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Anesthesia & Analgesia
Journal Prestige (SJR): 1.472
Citation Impact (citeScore): 3
Number of Followers: 192  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0003-2999 - ISSN (Online) 1526-7598
Published by LWW Wolters Kluwer Homepage  [310 journals]
  • The Next Frontier of Clinical Monitoring: Current and Future Directions of
           Remote Surveillance Technology
    • Authors: Nathan; Naveen
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Shiver Me Timbers: Magnesium and Postoperative Shivering
    • Authors: Wanderer; Jonathan P.; Nathan, Naveen
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Correct Baseline Comparisons in a Randomized Trial
    • Authors: Schober; Patrick; Vetter, Thomas R.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Remote Monitoring in the Perioperative Setting: Calling for Research and
           Innovation Ecosystem Development
    • Authors: Jalilian; Laleh; Cannesson, Maxime; Kamdar, Nirav
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Intraoperative Transfusion Targets: Avoiding the Extremes
    • Authors: Hensley; Nadia B.; Frank, Steven M.; Prochaska, Micah T.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Walking the Tightrope of Bleeding Control: Fibrinolysis in Trauma
    • Authors: Grissom; Thomas E.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Retrograde Type B Aortic Dissection Caused by Intraaortic Balloon
           Counterpulsation
    • Authors: Miles; Lachlan F.; Roscoe, Andrew J.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • A Bullet in the Aortic Root: Utility of Transesophageal Echocardiography
           in Penetrating Thoracic Trauma
    • Authors: Goeddel; Lee A.; Fraser, Charles D. III; Daly, Rodrigo J.; Sciortino, Christopher M.; Sheinberg, Rosanne B.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Grade 3 Echocardiographic Diastolic Dysfunction Is Associated With
           Increased Risk of Major Adverse Cardiovascular Events After Surgery: A
           Retrospective Cohort Study
    • Authors: Zhou; Yan; Liu, Lin; Cheng, Tong; Wang, Dong-Xin; Yang, Hong-Yun; Zhang, Bao-Wei; Yang, Ying; Chen, Feng; Li, Xue-Ying
      Abstract: imageBACKGROUND: Diastolic dysfunction is common and may increase the risk of cardiovascular complications. This study investigated the hypothesis that, in patients with isolated left ventricular diastolic dysfunction, higher grade diastolic dysfunction was associated with greater risk of major adverse cardiovascular events (MACEs) after surgery.METHODS: This was a retrospective cohort study. Data of adult patients with isolated echocardiographic diastolic dysfunction (ejection fraction, ≥50%) who underwent noncardiac surgery from January 1, 2015 to December 31, 2015 were collected. The primary end point was the occurrence of postoperative MACEs during hospital stay, which included acute myocardial infarction, congestive heart failure, stroke, nonfatal cardiac arrest, and cardiac death. The association between the grade of diastolic dysfunction and the occurrence of MACEs was assessed with a multivariable logistic model.RESULTS: A total of 2976 patients were included in the final analysis. Of these, 297 (10.0%) developed MACEs after surgery. After correction for confounding factors, grade 3 diastolic dysfunction was associated with higher risk of postoperative MACEs (odds ratio, 1.71; 95% confidence interval, 1.28–2.27; P < .001) when compared with grades 1 and 2. Patients with grade 3 diastolic dysfunction developed more non-MACE complications when compared with grades 1 and 2 (uncorrected odds ratio, 1.44; 95% confidence interval, 1.07–1.95; P = .017).CONCLUSIONS: In patients with isolated diastolic dysfunction undergoing noncardiac surgery, 10.0% develop MACEs during hospital stay after surgery; grade 3 diastolic dysfunction is associated with greater risk of MACEs.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Coagulation Factor Levels and Underlying Thrombin Generation Patterns in
           Adult Extracorporeal Membrane Oxygenation Patients
    • Authors: Mazzeffi; Michael; Strauss, Erik; Meyer, Michael; Hasan, Shaheer; Judd, Miranda; Abuelkasem, Ezeldeen; Chow, Jonathan; Nandwani, Veena; McCarthy, Paul; Tanaka, Kenichi
      Abstract: imageBACKGROUND: There is a paucity of data on the underlying procoagulant–anticoagulant balance during extracorporeal membrane oxygenation (ECMO). We hypothesized that adult ECMO patients would have an imbalance between procoagulant and anticoagulant factors, leading to an abnormal underlying thrombin generation (TG) pattern.METHODS: Twenty adult venoarterial (VA) ECMO patients had procoagulant and anticoagulant factor levels measured temporally on ECMO day 1 or 2, day 3, and day 5. In heparin-neutralized plasma, underlying TG patterns, and sensitivity to activated protein C were assessed using calibrated automated thrombogram. TG parameters including lag time, peak TG, and endogenous thrombin potential (ETP) were compared against 5 normal plasma controls (3 males and 2 females) obtained from a commercial supplier. Thrombomodulin (TM) was added to some samples to evaluate for activated protein C resistance.RESULTS: Procoagulant factors (factor [F] II, FV, and FX) were mostly in normal reference ranges and gradually increased during the first 5 ECMO days (P = .022,
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Feasibility of a Perioperative Text Messaging Smoking Cessation Program
           for Surgical Patients
    • Authors: Nolan; Margaret B.; Warner, Matthew A.; Jacobs, Megan A.; Amato, Michael S.; Graham, Amanda L.; Warner, David O.
      Abstract: imageAlthough surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1–3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message–based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Transport of Critically Ill Patients by the Anesthesia Versus the
           Intensive Care Unit Service: A Before–After Study of Operating Room
           Workflows
    • Authors: Dupont; Frank W.; Tung, Avery; Shahul, Sajid S.; Pohlman, Anne; Joseph, Silas; Gottlieb, Ori; O’Connor, Michael F.; Cutter, Thomas W.
