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Anesthesiology
Journal Prestige (SJR): 2.123
Citation Impact (citeScore): 3
Number of Followers: 230  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0003-3022 - ISSN (Online) 1528-1175
Published by LWW Wolters Kluwer Homepage  [299 journals]
  • Byline Backstory No. 6: Ethereal Inspirations in Scotland—Particular
           Then General
    • Abstract: After winning Pennsylvania’s intercollegiate St. Andrews Society scholarship competition, I studied natural philosophy at Scotland’s University of Edinburgh (1975 to 1976). My physics lab instructor was Edinburgh’s venerable James Kyles, FRSE, who had collaborated with neutron discoverer James Chadwick. As the visiting Andrew Mutch Scholar to the Scottish Universities Research Reactor Centre (photographed by me, left), I recorded Dr. Keith Boddy’s use of particle physics to investigate cadmium poisoning. Decades after these particular inspirations, I would revisit the Scottish capital for general inspiration or, more accurately, general inhalation. In 2004 and then 2014, as a medical antiques courier, I would hand-carry rare acquisitions, c. 1846 Hooper and Squire Ether Inhalers (right upper and lower, respectively) from an antiques dealer in Edinburgh back to Chicagoland’s Wood Library-Museum. (Copyright © the American Society of Anesthesiologists’ Wood Library-Museum of Anesthesiology.)
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Aftershocks for Quake-rattled Frueh: Dan “Wood’s Local Anaesthetic”
           Levels Its Namesake
    • Abstract: Named for a Union general from Indiana, Hoosier dentist Daniel Macauley Wood (1868 to 1934) moved to Ohio as founding business manager by 1900 for Cincinnati’s Union Painless Dentists (left, “Uncle Sam” holds “Old Glory” on their trade card’s obverse). In 1906, Wood began training his replacement, a patriotic Spanish-American War veteran who had actually been born on Independence Day, Dr. John F. Frueh (1877 to 1920). The hapless Frueh had recently married in Cincinnati after his original wedding plans had been flattened by the Great 1906 San Francisco Earthquake. Dr. Frueh took pains to use and advertise the cocaine-laced “application to the gum” (right, from the trade card’s reverse) previously popularized by “Specialist” Wood. Unfortunately, Dr. Dan Wood may have self-medicated his manic behavior with his namesake anesthetic. Indeed, divorce proceedings revealed that Dr. Wood had bankrupted his household while maintaining three mistresses. So ironically, his cocaine concoction had salvaged the seismically shifted Frueh, but its aftershocks had leveled the house of Wood. (Copyright © the American Society of Anesthesiologists’ Wood Library-Museum of Anesthesiology.)
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Shadowing the Abbot: Wood Library-Museum Graphic Illustrators Bill and
           Janet Lyle
    • Abstract: An earlier vignette reflected Wood Library-Museum (WLM) exhibit designer John Byrne “Shadowing the Abbess.” We now segue with “Shadowing the Abbot”: Father John Henry (bottom, standing left), the final Abbot of St. Herman’s Monastery in Cleveland, Ohio. When the monastery’s wheelchair lift at the men’s shelter needed repairs, these were funded by the author and accomplished by electrician William “Bill” Lyle (upper left). Before mastering the Ohio electrical code to full licensure without a mentor, Mr. Lyle had taught himself every graphics version of Photoshop and Illustrator. I have never met a brighter fellow. Bill composed signage for the Wood Library-Museum’s Park Ridge galleries, generated Wood Library-Museum exhibit graphics for American Society of Anesthesiologists Annual Meetings (2000 to 2011), and illustrated the initial 115 Reflections for Anesthesiology. After Bill suffered a devastating stroke in May of 2011, his wife Janet (upper right) grabbed the computer keyboard and generated 600-plus additional Anesthesiology Reflection images before retiring in April of 2020. The Wood Library-Museum thanks the Lyles for all of their artistic contributions to Anesthesiology and to the Wood Library-Museum over the past 28 years. (Copyright © the American Society of Anesthesiologists’ Wood Library-Museum of Anesthesiology.)
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • The Surgeon As “Swindler”: A Corny Use of Chloroform
    • Abstract: Hidden in the Wood Library-Museum Archives is this bifold sheet (top left) containing three autograph pages of “Riddles from Miss C. Corbet” of Adderley, England. Dated “Jany 10th / 56” (1856, top right), there are 19 riddles in all. The riddler was 20-year-old Clara Anna Corbet (1835 to 1916), the fourth of eight children born to soon-to-be Rector Richard Corbet and his wife Eleanor. In one instance, Clara likened “a surgeon using Chloroform,” who “cuts away without…pain,” to “a swindler,” who “cuts away without paying” (bottom). Miss Corbet, however, offered no chloroform to palliate the pain of reading her riddle. (Copyright © the American Society of Anesthesiologists’ Wood Library-Museum of Anesthesiology.)
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Instructions for Obtaining A nesthesiology Continuing Medical Education
           (CME) Credit
    • PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Ketamine for Neuropathic Pain: an Infusion of Relief'
    • Authors: Wanderer JP; Rathmell JP.
      Abstract: Complex Information for Anesthesiologists Presented Quickly and Clearly
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Science, Medicine, and the Anesthesiologist
    • Abstract: Key Papers from the Most Recent Literature Relevant to Anesthesiologists
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • This Month in Anesthesiology
    • PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Anesthesiology
    • PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Anesthesiology
    • PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Uncertainty and Certainty
    • Authors: Kharasch ED.
      Abstract: “An unsuspecting public cannot differentiate between preprint postings and peer-reviewed, published, trusted evidence.”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Anesthesia as Decoupling'
    • Authors: Hudson AE.
      Abstract: “…do general anesthetics equally disrupt relationships between all neurons, or...between particular functional networks…'”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Perioperative Neurocognitive Disorder: Reply
    • Authors: Eckenhoff RG; Eckenhoff MF.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Perioperative Neurocognitive Disorder: Comment
    • Authors: Giordano G; Pugliese F, Bilotta F.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Ketamine for Chronic Pain Old Drug New Trick'
    • Authors: Clark J.
