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Anesthesia & Analgesia
Journal Prestige (SJR): 1.472
Citation Impact (citeScore): 3
Number of Followers: 275  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0003-2999 - ISSN (Online) 1526-7598
Published by LWW Wolters Kluwer Homepage  [301 journals]
  • Human Leukocyte Antigen-DR Deficiency and Immunosuppression-Related
           End-Organ Failure in SARS-CoV2 Infection
    • Authors: Zmijewski; Jaroslaw W.; Pittet, Jean-Francois
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Reduced Monocytic Human Leukocyte Antigen-DR Expression Indicates
           Immunosuppression in Critically Ill COVID-19 Patients
    • Authors: Spinetti; Thibaud; Hirzel, Cedric; Fux, Michaela; Walti, Laura N.; Schober, Patrick; Stueber, Frank; Luedi, Markus M.; Schefold, Joerg C.
      Abstract: imageBACKGROUND: The cellular immune system is of pivotal importance with regard to the response to severe infections. Monocytes/macrophages are considered key immune cells in infections and downregulation of the surface expression of monocytic human leukocyte antigen-DR (mHLA-DR) within the major histocompatibility complex class II reflects a state of immunosuppression, also referred to as injury-associated immunosuppression. As the role of immunosuppression in coronavirus disease 2019 (COVID-19) is currently unclear, we seek to explore the level of mHLA-DR expression in COVID-19 patients.METHODS: In a preliminary prospective monocentric observational study, 16 COVID-19–positive patients (75% male, median age: 68 [interquartile range 59–75]) requiring hospitalization were included. The median Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score in 9 intensive care unit (ICU) patients with acute respiratory failure was 30 (interquartile range 25–32). Standardized quantitative assessment of HLA-DR on monocytes (cluster of differentiation 14+ cells) was performed using calibrated flow cytometry at baseline (ICU/hospital admission) and at days 3 and 5 after ICU admission. Baseline data were compared to hospitalized noncritically ill COVID-19 patients.RESULTS: While normal mHLA-DR expression was observed in all hospitalized noncritically ill patients (n = 7), 89% (8 of 9) critically ill patients with COVID-19–induced acute respiratory failure showed signs of downregulation of mHLA-DR at ICU admission. mHLA-DR expression at admission was significantly lower in critically ill patients (median, [quartiles]: 9280 antibodies/cell [6114, 16,567]) as compared to the noncritically ill patients (30,900 antibodies/cell [26,777, 52,251]), with a median difference of 21,508 antibodies/cell (95% confidence interval [CI], 14,118–42,971), P = .002. Reduced mHLA-DR expression was observed to persist until day 5 after ICU admission.CONCLUSIONS: When compared to noncritically ill hospitalized COVID-19 patients, ICU patients with severe COVID-19 disease showed reduced mHLA-DR expression on circulating CD14+ monocytes at ICU admission, indicating a dysfunctional immune response. This immunosuppressive (monocytic) phenotype remained unchanged over the ensuing days after ICU admission. Strategies aiming for immunomodulation in this population of critically ill patients should be guided by an immune-monitoring program in an effort to determine who might benefit best from a given immunological intervention.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Is Surgical Tracheostomy Better Than Percutaneous Tracheostomy in
           COVID-19–Positive Patients'
    • Authors: Bassi; Massimiliano; Ruberto, Franco; Poggi, Camilla; Diso, Daniele; Anile, Marco; De Giacomo, Tiziano; Pecoraro, Ylenia; Carillo, Carolina; Pugliese, Francesco; Venuta, Federico; Vannucci, Jacopo
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • The Argument for Monitoring: Identifying At-Risk Patients for Better
    • Authors: Woo; Jacqueline; Weber, Garret; Nathan, Naveen
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Postoperative Opioid-Induced Respiratory Depression: 3 Steps Forward
    • Authors: Prielipp; Richard C.; Fulesdi, Bela; Brull, Sorin J.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards
           Using Continuous Capnography and Oximetry: An International Prospective,
           Observational Trial
    • Authors: Khanna; Ashish K.; Bergese, Sergio D.; Jungquist, Carla R.; Morimatsu, Hiroshi; Uezono, Shoichi; Lee, Simon; Ti, Lian Kah; Urman, Richard D.; McIntyre, Robert Jr; Tornero, Carlos; Dahan, Albert; Saager, Leif; Weingarten, Toby N.; Wittmann, Maria; Auckley, Dennis; Brazzi, Luca; Le Guen, Morgan; Soto, Roy; Schramm, Frank; Ayad, Sabry; Kaw, Roop; Di Stefano, Paola; Sessler, Daniel I.; Uribe, Alberto; Moll, Vanessa; Dempsey, Susan J.; Buhre, Wolfgang; Overdyk, Frank J.; on behalf of the PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY Group CollaboratorsPRediction of O
      Abstract: imageBACKGROUND: Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring.METHODS: PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting>30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping.RESULTS: One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17–26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44–8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring.CONCLUSIONS: A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Preoperative Screening for Obstructive Sleep Apnea Using Alternative
           Scoring Models of the Sleep Tiredness Observed Pressure-Body Mass Index
           Age Neck Circumference Gender Questionnaire: An External Validation
    • Authors: Seguin; Ludovic; Tamisier, Renaud; Deletombe, Baptiste; Lopez, Mélanie; Pepin, Jean-Louis; Payen, Jean-François
      Abstract: imageBACKGROUND: The Sleep Tiredness Observed Pressure-Body mass index Age Neck circumference Gender (STOP-Bang) questionnaire is a validated preoperative screening tool for identifying patients with obstructive sleep apnea (OSA). Although it has a high sensitivity at scores ≥3, its specificity is moderate, particularly for scores of 3–4. This study aimed to externally validate the STOP-Bang questionnaire and the alternative scoring models that have been proposed to improve its predictive performance.METHODS: This prospective cohort study included 115 surgical patients with preoperative STOP-Bang scores of 3–8. Type 3 sleep recordings identified moderate-to-severe OSA, reflected by an apnea–hypopnea index (AHI) of>15. Patients were categorized into 2 subgroups: patients with an intermediate (STOP-Bang 3–4) or a high risk of OSA (STOP-Bang 5–8). For patients with scores of 3–4, we tested approaches identified in previous studies: stepwise stratification of the STOP-Bang questionnaire and additional preoperative measurement of serum bicarbonate concentrations.RESULTS: The incidence of moderate-to-severe OSA was significantly higher in patients with STOP-Bang scores of 5–8 than in patients with scores of 3–4: 45 of 58 patients (78%) versus 30 of 57 patients (53%), respectively (P < .01). For patients with STOP-Bang scores of 3–4, we found no differences regarding their OSA diagnosis between patients included in the alternative scoring models and those not included.CONCLUSIONS: The STOP-Bang questionnaire detected moderate-to-severe OSA patients when scores reached 5–8. However, its performance was altered in patients with STOP-Bang scores of 3–4, and alternative scoring models with specific combinations of factors failed to improve the screening of these patients.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Postoperative Critical Events Associated With Obstructive Sleep Apnea:
           Results From the Society of Anesthesia and Sleep Medicine Obstructive
           Sleep Apnea Registry
    • Authors: Bolden; Norman; Posner, Karen L.; Domino, Karen B.; Auckley, Dennis; Benumof, Jonathan L.; Herway, Seth T.; Hillman, David; Mincer, Shawn L.; Overdyk, Frank; Samuels, David J.; Warner, Lindsay L.; Weingarten, Toby N.; Chung, Frances
      Abstract: imageBACKGROUND: Obstructive sleep apnea (OSA) patients are at increased risk for pulmonary and cardiovascular complications; perioperative mortality risk is unclear. This report analyzes cases submitted to the OSA Death and Near Miss Registry, focusing on factors associated with poor outcomes after an OSA-related event. We hypothesized that more severe outcomes would be associated with OSA severity, less intense monitoring, and higher cumulative opioid doses.METHODS: Inclusion criteria were age ≥18 years, OSA diagnosed or suspected, event related to OSA, and event occurrence 1992 or later and
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Decoding Little Squiggles from Little People: EEG Monitoring for
    • Authors: Wanderer; Jonathan P.; Nathan, Naveen
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Case Studies Using the Electroencephalogram to Monitor Anesthesia-Induced
           Brain States in Children
    • Authors: Brandt; Steven P.; Walsh, Elisa C.; Cornelissen, Laura; Lee, Johanna M.; Berde, Charles; Shank, Erik S.; Purdon, Patrick L.
