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Anesthesia & Analgesia
Journal Prestige (SJR): 1.472
Citation Impact (citeScore): 3
Number of Followers: 309  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0003-2999 - ISSN (Online) 1526-7598
Published by LWW Wolters Kluwer Homepage  [301 journals]
  • Global Impact: The Environmental Effects of Anesthetic Drugs

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      Authors: Nathan; Naveen
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Environmental and Occupational Considerations of Anesthesia: A Narrative
           Review and Update

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      Authors: Varughese; Shane; Ahmed, Raza
      Abstract: imageWith an estimated worldwide volume of 266 million surgeries in 2015, the call for general inhalation anesthesia is considerable. However, widely used volatile anesthetics such as N2O and the highly fluorinated gases sevoflurane, desflurane, and isoflurane are greenhouse gases, ozone-depleting agents, or both. Because these agents undergo minimal metabolism in the body during clinical use and are primarily (≥95%) eliminated unchanged via exhalation, waste anesthetic gases (WAGs) in operating rooms and postanesthesia care units can pose a challenge for overall elimination and occupational exposure. The chemical properties and global warming impacts of these gases vary, with atmospheric lifetimes of 1−5 years for sevoflurane, 3−6 years for isoflurane, 9−21 years for desflurane, and 114 years for N2O. Additionally, the use of N2O as a carrier gas for the inhalation anesthetics and as a supplement to intravenous (IV) anesthetics further contributes to these impacts. At the same time, unscavenged WAGs can result in chronic occupational exposure of health care workers to potential associated adverse health effects. Few adverse effects associated with WAGs have been documented, however, when workplace exposure limits are implemented. Specific measures that can help reduce occupational exposure and the environmental impact of inhaled anesthetics include efficient ventilation and scavenging systems, regular monitoring of airborne concentrations of waste gases to remain below recommended limits, ensuring that anesthesia equipment is well maintained, avoiding desflurane and N2O if possible, and minimizing fresh gas flow rates (eg, use of low-flow anesthesia). One alternative to volatile anesthetics may be total intravenous anesthesia (TIVA). While TIVA is not associated with the risks of occupational exposure or atmospheric pollution that are inherent to volatile anesthetic gases, clinical considerations should be weighed in the choice of agent. Appropriate procedures for the disposal of IV anesthetics must be followed to minimize any potential for negative environmental effects. Overall, although their contributions are relatively low compared with those of other human-produced substances, inhaled anesthetics are intrinsically potent greenhouse gases and pose a risk to operating-room personnel if not properly managed and scavenged. Factors to reduce waste and minimize the future impact of these substances should be considered.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Man vs Machine: Closed Loop or Manual Intravenous Anesthesia'

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      Authors: Nathan; Naveen
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Postoperative Neurocognitive Disorders After Closed-Loop Versus Manual
           Target Controlled-Infusion of Propofol and Remifentanil in Patients
           Undergoing Elective Major Noncardiac Surgery: The Randomized Controlled
           Postoperative Cognitive Dysfunction-Electroencephalographic-Guided
           Anesthetic Administration Trial

