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Anesthesia & Analgesia
Journal Prestige (SJR): 1.472
Citation Impact (citeScore): 3
Number of Followers: 163  
 
  Full-text available via subscription Subscription journal
ISSN (Print) 0003-2999 - ISSN (Online) 1526-7598
Published by LWW Wolters Kluwer Homepage  [285 journals]
  • Beyond Emergence: Understanding postoperative Cognitive Dysfunction (POCD)
           
    • Authors: Nathan; Naveen
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Bubble Trouble: Venous Air Embolism in Endoscopic Retrograde
           Cholangiopancreatography
    • Authors: Wanderer; Jonathan P.; Nathan, Naveen
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Rashomon Effect and the Contradiction of Data, Practice, and Regulations
    • Authors: Shander; Aryeh; Gross, Irwin
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Agreement Between Transesophageal Echocardiography and
           Thermodilution-Based Cardiac Output
    • Authors: Millan; Patrick D.; Thiele, Robert H.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Costs and Costing of Regulatory Compliance
    • Authors: Glick; David B.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Vascular Air Embolism and Endoscopy: Every Bubble Matters
    • Authors: Prielipp; Richard C.; Brull, Sorin J.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Treating Chronic Pain: Is Buprenorphine the (or Even an) Answer'
    • Authors: Sun; Eric C.; Mao, Jianren; Anderson, T. Anthony
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Mythology of Plasma Transfusion
    • Authors: Waters; Jonathan H.; Yazer, Mark H.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Troubleshooting Technical Difficulties With Videolaryngoscope Use in
           Children: Initial Steps Toward Improving Tracheal Tube Passage
    • Authors: Jagannathan; Narasimhan; Sohn, Lisa; Hajduk, John
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Surveying the Literature: Synopsis of Recent Key Publications
    • Authors: Hessel; Eugene A. II
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Changes in International Normalized Ratios After Plasma Transfusion of
           Varying Doses in Unique Clinical Environments
    • Authors: Warner; Matthew A.; Hanson, Andrew C.; Weister, Timothy J.; Higgins, Andrew A.; Madde, Nageswar R.; Schroeder, Darrell R.; Kreuter, Justin D.; Kor, Daryl J.
      Abstract: imageBACKGROUND: Plasma transfusion is commonly performed for the correction of abnormal coagulation screening tests. The goal of this investigation was to assess the relationship between the dose of plasma administered and changes in coagulation test results in a large and diverse cohort of patients with varying levels of coagulation abnormalities and comorbid disease and in a variety of clinical settings.METHODS: In this single-center historical cohort study, all plasma transfusion episodes in adult patients with abnormal coagulation screening tests were extracted between 2011 and 2015. The primary outcome was the proportion of patients attaining normal posttransfusion international normalized ratio (INR ≤ 1.1) with secondary outcomes including the proportion of patients attaining partial normalization of INR (INR ≤ 1.5) or at least 50% normalization in pretransfusion values with respect to an INR of 1.1.RESULTS: In total, 6779 unique patients received plasma with a median (quartiles) pretransfusion INR of 1.9 (1.6–2.5) and a median transfusion volume of 2 (2–3) units. The majority (85%) of transfusions occurred perioperatively, with 20% of transfusions administered prophylactically before a procedure. The median decrease in INR was 0.4 (0.2–0.8). Complete INR normalization was obtained in 12%. Reductions in INR were modest with pretransfusion INR values
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Perioperative Care of the Transgender Patient
    • Authors: Tollinche; Luis Etienne; Walters, Chasity Burrows; Radix, Asa; Long, Michael; Galante, Larissa; Goldstein, Zil Garner; Kapinos, Yvonne; Yeoh, Cindy
      Abstract: imageAn estimated 25 million people identify as transgender worldwide, approximately 1 million of whom reside in the United States. The increasing visibility and acceptance of transgender people makes it likely that they will present in general surgical settings; therefore, perioperative health care providers must develop the knowledge and skills requisite for the safe management of transgender patients in the perioperative setting. Extant guidelines, such as those published by the World Professional Association for Transgender Health and the University of California San Francisco Center of Excellence for Transgender Health, serve as critical resources to those caring for transgender patients; however, they do not address their unique perioperative needs. It is essential that anesthesia providers develop the knowledge and skills necessary for safely managing transgender patients in the perioperative setting. This review provides an overview of relevant terminology, the imperative for the provision of culturally sensitive care, and guidelines for preoperative, intraoperative, and postoperative management of the transgender patient.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Does A Low 6-Minute Walk Distance Predict Elevated Postoperative
           Troponin'
    • Authors: Dhillon; Anahat K.; Disque, Andrew A.; Nguyen-Buckley, Christine T.; Grogan, Tristan R.; Russell, Dana L.; Gritsch, H. Albin; P. Neelankavil, Jacques
      Abstract: imageOur study of 100 major vascular and renal transplant patients evaluated the 6-minute walk test (6MWT) as an indicator of perioperative myocardial injury, using troponin as a marker. Using logistic regression and the area under the receiving operator characteristic curve, we compared the 6MWT to the Revised Cardiac Risk Index and metabolic equivalents. Only the 6MWT was associated with elevated postoperative troponins (95% CI, 0.98–0.99). However, the 6MWT area under the receiving operator characteristic curve (0.71 [95% CI, 0.57–0.85]) was not different from the Revised Cardiac Risk Index (P = .23) or metabolic equivalents (P = .14). The 6MWT may have a role in cardiac risk stratification in the perioperative setting.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Impact of Postreperfusion Syndrome on Acute Kidney Injury in Living
           Donor Liver Transplantation: A Propensity Score Analysis
    • Authors: Jun; In-Gu; Kwon, Hye-Mee; Jung, Kyeo-Woon; Moon, Young-Jin; Shin, Won-Jung; Song, Jun-Gol; Hwang, Gyu-Sam
      Abstract: imageBACKGROUND: Postreperfusion syndrome (PRS) has been shown to be related to postoperative morbidity and graft failure in orthotopic liver transplantation. To date, little is known about the impact of PRS on the prevalence of postoperative acute kidney injury (AKI) and the postoperative outcomes after living donor liver transplantation (LDLT). The purpose of our study was to determine the impact of PRS on AKI and postoperative outcomes after LDLT surgery.METHODS: Between January 2008 and October 2015, we retrospectively collected and evaluated the records of 1865 patients who underwent LDLT surgery. We divided the patients into 2 groups according to the development of PRS: PRS group (n = 715) versus no PRS group (n = 1150). Risk factors for AKI and mortality were investigated by multivariable logistic and Cox proportional hazards regression model analysis. Propensity score (PS) analysis (PS matching and inverse probability of treatment weighting analysis) was designed to compare the outcomes between the 2 groups.RESULTS: The prevalence of PRS and the mortality rate were 38% and 7%, respectively. In unadjusted analyses, the PRS group showed more frequent development of AKI (P < .001), longer hospital stay (P = .010), and higher incidence of intensive care unit stay over 7 days (P < .001) than the no PRS group. After PS matching and inverse probability of treatment weighting analysis, the PRS group showed a higher prevalence of postoperative AKI (P = .023 and P = .017, respectively) and renal dysfunction 3 months after LDLT (P = .036 and P = .006, respectively), and a higher incidence of intensive care unit stay over 7 days (P = .014 and P = .032, respectively).CONCLUSIONS: We demonstrated that the magnitude and duration of hypotension caused by PRS is a factor contributing to the development of AKI and residual renal dysfunction 3 months after LDLT.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Analgesic Effects of Oxycodone Relative to Those of Sufentanil, in the