      Abstract: imageFor this child, at this particular moment, how much anesthesia should I give? Determining the drug requirements of a specific patient is a fundamental problem in medicine. Our current approach uses population-based pharmacological models to establish dosing. However, individual patients, and children in particular, may respond to drugs differently. In anesthesiology, we have the advantage that we can monitor our patients in real time and titrate drugs to the desired effect. Examples include blood pressure management or muscle relaxation. Although the brain is the primary site of action for sedative-hypnotic drugs, the brain is not routinely monitored during general anesthesia or sedation, a fact that would surprise many patients. One reason for this is that, until recently, physiologically principled approaches for anesthetic brain monitoring have not been articulated. In the past few years, our knowledge of anesthetic brain mechanisms has developed rapidly. We now know that anesthetic drug effects are clearly visible in the electroencephalogram (EEG) of adults and reflect underlying anesthetic pharmacology and brain mechanisms. Most recently, similar effects have been characterized in children. In this article, we describe how EEG monitoring could be used to guide anesthetic management in pediatric patients. We review previous evidence and present multiple case studies showing how drug-specific and dose-dependent EEG signatures seen in adults are visible in children and infants, including those with neurological disorders. We propose that the EEG can be used in the anesthetic care of children to enable anesthesiologists to better assess the drug requirements of individual patients in real time and improve patient safety and experience.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Yes You Can—Cautiously—Infuse Norepinephrine Intraoperatively Through
           a Peripheral Intravenous Catheter
    • Authors: Perry; Tjorvi E.; Prielipp, Richard C.
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Risk of Major Complications After Perioperative Norepinephrine Infusion
           Through Peripheral Intravenous Lines in a Multicenter Study
    • Authors: Pancaro; Carlo; Shah, Nirav; Pasma, Wietze; Saager, Leif; Cassidy, Ruth; van Klei, Wilton; Kooij, Fabian; Vittali, Dave; Hollmann, Markus W.; Kheterpal, Sachin; Lirk, Philipp
      Abstract: imageBACKGROUND: Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs.METHODS: This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine.RESULTS: A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%–0.081%, indicating an estimated risk of 1–8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%–0.021% and indicating a risk of approximately 0–2 events per 10,000 patients.CONCLUSIONS: In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in
           California: The Ground Is Shifting
    • Authors: Cladis; Franklyn P.; Davis, Peter J.; DiNardo, James A.
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in
           California: 2000–2016
    • Authors: Muffly; Matthew K.; Honkanen, Anita; Scheinker, David; Wang, Tammy Nai-Yen; Saynina, Olga; Singleton, Mark A.; Wang, C. Jason; Sanders, Lee
      Abstract: imageBACKGROUND: We report hospitalization patterns from 2000 to 2016 for young children (ages 0–5 years old) in California who underwent 1 of the 20 most common inpatient procedures that required general anesthesia and evaluate the estimated probability of treatment at a tertiary care children’s hospital (CH) by year.METHODS: We hypothesized that children ≤5 years old increasingly undergo care at tertiary care CHs for common inpatient surgeries or other procedures that require general anesthesia. Data from the California Office of Statewide Health Planning and Development dataset were used to determine procedure, patient age, year of procedure, and hospital name. Hospitals were designated as either tertiary care CHs, children’s units within general hospitals (CUGHs), or general hospitals (GHs) based on the California Children’s Services Provider List. A tertiary care CH was defined using the California Children’s Services definition as a referral hospital that provides comprehensive, multidisciplinary, regionalized pediatric care to children from birth up to 21 years of age with a full range of medical and surgical care for severely ill children. We report the unadjusted percentage of patients treated at each hospital type and, after controlling for patient covariates and comorbidities, the estimated probability of undergoing care at a tertiary care CH from 2000 to 2016.RESULTS: There were 172,318 treatment episodes from 2000 to 2016. The estimated probability of undergoing care at a tertiary care CH increased from 63.4% (95% confidence interval [CI], 62.4%–64.4%) in 2000 to 78.3% (95% CI, 77.3%–79.4%) in 2016.CONCLUSIONS: Children ≤5 years old undergoing common inpatient procedures that require general anesthesia increasingly receive care at tertiary care CHs in California.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Risk Prediction in Children With Congenital Heart Disease: Business As
           Usual—Or Not'
    • Authors: Kloesel; Benjamin; Skubas, Nikolaos J.; Belani, Kumar
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Integration of the Intrinsic Surgical Risk With Patient Comorbidities and
           Severity of Congenital Cardiac Disease Does Not Improve Risk
           Stratification in Children Undergoing Noncardiac Surgery
    • Authors: Faraoni; David; Zou, Xue; DiNardo, James A.; Nasr, Viviane G.
      Abstract: imageBACKGROUND: The objective of this study is to estimate the surgical risk of noncardiac procedures on the incidence of 30-day mortality in children with congenital heart disease.METHODS: Children with congenital heart disease undergoing noncardiac surgery from 2012 to 2016 and included in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database were included in the derivation cohort, while the 2017 database was used as a validation cohort. Intrinsic surgical risk quartiles were built utilizing 30-day mortality rates for each Current Procedural Terminology code and relative value units to create 2 groups defined as low surgical risk (quartiles 1–3) and high surgical risk procedures (quartile 4). We used multivariable logistic regression to determine the predictors for 30-day mortality including patient comorbidities and intrinsic surgical risk. A partially external validation of the model was performed using the 2017 version of the database.RESULTS: We included 37,658 children with congenital heart disease undergoing noncardiac surgery with an incidence of overall 30-day mortality of 1.7% in the derivation cohort and 1.5% in the validation cohort (n = 13,129). Intrinsic surgical risk of procedures represented by Current Procedural Terminology procedural codes and relative value units risk quartiles was significantly associated with 30-day mortality (unadjusted P < .001). Predicted probability of 30-day mortality ranges from 0.2% (95% confidence interval [CI], 0.2–0.2) with no comorbidities to 39.6% (95% CI, 23.2–56.0) when all comorbidities were present among high surgical risk procedures and from 0.3% (95% CI, 0.3–0.3) to 54.8% (95% CI, 39.4–70.1) among low surgical risk procedures. An excellent discrimination was reported for the multivariable model with area under the curve (AUC) of 0.86 (95% CI, 0.85–0.88). High surgical risk was not associated with increased odds of 30-day mortality after adjustment for all other predictors (adjusted odds ratio [OR]: 0.75, 95% CI, 0.62–0.91). We also estimated the discriminative ability of a model that does not include the surgical risk (0.86 [95% CI, 0.84–0.88], with P value for the direct comparison of the AUC of the 2 models = 0.831). The multivariable model obtained from an external validation cohort reported an optimism corrected AUC of 0.88 (95% CI, 0.85–0.91).CONCLUSIONS: Our study demonstrates that integration of intrinsic surgical risk to comorbidities and severity of cardiac disease does not improve prediction of 30-day mortality in children undergoing noncardiac surgery. In children with congenital heart disease, patient comorbidities, and severity of the cardiac lesion are the predominant predictors of 30-day mortality.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Meta-Analysis in Clinical Research
    • Authors: Schober; Patrick; Vetter, Thomas R.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Comparison of Supraglottic Airway Devices With Endotracheal Intubation in
           Low-Risk Patients for Cesarean Delivery: Systematic Review and
    • Authors: White; Leigh D.; Thang, Christopher; Hodsdon, Anthony; Melhuish, Thomas M.; Barron, Fiona A.; Godsall, M. Guy; Vlok, Ruan
      Abstract: imageBACKGROUND: The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA).METHODS: Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI.RESULTS: Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85–4.32; I2 = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = −15.80 seconds; 95% CI, −25.30 to −6.31 seconds; I2= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08–0.32; I2= 53%; P < .001).CONCLUSIONS: Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • The Effectiveness of High-Flow Nasal Oxygen During the Intraoperative
           Period: A Systematic Review and Meta-analysis
    • Authors: Spence; Emily A.; Rajaleelan, Wesley; Wong, Jean; Chung, Frances; Wong, David T.
