACKGROUND: Dexmedetomidine provides smooth and hemodynamically stable emergence at the expense of hypotension, delayed recovery, and sedation. We investigated the optimal dose of dexmedetomidine for prevention of cough, agitation, hypertension, tachycardia, and shivering, with minimal side effects.METHODS: In this prospective, randomized, double-blind trial, 216 adult patients were randomly assigned to dexmedetomidine 1 µg/kg (D 1), 0.5 µg/kg (D 0.5), 0.25 µg/kg (D 0.25), or control (C). During emergence, cough, agitation, hemodynamic parameters, shivering, time to extubation, and sedation scores were recorded.RESULTS: A total of 190 patients were analyzed. The respective incidences for the groups D 1, D 0.5, and D 0.25 versus group C were 48%, 64%, and 64% vs 84% for cough—corrected P < .003 between groups D 1 and C; 33%, 34%, and 33% vs 72% for agitation—corrected P < .003 between group C and each of the study groups; and 4%, 2%, and 7% vs 22% for shivering—corrected P = .03 and corrected P = .009 between groups D 1 and D 0.5 versus group C, respectively. The percent increase from baseline blood pressure on extubation for the 3 treatment groups was significantly lower than group C. Percent increase in heart rate was lower than control in groups D 1 and D 0.5 but not in group D 0.25. Time to extubation and sedation scores were comparable. However, more hypotension was recorded during the emergence phase in the 3 treatment groups versus group C.CONCLUSIONS: D 1 at the end of surgery provides the best quality of emergence from general anesthesia including the control of cough, agitation, hypertension, tachycardia, and shivering. D 0.5 also controls emergence phenomena but is less effective in controlling cough. The 3 doses do not delay extubation. However, they cause dose-dependent hypotension.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Comparison of Intraoperative Sedation With Dexmedetomidine Versus Propofol
           on Acute Postoperative Pain in Total Knee Arthroplasty Under Spinal
           Anesthesia: A Randomized Trial
    • Authors: Shin; Hyun-Jung; Do, Sang-Hwan; Lee, Jae-Sung; Kim, Tae-Kyun; Na, Hyo-Seok
      Abstract: imageBACKGROUND: In patients undergoing total knee arthroplasty under spinal anesthesia, we compared the postoperative analgesic effect of intraoperative sedation with dexmedetomidine versus propofol. We hypothesized that sedation with dexmedetomidine would result in lower postoperative opioid analgesic consumption than with propofol.METHODS: Forty-eight patients were enrolled and randomly assigned to either a dexmedetomidine group (n = 24), which received a loading dose of 1 μg/kg dexmedetomidine over 10 minutes, followed by a continuous infusion of 0.1–0.5 μg·kg−1·hour−1, or a propofol group (n = 24), which received a continuous infusion of propofol via a target-controlled infusion to maintain the effect-site concentration within a range of 0.5–2.0 μg/mL. The drug infusion rate was determined according to the sedation level, targeting a modified observer’s assessment of alertness/sedation score of 3 or 4. The cumulative amounts of fentanyl administered via intravenous patient-controlled analgesia were recorded at 24 and 48 hours postoperatively (primary outcome). The postoperative numerical rating scale for pain was assessed at 6, 12, 24, and 48 hours (secondary outcome). The postoperative use of additional rescue analgesic (ketoprofen) and antiemetic drugs was also compared between the 2 groups at 24 and 48 hours.RESULTS: Dexmedetomidine significantly reduced postoperative fentanyl consumption (median [interquartile range]) during 0–24 hours (45 [30–71] vs 150 [49–248] μg, P = .004; median difference = −105 μg [99.98% CI, 210–7.5]), 24–48 hours (90 [45–143] vs 188 [75–266] μg, P = .005; median difference = −98 μg [99.98% CI, 195–45]), and 0–48 hours (135 [68–195] vs 360 [146–480] μg, P = .003; median difference = −225 μg [99.98% CI, 405–7.5]). The numerical rating scale (median [interquartile range]) was lower at 6 hours (1 [0–2] vs 2 [1–3], P = .003), 12 hours (1 [1–2] vs 3 [2–3], P < .001), 24 hours (1 [1–2] vs 3 [2–3], P < .001), and 48 hours (2 [2–3] vs 3 [3–4], P < .001) after surgery in the dexmedetomidine group compared to the propofol group. No significant intergroup differences were observed in the amount of rescue analgesics and antiemetics at 24 hours (P = .155 and P = .482) and 48 hours (P = .082 and P = .153) after surgery.CONCLUSIONS: Intraoperative dexmedetomidine sedation was associated with a small but clinically important reduction in postoperative opioid use after total knee arthroplasty.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Dexmedetomidine Pharmacokinetics and a New Dosing Paradigm in Infants
           Supported With Cardiopulmonary Bypass
    • Authors: Zimmerman; Kanecia O.; Wu, Huali; Laughon, Matthew; Greenberg, Rachel G.; Walczak, Richard; Schulman, Scott R.; Smith, P. Brian; Hornik, Christoph P.; Cohen-Wolkowiez, Michael; Watt, Kevin M.
      Abstract: imageBACKGROUND: Dexmedetomidine is increasingly used off-label in infants and children with cardiac disease during cardiopulmonary bypass (CPB) and in the postoperative period. Despite its frequent use, optimal dosing of dexmedetomidine in the setting of CPB has not been identified but is expected to differ from dosing in those not supported with CPB. This study had the following aims: (1) characterize the effect of CPB on dexmedetomidine clearance (CL) and volume of distribution (V) in infants and young children; (2) characterize tolerance and sedation in patients receiving dexmedetomidine; and (3) identify preliminary dosing recommendations for infants and children undergoing CPB. We hypothesized that CL would decrease, and V would increase during CPB compared to pre- or post-CPB states.METHODS: Open-label, single-center, opportunistic pharmacokinetics (PK) and safety study of dexmedetomidine in patients ≤36 months of age administered dexmedetomidine per standard of care via continuous infusion. We analyzed dexmedetomidine PK data using standard nonlinear mixed effects modeling with NONMEM software. We compared model-estimated PK parameters to those from historical patients receiving dexmedetomidine before anesthesia for urologic, lower abdominal, or plastic surgery; after low-risk cardiac or craniofacial surgery; or during bronchoscopy or nuclear magnetic resonance imaging. We investigated the influence of CPB-related factors on PK estimates and used the final model to simulate dosing recommendations, targeting a plasma concentration previously associated with safety and efficacy (0.6 ng/mL). We used the Wilcoxon rank sum test to evaluate differences in dexmedetomidine exposure between infants with hypotension or bradycardia and those who did not develop these adverse events.RESULTS: We collected 213 dexmedetomidine plasma samples from 18 patients. Patients had a median (range) age of 3.3 months (0.1–34.0 months) and underwent CPB for 161 minutes (63–394 minutes). We estimated a CL of 13.4 L/h/70 kg (95% confidence interval, 2.6–24.2 L/h/70 kg) during CPB, compared to 42.1 L/h/70 kg (95% confidence interval, 38.7–45.8 L/h/70 kg) in the historical patients. No specific CPB-related factor had a statistically significant effect on PK. A loading dose of 0.7 µg/kg over 10 minutes before CPB, followed by maintenance infusions through CPB of 0.2 or 0.25 µg/kg/h in infants with postmenstrual ages of 42 or 92 weeks, respectively, maintained targeted concentrations. We identified no association between dexmedetomidine exposure and selected adverse events (P = .13).CONCLUSIONS: CPB is associated with lower CL during CPB in infants and young children compared to those not undergoing CPB. Further study should more closely investigate CPB-related factors that may influence CL.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Dexmedetomidine Sedation for Paroxysmal Supraventricular Tachycardia
           Ablation Is Not Associated With Alteration of Arrhythmia Inducibility
    • Authors: Slupe; Andrew M.; Minnier, Jessica; Raitt, Merritt H.; Zarraga, Ignatius Gerardo E.; MacMurdy, Karen S.; Jessel, Peter M.