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      Authors: Mahr; Nicolas; Bouhake, Yannis; Chopard, Gilles; Liu, Ngai; Boichut, Nathalie; Chazot, Thierry; Claveau, Melanie; Vettoretti, Lucie; Tio, Gregory; Pili-Floury, Sebastien; Samain, Emmanuel; Besch, Guillaume
      Abstract: imageBACKGROUND: The aim of the study was to investigate whether closed-loop compared to manual bispectral index (BIS)–guided target-controlled infusion of propofol and remifentanil could decrease the incidence of postoperative neurocognitive disorders after elective major noncardiac surgery.METHODS: Patients aged>50 admitted for elective major noncardiac surgery were included in a single-blind randomized (ratio 2:1) trial. The anesthetic protocol was allocated by randomization into either closed-loop or manual BIS-guided propofol and remifentanil titration. The BIS target range was 40–60. All patients had cognitive assessment the day before surgery and within 72 hours after surgery using a battery of neuropsychological tests. The primary outcome was the rate of postoperative neurocognitive disorders. Postoperative neurocognitive disorders were defined as a decrease>20% from baseline on at least 3 scores. Intergroup comparison of the primary outcome was performed using the χ2 test.RESULTS: A total of 143 and 61 patients were included in the closed-loop and manual groups, respectively (age: 66 [8] vs 66 [9] years). The primary outcome was observed in 18 (13%) and 10 (16%) patients of the closed-loop and manual groups, respectively (relative risk [95% confidence interval {CI}], 0.77 [0.38-1.57], P = .47). Intraoperative propofol consumption was lower (4.7 [1.4] vs 5.7 [1.4] mg·kg−1·h−1, mean difference [MD] [95% CI], −0.73 [−0.98 to −0.48], P < .0001) and the proportion of time within the BIS target range higher (84 [77–89] vs 74 [54–81]%, MD [95% CI], 0.94 [0.67-1.21], P < .0001) in the closed-loop group.CONCLUSIONS: Closed-loop compared to manual BIS-guided total intravenous anesthesia provided a significant reduction in episodes of an excessive depth of anesthesia while decreasing intraoperative propofol requirement but no evidence for a reduction of the incidence of postoperative neurocognitive disorders after elective major noncardiac surgery was observed.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Focused Cardiac Ultrasound in the Operating Room—Another Important Tool
           for the Assessment of the Unstable Patient

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      Authors: Markin; Nicholas W.; Coker, Bradley J.; Tuck, Benjamin C.; Chacon, M. Megan
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A
           Systematic Review

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      Authors: Navas-Blanco; Jose R.; Louro, Jack; Reynolds, John; Epstein, Richard H.; Dudaryk, Roman
      Abstract: imageFocused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Home Is Where the Heart Is, but What About That Other Place You Spend Your
           Time'

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      Authors: Vinson; Amy E.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Determinants of Work-Related Quality of Life in French Anesthesiologists

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      Authors: Gafsou; Benjamin; Becq, Marie-Christine; Michelet, Daphné; Julien-Marsollier, Florence; Brasher, Christopher; Dahmani, Souhayl
      Abstract: imageBACKGROUND: Little evidence is available regarding work-related quality of life (WRQoL) for anesthesiologists. We aimed to explore factors associated with WRQoL among French anesthesiologists.METHODS: The study surveyed French anesthesiologists qualified for more than 2 years. The primary objective was the determination of factors associated with WRQoL. Factors analyzed included demographic characteristics, lifestyle, financial status, personality traits, professional relations, management and organization, and occupational tasks when at work. Statistical analyses were performed using a multivariable quantile regression model.RESULTS: Overall, 2040 anesthesiologists responded to the survey and 1922 responses were analyzed. The latter represents 19% of practicing French anesthesiologists. The following factors were independently associated with increased WRQoL: family income, long-term employment, organizational and managerial factors (lesser weekly workload, the belief of providing high quality, safe health care services, team management, and operating theatre organization), human relations (satisfaction with workplace ambiance and relations with hospital management and colleagues), and occupational tasks (participation in team activities). Three personality traits were found to be significantly associated with increased WRQoL: extraversion, conscientiousness, and openness. Neuroticism was associated with reduced WRQoL.CONCLUSIONS: The current study demonstrates exogenous and endogenous factors associated with increased WRQoL in anesthesiologists. Results should be considered as explorative and provide hypotheses for further research in this domain.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Guidance for a New Clinical Challenge

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      Authors: Joffe; Aaron M.; Tung, Avery
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Difficult Airway Management in Adult Coronavirus Disease 2019 Patients:
           Statement by the Society of Airway Management

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      Authors: Foley; Lorraine J.; Urdaneta, Felipe; Berkow, Lauren; Aziz, Michael F.; Baker, Paul A.; Jagannathan, Narasimhan; Rosenblatt, William; Straker, Tracey M.; Wong, David T.; Hagberg, Carin A.
      Abstract: imageThe coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Pediatric Airway Anatomy and Tracheal Tubes: It Is Not All About the Cuff