      Abstract: imageBACKGROUND: High-flow nasal oxygen (HFNO) is increasingly being used in intensive care units for management of hypoxemia and respiratory failure. However, the effectiveness of HFNO for preventing hypoxemia in the intraoperative period is unclear. The purpose of this systematic review was to compare patient oxygenation and end-tidal CO2 (Etco2), between HFNO and conventional oxygenation, during the intraoperative period in surgical patients.METHODS: Standard databases were searched from inception to February 2020. Studies involving intraoperative use of HFNO with 1 of the 4 outcomes: (1) oxygen (O2) desaturation, (2) minimum O2 saturation, (3) safe apnea time, or (4) Etco2 were included. Intraoperative period was divided into 2 phases: at induction with general anesthesia and during surgical procedure under sedation without tracheal intubation.RESULTS: Eight randomized controlled trials (RCTs; 4 induction, 4 procedure, 2314 patients) were included for systematic review and meta-analyses. We found the risk of intraoperative O2 desaturation was lower in HFNO versus conventional oxygenation control group; at induction with an odds ratio (OR; 95% confidence interval [CI]) of 0.06 (0.01–0.59, P = .02), and during procedure, OR (95% CI) of 0.09 (0.05–0.18; P < .001). The minimum O2 saturation was higher in HFNO versus conventional oxygenation; at induction by a mean difference (MD) (95% CI) of 5.1% (3.3–6.9; P < .001), and during procedure, by a MD (95% CI) of 4.0% (1.8–6.2; P < .001). Safe apnea time at induction was longer in HFNO versus conventional oxygenation by a MD (95% CI) of 33.4 seconds (16.8–50.1; P < .001). Etco2 at induction was not significantly different between HFNO and conventional oxygenation groups.CONCLUSIONS: This systematic review and meta-analysis show that, in the intraoperative setting, HFNO compared to conventional oxygenation reduces the risk of O2 desaturation, increases minimum O2 saturation, and safe apnea time. HFNO should be considered for anesthesia induction and during surgical procedures under sedation without tracheal intubation in patients at higher risk of hypoxemia.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • A Comprehensive Update on Aspirin Management During Noncardiac Surgery
    • Authors: Gerstein; Neal S.; Albrechtsen, Cory L.; Mercado, Nestor; Cigarroa, Joaquin E.; Schulman, Peter M.
      Abstract: imageAspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Management of Acute Ischemic Stroke–Specific Focus on Anesthetic
           Management for Mechanical Thrombectomy
    • Authors: Businger; Jerrad; Fort, Alexander C.; Vlisides, Phillip E.; Cobas, Miguel; Akca, Ozan
      Abstract: imageAcute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality, and long-term disability. Modern stroke care involves multidisciplinary management by neurologists, radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend thrombolytic therapy with intravenous (IV) alteplase within the first 3–4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16–24 hours depending on specific inclusion criteria. The anesthesia and critical care provider may become involved for airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data are unclear whether the mechanical thrombectomy procedure is best performed under general anesthesia or sedation. Retrospective cohort trials favor sedation over general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight blood pressure management. At different phases of stroke care, different blood pressure targets are recommended. This narrative review will focus on the anesthesia and critical care providers’ roles in the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic management for mechanical thrombectomy.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Adverse Events During Intrahospital Transport of Critically Ill Children:
           A Systematic Review
    • Authors: Haydar; Bishr; Baetzel, Anne; Elliott, Anila; MacEachern, Mark; Kamal, Afra; Christensen, Robert
      Abstract: imageIntrahospital transport of a critically ill patient is often required to achieve a diagnostic and/or therapeutic objective. However, clinicians who recommend a procedure that requires transport are often not fully aware of the risks of transport. Clinicians involved in the care of critically ill children may therefore benefit from a clear enumeration of adverse events that have occurred during transport, risk factors for those events, and guidance for event prevention. The objective of this review was to collect all published harm and adverse events that occurred in critically ill children in the context of transport within a medical center, as well as the incidence of each type of event. A secondary objective was to identify what interventions have been previously studied that reduce events and to collect recommendations for harm prevention from study authors. Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and CINAHL were searched in January 2018 and again in December 2018. Terms indicating pediatric patients, intrahospital transport, critical illness, and adverse events were used. Titles and abstracts were screened and full text was reviewed for any article meeting inclusion criteria. If articles included both children and adults, incidence data were collected only if the number of pediatric patients could be ascertained. Of 471 full-text articles reviewed, 40 met inclusion criteria, of which 24 included only children, totaling 4104 patient transports. Heterogeneity was high, owing to a wide range of populations, settings, data collection methods, and outcomes. The incidence of adverse events varied widely between studies. Examples of harm included emergent tracheostomy, pneumothorax, and cardiac arrest requiring chest compressions. Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. One transport-associated death was reported. When causation was assessed, most events were judged to have been preventable or potentially mitigated by improved double-checks and usage of checklists. Prospective studies demonstrated the superiority of mechanical ventilation over manual ventilation for intubated patients. Risk of adverse events during critical care transport appears to relate to the patient’s underlying illness and degree of respiratory support. Recommendations for reducing these adverse events have frequently included the use of checklists. Other recommendations include optimization of the patient’s physiological status before transport, training with transport equipment, double-checking of equipment before transport, and having experienced clinicians accompany the patient. All available recommendations for reducing transport-associated adverse events in included articles were collated and included.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Is Preoperative Quantitative Sensory Testing Related to Persistent
           Postsurgical Pain' A Systematic Literature Review
    • Authors: van Helmond; Noud; Aarts, Hugo M.; Timmerman, Hans; Olesen, Søren S.; Drewes, Asbjørn M.; Wilder-Smith, Oliver H.; Steegers, Monique A.; Vissers, Kris C.
      Abstract: imagePersistent postsurgical pain (PPSP) is a common complication of surgery that significantly affects quality of life. A better understanding of which patients are likely to develop PPSP would help to identify when perioperative and postoperative pain management may require specific attention. Quantitative sensory testing (QST) of a patient’s preoperative pain perception is associated with acute postoperative pain, and acute postoperative pain is a risk factor for PPSP. The direct association between preoperative QST and PPSP has not been reviewed to date. In this systematic review, we assessed the relationship of preoperative QST to PPSP. We searched databases with components related to (1) preoperative QST; (2) association testing; and (3) PPSP. Two authors reviewed all titles and abstracts for inclusion. Inclusion criteria were as follows: (1) QST performed before surgery; (2) PPSP assessed ≥3 months postoperatively; and (3) the association between QST measures and PPSP is investigated. The search retrieved 905 articles; 24 studies with 2732 subjects met inclusion criteria. Most studies (22/24) had moderate to high risk of bias in multiple quality domains. Fourteen (58%) studies reported a significant association between preoperative QST and PPSP. Preoperative temporal summation of pain (4 studies), conditioned pain modulation (3 studies), and pressure pain threshold (3 studies) showed the most frequent association with PPSP. The strength of the association between preoperative QST and PPSP varied from weak to strong. Preoperative QST is variably associated with PPSP. Measurements related to central processing of pain may be most consistently associated with PPSP.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Adverse Outcomes Associated With Delaying or Withholding β-Blockers After
           Cardiac Surgery: A Retrospective Single-Center Cohort Study
    • Authors: Chanan; Emily L.; Kendale, Samir M.; Cuff, Germaine; Galloway, Aubrey C.; Nunnally, Mark E.
