Journal Cover Anesthesia & Analgesia
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   ISSN (Print) 0003-2999 - ISSN (Online) 1526-7598
   Published by LWW Wolters Kluwer Homepage  [290 journals]
  • Perioperative Cardiac Arrest: Focus on Anaphylaxis
    • Abstract: imageNo abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Perioperative Cardiac Arrest: Focus on Local Anesthetic Systemic Toxicity
    • Abstract: imageNo abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Perioperative Cardiac Arrest: Focus on Malignant Hyperthermia (MH)
    • Authors: Nathan; Naveen
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Post-Cardiac Arrest Management: Time to Cool It on Cooling'
    • Authors: Wanderer; Jonathan P.; Nathan, Naveen
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Meta-analysis, Medical Reversal, and Settled Science
    • Authors: Nunnally; Mark E.; Tung, Avery
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Motor Evoked Potential Monitoring During Thoracoabdominal Aortic Surgery:
           Useful or Not'
    • Authors: Chung; Jennifer; Ouzounian, Maral; Lindsay, Thomas
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • The Night Shift Nightmare
    • Authors: Kiley; Sean; Fahy, Brenda G.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Anesthesia Advanced Cardiac Life Support: A Guideline Validated'
    • Authors: Tung; Avery
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Hyperglycemia and Elevated Lactate in Trauma: Where Do We Go From
    • Authors: Bellomy; Melissa L.; Freundlich, Robert E.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Between a ROCK and an IR Place
    • Authors: Pan; Jonathan Z.; Eckenhoff, Roderic G.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • To Ask or Not to Ask: The Ethics of Informed Consent for Transesophageal
           Echocardiography Education
    • Authors: Bryden; Pier; McKnight, David; Houston, Patricia
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Consensus Statement on Pregnant Women Receiving Thromboprophylaxis: An
           Essential Tool to Guide Our Management
    • Authors: Banayan; Jennifer M.; Scavone, Barbara M.; Mhyre, Jill M.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Surveying the Literature: Synopsis of Recent Key Publications
    • Authors: Hessel; Eugene A. II
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Clinical Utility of Intraoperative Motor-Evoked Potential Monitoring to
           Prevent Postoperative Spinal Cord Injury in Thoracic and Thoracoabdominal
           Aneurysm Repair: An Audit of the Japanese Association of Spinal Cord
           Protection in Aortic Surgery Database
    • Authors: Yoshitani; Kenji; Masui, Kenichi; Kawaguchi, Masahiko; Kawamata, Mikito; Kakinohana, Manabu; Kato, Shinya; Hasuwa, Kyoko; Yamakage, Michiaki; Yoshikawa, Yusuke; Nishiwaki, Kimitoshi; Aoyama, Tadashi; Inagaki, Yoshimi; Yamasaki, Kazumasa; Matsumoto, Mishiya; Ishida, Kazuyoshi; Yamashita, Atsuo; Seo, Katsuhiro; Kakumoto, Shinichi; Hayashi, Hironobu; Tanaka, Yuu; Tanaka, Satoshi; Ishida, Takashi; Uchino, Hiroyuki; Kakinuma, Takayasu; Yamada, Yoshitsugu; Mori, Yoshiteru; Izumi, Shunsuke; Nishimura, Kunihiro; Nakai, Michikazu; Ohnishi, Yoshihiko
      Abstract: imageBACKGROUND: Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits.METHODS: Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated whether intraoperative MEP monitoring was associated with postoperative motor deficits at discharge after open and endovascular aortic repair.RESULTS: We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge did not have a significant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69–1.88; P = .624), but with other factors: history of neural deficits (adjusted OR, 6.08; 95% CI, 3.10–11.91; P < .001), spinal drainage (adjusted OR, 2.14; 95% CI, 1.32–3.47; P = .002), and endovascular procedure (adjusted OR, 0.45; 95% CI, 0.27–0.76; P = .003). The sensitivity and specificity of MEP
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Systemic Hypotension Following Intravenous Administration of Nonionic
           Contrast Medium During Computed Tomography: Iopromide Versus Iodixanol
    • Authors: Widmann; Gerlig; Bale, Reto; Ulmer, Hanno; Putzer, Daniel; Schullian, Peter; Wiedermann, Franz-Josef; Lederer, Wolfgang
      Abstract: imageBACKGROUND: In light of the increasing number of radiologic interventions performed under general anesthesia, the effects of contrast media (CM) on circulation and organ perfusion are of paramount importance. The objectives of this study were to systematically quantify effects on blood pressure, heart rate, and kidney function following intravenous administration of nonionic CM with normal and low osmolality.METHODS: In this controlled, double-blinded phase IV clinical trial, 40 consecutive patients were randomly assigned to receive repeated measures of either low-osmolar iopromide or iso-osmolar iodixanol. Normal saline solution (NSS) served as control. Blood pressure and heart rate were measured continuously from 1 minute before until 3 minutes after administration of CM and NSS. Urine output was recorded hourly.RESULTS: Administration of iopromide resulted in systemic hypotension lasting up to 300 seconds (105 ± 61 seconds) with the lowest mean arterial pressure of 39 mm Hg (56.7 ± 12.2 mm Hg). Iopromide caused a systolic/diastolic decrease of 31/26 mm Hg (P < .001), significant increase in heart rate (P = .042), and significant diuresis with a 2-fold higher per-hour urine output (P = .010). Administration of iodixanol and NSS had no significant influence on blood pressure (P> .640).CONCLUSIONS: Administration of low-osmolar iopromide was followed by a significant transient decrease in blood pressure and a rise in heart rate. Anesthetists and radiologists should be aware of these effects in patients in whom short episodes of disturbed tissue microcirculation may pose a clinical risk.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Anesthetic Management and Procedural Outcomes of Patients Undergoing
           Off-Pump Transapical Implantation of Artificial Chordae to Correct Mitral
           Regurgitation: Case Series of 76 Patients
    • Authors: Samalavicius; Robertas Stasys; Norkiene, Ieva; Drasutiene, Agne; Lipnevicius, Arturas; Janusauskas, Vilius; Urbonas, Karolis; Zakarkaite, Diana; Aidietis, Audrius; Rucinskas, Kestutis
      Abstract: imageBACKGROUND: Transapical implantation of artificial chordae using the NeoChord system (NeoChord Inc, Minneapolis, MN) is an emerging beating-heart technique for correction of mitral regurgitation (MR) through a minimally invasive left minithoracotomy. The purpose of the study was to describe the anesthetic management and procedural success of patients undergoing this procedure.METHODS: All patients (n = 76) who underwent mitral valve repair with the NeoChord system in our institution from December 2011 to December 2016 were included in this observational prospective study. Balanced anesthesia with a combination of fentanyl, propofol, and sevoflurane was used in all patients. Each patient’s core temperature was maintained at>36°C whenever possible. Two- and 3-dimensional transesophageal echocardiography was used in all patients to navigate the device to the posterior mitral valve leaflet (68 of 76 patients), anterior mitral valve leaflet (3 of 76 patients), or both leaflets (5 of 76 patients). After effective leaflet capture, the artificial chordae were deployed. Position and function of the artificial chordae were assessed by evaluating the degree of MR when the neochordae were tensed. After surgery, all patients were transferred to the intensive care unit.RESULTS: The mean age of the patients was 60 ± 13 years (range, 33–87 years), and the male/female ratio was 52/24. Most patients had severe MR (grade 4+ in 25 [33%] patients, grade 3+ in 51 [67%] patients). The average preoperative EuroSCORE II was 1.23% ± 1.16% (range, 0.46%–4.23%). The median duration of the procedure was 120 minutes (interquartile range [IQR] 115–145 minutes). After the procedure, 42 (56%) patients had trivial MR, 27 (36%) had grade 1+ MR, 4 (5%) had grade 2+ MR, and 2 (3%) had>2+ MR. One patient underwent conversion to conventional mitral valve repair due to perforation of the posterior mitral valve leaflet. The whole procedure was well tolerated by the patients, with hemodynamics remaining stable in the majority of the cases. Only 20 (26%) patients needed low-dose inotropic support perioperatively. All patients had an uneventful postoperative course. The median time to extubation was 4 hours (IQR, 2.6–6), and the length of intensive care unit stay was 22 hours (IQR, 21–24). Five (6.6%) patients required allogeneic blood products.CONCLUSIONS: Anesthesia for transapical NeoChord implantation can be safely performed under beating-heart conditions, with low perioperative morbidity and rare blood transfusions. Transesophageal echocardiography is crucial for the guidance, safety, and effectiveness of the procedure.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Years Versus Days Between Successive Surgeries, After an Initial
           Outpatient Procedure, for the Median Patient Versus the Median Surgeon in
           the State of Iowa
    • Authors: Dexter; Franklin; Jarvie, Craig; Epstein, Richard H.