      Abstract: imageBACKGROUND: We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times.METHODS: In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR (“pre-ICU Pickup”). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service (“post-ICU Transfer”). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service (“post-ICU Pickup”). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation.RESULTS: We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3–125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (−6.9 minutes; 95% CI, −17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (H&P), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period.CONCLUSIONS: A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Invasive Respiratory or Vasopressor Support and/or Death as a Proposed
           Composite Outcome Measure for Perioperative Care Research
    • Authors: Mizota; Toshiyuki; Dong, Li; Takeda, Chikashi; Shiraki, Atsuko; Matsukawa, Shino; Shimizu, Satoshi; Kai, Shinichi
      Abstract: imageBACKGROUND: There is a need for a clinically relevant and feasible outcome measure to facilitate clinical studies in perioperative care medicine. This large-scale retrospective cohort study proposed a novel composite outcome measure comprising invasive respiratory or vasopressor support (IRVS) and death. We described the prevalence of IRVS in patients undergoing major abdominal surgery and assessed the validity of combining IRVS and death to form a composite outcome measure.METHODS: We retrospectively collected perioperative data for 2776 patients undergoing major abdominal surgery (liver, colorectal, gastric, pancreatic, or esophageal resection) at Kyoto University Hospital. We defined IRVS as requirement for mechanical ventilation for ≥24 hours postoperatively, postoperative reintubation, or postoperative vasopressor administration. We evaluated the prevalence of IRVS within 30 postoperative days and examined the association between IRVS and subsequent clinical outcomes. The primary outcome of interest was long-term survival. Multivariable Cox proportional regression analysis was performed to adjust for the baseline patient and operative characteristics. The secondary outcomes were length of hospital stay and hospital mortality.RESULTS: In total, 85 patients (3.1%) received IRVS within 30 postoperative days, 15 of whom died by day 30. Patients with IRVS had a lower long-term survival rate (1- and 3-year survival probabilities, 66.1% and 48.5% vs 95.2% and 84.0%, respectively; P < .001, log-rank test) compared to those without IRVS. IRVS was significantly associated with lower long-term survival after adjustment for the baseline patient and operative characteristics (adjusted hazard ratio, 2.72; 95% confidence interval, 1.97–3.77; P < .001). IRVS was associated with a longer hospital stay (median [interquartile range], 65 [39–326] vs 15 [12–24] days; adjusted P < .001) and a higher hospital mortality (24.7% vs 0.5%; adjusted P < .001). Moreover, IRVS was adversely associated with subsequent clinical outcomes including lower long-term survival (adjusted hazard ratio, 1.78; 95% confidence interval, 1.21–2.63; P = .004) when the analyses were restricted to 30-day survivors.CONCLUSIONS: Patients with IRVS can experience ongoing risk of serious morbidity and less long-term survival even if alive at postoperative day 30. Our findings support the validity of using IRVS and/or death as a composite outcome measure for clinical studies in perioperative care medicine.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Effectiveness of Magnesium in Preventing Shivering in Surgical Patients: A
           Systematic Review and Meta-analysis
    • Authors: Kawakami; Hiromasa; Nakajima, Daisuke; Mihara, Takahiro; Sato, Hitoshi; Goto, Takahisa
      Abstract: imageBACKGROUND: Clinical trials regarding the antishivering effect of perioperative magnesium have produced inconsistent results. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of perioperative magnesium on prevention of shivering.METHODS: We searched PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, and 2 registry sites for randomized clinical trials that compared the administration of magnesium to a placebo or no treatment in patients undergoing surgeries. The primary outcome of this meta-analysis was the incidence of shivering. The incidence of shivering was combined as a risk ratio with 95% CI using a random-effect model. The effect of the route of administration was evaluated in a subgroup analysis, and Trial Sequential Analysis with a risk of type 1 error of 5% and power of 90% was performed. The quality of each included trial was evaluated, and the quality of evidence was assessed using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events.RESULTS: Sixty-four trials and 4303 patients (2300 and 2003 patients in magnesium and control groups, respectively) were included. The overall incidence of shivering was 9.9% in the magnesium group and 23.0% in the control group (risk ratio, 0.42; 95% CI, 0.33–0.52). Subgroup analysis revealed that the incidence of shivering was lower with IV (risk ratio, 0.29; 95% CI, 0.29–0.54; Grading of Recommendation Assessment, Development, and Evaluation, moderate), epidural (risk ratio, 0.24; 95% CI, 0.13–0.43; Grading of Recommendation Assessment, Development, and Evaluation, low), and intrathecal administration (risk ratio, 0.64; 95% CI, 0.43–0.96; Grading of Recommendation Assessment, Development, and Evaluation, moderate). Only trials with low risk of bias were included for Trial Sequential Analysis. The Z-cumulative curve for IV magnesium crossed the Trial Sequential Analysis monitoring boundary for benefit even though only 34.9% of the target sample size had been reached. The Z-cumulative curve for epidural or intrathecal administration did not cross the Trial Sequential Analysis monitoring boundary for benefit. No increase in adverse events was reported.CONCLUSIONS: Perioperative IV administration of magnesium effectively reduced shivering and Trial Sequential Analysis suggested that no more trials are required to confirm that IV magnesium effectively reduces shivering.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Population Pharmacokinetics of Periarticular Ketorolac in Adult Patients
           Undergoing Total Hip or Total Knee Replacement Surgery
    • Authors: Gurunathan; Usha; Parker, Suzanne L.; Maguire, Richard; Ramdath, Dale; Bijoor, Manu; Wallis, Steven C.; Roberts, Jason A.
      Abstract: imageBACKGROUND: Ketorolac tromethamine has been used for joint infiltration by the orthopedic surgeons as a part of postoperative multimodal analgesia. The objective of this study is to investigate the pharmacokinetic properties of S (−) and R (+) enantiomers of ketorolac in adult patients undergoing total hip (THA) and knee arthroplasty (TKA).METHODS: Adult patients with normal preoperative renal function received a periarticular infiltration of 30 mg of ketorolac tromethamine along with 100 mL of 0.2% ropivacaine and 1 mg of epinephrine at the end of their THA or TKA surgery. Blood samples were taken from a venous cannula at various time points after infiltration. Pharmacokinetic modeling was performed using PMetrics 1.5.0.RESULTS: From 18 participants, 104 samples were analyzed. The peak plasma concentration for S (−) ketorolac was found to be lower than that of R (+) ketorolac, for both THA (0.19–1.22 mg/L vs 0.39–1.63 mg/L, respectively) and TKA (0.28–0.60 mg/L vs 0.48–0.88 mg/L, respectively). The clearance of the S (−) ketorolac enantiomer was higher than R (+) ketorolac (4.50 ± 2.27 vs 1.40 ± 0.694 L/h, respectively).CONCLUSIONS: Our study demonstrates that with periarticular infiltration, S (−) ketorolac was observed to have increased clearance rate and highly variable volume of distribution and lower peak plasma concentration compared to R (+) ketorolac.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Prolonged Duration Local Anesthesia by Combined Delivery of Capsaicin- and
           Tetrodotoxin-Loaded Liposomes
    • Authors: Shomorony; Andre; Santamaria, Claudia M.; Zhao, Chao; Rwei, Alina Y.; Mehta, Manisha; Zurakowski, David; Kohane, Daniel S.