           Presence of Midazolam, During Endoscopic Injection Sclerotherapy for
           Patients With Cirrhosis and Esophageal Varices
    • Authors: Quan; Zhefeng; Luo, Chao; Chi, Ping; Wang, Lujie; He, Haili
      Abstract: imageBACKGROUND: We evaluated the efficacy and gastroenterologist/patient satisfaction of midazolam combined with oxycodone, relative to that of midazolam combined with sufentanil, for anesthesia during endoscopic injection sclerotherapy (EIS) in patients with cirrhosis and esophageal varices.METHODS: Patients with cirrhosis (20–69 years of age), body mass index, 18–25 kg/m2, American Society of Anesthesiology patient classification physical status I–II who underwent elective EIS were randomly assigned to 1 of 2 groups. In this prospective, double-blinded, randomized controlled trial, 1 group received midazolam and oxycodone (n = 64), and the other group received midazolam and sufentanil (n = 63). Primary and secondary outcome measures were compared between groups. The primary outcome measure was the incidence of hypoxia. Secondary outcome measures included perioperative limb movement, need for rescue analgesics, need for additional sedative propofol, specified adverse reactions (postoperative myoclonus, nausea, vomiting, dizziness, and drowsiness), gastroenterologist satisfaction, and patient satisfaction with postoperative analgesia.RESULTS: Patients in the midazolam–oxycodone group had 32% fewer episodes of hypoxia than did those in the midazolam–sufentanil group (95% confidence interval [CI], –45% to –18%; P < .001), 36.73% fewer perioperative limb movements (95% CI, –51.73% to –21.73%; P < .001), 19.12% fewer required rescue analgesics (95% CI, –30.85% to –7.40%; P = .002), and less propofol requirement in the perioperative period (before EIS, –17.83%; 95% CI, –33.82% to –1.85%; P = .003; throughout EIS, –36.73%; 95% CI, –51.73% to –21.73%; P < .001). The incidence rates for adverse reactions were similar between groups. Both the gastroenterologist and patients reported higher degrees of satisfaction with oxycodone than with sufentanil.CONCLUSIONS: Oxycodone in combination with midazolam may provide an anesthetic technique that results in fewer episodes of hypoxia and other adverse conditions during EIS.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Propofol Attenuates the Myocardial Protection Properties of Desflurane by
           Modulating Mitochondrial Permeability Transition
    • Authors: Heiberg; Johan; Royse, Colin F.; Royse, Alistair G.; Andrews, David T.
      Abstract: imageBACKGROUND: Desflurane and propofol are cardioprotective, but relative efficacy is unclear. The aim was to compare myocardial protection of single, simultaneous, and serial administration of desflurane and propofol.METHODS: Sixty New Zealand White rabbits and 65 isolated Sprague Dawley rat hearts randomly received desflurane, propofol, simultaneous desflurane and propofol, or sequential desflurane then propofol. Rabbits were subdivided to receive either ischemia-reperfusion with temporary occlusion of the left anterior descending artery or a time-matched, nonischemic perfusion protocol, whereas rat hearts were perfused in a Langendorff model with global ischemia-reperfusion. End points were hemodynamic, functional recovery, and mitochondrial uptake of 3H-2-deoxy-D-glucose as an indicator of mitochondrial permeability transition.RESULTS: In rabbits, there were minimal increases in preload-recruitable stroke-work with propofol (P < .001), desflurane (P < .001), and desflurane-and-propofol (P < .001) groups, but no evidence of increases with pentobarbitone (P = .576) and desflurane-then-propofol (P = .374). In terms of end-diastolic pressure–volume relationship, there was no evidence of increase compared to nonischemic controls with desflurane-then-propofol (P = .364), a small but significant increase with desflurane (P < .001), and larger increases with pentobarbitone (P < .001), propofol (P < .001), and desflurane-and-propofol (P < .001).In rat hearts, there was no statistically significant difference in mitochondrial 3H-activity between propofol and desflurane-and-propofol (165 ± 51 × 10−5 vs 154 ± 51 × 10−5 g·mL·min/μmol; P = .998). Desflurane had lower uptake than propofol (65 ± 21 × 10−5 vs 165 ± 51 × 10−5 g·mL·min/μmol; P = .039), but there was no statistically significant difference between desflurane and desflurane-then-propofol (65 ± 21 × 10−5 vs 59 ± 11 × 10−5 g·mL·min/μmol; P = .999).CONCLUSIONS: Propofol and desflurane are cardioprotective, but desflurane is more effective than propofol. The added benefit of desflurane is lost when used simultaneously with propofol.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Comparing Methods for Cardiac Output: Intraoperatively Doppler-Derived
           Cardiac Output Measured With 3-Dimensional Echocardiography Is Not
           Interchangeable With Cardiac Output by Pulmonary Catheter Thermodilution
    • Authors: Graeser; Karin; Zemtsovski, Mikhail; Kofoed, Klaus F.; Winther-Jensen, Matilde; Nilsson, Jens C.; Kjaergaard, Jesper; Møller-Sørensen, Hasse
      Abstract: imageBACKGROUND: Estimation of cardiac output (CO) is essential in the treatment of circulatory unstable patients. CO measured by pulmonary artery catheter thermodilution is considered the gold standard but carries a small risk of severe complications. Stroke volume and CO can be measured by transesophageal echocardiography (TEE), which is widely used during cardiac surgery. We hypothesized that Doppler-derived CO by 3-dimensional (3D) TEE would agree well with CO measured with pulmonary artery catheter thermodilution as a reference method based on accurate measurements of the cross-sectional area of the left ventricular outflow tract.METHODS: The primary aim was a systematic comparison of CO with Doppler-derived 3D TEE and CO by thermodilution in a broad population of patients undergoing cardiac surgery. A subanalysis was performed comparing cross-sectional area by TEE with cardiac computed tomography (CT) angiography. Sixty-two patients, scheduled for elective heart surgery, were included; 1 was subsequently excluded for logistic reasons. Inclusion criteria were coronary artery bypass surgery (N = 42) and aortic valve replacement (N = 19). Exclusion criteria were chronic atrial fibrillation, left ventricular ejection fraction below 0.40 and intracardiac shunts. Nineteen randomly selected patients had a cardiac CT the day before surgery. All images were stored for blinded post hoc analyses, and Bland-Altman plots were used to assess agreement between measurement methods, defined as the bias (mean difference between methods), limits of agreement (equal to bias ± 2 standard deviations of the bias), and percentage error (limits of agreement divided by the mean of the 2 methods). Precision was determined for the individual methods (equal to 2 standard deviations of the bias between replicate measurements) to determine the acceptable limits of agreement.RESULTS: We found a good precision for Doppler-derived CO measured by 3D TEE, but although the bias for Doppler-derived CO by 3D compared to thermodilution was only 0.3 L/min (confidence interval, 0.04–0.58), there were wide limits of agreement (−1.8 to 2.5 L/min) with a percentage error of 55%. Measurements of cross-sectional area by 3D TEE had low bias of −0.27 cm2 (confidence interval, −0.45 to −0.08) and a percentage error of 18% compared to cardiac CT angiography.CONCLUSIONS: Despite low bias, the wide limits of agreement of Doppler-derived CO by 3D TEE compared to CO by thermodilution will limit clinical application and can therefore not be considered interchangeable with CO obtained by thermodilution. The lack of agreement is not explained by lack of agreement of the 3D technique.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Perioperative Noninvasive Blood Pressure Monitoring
    • Authors: Kuck; Kai; Baker, Philip D.