      Abstract: imageBACKGROUND: Previously, we studied the relative importance of different institutional interventions that the largest hospital in Iowa could take to grow the anesthesia department’s outpatient surgical care. Most (>50%) patients having elective surgery had not previously had surgery at the hospital. Patient perioperative experience was unimportant for influencing total anesthesia workload and numbers of patients. More important was the availability of surgical clinic appointments within several days. These results would be generalizable if the median time from surgery to a patient’s next surgical procedure was large (eg,>2 years), among all hospitals in Iowa with outpatient surgery, and without regard to the hospital where the next procedure was performed.METHODS: There were 37,172 surgical cases at hospital outpatient departments of any of the 117 hospitals in Iowa from July 1, 2013, to September 30, 2013. Data extracted about each case included its intraoperative work relative value units. The 37,172 cases were matched to all inpatient and outpatient records for the next 2 years statewide using patient linkage identifiers; from these were determined whether the patient had surgery again within 2 years. Furthermore, the cases’ 1820 surgeons were matched to the surgeon’s next outpatient or inpatient case, both including and excluding other cases performed on the date of the original case.RESULTS: By patient, the median time to their next surgical case, either outpatient or inpatient, exceeded 2 years, tested with weighting by intraoperative relative value units and repeated when unweighted (both P < .0001). Specifically, with weighting, 65.9% (99% confidence interval [CI], 65.2%–66.5%) of the patients had no other surgery within 2 years, at any hospital in the state. The median time exceeded 2 years for multiple categories of patients and similar measures of time to next surgery (all P < .01). In comparison, by surgeon, the median time to the next outpatient surgical case was 1 calendar day (99% CI, 0–1 day). The median was 3 days to the next date with at least 1 outpatient case (99% CI, 3–3 days).CONCLUSIONS: The median time to the next surgery was>2 years for patients versus 1 day for surgeons. Thus, although patients’ experiences are an important attribute of quality of care, surgeons’ experiences are orders of magnitude more important from the vantage point of marketing and growth of an anesthesia practice.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Impact of Inhalational Anesthetics on Liver Regeneration After Living
           Donor Hepatectomy: A Propensity Score-Matched Analysis
    • Authors: Jung; Kyeo-Woon; Kim, Wan-Joon; Jeong, Hye-Won; Kwon, Hye-Mee; Moon, Young-Jin; Jun, In-Gu; Song, Jun-Gol; Hwang, Gyu-Sam
      Abstract: imageBACKGROUND: Although desflurane and sevoflurane, the most commonly used inhalational anesthetics, have been linked to postoperative liver injury, their impact on liver regeneration remains unclear. We compared the influence of these anesthetics on the postoperative liver regeneration index (LRI) after living donor hepatectomy (LDH).METHODS: We conducted a retrospective chart review of 1629 living donors who underwent right hepatectomy for LDH between January 2008 and August 2016. The patients were divided into sevoflurane (n = 1206) and desflurane (n = 423) groups. Factors associated with LRI were investigated using multivariable logistic regression analysis. Propensity score matching analysis compared early (1 postoperative week) and late (within 1–2 months) LRIs and delayed recovery of hepatic function between the 2 groups.RESULTS: The mean early and late LRIs in the 1629 patients were 63.3% ± 41.5% and 93.7% ± 48.1%, respectively. After propensity score matching (n = 403 pairs), there were no significant differences in early and late LRIs between the sevoflurane and desflurane groups (early LRI: 61.2% ± 41.5% vs 58.9% ± 42.4%, P = .438; late LRI: 88.3% ± 44.3% vs 94.6% ± 52.4%, P = .168). Male sex (regression coefficient [β], 4.6; confidence interval, 1.6–7.6; P = .003) and remnant liver volume (β, –4.92; confidence interval, –5.2 to –4.7; P < .001) were associated with LRI. The incidence of delayed recovery of hepatic function was 3.6% (n = 29) with no significant difference between the 2 groups (3.0% vs 4.2%, P = .375) after LDH.CONCLUSIONS: Both sevoflurane and desflurane can be safely used without affecting liver regeneration and delaying liver function recovery after LDH.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Perioperative Steroid Use for Tonsillectomy and Its Association With
           Reoperation for Posttonsillectomy Hemorrhage: A Retrospective Cohort Study
    • Authors: Miyamoto; Yoshihisa; Shinzawa, Maki; Tanaka, Shiro; Tanaka-Mizuno, Sachiko; Kawakami, Koji
      Abstract: imageBACKGROUND: Steroids reduce postoperative complications after tonsillectomy such as nausea and vomiting, pain, and delayed recovery. However, steroids may also increase the risk of severe posttonsillectomy bleeding requiring reoperation.METHODS: To evaluate the risk of postoperative bleeding requiring reoperation related to perioperative steroid use, we conducted a retrospective cohort study of 6149 patients treated at 68 hospitals using a hospital-based claims database. The primary outcome was reoperation for bleeding within 14 postoperative days. We estimated odds ratios (ORs) between perioperative steroid use and reoperation by multivariable logistic regression analysis adjusted for confounders. We also estimated differences in the adjusted risk. Subgroup analyses after dividing patients into adults and children were also performed.RESULTS: The incidence of reoperation did not differ significantly between patients who received steroids on the day of tonsillectomy and those who did not (1.8%, n = 15 vs 1.5%, n = 79; adjusted OR 0.81, 95% confidence interval [CI], 0.45–1.43; P = .46). We also found nonsignificant associations in both adults (OR, 0.73; 95% CI, 0.38–1.38; P = .33) and children (OR, 1.18; 95% CI, 0.34–4.11; P = .80). The adjusted risk differences estimated by the logistic regression model were −0.30% (95% CI, −1.05 to 0.45) in all patients, −0.64% (95% CI, −1.82 to 0.54) in adults, and 0.13% (95% CI, −0.93 to 1.19) in children.CONCLUSIONS: Steroid use on the day of tonsillectomy was not associated with an increased risk of reoperation for bleeding. Although the wide range of CIs for the ORs could not eliminate the possibility of increased risk, especially in children, the incremental risks of reoperation for steroid use were within an acceptable range for both adults and children. Our results support the safety of perioperative steroid use for tonsillectomy, considering the magnitude of risk of reoperation because of bleeding.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Neuroprotective Effects of Fasudil, a Rho-Kinase Inhibitor, After Spinal
           Cord Ischemia and Reperfusion in Rats
    • Authors: Ohbuchi; Masahiko; Kimura, Tetsu; Nishikawa, Toshiaki; Horiguchi, Takashi; Fukuda, Masayuki; Masaki, Yoko
      Abstract: imageBACKGROUND: Excessive Rho/Rho-kinase pathway activation occurs subsequent to stroke. We examined the neuroprotective effects of pre- and posttreatment with fasudil (a Rho-kinase inhibitor) in a rat transient spinal cord ischemia-reperfusion model under normothermic conditions.METHODS: After approval by our animal research committee, male Sprague-Dawley rats were assigned to 1 of 6 groups: pre- and postcontrol (C); pre- and postfasudil (F); and pre- and postsham (S). Fasudil (10 mg/kg) or normal saline was administered intravenously over 30 minutes before ischemia in the pre-F or pre-C groups, and over 30 minutes after reperfusion in the post-F or post-C groups. Sham groups were not subjected to ischemia. Ischemia was induced by aortic occlusion using a balloon catheter combined with hypotension for 10 minutes. Neurologic deficit scores (NDS; 0–8 points) were assessed 1, 7, and 14 days after ischemia, and then histopathologic outcomes were assessed.RESULTS: NDS 7 and 14 days after ischemia in the pre-F group (median [range]; 3.5 [2–6] and 2.5 [0–6]) were lower than those in the pre-C group (5.5 [4–7] and 4.5 [4–6]; P = .046 and P = .049), whereas NDS in the post-F group and in the post-C group were not different. The numbers of intact neurons in the gray matter in the pre- and post-F groups (mean ± standard deviation [95% confidence interval]: 25 ± 7 [20–30] and 16 ± 5 [12–19]) were greater than those in the pre- and post-C groups (11 ± 5 [7–14] and 9 ± 3 [7–11]; P < .001 and P = .002). The number of intact neurons in the post-F group (16 ± 5 [12–19]) was lower than the number in the post-S group (26 ± 2 [24–29]; P < .001). The percentages of vacuolation in the white matter in the pre- and post-F groups (21.5 ± 8.4 [15.5–27.5] and 13.6 ± 7.4 [8.3–18.9]) were lower than those in the pre- and post-C groups (43.7 ± 10.4 [36.3–51.1] and 40.6 ± 12.3 [31.8–49.4]; P < .001 and P < .001).CONCLUSIONS: Our results demonstrated that intravenous fasudil administered before ischemia improved both neurologic and histopathologic outcomes even 14 days after ischemia, while fasudil administered postinsult improved histopathologic outcomes only in normothermic rats. Fasudil may be a relevant pretreatment paradigm for planned procedures at risk for spinal cord ischemia.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Characteristics of Desaturation and Respiratory Rate in Postoperative
           Patients Breathing Room Air Versus Supplemental Oxygen: Are They
    • Authors: Taenzer; Andreas H.; Perreard, Irina M.; MacKenzie, Todd; McGrath, Susan P.