      Abstract: imageBACKGROUND: Dexmedetomidine (Dex) is an attractive agent for procedural sedation due to its unique pharmacodynamic profile, specifically affording predictable sedation without concurrent respiratory depression. However, Dex has previously been reported to prevent or terminate arrhythmias. The purpose of this study was to investigate paroxysmal supraventricular tachycardia (PSVT) inducibility and homeostatic stability during electrophysiology studies (EPSs) and ablation when a standardized Dex protocol was used as the primary sedation agent.METHODS: We performed a retrospective review of 163 consecutive procedures for PSVT ablation that received Dex as the primary sedative with adjunct fentanyl and midazolam boluses (DEX-FENT-MIDAZ). This cohort was compared to 163 consecutive control procedures wherein strictly fentanyl and midazolam were used for sedation. The primary outcome reviewed was PSVT inducibility assessed before ablation. Reviewed secondary outcomes included level of sedation and intraprocedure hemodynamics and oxygenation.RESULTS: The arrhythmia profiles of the DEX-FENT-MIDAZ and control cohorts were very similar. The overall incidence of a “negative” EPSs in which arrhythmia was not induced was 24% in the DEX-FENT-MIDAZ group and 26% in the control group (P = .7). Unintended deep sedation was significantly less with DEX-FENT-MIDAZ (4.3% vs 27%; P ≤ .0001). However, DEX-FENT-MIDAZ use was associated with a higher incidence of intraprocedure hypotension.CONCLUSIONS: Dex sedation during EPSs is not associated with a reduction in PSVT inducibility. The therapeutic utility of Dex during EPS arises from the predictable sedation Dex affords but is associated with an increased incidence of intraprocedure hypotension.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Using Pupillary Pain Index to Assess Nociception in Sedated Critically Ill
    • Authors: Vinclair; Marc; Schilte, Clotilde; Roudaud, Florian; Lavolaine, Julien; Francony, Gilles; Bouzat, Pierre; Bosson, Jean-Luc; Payen, Jean-Francois
      Abstract: imageBACKGROUND: Pupillary reflex dilation is a reliable indicator of response to noxious stimulation. In a proof of concept study, we investigated the performance of pupillary pain index, a new score derived from pupillary reflex dilation measurements, to predict nociceptive response to endotracheal suctioning in sedated critically ill patients.METHODS: Twenty brain-injured and 20 non–brain-injured patients were studied within 48 hours of admission (T1) in the intensive care unit and at 48–72 hours later (T2). Video-based pupillometer was used to determine pupillary reflex dilation during tetanic stimulation. The tetanic stimulation (100 Hz) was applied to the skin area innervated by the ulnar nerve and was stepwise increased from 10 to 60 mA until pupil size had increased by 13% compared to baseline. The maximum intensity value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception). The Behavioral Pain Scale response to endotracheal suctioning was measured thereafter.RESULTS: Behavioral Pain Scale responses to endotracheal suctioning and pupillary pain index scores were positively correlated at T1 and T2 (both P < .01). After adjustments for repeated measurements and group of patients, the area under the receiver operating characteristic curve of pupillary pain index to predict Behavioral Pain Scale response to endotracheal suctioning was of 0.862 (95% CI, 0.714–0.954). In the combined set of patients, a pupillary pain index score of ≤4 could predict no nociceptive response to endotracheal suctioning with a sensitivity of 88% (95% CI, 68%–97%) and a specificity of 79% (95% CI, 66%–88%). By contrast with endotracheal suctioning, tetanic stimulation had no effect on intracranial pressure in the brain-injured group.CONCLUSIONS: These results are a proof of concept. The nociceptive response to endotracheal suctioning could be accurately predicted using the determination of pupillary pain index score in sedated critically ill patients whether they have brain injury or not.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • A Simple Method for Estimating Hand Hygiene Use Among Anesthesia
           Personnel: Development, Validation, and Use in a Quality Improvement
    • Authors: Segal; Scott; Harris, Hannah M.; Gunawan, Antonius; Schumann, Roman
      Abstract: imageBACKGROUND: Frequent hand hygiene by anesthesia personnel may be an important factor in reducing contamination of IV lines and medication access ports and may reduce hospital-acquired infections. Measurement of hand hygiene frequency at the individual clinician level by direct observation or electronic devices is cumbersome and expensive. We developed and validated a simple method for estimating hand hygiene frequency by individual anesthesia providers and utilized it in a quality improvement initiative to increase hand hygiene use.METHODS: Pump-style, alcohol-based hand hygiene container weight at the anesthesia work station was measured before and after each surgical operation and converted to estimated number of accesses (pumps) per hour. Video observation was used to validate the estimated hand hygiene use. A quality improvement initiative utilized periodic measurement of hand hygiene frequency via the validated method, and incorporated individual provider feedback, email reminders, monthly departmental performance reports, and reminders in the electronic anesthesia record. Segmented linear regression was used to evaluate the effect of the intervention on hand hygiene use.RESULTS: Delivered product per pump was consistent for containers at least half-full and averaged (mean ± SD) 0.92 ± 0.13 g per pump. Video observation in 26 cases showed a strong correlation between observed hand hygiene episodes and estimated hand hygiene use frequency based on weight change of the container (linear regression, R2 = 0.97, P < .0001). Median hand hygiene frequency was near 0 at baseline but increased progressively throughout the intervention period (segmented linear regression, overall R2 = 0.76, P < .0001; change of intercept or mean hand hygiene after initiation of intervention [parameter estimate ± SE] [0.970 ± 0.29], P = .0008).CONCLUSIONS: A low-cost, simple method for measuring individual anesthesia clinician use of hand hygiene intraoperatively based on container weight change is feasible and sufficiently accurate to support a quality improvement initiative to increase its use.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense
           Periods: One Step Closer to Pathogen Containment by Anesthesia Providers
           in the Operating Room
    • Authors: Birnbach; David J.; Thiesen, Taylor C.; McKenty, Nathan T.; Rosen, Lisa F.; Arheart, Kristopher L.; Fitzpatrick, Maureen; Everett-Thomas, Ruth
      Abstract: imageBACKGROUND: Anesthesia providers’ hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands.METHODS: To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period.RESULTS: Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration–approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness.CONCLUSIONS: This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Does Adherence to World Health Organization Hand Hygiene Protocols in the
           Operating Room Have the Potential to Produce Irritant Contact Dermatitis
           in Anesthesia Providers'
    • Authors: Birnbach; David J.; McKenty, Nathan T.; Rosen, Lisa F.; Arheart, Kristopher L.; Everett-Thomas, Ruth; Lindsey, Scott F.
      Abstract: imageAnesthesia providers have the burden of constant hand hygiene during task dense periods. The requirement for hand hygiene often demands frequent application of alcohol-based hand rub. To assess whether frequent alcohol-based hand rub use leads to skin changes or irritant contact dermatitis, volunteers cleaned their hands with alcohol-based hand rub every 15 minutes for 8 hours for 5 sequential days. They were examined by a dermatologist before and after and asked about subjective skin changes. Results suggest an increase in irritant contact dermatitis scores and subjective complaints.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Global and Regional Respiratory Mechanics During Robotic-Assisted
           Laparoscopic Surgery: A Randomized Study
    • Authors: Brandão; Julio C.; Lessa, Marcos A.; Motta-Ribeiro, Gabriel; Hashimoto, Soshi; Paula, Luis Felipe; Torsani, Vinicius; Le, Linh; Bao, Xiaodong; Eikermann, Matthias; Dahl, Douglas M.; Deng, Hao; Tabatabaei, Shahin; Amato, Marcelo B. P.; Vidal Melo, Marcos F.