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      Authors: Peyton; James; Foglia, Elizabeth; Lee, Gi Soo
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Anatomical In Vitro Investigations of the Pediatric Larynx: A Call for
           Manufacturer Redesign of Tracheal Tube Cuff Location and Perhaps a Call to
           Reconsider the Use of Uncuffed Tracheal Tubes

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      Authors: Isa; Malaak; Holzki, Josef; Hagemeier, Anna; Rothschild, Markus A.; Coté, Charles J.
      Abstract: imageBACKGROUND: Some in vivo studies question the traditional “funnel-shaped” infant larynx; further anatomic examinations were warranted. Examination of fixative free fresh autopsy laryngeal and upper tracheal specimens and multiple measurements was needed to determine consistency between current tracheal tube designs and anatomic observations.METHODS: Larynges from 19 males and 11 females (Caucasian term newborn to 126 months) were examined by the same forensic pathologist. Measurements included anterior/posterior (A/P) and transverse (T) diameters of the cricoid outlet (CO), interarytenoid diameter (IAD), cricothyroid membrane (CTM), distance from the vocal cords (VC) to CO (VC-CO), and calibration of the larynx lumen with uncuffed tracheal tubes as measuring rods. Assessment of “safe tracheal tube placement” was assessed using manufacturer recommended cuffed Microcuff (Kimberly-Clark, Koblenz, Germany) tubes.RESULTS: In 77% (95% confidence interval [CI], 58-90) of specimens, the proximal end of the cuff was within the CO and in 23% even with or close to the CO. The VC-CO varied from 9.1 to 13.17 mm in infants, 11.55 to 15.17 mm in toddlers, and 13.19 to 18.34 mm in children. The A-P/T ratio of the CO was nearly 0.99 in most larynges; the IAD was greater than CO in all specimens. The CTM could be minimally distended in all specimens.CONCLUSIONS: First, despite being marketed as a safer tracheal tube design, the proximal end of the Microcuff cuff rested within or close to the cricoid cartilage theoretically increasing potential cuff-induced injury when using the VC markings for positioning. Our data suggest that the optimal cuff free distance (VC-CO) would be ~13.5 mm for a Microcuff internal diameter (ID) size 3.0, ~15 mm for size 3.5, and ~16 to 19 mm for greater sizes.Second, the CO was virtually circular in all specimens, suggesting that appropriately sized uncuffed tubes should provide an adequate seal in most neonates and toddlers, thus avoiding the potential for cuff-related necrosis injury.Third, the IAD was always greater than CO confirming that the narrowest point of the infant larynx is the nondistensible cricoid cartilage and not the easily distended glottis.Fourth, appropriately sized Microcuff tubes with the cuff deflated completely filled the lumen of the CO and proximal trachea in all specimens. Our data suggest the need for all manufacturers to further evaluate tracheal tube cuff locations and lengths in relation to the VC safe insertion markings, particularly for neonates and toddlers.Fifth, the CTM is minimally distensible, thus having important implications for emergency surgical airway access with most currently available emergency airway devices.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • The International Anesthesia Research Society Coronavirus Disease 2019
           Pandemic Scientific Advisory Board: Supporting a Pandemic of Positivity

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      Authors: Orser; Beverley A.; Jones, Keith A.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Effect of 6% Hydroxyethyl Starch 130/0.4 on Inflammatory Response and
           Pulmonary Function in Patients Having Cardiac Surgery: A Randomized
           Clinical Trial