      Abstract: imageBACKGROUND: Capsaicin, the active component of chili peppers, can produce sensory-selective peripheral nerve blockade. Coadministration of capsaicin and tetrodotoxin, a site-1 sodium channel blocker, can achieve a synergistic effect on duration of nerve blocks. However, capsaicin can be neurotoxic, and tetrodotoxin can cause systemic toxicity. We evaluated whether codelivery of capsaicin and tetrodotoxin liposomes can achieve prolonged local anesthesia without local or systemic toxicity.METHODS: Capsaicin- and tetrodotoxin-loaded liposomes were developed. Male Sprague-Dawley rats were injected at the sciatic nerve with free capsaicin, capsaicin liposomes, free tetrodotoxin, tetrodotoxin liposomes, and blank liposomes, singly or in combination. Sensory and motor nerve blocks were assessed by a modified hotplate test and a weight-bearing test, respectively. Local toxicity was assessed by histologic scoring of tissues at the injection sites and transmission electron microscopic examination of the sciatic nerves. Systemic toxicity was assessed by rates of contralateral nerve deficits and/or mortality.RESULTS: The combination of capsaicin liposomes and tetrodotoxin liposomes achieved a mean duration of sensory block of 18.2 hours (3.8 hours) [mean (SD)], far longer than that from capsaicin liposomes [0.4 hours (0.5 hours)] (P < .001) or tetrodotoxin liposomes [0.4 hours (0.7 hours)] (P < .001) given separately with or without the second drug in free solution. This combination caused minimal myotoxicity and muscle inflammation, and there were no changes in the percentage or diameter of unmyelinated axons. There was no systemic toxicity.CONCLUSIONS: The combination of encapsulated tetrodotoxin and capsaicin achieved marked prolongation of nerve block. This combination did not cause detectable local or systemic toxicity. Capsaicin may be useful for its synergistic effects on other formulations even when used in very small, safe quantities.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Device-Related Error in Patient-Controlled Analgesia: Analysis of 82,698
           Patients in a Tertiary Hospital
    • Authors: Son; Hyo-Jung; Kim, Sung-Hoon; Ryu, Jeong-Ok; Kang, Mi-Ra; Kim, Myeong-Hee; Suh, Jeong-Hun; Hwang, Jai-Hyun
      Abstract: imageBACKGROUND: Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA.METHODS: Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital. Devices for all types of PCA, including intravenous PCA, epidural PCA, and nerve block PCA, were included for analysis. The following 4 types of infusion pumps were used during the study period: elastomeric balloon infusers, carbon dioxide-driven infusers, semielectronic disposable pumps, and electronic programmable pumps. We categorized PCA device-related errors based on the error mechanism and clinical features.RESULTS: Among 82,698 surgical patients using PCA, 610 cases (0.74%) were reported as human error, and 155 cases (0.19%) of device-related errors were noted during the 4-year study period. The most common type of device-related error was underflow, which was observed in 47 cases (30.3%). The electronic programmable pump exhibited the high incidence of errors in PCA (70 of 15,052 patients; 0.47%; 95% confidence interval, 0.36–0.59) among the 4 types of devices, and 96 of 152 (63%) patients experienced some type of adverse outcome, ranging from minor symptoms to respiratory arrest.CONCLUSIONS: The incidence of PCA device-related errors was
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Profound Intraoperative Hypotension Associated With Transfusion via the
           Belmont Fluid Management System
    • Authors: Miller; Joanna; Kim, Sang; Adelmann, Dieter; Hill, Bryan; Schlichting, Nicolette; Smith, Natalie; DeMaria, Samuel Jr; Zerillo, Jeron
      Abstract: imageThis retrospective observational case series conducted at 2 large academic centers over a 4-year period consists of 15 cases of profound hypotension in surgical patients immediately after initiation of the Belmont Fluid Management System for rapid transfusion of blood products. Halting the infusion and administering vasoactive agents led to resolution of hypotension. Repeat transfusion with the Belmont system resulted in repeat hypotension unless counteracted with vasopressors. No etiology was elucidated. This represents the largest documented association of acute hypotensive transfusion reaction with any rapid infusion system in surgical patients.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Remote Surveillance Technologies: Realizing the Aim of Right Patient,
           Right Data, Right Time
    • Authors: Safavi; Kyan C.; Driscoll, William; Wiener-Kronish, Jeanine P.
      Abstract: imageThe convergence of multiple recent developments in health care information technology and monitoring devices has made possible the creation of remote patient surveillance systems that increase the timeliness and quality of patient care. More convenient, less invasive monitoring devices, including patches, wearables, and biosensors, now allow for continuous physiological data to be gleaned from patients in a variety of care settings across the perioperative experience. These data can be bound into a single data repository, creating so-called data lakes. The high volume and diversity of data in these repositories must be processed into standard formats that can be queried in real time. These data can then be used by sophisticated prediction algorithms currently under development, enabling the early recognition of patterns of clinical deterioration otherwise undetectable to humans. Improved predictions can reduce alarm fatigue. In addition, data are now automatically queriable on a real-time basis such that they can be fed back to clinicians in a time frame that allows for meaningful intervention. These advancements are key components of successful remote surveillance systems. Anesthesiologists have the opportunity to be at the forefront of remote surveillance in the care they provide in the operating room, postanesthesia care unit, and intensive care unit, while also expanding their scope to include high-risk preoperative and postoperative patients on the general care wards. These systems hold the promise of enabling anesthesiologists to detect and intervene upon changes in the clinical status of the patient before adverse events have occurred. Importantly, however, significant barriers still exist to the effective deployment of these technologies and their study in impacting patient outcomes. Studies demonstrating the impact of remote surveillance on patient outcomes are limited. Critical to the impact of the technology are strategies of implementation, including who should receive and respond to alerts and how they should respond. Moreover, the lack of cost-effectiveness data and the uncertainty of whether clinical activities surrounding these technologies will be financially reimbursed remain significant challenges to future scale and sustainability. This narrative review will discuss the evolving technical components of remote surveillance systems, the clinical use cases relevant to the anesthesiologist’s practice, the existing evidence for their impact on patients, the barriers that exist to their effective implementation and study, and important considerations regarding sustainability and cost-effectiveness.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • A Prospective Observational Cohort Study of Calls for Help in a Tertiary
           Care Academic Operating Room Suite
    • Authors: Ricks; Cameron J.; Ma, Michael W.; Gastelum, Jennifer R.; Rajan, Govind R.; Rinehart, Joseph B.
      Abstract: imageWhile significant literature exists on hospital-based “code calls,” there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1–1.8), corresponding to a rate of 5.0 (3.8–6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Postoperative Corneal Injuries: Incidence and Risk Factors
    • Authors: Deljou; Atousa; Weingarten, Toby N.; Mahr, Michael A.; Sprung, Juraj; Martin, David P.