      Abstract: imageThe most commonly monitored variable for perioperative hemodynamic management is blood pressure. Several indirect noninvasive blood pressure monitoring techniques have been developed over the last century, including intermittent techniques such as auscultation (Riva-Rocci and Korotkoff) and oscillometry (Marey) and continuous techniques. With the introduction of automated noninvasive blood pressure devices in the 1970s, the oscillometric technique quickly became and remains the standard for automated, intermittent blood pressure measurement. It tends to estimate more extreme high and low blood pressures closer to normal than what invasive measurements indicate. The accuracy of the oscillometric maximum amplitude algorithm for estimating mean arterial pressure is affected by multiple factors, including the cuff size and shape, the shape of the arterial compliance curve and arterial pressure pulse, and pulse pressure itself. Additionally, the technique typically assumes a consistent arterial compliance and arterial pressure pulse, thus changes in arterial compliance and arrhythmias that lead to variation in the pressure pulse can affect accuracy. Volume clamping, based on the Penaz principle, and arterial tonometry provide continuous tracking of the arterial pressure pulse. The ubiquitous use of blood pressure monitoring is in contrast with the lack of evidence for optimal perioperative blood pressure targets.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Improvement of the Elevated Tryptase Criterion to Discriminate IgE- From
           Non–IgE-Mediated Allergic Reactions
    • Authors: Gastaminza; Gabriel; Lafuente, Alberto; Goikoetxea, Maria Jose; D’Amelio, Carmen M.; Bernad-Alonso, Amalia; Vega, Olga; Martinez-Molina, Juan Ambrosio; Ferrer, Marta; Nuñez-Cordoba, Jorge M.
      Abstract: imageBACKGROUND: Differentiating between immunoglobulin E (IgE)-dependent and IgE-independent hypersensitivity reactions may improve the etiologic orientation and clinical management of patients with allergic reactions in the anesthesia setting. Serum tryptase levels may be useful to discriminate the immune mechanism of allergic reactions, but the diagnostic accuracy and optimal cutpoint remain unclear.We aimed to compare the diagnostic accuracy of tryptase during reaction (TDR) alone and the TDR/basal tryptase (TDR/BT) ratio for discriminating IgE- from non–IgE-mediated allergic reactions, and to estimate the best cut point for these indicators.METHODS: We included 111 patients (45% men; aged 3–99 years) who had experienced an allergic reaction, even though the allergic reaction could be nonanaphylactic. Allergy tests were performed to classify the reaction as an IgE- or non–IgE-mediated one. The area under the curve (AUC) of the receiver operating characteristic analysis was performed to estimate the discriminative ability of TDR and TDR/BT ratio.RESULTS: An IgE-mediated reaction was diagnosed in 49.5% of patients, of whom 56% met anaphylaxis criteria. The median (quartiles) TDR for the IgE-mediated reactions was 8.0 (4.9–19.6) and 5.1 (3.5–8.1) for the non–IgE-mediated (P = .022). The median (quartiles) TDR/BT ratio was 2.7 (1.7–4.5) in IgE-mediated and 1.1 (1.0–1.6) in non–IgE-mediated reactions (P < .001). The TDR/BT ratio showed the greatest ability to discriminate IgE- from non–IgE-mediated reactions compared to TDR (AUC TDR/BT = 0.79 [95% confidence interval (CI), 1.1–2.2] and AUC TDR = 0.66 [95% CI, 1.1–2.2]; P = .003). The optimal cut point for TDR/BT (maximization of the sum of the sensitivity and specificity) was 1.66 (95% CI, 1.1–2.2).CONCLUSIONS: The TDR/BT ratio showed a significantly better discriminative ability than TDR to discriminate IgE- from non–IgE-mediated allergic reactions. An optimal TDR/BT ratio threshold of approximately 1.66 may be useful in clinical practice to classify allergic reactions as IgE- or non–IgE-mediated.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Incidence of Venous Air Embolism During Endoscopic Retrograde
           Cholangiopancreatography
    • Authors: Afreen; Lubana K.; Bryant, Ayesha S.; Nakayama, Tetsuzo; Ness, Timothy J.; Jones, Keith A.; Morgan, Charity J.; Wilcox, Charles M.; Phillips, Mark C.
      Abstract: imageBACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures.METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed.RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE’s occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed.CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • A Randomized Trial of Continuous Noninvasive Blood Pressure Monitoring
           During Noncardiac Surgery
    • Authors: Maheshwari; Kamal; Khanna, Sandeep; Bajracharya, Gausan Ratna; Makarova, Natalya; Riter, Quinton; Raza, Syed; Cywinski, Jacek B.; Argalious, Maged; Kurz, Andrea; Sessler, Daniel I.
      Abstract: imageBACKGROUND: Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension.METHODS: Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Life Cycle Assessment and Costing Methods for Device Procurement:
           Comparing Reusable and Single-Use Disposable Laryngoscopes
    • Authors: Sherman; Jodi D.; Raibley, Lewis A. IV; Eckelman, Matthew J.
      Abstract: imageBACKGROUND: Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health.METHODS: We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency’s Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions.RESULTS: The SUD plastic handle generates an estimated 16–18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5–6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4–5 uses, and reusable blades 5–7 uses, before loss.CONCLUSIONS: LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Incidence of Transfusion-Related Acute Lung Injury at a Large, Urban
           Tertiary Medical Center: A Decade’s Experience
    • Authors: Meyer; David E.; Reynolds, Jacob W.; Hobbs, Rhonda; Bai, Yu; Hartwell, Beth; Pommerening, Matthew J.; Fox, Erin E.; Wade, Charles E.; Holcomb, John B.; Cotton, Bryan A.
      Abstract: imageBACKGROUND: While transfusion-related acute lung injury (TRALI) remains the primary cause of transfusion-related fatalities (37%), recent reports estimate the incidence of TRALI at 0.008% per unit of plasma transfused and 0.004% per all products transfused. Because blood banks have moved toward male-predominant plasma, TRALI appears, anecdotally, to have been reduced to an extremely rare event. The purpose of this study was to estimate the current incidence of TRALI at a large, urban center known for its early and aggressive use of plasma in the setting of trauma, hemorrhagic shock, and massive transfusion.METHODS: The Blood Bank Registry of our hospital was queried for all transfused patients admitted from September 2002 through March 2013. The blood bank collected and investigated all cases of clinical acute lung injury meeting the consensus definition for TRALI, as well as potential cases for which the donor product was recalled for having a high reactivity level of human leukocyte antigen antibodies (ie, the antibodies that could cause TRALI). Clinical reactions were reviewed in conjunction with independent serological testing and classified by transfusion medicine physicians as being “probable TRALI” or of “unrelated etiology.” The total number of units transfused at our facility during this time period was also obtained, allowing the incidence of TRALI to be estimated. Cases were analyzed based on demographics, outcome, blood types, observed symptoms and their duration, and type of product transfused.RESULTS: Seven cases were identified at our center for the indicated time period, with only 3 of these occurring in trauma. A total of 714,757 units of blood products were transfused between September 2002 and March 2013. The incidence of TRALI was estimated to be 1 case per 100,000 units of product for the entire study period. A broad range of patients was affected. Consistent with previous descriptions, an acute duration of symptoms (average, 1.4 days) was observed and usually resolved with supportive care. Reactions were observed predominantly in plasma products, both type specific and nontype specific.CONCLUSIONS: This study demonstrates that while TRALI still occurs, clinically meaningful cases are rare. Moreover, TRALI rates remain low despite the increasingly aggressive use of plasma and platelets in the trauma setting.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Airway Management Practice in Adults With an Unstable Cervical Spine: The
           Harborview Medical Center Experience
    • Authors: Holmes; Michael G.; Dagal, Armagan; Feinstein, Bryan A.; Joffe, Aaron M.