      Abstract: imageBACKGROUND: Routine monitoring of postoperative patients with pulse oximetry–based surveillance monitoring has been shown to reduce adverse events. However, there is some concern that pulse oximetry is limited in its ability to detect deterioration quickly enough to allow for intervention in patients receiving supplemental oxygen. To address such concerns, this study expands on the current limited knowledge of differences in desaturation and respiratory rate characteristics between patients breathing room air and those receiving supplemental oxygen.METHODS: Pulse oximetry–derived data and patient characteristics were used to examine overnight desaturation patterns of 67 postoperative patients who were receiving either supplemental oxygen or breathing room air. The 2 modalities with respect to the speed of desaturation, in addition to magnitude and duration of desaturation events, are compared. Night-time pulse rate, oxygen saturation, respiratory rate, and the transition times from normal oxygen saturation levels to desaturated states are also compared. The behavior of respiratory rate in proximity to desaturation events is described. Statistical methods included multivariable regression and inverse probability of treatment weighted to adjust for any imbalance in patient characteristics between the oxygen and room air patients and linear mixed effect models to account for clustering by patient.RESULTS: The study included 33 patients on room air and 34 receiving supplemental oxygen. The speed of desaturation was not different for room air versus oxygen for 2 types of desaturation (adjusted % difference, 95% confidence interval [CI]: type I; 22.4%, −51.5% to 209%; P = .67, type II; −17.3%, −53.8% to 47.6%; P = .52). Patients receiving supplemental oxygen had a higher mean oxygen saturation (adjusted difference, 95% CI, 2.4 [0.7–4.0]; P = .006). No differences were found for the average overnight respiratory or pulse rate, or proportion of time in desaturation states between the 2 groups.The time to transition from a normal oxygen saturation (92%) to 88% or below was not longer for supplemental oxygen patients (P = .42, adjusted difference 26.1%: 95% CI, −28.1% to 121%). Respiratory rates did not differ between the overall mean and desaturation or recovery phases or between the oxygen and room air group.CONCLUSIONS: In this study, desaturation characteristics did not differ between patients receiving supplemental oxygen and breathing room air with regard to speed, depth, or duration of desaturation. Transition time for desaturations to reach low oxygen saturation alarms was not different, while respiratory rate remained in the normal range during these events. These findings suggest that pulse oximetry–based surveillance monitoring for deterioration detection can be used equally effectively for patients on supplemental oxygen and for those on room air.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Axillary Temperature, as Recorded by the iThermonitor WT701, Well
           Represents Core Temperature in Adults Having Noncardiac Surgery
    • Authors: Pei; Lijian; Huang, Yuguang; Mao, Guangmei; Sessler, Daniel I.
      Abstract: imageBACKGROUND: Core temperature can be accurately measured from the esophagus or nasopharynx during general anesthesia, but neither site is suitable for neuraxial anesthesia. We therefore determined the precision and accuracy of a novel wireless axillary thermometer, the iThermonitor, to determine its suitability for use during neuraxial anesthesia and in other patients who are not intubated.METHODS: We enrolled 80 adults having upper abdominal surgery with endotracheal intubation. Intraoperative core temperature was measured in distal esophagus and was estimated at the axilla with a wireless iThermonitor WT701 (Raiing Medical, Boston MA) at 5-minute intervals. Pairs of axillary and reference distal esophageal temperatures were compared and summarized using linear regression and repeated-measured Bland–Altman methods. We a priori determined that the iThermonitor would have clinically acceptable accuracy if most estimates were within ±0.5°C of the esophageal reference, and suitable precision if the limits of agreement were within ±0.5°C.RESULTS: There were 3339 sets of paired temperatures. Axillary and esophageal temperatures were similar, with a mean difference (esophageal minus axillary) of only 0.14°C ± 0.26°C (standard deviation). The Bland–Altman 95% limits of agreement were reasonably narrow, with the estimated upper limit at 0.66°C and the lower limit at −0.38°C, thus ±0.52°C, indicating good agreement across the range of mean temperatures from 34.9°C to 38.1°C. The absolute difference was within 0.5°C in 91% of the measurements (95% confidence interval, 88%–93%).CONCLUSIONS: Axillary temperature, as recorded by the iThermonitor WT701, well represents core temperature in adults having noncardiac surgery and thus appears suitable for clinical use.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Respiratory Gas Analysis—Technical Aspects
    • Authors: Jaffe; Michael B.
      Abstract: imageA technology-focused review of respiratory gas analysis, with an emphasis on carbon dioxide analysis, is presented. The measurement technologies deployed commercially are highlighted, and the basic principles and technical concerns of infrared spectroscopy and mainstream versus sidestream gas sampling are discussed. The specifications of particular interest to the clinician, accuracy and response time, and the related standard, with typical values for a capnometer, are presented. Representative time and volumetric capnograms are shown with the clinically relevant parameters described. Aspects of the terminology in present-day use and the need for clarity in defining what is a breath and an end-tidal value are reviewed. The applications of capnography of particular interest to the anesthesiologist are noted, and key references are provided. Ongoing developments with respect to respiratory gas analysis, and those that will impact it, are noted.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Risk Stratification for Major Postoperative Complications in Patients
           Undergoing Intra-abdominal General Surgery Using Latent Class Analysis
    • Authors: Kim; Minjae; Wall, Melanie M.; Li, Guohua
      Abstract: imageBACKGROUND: Preoperative risk stratification is a critical element in assessing the risks and benefits of surgery. Prior work has demonstrated that intra-abdominal general surgery patients can be classified based on their comorbidities and risk factors using latent class analysis (LCA), a model-based clustering technique designed to find groups of patients that are similar with respect to characteristics entered into the model. Moreover, the latent risk classes were predictive of 30-day mortality. We evaluated the use of latent risk classes to predict the risk of major postoperative complications.METHODS: An observational, retrospective cohort of patients undergoing intra-abdominal general surgery in the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program was obtained. Known preoperative comorbidity and risk factor data were entered into LCA models to identify the latent risk classes. Complications were defined as: acute kidney injury, acute respiratory failure, cardiac arrest, deep vein thrombosis, myocardial infarction, organ space infection, pneumonia, postoperative bleeding, pulmonary embolism, sepsis/septic shock, stroke, unplanned reintubation, and/or wound dehiscence. Relative risk regression determined the associations between the latent classes and the 30-day complication risks, with adjustments for the surgical procedure. The area under the curve (AUC) of the receiver operator characteristic curve assessed model performance.RESULTS: LCA fit a 9-class model on 466,177 observations. The composite complication risk was 18.4% but varied from 7.7% in the lowest risk class to 56.7% in the highest risk class. After adjusting for procedure, the latent risk classes were significantly associated with complications, with risk ratios (95% confidence intervals) (compared to the class with the average risk) varying from 0.56 (0.54–0.58) in the lowest risk class to 2.15 (2.11–2.20) in the highest risk class, a 4-fold difference. In models incorporating surgical procedure, latent risk class, and the American Society of Anesthesiologists Physical Status, the AUC for composite complications was 0.76 (0.76–0.76). However, for individual complications, there was heterogeneity in model performance using these variables, with AUCs ranging from 0.70 (0.69–0.71) for pulmonary embolus to 0.90 (0.90–0.90) for acute respiratory failure.CONCLUSIONS: LCA can be used to classify patients undergoing intra-abdominal general surgery based on preoperative risk factors, and the classes are independently associated with postoperative complications. However, model performance is not uniform across individual complications, resulting in variations in the utility of preoperative risk stratification tools depending on the complication evaluated.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Postoperative Complications Affecting Survival After Cardiac Arrest in
           General Surgery Patients
    • Authors: Kim; Minjae; Li, Guohua
      Abstract: imageBACKGROUND: Postoperative cardiac arrest is uncommon but associated with a high mortality risk in general surgery patients and is often preceded by postoperative complications. The relationships between previous complications and mortality after cardiac arrest in general surgery patients have not been completely evaluated.METHODS: A retrospective, observational cohort of general surgery in patients with cardiac arrest occurring after postoperative day (POD) #0 (and up to POD #30) was obtained from the 2012–2013 American College of Surgeons National Surgical Quality Improvement Program. Previous complication was defined as at least one of the following occurring before the POD of cardiac arrest: (1) acute kidney injury; (2) acute respiratory failure; (3) deep vein thrombosis/pulmonary embolus; (4) myocardial infarction; (5) sepsis/septic shock; (6) stroke; and/or (7) transfusion. The associations between previous complications and mortality after cardiac arrest were assessed using Cox proportional hazards models that adjusted for preoperative risk factors.RESULTS: Of 1352 patients with postoperative cardiac arrest, 746 patients (55%) developed at least 1 complication before cardiac arrest. Overall 30-day mortality was 71% (958/1352) and was similar among patients with and without a previous complication (71% [533/746] vs 70% [425/606]; P = .60). Patients with previous complications did not have an increased risk of mortality, compared to patients without previous complications, in adjusted Cox models (hazard ratio, 1.03; 95% confidence interval, 0.90–1.18; P = .70). In addition, no previous complication was associated with increased mortality risk in individual analyses.CONCLUSIONS: Among general surgery patients with cardiac arrest after POD #0, complications occurring before cardiac arrest are common but are not associated with increased mortality risk.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Targeted Temperature Management After Cardiac Arrest: Systematic Review
           and Meta-analyses
    • Authors: Kalra; Rajat; Arora, Garima; Patel, Nirav; Doshi, Rajkumar; Berra, Lorenzo; Arora, Pankaj; Bajaj, Navkaranbir S.