      Abstract: imageBACKGROUND: Ideal timing of postoperative β-blockers is unclear. We hypothesized that patients who do not receive β-blockers immediately after cardiac surgery would have increased in-hospital mortality (primary outcome) and postoperative hemodynamic, pulmonary, neurologic, or respiratory complications (secondary outcomes).METHODS: We performed a retrospective cohort study evaluating patients who underwent cardiac surgery at our institution from January 1, 2013 to September 30, 2017. We compared outcomes between patients who received β-blockers by postoperative day (POD) 5 with outcomes in patients who did not receive β-blockers at any time or received them after POD 5. Inverse probability of treatment weighting was used to minimize confounding. Univariate logistic regression analyses were performed on the weighted sets using absent or delayed β-blockers as the independent variable and each outcome as dependent variables in separate analyses. A secondary analysis was performed in patients prescribed preoperative β-blockers. E-values were calculated for significant outcomes.RESULTS: All results were confounder adjusted. Among patients presenting for cardiac surgery, not receiving β-blockers by POD 5 or at any time was not associated with the primary outcome in-hospital mortality, estimated odds ratio (OR; 99.5% confidence interval [CI]) of 1.6 (0.49–5.1), P = .28. Not receiving β-blockers by POD 5 or at any time was associated with postoperative atrial fibrillation, estimated OR (99.5% CI) of 1.5 (1.1–2.1), P < .001, and pulmonary complications, estimated OR (99.5% CI) of 3.0 (1.8–5.2), P < .001. E-values were 2.4 for postoperative atrial fibrillation and 5.6 for pulmonary complications. Among patients presenting for cardiac surgery taking preoperative β-blockers, not receiving β-blockers by POD 5 or at any time was not associated with the primary outcome mortality, with estimated OR (99.5% CI) of 1.3 (0.43–4.1), P = .63. In this subset, not receiving β-blockers by POD 5 or at any time was associated with increased adjusted ORs of postoperative atrial fibrillation (OR = 1.6; 99.5% CI, 1.1–2.4; P < .001) and postoperative pulmonary complications (OR = 2.8; 99.5% CI, 1.6–5.2; P < .001). Here, e-values were 2.7 for postoperative atrial fibrillation and 5.1 for pulmonary complications. For the sensitivity analyses for secondary outcomes, exposure and outcome periods overlap. Outcomes may have occurred before or after postoperative β-blocker administration.CONCLUSIONS: Among patients who undergo cardiac surgery, not receiving postoperative β-blockers within the first 5 days after cardiac surgery or at any time is not associated with in-hospital mortality and is associated with, but may not necessarily cause, postoperative atrial fibrillation and pulmonary complications.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • A Single Prophylactic Dose of Ondansetron Given at Cessation of
           Postoperative Propofol Sedation Decreases Postoperative Nausea and
           Vomiting in Cardiac Surgery Patients: A Randomized Controlled Trial
    • Authors: Wang; Erica H. Z.; Sunderland, Sarah; Edwards, Nicola Y.; Chima, Navraj S.; Yarnold, Cynthia H.; Schwarz, Stephan K. W.; Coley, Matthew A.
      Abstract: imageBACKGROUND: Postoperative nausea and vomiting (PONV) is a common occurrence after cardiac surgery. However, in contrast to other surgical populations, routine PONV prophylaxis is not a standard of care in cardiac surgery. We hypothesized that routine administration of a single prophylactic dose of ondansetron (4 mg) at the time of stopping postoperative propofol sedation before extubation in the cardiac surgery intensive care unit would decrease the incidence of PONV.METHODS: With institutional human ethics board approval and written informed consent, we conducted a randomized controlled trial in patients ≥19 years of age with no history of PONV undergoing elective or urgent cardiac surgery procedures requiring cardiopulmonary bypass. The primary outcome was the incidence of PONV in the first 24 hours postextubation, compared by the χ2 test. Secondary outcomes included the incidence and times to first dose of rescue antiemetic treatment administration, the incidence of headaches, and the incidence of ventricular arrhythmias.RESULTS: PONV within the first 24 hours postextubation occurred in 33 of 77 patients (43%) in the ondansetron group versus 50 of 82 patients (61%) in the placebo group (relative risk, 0.70 [95% confidence interval {CI}, 0.51–0.95]; absolute risk difference, −18% [95% CI, −33 to −2]; number needed to treat, 5.5 [95% CI, 3.0–58.4]; χ2 test, P = .022). Kaplan-Meier “survival” analysis of the times to first rescue antiemetic treatment administration over 24 hours indicated that patients in the ondansetron group fared better than those in the placebo group (log-rank [Mantel-Cox] test; P = .028). Overall, 32 of 77 patients (42%) in the ondansetron group received rescue antiemetic treatment over the first 24 hours postextubation versus 47 of 82 patients (57%) in the placebo group (relative risk, 0.73 [95% CI, 0.52–1.00]; absolute risk difference, −16% [95% CI, −31 to 1]); P = .047. There were no significant differences between the groups in the incidence of postoperative headache (ondansetron group, 5 of 77 patients [6%] versus placebo group, 4 of 82 patients [5%]; Fisher exact test; P = .740) or ventricular arrhythmias (ondansetron group, 2 of 77 patients [3%] versus placebo group, 4 of 82 patients [5%]; P = .68).CONCLUSIONS: These findings support the routine administration of ondansetron prophylaxis at the time of discontinuation of postoperative propofol sedation before extubation in patients following cardiac surgery. Further research is warranted to optimize PONV prophylaxis in cardiac surgery patients.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Moderate-to-Deep Sedation Using Target-Controlled Infusions of Propofol
           and Remifentanil: Adverse Events and Risk Factors: A Retrospective Cohort
           Study of 2937 Procedures
    • Authors: Barends; Clemens R. M.; Driesens, Mendy K.; van Amsterdam, Kai; Struys, Michel M. R. F.; Absalom, Anthony R.
      Abstract: imageBACKGROUND: In the University Medical Center Groningen in Groningen, the Netherlands, moderate-to-deep sedation is provided by nursing staff trained and supervised by the anesthesia department using protocol-based target-controlled infusions (TCIs) of propofol and remifentanil. The aim of this retrospective cohort study was to investigate the incidence of events with potential adverse health consequences within this service model and the risk factors for the occurrence of these events.METHODS: We retrospectively interrogated a database containing the computerized anesthetic records of 2937 procedures where moderate-to-deep sedation was provided using TCI administration of propofol and remifentanil between May 2014 and October 2017. The primary outcome measures were the incidence of sedation-related events with potential adverse health consequences and risk factors for the occurrence of such events. The events under investigation were unplanned intensive care unit (ICU) admission, need for cardiopulmonary resuscitation (CPR), death on the day of the procedure due to sedation-related events, cardiovascular events (arrhythmias, hypertension, and hypotension), pulmonary events (aspiration, desaturation, unplanned tracheal intubation), anaphylactic or allergic reactions, and the termination of the procedure due to sedation-related events. Cardiovascular and pulmonary events were classified as severe, significant, or moderate. Events were identified by using computer algorithms to search the computerized records from all included procedures.RESULTS: Data from 2937 procedures were analyzed. No patients suffered catastrophic events (death, need for CPR, or unplanned ICU admission). Thirty-two severe sedation-related events occurred in 32 procedures. Severe desaturation (0.6%; 95% confidence interval [CI], 0.4–0.9) and severe hypertension (0.2%; 95% CI, 0.04–0.37) were the most common severe events. Significant hypotension (8.8%; 95% CI, 7.73–9.77) and significant desaturation (1.6%; 95% CI, 1.12–2.02) were found to be the most common events with potential adverse health consequences. No patient suffered lasting health consequences. Average mean and maximum targeted effect-site concentrations (Cet) for propofol were 2.6 ± 0.83 and 3.3 ± 1.09 µg·mL−1, respectively, and for remifentanil 0.84 ± 0.18 and 0.99 ± 0.22 ng·mL−1, respectively. Maximum Cets of propofol were lower among patients with higher body mass index (BMI) and were higher among patients of younger age. Higher BMI was a risk factor for desaturation. Increased age and lower BMI were risk factors for hypotension. Longer procedure time was a risk factor for both desaturation and hypotension.CONCLUSIONS: Moderate-to-deep sedation by propofol and remifentanil TCI has a low incidence of catastrophic and severe events.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Influence of an “Electroencephalogram-Based” Monitor Choice on the
           Delay Between the Predicted Propofol Effect-Site Concentration and the
           Measured Drug Effect
    • Authors: Sahinovic; Marko M.; van den Berg, Johannes P.; Colin, Pieter J.; Gambus, Pedro L.; Jensen, Erik W.; Agustí, Mercé; Ferreiro, Teresa; Struys, Michel M. R. F.