      Abstract: imageBACKGROUND: Pneumoperitoneum and nonphysiological positioning required for robotic surgery increase cardiopulmonary risk because of the use of larger airway pressures (Paws) to maintain tidal volume (Vt). However, the quantitative partitioning of respiratory mechanics and transpulmonary pressure (Pl) during robotic surgery is not well described. We tested the following hypothesis: (1) the components of driving pressure (transpulmonary and chest wall components) increase in a parallel fashion at robotic surgical stages (Trendelenburg and robot docking); and (2) deep, when compared to routine (moderate), neuromuscular blockade modifies those changes in Pls as well as in regional respiratory mechanics.METHODS: We studied 35 American Society of Anesthesiologists (ASA) I-II patients undergoing elective robotic surgery. Airway and esophageal balloon pressures and respiratory flows were measured to calculate respiratory mechanics. Regional lung aeration and ventilation was assessed with electrical impedance tomography and level of neuromuscular blockade with acceleromyography. During robotic surgical stages, 2 crossover randomized groups (conditions) of neuromuscular relaxation were studied: Moderate (1 twitch in the train-of-four stimulation) and Deep (1–2 twitches in the posttetanic count).RESULTS: Pneumoperitoneum was associated with increases in driving pressure, tidal changes in Pl, and esophageal pressure (Pes). Steep Trendelenburg position during robot docking was associated with further worsening of the respiratory mechanics. The fraction of driving pressures that partitioned to the lungs decreased from baseline (63% ± 15%) to Trendelenburg position (49% ± 14%, P < .001), due to a larger increase in chest wall elastance (Ecw; 12.7 ± 7.6 cm H2O·L−1) than in lung elastance (El; 4.3 ± 5.0 cm H2O·L−1, P < .001). Consequently, from baseline to Trendelenburg, the component of Paw affecting the chest wall increased by 6.6 ± 3.1 cm H2O, while Pls increased by only 3.4 ± 3.1 cm H2O (P < .001). Pl and driving pressures were larger at surgery end than at baseline and were accompanied by dorsal aeration loss. Deep neuromuscular blockade did not change respiratory mechanics, regional aeration and ventilation, and hemodynamics.CONCLUSIONS: In robotic surgery with pneumoperitoneum, changes in ventilatory driving pressures during Trendelenburg and robot docking are distributed less to the lungs than to the chest wall as compared to routine mechanical ventilation for supine patients. This effect of robotic surgery derives from substantially larger increases in Ecw than Els and reduces the risk of excessive Pls. Deep neuromuscular blockade does not meaningfully change global or regional lung mechanics.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Tranexamic Acid for Acute Hemorrhage: A Narrative Review of Landmark
           Studies and a Critical Reappraisal of Its Use Over the Last Decade
    • Authors: Lier; Heiko; Maegele, Marc; Shander, Aryeh
      Abstract: imageThe publication of the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study and its intense dissemination prompted a renaissance for the use of the antifibrinolytic agent tranexamic acid (TXA) in acute trauma hemorrhage. Subsequent studies led to its widespread use as a therapeutic as well as prophylactic agent across different clinical scenarios involving bleeding, such as trauma, postpartum, and orthopedic surgery. However, results from the existing studies are confounded by methodological and statistical ambiguities and are open to varied interpretations. Substantial knowledge gaps remain on dosing, pharmacokinetics, mechanism of action, and clinical applications for TXA. The risk for potential thromboembolic complications with the use of TXA must be balanced against its clinical benefits. The present article aims to provide a critical reappraisal of TXA use over the last decade and a “thought exercise” in the potential downsides of TXA. A more selective and individualized use of TXA, guided by extended and functional coagulation assays, is advocated in the context of the evolving concept of precision medicine.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Do Epidural Catheter Size and Flow Rate Affect Bolus Injection Pressure in
           Different Programmed Intermittent Epidural Bolus Regimens' An In Vitro
    • Authors: Krawczyk; Pawel; Piwowar, Piotr; Salapa, Kinga; Lonc, Tomasz; Andres, Janusz
      Abstract: imageBACKGROUND: The optimal programmed intermittent epidural bolus regimen for labor analgesia remains unknown. Some studies indicate that better drug spread in the epidural space results from greater injection pressure; however, there is a lack of data regarding the maximum pressure generated by epidural bolus injection using different catheters and flow rates.METHODS: We evaluated the flow and pressure characteristics of 11 commonly used epidural catheters combined with 3 different infusion pumps that deliver epidural infusions according to the programmed intermittent epidural bolus regimen. Pressure changes were measured over time at flow rates of 100, 250, and 400 mL·hour−1 and with a bolus volume of 10 mL. To account for repeated measures, linear mixed models were used. Features were selected with a backward stepwise procedure continued until only statistically significant variables were left in the model.RESULTS: We performed 660 measurements. The mean maximal pressure generated during bolus injection ranged from 86 to 863 mm Hg for different flow rates and catheter designs. The interaction between flow rate and catheter gauge resulted in 1.31, 1.65, and 2.00 mm Hg of pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour−1 of increased flow rate (P< .001). Analyses including wire-reinforced catheters revealed a 1.16, 1.76, and 2.36 mm Hg pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour−1 of increased flow rate (P< .001). In some cases, it triggered the occlusion pump alarm.CONCLUSIONS: Significant differences were observed in the in vitro maximum pressure value among the various catheter and flow rate combinations with a higher pressure value for wire-reinforced catheters used in the study. The optimal flow rate and epidural catheter combination may allow for delivery of the bolus with high flow rate without triggering the occlusion alarm.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Distribution of Extreme Vital Signs and Complete Blood Count Values of
           Healthy Parturients: A Retrospective Database Analysis and Review of the
    • Authors: Gat; Roi; Hadar, Eran; Orbach-Zinger, Sharon; Shochat, Tzippy; Kushnir, Shiri; Einav, Sharon
      Abstract: imageBACKGROUND: The impact of physiological adjustments throughout pregnancy on maternal vital signs and laboratory values has yet to be fully defined. The present study was designed to determine the normal range of these parameters among healthy pregnant women during the peripartum period.METHODS: This is a retrospective analysis of data collected during real-time deliveries in a single medical center. Vital signs and laboratory results from the 24 hours preceding delivery room admission and up to 72 hours postpartum were collected. Only pregnant women at term (370/7 to 416/7 weeks’ gestation) with a liveborn, singleton gestation, and no chronic disease or obstetric complication that could affect the physiological parameters under study were included. The mean, range, and standard deviations of the extremes of all parameters at 3 distinct time points (prelabor, intrapartum, and postpartum) were calculated. The 2.5 and 97.5 percentiles for each parameter were reported as the normal range.RESULTS: A total of 32,161 cases fulfilled inclusion criteria. The average gestational age at delivery was 393/7 weeks ± 8 days, and one-third of the cases were