      Abstract: imageBACKGROUND: Targeted temperature management (TTM) with therapeutic hypothermia is an integral component of postarrest care for survivors. However, recent randomized controlled trials (RCTs) have failed to demonstrate the benefit of TTM on clinical outcomes. We sought to determine if the pooled data from available RCTs support the use of prehospital and/or in-hospital TTM after cardiac arrest.METHODS: A comprehensive search of SCOPUS, Elsevier's abstract and citation database of peer-reviewed literature, from 1966 to November 2016 was performed using predefined criteria. Therapeutic hypothermia was defined as any strategy that aimed to cool post–cardiac arrest survivors to a temperature ≤34°C. Normothermia was temperature of ≥36°C. We compared mortality and neurologic outcomes in patients by categorizing the studies into 2 groups: (1) hypothermia versus normothermia and (2) prehospital hypothermia versus in-hospital hypothermia using standard meta-analytic methods. A random effects modeling was utilized to estimate comparative risk ratios (RR) and 95% confidence intervals (CIs).RESULTS: The hypothermia and normothermia strategies were compared in 5 RCTs with 1389 patients, whereas prehospital hypothermia and in-hospital hypothermia were compared in 6 RCTs with 3393 patients. We observed no difference in mortality (RR, 0.88; 95% CI, 0.73–1.05) or neurologic outcomes (RR, 1.26; 95% CI, 0.92–1.72) between the hypothermia and normothermia strategies. Similarly, no difference was observed in mortality (RR, 1.00; 95% CI, 0.97–1.03) or neurologic outcome (RR, 0.96; 95% CI, 0.85–1.08) between the prehospital hypothermia versus in-hospital hypothermia strategies.CONCLUSIONS: Our results suggest that TTM with therapeutic hypothermia may not improve mortality or neurologic outcomes in postarrest survivors. Using therapeutic hypothermia as a standard of care strategy of postarrest care in survivors may need to be reevaluated.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Cardiac Arrest in the Operating Room: Resuscitation and Management for the
           Anesthesiologist Part 1
    • Authors: Moitra; Vivek K.; Einav, Sharon; Thies, Karl-Christian; Nunnally, Mark E.; Gabrielli, Andrea; Maccioli, Gerald A.; Weinberg, Guy; Banerjee, Arna; Ruetzler, Kurt; Dobson, Gregory; McEvoy, Matthew D.; O’Connor, Michael F.
      Abstract: imageCardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Cardiac Arrest in the Operating Room: Part 2—Special Situations in
           the Perioperative Period
    • Authors: McEvoy; Matthew D.; Thies, Karl-Christian; Einav, Sharon; Ruetzler, Kurt; Moitra, Vivek K.; Nunnally, Mark E.; Banerjee, Arna; Weinberg, Guy; Gabrielli, Andrea; Maccioli, Gerald A.; Dobson, Gregory; O’Connor, Michael F.
      Abstract: imageAs noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Does Lactate Affect the Association of Early Hyperglycemia and Multiple
           Organ Failure in Severely Injured Blunt Trauma Patients'
    • Authors: Richards; Justin E.; Scalea, Thomas M.; Mazzeffi, Michael A.; Rock, Peter; Galvagno, Samuel M. Jr
      Abstract: imageBACKGROUND: Early hyperglycemia is associated with multiple organ failure (MOF) after traumatic injury; however, few studies have considered the contribution of depth of clinical shock. We hypothesize that when considered simultaneously, glucose and lactate are associated with MOF in severely injured blunt trauma patients.METHODS: We performed a retrospective investigation at a single tertiary care trauma center. Inclusion criteria were patient age ≥18 years, injury severity score (ISS)>15, blunt mechanism of injury, and an intensive care unit length of stay>48 hours. Patients with a history of diabetes or who did not survive the initial 48 hours were excluded. Demographics, injury severity, and physiologic data were recorded. Blood glucose and lactate values were collected from admission through the initial 24 hours of hospitalization. Multiple metrics of glucose and lactate were calculated: the first glucose (Glucadm, mg/dL) and lactate (Lacadm, mmol/L) at hospital admission, the mean initial 24-hour glucose (Gluc24hMean, mg/dL) and lactate (Lac24hMean, mmol/L), and the time-weighted initial 24-hour glucose (Gluc24hTW) and lactate (Lac24hTW). These metrics were divided into quartiles. The primary outcome was MOF. Separate Cox proportional hazard models were generated to assess the association of each individual glucose and lactate metric on MOF, after controlling for ISS, admission shock index, and disposition to the operating room after hospital admission. We assessed the interaction between glucose and lactate metrics in the multivariable models. Results are reported as hazard ratios (HRs) for an increase in the quartile level of glucose and lactate measurements, with 95% confidence intervals (CIs).RESULTS: A total of 507 severely injured blunt trauma patients were evaluated. MOF occurred in 46 of 507 (9.1%) patients and was associated with a greater median ISS (33.5, interquartile range [IQR]: 22–41 vs 27, IQR: 21–34; P < .001) and a greater median admission shock index (0.82, IQR: 0.68–1.1 vs 0.73, IQR: 0.60–0.91; P = .02). Patients who were transferred to the operating room after the initial trauma resuscitation were also more likely to develop MOF (20 of 119, 14.4% vs 26 of 369, 7.1%; P = .01). Three separate Cox proportional regression models demonstrated the following HR for an increase in the individual glucose metric quartile and MOF, while controlling for confounding variables: Glucadm HR: 1.35, 95% CI, 1.02–1.80; Gluc24hMean HR: 1.63, 95% CI, 1.14–2.32; Gluc24hTW HR: 1.14, 95% CI, 0.86–1.50. Three separate Cox proportional hazards models also demonstrated the following HR for each individual lactate metric quartile while controlling for the same confounders, with MOF again representing the dependent variable: Lacadm HR: 1.94, 95% CI, 1.38–2.96; Lac24hMean HR: 1.68, 95% CI, 1.22–2.31; Lac24hTW HR: 1.49, 95% CI, 1.10–2.02. When metrics of both glucose and lactate were entered into the same model only lactate remained significantly associated with MOF: Lacadm HR: 1.86, 95% CI, 1.29–2.69, Lac24hMean HR: 1.54, 95% CI, 1.11–2.12, and Lac24hTW HR: 1.48, 95% CI, 1.08–2.01. There was no significant interaction between lactate and glucose variables in relation to the primary outcome.CONCLUSIONS: When glucose and lactate are considered simultaneously, only lactate remained significantly associated with MOF in severely injured blunt trauma patients.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Photoplethysmography and Heart Rate Variability for the Diagnosis of
    • Authors: Euliano; Tammy Y.; Michalopoulos, Kostas; Singh, Savyasachi; Gregg, Anthony R.; Del Rio, Mariem; Vasilopoulos, Terrie; Johnson, Amber M.; Onkala, Allison; Darmanjian, Shalom; Euliano, Neil R.; Ho, Monique
      Abstract: imageBACKGROUND: The goal of this study was to determine a set of timing, shape, and statistical features available through noninvasive monitoring of maternal electrocardiogram and photoplethysmography that identifies preeclamptic patients.METHODS: Pregnant women admitted to Labor and Delivery were monitored with pulse oximetry and electrocardiogram for 30 minutes. Photoplethysmogram features and heart rate variability were extracted from each data set and applied to a sequential feature selection algorithm to discriminate women with preeclampsia with severe features, from normotensive and hypertensive controls. The classification boundary was chosen to minimize the expected misclassification cost. The prior probabilities of the misclassification costs were assumed to be equal.RESULTS: Thirty-seven patients with clinically diagnosed preeclampsia with severe features were compared with 43 normotensive controls; all were in early labor or beginning induction. Six variables were used in the final model. The area under the receiver operating characteristic curve was 0.907 (standard error [SE] = 0.004) (sensitivity 78.2% [SE = 0.3%], specificity 89.9% [SE = 0.1%]) with a positive predictive value of 0.883 (SE = 0.001). Twenty-eight subjects with chronic or gestational hypertension were compared with the same preeclampsia group, generating a model with 5 features with an area under the curve of 0.795 (SE = 0.007; sensitivity 79.0% [SE = 0.2%], specificity 68.7% [SE = 0.4%]), and a positive predictive value of 0.799 (SE = 0.002).CONCLUSIONS: Vascular parameters, as assessed noninvasively by photoplethysmography and heart rate variability, may have a role in screening women suspected of having preeclampsia, particularly in areas with limited resources.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Patients Undergoing Cesarean Delivery After Exposure to Oxytocin During
           Labor Require Higher Postpartum Oxytocin Doses
    • Authors: Foley; Amanda; Gunter, Ashley; Nunes, Kenneth J.; Shahul, Sajid; Scavone, Barbara M.