      Abstract: “Ketamine is exceedingly use-ful in … anesthesia and … psychiatry. Despite these suc-cesses, we struggle to identify clear roles for ketamine in patients affected by chronic pain.”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Priming Cardiopulmonary Bypass in Pediatric Surgery: Reply
    • Authors: Dieu A; Momeni M.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Priming Cardiopulmonary Bypass in Pediatric Surgery: Comment
    • Authors: Van Der Linden P; Blanjean A, Schmartz D.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Practice Guidelines for Central Venous Access: Comment
    • Authors: Shrestha G.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Practice Guidelines for Central Venous Access: Reply
    • Authors: Apfelbaum JL; Rupp SM, Tung A, et al.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Management of the Traumatic Airway Obstructed by Foreign Body
    • Authors: Hollon MM; Hunter M, Johnson R.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Incidence and Classification of Nonroutine Events during Anesthesia Care
    • Authors: Liberman JS; Slagle JM, Whitney G, et al.
      Abstract: Background A nonroutine event is any aspect of clinical care perceived by clinicians or trained observers as a deviation from optimal care based on the context of the clinical situation. The authors sought to delineate the incidence and nature of intraoperative nonroutine events during anesthesia care. Methods The authors prospectively collected audio, video, and relevant clinical information on 556 cases at three academic hospitals from 1998 to 2004. In addition to direct observation, anesthesia providers were surveyed for nonroutine event occurrence and details at the end of each study case. For the 511 cases with reviewable video, 400 cases had no reported nonroutine events and 111 cases had at least one nonroutine event reported. Each nonroutine event was analyzed by trained anesthesiologists. Rater reliability assessment, comparisons (nonroutine event vs. no event) of patient and case variables were performed. Results Of 511 cases, 111 (21.7%) contained 173 nonroutine events; 35.1% of event-containing cases had more than one nonroutine event. Of the 173 events, 69.4% were rated as having patient impact and 12.7% involved patient injury. Longer case duration (25th vs. 75th percentile; odds ratio, 1.83; 95% CI, 1.15 to 2.93; P = 0.032) and presence of a comorbid diagnosis (odds ratio, 2.14; 95% CI, 1.35 to 3.40; P = 0.001) were associated with nonroutine events. Common contributory factors were related to the patient (63.6% [110 of 173]) and anesthesia provider (59.0% [102 of 173]) categories. The most common patient impact events involved the cardiovascular system (37.4% [64 of 171]), airway (33.3% [57 of 171]), and human factors, drugs, or equipment (31.0% [53 of 171]). Conclusions This study describes characteristics of intraoperative nonroutine events in a cohort of cases at three academic hospitals. Nonroutine event–containing cases were commonly associated with patient impact and injury. Thus, nonroutine event monitoring in conjunction with traditional error reporting may enhance our understanding of potential intraoperative failure modes to guide prospective safety interventions. Editor’s Perspective What We Already Know about This Topic A nonroutine event is defined as any aspect of clinical care perceived by clinicians or observers as a deviation from optimal care for a patient in a clinical situationNonroutine events are frequent and associated with increased clinician workload and patient physiologic disturbances What This Article Tells Us That Is New Video recordings of 511 cases from 1998 to 2004 were viewed to identify nonroutine events, which occurred in 22% of cases, and some cases had multiple eventsOne in fifteen patients had events associated with some degree of patient injuryThe most common contributory factors were related to provider, patient, or teaching/supervision
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • “Nonroutine Events” as a Nonroutine Outcome for Perioperative
           Systems Research
    • Authors: Lane-Fall MB; Bass EJ.
      Abstract: “[I]n health services research, we have seen a shift away from the acceptance of process outcomes as valid measures of intervention effectiveness.”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Ketamine and Magnesium for Refractory Neuropathic Pain A Randomized,
           Double-blind, Crossover Trial
    • Authors: Pickering G; Pereira B, Morel V, et al.
      Abstract: Background Ketamine is often used for the management of refractory chronic pain. There is, however, a paucity of trials exploring its analgesic effect several weeks after intravenous administration or in association with magnesium. The authors hypothesized that ketamine in neuropathic pain may provide pain relief and cognitive–emotional benefit versus placebo and that a combination with magnesium may have an additive effect for 5 weeks. Methods A randomized, double-blind, crossover, placebo-controlled study (NCT02467517) included 20 patients with neuropathic pain. Each ketamine-naïve patient received one infusion every 35 days in a random order: ketamine (0.5 mg/kg)/placebo or ketamine (0.5 mg/kg)/magnesium sulfate (3g) or placebo/placebo. The primary endpoint was the area under the curve of daily pain intensity for a period of 35 days after infusion. Secondary endpoints included pain (at 7, 15, 21 and 28 days) and health-related, emotional, sleep, and quality of life questionnaires. Results Daily pain intensity was not significantly different between the three groups (n = 20) over 35 days (mean area under the curve = 185 ± 100, 196 ± 92, and 187 ± 90 pain score-days for ketamine, ketamine/magnesium, and placebo, respectively, P = 0.296). The effect size of the main endpoint was −0.2 (95% CI [−0.6 to 0.3]; P = 0.425) for ketamine versus placebo, 0.2 (95% CI [−0.3 to 0.6]; P = 0.445) for placebo versus ketamine/magnesium and -0.4 (95% CI [−0.8 to 0.1]; P = 0.119) for ketamine versus ketamine/magnesium. There were no significant differences in emotional, sleep, and quality of life measures. During placebo, ketamine, and ketamine/magnesium infusions, 10%, 20%, and 35% of patients respectively reported at least one adverse event. Conclusions The results of this trial in neuropathic pain refuted the hypothesis that ketamine provided pain relief at 5 weeks and cognitive–emotional benefit versus placebo and that a combination with magnesium had any additional analgesic effect. Editor’s Perspective What We Already Know about This Topic The use of low-dose ketamine infusion for the treatment of chronic pain has expanded rapidly despite a paucity of data supporting the practiceMagnesium ion, like ketamine, is a blocker of N-methyl-d-aspartate receptor function that may have analgesic properties in some settings What This Article Tells Us That Is New Using a triple-crossover paradigm, saline, ketamine, and ketamine + magnesium infusions were given to a group of 20 patients with chronic neuropathic painNo effect of either the ketamine or ketamine + magnesium in terms of pain relief over the 35 days after infusions was identifiedAdditional secondary health-related, emotional, sleep, and quality of life measures were also unchanged by the drug infusions
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Personalizing the Definition of Hypotension to Protect the Brain: Erratum
    • Abstract: In the January 2020 issue, the Clinical Focus Review article “Personalizing the Definition of Hypotension to Protect the Brain” (Brady KM, Hudson A, Hood R, DeCaria B, Lewis C, Hogue CW. Anesthesiology 2020; 132:170–9. doi: 10.1097/ALN.0000000000003005) contains an error in the next to last paragraph. The authors erroneously stated that 1.35 mmHg should be subtracted from blood pressure measured at the heart level for each 1 cm of head elevation such as with “beach chair” patient positioning. The aim of that subtraction is to obtain an estimate of the blood pressure at the Circle of Willis as widely discussed. This sentence should read 1 mmHg should be subtracted from the blood pressure measured at heart level for each 1.35 cm of head elevation. The corrected sentence reads: “Our findings are further consistent with the conclusion in a recent review by Drummond,47 who emphasized the need to consider the projected blood pressure at the circle of Willis when the head is elevated above the horizontal as for surgery in the beach chair position (i.e., subtract 1 mmHg per 1.35 cm of head elevation from blood pressure measured from arm or leg).”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
      DOI: 10.1097/aln.0000000000003005) contains an error in the next to last paragraph. the authors erroneous
       
  • Goal-directed Therapy Why Benefit Remains Uncertain
    • Authors: Maheshwari K; Sessler DI.