primiparous. During labor and after delivery, the upper limits of normal blood pressure values were 147/94 and 145/94 mm Hg, respectively. The lower limits were 83/43 and 83/42 mm Hg, respectively. Normal heart rates were 60–115 beats/min prelabor, 51–120 beats/min intrapartum, and 50–120 beats/min postpartum. Lowest normal temperatures ranged between 36.0°C and 36.3°C in the 3 study time points, and highest normal temperatures were 37.2°C prelabor and 37.6°C intra- and postpartum. The normal ranges of white blood cell counts were 6.1–16.8 prelabor, 6.5–22.5 intrapartum, and 6.4–23.9 K/µL postpartum. Normal low values of hemoglobin were 9.7, 8.7, and 7.1 g/dL and of platelets were 117, 113, and 105 K/µL, respectively.CONCLUSIONS: Our findings justify the practice of using ≥2 repeated measurements for diagnosing hypertensive disorders of pregnancy. Lower normal blood pressure limits may be below those defining hypotensive shock. Normal heart rates exceed the accepted definitions of both tachy- and bradycardia. Normal temperatures at all times have a more narrow range than previously thought, and the normal range of white blood cell count has outliers exceeding the current definitions of leukocytosis or leukopenia at all times. The normal lower range of hemoglobin was constantly below 10 g/dL, and normal platelet counts were considerably lower than those previously described. The vital signs and complete blood count values thus far considered normal for the peripartum period may require some adjustment. New definitions for hypotension, tachy- and bradycardia, fever, and leukocyte quantitative disorders should be considered.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Rapid Titration of Intravenous Treprostinil to Treat Severe Pulmonary
           Arterial Hypertension Postpartum: A Retrospective Observational Case
           Series Study
    • Authors: Wang; Tengke; Lu, Jiakai; Li, Qiang; Chen, Yao; Ye, Qing; Gao, Jie; Yang, Dong; Zhao, Liyun; Huang, Jiapeng; Zhang, Jinglan
      Abstract: imageBACKGROUND: Pulmonary hypertension during pregnancy carries high mortality rate. The relatively long-acting, specific pulmonary vasodilator treprostinil has been used to improve survival in these parturients. Slow uptitration is performed in most cases, and rapid titration has not been reported in the postpartum period.METHODS: We retrospectively reviewed 17 pregnant patients with severe pulmonary arterial hypertension who were treated with intravenous treprostinil in our institution between 2014 and 2016. Patients’ demographic characteristics, etiology, functional status, mode of delivery, anesthetic administration, medical therapy, echocardiographic and hemodynamic measurements, subsequent clinical course, and maternal–fetal outcomes were assessed. The a priori primary outcome is maternal mortality in this study.RESULTS: Rapid titration of intravenous treprostinil was initiated at 1.25 ng/kg/min and increased to effective dose of 10 ng/kg/min by 1.25–2.5 ng/kg/min every 3 hours. In the next 24 hours, we adjusted the dosage to a median maximum dose of 15 ng/kg/min (interquartile range, 15–20 ng/kg/min) over a median uptitration period of 34 hours (interquartile range, 24–41 hours) for 17 parturients with severe pulmonary hypertension. Treprostinil was weaned off by 0.50–1.25 ng/kg/min every 3 hours in 94.3 ± 42.4 hours. Fifteen patients survived to discharge, and only 2 patients died of pulmonary hypertensive crisis (maternal mortality rate, 11.7%). No treprostinil infusion-related postpartum complication was observed.CONCLUSIONS: Our experience suggested that rapid uptitration of intravenous treprostinil combined with oral sildenafil in the postpartum period may be a safe and effective approach for these very sick parturients with severe pulmonary hypertension.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant
           Women: A Multicenter Case–Control Study
    • Authors: Bauer; Melissa E.; Housey, Michelle; Bauer, Samuel T.; Behrmann, Sydney; Chau, Anthony; Clancy, Caitlin; Clark, Erin A. S.; Einav, Sharon; Langen, Elizabeth; Leffert, Lisa; Lin, Stephanie; Madapu, Manokanth; Maile, Michael D.; McQuaid-Hanson, Emily; Priessnitz, Kristina; Sela, Hen Y.; Shah, Anuj; Sobolewski, Paul; Toledo, Paloma; Tsen, Lawrence C.; Bateman, Brian T.
      Abstract: imageBACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis.METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls.RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after>1 hour.CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after>1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • National Partnership for Maternal Safety Recommended Maternal Early
           Warning Criteria Are Associated With Maternal Morbidity
    • Authors: Arnolds; David E.; Smith, Aaron; Banayan, Jennifer M.; Holt, Roxane; Scavone, Barbara M.
      Abstract: imageBACKGROUND: Many cases of maternal mortality and morbidity are preventable. A delayed response to clinical warning signs contributes to preventability. Therefore, the National Partnership for Maternal Safety devised maternal early warning criteria (MEWC), composed of abnormal vital signs that trigger bedside evaluation by a provider with the capacity to escalate care. The relationship of the MEWC to maternal morbidity has not been studied. We evaluated the correlation between the MEWC and maternal morbidity.METHODS: We retrospectively reviewed the first 400 deliveries at the University of Chicago in 2016. We analyzed the electronic medical record to determine whether vital signs triggered the MEWC during the admission to labor and delivery and whether patients experienced morbidity during their delivery hospitalization. The association between MEWC and morbidity was tested using χ2 analysis. We calculated the sensitivity, specificity, and positive and negative predictive values of the MEWC.RESULTS: Two hundred eighty-one (70%) of 400 patients triggered the MEWC at least once, and 198 (50%) of 400 patients had multiple or recurrent triggers. Ninety-nine (25%) of 400 patients experienced morbidity. The most common causes of morbidity were hemorrhage, suspected infection, and preeclampsia with severe features. The relative risk of maternal morbidity with at least a single trigger was 13.55 (95% confidence interval [CI], 4.38–41.91) and with recurrent or multiple triggers was 5.29 (95% CI, 3.22–8.71). The sensitivity of the MEWC in predicting morbidity was 0.97 (95% CI, 0.92–0.99) and the specificity was 0.39 (95% CI, 0.33–0.44) when patients with at least a single trigger were included. When including only patients with multiple or recurrent triggers, the sensitivity was 0.84 (95% CI, 0.75–0.90) and the specificity was 0.62 (95% CI, 0.56–0.67). The positive predictive value of the MEWC in our population was 0.34 (95% CI, 0.29–0.40), and the negative predictive value was 0.97 (95% CI, 0.93–0.99). When considering only patients with multiple or recurrent triggers, the positive predictive value was 0.42 (95% CI, 0.38–0.46) and the negative predictive value was 0.92 (95% CI, 0.88–0.95).CONCLUSIONS: The MEWC are associated with maternal morbidity. As a screening tool, they appropriately prioritize sensitivity and have an excellent negative predictive value. The criteria demonstrate low specificity, which is slightly improved by considering only patients with recurrent or multiple triggers. Additional efforts to improve the specificity of MEWC, with a focus on identifying sustained or recurrent patterns of abnormal vital signs, may be necessary before their widespread implementation.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Incentive-Based Game for Allaying Preoperative Anxiety in Children: A
           Prospective, Randomized Trial
    • Authors: Chaurasia; Bijay; Jain, Divya; Mehta, Swati; Gandhi, Komal; Mathew, Preethy J.