      Abstract: imageBACKGROUND: Experts recommend postpartum oxytocin to prevent uterine atony and hemorrhage, but oxytocin may be associated with dose-dependent adverse effects, and the correct dose of postpartum oxytocin has yet to be determined. The effective dose in 90% of patients (ED90) of oxytocin after cesarean delivery may be higher in patients exposed to oxytocin during labor compared to patients unexposed. We therefore undertook this study to compare postpartum oxytocin requirements in patients exposed to oxytocin prior to cesarean delivery versus those not exposed, when all were treated according to a specific institutional protocol.METHODS: In this retrospective chart review, we reviewed medical records of patients who underwent cesarean delivery under neuraxial anesthesia and noted demographic data, relevant comorbidities, and oxytocin exposure, infusion rate, and duration prior to delivery. Patients exposed to oxytocin before cesarean (OXY+ group) were compared to those not exposed (OXY− group). The primary outcome variable was highest infusion rate of postpartum oxytocin required per institutional protocol. Secondary outcomes included estimated blood loss, proportion of patients with postpartum hemorrhage, and proportions who received other uterotonic medications or red blood cell transfusion.RESULTS: OXY+ patients were more likely to be nulliparous and had higher estimated gestational age and neonatal weight than OXY− patients. They also had higher incidence of chorioamnionitis and lower incidence of multiple gestation. OXY+ patients required a high postpartum oxytocin infusion rate more often than OXY− patients (adjusted odds ratio 1.94 [95% confidence interval, 1.19–3.15; P = .008]). They also received other uterotonic agents more commonly. Estimated blood loss, hemorrhage rates, and transfusion rates did not differ between groups.CONCLUSIONS: Reported increases in the ED90 of postpartum oxytocin after oxytocin exposure during labor appear to be clinically significant. We have therefore altered our institutional protocol so that women preexposed to oxytocin routinely receive higher initial postpartum oxytocin infusion rates.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Microparticle Release During Normal Cesarean Delivery
    • Authors: Hofer; Jennifer E.; Scavone, Barbara M.
      Abstract: imageCoagulation increases during pregnancy and peaks during parturition. We hypothesized that an increase in microparticle (MP) levels in plasma occurs around the time of placental separation and subsides over several hours. We performed a prospective observational pilot study to investigate plasma MP levels in healthy parturients immediately before and after cesarean delivery. The primary outcome was MP levels at postdelivery time points compared to baseline levels. Samples underwent flow cytometry and staining to determine MP levels. Placental-derived MPs were further characterized for the presence of procoagulant proteins. Placental-derived MPs increased immediately after delivery before returning to baseline in healthy parturients.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • The Society for Obstetric Anesthesia and Perinatology Consensus Statement
           on the Anesthetic Management of Pregnant and Postpartum Women Receiving
           Thromboprophylaxis or Higher Dose Anticoagulants
    • Authors: Leffert; Lisa; Butwick, Alexander; Carvalho, Brendan; Arendt, Katherine; Bates, Shannon M.; Friedman, Alex; Horlocker, Terese; Houle, Timothy; Landau, Ruth; Dubois, Heloise; Fernando, Roshan; Houle, Tim; Kopp, Sandra; Montgomery, Douglas; Pellegrini, Joseph; Smiley, Richard; Toledo, Paloma; the members of the SOAP VTE Taskforce
      Abstract: imageVenous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism–related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies’ recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk–benefit discussions with patients and facilitate shared decision making.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Evaluation of the Augmented Infant Resuscitator: A Monitoring Device for
           Neonatal Bag-Valve-Mask Resuscitation
    • Authors: Bennett; Desmond J.; Itagaki, Taiga; Chenelle, Christopher T.; Bittner, Edward A.; Kacmarek, Robert M.
      Abstract: imageBACKGROUND: Annually, 6 million newborns require bag-valve-mask resuscitation, and providing live feedback has the potential to improve the quality of resuscitation. The Augmented Infant Resuscitator (AIR), a real-time feedback device, has been designed to identify leaks, obstructions, and inappropriate breath rates during bag-valve-mask resuscitation. However, its function has not been evaluated.METHODS: The resistance of the AIR was measured by attaching it between a ventilator and a ventilator tester. To test the device’s reliability in training and clinical-use settings, it was placed in-line between a ventilation bag or ventilator and a neonatal manikin and a clinical lung model simulator. The lung model simulator simulated neonates of 3 sizes (2, 4, and 6 kg). Leaks, obstructions, and respiratory rate alterations were introduced.RESULTS: At a flow of 5 L/min, the pressure drop across the AIR was only 0.38 cm H2O, and the device had almost no effect on ventilator breath parameters. During the manikin trials, it was able to detect all leaks and obstructions, correctly displaying an alarm 100% of the time. During the simulated clinical trials, the AIR performed best on the 6-kg neonatal model, followed by the 4-kg model, and finally the 2-kg model. Over all 3 clinical models, the prototype displayed the correct indicator 73.5% of the time, and when doing so, took 1.6 ± 0.9 seconds.CONCLUSIONS: The AIR is a promising innovation that has the potential to improve neonatal resuscitation. It introduces only marginal resistance and performs well on neonatal manikins, but its firmware should be improved before clinical use.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical
           Trials: An ACTTION Systematic Review
    • Authors: Williams; Mark R.; Nayshtut, Michael; Hoefnagel, Amie; McKeown, Andrew; Carlson, Douglas W.; Cravero, Joseph; Lightdale, Jenifer; Mason, Keira P.; Wilson, Stephen; Turk, Dennis C.; Dworkin, Robert H.; Ward, Denham S.
      Abstract: imageObjective evaluations comparing different techniques and approaches to pediatric procedural sedation studies have been limited by a lack of consistency among the outcome measures used in assessment. This study reviewed those existing measures, which have undergone psychometric analysis in a pediatric procedural sedation setting, to determine to what extent and in what circumstances their use is justified across the spectrum of procedures, age groups, and techniques. The results of our study suggest that a wide range of measures has been used to assess the efficacy and effectiveness of pediatric procedural sedation. Most lack the evidence of validity and reliability that is necessary to facilitate rigorous clinical trial design, as well as the evaluation of new drugs and devices. A set of core pediatric sedation outcome domains and outcome measures can be developed on the basis of our findings. We believe that consensus among all stakeholders regarding appropriate domains and measures to evaluate pediatric procedural sedation is possible and that widespread implementation of such recommendations should be pursued.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Endoscopic Versus Open Repair for Craniosynostosis in Infants Using
           Propensity Score Matching to Compare Outcomes: A Multicenter Study from
           the Pediatric Craniofacial Collaborative Group
    • Authors: Thompson; Douglas R.; Zurakowski, David; Haberkern, Charles M.; Stricker, Paul A.; Meier, Petra M.; Bannister, Carolyn; Benzon, Hubert; Binstock, Wendy; Bosenberg, Adrian; Brzenski, Alyssa; Budac, Stefan; Busso, Veronica; Capehart, Samantha; Chiao, Franklin; Cladis, Franklyn; Collins, Michael; Cusick, Jordan; Dabek, Rachel; Dalesio, Nicholas; Falcon, Ricardo; Fernandez, Allison; Fernandez, Patrick; Fiadjoe, John; Gangadharan, Meera; Gentry, Katherine; Glover, Chris; Goobie, Susan; Gries, Heike; Griffin, Allison; Groenewald, Cornelius Botha; Hajduk, John; Hall, Rebecca; Hansen, Jennifer; Hetmaniuk, Mali; Hsieh, Vincent; Huang, Henry; Ingelmo, Pablo; Ivanova, Iskra; Jain, Ranu; Koh, Jeffrey; Kowalczyk-Derderian, Courtney; Kugler, Jane; Labovsky, Kristen; Martinez, José Luis; Mujallid, Razaz; Muldowney, Bridget; Nguyen, Kim-Phuong; Nguyen, Thanh; Olutuye, Olutoyin; Soneru, Codruta; Petersen, Timothy; Poteet-Schwartz, Kim; Reddy, Srijaya; Reid, Russell; Ricketts, Karene; Rubens, Daniel; Skitt, Rochelle; Sohn, Lisa; Staudt, Susan; Sung, Wai; Syed, Tariq; Szmuk, Peter; Taicher, Brad; Tetreault, Lisa; Watts, Rheana; Wong, Karen; Young, Vanessa; Zamora, Lillian; The Pediatric Craniofacial Collaborative Group
      Abstract: imageBACKGROUND: The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry.METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis.RESULTS: Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3–12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • A Retrospective Analysis of Clinical Research Misconduct Using FDA-Issued
           Warning Letters and Clinical Investigator Inspection List From 2010 to
    • Authors: Romano; Christopher A.; Nair, Singh; Delphin, Ellise S.