      Abstract: imageBACKGROUND: Airway management in the presence of acute cervical spine injury (CSI) is challenging. Because it limits cervical spine motion during tracheal intubation and allows for neurological examination after the procedure, awake fiberoptic bronchoscopy (FOB) has traditionally been recommended. However, with the widespread availability of video laryngoscopy (VL), its use has declined dramatically. Our aim was to describe the frequency of airway management techniques used in patients with CSI at our level I trauma center and report the incidence of neurological injury attributable to airway management.METHODS: Adults presenting to the operating room with CSI without a tracheal tube in situ between September 2010 and June 2017 were included. All patients were intubated in the presence of manual-in-line stabilization, a hard cervical collar, or surgical traction. Worsening neurological status was defined as new motor or sensory deficits on postoperative examination.RESULTS: Two hundred fifty-two patients were included, of which 76 (30.2%) had preexisting neurological deficits. VL was the most frequent initial airway management technique used (49.6%). Asleep FOB was commonly performed alone (30.6%) or in conjunction with VL (13.5%). Awake FOB was rarely performed (2.3%), as was direct laryngoscopy (2.8%). All techniques were associated with high first-attempt success rates, and no cases of neurological injury attributable to airway management technique were identified.CONCLUSIONS: Among patients with acute CSI at a high-volume academic trauma center, VL was the most commonly used initial intubation technique. Awake FOB and direct laryngoscopy were performed infrequently. No cases of neurological deterioration secondary to airway management occurred with any method. Assuming care is taken to limit neck movement, providers should use the intubation technique with which they have the most comfort and skill.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Pulse Pressure and Carotid Artery Doppler Velocimetry as Indicators of
           Maternal Volume Status: A Prospective Cohort Study
    • Authors: Lappen; Justin R.; Myers, Stephen A.; Bolden, Norman; Shaman, Ziad; Angirekula, Venkata; Chien, Edward K.
      Abstract: imageBACKGROUND: Narrow pulse pressure has been demonstrated to indicate low central volume status. In critically ill patients, volume status can be qualitatively evaluated using Doppler velocimetry to assess hemodynamic changes in the carotid artery in response to autotransfusion with passive leg raise (PLR). Neither parameter has been prospectively evaluated in an obstetric population. The objective of this study was to determine if pulse pressure could predict the response to autotransfusion using carotid artery Doppler in healthy intrapartum women. We hypothesized that the carotid artery Doppler response to PLR would be greater in women with a narrow pulse pressure, indicating relative hypovolemia.METHODS: Intrapartum women with singleton gestations ≥35 weeks without acute or chronic medical conditions were recruited to this prospective cohort study. Participants were grouped by admission pulse pressure as
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Retrospective Review of Universal Preoperative Pregnancy Testing: Results
           and Perspectives
    • Authors: Gong; Xun; Poterack, Karl A.
      Abstract: imageUnrecognized pregnancy in patients presenting for elective surgery is of particular concern due to the potential for significant complications. Accurate and inexpensive urine pregnancy tests are widely available in the developed world. As a result, universal preoperative pregnancy screening is commonly implemented. However, the utility of such routine testing is controversial. We retrospectively studied 8245 immediate presurgery pregnancy tests at Mayo Clinic Hospital, Phoenix, AZ, and found 11 positive tests of which 6 were false positives. We constructed a census-based approximation for unrecognized pregnancies, which shows significantly low pretest probability in this patient population. Taken together, the utility of immediate universal presurgical pregnancy testing is questionable.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • A Prospective Observational Study of Technical Difficulty With
           GlideScope-Guided Tracheal Intubation in Children
    • Authors: Zhang; Bin; Gurnaney, Harshad G.; Stricker, Paul A.; Galvez, Jorge A.; Isserman, Rebecca S.; Fiadjoe, John E.
      Abstract: imageBACKGROUND: The GlideScope Cobalt is one of the most commonly used videolaryngoscopes in pediatric anesthesia. Although visualization of the airway may be superior to direct laryngoscopy, users need to learn a new indirect way to insert the tracheal tube. Learning this indirect approach requires focused practice and instruction. Identifying the specific points during tube placement, during which clinicians struggle, would help with targeted education. We conducted this prospective observational study to determine the incidence and location of technical difficulties using the GlideScope, the success rates of various corrective maneuvers used, and the impact of technical difficulty on success rate.METHODS: We conducted this observational study at our quaternary pediatric hospital between February 2014 and August 2014. We observed 200 GlideScope-guided intubations and documented key intubation–related outcomes. Inclusion criteria for patients were
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Pediatric Perioperative Cardiac Arrest, Death in the Off Hours: A Report
           From Wake Up Safe, The Pediatric Quality Improvement Initiative
    • Authors: Christensen; Robert E.; Lee, Angela C.; Gowen, Marie S.; Rettiganti, Mallikarjuna R.; Deshpande, Jayant K.; Morray, Jeffrey P.
      Abstract: imageBACKGROUND: Pediatric perioperative cardiac arrest (CA) is a rare but catastrophic event. This case–control study aims to analyze the causes, incidence, and outcomes of all pediatric CA reported to Wake Up Safe. Factors associated with CA and mortality after arrest are examined and possible strategies for improving outcomes are considered.METHODS: CA in children was identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Incidence, demographics, underlying conditions, causes of CA, and outcomes were extracted. Descriptive statistics and logistic regression were used to study the above factors associated with CA and mortality after CA.RESULTS: A total of 531 cases of CA occurred during 1,006,685 anesthetics. CA was associated with age (odds ratio [95% confidence interval] comparing ≥6 vs
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Impact of Clinical Guidelines on Revisits After Ambulatory Pediatric
           Adenotonsillectomy
    • Authors: Lee; Helen H.; Dalesio, Nicholas M.; Lo Sasso, Anthony T.; Van Cleve, William C.