      Abstract: “...recent robust trials [of goal-directed fluid therapy] with large sample sizes have shown little or no benefit.”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Risk Factors for Failure to Rescue in Myocardial Infarction after
           Noncardiac Surgery A Cohort Study
    • Authors: Mazzarello S; McIsaac DI, Beattie W, et al.
      Abstract: Background Compared to other perioperative complications, failure to rescue (i.e., death after suffering a complication) is highest after perioperative myocardial infarction (a myocardial infarction that occurs intraoperatively or within 30 days after surgery). The purpose of this study was to identify patient and surgical risk factors for failure to rescue in patients who have had a perioperative myocardial infarction. Methods Individuals who experienced a perioperative myocardial infarction after noncardiac surgery between 2012 and 2016 were identified from the American College of Surgeons (Chicago, Illinois) National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue. Subgroup and sensitivity analyses evaluated the robustness of primary findings. Results The authors identified 1,307,884 individuals who had intermediate to high-risk noncardiac surgery. A total of 8,923 (0.68%) individuals had a perioperative myocardial infarction, of which 1,726 (19.3%) experienced failure to rescue. Strongest associations (adjusted odds ratio greater than 1.5) were age 85 yr or older (2.52 [95% CI, 2.05 to 3.09] vs. age younger than 65 yr), underweight body mass index (1.53 [95% CI, 1.17 to 2.01] vs. normal body mass index), American Society of Anesthesiologists class IV (1.76 [95% CI, 1.33 to 2.31] vs. class I or II) and class V (3.48 [95% CI, 2.20 to 5.48] vs. class I or II), and presence of: ascites (1.81 [95% CI, 1.15 to 2.87]), disseminated cancer (1.54 [95% CI, 1.18 to 2.00]), systemic inflammatory response syndrome (1.55 [95% CI, 1.26 to 1.90]), sepsis (1.75 [95% CI, 1.39 to 2.20]), septic shock (1.79 [95% CI, 1.34 to 2.37]), and dyspnea at rest (1.94 [95% CI, 1.32 to 2.86]). Patients who had emergency surgery, high-risk procedures, and postoperative complications were at higher risk of failure to rescue. Conclusions Routinely identified patient and surgical factors predict risk of failure to rescue after perioperative myocardial infarction. Editor’s Perspective What We Already Know about This Topic Patients experiencing perioperative myocardial infarction are at high risk for mortalityWhich patients are at highest risk of failure to rescue (death after a complication) What This Article Tells Us That Is New In a multinational cohort of 8,923 patients experiencing perioperative myocardial infarction after intermediate to high-risk noncardiac surgery, one in five died within 30 daysPatients age 85 yr or older, and those with advanced systemic disease, underweight body mass index, ascites, disseminated cancer, sepsis, or dyspnea at rest were at highest risk
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Association between Use of Angiotensin-converting Enzyme Inhibitors or
           Angiotensin Receptor Blockers and Postoperative Delirium
    • Authors: Farag E; Liang C, Mascha EJ, et al.
      Abstract: Background Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed. Methods The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer’s disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed. Results The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001). Conclusions Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified. Editor’s Perspective What We Already Know about This Topic Postoperative delirium is common in surgical intensive care patientsAngiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function What This Article Tells Us That Is New In a single-center cohort study of adults admitted to a surgical intensive care unit, preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was not associated with reduced postoperative deliriumHowever, rapidly starting angiotensin-converting enzyme inhibitors or angiotensin receptor blockers postoperatively was associated with reduced delirium
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Mechanical Ventilation Guided by Uncalibrated Esophageal Pressure May Be
           Potentially Harmful
    • Authors: Cammarota G; Lauro G, Santangelo E, et al.