      Abstract: imageBACKGROUND: Previous studies of postoperative corneal injury rates relied on provider-initiated incident reports, which may underestimate the true incidence. Postoperative administration of proparacaine eye drops is used almost exclusively to diagnose corneal injury; therefore, identifying instances of administration may provide a better estimate of corneal injuries. We compared proparacaine administration versus provider-initiated reports to determine rates of corneal injury. In addition, potential associations between clinical variables and injury were assessed with a matched case–control study.METHODS: The health records of 132,511 sequential adult postanesthesia recovery room admissions (January 1, 2011 to June 30, 2017) were reviewed to identify postoperative proparacaine administration and incident reports of corneal injury. Patients with corneal injury were matched with control patients at a 1:2 ratio to assess factors associated with injury.RESULTS: Proparacaine drops were administered to 442 patients (425 patients received proparacaine for diagnosis and 17 patients received proparacaine for unrelated reasons). Incident reports identified 320 injuries, and the aggregate corneal injury count was 436 (incidence, 3.3 injuries [95% confidence interval {CI}, 3.0–3.6] per 1000 cases of general anesthesia). Proparacaine administration had a greater case ascertainment percentage than incident reporting (97.5% vs 73.4%; P < .001). The matched case–control analysis found greater risks associated with longer duration of anesthesia (odds ratio, 1.05 [95% CI, 1.03–1.07] per 10 minutes of anesthesia; P < .001) and nonsupine surgical position (odds ratio, 3.89 [95% CI, 2.17–6.98]; P < .001). Patients with injuries also had more evidence of sedation and agitation during anesthesia recovery.CONCLUSIONS: Calculation of incidence by using the administration of a medication (proparacaine eye drops) that is almost exclusively used to diagnose a specific injury (corneal injury) showed higher case ascertainment percentage than incident-reporting methods. Similar strategies could be used to monitor the rates of other adverse events.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Reversing Cholinergic Bronchoconstriction by Common Inotropic Agents: A
           Randomized Experimental Trial on Isolated Perfused Rat Lungs
    • Authors: Fodor; Gergely H.; Bayat, Sam; Babik, Barna; Habre, Walid; Peták, Ferenc
      Abstract: imageBACKGROUND: The ability of inotropic agents to alter airway reactivity and lung tissue mechanics has not been compared in a well-controlled experimental model. Therefore, we compared the potential to alter lung tissue viscoelasticity and bronchodilator effects of commonly used inotropic agents in an isolated perfused rat lung model.METHODS: After achieving steady state lung perfusion, sustained bronchoconstriction was induced by acetylcholine (ACh). Isolated rat lungs were then randomly allocated to 6 groups treated with either saline vehicle (n = 8) or incremental concentrations of inotropes (adrenaline, n = 8; dopamine, n = 7; dobutamine, n = 7; milrinone, n = 8; or levosimendan, n = 6) added to the whole-blood perfusate. Airway resistance (Raw), lung tissue damping (G), and elastance were measured under baseline conditions, during steady-state ACh-induced constriction and for each inotrope dose.RESULTS: No change in Raw was observed after addition of the saline vehicle. Raw was significantly lower after addition of dopamine (maximum difference [95% CI] of 29 [12–46]% relative to the saline control, P = .004), levosimendan (58 [39–77]%, P < .001), and adrenaline (37 [21–53]%, P < .001), whereas no significant differences were observed at any dose of milrinone (5 [−12 to 22]%) and dobutamine (4 [−13 to 21]%). Lung tissue damping (G) was lower in animals receiving the highest doses of adrenaline (difference: 22 [7–37]%, P = .015), dobutamine (20 [5–35]%, P = .024), milrinone (20 [6–34]%, P = .026), and levosimendan (36 [19–53]%, P < .001) than in controls.CONCLUSIONS: Although dobutamine and milrinone did not reduce cholinergic bronchoconstriction, they reversed the ACh-induced elevations in lung tissue resistance. In contrast, adrenaline, dopamine, and levosimendan exhibited both potent bronchodilatory action against ACh and diminished lung tissue damping. Further work is needed to determine whether these effects are clinically relevant in humans.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • The Impact of Postoperative Intensive Care Unit Admission on Postoperative
           Hospital Length of Stay and Costs: A Prespecified Propensity-Matched
           Cohort Study
    • Authors: Thevathasan; Tharusan; Copeland, Curtis C.; Long, Dustin R.; Patrocínio, Maria D.; Friedrich, Sabine; Grabitz, Stephanie D.; Kasotakis, George; Benjamin, John; Ladha, Karim; Sarge, Todd; Eikermann, Matthias
      Abstract: imageBACKGROUND: In this prespecified cohort study, we investigated the influence of postoperative admission to the intensive care unit versus surgical ward on health care utilization among patients undergoing intermediate-risk surgery.METHODS: Of adult surgical patients who underwent general anesthesia without an absolute indication for postoperative intensive care unit admission, 3530 patients admitted postoperatively to an intensive care unit were matched to 3530 patients admitted postoperatively to a surgical ward using a propensity score based on 23 important preoperative and intraoperative predictor variables. Postoperative hospital length of stay and hospital costs were defined as primary and secondary end points, respectively.RESULTS: Among patients with low propensity for postoperative intensive care unit admission, initial triage to an intensive care unit was associated with increased postoperative length of stay (incidence rate ratio, 1.69 [95% CI, 1.59–1.79]; P < .001) and hospital costs (incidence rate ratio, 1.92 [95% CI, 1.81–2.03]; P < .001). By contrast, postoperative intensive care unit admission of patients with high propensity was associated with decreased postoperative length of stay (incidence rate ratio, 0.90 [95% CI, 0.85–0.95]; P < .001) and costs (incidence rate ratio, 0.92 [95% CI, 0.88–0.97]; P = .001). Decisions regarding postoperative intensive care unit resource utilization were influenced by individual preferences of anesthesiologists and surgeons.CONCLUSIONS: In patients with an unclear indication for postoperative critical care, intensive care unit admission may negatively impact postoperative hospital length of stay and costs. Postoperative discharge disposition varies substantially based on anesthesia and surgical provider preferences but should optimally be driven by an objective assessment of a patient’s status at the end of surgery.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Fibrinolysis Shutdown in Trauma: Historical Review and Clinical
           Implications
    • Authors: Moore; Hunter B.; Moore, Ernest E.; Neal, Matthew D.; Sheppard, Forest R.; Kornblith, Lucy Z.; Draxler, Dominik F.; Walsh, Mark; Medcalf, Robert L.; Cohen, Mitch J.; Cotton, Bryan A.; Thomas, Scott G.; Leeper, Christine M.; Gaines, Barbara A.; Sauaia, Angela
      Abstract: imageDespite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Predictors of Admission After the Implementation of an Enhanced Recovery
           After Surgery Pathway for Minimally Invasive Gynecologic Surgery
    • Authors: Keil; Dayley S.; Schiff, Lauren D.; Carey, Erin T.; Moulder, Janelle K.; Goetzinger, Amy M.; Patidar, Seema M.; Hance, Lyla M.; Kolarczyk, Lavinia M.; Isaak, Robert S.; Strassle, Paula D.; Schoenherr, Jay W.
      Abstract: imageBACKGROUND: Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway.METHODS: This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway.RESULTS: There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36–7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02–5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02–1.50; P = .04).CONCLUSIONS: We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Point-of-Care Fibrinogen Testing in Pregnancy
    • Authors: Katz; Daniel; Hamburger, Joshua; Batt, Dorian; Zahn, Jeffrey; Beilin, Yaakov
      Abstract: imageAgreement between estimated fibrinogen concentration via thromboelastography and traditional assays is not established in the parturient. We therefore recruited 56 parturients and performed Clauss and functional fibrinogen level (FLEV) tests. Mean difference of measurements was 36.8 mg/dL (95% CI, 21.8–51.9) with a standard deviation of 52.8 mg/dL. Calculated limits of agreement were 140.2 mg/dL (95% CI, 166.3–114.6) and −66.6 mg/dL (95% CI, −40.8 to −92.5), within the maximum allowable difference of 165 mg/dL. We therefore conclude that while most measurements fell within the limits of agreement, more work is needed to clearly define the role of this test in the obstetric population.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A
           Prospective Observational Cohort Study in a Mixed-Parity Cohort
    • Authors: Orbach-Zinger; Sharon; Landau, Ruth; Davis, Atara; Oved, Oren; Caspi, Liron; Fireman, Shlomo; Fein, Shai; Ioscovich, Alexander; Bracco, Danielle; Hoshen, Moshe; Eidelman, Leonid A.
      Abstract: imageBACKGROUND: The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding.METHODS: In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ2 test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks.RESULTS: The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40–0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72–5.80; P < .001).CONCLUSIONS: In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women’s previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Distraction-Free Induction Zone: A Quality Improvement Initiative at a
           Large Academic Children’s Hospital to Improve the Quality and Safety of
           Anesthetic Care for Our Patients
    • Authors: Crockett; Christy J.; Donahue, Brian S.; Vandivier, Deana C.