      Abstract: imageBACKGROUND: Pediatric adenotonsillectomies are common and carry known risks of potentially severe complications. Complications that require a revisit, to either the emergency department or hospital readmission, increase costs and may be tied to lower reimbursements by federal programs. In 2011 and 2012, recommendations by pediatric and surgical organizations regarding selection of candidates for ambulatory procedures were issued. We hypothesized that guideline-associated changes in practice patterns would lower the odds of revisits. The primary objective of this study was to assess whether the odds of a complication-related revisit decreased after publication of guidelines after accounting for preintervention temporal trends and levels. The secondary objective was to determine whether temporal associations existed between guideline publication and characteristics of the ambulatory surgical population.METHODS: This study employs an interrupted time series design to evaluate the longitudinal effects of clinical guidelines on revisits. The outcome was defined as revisits after ambulatory tonsillectomy for privately insured patients. Data were sourced from the Truven Health Analytics MarketScan database, 2008–2015. Revisits were defined by the most prevalent complication types: hemorrhage, dehydration, pain, nausea, respiratory problem, infection, and fever. Time periods were defined by surgeries before, between, and after guidelines publication. Unadjusted odds ratios estimated associations between revisits and clinical covariates. Multivariable logistic regression was used to estimate the impact of guidelines on revisits. Differences in revisit trends among pre-, peri-, and postguideline periods were tested using the Wald test. Results were statistically significant at P < .005.RESULTS: A total of 326,993 surgeries met study criteria. The absolute revisit rate increased over time, from 5.9% (95% confidence interval [CI], 5.8–6.0) to 6.7% (95% CI, 6.6–6.9). The proportion of young children declined slightly, from 6.4% to 5.9% (P < .001). The proportion of patients having a tonsillectomy in an ambulatory surgery center increased (16.5%–31%; P < .001), as did the prevalence of obstructive sleep apnea (7.0%–14.0%; P < .001) and sleep-disordered breathing (20.6%–35.0%; P < .001). In a multivariable logistic regression model adjusted for age, sex, comorbidities, and surgical location, odds of a revisit increased during the preguideline period (0.4% increase per month; 95% CI, 0.24%–0.54%; P < .001). This monthly increase did not continue after guidelines (P = .002).CONCLUSIONS: While odds of a postoperative revisit did not decline after guideline publication, there was a significant difference in trend between the pre- and postguideline periods. Changes in the ambulatory surgery population also suggest at least partial adherence to guidelines.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • A Randomized Trial Comparing the Effect of Fiberoptic Selection and
           Guidance Versus Random Selection, Blind Insertion, and Direct
           Laryngoscopy, on the Incidence and Severity of Epistaxis After
           Nasotracheal Intubation
    • Authors: Tong; Jeffrey Leighton; Tung, Avery
      Abstract: imageBACKGROUND: Epistaxis, or nasal bleeding, is a common complication after nasotracheal intubation (NTI). Because such bleeding is likely related to trauma during intubation, use of fiberoptic visualization and guidance rather than direct laryngoscopy may affect the incidence and severity of epistaxis. We compared the incidence of epistaxis after NTI using a fiberoptic versus a direct laryngoscopy approach.METHODS: Seventy patients who were able to breathe easily through unobstructed nostrils and required NTI as part of their anesthetic management were recruited. Exclusion criteria included unequal nasal airflow, nostril obstruction, previous nasal trauma or surgery, and coagulation abnormalities as determined by history. Patients were randomly assigned to undergo NTI with thermosoftened Mallinckrodt nasal Ring-Adair-Elwyn (RAE) tubes via either traditional direct laryngoscopy using a Macintosh blade or fiberoptic nasal intubation. All patients first underwent anesthetic induction and were randomized to blind or fiberoptic groups. Patients in the blind insertion/direct laryngoscopy group were then intubated via a randomly selected nostril. Patients in the fiberoptic group underwent an asleep nasal fiberoptic examination to determine the most patent nostril, followed by tube insertion under fiberoptic guidance. Ten minutes after NTI, the incidence and severity of epistaxis were evaluated and graded by the surgeon, who was blinded to the intubation method.RESULTS: Initial nasal fiberoptic endoscopy identified asymptomatic nasal pathology in 51% of patients: inferior turbinate hypertrophy (28.6%) and deviation of the nasal septum in (22.8%). The incidence of epistaxis was higher in the blind insertion/direct laryngoscopy group (88%) than in the fiberoptic group (51%; relative risk, 0.55; 95% confidence interval, 0.38–0.79; P = .0011). The severity of bleeding was also greater in the blind tube insertion/direct laryngoscopy cohort (Wilcoxon Mann-Whitney odds, 3.5; 95% confidence interval, 1.8–11.1).CONCLUSIONS: Fiberoptic nostril selection and guidance during NTI reduced the incidence and severity of epistaxis when compared with NTI performed via blind insertion and direct laryngoscopy.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Outcomes in Patients Undergoing Cardiac Surgery Who Decline Transfusion
           and Received Erythropoietin Compared to Patients Who Did Not: A Matched
           Cohort Study
    • Authors: Duce; Lorent; Cooter, Mary L.; McCartney, Sharon L.; Lombard, Frederick W.; Guinn, Nicole R.
      Abstract: imageBACKGROUND: Erythropoiesis-stimulating agents, such as erythropoietin (EPO), can be used to treat preoperative anemia. Some studies suggest an increased risk of mortality and thrombotic events, and use in cardiovascular surgery remains off-label. This study compares outcomes in cardiac surgery patients declining blood transfusion who received EPO with a matched cohort who did not.METHODS: After institutional review board approval, we conducted a retrospective review of all patients who decline blood transfusion who underwent cardiac surgery and received EPO between January 1, 2004, and June 15, 2015, at a single institution. Control patients who did not receive EPO and were not transfused allogeneic red blood cells perioperatively were identified during the same period. Two controls were matched to each EPO patient using an optimal matching algorithm based on age, date of surgery, gender, operative procedure, and surgeon. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and baseline characteristics remaining unbalanced in the matched cohorts were controlled for in assessing patient outcomes. The primary outcome was a composite of mortality and thrombotic events, and secondary outcomes included change in hemoglobin (Hb) from baseline to discharge, acute kidney injury (AKI), sternal wound infection, atrial fibrillation, time to extubation, intensive care unit, and hospital length of stay (LOS).RESULTS: Fifty-three patients who decline transfusion and received EPO were compared to 106 optimally matched control patients who did not receive EPO or red blood cell transfusion in the perioperative period. The median additive EuroSCORE was similar between the EPO and control group [6 (4, 9) vs 5 (3, 7), respectively; P = .39]. There was no difference in the primary outcome (P = .12) and mortality was zero in both groups. The EPO group had a higher mean preoperative Hb (13.91 g/dL vs 13.31; P = .02) and a smaller change in Hb from baseline (−2.65 vs −3.60; P = .001). The incidence of AKI (47.17% vs 41.51%; P = .49) was similar and there was no significant difference in all other outcomes, including time to extubation, hospital LOS, or intensive care unit LOS.CONCLUSIONS: In this retrospective matched cohort study of patients declining transfusion and receiving EPO matched to control patients, there were no clinically meaningful differences in the outcomes.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Postoperative Cognitive Dysfunction and Noncardiac Surgery
    • Authors: Evered; Lisbeth A.; Silbert, Brendan S.
      Abstract: imagePostoperative cognitive dysfunction (POCD) is an objectively measured decline in cognition postoperatively compared with preoperative function. POCD has been considered in the anesthetic and surgical literature in isolation of cognitive decline which is common in the elderly within the community and where it is labeled as mild cognitive impairment, neurocognitive disorder, or dementia. This narrative review seeks to place POCD in the broad context of cognitive decline in the general population. Cognitive change after anesthesia and surgery was described over 100 years ago, initially as delirium and dementia. The term POCD was applied in the 1980s to refer to cognitive decline assessed purely on the basis of a change in neuropsychological test results, but the construct has been the subject of great heterogeneity. The cause of POCD remains unknown. Increasing age, baseline cognitive impairment, and fewer years of education are consistently associated with POCD.In geriatric medicine, cognitive disorders defined and classified as mild cognitive impairment, neurocognitive disorder, and dementia have definitive clinical features. To identify the clinical impact of cognitive impairment associated with the perioperative period, POCD has recently been redefined in terms of these geriatric medicine constructs so that the short-, medium-, and long-term clinical and functional impact can be elucidated. As the aging population present in ever increasing numbers for surgery, many individuals with overt or subclinical dementia require anesthesia. Anesthesiologists must be equipped to understand and manage these patients.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • A Prospective Observational Study of Anesthesia-Related Adverse Events and
           Postoperative Complications Occurring During a Surgical Mission in
           Madagascar
    • Authors: White; Michelle C.; Barki, Brian J.; Lerma, Stephen A.; Couch, Sarah Kate; Alcorn, Dennis; Gillerman, Richard G.