      Abstract: Background Esophageal balloon calibration was proposed in acute respiratory failure patients to improve esophageal pressure assessment. In a clinical setting characterized by a high variability of abdominal load and intrathoracic pressure (i.e., pelvic robotic surgery), the authors hypothesized that esophageal balloon calibration could improve esophageal pressure measurements. Accordingly, the authors assessed the impact of esophageal balloon calibration compared to conventional uncalibrated approach during pelvic robotic surgery. Methods In 30 adult patients, scheduled for elective pelvic robotic surgery, calibrated end-expiratory and end-inspiratory esophageal pressure, and the associated respiratory variations were obtained at baseline, after pneumoperitoneum–Trendelenburg application, and with positive end-expiratory pressure (PEEP) administration and compared to uncalibrated values measured at 4-ml filling volume, as per manufacturer recommendation. Data are expressed as median and [25th, 75th percentile]. Results Ninety calibrations were successfully performed. Chest wall elastance worsened with pneumoperitoneum–Trendelenburg and PEEP (19.0 [15.5, 24.6] and 16.7 [11.4, 21.7] cm H2O/l) compared to baseline (8.8 [6.3, 9.8] cm H2O/l; P < 0.0001 for both comparisons). End-expiratory and end-inspiratory calibrated esophageal pressure progressively increased from baseline (3.7 [2.2, 6.0] and 7.7 [5.9, 10.2] cm H2O) to pneumoperitoneum–Trendelenburg (6.2 [3.8, 10.2] and 16.1 [13.1, 20.6] cm H2O; P = 0.014 and P < 0.001) and PEEP (8.8 [7.7, 15.6] and 18.9 [16.3, 22.0] cm H2O; P < 0.0001 vs. baseline for both comparison; P < 0.001 and P = 0.002 vs. pneumoperitoneum–Trendelenburg) and, at each study step, they were persistently lower than uncalibrated esophageal pressure (P < 0.0001 for all comparisons). Overall, difference among uncalibrated and calibrated esophageal pressure was 5.1 [3.8, 8.4] cm H2O at end-expiration and 3.8 [3.0, 6.3] cm H2O at end-inspiration. Uncalibrated esophageal pressure swing was always lower than calibrated one (P < 0.0001 for all comparisons) with a difference of −1.0 [−1.8, −0.4] cm H2O. Conclusions In a clinical setting with variable chest wall mechanics, uncalibrated measurements substantially overestimated absolute values and underestimated respiratory variations of esophageal pressure. Calibration could substantially improve mechanical ventilation guided by esophageal pressure. Editor’s Perspective What We Already Know about This Topic Esophageal pressure can be used as a surrogate for pleural pressure for optimizing mechanical ventilationHowever, surgeries such as pelvic robotic surgery involve fluctuations in abdominal load and intrathoracic pressure that may artificially influence esophageal pressure What This Article Tells Us That Is New This study enrolled patients undergoing pelvic robotic surgery and found that esophageal balloon calibration significantly improved assessment of esophageal pressure when compared with the conventional uncalibrated approach to measuring esophageal pressure
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Distinct Function of Estrogen Receptors in the Rodent Anterior Cingulate
           Cortex in Pain-related Aversion
    • Authors: Zang K; Xiao X, Chen L, et al.
      Abstract: Background Brain-derived estrogen is implicated in pain-related aversion; however, which estrogen receptors mediate this effect remains unclear. This study hypothesized that the different estrogen receptors in the rostral anterior cingulate cortex play distinct roles in pain-related aversion. Methods Formalin-induced conditioned place avoidance and place escape/avoidance paradigms were used to evaluate pain-related aversion in rodents. Immunohistochemistry and Western blotting were used to detect estrogen receptor expression. Patch-clamp recordings were used to examine N-methyl-d-aspartate–mediated excitatory postsynaptic currents in rostral anterior cingulate cortex slices. Results The administration of the estrogen receptor-β antagonist 4-(2-phenyl-5,7-bis [trifluoromethyl] pyrazolo [1,5-a] pyrimidin-3-yl) phenol (PHTPP) or the G protein–coupled estrogen receptor-1 antagonist (3aS*,4R*,9bR*)-4-(6-bromo-1,3-benzodioxol-5-yl)-3a,4,5,9b-3H-cyclopenta [c] quinolone (G15) but not the estrogen receptor-α antagonist 1,3-bis (4-hydroxyphenyl)-4-methyl-5-[4-(2-piperidinylethoxy) phenol]-1H-pyrazole dihydrochloride (MPP) into the rostral anterior cingulate cortex blocked pain-related aversion in rats (avoidance score, mean ± SD: 1,3-bis [4-hydroxyphenyl]-4-methyl-5-(4-[2-piperidinylethoxy] phenol)-1H-pyrazole dihydrochloride (MPP): 47.0 ± 18.9%, 4-(2-phenyl-5,7-bis [trifluoromethyl] pyrazolo [1,5-a] pyrimidin-3-yl) phenol (PHTPP): −7.4 ± 20.6%, and [3aS*,4R*,9bR*]-4-[6-bromo-1,3-benzodioxol-5-yl]-3a,4,5,9b-3H-cyclopenta [c] quinolone (G15): −4.6 ± 17.0% vs. vehicle: 46.5 ± 12.2%; n = 7 to 9; P < 0.0001). Consistently, estrogen receptor-β knockdown but not estrogen receptor-α knockdown by short-hairpin RNA also inhibited pain-related aversion in mice (avoidance score, mean ± SD: estrogen receptor-α–short-hairpin RNA: 26.0 ± 7.1% and estrogen receptor-β–short-hairpin RNA: 6.3 ± 13.4% vs. control short-hairpin RNA: 29.1 ± 9.1%; n = 7 to 10; P < 0.0001). Furthermore, the direct administration of the estrogen receptor-β agonist 2,3-bis (4-hydroxyphenyl)-propionitrile (DPN) or the G protein–coupled estrogen receptor-1 agonist (±)-1-([3aR*,4S*,9bS*]-4-(6-bromo-1,3-benzodioxol-5-yl)-3a,4,5,9b-tetrahydro-3H-cyclopenta [c]quinolin-8-yl)-ethanone (G1) into the rostral anterior cingulate cortex resulted in conditioned place avoidance (avoidance score, mean ± SD: 2,3-bis (4-hydroxyphenyl)-propionitrile (DPN): 35.3 ± 9.5% and (±)-1-([3aR*,4S*,9bS*]-4-(6-bromo-1,3-benzodioxol-5-yl)-3a,4,5,9b-tetrahydro-3H-cyclopenta [c]quinolin-8-yl)-ethanone (G1): 43.5 ± 22.8% vs. vehicle: 0.3 ± 14.9%; n = 8; P < 0.0001) but did not affect mechanical or thermal sensitivity. The activation of the estrogen receptor-β/protein kinase A or G protein–coupled estrogen receptor-1/protein kinase B pathway elicited the long-term potentiation of N-methyl-d-aspartate–mediated excitatory postsynaptic currents. Conclusions These findings indicate that estrogen receptor-β and G protein–coupled estrogen receptor-1 but not estrogen receptor-α in the rostral anterior cingulate cortex contribute to pain-related aversion by modulating N-methyl-d-aspartate receptor–mediated excitatory synaptic transmission. Editor’s Perspective What We Already Know about This Topic Estrogen produced within the central nervous system may modulate pain in both males and femalesEstrogen receptors within the rostral anterior cingulate cortex modulate pain-related behaviors in rodent pain models What This Article Tells Us That Is New Blockade of the estrogen receptor-β but not the estrogen receptor-α reduced pain-related aversion in rats, a model of the affective components of painAdministration of an estrogen receptor-β agonist to the rostral anterior cingulate cortex caused conditioned place aversion without altering mechanical or thermal sensitivityEstrogen receptor-β may be a key receptor controlling the affective components of pain-related behaviors in laboratory models
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Bloody Cerebrospinal Fluid Drainage
    • Authors: Maurer AJ; Kedrowski J, Wardhan R.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Manipulating Neural Circuits in Anesthesia Research
    • Authors: Melonakos ED; Moody OA, Nikolaeva K, et al.