      Abstract: imageBACKGROUND: Induction of anesthesia can be distressing both for children and their parents. Nonpharmacological behavioral interventions can reduce the anxiety of children without significant adverse effects as seen with sedative medications. We hypothesized that the use of incentive-based game therapy in conjunction with parental involvement would be a simple and cost-effective intervention in reducing the preoperative anxiety in children.METHODS: Eighty children between the age group of 4 and 8 years scheduled to undergo surgery were randomly assigned to a control group (n = 40) and intervention group (n = 40). Children in the intervention group participated in an incentive-based game in the preoperative room. Anesthesia was induced with parental presence in both the groups. The modified Yale Preoperative Anxiety Scale (mYPAS) score to measure the anxiety of the children during induction was taken as the primary outcome. Induction Compliance Checklist score and parental satisfaction were assessed as secondary outcomes.RESULTS: The mYPAS score of children in the intervention group was significantly less than the control group during anesthesia induction. The mean difference (95% confidence interval [CI]) of the mYPAS at induction between the 2 groups was 20 (95% CI, 16–24; P < .001). Fourteen (35%) children in the intervention group and 2 (5%) children in control group displayed no anxiety (mYPAS score
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Development and Usability Testing of the Society for Pediatric Anesthesia
           Pedi Crisis Mobile Application
    • Authors: Clebone; Anna; Strupp, Kim M.; Whitney, Gina; Anderson, Michael R.; Hottle, Jeffrey; Fehr, James; Yaster, Myron; Schleelein, Laura E.; Burian, Barbara K.; Galvez, Jorge A.; Lockman, Justin L.; Polaner, David; Barnett, Natalie R.; Keane, Michael J.; Manikappa, Shashikanth; Gleich, Stephen; Greenberg, Robert S.; Vincent, Ariel; Oswald, Sarah L.; Starks, Red; Licata, Scott; the Pedi Crisis Application Working Group
      Abstract: imageWhen life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists—the Pedi Crisis 2.0 application—as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above “excellent” overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • A Multivariable Model Predictive of Unplanned Postoperative Intubation in
           Infant Surgical Patients
    • Authors: Eisler; Lisa D.; Hua, May; Li, Guohua; Sun, Lena S.; Kim, Minjae
      Abstract: imageBACKGROUND: Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures.METHODS: In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and perioperative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012–2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve.RESULTS: In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time>120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85–0.87) for the derivation cohort and 0.83 (95% CI, 0.82–0.85) for the validation cohort.CONCLUSIONS: About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in
           Pediatric Cancer Patients: A Comprehensive Review of the Literature
    • Authors: Cata; Juan P.; Owusu-Agyemang, Pascal; Kapoor, Ravish; Lonnqvist, Per-Arne
      Abstract: imageCancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Cervical Spine Motion During Tracheal Intubation Using an Optiscope Versus
           the McGrath Videolaryngoscope in Patients With Simulated Cervical
           Immobilization: A Prospective Randomized Crossover Study
    • Authors: Nam; Karam; Lee, Younsuk; Park, Hee-Pyoung; Chung, Jaeyeon; Yoon, Hyun-Kyu; Kim, Tae Kyong
      Abstract: imageBACKGROUND: In patients with an unstable cervical spine, maintenance of cervical immobilization during tracheal intubation is important. In McGrath videolaryngoscopic intubation, lifting of the blade to raise the epiglottis is needed to visualize the glottis, but in patients with an unstable cervical spine, this can cause cervical spine movement. By contrast, the Optiscope, a rigid video-stylet, does not require raising of the epiglottis during tracheal intubation. We therefore hypothesized that the Optiscope would produce less cervical spine movement than the McGrath videolaryngoscope during tracheal intubation. The aim of this study was to compare the Optiscope with the McGrath videolaryngoscope with respect to cervical spine motion during intubation in patients with simulated cervical immobilization.METHODS: The primary outcome of the study was the extent of cervical spine motion at the occiput–C1, C1–C2, and C2–C5 segments. In this randomized crossover study, the cervical spine angle was measured before and during tracheal intubation using either the Optiscope or the McGrath videolaryngoscope in 21 patients with simulated cervical immobilization. Cervical spine motion was defined as the change in angle at each cervical segment during tracheal intubation.RESULTS: There was significantly less cervical spine motion at the occiput–C1 segment using the Optiscope rather than the McGrath videolaryngoscope (mean [98.33% CI]: 4.7° [2.4–7.0] vs 10.4° [8.1–12.7]; mean difference [98.33% CI]: −5.7° [−7.5 to −3.9]). There were also fewer cervical spinal motions at the C1–C2 and C2–C5 segments using the Optiscope (mean difference versus the McGrath videolaryngoscope [98.33% CI]: −2.4° [−3.7 to −1.2]) and −3.7° [−5.9 to −1.4], respectively).CONCLUSIONS: The Optiscope produces less cervical spine motion than the McGrath videolaryngoscope during tracheal intubation of patients with simulated cervical immobilization.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Point-of-Care Ultrasound for Obstructive Sleep Apnea Screening: Are We
           There Yet' A Systematic Review and Meta-analysis
    • Authors: Singh; Mandeep; Tuteja, Arvind; Wong, David T.; Goel, Akash; Trivedi, Aditya; Tomlinson, George; Chan, Vincent
      Abstract: imageBACKGROUND: Perioperative diagnosis of obstructive sleep apnea (OSA) has important resource implications as screening questionnaires are overly sensitive, and sleep studies are expensive and time-consuming. Ultrasound (US) is a portable, noninvasive tool potentially useful for airway evaluation and OSA screening in the perioperative period. The objective of this systematic review was to evaluate the correlation of surface US with OSA diagnosis and to determine whether a point-of-care ultrasound (PoCUS) for OSA screening may help with improved screening in perioperative period.METHODS: A search of all electronic databases including Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from database inception to September 2017. Inclusion criteria were observational cohort studies and randomized controlled trials of known or suspected OSA patients undergoing surface US assessment. Article screening, data extraction, and summarization were conducted by 2 independent reviewers with ability to resolve conflict with supervising authors. Diagnostic properties and association between US parameters (index test) and OSA diagnosis using sleep study (reference standard) were evaluated. The US parameters were divided into airway and nonairway parameters. A random-effects meta-analysis was planned, wherever applicable.RESULTS: Of the initial 3865 screened articles, 21 studies (7 airway and 14 nonairway) evaluating 3339 patients were included. Majority of studies were conducted in the general population (49%), respirology (23%), and sleep clinics (12%). No study evaluated the use of US for OSA in perioperative setting. Majority of included studies had low risk of bias for reference standard and flow and timing. Airway US parameters having moderate–good correlation with moderate–severe OSA were distance between lingual arteries (DLAs> 30 mm; sensitivity, 0.67; specificity, 0.59; 1 study/66 patients); mean resting tongue thickness (>60 mm; sensitivity, 0.85; specificity, 0.59; 1 study/66 patients); tongue base thickness during Muller maneuver (MM; sensitivity, 0.59; specificity, 0.78; 1 study/66 patients); and a combination of neck circumference and retropalatal (RP) diameter shortening during MM (sensitivity, 1.0; specificity, 0.65; 1 study/104 patients). Nonairway US parameters having a low–moderate correlation with moderate–severe OSA were carotid intimal thickness (pooled correlation coefficient, 0.444; 95% confidence interval [CI], 0.320–0.553; P value = .000, 8 studies/727 patients) and plaque presence (sensitivity, 0.24–0.75; specificity, 0.13–1.0; 4 studies/1183 patients).CONCLUSIONS: We found that a number of airway and nonairway parameters were identified with moderate to good correlation with OSA diagnosis in the general population. In future studies, it remains to be seen whether PoCUS screening for a combination of these parameters can address the pitfalls of OSA screening questionnaires.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • A Prospective, Ex Vivo Trial of Endobronchial Blockade Management
           Utilizing 3 Commonly Available Bronchial Blockers
    • Authors: Gilbert; Christopher R.; Mallow, Christopher; Wishire, Candice L.; Chang, Shu-Ching; Yarmus, Lonny B.; Vallieres, Eric; Haeck, Katherine; Gorden, Jed A.