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      Authors: Lee; Mee Jee; Tannenbaum, Charles; Mao, Guangmei; Jia, Yuan; Leung, Steve; Yilmaz, Hüseyin Oguz; Ince, Ilker; Soltesz, Edward; Duncan, Andra E.
      Abstract: imageBACKGROUND: Cardiac surgery with cardiopulmonary bypass induces a profound inflammatory response that, when severe, can lead to multiorgan system dysfunction. Preliminary data suggest that administration of hydroxyethyl starch (HES) solutions may mitigate an inflammatory response and improve pulmonary function. Our goal was to examine the effect of 6% HES 130/0.4 versus 5% human albumin given for intravascular plasma volume replacement on the perioperative inflammatory response and pulmonary function in patients undergoing cardiac surgery.METHODS: This was a subinvestigation of a blinded, parallel-group, randomized clinical trial of patients undergoing elective aortic valve replacement surgery at the Cleveland Clinic main campus, titled “Effect of 6% Hydroxyethyl Starch 130/0.4 on Kidney and Haemostatic Function in Cardiac Surgical Patients.” Of 141 patients who were randomized to receive either 6% HES 130/0.4 or 5% human albumin for intraoperative plasma volume replacement, 135 patients were included in the data analysis (HES n = 66, albumin n = 69). We assessed the cardiopulmonary bypass–induced inflammatory response end points by comparing the 2 groups’ serum concentrations of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and macrophage migration inhibitory factor (MIF), measured at baseline and at 1 and 24 hours after surgery. We also compared the 2 groups’ postoperative pulmonary function end points, including the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (Pao2:Fio2 ratio), dynamic lung compliance, oxygenation index (OI), and ventilation index (VI) at baseline, within 1 hour of arrival to the intensive care unit, and before tracheal extubation. The differences in the postoperative levels of inflammatory response and pulmonary function between the HES and albumin groups were assessed individually in linear mixed models.RESULTS: Serum concentrations of the inflammatory markers (TNF-α, IL-6, MIF) were not significantly different (P ≥ .05) between patients who received 6% HES 130/0.4 or 5% albumin, and there was no significant heterogeneity of the estimated treatment effect over time (P ≥ .15). The results of pulmonary function parameters (Pao2:Fio2 ratio, dynamic compliance, OI, VI) were not significantly different (P ≥ .05) between groups, and there was no significant heterogeneity of the estimated treatment effect over time (P ≥ .15).CONCLUSIONS: Our investigation found no significant difference in the concentrations of inflammatory markers and measures of pulmonary function between cardiac surgical patients who received 6% HES 130/0.4 versus 5% albumin.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Association Between Short-, Intermediate-, and Long-term Mortality and
           Myocardial Injury After Noncardiac Surgery After Hip Fracture Surgery: A
           Retrospective Cohort

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      Authors: Vacheron; Charles-Hervé; Hentzen, Julie; Fauvernier, Mathieu; Fessy, Michel; Chaudier, Philippe; Landel, Verena; David, Jean Stephane; Incagnoli, Pascal; Piriou, Vincent; Friggeri, Arnaud
      Abstract: imageBACKGROUND: For more than 20 years, hip fracture 1-year mortality has remained around 20%. An elevation of the postoperative troponin peak within 72 hours (myocardial injury after noncardiac surgery [MINS]) is associated with a greater risk of short-term mortality in the general population. However, there seem to be conflicting results in the specific population who undergo hip fracture surgery, with some studies finding an association between troponin and mortality and some not. The objective of the present study was to investigate the association of MINS and the short- (before 28th day), intermediate- (before 180th day), and long-term (before 365th day) mortality after hip fracture surgery.METHODS: We conducted a single-center retrospective cohort of patients undergoing hip fracture surgery from November 2013 to December 2015. MINS was defined as postoperative troponin peak within the 72 hours>5 ng/L. Four MINS subgroups were defined according to the value of troponin peak (ie, ≥5–
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Anesthetic Hypersensitivity in a Case-Controlled Series of Patients With
           Mitochondrial Disease