      Abstract: The neural circuits underlying the distinct endpoints that define general anesthesia remain incompletely understood. It is becoming increasingly evident, however, that distinct pathways in the brain that mediate arousal and pain are involved in various endpoints of general anesthesia. To critically evaluate this growing body of literature, familiarity with modern tools and techniques used to study neural circuits is essential. This Readers’ Toolbox article describes four such techniques: (1) electrical stimulation, (2) local pharmacology, (3) optogenetics, and (4) chemogenetics. Each technique is explained, including the advantages, disadvantages, and other issues that must be considered when interpreting experimental results. Examples are provided of studies that probe mechanisms of anesthesia using each technique. This information will aid researchers and clinicians alike in interpreting the literature and in evaluating the utility of these techniques in their own research programs.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Magnesium and Bladder Discomfort after Transurethral Resection of Bladder
           Tumor A Randomized, Double-blind, Placebo-controlled Study
    • Authors: Park J; Hong J, Kim D, et al.
      Abstract: Background Catheter-related bladder discomfort occurs because of involuntary contractions of the bladder smooth muscle after urinary catheterization. Magnesium is associated with smooth muscle relaxation. This study hypothesized that among patients having transurethral resection of bladder tumor, magnesium will reduce the incidence of postoperative moderate-to-severe catheter-related bladder discomfort. Methods In this double-blind, randomized study, patients were randomly allocated to the magnesium group (n = 60) or the control group (n = 60). In magnesium group, a 50 mg/kg loading dose of intravenous magnesium sulfate was administered for 15 min, followed by an intravenous infusion of 15 mg · kg−1 · h−1 during the intraoperative period. Patients in the control group similarly received normal saline. The primary outcome was the incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively. None, mild, moderate, and severe catheter-related bladder discomfort at 1, 2, and 6 h postoperatively, patient satisfaction, and magnesium-related adverse effects were also assessed. Results The incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively was significantly lower in the magnesium group than in the control group (13 [22%] vs. 46 [77%]; P < 0.001; relative risk = 0.283; 95% CI, 0.171 to 0.467; absolute risk reduction = 0.55; number needed to treat = 2); similar results were observed for catheter-related bladder discomfort above a moderate grade at 1 and 2 h postoperatively (5 [8%] vs. 17 [28%]; P = 0.005; relative risk = 0.294; 95% CI, 0.116 to 0.746; and 1 [2%] vs. 14 [23%]; P < 0.001; relative risk = 0.071; 95% CI, 0.010 to 0.526, respectively). Patient satisfaction on a scale from 1 to 7 was significantly higher in the magnesium group than in the control group (5.1 ± 0.8 vs. 3.5 ± 1.0; P < 0.001; 95% CI, 1.281 to 1.919). Magnesium-related adverse effects were not significantly different between groups. Conclusions Magnesium reduced the incidence of catheter-related bladder discomfort above a moderate grade and increased patient satisfaction among patients having transurethral resection of bladder tumor. Editor’s Perspective What We Already Know about This Topic Catheter-related bladder discomfort results from involuntary muscle contractionMagnesium relaxes smooth muscle and may therefore relieve bladder discomfort What This Article Tells Us That Is New In a randomized trial of 120 patients recovering from transurethral resection of bladder tumor, intravenous magnesium substantially reduced discomfort with a number needed to treat of only 2Intravenous magnesium is a simple and inexpensive way to reduce bladder discomfort
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Stress Management Training Improves Overall Performance during Critical
           Simulated Situations A Prospective Randomized Controlled Trial
    • Authors: Sigwalt F; Petit G, Evain J, et al.
      Abstract: Background High-fidelity simulation improves participant learning through immersive participation in a stressful situation. Stress management training might help participants to improve performance. The hypothesis of this work was that Tactics to Optimize the Potential, a stress management program, could improve resident performance during simulation. Methods Residents participating in high-fidelity simulation were randomized into two parallel arms (Tactics to Optimize the Potential or control) and actively participated in one scenario. Only residents from the Tactics to Optimize the Potential group received specific training a few weeks before simulation and a 5-min reactivation just before beginning the scenario. The primary endpoint was the overall performance during simulation measured as a composite score (from 0 to 100) combining a specific clinical score with two nontechnical scores (the Ottawa Global Rating Scale and the Team Emergency Assessment Measure scores) rated for each resident by four blinded independent investigators. Secondary endpoints included stress level, as assessed by the Visual Analogue Scale during simulation. Results Of the 134 residents randomized, 128 were included in the analysis. The overall performance (mean ± SD) was higher in the Tactics to Optimize the Potential group (59 ± 10) as compared with controls ([54 ± 10], difference, 5 [95% CI, 1 to 9]; P = 0.010; effect size, 0.50 [95% CI, 0.16 to 0.91]). After specific preparation, the median Visual Analogue Scale was 17% lower in the Tactics to Optimize the Potential group (52 [42 to 64]) than in the control group (63 [50 to 73]; difference, −10 [95% CI, −16 to −3]; P = 0.005; effect size, 0.44 [95% CI, 0.26 to 0.59]. Conclusions Residents coping with simulated critical situations who have been trained with Tactics to Optimize the Potential showed better overall performance and a decrease in stress level during high-fidelity simulation. The benefits of this stress management training may be explored in actual clinical settings, where a 5-min Tactics to Optimize the Potential reactivation is feasible prior to delivering a specific intervention. Editor’s Perspective What We Already Know about This Topic Stress may be associated with impaired performance on cognitive tasksStress management training may lead to a reduced response to stress What This Article Tells Us That Is New Stress management training may improve performance among trainees subjected to a stressful simulated clinical environment
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Balancing Supply and Demand for Blood during the COVID-19 Pandemic
    • Authors: Gehrie EA; Frank SM, Goobie SM.