      Abstract: imageBACKGROUND: Two-thirds of the world’s population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesia-related and postoperative complications during a 2-year surgical mission in Madagascar.METHODS: As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification.RESULTS: Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4–2.6). The majority (85% CI, 74–96) of adverse events occurred intraoperatively with 15% (CI, 3–26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3–12.0) per surgery and 9.4% (CI, 8.1–10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0–41.3 and 33.2%; CI, 31.1–35.3 of all complications, respectively). The most common (42.9%; CI, 40.7–45.1) grade of complication was grade II. There was 1 death.CONCLUSIONS: This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Decision Support Tool Improves Real and Perceived Anesthesiology Resident
           Relief Equity
    • Authors: Bhutiani; Monica; Jablonski, Patrick M.; Ehrenfeld, Jesse M.; McEvoy, Matthew D.; Fowler, Leslie C.; Wanderer, Jonathan P.
      Abstract: imageBACKGROUND: The Accreditation Council of Graduate Medical Education requires monitoring of resident clinical and educational hours but does not require tracking daily work patterns or duty hour equity. Lack of such monitoring may allow for inequity that affects resident morale. No defined system for resident relief of weekday operating room (OR) clinical duties existed at our institution, leaving on-call residents to independently decide daily relief order. We developed an automated decision support tool (DST) to improve equitable decision making for clinical relief and assessed its impact on real and perceived relief equity.METHODS: The DST sent a daily e-mail to the senior resident responsible for relief decisions. It contained a prioritized relief list of noncall residents who worked in the OR beyond 5 PM the prior clinical day. We assessed actual relief equity using the number of times a resident worked in the OR past 5:30 PM on 2 consecutive weekdays as our outcome, adjusting for the mean number of open ORs each day between 5:00 PM and 6:59 PM in our main OR areas. We analyzed 14 months of data before implementation and 16 months of data after implementation. We assessed perceived relief equity before and after implementation using a questionnaire.RESULTS: After implementing the DST, the percentage of residents held 2 consecutive weekdays over the total of resident days worked decreased from 1.33% to 0.43%. The percentage of residents held beyond 5:30 PM on any given day decreased from 18.09% to 12.64%. Segmented regression analysis indicated that implementation of the DST was associated with a reduction in biweekly time series of residents kept late 2 days in a row, independent of the mean number of ORs in use. Surveyed residents reported the DST aided their ability to make equitable relief decisions (pre 60% versus post 94%; P = .0003). Eighty-five percent of residents strongly agreed that a prioritized relief list based on prior day work hours after 5 PM aided their decision making. After implementation, residents reported fewer instances of working past 5 PM within the past month (P < .005).CONCLUSIONS: A DST systematizing the relief process for anesthesiology residents was associated with a lower frequency of residents working beyond 5:30 PM in the OR on 2 consecutive days. The DST improved the perceived ability to make equitable relief decisions by on-call senior residents and residents being relieved. Success with this tool allows for broader applications in resident education, enabling enhanced monitoring of resident experiences and support for OR assignment decisions.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Dexamethasone as an Adjuvant for Caudal Blockade in Pediatric Surgical
           Patients: A Systematic Review and Meta-analysis
    • Authors: Chong; Matthew A.; Szoke, Daniel J.; Berbenetz, Nicolas M.; Lin, Cheng
      Abstract: imageBACKGROUND: Caudal block is commonly used to provide postoperative analgesia after pediatric surgery in the lower abdomen. Typically administered as a single-shot technique, 1 limitation of this block is the short duration of analgesia. To overcome this, dexamethasone has been used as an adjuvant to prolong block duration. However, there are concerns about steroid-related morbidity and the optimal route of dexamethasone administration (eg, caudal or intravenous) is unknown.METHODS: We conducted a systematic review and random-effects meta-analysis of randomized controlled trials recruiting pediatric surgical patients receiving a caudal block for surgical anesthesia or postoperative analgesia. Included studies compared dexamethasone (caudal, intravenous, or both) to control. Duration of analgesia was the primary outcome. Database sources were Medline, Embase, the Cochrane Library, and Google Scholar searched up to August 18, 2017, without language restriction. Screening of studies, data extraction, and risk of bias assessment were performed independently and in duplicate by 2 authors. Risk of bias was assessed using Cochrane methodology and the strength of evidence was scored using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.RESULTS: The initial search retrieved 93 articles. Fourteen randomized controlled trials that comprised 1315 pediatric patients met the inclusion criteria. All but 1 study involved lower abdominal operations (orchidopexy, inguinal hernia repair, and hypospadias repair). The caudal and intravenous dose of dexamethasone ranged from 0.1 to 0.2 mg/kg and 0.5 to 1.5 mg/kg, respectively, and all studies were pooled in the main analysis. Dexamethasone prolonged the duration of analgesia by both the caudal route (5.43 hours, 95% confidence interval [CI], 3.52–7.35; P < .001; I2 = 99.3%; N = 9; n = 620; GRADE quality = moderate) and intravenous route (5.51 hours; 95% CI, 3.56–7.46; P < .001; I2 = 98.9%; N = 5; n = 364; GRADE quality = moderate) versus control. Secondary benefits of dexamethasone included reduced narcotic rescue analgesia requirement in the postanesthetic care unit (relative risk [RR], 0.30; 95% CI, 0.18–0.51; P < .001; I2 = 0.0%; N = 5; number needed to treat for benefit [NNTB] = 5; 95% CI, 4–7), less subsequent postoperative rescue analgesia requirement (RR, 0.46; 95% CI, 0.23–0.92; P = .03; I2 = 96.0%; N = 9; n = 629; NNTB = 3; 95% CI, 2–20; n = 310), and lower rates of postoperative nausea and vomiting (RR, 0.47; 95% CI, 0.30–0.73; P = .001; I2 = 0.0%; NNTB = 11; 95% CI, 8–21; N = 9; n = 628). Adverse events linked to the dexamethasone were rare.CONCLUSIONS: Caudal and intravenous dexamethasone are similarly effective for prolonging the duration of analgesia from caudal blockade, resulting in a doubled to tripled duration. Given the off-label status of caudal dexamethasone, intravenous administration is recommended—although only high intravenous doses (0.5 mg/kg up to 10 mg) have been studied.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Treatment of Chronic Pain With Various Buprenorphine Formulations: A
           Systematic Review of Clinical Studies
    • Authors: Aiyer; Rohit; Gulati, Amitabh; Gungor, Semih; Bhatia, Anuj; Mehta, Neel
      Abstract: imageClinical studies demonstrate that buprenorphine is a pharmacologic agent that can be used for the treatment of various types of painful conditions. This study investigated the efficacy of 5 different types of buprenorphine formulations in the chronic pain population. The literature was reviewed on PubMed/MEDLINE, EMBASE, Cochrane Database, clinicaltrials.gov, and PROSPERO that dated from inception until June 30, 2017. Using the population, intervention, comparator, and outcomes method, 25 randomized controlled trials were reviewed involving 5 buprenorphine formulations in patients with chronic pain: intravenous buprenorphine, sublingual buprenorphine, sublingual buprenorphine/naloxone, buccal buprenorphine, and transdermal buprenorphine, with comparators consisting of opioid analgesics or placebo. Of the 25 studies reviewed, a total of 14 studies demonstrated clinically significant benefit with buprenorphine in the management of chronic pain: 1 study out of 6 sublingual and intravenous buprenorphine, the only sublingual buprenorphine/naloxone study, 2 out of 3 studies of buccal buprenorphine, and 10 out of 15 studies for transdermal buprenorphine showed significant reduction in pain against a comparator. No serious adverse effects were reported in any of the studies. We conclude that a transdermal buprenorphine formulation is an effective analgesic in patients with chronic pain, while buccal buprenorphine is also a promising formulation based on the limited number of studies.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Opioid Use Disorders: Perioperative Management of a Special Population
    • Authors: Ward; Emine Nalan; Quaye, Aurora Naa-Afoley; Wilens, Timothy E.