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      Authors: Hsieh; Vincent C.; Niezgoda, Julie; Sedensky, Margaret M.; Hoppel, Charles L.; Morgan, Philip G.
      Abstract: imageBACKGROUND: Children with mitochondrial disease undergo anesthesia for a wide array of surgical procedures. However, multiple medications used for their perioperative care can affect mitochondrial function. Defects in function of the mitochondrial electron transport chain (ETC) can lead to a profound hypersensitivity to sevoflurane in children. We studied the sensitivities to sevoflurane, during mask induction and maintenance of general anesthesia, in children presenting for muscle biopsies for diagnosis of mitochondrial disease.METHODS: In this multicenter study, 91 children, aged 6 months to 16 years, presented to the operating room for diagnostic muscle biopsy for presumptive mitochondrial disease. General anesthesia was induced by a slow increase of inhaled sevoflurane concentration. The primary end point, end-tidal (ET) sevoflurane necessary to achieve a bispectral index (BIS) of 60, was recorded. Secondary end points were maximal sevoflurane used to maintain a BIS between 40 and 60 during the case, and maximum and minimum heart rate and blood pressures. After induction, general anesthesia was maintained according to the preferences of the providers directing the cases. Primary data were analyzed comparing data from patients with complex I deficiencies to other groups using nonparametric statistics in SPSS v.27.RESULTS: The median sevoflurane concentration to reach BIS of 60 during inductions (ET sevoflurane % [BIS = 60]) was significantly lower for patients with complex I defects (0.98%; 95% confidence interval [CI], 0.5-1.4) compared to complex II (1.95%; 95% CI, 1.2-2.7; P < .001), complex III (2.0%; 95% CI, 0.7-3.5; P < .001), complex IV (2.0%; 95% CI, 1.7-3.2; P < .001), and normal groups (2.2%; 95% CI, 1.8-3.0; P < .001). The sevoflurane sensitivities of complex I patients did not reach significance when compared to patients diagnosed with mitochondrial disease but without an identifiable ETC abnormality (P = .172). Correlation of complex I activity with ET sevoflurane % (BIS = 60) gave a Spearman’s coefficient of 0.505 (P < .001). The differences in sensitivities between groups were less during the maintenance of the anesthetic than during induction.CONCLUSIONS: The data indicate that patients with complex I dysfunction are hypersensitive to sevoflurane compared to normal patients. Hypersensitivity was less common in patients presenting with other mitochondrial defects or without a mitochondrial diagnosis.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • A Remote Surveillance Platform to Monitor General Care Ward Surgical
           Patients for Acute Physiologic Deterioration

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      Authors: Safavi; Kyan C.; Deng, Hao; Driscoll, William; Nikolov, Milcho; Tolia, Kalpan; Wiener-Kronish, Jeanine P.
      Abstract: imageBACKGROUND: The traditional paradigm of hospital surgical ward care consists of episodic bedside visits by providers with periodic perusals of the patient’s electronic health record (EHR). Vital signs and laboratory results are directly pushed to the EHR but not to providers themselves. Results that require intervention may not be recognized for hours. Remote surveillance programs continuously monitor electronic data and provide automatic alerts that can be routed to multidisciplinary providers. Such programs have not been explored in surgical general care wards.METHODS: We performed a quality improvement observational study of otolaryngology and ophthalmology patients on a general care ward from October 2017 to March 2019 during nighttime hours (17:00–07:00). The study was initiated due to the loss of on-site anesthesiology resources that historically helped respond to acute physiologic deterioration events. We implemented a remote surveillance software program to continuously monitor patients for severe vital signs and laboratory abnormalities and automatically alert the ward team and a remote critical care anesthesiology team. The primary end point was the true positive rate, defined as the proportion of alerts that were associated with a downstream action that changed the care of the patient. This was determined using systematic chart review. The secondary end point, as a measure of alarm fatigue, was the average number of alerts per clinician shift.RESULTS: The software monitored 3926 hospital visits and analyzed 1,560,999 vitals signs and 16,635 laboratories. It generated 151 alerts, averaging 2.6 alerts per week. Of these, 143 (94.7%) were numerically accurate and 8 (5.3%) were inaccurate. Hypoxemia with oxygen saturation 130 beats per minute (19, 13.3%). Among the accurate alerts, 133 (88.1%) were true positives with an associated clinical action. Actions included a change in management 113 (67.7%), new diagnostic test 26 (15.6%), change in discharge planning 20 (12.0%), and change in level of care to the intensive care unit (ICU) 8 (4.8%). As a measure of alarm fatigue, there were 0.4 alerts per clinician shift.CONCLUSIONS: In a surgical general care ward, a remote surveillance software program that continually and automatically monitors physiologic data streams from the EHR and alerts multidisciplinary providers for severe derangements provided highly actionable alarms at a rate that is unlikely to cause alarm fatigue. Such programs are feasible and could be used to change the paradigm of monitoring.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Patient Satisfaction Through an Immersive Experience Using a Mobile
           Phone–Based Head-Mounted Display During Arthroscopic Knee Surgery Under
           Spinal Anesthesia: A Randomized Clinical Trial