      Abstract: “The threat to the blood supply during this [coronavirus] pandemic is not SARS-CoV-2 itself, but rather the unintended consequences of social distancing on blood drives.”
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and
           Isoflurane-anesthetized Volunteers: Retraction
    • Abstract: At the request of the authors, the Editors and Publisher retract the article “Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and Isoflurane-anesthetized Volunteers” by Nyberg et al. published in the September 2019 issue of Anesthesiology.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Analysis of Laryngoscopy Attempts in Infants: Reply
    • Authors: Gálvez JA; Acquah S, Ahumada L, et al.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Analysis of Laryngoscopy Attempts in Infants: Comment
    • Authors: Horvath B.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Bronchus Intermedius Compression from Idiopathic Thoracic Scoliosis
    • Authors: Atteri M; Allphin C, Mahmoud M, et al.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Emergency Open-source Three-dimensional Printable Ventilator Circuit
           Splitter and Flow Regulator during the COVID-19 Pandemic
    • Authors: Lai BK; Erian JL, Pew SH, et al.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Subcutaneous Nitroglycerin for Radial Arterial Catheterization in
           Pediatric Patients A Randomized Controlled Trial
    • Authors: Jang Y; Ji S, Kim E, et al.
      Abstract: Background Pediatric radial artery cannulation is challenging because of the small vessel size. Nitroglycerin is a potent vasodilator and facilitates radial artery cannulation by increasing the internal diameter and preventing the vasospasm in adult patients. The authors hypothesize that subcutaneous nitroglycerin injection will improve the success rate of pediatric radial artery cannulation. Methods This double-blind, randomized, controlled, single-center study enrolled pediatric patients (n = 113, age less than 2 yr) requiring radial artery cannulation during general anesthesia. The participants were randomized into the nitroglycerin group (n = 57) or control group (n = 56). After inducing general anesthesia, nitroglycerin solution (5 μg/kg in 0.5 ml), or normal saline (0.5 ml) was subcutaneously injected above the chosen radial artery over 10 s with ultrasound guidance. Three minutes later, the ultrasound-guided radial artery cannulation was performed. Radial artery diameter was measured before and after the subcutaneous injection and after cannulation. The primary outcome was the first-attempt successful cannulation rate. The secondary outcomes included the diameter of the radial artery and the overall complication rate including hematoma and vasospasm. Results A total of 113 children were included in the analysis. The nitroglycerin group had a higher first-attempt success rate than the control group (91.2% [52 of 57] vs. 66.1% [37 of 56]; P = 0.002; odds ratio, 5.3; 95% CI, 1.83 to 15.6; absolute risk reduction, –25.2%; 95% CI, –39.6 to –10.7%). Subcutaneous nitroglycerin injection increased the diameter of the radial artery greater than normal saline (25.0 ± 19.5% vs. 1.9 ± 13.1%; 95% CI of mean difference, 16.9 to 29.3%; P < 0.001). Overall complication rate was lower in the nitroglycerin group than in the control group (3.5% [2 of 57] vs. 31.2% [18 of 56]; P = 0.001; odds ratio, 0.077; 95% CI, 0.017 to 0.350; absolute risk reduction, 28.6%; 95% CI, 15.5 to 41.8%). Conclusions Subcutaneous nitroglycerin injection before radial artery cannulation improved the first-attempt success rate and reduced the overall complication rates in pediatric patients. Editor’s Perspective What We Already Know about This Topic Radial artery cannulation in infants can be technically challengingIn adult patients, nitroglycerin has been found to facilitate radial artery cannulation What This Article Tells Us That Is New In children less than 2 yr of age, infiltration around the radial artery with 5 mcg/kg of nitroglycerin in 0.5 ml of saline increased the first success rate of arterial cannulation
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Rapid COVID-19–related Clinical Adaptations and Unanticipated Risks
    • Authors: Schrock CR; Montana MC.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Collapse of Global Neuronal States in Caenorhabditis elegans under
           Isoflurane Anesthesia
    • Authors: Awal MR; Wirak GS, Gabel CV, et al.