      Abstract: imageBACKGROUND: Clinicians can optimize propofol titration by using 2 sources of pharmacodynamic (PD) information: the predicted effect-site concentration for propofol (Ceprop) and the electroencephalographically (EEG) measured drug effect. Relation between these sources should be time independent, that is, perfectly synchronized. In reality, various issues corrupt time independency, leading to asynchrony or, in other words, hysteresis. This asynchrony can lead to conflicting information, making effective drug dosing challenging. In this study, we tried to quantify and minimize the hysteresis between the Ceprop (calculated using the Schnider model for propofol) and EEG measured drug effect, using nonlinear mixed-effects modeling (NONMEM). Further, we measured the influence of EEG-based monitor choice, namely Bispectral index (BIS) versus qCON index (qCON) monitor, on propofol PD hysteresis.METHODS: We analyzed the PD data from 165 patients undergoing propofol–remifentanil anesthesia for outpatient surgery. Drugs were administered using target-controlled infusion (TCI) pumps. Pumps were programmed with Schnider model for propofol and Minto model for remifentanil. We constructed 2 PD models (direct models) relating the Schnider Ceprop to the measured BIS and qCON monitor values. We quantified the models’ misspecification due to hysteresis, on an individual level, using the root mean squared errors (RMSEs). Subsequently, we optimized the PD models’ predictions by adding a lag term to both models (lag-time PD models) and quantified the optimization using the RMSE.RESULTS: There is a counterclockwise hysteresis between Ceprop and BIS/qCON values. Not accounting for this hysteresis results in a direct PD model with an effect-site concentration which produces 50% of the maximal drug effect (Ce50) of 6.24 and 8.62 µg/mL and RMSE (median and interquartile range [IQR]) of 9.38 (7.92–11.23) and 8.41(7.04–10.2) for BIS and qCON, respectively. Adding a modeled lag factor of 49 seconds to the BIS model and 53 seconds to the qCON model improved both models’ prediction, resulting in similar Ce50 (3.66 and 3.62 µg/mL for BIS and qCON) and lower RMSE (median (IQR) of 7.87 (6.49–9.90) and 6.56 (5.28–8.57) for BIS and qCON.CONCLUSIONS: There is a significant “Ceprop versus EEG measured drug effect” hysteresis. Not accounting for it leads to conflicting PD information and false high Ce50 for propofol in both monitors. Adding a lag term improved the PD model performance, improved the “pump-monitor” synchrony, and made the estimates of Ce50 for propofol more realistic and less monitor dependent.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Bleeding After Musculoskeletal Surgery in Hospitals That Switched From
           Hydroxyethyl Starch to Albumin Following a Food and Drug Administration
    • Authors: Krishnamoorthy; Vijay; Ellis, Alan R.; McLean, Duncan J.; Stefan, Mihaela S.; Nathanson, Brian H.; Cobert, Julien; Lindenauer, Peter K.; Brookhart, M. Alan; Ohnuma, Tetsu; Raghunathan, Karthik
      Abstract: imageBACKGROUND: While US Food and Drug Administration (FDA) black box warnings are common, their impact on perioperative outcomes is unclear. Hydroxyethyl starch (HES) is associated with increased bleeding and kidney injury in patients with sepsis, leading to an FDA black box warning in 2013. Among patients undergoing musculoskeletal surgery in a subset of hospitals where colloid use changed from HES to albumin following the FDA warning, we examined the rate of major perioperative bleeding post- versus pre-FDA warning.METHODS: The authors of this article used a retrospective, quasi-experimental, repeated cross-sectional, interrupted time series study of patients undergoing musculoskeletal surgery in hospitals within the Premier Healthcare Database, in the year before and year after the 2013 FDA black box warning. We examined patients in 23 “switcher” hospitals (where the percentage of colloid recipients receiving HES exceeded 50% before the FDA warning and decreased by at least 25% in absolute terms after the FDA warning) and patients in 279 “nonswitcher” hospitals. Among patients having surgery in “switcher” and “nonswitcher” hospitals, we determined monthly rates of major perioperative bleeding during the 12 months after the FDA warning, compared to 12 months before the FDA warning. Among patients who received surgery in “switcher” hospitals, we conducted a propensity-weighted segmented regression analysis assessing differences-in-differences (DID), using patients in “nonswitcher” hospitals as a control group.RESULTS: Among 3078 patients treated at “switcher” hospitals (1892 patients treated pre-FDA warning versus 1186 patients treated post-FDA warning), demographic and clinical characteristics were well-balanced. Two hundred fifty-one (13.3%) received albumin pre-FDA warning, and 900 (75.9%) received albumin post-FDA warning. Among patients undergoing surgery in “switcher” hospitals during the pre-FDA warning period, 282 of 1892 (14.9%) experienced major bleeding during the hospitalization, compared to 149 of 1186 (12.6%) following the warning. In segmented regression, the adjusted ratio of slopes for major perioperative bleeding post- versus pre-FDA warning was 0.98 (95% confidence interval [CI], 0.93–1.04). In the DID estimate using “nonswitcher” hospitals as a control group, the ratio of ratios was 0.93 (95% CI, 0.46–1.86), indicating no significant difference.CONCLUSIONS: We identified a subset of hospitals where colloid use for musculoskeletal surgery changed following a 2013 FDA black box warning regarding HES use in sepsis. Among patients undergoing musculoskeletal surgery at these “switcher” hospitals, there was no significant decrease in the rate of major perioperative bleeding following the warning, possibly due to incomplete practice change. Evaluation of the impact of systemic changes in health care may contribute to the understanding of patient outcomes in perioperative medicine.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Racial, Ethnic, and Gender Diversity in Pediatric Anesthesiology
           Fellowship and Anesthesiology Residency Programs in the United States:
           Small Reservoir, Leaky Pipeline
    • Authors: Nafiu; Olubukola O.; Leis, Aleda M.; Wang, Wendy; Wixson, Matthew; Zisblatt, Lara
      Abstract: imageBACKGROUND: The critical question of racial and gender diversity in pediatric anesthesia training programs has not been previously explored. The primary objective of this study was to evaluate trends by race/ethnicity and gender in pediatric anesthesiology fellowship training programs in the United States for the years 2000 to 2018.METHODS: Demographic data on pediatric anesthesiology fellows and anesthesiology residents were obtained from the self-reported data collected for the Journal of the American Medical Association’s annual report on Graduate Medical Education for the years 2000 to 2018. Diversity was assessed by calculating the proportions of trainees per year by gender and racial/ethnic groups in pediatric anesthesiology fellowship and anesthesiology residency programs. Logistic regression equations were developed to estimate the annual growth rate of each racial/ethnic groups.RESULTS: The number of pediatric anesthesiology fellows increased from 57 trainees in 2000–2001 to 202 in 2017–2018 at an average rate of 9 fellows per year (95% confidence interval [CI], 8–10). These increases were primarily due to white trainees (54.4%–63.4%) as the proportions of black (7.0%–4.5%), Asian (26.3%–21.3%), and other minority (12.3%–10.9%) trainees have remained low. The number of anesthesiology residents increased from 3950 trainees in 2000–2001 to 5940 in 2017–2018 at an average rate of 99 residents per year (95% CI, 88–111). Within all anesthesiology trainees, these increases were due to white trainees (55.7%–61.3%) as the proportion of black (5.0%–6.0%), Asian (25.8%–24.1%), and other minority trainees (8.2%–8.5%) has remained fairly constant over the time period. Despite the overall lower proportion of female anesthesiology residents (range: 27.0%–37.5%), a steady increase in the number of women in pediatric anesthesiology fellowship programs has reversed the gender imbalance in this population as of 2010.CONCLUSIONS: While historic gains have been made in gender diversity in pediatric anesthesiology, there is persistent underrepresentation of black and Hispanic trainees in pediatric anesthesiology. It appears that their low numbers in anesthesiology residency programs (the reservoir) may be partly responsible. Efforts to increase ethnic/racial diversity in pediatric anesthesiology fellowship and anesthesiology residency training programs are urgently needed.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • The Effects of a Shoulder Roll During Laryngoscopy in Infants: A