      Abstract: imageBACKGROUND: Noise in the operating room may cause distractions during critical periods and impair reliable communication between staff. Even momentary inefficiency while administering anesthesia can lead to errors and serious consequences for the patient. Distractions to an anesthesia provider during critical periods such as induction and emergence are a patient safety issue. Because of concerns regarding unacceptable noise levels and distractions during induction of general anesthesia, our institution developed a quality improvement initiative, the “Distraction-Free Induction Zone.” The specific aim of this project was to decrease the percentage of cases with a distraction, described as music, unnecessary conversations, or loud noises, occurring during induction of general anesthesia in pediatric otolaryngology operating rooms from 61% to 15%.METHODS: To complete this quality improvement initiative, a multidisciplinary team used improvement science methods, including The Model for Improvement with interventions tested via Plan-Do-Study-Act cycles. We used tools such as the Key Driver Diagram, Pareto Charts, Process Flow Chart, and Plan-Do-Study-Act worksheets. Data were manually collected and entered weekly in an Excel spreadsheet. Statistical process control methods, including a run chart and a P-control chart, were used for data analysis. Our measure was a composite measure in which observation of 1 of the 3 distractions during induction of general anesthesia categorized the case as a case with a distraction.RESULTS: We tested and implemented several interventions via Plan-Do-Study-Act cycles in which 3 main interventions collectively were associated with an observed decrease in distractions during induction of general anesthesia. These included educating the perioperative staff present in the operating room to help them understand that distractions to anesthesia providers represent a patient safety issue, the operating room circulating nurse taking responsibility to pause any music on arrival to the operating room, and the anesthesiologist reminding the staff in the operating room of induction time and/or asking for quiet during induction if a distraction occurs. The percentage of cases with a distraction during induction of general anesthesia in our pediatric otolaryngology operating rooms decreased from 61% to 15% by April 15, 2017 and to 10% by June 5, 2017.CONCLUSIONS: Using improvement science methods, we observed a decrease in distractions during induction of general anesthesia, improved a process, and encouraged change in culture at a large academic children’s hospital to enhance the quality and safety of the anesthetic care we provide our patients.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel
           Release Surgery
    • Authors: Harris; Alex H. S.; Meerwijk, Esther L.; Kamal, Robin N.; Sears, Erika D.; Hawn, Mary; Eisenberg, Dan; Finlay, Andrea K.; Hagedorn, Hildi; Mudumbai, Seshadri
      Abstract: imageBACKGROUND: The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes “Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.” Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).METHODS: Using fiscal year (FY) 2015–2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.RESULTS: From FY15–17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%–100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.CONCLUSIONS: Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Is Tube Thermosoftening Helpful for Videolaryngoscope-Guided Nasotracheal
           Intubation':: A Randomized Controlled Trial
    • Authors: Kim; Eun Mi; Chung, Mi Hwa; Lee, Mi Hyeon; Choi, Eun Mi; Jun, In-Jung; Yun, Tae Hyung; Ko, Yong Kuk; Kim, Jin Hwan; Jun, Joo Hyun
      Abstract: imageBACKGROUND: Thermosoftening of the endotracheal tube (ETT) and telescoping the ETT into a rubber catheter have been suggested as a method for reducing epistaxis during nasotracheal intubation (NTI). However, thermosoftening technique is known to make it difficult to navigate the ETT into trachea without the use of Magill forceps during NTI. The cuff inflation technique has been suggested as an effective alternative to the use of Magill forceps to improve the oropharyngeal navigation of the ETT, irrespective of their stiffness, during direct laryngoscope-guided NTI. We evaluated whether thermosoftening of the ETT telescoped into rubber catheters has an additional benefit in reducing nasal injury. Simultaneously, we also evaluated whether thermosoftening of the ETT worsened orotracheal navigability during cuff inflation-supplemented videolaryngoscope-guided NTI.METHODS: One hundred forty patients were randomly assigned to 1 of the 2 groups depending on whether the ETT was softened by warming or not. The primary outcome was the incidence of epistaxis during NTI. The secondary outcome was nasotracheal navigability of the ETT, assessed by navigation grade and time required for insertion of ETT in each phase (from nose to oropharynx, from oropharynx to glottic inlet aided by cuff inflation if needed, and from glottic inlet to trachea).RESULTS: The ETTs were successfully inserted through the selected nostril of all 140 patients. In the thermosoftening group, the incidence and severity of epistaxis was significantly lower (7% vs 51%; difference of 44.2%; 95% confidence interval, 29.9%–56.2%; P < .001), and the ETT passed through the nasal cavity with lower resistance (P = .001) and less time (P < .001) when compared to the control group. No difference was found in the ease of ETT insertion (navigation grade and time required) from the oropharynx to the glottic inlet (P> .99 and P = .054, respectively) and from the glottic inlet to the trachea (P> .99 and P = .750, respectively) between the 2 groups. In both groups, all ETTs could be navigated into the trachea without the use of Magill forceps.CONCLUSIONS: Supplemented with cuff inflation during videolaryngoscope-guided NTI, thermosoftening of the ETT telescoped into rubber catheters has a substantial benefit because it significantly reduces the incidence of epistaxis without worsening the oropharyngeal navigability of the ETT.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Initial Postoperative Hemoglobin Values and Clinical Outcomes in
           Transfused Patients Undergoing Noncardiac Surgery
    • Authors: Will; Nicholas D.; Kor, Daryl J.; Frank, Ryan D.; Passe, Melissa A.; Weister, Timothy J.; Zielinski, Martin D.; Warner, Matthew A.
      Abstract: imageBACKGROUND: Intraoperative red blood cell (RBC) transfusion is common, yet transfusion strategies remain controversial as pretransfusion hemoglobin triggers are difficult to utilize during acute bleeding. Alternatively, postoperative hemoglobin values may provide useful information regarding transfusion practices, though optimal targets remain undefined.METHODS: This is a single-center observational cohort study of adults receiving allogeneic RBCs during noncardiac surgery from 2010 through 2014. Multivariable regression analyses adjusting for patient illness, laboratory derangements, and surgical features were used to assess relationships between initial postoperative hemoglobin values and a primary outcome of hospital-free days.RESULTS: A total of 8060 patients were included. Those with initial postoperative hemoglobin
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Pilot Study: Neurocognitive Disorders and Colonoscopy in Older Adults
    • Authors: Arias; Franchesca; Riverso, Michael; Levy, Shellie-Anne; Armstrong, Rebecca; Estores, David S.; Tighe, Patrick; Price, Catherine C.
      Abstract: imageIn a preoperative anesthesia setting with integrated neuropsychology for individuals>64 years of age, we completed a pilot study examining the association between neurocognitive disorders with frequency of missed colonoscopies and quality of bowel preparation (prep). Gastroenterologists completed the Boston Bowel Preparation Scale (BBPS) for each patient. Of 47 older adults seen in our service, 68% met criteria for neurocognitive disorders. All individuals failing to attend the colonoscopy procedure had met criteria for major neurocognitive disorder. Poor bowel prep was also identified in 100% of individuals with major neurocognitive disorder and 28% of individuals with mild neurocognitive disorder. Our pilot data suggest that, in high-risk individuals, the presence of neurocognitive disorders is risk factors for missed appointments and inadequate bowel prep. These pilot data provide reference statistics for future intervention protocols.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Feasibility and Rationale for Incorporating Frailty and Cognitive
           Screening Protocols in a Preoperative Anesthesia Clinic
    • Authors: Amini; Shawna; Crowley, Samuel; Hizel, Loren; Arias, Franchesca; Libon, David J.; Tighe, Patrick; Giordano, Chris; Garvan, Cynthia W.; Enneking, F. Kayser; Price, Catherine C.