      Abstract: Background A comprehensive understanding of how anesthetics facilitate a reversible collapse of system-wide neuronal function requires measurement of neuronal activity with single-cell resolution. Multineuron recording was performed in Caenorhabditis elegans to measure neuronal activity at varying depths of anesthesia. The authors hypothesized that anesthesia is characterized by dyssynchrony between neurons resulting in a collapse of organized system states. Methods Using light-sheet microscopy and transgenic expression of the calcium-sensitive fluorophore GCaMP6s, a majority of neurons (n = 120) in the C. elegans head were simultaneously imaged in vivo and neuronal activity was measured. Neural activity and system-wide dynamics were compared in 10 animals, progressively dosed at 0%, 4%, and 8% isoflurane. System-wide neuronal activity was analyzed using principal component analysis. Results Unanesthetized animals display distinct global neuronal states that are reflected in a high degree of correlation (R = 0.196 ± 0.070) between neurons and low-frequency, large-amplitude neuronal dynamics. At 4% isoflurane, the average correlation between neurons is significantly diminished (R = 0.026 ± 0.010; P < 0.0001 vs. unanesthetized) and neuron dynamics shift toward higher frequencies but with smaller dynamic range. At 8% isoflurane, interneuronal correlations indicate that neuronal activity remains uncoordinated (R = 0.053 ± 0.029; P < 0.0001 vs. unanesthetized) with high-frequency dynamics that are even further restricted. Principal component analysis of unanesthetized neuronal activity reveals distinct structure corresponding to known behavioral states. At 4% and 8% isoflurane this structure is lost and replaced with randomized dynamics, as quantified by the percentage of total ensemble variance captured by the first three principal components. In unanesthetized worms, this captured variance is high (88.9 ± 5.4%), reflecting a highly organized system, falling significantly at 4% and 8% isoflurane (57.9 ± 11.2%, P < 0.0001 vs. unanesthetized, and 76.0 ± 7.9%, P < 0.001 vs. unanesthetized, respectively) and corresponding to increased randomization and collapse of system-wide organization. Conclusions Anesthesia with isoflurane in C. elegans corresponds to high-frequency randomization of individual neuron activity, loss of coordination between neurons, and a collapse of system-wide functional organization. Editor’s Perspective What We Already Know about This Topic Experimental and human electrophysiologic data suggest that the anesthetic state results from a breakdown in effective communication between neurons in the central nervous systemSystem-wide measurements of neuronal activity with single cell resolution under anesthesia have not been previously reported What This Article Tells Us That Is New In vivo imaging of neuronal network activity with single cell resolution in Caenorhabditis elegans reveals that although neurons display highly correlated activity in awake animals, this system-wide organization in neuronal activity is lost under isoflurane anesthesiaThese observations at the single cell level in a complex neuronal network confirm previous electrophysiologic works suggesting functional disintegration of neuronal circuitry as a mechanism of anesthetic-induced unconsciousness
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Flying with a Compass Goals of Care in the Perioperative Setting
    • Authors: Cushman T; Treggiari MM.
      Abstract: I met VC in an inpatient progress note. I felt I was standing by the window, watching the attending on rounds come and sit by the bed of this dying retired family doctor. I could almost hear the pleasant, unhurried conversation about VC’s life and what he wanted from what remained of it. The note immortalized in the electronic health record was written with poetic brevity and it was the most beautiful, succinct, and thorough description of goals of care I’d ever seen.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Accuracy and Feasibility of Clinically Applied Frailty Instruments before
           Surgery A Systematic Review and Meta-analysis
    • Authors: Aucoin SD; Hao M, Sohi R, et al.
      Abstract: Background A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice. Methods The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed. Results Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility. Conclusions Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility. Editor’s Perspective What We Already Know about This Topic Preoperative frailty has been associated with adverse postoperative outcomesIt remains unclear which frailty scale is the best predictor of adverse postoperative outcomes What This Article Tells Us That Is New This meta-analysis of 45 articles identified that specific frailty scales may be better predictors for some adverse outcomes when compared to othersThe Clinical Frailty Scale was most strongly associated with mortality and discharge not to homeThe Edmonton Frail Scale was a better predictor of complicationsThe Frailty phenotype was most strongly associated with postoperative delirium
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Setup of a Dedicated Coronavirus Intensive Care Unit Logistical Aspects
    • Authors: Mojoli F; Mongodi S, Grugnetti G, et al.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Assessing and Reversing the Effect of Direct Oral Anticoagulants on
           Coagulation
    • Authors: Langer A; Connors JM.
      Abstract: Direct oral anticoagulants have improved anticoagulation options for many patients, but they present challenges regarding monitoring and reversal of anticoagulant activity. Anesthesiologists are likely to encounter patients taking direct oral anticoagulants in a variety of clinical settings including scheduled procedures, emergency procedures, trauma, and critical care units. This review focuses on the pharmacokinetics of direct oral anticoagulants, testing methods to assess anticoagulant activity, and the use of reversal agents, to give the practicing anesthesiologist the necessary knowledge to manage situations encountered in clinical practice.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Individualized Fluid Management Using the Pleth Variability Index A
           Randomized Clinical Trial
    • Authors: Fischer M; Lemoine S, Tavernier B, et al.
      Abstract: Background The present trial was designed to assess whether individualized strategies of fluid administration using a noninvasive plethysmographic variability index could reduce the postoperative hospital length of stay and morbidity after intermediate-risk surgery. Methods This was a multicenter, randomized, nonblinded parallel-group clinical trial conducted in five hospitals. Adult patients in sinus rhythm having elective orthopedic surgery (knee or hip arthroplasty) under general anesthesia were enrolled. Individualized hemodynamic management aimed to achieve a plethysmographic variability index under 13%, and the standard management strategy aimed to maintain a mean arterial pressure above 65 mmHg during general anesthesia. The primary outcome was the postoperative hospital length of stay decided by surgeons blinded to the group allocation of the patient. Results In total, 447 patients were randomized, and 438 were included in the analysis. The mean hospital length of stay ± SD was 6 ± 3 days for the plethysmographic variability index group and 6 ± 3 days for the control group (adjusted difference, 0.0 days; 95% CI, −0.6 to 0.5; P = 0.860); the theoretical postoperative hospital length of stay was 4 ± 2 days for the plethysmographic variability index group and 4 ± 1 days for the control group (P = 0.238). In the plethysmographic variability index and control groups, serious postoperative cardiac complications occurred in 3 of 217 (1%) and 2 of 224 (1%) patients (P = 0.681), acute postoperative renal failure occurred in 9 (4%) and 8 (4%) patients (P = 0.808), the troponin Ic concentration was more than 0.06 μg/l within 5 days postoperatively for 6 (3%) and 5 (2%) patients (P = 0.768), and the postoperative arterial lactate measurements were 1.44 ± 1.01 and 1.43 ± 0.95 mmol/l (P = 0.974), respectively. Conclusions Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications. Editor’s Perspective What We Already Know about This Topic The role of guided fluid management remains unclear, with contradictory trial results.The noninvasive plethysmographic variability index is one method of guiding fluid administration. What This Article Tells Us That Is New The investigators randomized 447 moderate-risk major arthroplasty patients to plethysmographic-guided versus routine fluid management.Fitness for discharge and actual hospital durations were essentially identical in each group. Complications were rare and similar in each group.Plethysmographic-guided fluid management did not reduce the duration of hospitalization or complications in moderate-risk surgery patients.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • An Effective and Efficient Testing Protocol for Diagnosing Iron-deficiency
           Anemia Preoperatively
    • Authors: Okocha O; Dand H, Avram MJ, et al.