      Abstract: imageBACKGROUND: The US Food and Drug Administration (FDA) conducts inspections of clinical investigation sites as a component of clinical trial regulation. The FDA describes the results of these inspections in the Clinical Investigator Inspection List (CLIIL). More serious violations are followed up in FDA warning letters issued to investigators. The primary objective of the current study is to qualitatively and quantitatively describe the CLIIL data and contents of FDA-issued warning letters from 2010 to 2014.METHODS: We retrospectively analyzed the CLIIL and FDA warning letters. For the CLIIL, we quantified the frequency of each violation among other data points. We compared recent data (2010–2014) to the previous 5 years (2005–2009). To analyze FDA warning letters, we developed a coding system to quantify the frequency of violations found.RESULTS: We analyzed 3637 inspections in the CLIIL database and 60 warning letters. Overall, there was a decrease or no change in all violations in the CLIIL database. The largest violation code reported was “failure to follow investigational plan” in both the 2005–2009 and 2010–2014 timeframes. Coding of FDA warning letters shows that the most common violations reported were failing to maintain accurate case histories (10.82%), enrolling ineligible subjects (8.85%), and failing to perform required tests (8.52%).CONCLUSIONS: The overall decrease in violations is encouraging. But, the high proportion of violations related to failure to follow the investigational plan is concerning as the complexity of trials increases. We conclude that more detailed information is necessary to accurately evaluate these violations. The current study provides a model for creating more granular data of violations to better inform clinical investigators and improve clinical trials.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Reductions in Average Lengths of Stays for Surgical Procedures Between the
           2008 and 2014 United States National Inpatient Samples Were Not Associated
           With Greater Incidences of Use of Postacute Care Facilities
    • Authors: Dexter; Franklin; Epstein, Richard H.
      Abstract: imageBACKGROUND: Diagnosis-related group (DRG) based reimbursement creates incentives for reduction in hospital length of stay (LOS). Such reductions might be accomplished by lesser incidences of discharges to home. However, we previously reported that, while controlling for DRG, each 1-day decrease in hospital median LOS was associated with lesser odds of transfer to a postacute care facility (P = .0008). The result, though, was limited to elective admissions, 15 common surgical DRGs, and the 2013 US National Readmission Database.METHODS: We studied the same potential relationship between decreased LOS and postacute care using different methodology and over 2 different years. The observational study was performed using summary measures from the 2008 and 2014 US National Inpatient Sample, with 3 types of categories (strata): (1) Clinical Classifications Software’s classes of procedures (CCS), (2) DRGs including a major operating room procedure during hospitalization, or (3) CCS limiting patients to those with US Medicare as the primary payer.RESULTS: Greater reductions in the mean LOS were associated with smaller percentages of patients with disposition to postacute care. Analyzed using 72 different CCSs, 174 DRGs, or 70 CCSs limited to Medicare patients, each pairwise reduction in the mean LOS by 1 day was associated with an estimated 2.6% ± 0.4%, 2.3% ± 0.3%, or 2.4% ± 0.3% (absolute) pairwise reduction in the mean incidence of use of postacute care, respectively. These 3 results obtained using bivariate weighted least squares linear regression were all P < .0001, as were the corresponding results obtained using unweighted linear regression or the Spearman rank correlation.CONCLUSIONS: In the United States, reductions in hospital LOS, averaged over many surgical procedures, are not accomplished through a greater incidence of use of postacute care.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Macintosh Blade Videolaryngoscopy Combined With Rigid Bonfils Intubation
           Endoscope Offers a Suitable Alternative for Patients With Difficult
    • Authors: Pieters; Barbe M.; Theunissen, Maurice; van Zundert, Andre A.
      Abstract: imageBACKGROUND: In the armamentarium of an anesthesiologist, videolaryngoscopy is a valuable addition to secure the airway. However, when the videolaryngoscope (VLS) offers no solution, few options remain. Earlier, we presented an intubation technique combining Macintosh blade VLS and Bonfils intubation endoscope (BIE) for a patient with a history of very difficult intubation. In the present study, we evaluated this technique to establish whether it is a valuable alternative.METHODS: In this single-blinded nonrandomized study, 38 patients with a history of difficult intubation or 1 or more predictors of difficult intubation, scoring a Cormack & Lehane (C&L) grade III or IV using Macintosh blade VLS, were included. Patients were intubated combining the VLS with the BIE. The C&L grade was scored 3 times during (1) direct laryngoscopy; (2) indirect videolaryngoscopy; and (3) using the combined technique (VLS + BIE). Afterward, 2 blinded anesthesiologists assessed the C&L grade using the pictures taken during the procedure.RESULTS: Data of 38 patients were analyzed. An improvement of the C&L grade with the combined technique occurred in 33 of 38 patients (86.8%; 95% confidence interval, 71.9%–95.6%). Reviewer 1 reported an improvement of the C&L grade with the combined technique in 37 of 38 patients. Reviewer 2 reported improvement in 33 and deterioration in 2 of the patients. No complications occurred.CONCLUSIONS: The combined use of a VLS with Macintosh blade and BIE gives the anesthesiologist a valuable alternative intubation option in patients with extremely difficult airways.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Cardiorespiratory Alterations Following Acute Normovolemic Hemodilution in
           a Pediatric and an Adult Porcine Model: A Prospective Interventional Study
    • Authors: Albu; Gergely; Sottas, Cédric; Dolci, Mirko; Walesa, Magali; Peták, Ferenc; Habre, Walid
      Abstract: imageBACKGROUND: Acute normovolemic hemodilution (ANH) is considered as a blood-sparing intervention during the perioperative management. We aimed at comparing the cardiopulmonary consequences of ANH between adult pigs and weaned piglets to establish the effects of lowering hematocrit in these age groups, and thereby testing the hypothesis that difference in the age-related physiological behavior will be reflected in the cardiorespiratory changes following ANH.METHODS: ANH was achieved in anesthetized, mechanically ventilated adult minipigs and 5-week-old weaned piglets by stepwise blood withdrawal (10 mL/kg) with crystalloids replacement. Cardiorespiratory assessments consisted of measuring airway resistance, respiratory tissue elastance, effective lung volume, extravascular lung water, mean arterial pressure, pulmonary blood flow, and cardiac output. Respiratory and hemodynamic measurements were made at control conditions and following each ANH condition obtained with 5 to 7 steps.RESULTS: ANH induced immediate and progressive increases in airway resistance and tissue elastance in both groups, with more pronounced worsening in adults despite the similar decreases in hematocrit. The increases in extravascular lung water were significantly greater in the adult population with the differences in mean (DM) of 25.1% (95% confidence interval [CI], 5.3%–44.9%). Progressive ANH led to significant decreases in the DM of pulmonary blood flow (45.3%; 95% CI, 19.8%–70.8%) and mean arterial pressure (36.3%; 95% CI, 18.7%–53.9%) only in adults, whereas cardiac output increased significantly only in the piglets (DM, 51.6; 95% CI, 14.2%–89.0%).CONCLUSIONS: While ANH led to mild detrimental cardiorespiratory changes in weaned piglets, gradual developments of bronchoconstriction, lung tissue extravasation and stiffening, and deteriorations in systemic and pulmonary hemodynamics were observed in adults. ANH may exert age-dependent cardiorespiratory effect.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Chinese Anesthesiologists Have High Burnout and Low Job Satisfaction: A
           Cross-Sectional Survey
    • Authors: Li; Hange; Zuo, Mingzhang; Gelb, Adrian W.; Zhang, Biao; Zhao, Xiaohui; Yao, Dongdong; Xia, Di; Huang, Yuguang
      Abstract: imageBACKGROUND: The Chinese health care system must meet the needs of 19% of the world’s population. Despite recent economic growth, health care resources are unevenly distributed. This creates the potential for job stress and burnout. We therefore conducted a survey among anesthesiologists in the Beijing–Tianjin–Hebei region focusing on job satisfaction and burnout to determine the incidence and associated factors.METHODS: A large cross-sectional study was performed in the Beijing–Tianjin–Hebei region of China. The anonymous questionnaire was designed to collect and analyze the following information: (1) demographic characteristics and employer information; (2) job satisfaction assessed by Minnesota Satisfaction Questionnaire; (3) burnout assessed by Maslach Burnout Inventory-Human Service Survey; and (4) sleep pattern and physician–patient communication.RESULTS: Surveys were completed and returned from 211 hospitals (response rate 74%) and 2873 anesthesiologists (response rate 70%) during the period of June to August 2015. The overall job satisfaction score of Minnesota Satisfaction Questionnaire was 65.3 ± 11.5. Among the participants, 69% (95% confidence interval [CI], 67%–71%) met the criteria for burnout. The prevalence of high emotional exhaustion, high depersonalization, and low personal accomplishment was 57% (95% CI, 55%–59%), 49% (95% CI, 47%–51%), and 57% (95% CI, 55%–58%), respectively. Using multivariable logistic regression analysis, we found that age, hospital category, working hours per week, caseload per day, frequency of perceived challenging cases, income, and sleep quality were independent variables associated with burnout. Anesthesiologists with a high level of depersonalization tended to engage in shorter preoperative conversations with patients, provide less information about pain or the procedure, and to have less empathy with them.CONCLUSIONS: The anesthesiologists in the Beijing–Tianjin–Hebei region of China expressed a below-average level of job satisfaction, and suffered a significant degree of burnout. Improvement in job satisfaction and burnout might create a positive work climate that could benefit both the quality of patient care and the profession of anesthesiology in China.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Decreased Parasympathetic Activity of Heart Rate Variability During