      Abstract: imageBACKGROUND: Advanced age, frailty, low education level, and impaired cognition are generally reported to be associated with postoperative cognitive complications. To translate research findings into hospital-wide preoperative assessment clinical practice, we examined the feasibility of implementing a preoperative frailty and cognitive assessment for all older adults electing surgical procedures in a tertiary medical center. We examined associations among age, education, frailty, and comorbidity with the clock and 3-word memory scores, estimated the prevalence of mild to major cognitive impairment in the presurgical sample, and examined factors related to hospital length of stay.METHODS: Medical staff screened adults ≥65 years of age for frailty, general cognition (via the clock-drawing test command and copy, 3-word memory test), and obtained years of education. Feasibility was studied in 2 phases: (1) a pilot phase involving 4 advanced nurse practitioners and (2) a 2-month implementation phase involving all preoperative staff. We tracked sources of missing data, investigated associations of study variables with measures of cognition, and used 2 approaches to estimate the likelihood of dementia in our sample (ie, using extant data and logistic regression modeling and using Mini-Cog cut scores). We explored which protocol variables related to hospital length of stay.RESULTS: The final implementation phase sample included 678 patients. Clock and 3-word memory scores were significantly associated with age, frailty, and education. Education, clock scores, and 3-word scores were not significantly different by surgery type. Likelihood of preoperative cognitive impairment was approximately 20%, with no difference by surgery type. Length of stay was significantly associated with preoperative comorbidity and performance on the clock copy condition.CONCLUSIONS: Frailty and cognitive screening protocols are feasible and provide information for perioperative care planning. Challenges to clinical adaptation include staff training, missing data, and additional administration time. These challenges appear minimal relative to the benefits of identifying frailty and cognitive impairment in a group at risk for negative postoperative cognitive outcome.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Anesthesia Provider Training and Practice Models: A Survey of Africa
    • Authors: Law; Tyler J.; Bulamba, Fred; Ochieng, John Paul; Edgcombe, Hilary; Thwaites, Victoria; Hewitt-Smith, Adam; Zoumenou, Eugene; Lilaonitkul, Maytinee; Gelb, Adrian W.; Workneh, Rediet S.; Banguti, Paulin M.; Bould, Dylan; Rod, Pascal; Rowles, Jackie; Lobo, Francisco; Lipnick, Michael S.; The Global Anesthesia Workforce Study Group
      Abstract: imageBACKGROUND: In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries.METHODS: Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation.RESULTS: One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36–72, 9–48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia).CONCLUSIONS: Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Do You Really Mean It' Assessing the Strength, Frequency, and
           Reliability of Applicant Commitment Statements During the Anesthesiology
           Residency Match
    • Authors: Moran; Kenneth R.; Schell, Randall M.; Smith, Kathleen A.; Abdel-Rasoul, Mahmoud; Lekowski, Robert W. Jr; Rankin, Demicha D.; DiLorenzo, Amy; McEvoy, Matthew D.
      Abstract: imageBACKGROUND: Despite the critical nature of the residency interview process, few metrics have been shown to adequately predict applicant success in matching to a given program. While evaluating and ranking potential candidates, bias can occur when applicants make commitment statements to a program. Survey data show that pressure to demonstrate commitment leads applicants to express commitment to multiple institutions including telling>1 program that they will rank them #1. The primary purpose of this cross-sectional observational study is to evaluate the frequency of commitment statements from applicants to 5 anesthesiology departments during a single interview season, report how often each statement is associated with a successful match, and identify how frequently candidates incorrectly represented commitments to rank a program #1.METHODS: During the 2014 interview season, 5 participating anesthesiology programs collected written and verbal communications from applicants. Three residency program directors independently reviewed the statements to classify them into 1 of 3 categories; guaranteed commitment, high rank commitment, or strong interest. Each institution provided a deidentified rank list with associated commitment statements, biographical data, whether candidates were ranked-to-match, and if they successfully matched.RESULTS: Program directors consistently differentiated among strong interest, high rank, and guaranteed commitment statements with κ coefficients of 0.9 (95% CI, 0.8–0.9) or greater between any pair of reviewers. Overall, 35.8% of applicants (226/632) provided a statement demonstrating at least strong interest and 5.4% (34/632) gave guaranteed commitment statements. Guaranteed commitment statements resulted in a 95.7% match rate to that program in comparison to statements of high rank (25.6%), strong interest (14.6%), and those who provided no statement (5.9%). For those providing guaranteed commitment statements, it can be assumed that the 1 candidate (4.3%) who did not match incorrectly represented himself. Variables such as couples match, “R” positions, and not being ranked-to-match on both advanced and categorical rank lists were eliminated because they can result in a nonmatch despite truthfully ranking a program #1.CONCLUSIONS: Each level of commitment statement resulted in a progressively increased frequency of a successful match to the recipient program. Only 5.4% of applicants committed to rank a program #1, but these statements were very reliable. These data can help program directors interpret commitment statements and assist accurate evaluation of the interest of candidates throughout the match process.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Bilateral Thoracic Paravertebral Blocks Compared to Thoracic Epidural
           Analgesia After Midline Laparotomy: A Pragmatic Noninferiority Clinical
           Trial
    • Authors: Sondekoppam; Rakesh V.; Uppal, Vishal; Brookes, Jonathan; Ganapathy, Sugantha
      Abstract: imageBACKGROUND: Bilateral paravertebral block (PVB) is a suitable alternative to thoracic epidural analgesia (TEA) for abdominal surgeries. This randomized clinical trial aims to determine if PVB is noninferior to TEA in terms of analgesia after midline laparotomy.METHODS: Seventy American Society of Anesthesiologists (ASA) class I–III patients undergoing a laparotomy through a midline incision were randomized to receive either TEA (TEA group) or continuous bilateral PVB (PVB group) as a part of a multimodal analgesia regimen in an open-label design. Noninferiority was to be concluded if the mean between-group difference in pain on movement at the 24 postoperative hours was within a margin of 2 points on a 0–10 numerical rating scale (NRS). Pain score at rest and on movement, analgesic consumption, hemodynamics, and adverse events during the first 72 postoperative hours were the secondary outcome measures assessed for superiority. Postblock and steady-state plasma concentrations of ropivacaine and pattern of dye spread were also recorded in the PVB group.RESULTS: The primary outcome of pain scores on movement at 24 postoperative hours was noninferior in PVB group in comparison to TEA group (mean difference [95% confidence interval {CI}], 0.43 [−0.72–1.58]). The pain scores at rest and on movement at other time points of assessment were within clinically acceptable limits in both groups with no significant differences between the groups over time. Arterial plasma ropivacaine levels were within safe limits, while steady-state venous level was higher than an acceptable threshold in 9 of 34 cases.CONCLUSIONS: As a component of multimodal analgesia, bilateral PVB provides noninferior analgesia compared to TEA for midline laparotomy.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Usefulness of the Korean Version of the CAGE-Adapted to Include Drugs