      Abstract: Background Iron-deficiency anemia is a common perioperative condition and increases perioperative morbidity and mortality. Timely diagnosis and treatment are important. This retrospective cohort study tested the hypothesis that a newly developed preprocedure evaluation protocol diagnoses more patients with iron-deficiency anemia than the traditional practice of obtaining a complete blood count followed by iron studies. Methods The preprocedure anemia evaluation is an order for a complete blood count and reflex anemia testing, which can be completed with a single patient visit. A hemoglobin concentration of 12 g/dl or less with serum ferritin concentration less than 30 ng/ml or transferrin saturation less than 20% defined iron-deficiency anemia. Northwestern Medicine’s database was queried for preoperative clinic patients, age 16 to 89 yr, before (2015 to 2016) and after (2017 to 2018) protocol implementation. The proportion of patients diagnosed with iron-deficiency anemia before and after the preprocedure anemia evaluation implementation was compared. Results Before implementing the protocol, 8,816 patients were screened with a traditional complete blood count. Subsequent iron studies at the providers’ discretion diagnosed 107 (1.2%) patients with iron-deficiency anemia. Some patients were still screened with a complete blood count after implementing the protocol; 154 of 4,629 (3.3%) patients screened with a complete blood count and 738 of 2,828 (26.1%) patients screened with the preprocedure anemia evaluation were diagnosed with iron-deficiency anemia. The preprocedure anemia evaluation identified a far larger proportion of patients with iron-deficiency anemia than did the traditional complete blood count when compared both before (relative risk [95% CI], 21.5 (17.6 to 26.2); P < 0.0001) and after (7.8 [6.6 to 9.3]; P < 0.0001) its implementation. Conclusions The preprocedure anemia evaluation improved identification of iron-deficiency anemia preoperatively. It is more effective and efficient, allowing anemia evaluation with a single patient visit. Editor’s Perspective What We Already Know about This Topic Iron-deficiency anemia is common and increases perioperative morbidity and mortalityTimely diagnosis facilitates treatment and may reduce complications What This Article Tells Us That Is New The investigators implemented a novel screening system in which anemia automatically triggered evaluation for iron deficiency using previously collected bloodThe automated system identified iron-deficiency anemia far better than clinicians using normal procedures
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • An ER Doctor Finds His Daughter in Critical Condition
    • Authors: Nicely J.
      Abstract: The operating room sounds oddly like jazz.
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Patient Blood Management Effectiveness and Future Potential
    • Authors: Spahn DR; Muñoz M, Klein AA, et al.
      Abstract: Before major surgery, 30 to 40% of patients are anemic, an important consideration that is associated with increased erythrocyte transfusions, prolonged hospital length of stay, more frequent intensive care admissions, infections, and thromboembolic events, and mortality.1–4 Surgical bleeding contributes to anemia, increases transfusions, and independently increases mortality.5 In addition, transfusion of allogeneic blood products is associated with increased morbidity and mortality6 and increased costs, and allogeneic blood products are a limited resource.6–8 Therefore, as a pragmatic solution, the concept of Patient Blood Management was developed and published in its preliminary form, first in the anesthesia literature as an editorial in Anesthesiology in 2008.9 The authors hypothesized that “Patient Blood Management will decrease the use of allogeneic erythrocyte transfusion and its cost and adverse sequelae significantly.” Currently, 12 yr later, we can conclude this is indeed the case.10–12
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
  • Neural Selective Cryoneurolysis with Ice Slurry Injection in a Rat Model
    • Authors: Garibyan L; Moradi Tuchayi S, Wang Y, et al.
      Abstract: Background Postoperative pain caused by trauma to nerves and tissue around the surgical site is a major problem. Perioperative steps to reduce postoperative pain include local anesthetics and opioids, the latter of which are addictive and have contributed to the opioid epidemic. Cryoneurolysis is a nonopioid and long-lasting treatment for reducing postoperative pain. However, current methods of cryoneurolysis are invasive, technically demanding, and are not tissue-selective. This project aims to determine whether ice slurry can be used as a novel, injectable, drug-free, and tissue-selective method of cryoneurolysis and resulting analgesia. Methods The authors developed an injectable and selective method of cryoneurolysis using biocompatible ice slurry, using rat sciatic nerve to investigate the effect of slurry injection on the structure and function of the nerve. Sixty-two naïve, male Sprague-Dawley rats were used in this study. Advanced Coherent anti-Stokes Raman Scattering microscopy, light, and fluorescent microscopy imaging were used at baseline and at various time points after treatment for evaluation and quantification of myelin sheath and axon structural integrity. Validated motor and sensory testing were used for evaluating the sciatic nerve function in response to ice slurry treatment. Results Ice slurry injection can selectively target the rat sciatic nerve. Being injectable, it can infiltrate around the nerve. The authors demonstrate that a single injection is safe and selective for reversibly disrupting the myelin sheaths and axon density, with complete structural recovery by day 112. This leads to decreased nocifensive function for up to 60 days, with complete recovery by day 112. There was up to median [interquartile range]: 68% [60 to 94%] reduction in mechanical pain response after treatment. Conclusions Ice slurry injection selectively targets the rat sciatic nerve, causing no damage to surrounding tissue. Injection of ice slurry around the rat sciatic nerve induced decreased nociceptive response from the baseline through neural selective cryoneurolysis. Editor’s Perspective What We Already Know about This Topic Achieving long-lasting surgical site anesthesia can be problematicCryoneurolysis is effective in providing long-lasting analgesia, but current techniques are nonselective for neural tissue What This Article Tells Us That Is New Using a rat sciatic nerve block model, an injectable biocompatible ice slurry preparation was shown to provide analgesic effects for at least 60 daysDisruption of myelin sheaths recovered by 112 days after injections, suggesting that the slurry-induced cryoneurolysis is reversibleProviding sustained analgesia using injected ice slurries may be possible
      PubDate: Wed, 01 Jul 2020 00:00:00 GMT
       
 
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