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      Authors: Tharion; Joseph G.; Kale, Suniti
      Abstract: imageBACKGROUND: Patient satisfaction is an important element of high-quality health care. Virtual reality has been studied for its sedative and analgesic effects, as it immerses the patient into an artificial interactive environment. Deriving from this concept, we hypothesized that an immersive experience that engulfs the senses with noninteractive visual and auditory stimuli would have a positive effect on satisfaction and anxiety in patients undergoing spinal anesthesia.METHODS: We enrolled and randomized 90 patients undergoing spinal anesthesia for arthroscopic knee surgery into an immersive experience arm and an intravenous midazolam sedation arm. The immersive experience was provided through a mobile phone–based head-mounted display showing binocular monoscopic video and noise-canceling headphones playing audio. The primary outcome measure was postoperative satisfaction, measured using a visual analog scale and compared using the Mann-Whitney U test; secondary outcomes included anxiety score (measured using the 6-item State-Trait Anxiety Inventory), hemodynamic stability, and additional sedative requirement.RESULTS: The visual analog scale satisfaction score with immersive experience was significantly higher than with midazolam (median [interquartile range {IQR}] of 93 [82–98] and 80 [73–93], respectively, P = .004), with Hodges-Lehmann median difference estimate of 7 (95% confidence interval, 3–14). The change in anxiety scores from the preoperative to postoperative period between the groups was not significantly different (P = .08), with a Hodges-Lehmann median difference estimate of 3.3 (95% confidence interval, 0–6.7). All patients were hemodynamically stable, were without significant adverse events, and did not require additional sedatives.CONCLUSIONS: We have found that an immersive experience is an effective and acceptable intraoperative alternative to pharmacological sedation in patients undergoing arthroscopic knee surgery under spinal anesthesia, with higher satisfaction levels and no detected difference in preoperative to postoperative anxiolytic effect.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Comparative Effect of Propofol and Volatile Anesthetics on Postoperative
           Pulmonary Complications After Lung Resection Surgery: A Randomized
           Clinical Trial

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      Authors: Li; Xue-Fei; Hu, Jian-Rong; Wu, Yan; Chen, Ying; Zhang, Meng-Qiu; Yu, Hai
      Abstract: imageBACKGROUND: The effect of general anesthetics (propofol and volatile anesthetics) on pulmonary outcome after lung resection surgery with one-lung ventilation (OLV) is yet undetermined. We evaluated the effect of intravenous anesthesia (propofol) and volatile anesthesia (sevoflurane or desflurane) regimens on postoperative pulmonary complications (PPCs) in patients undergoing lung resection surgery.METHODS: This prospective, randomized controlled trial enrolled 555 adult patients scheduled for lung resection surgery with OLV. Participants were randomized to 1 of 3 general anesthetic regimens (propofol, sevoflurane, or desflurane). Standard anesthesia and ventilation protocols were followed in all groups. The primary outcome was a composite of PPCs in the first 7 postoperative days. Secondary outcomes included the severity of PPCs and major postoperative complications classification. Intergroup difference in the primary outcome was assessed for significance using the Pearson χ2 test.RESULTS: Of 837 patients who were assessed for eligibility, 555 were randomized and 545 were analyzed. One hundred and seventy-nine patients were assigned to the propofol group, 182 in the sevoflurane group, and 184 in the desflurane group. The incidence of PPCs did not differ between the combined volatile anesthetics (sevoflurane and desflurane) group and the propofol group (21.9% vs 24.0%; odds ratio, 0.89; 95% confidence interval, 0.58-1.35; P = .570). The PPCs grade and Clavien-Dindo scores did not differ significantly across groups.CONCLUSIONS: In patients undergoing lung resection surgery with OLV, general anesthesia with volatile anesthetics (sevoflurane or desflurane) did not reduce PPCs compared with propofol. No difference in secondary outcomes was observed.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Unanticipated Consequences of Switching to Sugammadex: Anesthesia Provider
           Survey on the Hormone Contraceptive Drug Interaction