      Abstract: imageBACKGROUND: Lung isolation with bronchial blockers is a well-described and accepted procedure, often described for use during the management of massive hemoptysis. Recommendations for balloon inflation are sparse, with some advocating for saline whereas other suggest air, including the manufacturers. We sought to evaluate the optimal method for balloon inflation in an ex vivo trial.METHODS: We performed a prospective trial utilizing 3 commercially available bronchial blockers commonly described for use in lung isolation and massive hemoptysis management. We utilized the Arndt Endobronchial Blocker (Cook Medical), the Cohen Tip Deflecting Endobronchial Blocker (Cook Medical), and the Fogarty Venous Thrombectomy Catheter (Edwards LifeSciences). Balloon size and deflation assessment were tested within 3 different scenarios comparing air versus saline.Welch t test was performed to compare means between groups, and a generalized estimating equation model was utilized to compare balloon diameter over time to account for correlation among repeated measures from the same balloon.RESULTS: All 3 endobronchial blocker systems were observed in triplicate. During free-standing balloon inflation, all 3 endobronchial systems displayed a greater degree of balloon deflation over time with air as opposed to saline (P < .001). Within a stent-based model, inflation with air of all 3 endobronchial systems, according to manufacturer recommendations, demonstrated significantly decreased time until fluid transgression occurred when compared to a saline model (P < .001). Within a stent-based model, inflation with air, according to clinical judgment, demonstrated significantly decreased time until fluid transgression in the Arndt (P = .016) and the Fogarty (P < .001) system, but not the Cohen (P = .173) system, when compared with saline.CONCLUSIONS: The utilization of saline for balloon inflation during bronchial blockade allows for more consistent balloon inflation. The use of saline during balloon inflation appears to delay passive, spontaneous balloon deflation time when compared to air during a model of endobronchial blockade. The approach of saline inflation should be tested in humans to demonstrate the overall applicability and validity of the current findings.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • How Do Common Comorbidities Modify the Association of Frailty With
           Survival After Elective Noncardiac Surgery' A Population-Based Cohort
    • Authors: Hui; Yin; van Walraven, Carl; McIsaac, Daniel I.
      Abstract: imageBACKGROUND: Older people with frailty have decreased postoperative survival. Understanding how comorbidities modify the association between frailty and survival could improve risk stratification and guide development of interventions. Therefore, we evaluated whether the concurrent presence of common and high-risk comorbidities (dementia, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes mellitus, heart failure [HF]) in conjunction with frailty might be associated with a larger decrease in postoperative survival after major elective surgery than would be expected based on the presence of the comorbidity and frailty on their own.METHODS: This cohort study used linked administrative data from Ontario, Canada to identify adults>65 years having elective noncardiac surgery from 2010 to 2015. Frailty was identified using a validated index; comorbidities were identified with validated codes. We evaluated the presence of effect modification (also called interaction) between frailty and each comorbidity on (1) the relative (or multiplicative) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was different than the product of the risks associated with each condition; and (2) the absolute risk difference (or additive) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was greater than the sum of the risks associated with each condition.RESULTS: 11,150 (9.7%) people with frailty died versus 7826 (2.8%) without frailty. After adjustment, frailty was associated with decreased survival (adjusted hazard ratio [HR] = 2.42; 95% confidence interval [CI], 2.31–2.54). On the relative (multiplicative) scale, only diabetes mellitus demonstrated significant effect modification (P value for interaction .03; reduced risk together). On the absolute risk difference (additive) scale, all comorbidities except for coronary disease demonstrated effect modification of the association of frailty with survival. Co-occurrence of dementia with frailty carried the greatest excess risk (Synergy Index [S; the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation] = 2.29; 95% CI, 1.32–10.80, the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation).CONCLUSIONS: Common comorbidities modify the association of frailty with postoperative survival; however, this effect was only apparent when analyses accounted for effect modification on the absolute risk difference, as opposed to relative scale. While the relative scale is more commonly used in biomedical research, smaller effects may be easier to detect on the risk difference scale. The concurrent presence of dementia, COPD, and HF with frailty were all associated with excess mortality on the absolute risk difference scale.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • A Mixed-Method Design Evaluation of the SAFE Obstetric Anaesthesia Course
           at 4 and 12–18 Months After Training in the Republic of Congo and
    • Authors: White; Michelle C.; Rakotoarisoa, Tsiferana; Cox, Nicola H.; Close, Kristin L.; Kotze, Joan; Watrous, Abigail
      Abstract: imageBACKGROUND: Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12–18 months after SAFE-OB courses in Madagascar and the Republic of Congo.METHODS: We used a concurrent embedded mixed-methods design based on the Kirkpatrick model for evaluating educational training courses. The primary outcome was qualitative determination of personal and organizational change at 4 months and 12–18 months. Secondary outcomes were quantitative evaluations of knowledge and skill retention over time. From 2014 to 2016, 213 participants participated in 5 SAFE-OB courses in 2 countries. Semistructured interviews were conducted at 4 and 12–18 months using purposive sampling and analyzed using thematic content analysis. Participants underwent baseline knowledge and skill assessment, with 1 cohort reevaluated using repeat knowledge and skills tests at 4 months and another at 12–18 months.RESULTS: At 4 months, 2 themes of practice change (Kirkpatrick level 3) emerged that were not present at 12–18 months: neonatal resuscitation and airway management. At 12–18 months, 4 themes emerged: management of obstetric hemorrhage, management of eclampsia, using a structured approach to assessing a pregnant woman, and management of spinal anesthesia. With respect to organizational culture change (Kirkpatrick level 4), the same 3 themes emerged at both 4 and 12–18 months: improved teamwork, communication, and preparation. Resistance from peers, lack of senior support, and lack of resources were cited as barriers to change at 4 months, but at 12–18 months, very few interviewees mentioned lack of resources. Identified catalysts for change were self-motivation, credibility, peer support, and senior support. Knowledge and skills tests both showed an immediate improvement after the course that was sustained. This supports the qualitative responses suggesting personal and organizational change.CONCLUSIONS: Participation at a SAFE-OB course in the Republic of Congo and in Madagascar was associated with personal and organizational changes in practice and sustained improvements in knowledge and skill at 12–18 months.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Impact of Local Infiltration Analgesia on the Quality of Recovery After
           Anterior Total Hip Arthroplasty: A Randomized, Triple-Blind,
           Placebo-Controlled Trial
    • Authors: Tan; Nicole L.; Gotmaker, Robert; Barrington, Michael J.
      Abstract: imageBACKGROUND: Local infiltration analgesia (LIA) is commonly used in anterior total hip arthroplasty (THA) surgery; however, evidence for its efficacy is lacking. We hypothesized that LIA with 0.2% ropivacaine when compared with injection of placebo (0.9% saline) would improve patient quality of recovery on postoperative day (POD) 1, as measured by the Quality of Recovery-15 (QoR-15) score.METHODS: Patients scheduled to have a primary unilateral anterior THA with a single surgeon in a tertiary level metropolitan hospital were randomized to receive LIA with either 2.5 mL/kg of 0.2% ropivacaine or 0.9% saline as placebo. Patients and clinical and study personnel were blinded to group allocation. Perioperative care was standardized and this included spinal anesthesia and oral multimodal analgesia. The primary outcome was a multidimensional (pain, physical comfort, physical independence, emotions, and psychological support) patient-reported quality of recovery scale, QoR-15, measured on POD 1.RESULTS: One hundred sixty patients were randomized; 6 patients were withdrawn after randomization and 2 patients had incomplete outcome data. The intention-to-treat analysis included 152 patients. The median (interquartile range [IQR]) QoR-15 score on POD 1 of the ropivacaine group was 119.5 (102–124), compared with the placebo group which had a median (IQR) of 115 (98–126). The median difference of 2 (95% confidence interval [CI], −4 to 7; P = .56) was not statistically or clinically significant. An as-per-protocol sensitivity analysis of 146 patients who received spinal anesthesia without general anesthesia, and the allocated intervention, also showed no evidence of a significant difference between groups. Secondary outcomes (worst pain numerical rating scale at rest and with movement on POD 1, opioid consumption on PODs 1 and 2, mobilization on POD 1, Brief Pain Inventory severity and interference on POD 90, and length of stay) were similar in both groups.CONCLUSIONS: LIA with 0.2% ropivacaine when compared with 0.9% saline as placebo did not improve quality of recovery 1 day after anterior THA.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Intraoperative Methadone Reduces Pain and Opioid Consumption in Acute
           Postoperative Pain: A Systematic Review and Meta-analysis
    • Authors: Machado; Felipe C.; Vieira, Joaquim E.; de Orange, Flávia A.; Ashmawi, Hazem A.