           Randomized, Single-Blinded, Crossover Study
    • Authors: Alfahel; Waseem; Gopinath, Anupama; Arheart, Kristopher L.; Gensler, Tara; Lerman, Jerrold
      Abstract: imageBACKGROUND: The use of a shoulder roll to view the glottic opening during direct laryngoscopy in infants has been recommended but is not evidence based.METHODS: Twenty infants with normal airways,
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Improving Transfusion Safety in the Operating Room With a Barcode Scanning
           System Designed Specifically for the Surgical Environment and Existing
           Electronic Medical Record Systems: An Interrupted Time Series Analysis
    • Authors: Vanneman; Matthew W.; Balakrishna, Aditi; Lang, Angela L.; Eliason, Kent D.; Payette, Alyssa M.; Xu, Xiaojun; Driscoll, William D.; Donovan, Kimberly M.; Deng, Hao; Dzik, Walter H.; Levine, Wilton C.
      Abstract: imageBACKGROUND: Manual processes for verifying patient identification before blood transfusion and documenting this pretransfusion safety check are prone to errors, and compliance with manual systems is especially poor in urgent operating room settings. An automated, electronic barcode scanner system would be expected to improve pretransfusion verification and documentation.METHODS: Audits were conducted of blood transfusion documentation under a manual paper system from January to October 2014. An electronic barcode scanning system was developed to streamline transfusion safety checking and automate documentation. This system was implemented in 58 operating rooms between October and December 2014, with follow-up compliance audits through December 2015. The association of barcode scanner implementation with transfusion documentation compliance was assessed using an interrupted time series analysis. Anesthesia providers were surveyed regarding their opinions on the electronic system. In mid-2016, the scanning system was modified to transfer from the Metavision medical record system to Epic OpTime. Follow-up analysis assessed performance of this system within Epic during 2017.RESULTS: In an interrupted time series analysis, the proportion of units with compliant documentation was estimated to be 19.6% (95% confidence interval [CI], 10.7–25.6) the week before scanner implementation, and 74.4% (95% CI, 59.4–87.4) the week after implementation. There was a significant postintervention level change (odds ratio 10.80, 95% CI, 6.31–18.70; P < .001) and increase in slope (odds ratio 1.14 per 1-week increase, 95% CI, 1.11–1.17; P < .001). After implementation, providers chose to use the new electronic system for 98% of transfusions. Across the 2 years analyzed (15,997 transfusions), the electronic system detected 45 potential transfusion errors in 27 unique patients, and averted transfusion of 36 mismatched blood products into 20 unique patients. A total of 69%, 86%, and 88% of providers reported the electronic system improved patient safety, blood transfusion workflow, and transfusion documentation, respectively. When providers used the barcode scanner, no transfusion errors or reactions were reported. The scanner system was successfully transferred from Metavision to Epic without retraining staff or changing workflows.CONCLUSIONS: A barcode-based system designed for easy integration to different commonly used anesthesia information management systems was implemented in a large urban academic hospital. The system allows a single user with the assistance of a software system to perform and document pretransfusion safety verification. The system improved transfusion documentation compliance, averted potential transfusion errors, and became the preferred method of blood transfusion safety checking.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • ADAPT-2: A Randomized Clinical Trial to Reduce Intraoperative EEG
           Suppression in Older Surgical Patients Undergoing Major Noncardiac Surgery
    • Authors: Tang; Christopher J.; Jin, Zhongnan; Sands, Laura P.; Pleasants, Devon; Tabatabai, Sanam; Hong, Yili; Leung, Jacqueline M.
      Abstract: imageBACKGROUND: Recent limited evidence suggests that the use of a processed electroencephalographic (EEG) monitor to guide anesthetic management may influence postoperative cognitive outcomes; however, the mechanism is unclear.METHODS: This exploratory, single-center, randomized clinical trial included patients who were ≥65 years of age undergoing elective noncardiac surgery. The study aimed to determine whether monitoring the brain using a processed EEG monitor reduced EEG suppression and subsequent postoperative delirium. The interventional group received processed EEG-guided anesthetic management to keep the Patient State Index (PSI) above 35 computed by the SEDline Brain Function Monitor (Masimo, Inc, Irvine, CA), while the standard care group was also monitored, but the EEG data were blinded from the clinicians. The primary outcome was intraoperative EEG suppression. A secondary outcome was incident postoperative delirium during the first 3 days after surgery.RESULTS: All outcomes were analyzed using the intention-to-treat paradigm. Two hundred and four patients with a mean age of 72 ± 5 years were studied. Minutes of EEG suppression adjusted by the length of surgery was found to be less for the interventional group than the standard care group (median [interquartile range], 1.4% [5.0%] and 2.5% [10.4%]; Hodges-Lehmann estimated median difference [95% confidence interval {CI}] of −0.8% [−2.1 to −0.000009]). The effect of the intervention on EEG suppression differed for those with and without preoperative cognitive impairment (interaction P = .01), with the estimated incidence rate ratio (95% CI) of 0.39 (0.33–0.44) for those with preoperative cognitive impairment and 0.48 (0.44–0.51) for those without preoperative cognitive impairment. The incidence of delirium was not found to be different between the interventional (17%) and the standard care groups (20%), risk ratio = 0.85 (95% CI, 0.47–1.5).CONCLUSIONS: The use of processed EEG to maintain the PSI>35 was associated with less time spent in intraoperative EEG suppression. Preoperative cognitive impairment was associated with a greater percent of surgical time spent in EEG suppression. A larger prospective cohort study to include more cognitively vulnerable patients is necessary to show whether an intervention to reduce EEG suppression is efficacious in reducing postoperative delirium.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Incidence of and Factors Associated With Prolonged and Persistent
           Postoperative Opioid Use in Children 0–18 Years of Age
    • Authors: Ward; Andrew; De Souza, Elizabeth; Miller, Daniel; Wang, Ellen; Sun, Eric C.; Bambos, Nicholas; Anderson, T. Anthony