           Combined With Clinical Predictors to Screen for Opioid-Related Aberrant
           Behavior
    • Authors: Lee; Chang-Soon; Kim, Daehyun; Park, Sang-Yoen; Lee, Sang Chul; Kim, Young-Chul; Moon, Jee Youn
      Abstract: imageBACKGROUND: As national opioid consumption in South Korea has soared, well-validated screening tools for opioid use disorder (OUD) have become indispensable. The aims of our study were to evaluate OUD using the Korean version of the CAGE-Adapted to Include Drugs (CAGE-AID) and the CAGE-Opioid (an alternative version of the CAGE-AID), and to investigate clinical predictors that might be useful to screen for OUD in conjunction with the CAGE-AID/Opioid questionnaires.METHODS: A single-center, prospective, observational study was performed. After linguistic validation of the Korean version of the CAGE-AID/Opioid questionnaires, we assessed OUD in patients with chronic opioid treatment. Multivariable logistic models of the CAGE-AID/Opioid questionnaires combined with relevant clinical predictors were established. Then, the receiver operating characteristic curve analysis of the multivariable CAGE-AID/Opioid models was conducted to assess diagnostic accuracy to screen for OUD. Next, we calculated predicted probability with>85% sensitivity and>50% specificity in each CAGE-AID and CAGE-Opioid model. Using the optimal value of the predicted probability, a cutoff score of the CAGE-AID/Opioid questionnaires combined with the relevant clinical factors was suggested to screen for OUD.RESULTS: Among 201 participants, 51 patients showed ≥1 OUDs. In the multivariable regression model, male sex, comorbid neuropsychiatric disorder, and current heavy drinking significantly remained as clinical variables to predict OUD combined with the scores of the Korean CAGE-AID/Opioid questionnaire. The area under the curve was 0.77 (95% confidence interval, 0.71–0.83) for the CAGE-AID model and 0.78 (95% confidence interval, 0.71–0.83) for the CAGE-Opioid model. The optimal predicted probability values to screen for OUD in the CAGE-AID/Opioid models were>0.135 (sensitivity, 0.86; specificity, 0.52) and>0.142 (sensitivity, 0.86; specificity, 0.53), respectively. When we used these predictive probabilities, the cutoff score of the CAGE-AID/Opioid questionnaires ranged from 0 to 3, which was dependent on the presence of the relevant clinical variables in each model.CONCLUSIONS: In this study, one fourth of the total participants with chronic opioid treatment showed OUD in the Korean population. The multivariable models of the CAGE-AID/Opioid with sex, comorbid neuropsychiatric disorder, and current heavy drinking are valid parameters to screen for OUD, with the cutoff scores of the CAGE-AID/Opioid questionnaires ranging from 0 to 3 depending on the presence of the clinical variables.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Weeding Out the Problem: The Impact of Preoperative Cannabinoid Use on
           Pain in the Perioperative Period
    • Authors: Liu; Christopher W.; Bhatia, Anuj; Buzon-Tan, Arlene; Walker, Susan; Ilangomaran, Dharini; Kara, Jamal; Venkatraghavan, Lakshmikumar; Prabhu, Atul J.
      Abstract: imageBACKGROUND: The recreational and medical use of cannabinoids has been increasing. While most studies and reviews have focused on the role of cannabinoids in the management of acute pain, no study has examined the postoperative outcomes of surgical candidates who are on cannabinoids preoperatively. This retrospective cohort study examined the impact of preoperative cannabinoid use on postoperative pain scores and pain-related outcomes in patients undergoing major orthopedic surgery.METHODS: Outcomes of patients who had major orthopedic surgery at our hospital between April 1, 2015 and June 30, 2017 were reviewed. Data were obtained from Networked Online Processing of Acute Pain Information, a locally developed database for our Acute Pain Service. Propensity score matching was used to balance baselines variables including age, sex, type of surgery, history of depression or anxiety, and perioperative use of regional anesthesia between patients who reported use of cannabinoids and those not on this substance. Intensity of pain with movement in the early postoperative period (defined as up to 36 hours after surgery) was the primary outcome of this study. The secondary outcomes (all in early postoperative period) were pain at rest, opioid consumption, incidence of pruritus, nausea and vomiting, sedation, delirium, constipation, impairment of sleep and physical activity, patient satisfaction with analgesia, and the length of Acute Pain Service follow-up.RESULTS: A total of 3793 patients were included in the study. Of these, 155 patients were identified as being on cannabinoids for recreational or medical indications in the preoperative period. After propensity score matching, we compared data from 155 patients who were on cannabinoids and 155 patients who were not on cannabinoids. Patients who were on preoperative cannabinoids had higher pain numerical rating score (median [25th, 75th percentiles]) at rest (5.0 [3.0, 6.1] vs 3.0 [2.0, 5.5], P = .010) and with movement (8.0 [6.0, 9.0] vs 7.0 [3.5, 8.5], P = .003), and a higher incidence of moderate-to-severe pain at rest (62.3% vs 45.5%, respectively, P = .004; odds ratio, 1.98; 95% CI, 1.25–3.14) and with movement (85.7% vs 75.2% respectively, P = .021; odds ratio, 1.98; 95% CI, 1.10–3.57) in the early postoperative period compared to patients who were not on cannabinoids. There was also a higher incidence of sleep interruption in the early postoperative period for patients who used cannabinoids.CONCLUSIONS: This retrospective study with propensity-matched cohorts showed that cannabinoid use was associated with higher pain scores and a poorer quality of sleep in the early postoperative period in patients undergoing major orthopedic surgery.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Parasympathetic Tone Activity Evaluation to Discriminate Ketorolac and
           Ketorolac/Tramadol Analgesia Level in Swine
    • Authors: Leitão; Carlos J.; Lima-Rodríguez, Juan Rafael; Ferreira, Fatima; Avelino, Catarina; Sánchez-Margallo, Francisco M.; Antunes, Luís
      Abstract: imageBACKGROUND: Evaluation of nociceptive–antinociceptive balance during general anesthesia is still challenging and routinely based on clinical criteria. Analgesic drug delivered may be optimized with parasympathetic tone activity (PTA) monitor. This study compares ketorolac and ketorolac/tramadol balance analgesia using a PTA monitor.METHODS: Pain intensity response was assessed using a 0–100 numerical state scale (PTA) after nociceptive stimuli in pigs under stable sevoflurane anesthesia. Bispectral index, heart rate, noninvasive blood pressure, and respiratory parameters were also measured. Animals were divided into 3 groups: without analgesia, ketorolac, and ketorolac/tramadol. Mean values or mean areas under the curve (AUC) in selected time periods were compared over time and between groups through a mixed-model repeated measures analysis of variance and nonparametric Kruskal-Wallis tests, followed by Bonferroni or Dunn’s multiple comparisons.RESULTS: It was observed a significant decrease in the PTA AUC mean value after application of the stimulus in animals treated without analgesia and only with ketorolac. The PTA AUC mean value in the control group was significantly lower than the corresponding mean in ketorolac group. The ketorolac/tramadol group showed the highest PTA AUC mean values, significantly different from those obtained for the other 2 groups, with no significant differences detected over time. Bispectral index means showed no statistically significant differences either over time periods or between different treatment groups. Heart rate showed only a statistically significant increase in AUC mean between without analgesia and ketorolac/tramadol group, in the time period after the stimulus application. Noninvasive blood pressure means showed no statistically significant differences over time and between treatment groups.CONCLUSIONS: This study shows that a low dose combination of ketorolac and tramadol is sufficient to block the pain responses induced with a needle holder in pigs 20 minutes after its administration. The PTA monitor was able to clearly recognize the analgesic level between treatments and may be used to optimize analgesic drug delivered.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Persistent Nociception Facilitates the Extinction of Morphine-Induced