      Abstract: imageBACKGROUND: Methadone is a potent opioid exerting an analgesic effect through N-methyl-d-aspartate receptor antagonism and the inhibition of serotonin and noradrenaline reuptake. It has also been used in several procedures to reduce postoperative pain and opioid use. This meta-analysis aimed to determine whether the intraoperative use of methadone lowers postoperative pain scores and opioid consumption in comparison to other opioids.METHODS: Double-blinded, controlled trials without language restrictions were included from MEDLINE, Embase, LILACS, The Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL via EBSCOhost. The included studies tracked total opioid consumption, postoperative pain scores, opioid-related side effects, and patient satisfaction until 72 hours postoperatively. Mean difference (MD) was used for effect size.RESULTS: In total, 476 articles were identified and 13 were considered eligible for inclusion in the meta-analysis. In 486 patients (7 trials), pain at rest (MD, 1.09; 95% confidence interval (CI), 1.47–0.72; P < .00001) and at movement (MD, 2.48; 95% CI, 3.04–1.92; P = .00001) favored methadone 24 hours after surgery. In 374 patients (6 trials), pain at rest (MD, 1.47; 95% CI, 3.04–1.02; P < .00001) and at movement (MD, 2.03; 95% CI, 3.04–1.02; P < .00001) favored methadone 48 hours after surgery. In 320 patients (4 trials), pain at rest (MD, 1.02; 95% CI, 1.65–0.39; P = .001) and at movement (MD, 1.34; 95% CI, 1.82–0.87; P < .00001) favored methadone 72 hours after surgery. A Trial Sequential Analysis was performed and the Z-cumulative curve for methadone crossed the monitoring boundary at all evaluations, additionally crossing Required Information Size at 24 and 48 hours at rest. Methadone group also showed lower postoperative opioid consumption in morphine equivalent dosage (mg) at 24 hours (MD, 8.42; 95% CI, 12.99–3.84 lower; P < .00001), 24–48 hours (MD, 14.33; 95% CI, 26.96–1.91 lower; P < .00001), 48–72 hours (MD, 3.59; 95% CI, 6.18–1.0 lower; P = .007) postoperatively.CONCLUSIONS: Intraoperative use of methadone reduced postoperative pain scores compared to other opioids, and Trial Sequential Analysis suggested that no more trials are required to confirm pain reduction at rest until 48 hours after surgery. Methadone also reduced postoperative opioid consumption and led to better patient satisfaction scores through 72 hours postoperatively compared to other opioids.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Minocycline Relieves Depressive-Like Behaviors in Rats With Bone Cancer
           Pain by Inhibiting Microglia Activation in Hippocampus
    • Authors: Dai; Jiajia; Ding, Zhuofeng; Zhang, Jie; Xu, Wei; Guo, Qulian; Zou, Wangyuan; Xiong, Yunchuan; Weng, Yingqi; Yang, Yong; Chen, Sisi; Zhang, Jun-Ming; Song, Zongbin
      Abstract: imageBACKGROUND: Pain and depression are highly prevalent symptoms in cancer patients. They tend to occur simultaneously and affect each other and share biological pathways and neurotransmitters. In this study, we investigated the roles of microglia in the hippocampus in the comorbidity of bone cancer pain and depressive-like behaviors in an animal model of bone cancer pain.METHODS: Bone cancer pain was induced by injection of Walker 256 mammary gland carcinoma cells into the tibia of rats. The effects of intracerebroventricular administration of microglia inhibitor minocycline were examined.RESULTS: Carcinoma intratibia injection caused comorbidity of mechanical allodynia and depressive-like behaviors in rats and activation of microglia in the hippocampus. Both mechanical allodynia and depressive-like behaviors were attenuated by minocycline. Enzyme-linked immunosorbent assay analysis showed that the enhanced expressions of M1 microglia marker (CD 86) and the proinflammatory cytokines tumor necrosis factor-α and interleukin-1β in the hippocampus of cancer-bearing rats were decreased by minocycline. On the other hand, minocycline also increased the expressions of M2 microglia marker (MRC1) and anti-inflammatory cytokine interleukin-10.CONCLUSIONS: The results suggest that the activation of microglia in the hippocampus plays an important role in the development of pain and depressive-like behaviors in bone cancer condition.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Effect of Remote Ischemic Preconditioning in Patients Undergoing
           Hepatectomy With Portal Triad Clamping: A Randomized Controlled Trial
    • Authors: Liu; Xiaoqing; Cao, Longhui; Zhang, Tianhua; Guo, Rongping; Lin, Wenqian
      Abstract: imageBACKGROUND: Remote ischemic preconditioning (RIPC) is reported to reduce liver injury in patients undergoing hepatectomy for colorectal liver metastasis, but its role is unclear in hepatocellular carcinoma patients with portal triad clamping during hepatectomy.METHODS: In this prospective, randomized trial, 140 patients with hepatocellular carcinoma undergoing liver resection requiring portal triad clamping were randomized to a RIPC group or a control group. Patients in the RIPC group received RIPC (3 cycles of 5-minute ischemia and 5-minute reperfusion in right upper limb with cuff pressure at 30 kPa [225 mm Hg]) approximately 10 minutes after induction of anesthesia. In the control group, patients received sham RIPC (the cuff was not inflated). The primary outcome was the postoperative peak level of total bilirubin (TBIL) and was analyzed with the independent t test. Secondary outcomes were liver function test at postoperative days 1, 3, and 5; postoperative morbidity and mortality during the first month; and the length of postoperative hospital stay.RESULTS: Data from 136 patients (69 in the RIPC group and 67 in the control group) were analyzed. The RIPC group had on average a 5.9 μmol lower peak level of TBIL than the control group; the mean difference is −5.9, and the 95% confidence interval (CI) reverses to −17.9 to 6.1. There were no significant differences between the 2 groups in liver function test at postoperative days 1, 3, and 5; postoperative morbidity and mortality during the first month; and the length of postoperative hospital stay.CONCLUSIONS: We found no evidence that RIPC can reduce postoperative liver injury after hepatectomy.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Perioperative Oxidative Stress: The Unseen Enemy
    • Authors: Stevens; Jia L.; Feelisch, Martin; Martin, Daniel S.