      Abstract: imageOpioid-related overdose deaths have reached epidemic levels within the last decade. The efforts to prevent, identify, and treat opioid use disorders (OUDs) mostly focus on the outpatient setting. Despite their frequent overrepresentation, less is known about the inpatient management of patients with OUDs. Specifically, the perioperative phase is a very vulnerable time for patients with OUDs, and little has been studied on the optimal management of acute pain in these patients. The preoperative evaluation should aim to identify those with OUDs and assess factors that may interfere with OUD treatment and pain management. Efforts should be made to provide education and assistance to patients and their support systems. For those who are actively struggling with opioid use, the perioperative phase can be an opportunity for engagement and to initiate treatment. Buprenorphine, methadone, and naltrexone medication treatment for OUD and opioid tolerance complicate perioperative pain management. A multidisciplinary team approach is crucial to provide clinically balanced pain relief without jeopardizing the patient’s recovery. This article reviews the existing literature on the perioperative management of patients with OUDs and provides clinical suggestions for the optimal care of this patient population.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • An Intraplantar Hypertonic Saline Assay in Mice for Rapid Screening of
           Analgesics
    • Authors: Asiri; Yahya I.; Fung, Timothy; Schwarz, Stephan K. W.; Asseri, Khalid A.; Welch, Ian D.; Schuppli, Catherine A.; Barr, Alasdair M.; Wall, Richard A.; Puil, Ernest; MacLeod, Bernard A.
      Abstract: imageBACKGROUND: Development of new analgesics is limited by shortcomings of existing preclinical screening assays such as wide variations in response, suitability for a narrow range of analgesics, and propensity to induce tissue damage. Our aim was to determine the feasibility of a new in vivo animal assay as an analgesic screen based on nociceptive responses (licking and biting) after intraplantar (i.pl.) injection of hypertonic saline (HS) in mice.METHODS: With approval from the Institutional Animal Care Committee, we conducted a randomized, investigator-blinded in vivo study in adult CD-1 mice. We first studied the concentration–response relationship, time course, and sex difference of animals’ nociceptive responses to HS. Subsequently, we assessed the screening ability of the HS assay to detect a range of established analgesics belonging to different classes. Finally, we performed histopathologic studies to assess potential tissue damage.RESULTS: The response produced by i.pl. HS was greater and longer in female than in male mice. The responses to HS were concentration dependent with minimal variance. Ten percent HS evoked a maximal response within the first 5 minutes. Morphine dose-dependently attenuated animals’ nociceptive responses (1–10 mg/kg intraperitoneally [i.p.]). The peripherally restricted µ-opioid receptor agonist, loperamide, reduced nociceptive responses when injected locally (30–100 µg/paw, i.pl.) but not systemically (1–10 mg/kg, i.p.). Acetylsalicylic acid (300 mg/kg, i.p.), naproxen (150 mg/kg, i.p), and acetaminophen (300 mg/kg, i.p.) all decreased nociceptive responses, as did i.pl. coinjections of lidocaine (0.003%–1%) with 10% HS. Histopathologic assessment revealed no tissue damage due to HS.CONCLUSIONS: The i.pl. HS assay is easily performed, rapidly detects standard analgesics, and produces minimal animal suffering without tissue damage. We propose this assay as a useful addition to the armamentarium of existing preclinical analgesic screens.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Stress Hormone Cortisol Enhances Interferon-υ–Mediated
           Proinflammatory Responses of Human Immune Cells
    • Authors: Yeager; Mark P.; Guyre, Cheryl A.; Sites, Brian D.; Collins, Jane E.; Pioli, Patricia A.; Guyre, Paul M.
      Abstract: imageBACKGROUND: Cortisol is a prototypical human stress hormone essential for life, yet the precise role of cortisol in the human stress response to injury or infection is still uncertain. Glucocorticoids (GCs) such as cortisol are widely understood to suppress inflammation and immunity. However, recent research shows that GCs also induce delayed immune effects manifesting as immune stimulation. In this study, we show that cortisol enhances the immune-stimulating effects of a prototypical proinflammatory cytokine, interferon-υ (IFN-υ). We tested the hypothesis that cortisol enhances IFN-υ–mediated proinflammatory responses of human mononuclear phagocytes (monocyte/macrophages [MOs]) stimulated by bacterial endotoxin (lipopolysaccharide [LPS]).METHODS: Human MOs were cultured for 18 hours with or without IFN-υ and/or cortisol before LPS stimulation. MO differentiation factors granulocyte-macrophage colony stimulating factor (GM-CSF) or M-CSF were added to separate cultures. We also compared the inflammatory response with an acute, 4-hour MO incubation with IFN-υ plus cortisol and LPS to a delayed 18-hour incubation with cortisol before LPS exposure. MO activation was assessed by interleukin-6 (IL-6) release and by multiplex analysis of pro- and anti-inflammatory soluble mediators.RESULTS: After the 18-hour incubation, we observed that cortisol significantly increased LPS-stimulated IL-6 release from IFN-υ–treated undifferentiated MOs. In GM-CSF–pretreated MOs, cortisol increased IFN-υ–mediated IL-6 release by>4-fold and release of the immune stimulant IFN-α2 (IFN-α2) by>3-fold, while suppressing release of the anti-inflammatory mediator, IL-1 receptor antagonist to 15% of control. These results were reversed by either the GC receptor antagonist RU486 or by an IFN-υ receptor type 1 antibody antagonist. Cortisol alone increased expression of the IFN-υ receptor type 1 on undifferentiated and GM-CSF–treated MOs. In contrast, an acute 4-hour incubation of MOs with IFN-υ and cortisol showed classic suppression of the IL-6 response to LPS.CONCLUSIONS: These results reveal a surprisingly robust proinflammatory interaction between the human stress response hormone cortisol and the immune activating cytokine IFN-υ. The results support an emerging physiological model with an adaptive role for cortisol, wherein acute release of cortisol suppresses early proinflammatory responses but also primes immune cells for an augmented response to a subsequent immune challenge. These findings have broad clinical implications and provide an experimental framework to examine individual differences, mechanisms, and translational implications of cortisol-enhanced immune responses in humans.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Gender Distribution of the American Board of Anesthesiology Diplomates,
           Examiners, and Directors (1985–2015)
    • Authors: Fahy; Brenda G.; Culley, Deborah J.; Sun, Huaping; Dainer, Rupa; Lutkoski, Benjamin P.; Lien, Cynthia A.