      Abstract: imageBACKGROUND: Long-term opioid use has negative health care consequences. Opioid-naïve adults are at risk for prolonged and persistent opioid use after surgery. While these outcomes have been examined in some adolescent and teenage populations, little is known about the risk of prolonged and persistent postoperative opioid use after common surgeries compared to children who do not undergo surgery and factors associated with these issues among pediatric surgical patients of all ages.METHODS: Using a national administrative claims database, we identified 175,878 surgical visits by opioid-naïve children aged ≤18 years who underwent ≥1 of the 20 most common surgeries from each of 4 age groups between December 31, 2002, and December 30, 2017, and who filled a perioperative opioid prescription 30 days before to 14 days after surgery. Prolonged opioid use after surgery (filling ≥1 opioid prescription 90–180 days after surgery) was compared to a reference sample of 1,354,909 nonsurgical patients randomly assigned a false “surgery” date. Multivariable logistic regression models were used to estimate the association of surgical procedures and 22 other variables of interest with prolonged opioid use and persistent postoperative opioid use (filling ≥60 days’ supply of opioids 90–365 days after surgery) for each age group.RESULTS: Prolonged opioid use after surgery occurred in 0.77%, 0.76%, 1.00%, and 3.80% of surgical patients ages 0–
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Perioperative Prescribing Practices of Extended-Release Opioids in
           Noncancer Surgical Patients, 2015–2018
    • Authors: Rodriguez-Monguio; Rosa; Naveed, Mahim; Croci, Rhiannon; Gross, Kendall; Langnas, Erica; Chen, Catherine L.; Seoane-Vazquez, Enrique
      Abstract: imageBACKGROUND: Extended-release (ER) opioids are indicated for the management of persistent moderate to severe pain in patients requiring around-the-clock opioid analgesics for an extended period of time. Concerns have been raised regarding safety of ER opioids due to its potential for abuse and dependence. However, little is known about perioperative prescribing practices of ER opioids. This study assessed perioperative prescribing practices of ER opioids in noncancer surgical patients stratified by type of opioid exposure prior to admission and examined predictors of postoperative opioid administration in oral morphine equivalents (OME).METHODS: This was a retrospective cohort study using the University of California San Francisco Medical Center electronic health record data. This study included 25,396 adult noncancer patients undergoing elective surgery under general anesthesia in the period 2015–2018. The primary study outcome was predictors of postoperative administration of opioids in hospitalized surgical patients. Secondary outcomes included patients discontinued and initiated on ER opioids during their hospital stay.RESULTS: substance use disorder diagnosis and use of opioids, surgery type, and postoperative administration of nonopioid analgesics were associated with postoperative administration of opioids (P < .0001). The estimated adjusted mean (95% confidence interval [CI]) of postoperative administration of OME prior to admission in ER opioid users (170.08 mg; 147.08–196.67) was twice the amount for opioid-naïve patients (81.36 mg; 70.7–93.63; P < .0001). One in 5 prior to admission ER opioid users were weaned off ER opioids while hospitalized without adversely affecting their postoperative pain or hospital length of stay (LOS). Four of 5 patients who used ER opioids prior to admission also received ER opioids after surgery, whereas, 1 in 100 opioid-naïve patients received ER opioids during their hospital stay.CONCLUSIONS: We found significant variability in the perioperative prescribing practices of ER opioids in hospitalized noncancer surgical patients by use of opioids prior to admission and surgery type. Pain medicine practitioners and surgeons may play a significant role tackling the surgery-related risk of exposure to ER opioids and decreasing opioid-related complications.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Hydroxyethyl Starch 6% 130/0.4 in a Balanced Electrolyte Solution and
           Renal Function After Nephrectomy
    • Authors: Lee; Ho-Jin; Kwon, Yongsuk; Bae, Jinyoung; Yoo, Seokha; Yoon, Hee-Chul; Yoon, Soo-Hyuk; Kim, Jin-Tae; Bahk, Jae-Hyon; Kim, Won Ho
      Abstract: imageBACKGROUND: Although previous studies have reported nephrotoxicity associated with hydroxyethyl starch (HES), the long-term effect of HES on renal function after nephrectomy has rarely been reported. We evaluated the association between intraoperative HES administration and short- and long-term renal function after nephrectomy.METHODS: We retrospectively reviewed 1106 patients who underwent partial or radical nephrectomy. The patients were divided into 2 groups: patients who received (HES group) or did not receive 6% HES 130/0.4 intraoperatively (non-HES group). The primary outcome was new-onset chronic kidney disease (CKD) stage 3a (estimated glomerular filtration rate [eGFR]
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Propofol Affects Non–Small-Cell Lung Cancer Cell Biology By Regulating
           the miR-21/PTEN/AKT Pathway In Vitro and In Vivo
    • Authors: Zheng; Xiaoyu; Dong, Linlin; Zhao, Su; Li, Quanyi; Liu, Dandan; Zhu, Xidong; Ge, Xiaona; Li, Ruzhe; Wang, Guonian
      Abstract: imageBACKGROUND: Propofol is a common sedative-hypnotic drug traditionally used for inducing and maintaining general anesthesia. Recent studies have drawn attention to the nonanesthetic effects of propofol, but the potential mechanism by which propofol suppresses non–small-cell lung cancer (NSCLC) progression has not been fully elucidated.METHODS: For the in vitro experiments, we used propofol (0, 2, 5, and 10 µg/mL) to treat A549 cells for 1, 4, and 12 hours and Cell Counting Kit-8 (CCK-8) to detect proliferation. Apoptosis was measured with flow cytometry. We also transfected A549 cells with an microribonucleic acid-21 (miR-21) mimic or negative control ribonucleic acid (RNA) duplex and phosphatase and tensin homolog, deleted on chromosome 10 (PTEN) small interfering ribonucleic acid (siRNA) or negative control. PTEN, phosphorylated protein kinase B (pAKT), and protein kinase B (AKT) expression were detected using Western blotting, whereas miR-21 expression was examined by real-time polymerase chain reaction (RT-PCR). In vivo, nude mice were given injections of A549 cells to grow xenograft tumors; 8 days later, the mice were intraperitoneally injected with propofol (35 mg/kg) or soybean oil. Tumors were then collected from mice and analyzed by immunohistochemistry and Western blotting.RESULTS: Propofol inhibited growth (1 hour, P = .001; 4 hours, P ≤ .0001; 12 hours, P = .0004) and miR-21 expression (P ≤ .0001) and induced apoptosis (1 hour, P = .0022; 4 hours, P = .0005; 12 hours, P ≤ .0001) in A549 cells in a time and concentration-dependent manner. MiR-21 mimic and PTEN siRNA transfection antagonized the suppressive effects of propofol on A549 cells by decreasing PTEN protein expression (mean differences [MD] [95% confidence interval {CI}], –0.51 [–0.86 to 0.16], P = .0058; MD [95% CI], 0.81 [0.07–1.55], P = .0349, respectively), resulting in an increase in pAKT levels (MD [95% CI] = –0.82 [–1.46 to –0.18], P = .0133) following propofol exposure. In vivo, propofol treatment reduced NSCLC tumor growth (MD [95% CI] = –109.47 [–167.03 to –51.91], P ≤ .0001) and promoted apoptosis (MD [95% CI] = 38.53 [11.69–65.36], P = .0093).CONCLUSIONS: Our study indicated that propofol inhibited A549 cell growth, accelerated apoptosis via the miR-21/PTEN/AKT pathway in vitro, suppressed NSCLC tumor cell growth, and promoted apoptosis in vivo. Our findings provide new implications for propofol in cancer therapy and indicate that propofol is extremely advantageous in surgical treatment.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Antistasis Retrograde Flow Vascular Catheter: A Novel Solution to
           Thrombogenicity: A Computational Fluid Dynamics Study
    • Authors: Abdelaal Ahmed Mahmoud M. Alkhatip; Ahmed; Yassin, Hany M.; Farag, Ehab; Hamza, Mohamed K.; Bahr, Mahmoud H.; Ahmed, Ahmed Goda; El Emady, Mohamed Farid; Sallam, Amr M.; Elayashy, Mohamed; Abdelhaq, Mohamed; Kamal, Ahmed M.; Elramely, Mohamed A.