           Anticipation of Night Duty in Anesthesiology Residents
    • Authors: Wang; Man-Ling; Lin, Pei-Lin; Huang, Chi-Hsiang; Huang, Hui-Hsun
      Abstract: imageBACKGROUND: In residency programs, it is well known that autonomic regulation is influenced by night duty due to workload stress and sleep deprivation. A less investigated question is the impact on the autonomic nervous system of residents before or when anticipating a night duty shift. In this study, heart rate variability (HRV) was evaluated as a measure of autonomic nervous system regulation.METHODS: Eight residents in the Department of Anesthesiology were recruited, and 5 minutes of electrocardiography were recorded under 3 different conditions: (1) the morning of a regular work day (baseline); (2) the morning before a night duty shift (anticipating the night duty); and (3) the morning after a night duty shift. HRV parameters in the time and frequency domains were calculated. Repeated measures analysis of variance was performed to compare the HRV parameters among the 3 conditions.RESULTS: There was a significant decrease of parasympathetic-related HRV measurements (high-frequency power and root mean square of the standard deviation of R–R intervals) in the morning before night duty compared with the regular work day. The mean difference of high-frequency power between the 2 groups was 80.2 ms2 (95% confidence interval, 14.5–146) and that of root mean square of the standard deviation of R–R intervals was 26 milliseconds (95% confidence interval, 7.2–44.8), with P = .016 and .007, respectively. These results suggest that the decrease of parasympathetic activity is associated with stress related to the condition of anticipating the night duty work. On the other hand, the HRV parameters in the morning after duty were not different from the regular workday.CONCLUSIONS: The stress of anticipating the night duty work may affect regulation of the autonomic nervous system, mainly manifested as a decrease in parasympathetic activity. The effect of this change on the health of medical personnel deserves our concern.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • The Effect of Adductor Canal Block on Knee Extensor Muscle Strength 6
           Weeks After Total Knee Arthroplasty: A Randomized, Controlled Trial
    • Authors: Rousseau-Saine; Nicolas; Williams, Stephan R.; Girard, François; Hébert, Luc J.; Robin, Florian; Duchesne, Luc; Lavoie, Frédéric; Ruel, Monique
      Abstract: imageBACKGROUND: Total knee arthroplasty (TKA) reduces knee extensor muscle strength (KES) in the operated limb for several months after the surgery. Immediately after TKA, compared to either inguinal femoral nerve block or placebo, adductor canal block (ACB) better preserves KES. Whether this short-term increase in KES is maintained several weeks after surgery remains unknown. We hypothesized that 48 hours of continuous ACB immediately after TKA would improve KES 6 weeks after TKA, compared to placebo.METHODS: Patients scheduled for primary unilateral TKA were randomized to receive either a continuous ACB (group ACB) or a sham block (group SHAM) for 48 hours after surgery. Primary outcome was the difference in maximal KES 6 weeks postoperatively, measured with a dynamometer during maximum voluntary isometric contraction. Secondary outcomes included postoperative day 1 (POD1) and day 2 (POD2) KES, pain scores at rest and peak effort, and opioid consumption; variation at 6 weeks of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of hospital stay.RESULTS: Sixty-three subjects were randomized and 58 completed the study. Patients in group ACB had less pain at rest during POD1 and during peak effort on POD1 and POD2, consumed less opioids on POD1 and POD2, and had higher median KES on POD1. There was no significant difference between groups for median KES on POD2, variation of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of stay. There was no difference between groups in median KES 6 weeks after surgery (52 Nm [31–89 Nm] for group ACB vs 47 Nm [30–78 Nm] for group SHAM, P= .147).CONCLUSIONS: Continuous ACB provides better analgesia and KES for 24–48 hours after surgery, but does not affect KES 6 weeks after TKA. Further research could evaluate whether standardized and optimized rehabilitation over the long term would allow early KES improvements with ACB to be maintained over a period of weeks or months.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • The Effect of High-Frequency, Structured Expert Feedback on the Learning
           Curves of Basic Interventional Ultrasound Skills Applied to Regional
    • Authors: de Oliveira Filho; Getúlio Rodrigues; Mettrau, Francisco de Assis Caire
      Abstract: imageBACKGROUND: Proficiency in needle-to-ultrasound beam alignment and accurate approach to structures are pivotal for ultrasound-guided regional anesthesia. This study evaluated the effects of high-frequency, structured expert feedback on simulation training of such abilities.METHODS: Forty-two subjects randomly allocated as controls or intervention participated in two 25-trial experiments. Experiment 1 consisted of inserting a needle into a bovine muscular phantom parallel to the ultrasound beam while maintaining full imaging of the needle. In experiment 2, the needle aimed to contact a target inside the phantom. Intervention subjects received structured feedback between trials. Controls received a global critique after completing the trials. The slopes of the learning curves derived from the sequences of successes and failures were compared. Change-point analyses identified the start and the end of learning in trial sequences. The number of trials associated with learning, the number of technical errors, and the duration of training sessions were compared between intervention and controls.RESULTS: In experiment 1, learning curves departed from 73% (controls) and 76% (intervention) success rates; slopes (standard error) were 0.79% (0.02%) and 0.71% (0.04), respectively, with mean absolute difference of 0.18% (95% confidence interval [CI], 0.17%–0.19%; P = 0). Intervention subjects’ learning curves were shorter and steeper than those of controls. In experiment 2, the learning curves departed from 43% (controls) and 80% (intervention) success rates; slopes (standard error) were 1.06% (0.02%) and 0.42% (0.03%), respectively, with a mean difference of 0.65% (95% CI, 0.64%–0.66%; P = 0). Feedback was associated with a greater number of trials associated with learning in both experiment 1 (mean difference, 1.55 trials; 95% CI, 0.15–3 trials; P = 0) and experiment 2 (mean difference, 4.25 trials; 95% CI, 1.47–7.03 trials; P = 0) and a lower number of technical errors per trial in experiments 1 (mean difference, 0.19; 95% CI, 0.07–0.30; P = .02) and 2 (mean difference, 0.58; 95% CI, 0.45–0.70; P = 0), but longer training sessions in both experiments 1 (mean difference, 9.2 minutes; 95% CI, 4.15–14.24 minutes; P = .01) and 2 (mean difference, 7.4 minutes; 95% CI, 1.17–13.59 minutes; P = .02).CONCLUSIONS: High-frequency, structured expert feedback compared favorably to self-directed learning, being associated with shorter learning curves, smaller number of technical errors, and longer duration of in-training improvement, but increased duration of the training sessions.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Intraoperative Esmolol as an Adjunct for Perioperative Opioid and
           Postoperative Pain Reduction: A Systematic Review, Meta-analysis, and
    • Authors: Gelineau; Amanda M.; King, Michael R.; Ladha, Karim S.; Burns, Sara M.; Houle, Timothy; Anderson, T. Anthony
      Abstract: imageBACKGROUND: Esmolol is an ultrashort β-1 receptor antagonist. Recent studies suggest a role for esmolol in pain response modulation. The authors performed a meta-analysis to determine if the intraoperative use of esmolol reduces opioid consumption or pain scores.METHODS: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, pubget, and Google Scholar were searched. Studies were included if they were randomized, placebo- or opioid-controlled trials written in English, and performed on patients 18 years of age or older. For comparison of opioid use, included studies tracked opioid consumption intraoperatively and/or in the postanesthesia care unit. Pain score comparisons were performed during the first hour after surgery.RESULTS: Seventy-three studies were identified, 23 were included in the systematic review, and 19 were eligible for 1 or more comparisons. In 433 patients from 7 trials, intraoperative esmolol decreased intraoperative opioid consumption (Standard Mean Difference [SMD], −1.60; 95% confidence interval [CI], −2.25 to −0.96; P ≤ .001). In 659 patients from 12 trials, intraoperative esmolol decreased postanesthesia care unit opioid consumption (SMD, −1.21; 95% CI, −1.66 to −0.77; P ≤ .001). In 688 patients from 11 trials, there was insufficient evidence of change in postoperative 1 hour pain scores (SMD, −0.60; 95% CI, −1.44 to 0.24; P = .163).CONCLUSIONS: This meta-analysis demonstrates that intraoperative esmolol use reduces both intraoperative and postoperative opioid consumption, with no change in postoperative pain scores.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Truncated μ-Opioid Receptors With 6 Transmembrane Domains Are