      Abstract: imageTo understand the potential role of women in leadership positions, data from the American Board of Anesthesiology (ABA) were analyzed to explore the impact of women in the specialty of anesthesiology. The number of newly certified ABA diplomates, oral examiners, and directors from 1985 to 2015 was obtained from the ABA database. The percentages of women in each group were calculated for each year. Because it took an average of 10 years for a diplomate to become an oral examiner and an average of 7 years for an oral examiner to be elected as a director during the study period, the following percentages were compared: women oral examiners versus newly certified women diplomates 10 years prior and women directors versus women oral examiners 7 years prior. The correlation coefficients between the percentages of women oral examiners and of newly certified women diplomates 10 years prior and between the percentages of women directors and women oral examiners 7 years prior were calculated. From 1985 to 2015, the percentage of newly certified women diplomates increased from 15% to 38% with an average annual increase of 0.74%, percentage of women oral examiners increased from 8% to 26% with an average annual increase of 0.63%, and percentage of women directors increased from 8% to 25% with an average annual increase of 0.56%. The percentage of women examiners consistently lagged behind the percentage of women diplomates who were certified 10 years earlier; the average difference over 21 years from 1995 to 2015 was −3.7% with a standard deviation of 2.1%. The correlation coefficient between the percentages of women examiners and newly certified women diplomates 10 years earlier from 1995 to 2015 was 0.86 (P < .001). However, the percentage of women directors was generally higher than that of women examiners 7 years earlier; the average difference over 24 years from 1992 to 2015 was 3.5% with a standard deviation of 4.0%. The correlation coefficient between the percentages of women directors and women examiners 7 years prior from 1992 to 2015 was 0.86 (P < .001). The percentage of newly certified women diplomates, examiners, and directors increased steadily from 1985 to 2015. The percentage of women examiners lagged behind that of women diplomates 10 years prior from 1995 to 2015; however, the percentage of women directors was, on average, higher than that of the women examiners 7 years prior from 1992 to 2015.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Repeated Measures Designs and Analysis of Longitudinal Data: If at First
           You Do Not Succeed—Try, Try Again
    • Authors: Schober; Patrick; Vetter, Thomas R.
      Abstract: imageAnesthesia, critical care, perioperative, and pain research often involves study designs in which the same outcome variable is repeatedly measured or observed over time on the same patients. Such repeatedly measured data are referred to as longitudinal data, and longitudinal study designs are commonly used to investigate changes in an outcome over time and to compare these changes among treatment groups. From a statistical perspective, longitudinal studies usually increase the precision of estimated treatment effects, thus increasing the power to detect such effects. Commonly used statistical techniques mostly assume independence of the observations or measurements. However, values repeatedly measured in the same individual will usually be more similar to each other than values of different individuals and ignoring the correlation between repeated measurements may lead to biased estimates as well as invalid P values and confidence intervals. Therefore, appropriate analysis of repeated-measures data requires specific statistical techniques. This tutorial reviews 3 classes of commonly used approaches for the analysis of longitudinal data. The first class uses summary statistics to condense the repeatedly measured information to a single number per subject, thus basically eliminating within-subject repeated measurements and allowing for a straightforward comparison of groups using standard statistical hypothesis tests. The second class is historically popular and comprises the repeated-measures analysis of variance type of analyses. However, strong assumptions that are seldom met in practice and low flexibility limit the usefulness of this approach. The third class comprises modern and flexible regression-based techniques that can be generalized to accommodate a wide range of outcome data including continuous, categorical, and count data. Such methods can be further divided into so-called “population-average statistical models” that focus on the specification of the mean response of the outcome estimated by generalized estimating equations, and “subject-specific models” that allow a full specification of the distribution of the outcome by using random effects to capture within-subject correlations. The choice as to which approach to choose partly depends on the aim of the research and the desired interpretation of the estimated effects (population-average versus subject-specific interpretation). This tutorial discusses aspects of the theoretical background for each technique, and with specific examples of studies published in Anesthesia & Analgesia, demonstrates how these techniques are used in practice.
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Balancing Infection Control and Environmental Protection as a Matter of
           Patient Safety: The Case of Laryngoscope Handles
    • Authors: Sherman; Jodi D.; Hopf, Harriet W.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Adding to Our Competitive Advantage: Making the Case for Teaching
           Communication and Professionalism
    • Authors: Chanan; Emily; Rollins, Mark D.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Some Cautionary Tales About Ideal Body Weight Dosing of Anesthetic
           Medications: It Is Not All That Ideal!
    • Authors: Nafiu; Olubukola O.; Mills, Katherine; Tremper, Kevin K.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Stoelting’s Anesthesia and Co-Existing Disease, 7th ed
    • Authors: Handlogten; Kathryn S.; Johnson, Rebecca L.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Anesthesiology: Clinical Case Reviews
    • Authors: Hasan; Najia; Singh, Mandeep
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Global Health: Issues, Challenges, and Global Action
    • Authors: Jamrozik; Euzebiusz; Riedel, Bernhard
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Complications in Anesthesia, 3rd ed
    • Authors: Lalonde; Genevieve
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Pain Medicine Board Review
    • Authors: Abrecht; Christopher R.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Interviewing in Social Science Research: A Relational Approach
    • Authors: Marinkovic; Angelina; Lee, Susan M.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Perioperative Management in Robotic Surgery, 1st ed
    • Authors: Awad; Hamdy
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Anesthesia and Neurotoxicity
    • Authors: Bai; Xiaowen
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Hagberg and Benumof’s Airway Management, 4th ed
    • Authors: Furman; William R.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Under the Knife: The History of Surgery in 28 Remarkable Operations
    • Authors: Brindley; Peter G.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Physics for Anesthesiologists: From Daily Life to the Operating Room
    • Authors: Spieth; Peter Markus
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Postoperative Care Handbook of the Massachusetts General Hospital
    • Authors: Gabriel; Rodney A.; Schmidt, Ulrich H.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Miller’s Anesthesia Review
    • Authors: Noonan; Craig L. F.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Only New Red Blood Cells for Orthotopic Liver Transplant'
    • Authors: Ariza; Fredy; Raffan, Fernando
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Wang; Yue; Wu, Rongqian
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Exploring Beyond the Duration of Analgesia: Can Adjuncts Improve More
           Meaningful Outcomes in Obstetric Patients'
    • Authors: Kendall; Mark C.; Cohen, Alexander D.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Katz; Daniel; Beilin, Yaakov
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Flupirtine Is an Effective Analgesic: Is the Associated Rare Liver Injury
           a Limiting Factor to Its Use'
    • Authors: Lawson; Kim
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Future of Activated Clotting Time'
    • Authors: Carroll; Roseita; Mansell, Josephine; Platton, Sean; Green, Laura; MacCallum, P. K.
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Shore-Lesserson; Linda; Ferraris, Victor; Fitzgerald, David; Baker, Robert A.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • The Use of Hydroxyethyl Starch 130/0.4 in Surgery Patients
    • Authors: Reinhart; Konrad
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Pagel; Judith-Irina; Rehm, Markus; Hofmann-Kiefer, Klaus F.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Adjusting the Ventilator' Not Only Size Matters!
    • Authors: Weil; Grégoire; Motamed, Cyrus
      Abstract: imageNo abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Josephs; Sean A.; Lemmink, Gretchen A.; Strong, Judith A.; Hurford, William E.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Perioperative Hydroxyethyl Starch: A Potential Threat to Patient Safety
    • Authors: Bilotta; Federico
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Pagel; Judith-Irina; Rehm, Markus; Hofmann-Kiefer, Klaus F.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • More on Fatigue Mitigation for Anesthesiology Residents
    • Authors: Pivalizza; Evan G.; Ghebremichael, Semhar J.; Markham, Travis H.; Guzman-Reyes, Sara; Nwokolo, Omonele O.; Williams, George W.; Gumbert, Sam D.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Propofol and Remote Ischemic Preconditioning: Possible Implications for
           Studies of Clinical Myocardial Protection Using Volatile Anesthetics in
           Cardiac Surgery Patients'
    • Authors: Pagel; Paul S.; Crystal, George J.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • Comparing Anesthesia Durations Among Hospitals Based on Statistical
           Methods Described in Previous Publications in Anesthesia & Analgesia
    • Authors: Dexter; Franklin; Epstein, Richard H.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
  • In Response
    • Authors: Glance; Laurent G.; Dutton, Richard P.; Feng, Changyong; Li, Yue; Lustik, Stewart J.; Dick, Andrew W.
      Abstract: No abstract available
      PubDate: Wed, 01 Aug 2018 00:00:00 GMT-
       
 
 
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