      Abstract: imageBACKGROUND: Catheter-related thrombosis (CRT) is a serious complication of vascular catheters. Retrograde catheter insertion has been shown to decrease pericatheter hemostasis and thrombosis, but it is technically challenging. The current in silico trial is an analytical approach to evaluating different approaches to designing retrograde flow into a vascular catheter.METHODS: The novel catheter design aims to provide antistasis retrograde flow (ASRF) of fluid through multiple backward-directed side openings, with a self-closing terminal opening to facilitate standard insertion. Four different models of the catheter were evaluated by computational fluid dynamic studies, with retrograde-angled openings of 15°, 30°, 45°, and 60° to the long axis of the catheter.RESULTS: ASRF successfully reduced the areas of fluid stagnation in models with 15° and 30° openings. Models with 45° and 60° did not significantly reduce stagnation. ASRF is reversed by the main bloodstream after a few millimeters. The novel catheter design achieved a slightly higher saline flow rate compared with the standard catheter (89.75, 91.72, 94.13, and 94.26 mL/min for 15°, 30°, 45°, and 60° designs, respectively, versus 86.93 mL/min for the standard catheter).CONCLUSIONS: The novel ASRF vascular catheter reduces pericatheter fluid stasis and has the potential to reduce CRT. Further in vitro and in vivo trials are warranted to validate these findings and evaluate clinical efficacy.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • A Methyltransferase Inhibitor (Decitabine) Alleviates Intergenerational
           Effects of Paternal Neonatal Exposure to Anesthesia With Sevoflurane
    • Authors: Xu; Ning; Lei, Lei; Lin, Yunan; Ju, Ling-Sha; Morey, Timothy E.; Gravenstein, Nikolaus; Yang, Jianjun; Martynyuk, Anatoly E.
      Abstract: imageBACKGROUND: Neonatal exposure to sevoflurane induces neurobehavioral and neuroendocrine abnormalities in exposed male rats (generation F0) and neurobehavioral, but not neuroendocrine, abnormalities in their male, but not female, offspring (generation F1). These effects of sevoflurane are accompanied by a hypermethylated neuron-specific K+-2Cl− (Kcc2) Cl− exporter gene in the F0 spermatozoa and the F1 male hypothalamus, while the gene’s expression is reduced in the F0 and F1 hypothalamus. We investigated whether inhibition of deoxyribonucleic acid methyltransferases (DNMTs) before paternal sevoflurane exposure could alleviate the anesthetic’s F0 and F1 effects.METHODS: Sprague-Dawley male rats were anesthetized with 2.1% sevoflurane for 5 hours on postnatal day (P) 5 and mated with control females on P90 to generate offspring. The nonselective DNMT inhibitor decitabine (0.5 mg/kg, intraperitoneally) was administered 30 minutes before sevoflurane exposure. The F0 and F1 male rats were evaluated in in vivo and in vitro tests in adulthood.RESULTS: Paternal exposure to sevoflurane induced impaired prepulse inhibition of the acoustic startle response and exacerbated corticosterone responses to stress in F0 males and impaired prepulse inhibition of the startle responses in F1 males. These effects were accompanied in both generations by reduced and increased expressions of hypothalamic Kcc2 and Dnmt3a/b, respectively. Decitabine deterred the effects of paternal exposure to sevoflurane in F0 and F1 males.CONCLUSIONS: These results suggest that similar decitabine-sensitive mechanisms regulating expression of multiple genes are involved in the mediation of neurobehavioral abnormalities in sires neonatally exposed to sevoflurane and in their future unexposed male offspring.
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Creation of the Anesthesia Research Council
    • Authors: Culley; Deborah J.; Kelz, Max B.; Koch, Colleen G.; Eisenach, James C.; Neuman, Mark D.; Whitlock, Elizabeth L.; Robertson, Rose Marie; Cooper, Thomas; Pomerantz, Paul
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Supporting Lactation Within an Academic Anesthesia Department: Obstacles
           and Opportunities
    • Authors: Titler; Sarah S.; Pearson, Amy C. S.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Physician Disrupt Thyself: Building Individual and Institutional
    • Authors: Fischer; Nathan A.; Persaud, Michael A.; Tsai, Mitchell H.; Paiste, Juhan
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Videolaryngoscopy: Is There a Path to Becoming a Standard of Care for
    • Authors: Hemmerling; Thomas M.; Zaouter, Cedrick
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Desflurane Should Des-appear: Global and Financial Rationale
    • Authors: Meyer; Matthew J.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Inhaled Sedation in the Intensive Care Unit: A New Option and Its
           Technical Prerequisites
    • Authors: Møller; Ann Merete
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Maths, Physics and Clinical Measurement for Anaesthesia and Intensive Care
    • Authors: Wood; Christine F.; Kennedy, R. Ross
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Handbook of Drugs in Intensive Care Book Review, An A-Z Guide, 6th ed
    • Authors: Mavrothalassitis; Orestes; Legrand, Matthieu
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Program Directors’ Response to a Pass/Fail US Medical Licensing
           Examination Step 1
    • Authors: Erath; Alexandra; Makhoul, Alan T.; Drolet, Brian C.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • The Adverse Impact of COVID-19 on Health Care Providers: Time to Start
    • Authors: Urdaneta; Felipe; Stacey, Mark; Sorbello, Massimiliano
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Cross-Holes on a Plastic Bag Can Prevent Droplet Spread During Extubation
    • Authors: Sakai; Wataru; Tachibana, Shunsuke; Yamakage, Michiaki
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Elective Tracheotomy in COVID-19 Patients: A Team-Based Approach
    • Authors: Ander; Michael; Yang, Sara; Thorpe, Eric; Goyal, Amit; Bier-Laning, Carol
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Clarifications on Technologies to Optimize Care of Severe COVID-19
    • Authors: Brull; Sorin J.; Kopman, Aaron F.
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • In Response
    • Authors: Rubulotta; Francesca; Soliman-Aboumarie, Hatem; Filbey, Kevin; Geldner, Goetz; Kuck, Kai; Ganau, Mario; Hemmerling, Thomas M.
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Mayo Mat: An Initiative to Improve the Safety and Efficiency of the
           Anesthesia Cart in Cases Requiring Strict Isolation Precautions
    • Authors: Lean; Alexa; Brown, Sarah
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Preloading Head Supports to Avoid Anesthesia Circuit Disconnections During
           the COVID-19 Pandemic
    • Authors: Green; James S.; Dillane, Derek
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • The Use of Analgesia and Sedation in Mechanically Ventilated Patients With
           COVID-19 Acute Respiratory Distress Syndrome
    • Authors: Kapp; Christopher M.; Zaeh, Sandra; Niedermeyer, Shannon; Punjabi, Naresh M.; Siddharthan, Trishul; Damarla, Mahendra
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • In Response
    • Authors: Hanidziar; Dusan; Bittner, Edward A.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • N95 Respirator Alternatives and Conservation Strategies
    • Authors: Wong; Becky J.; Lu, Amy C.; Tarlow, Branden D.; Tompkins, Lucy S.; Chawla, Amanda; Pearl, Ronald G.; Wald, Samuel H.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • Administering Cardiopulmonary Resuscitation to Personal Protective
           Equipment–Protected Health Care Worker During COVID-19
    • Authors: Mahajan; Varun; Ray, Ananya; Puri, Goverdhan Dutt
      Abstract: No abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
  • In Response
    • Authors: Lu; Amy C.; Wong, Becky J.; Sastry, Sunita G.; Wald, Samuel H.; Pearl, Ronald G.; Tsui, Ban C. H.
      Abstract: imageNo abstract available
      PubDate: Thu, 01 Oct 2020 00:00:00 GMT-
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