      Abstract: imageReactive oxygen species (ROS) are essential for cellular signaling and physiological function. An imbalance between ROS production and antioxidant protection results in a state of oxidative stress (OS), which is associated with perturbations in reduction/oxidation (redox) regulation, cellular dysfunction, organ failure, and disease. The pathophysiology of OS is closely interlinked with inflammation, mitochondrial dysfunction, and, in the case of surgery, ischemia/reperfusion injury (IRI). Perioperative OS is a complex response that involves patient, surgical, and anesthetic factors. The magnitude of tissue injury inflicted by the surgery affects the degree of OS, and both duration and nature of the anesthetic procedure applied can modify this. Moreover, the interindividual susceptibility to the impact of OS is likely to be highly variable and potentially linked to underlying comorbidities. The pathological link between OS and postoperative complications remains unclear, in part due to the complexities of measuring ROS- and OS-mediated damage. Exogenous antioxidant use and exercise have been shown to modulate OS and may have potential as countermeasures to improve postoperative recovery. A better understanding of the underlying mechanisms of OS, redox signaling, and regulation can provide an opportunity for patient-specific phenotyping and development of targeted interventions to reduce the disruption that surgery can cause to our physiology. Anesthesiologists are in a unique position to deliver countermeasures to OS and improve physiological resilience. To shy away from a process so fundamental to the welfare of these patients would be foolhardy and negligent, thus calling for an improved understanding of this complex facet of human biology.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • National Institutes of Health–Funded Anesthesiology Research and
           Anesthesiology Physician-Scientists: Trends, Promises, and Concerns
    • Authors: Chandrakantan; Arvind; Adler, Adam C.; Stayer, Stephen; Roth, Steven
      Abstract: imageWith a difficult National Institutes of Health (NIH) funding climate, the pipeline of physician-scientists in Anesthesiology is continuing to get smaller with fewer new entrants. This article studies current NIH funding trends and offers potential solutions to continue the historical trend of academic innovation and research that has characterized academic Anesthesiology. Using publicly available data, specifically the NIH REPORTeR and Blue Ridge Institute for Medical Research, we examined NIH trends in funding in academic Anesthesiology departments that have Anesthesiology residency training programs. When adjusted for inflation, median NIH funding of departments of Anesthesiology declined approximately 15% between 2008 and 2017. The majority (55%) of NIH funding to academic Anesthesiology departments, including R01 and K-series grants, went to 10 departments in the United States. This trend has remained relatively constant for the 9-year period we studied (2009–2017). There is an inequitable distribution of NIH funding to Anesthesiology departments. Arguably, this may be a case of the “rich get richer,” but the implications for those who are trying to become or remain NIH-funded investigators are that success may depend, in part, on securing a faculty position in one of these well-funded departments.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Consistent Definitions of Clinical Practice Guidelines, Consensus
           Statements, Position Statements, and Practice Alerts
    • Authors: Joshi; Girish P.; Benzon, Honorio T.; Gan, Tong J.; Vetter, Thomas R.
      Abstract: imageAn evidence-based approach to clinical decision-making for optimizing patient care is desirable because it promotes quality of care, improves patient safety, decreases medical errors, and reduces health care costs. Clinical practice recommendations are systematically developed documents regarding best practice for specific clinical management issues, which can assist care providers in their clinical decision-making. However, there is currently wide variation in the terminology used for such clinical practice recommendations. The aim of this article is to provide guidance to authors, reviewers, and editors on the definitions of terms commonly used for clinical practice recommendations. This is intended to improve transparency and clarity regarding the definitions of these terminologies.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Development, Reporting, and Evaluation of Clinical Practice Guidelines
    • Authors: Benzon; Honorio T.; Joshi, Girish P.; Gan, Tong J.; Vetter, Thomas R.
      Abstract: imageClinical practice parameters have been published with greater frequency by professional societies and groups of experts. These publications run the gamut of practice standards, practice guidelines, consensus statements or practice advisories, position statements, and practice alerts. The definitions of these terms have been clarified in an accompanying article. In this article, we present the criteria for high-quality clinical practice parameters and outline a process for developing them, specifically the Delphi method, which is increasingly being used to build consensus among content experts and stakeholders. Several tools for grading the level of evidence and strength of recommendation are offered and compared. The speciousness of categorizing guidelines as evidence-based or consensus-based will be explained. We examine the recommended checklist for reporting and appraise the tools for evaluating a practice guideline. This article is geared toward developers and reviewers of clinical practice guidelines and consensus statements.
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Achieving Gender Parity in Acute Care Medicine Requires a Multidimensional
           Perspective and a Committed Plan of Action
    • Authors: Fisler; Nadja; Sweitzer, Bobbie Jean; Wurz, Jeannie; Kleiman, Amanda M.; Stueber, Frank; Luedi, Markus M.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Pediatric Anesthesiology Fellowship Positions: Is There a Mismatch'
    • Authors: Cladis; Franklyn P.; Lockman, Justin L.; Lupa, M. Concetta; Chatterjee, Debnath; Lim, Doyle; Hernandez, Michael; Yanofsky, Samuel; Waldrop, William B.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • The Age of Addiction: How Bad Habits Became Big Business
    • Authors: Brindley; Peter G.; Brindley, Jack D.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Textbook of Neuroanesthesia and Neurocritical Care: Volume II –
           Neurocritical Care
    • Authors: Lu; Meilin; He, Liang
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Faust’s Anesthesiology Review, 5th ed
    • Authors: Mizutani; Koh
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Anesthesia in Day Care Surgery, 1st ed
    • Authors: Radke; Oliver C.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Neurocritical Care
    • Authors: Meier; Isabella; Luedi, Markus M.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Essentials of Interventional Cancer Pain Management, 1st ed
    • Authors: Goucke; C. Roger
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Pediatric Liver Intensive Care
    • Authors: Mancuso; Thomas J.; Cuenca, Alex
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • A Review of Errors in Emergency and Trauma Radiology
    • Authors: Smulski; Stefanie; Faraoni, David
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Review of Consults in Obstetric Anesthesiology
    • Authors: Chikumba; Edson
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Anesthetic Management for the Pediatric Airway: Advanced Approaches and
    • Authors: Mannion; Stephen; Joyce, Kirsten; Crowley, Kieran
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Peripheral Interventional Management in Headache
    • Authors: Préel; Nadège; Luedi, Markus M.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Milk of Paradise: A History of Opium
    • Authors: Brindley; Peter G.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Principles and Practice of Anesthesia for Thoracic Surgery, 2nd ed
    • Authors: Royse; Colin
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Mobile Applications in a Crisis
    • Authors: Navarro-Martínez; Jose; Ferrero-Coloma, Carlos; Carrió-Font, Marta; Galiana-Ivars, María; Cuesta-Montero, Pablo
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • In Response
    • Authors: Clebone; Anna; Strupp, Kim M.; Fehr, James; Burian, Barbara K.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Interpretation Woes of Bispectral Index–Based Closed-Looped
           Anesthesia Delivery Systems
    • Authors: Baskar; Nisha; Nedunchezhian, Aishvarya Shree; Hrishi, Ajay Prasad
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • In Response
    • Authors: Dutta; Amitabh; Sethi, Nitin; Puri, Goverdhan D.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Pennywise and a Pound Foolish: The Advantage of Dantrolene Nanosuspension
           (Ryanodex) in the Treatment of Malignant Hyperthermia
    • Authors: McAvoy; James C.; Brodsky, Jay B.; Brock-Utne, John
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • In Response
    • Authors: Urman; Richard D.; Rajan, Niraja; Belani, Kumar; Gayer, Steven; Joshi, Girish P.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Is Remote Ischemic Preconditioning on Cardiovascular Surgery a Benefit in
           Clinical Anesthesia'
    • Authors: Kinoshita; Hiroyuki; Morita, Yoshihisa
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • In Response
    • Authors: Zhou; Hui; Wang, Guyan
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Cerebral Oximetry and Mean Arterial Pressure: Not a Straight Relationship,
           the Flow Between'
    • Authors: Desebbe; Olivier; Joosten, Alexandre; Denault, Andre
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • In Response
    • Authors: Holmgaard; Frederik; Vedel, Anne G.; Lange, Theis; Nilsson, Jens C.; Ravn, Hanne B.
      Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric
           Hemorrhage: Erratum
    • Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • Consensus Bundle on Prevention of Surgical Site Infections After Major
           Gynecologic Surgery: Erratum
    • Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • National Partnership for Maternal Safety: Consensus Bundle on Severe
           Hypertension During Pregnancy and the Postpartum Period: Erratum
    • Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
  • National Partnership for Maternal Safety: Consensus Bundle on Venous
           Thromboembolism: Erratum
    • Abstract: No abstract available
      PubDate: Sun, 01 Dec 2019 00:00:00 GMT-
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