           Conditioned Place Preference
    • Authors: You; Zerong; Ding, Weihua; Doheny, Jason T.; Yang, Jinsheng; Yang, Liuyue; Lim, Grewo; Miao, Jiamin; Chen, Lucy; Shen, Shiqian; Mao, Jianren
      Abstract: imageBACKGROUND: As opioid abuse and addiction have developed into a major national health crisis, prescription of opioids for pain management has become more controversial. However, opioids do help some patients by providing pain relief and improving the quality of life. To better understand the addictive properties of opioids under chronic pain conditions, we used a conditioned place preference (CPP) paradigm to examine the rewarding properties of morphine in rats with persistent nociception.METHODS: Spared nerve injury (SNI) model was used to induce persistent nociception in rats. Nociceptive behavior was assessed by von Frey test. CPP test was used to examine the rewarding properties of morphine.RESULTS: Our findings are as follows: (1) SNI rats did not show a difference compared with sham rats in magnitude of morphine-induced CPP 1 day after last morphine injection (2-way analysis of variance; for SNI versus sham, F[1,42] = 0.014, P = .91; and 95% confidence intervals for difference of means, −5.9 [−58 to 46], 0.76 [−51 to 53], and 0.90 [−51 to 53] for 2.5, 5, and 10 mg/kg, respectively); (2) increasing morphine dosage (2.5, 5, and 10 mg/kg) did not further increase the magnitude of CPP in both sham and SNI rats (for dosage: F[2,42] = 0.94, P = .40); and (3) morphine-induced CPP persisted in sham rats but extinguished in SNI rats when tested at 8 days after last morphine injection (for sham versus SNI: Bonferroni correction, P < .006 for both 5 and 10 mg/kg doses; and 95% confidence intervals for difference of means, 80.3 [19.7–141] and 87.0 [26.3–148] for 5 and 10 mg/kg, respectively).CONCLUSIONS: Our data provide new evidence supporting the notion that the brain’s reward circuitry changes in the context of persistent pain. This observational study suggests that future investigation into the neurobiology of opioid reward requires consideration of the circumstances in which opioid analgesics are administered.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Vasopressor Infusion During Prone Spine Surgery and Acute Renal Injury: A
           Retrospective Cohort Analysis
    • Authors: Farag; Ehab; Makarova, Natalya; Argalious, Maged; Cywinski, Jacek B.; Benzel, Edward; Kalfas, Iain; Sessler, Daniel I.
      Abstract: imageBACKGROUND: Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function.METHODS: In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables.RESULTS: In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m2 (95% CI, −0.6 to 2.2 mL/min/1.73 m2) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage.CONCLUSIONS: Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Road to Perioperative Medicine: A Perspective From China
    • Authors: Wang; Tianlong; Deng, Xiaoming; Huang, Yuguang; Fleisher, Lee A.; Xiong, Lize
      Abstract: With the development of anesthesiology, patient safety has been remarkably improved, but the postoperative mortality rate at 30 days is still as high as 0.56%–4%, and the morbidity is even higher. Three years ago, the Chinese Society of Anesthesiology proposed that the direction of the anesthesiology development should be changed to perioperative medicine in China. Anesthesiologists should pay more attention to the long-term outcome. In this article, we introduced what we have done, what the challenges are, and what we should do in the future with regard to the practice of perioperative medicine in China.
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Neuroanesthesia: A Problem-Based Learning Approach, 1st ed
    • Authors: Altas; Anday; Garavaglia, Marco M.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Transfusion Management of the Obstetrical Patient: A Clinical Casebook
    • Authors: Zhang; Yao; Zhou, Danran; Zhou, Jie
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Co-existing Diseases and Neuroanesthesia
    • Authors: Charchaflieh; Jean Gabriel
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Functional MRI: Basic Principles and Emerging Clinical Applications for
           Anesthesiology and the Neurological Sciences
    • Authors: Torsher; Laurence C.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Perioperative Pain Management for Orthopedic and Spine Surgery
    • Authors: Pushparaj; Hemkumar; Bhatia, Anuj
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Families in the Intensive Care Unit: A Guide to Understanding, Engaging,
           and Supporting at the Bedside
    • Authors: White; Alexander; Parotto, Matteo
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Anesthesia: A Topical Update – Thoracic, Cardiac, Neuro, ICU, and
           Interesting Cases [Book Series: Recent Advances in Anesthesiology, Volume
           2]
    • Authors: Chow; Jarva
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Hensley’s Practical Approach to Cardiothoracic Anesthesia, 6th ed
    • Authors: Weiss; Nicole; Applegate, Richard L. II
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Ketamine-(Dex)Medetomidine, Hyperglycemia, Glycocalyx, and Vascular
           Permeability
    • Authors: Zuurbier; Coert J.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Guerci; Philippe; Ergin, Bulent; Ince, Can
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Another Nail in the Coffin of the Practice of Checking Mask Ventilation
           Before Administration of a Muscle Relaxant
    • Authors: Priebe; Hans-Joachim
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Min; Se-Hee; Seo, Jeong-Hwa
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Postoperative Respiratory Depression May Be Related to Undiagnosed
           Sleep-Disordered Breathing or Obstructive Sleep Apnea
    • Authors: Elleby; Liselotte M.; Sprung, Juraj; Weingarten, Toby N.
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Adductor Canal Block: A Synthesis of the Evidence'
    • Authors: Zeidan; Ahed
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Abdallah; Faraj W.; Brull, Richard; Joshi, Girish P.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Obstructive Sleep Apnea and Perioperative Outcomes: We Should Not Confuse
           the Probability With the Established Diagnosis
    • Authors: Deflandre; Eric P.; Brichant, Jean-Francois H.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Simon; Brett; Twersky, Rebecca S.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Heads Up: Our Definition of “Normal” Matters
    • Authors: Munis; James
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Drummond; John C.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Increasing the Scope on Difficult Airways: What About Mask
           Ventilation'
    • Authors: Nielsen; James R.; Lim, Kar-Soon
      Abstract: imageNo abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Bradley; James A.; Urman, Richard D.; Yao, Dongdong
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Preoperative Erythropoietin in Cardiac Surgery: Evolving Standard of Care
           or Aggregation of Marginal Gain'
    • Authors: Mazzeffi; Michael; Chow, Jonathan H.; Tanaka, Kenichi
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Grant; Michael C.; Lester, Laeben; Cho, Brian C.
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • Comments Regarding Recommendations by the Perioperative Neurotoxicity
           Working Group
    • Authors: Sinclair; Thomas
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
  • In Response
    • Authors: Berger; Miles; Angst, Martin S.; Culley, Deborah J.; Price, Catherine E.; Scott, David A.; Whittington, Robert A.; Eckenhoff, Roderic G.; for the Perioperative Neurotoxicity Working Group
      Abstract: No abstract available
      PubDate: Sun, 01 Sep 2019 00:00:00 GMT-
       
 
 
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