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      Authors: Dwan; Robyn L.; Raymond, Britany L.; Richardson, Michael G.
      Abstract: imageBACKGROUND: Sugammadex binds progesterone with high affinity and may interfere with hormonal contraceptive effectiveness. The clinical, economical, and ethical implications of unintended pregnancy should prompt anesthesiologists to actively consider and manage this pharmacologic interaction. We surveyed anesthesiology providers at our institution about knowledge of this potential adverse drug interaction, how they manage it clinically, and the extent to which they involve patients in shared decision-making regarding choice of neuromuscular blocker antagonist.METHODS: A survey instrument was distributed to anesthesiology providers at a large, tertiary-care medical center. The survey explored prior experience using neostigmine and sugammadex, knowledge about potential sugammadex interference with hormonal contraception, pre-/postoperative counseling practices, clinical management, and shared decision-making regarding potential use of neostigmine in lieu of sugammadex to avoid this drug-drug interaction.RESULTS: Of 259 surveys distributed, 155 were fully completed, and 10 were partially completed. Overall response rate was 60% (residents 85%, student nurse anesthetists 53%, certified registered nurse anesthetists 58%, attendings 48%). All but 1 respondent recognized the potential for sugammadex interference with oral hormonal contraception. Far fewer accurately identified potential interference with hormonal intrauterine devices (44%) and hormonal contraceptive implants (55%). The manufacturer’s recommended 7-day duration of alternative contraception was correctly identified by 72% of respondents; others (22%) reported longer durations (range 10–30 days). Most (78% overall) agreed/strongly agreed that potential interference with contraceptive effectiveness should be discussed with patients preoperatively. Despite the majority (86% overall) that endorsed shared decision-making and inviting patient input regarding choice between sugammadex and neostigmine, many respondents reported “rarely/never” having discussed this drug interaction with patients in actual clinical practice, either preoperatively (67%) or postoperatively (80%). Furthermore, most respondents (79%) reported “rarely/never” administering neostigmine to intentionally avoid this drug interaction.CONCLUSIONS: Two years after designating sugammadex as antagonist of choice, physician and nurse anesthesia providers reported seldom inquiring about contraceptive use among women of childbearing potential and rarely discussing potential risk of contraceptive failure from sugammadex exposure. Most lack accurate knowledge of sugammadex interference with hormonal intrauterine and subcutaneous contraceptive devices. Although most endorse preoperative counseling and support patient autonomy or shared decision-making regarding choice of reversal agent, the same respondents report rarely, if ever, actualizing these positions in clinical practice. These conflicting findings highlight the need for education regarding residual neuromuscular block versus adverse drug interactions, collaboration among providers involved in patient counseling, and intentional mindfulness of reproductive justice when caring for women of childbearing potential.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Association Between Hyperbaric Bupivacaine Dose and Maternal Hypotension:
           Retrospective Database Study of 8226 Women Undergoing Cesarean Delivery
           Under Spinal Anesthesia