           Essential for Opioid Analgesia
    • Authors: Lu; Zhigang; Xu, Jin; Xu, Mingming; Rossi, Grace C.; Majumdar, Susruta; Pasternak, Gavril W.; Pan, Ying-Xian
      Abstract: imageBACKGROUND: Most clinical opioids act through μ-opioid receptors. They effectively relieve pain but are limited by side effects, such as constipation, respiratory depression, dependence, and addiction. Many efforts have been made toward developing potent analgesics that lack side effects. Three-iodobenzoyl-6β-naltrexamide (IBNtxA) is a novel class of opioid active against thermal, inflammatory, and neuropathic pain, without respiratory depression, physical dependence, and reward behavior. The μ-opioid receptor (OPRM1) gene undergoes extensive alternative precursor messenger ribonucleic acid splicing, generating multiple splice variants that are conserved from rodents to humans. One type of variant is the exon 11 (E11)–associated truncated variant containing 6 transmembrane domains (6TM variant). There are 5 6TM variants in the mouse OPRM1 gene, including mMOR-1G, mMOR-1M, mMOR-1N, mMOR-1K, and mMOR-1L. Gene-targeting mouse models selectively removing 6TM variants in E11 knockout (KO) mice eliminated IBNtxA analgesia without affecting morphine analgesia. Conversely, morphine analgesia is lost in an exon 1 (E1) KO mouse that lacks all 7 transmembrane (7TM) variants but retains 6TM variant expression, while IBNtxA analgesia remains intact. Elimination of both E1 and E11 in an E1/E11 double KO mice abolishes both morphine and IBNtxA analgesia. Reconstituting expression of the 6TM variant mMOR-1G in E1/E11 KO mice through lentiviral expression rescued IBNtxA but not morphine analgesia. The aim of this study was to investigate the effect of lentiviral expression of the other 6TM variants in E1/E11 KO mice on IBNtxA analgesia.METHODS: Lentiviruses expressing 6TM variants were packaged in HEK293T cells, concentrated by ultracentrifugation, and intrathecally administered 3 times. Opioid analgesia was determined using a radiant-heat tail-flick assay. Expression of lentiviral 6TM variant messenger ribonucleic acids was examined by polymerase chain reaction (PCR) or quantitative PCR.RESULTS: All the 6TM variants restored IBNtxA analgesia in the E1/E11 KO mouse, while morphine remained inactive. Expression of lentiviral 6TM variants was confirmed by PCR or quantitative PCR. IBNtxA median effective dose values determined from cumulative dose–response studies in the rescued mice were indistinguishable from wild-type animals. IBNtxA analgesia was maintained for up to 33 weeks in the rescue mice and was readily antagonized by the opioid antagonist levallorphan.CONCLUSIONS: Our study demonstrated the pharmacological relevance of mouse 6TM variants in IBNtxA analgesia and established that a common functional core of the receptors corresponding to the transmembrane domains encoded by exons 2 and 3 is sufficient for activity. Thus, 6TM variants offer potential therapeutic targets for a distinct class of analgesics that are effective against broad-spectrum pain models without many side effects associated with traditional opioids.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Perioperative Inflammation and Its Modulation by Anesthetics
    • Authors: Rossaint; Jan; Zarbock, Alexander
      Abstract: imageSurgery and other invasive procedures, which are routinely performed during general anesthesia, may induce an inflammatory response in the patient. This inflammatory response is an inherent answer of the body to the intervention and can be both beneficial and potentially harmful. The immune system represents a unique evolutionary achievement equipping higher organisms with an effective defense mechanism against exogenous pathogens. However, not only bacteria might evoke an immune response but also other noninfectious stimuli like the surgical trauma or mechanical ventilation may induce an inflammatory response of varying degree. In these cases, the immune system activation is not always beneficial for the patients and might carry the risk of concomitant, harmful effects on host cells, tissues, or even whole organ systems. Research over the past decades has contributed substantial information in which ways surgical patients may be affected by inflammatory reactions. Modulations of the patient’s immune system may be evoked by the use of anesthetic agents, the nature of surgical trauma and the use of any supportive therapy during the perioperative period. The effects on the patient may be manifold, including various proinflammatory effects. This review focuses on the causes and effects of inflammation in the perioperative period. In addition, we also highlight possible approaches by which inflammation in the perioperative may be modulated in the future.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Statistical Significance Versus Clinical Importance of Observed Effect
           Sizes: What Do P Values and Confidence Intervals Really Represent'
    • Authors: Schober; Patrick; Bossers, Sebastiaan M.; Schwarte, Lothar A.
      Abstract: imageEffect size measures are used to quantify treatment effects or associations between variables. Such measures, of which>70 have been described in the literature, include unstandardized and standardized differences in means, risk differences, risk ratios, odds ratios, or correlations. While null hypothesis significance testing is the predominant approach to statistical inference on effect sizes, results of such tests are often misinterpreted, provide no information on the magnitude of the estimate, and tell us nothing about the clinically importance of an effect. Hence, researchers should not merely focus on statistical significance but should also report the observed effect size. However, all samples are to some degree affected by randomness, such that there is a certain uncertainty on how well the observed effect size represents the actual magnitude and direction of the effect in the population. Therefore, point estimates of effect sizes should be accompanied by the entire range of plausible values to quantify this uncertainty. This facilitates assessment of how large or small the observed effect could actually be in the population of interest, and hence how clinically important it could be. This tutorial reviews different effect size measures and describes how confidence intervals can be used to address not only the statistical significance but also the clinical significance of the observed effect or association. Moreover, we discuss what P values actually represent, and how they provide supplemental information about the significant versus nonsignificant dichotomy. This tutorial intentionally focuses on an intuitive explanation of concepts and interpretation of results, rather than on the underlying mathematical theory or concepts.
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Minimizing the Harm of Accidental Awareness Under General Anesthesia: New
           Perspectives From Patients Misdiagnosed as Being in a Vegetative State
    • Authors: Graham; Mackenzie; Owen, Adrian M.; Çipi, Kaman; Weijer, Charles; Naci, Lorina
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Teacher and Trustee: Examining the Ethics of Experiential Learning in
           Transesophageal Echocardiography Education
    • Authors: Ivascu; Natalia S.; Meltzer, Ellen C.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • You’re Wrong, I’m Right: Dueling Authors Reexamine Classic
           Teachings in Anesthesia
    • Authors: Goyal; Rakhee
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Observation Medicine: Principles and Protocols
    • Authors: Arthur; Mary E.; Basta, Mafdy N.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • The Pediatric Cardiac Anesthesia Handbook
    • Authors: Rex; Steffen
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Another Possible Reason to Use Prophylactic Phenylephrine Infusions to
           Reduce Spinal Anesthesia‚ÄďAssociated Hypotension: Do These Patients Stay
    • Authors: Roth; Jonathan V.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • In Response
    • Authors: Bishop; David; Cairns, Carel; Grobbelaar, Mariette; Rodseth, Reitze
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • An Environment Is More Than a Climate
    • Authors: Anwari; Jamil Sharif
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • In Response
    • Authors: Katz; Jonathan D.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Bolus Norepinephrine Administration and Fetal Acidosis at Cesarean
           Delivery Under Spinal Anesthesia
    • Authors: Cooper; David W.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • In Response
    • Authors: Onwochei; Desire N.; Ngan Kee, Warwick D.; Ye, Xiang Y.; Downey, Kristi; Carvalho, Jose C. A.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • The Unknown Mechanism of Exogenous Tetrahydrobiopterin in the Renal
           Protection of Sheep Ischemia and Reperfusion
    • Authors: Kinoshita; Hiroyuki; Otake, Kazunobu; Yamasaki, Takashi
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • In Response
    • Authors: Rahmania; Lokmane; Vincent, Jean-Louis; De Backer, Daniel
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Continuous Pulse Oximetry Does Not Measure Blood Pressure
    • Authors: Overdyk; Frank J.; Broens, Suzanne J. L.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • In Response
    • Authors: Nagappa; Mahesh; Lam, Thach; Chung, Frances
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Nonpharmacologic Management of Acute Singultus (Hiccups)
    • Authors: Orlovich; Daniel S.; Brodsky, Jay B.; Brock-Utne, John G.
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • In Response
    • Authors: Kohse; Eva K.; Hollmann, Markus W.; Kessler, Jens
      Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
  • Guest Reviewers
    • Abstract: No abstract available
      PubDate: Thu, 01 Mar 2018 00:00:00 GMT-
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
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