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      Authors: Weiniger; Carolyn F.; Heesen, Michael; Knigin, David; Deutsch, Frederic; Hilber, Nicole; Avidan, Alexander
      Abstract: imageBACKGROUND: Low-dose (≤8 mg) hyperbaric bupivacaine for spinal anesthesia during cesarean delivery results in reduced efficacy, yet as a secondary outcome was associated with reduced frequency of spinal-induced hypotension. Our primary aim was to investigate the relationship between hyperbaric bupivacaine dose and the occurrence of spinal-induced hypotension for cesarean delivery.METHODS: Retrospective study of cesarean delivery under spinal or combined spinal anesthesia with hyperbaric bupivacaine in 1 academic institution (2 centers—tertiary and district) from 2012 to 2018. Data were retrieved from the anesthesia information management systems (Metavision, iMDsoft, Tel Aviv, Israel) and the hospital information system, including potential confounding factors, maternal age and weight, hypertensive disease of pregnancy, single/multiple gestation, gestational age, vasopressor administration, planned/urgent surgery, position during anesthesia placement (sitting/lateral), and anesthesiologist seniority. Spinal-induced hypotension was defined as systolic blood pressure that either dropped>20% from baseline or
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Effect of Permissive Mild Hypercapnia on Cerebral Vasoreactivity in
           Infants: A Randomized Controlled Crossover Trial

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      Authors: Schopfer; Leonore; Habre, Walid; Pichon, Isabelle; Fodor, Gergely H.
      Abstract: imageBACKGROUND: Mechanical ventilation interferes with cerebral perfusion via changes in intrathoracic pressure and/or as a consequence of alterations in CO2. Cerebral vascular vasoreactivity is dependent on CO2, and hypocapnia can potentially lead to vasoconstriction and subsequent decrease in cerebral blood flow. Thus, we aimed at characterizing whether protective ventilation with mild permissive hypercapnia improves cerebral perfusion in infants.METHODS: Following ethical approval and parental consent, 19 infants were included in this crossover study and randomly assigned to 2 groups for which the initial ventilation parameters were set to achieve an end-tidal carbon dioxide (Etco2) of 6.5 kPa (group H: mild hypercapnia, n = 8) or 5.5 kPa (group N: normocapnia, n = 11). The threshold was then reversed before going back to the initial set value of normo- or hypercapnia. At each step, hemodynamic, respiratory, and near-infrared spectroscopy (NIRS)–derived parameters, including tissue oxygenation index (TOI) and tissue hemoglobin index (THI), concentration of deoxygenated hemoglobin (HHb) and oxygenated hemoglobin (O2Hb), were collected. Concomitantly, sevoflurane maintenance concentration, ventilatory (driving pressure) and hemodynamic parameters, as mean arterial pressure (MAP), were recorded.RESULTS: Targeting an Etco2 of 5.5 kPa resulted in significantly higher mean driving pressure than an Etco2 of 6.5 kPa (P < .01) with no difference between the groups in end-tidal sevoflurane, MAP, and heart rate. A large scatter was observed in NIRS-derived parameters, with no evidence for difference in Etco2 changes between or within groups. A mild decrease with time was observed in THI and MAP in infants randomly assigned to group N (P < .036 and P < .017, respectively). When pooling all groups together, a significant correlation was found between the changes in MAP and TOI (r = 0.481, P < .001).CONCLUSIONS: Allowing permissive mild hypercapnia during mechanical ventilation of infants led to lower driving pressure and comparable hemodynamic, respiratory, and cerebral oxygenation parameters than during normocapnia. Whereas a large scatter in NIRS-derived parameters was observed at all levels of Etco2, the correlation between TOI and MAP suggests that arterial pressure is an important component of cerebral oxygenation at mild hypercapnia.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Association Between Intraoperative Remifentanil Dosage and Postoperative
           Opioid Consumption in Adolescent Idiopathic Spine Surgery: A Retrospective
           Cohort Study

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      Authors: Lo; Calvin; Schwindt, Stephanie; Sharma, Richa; Dubé, Rebecca; Faraoni, David; Steinberg, Benjamin E.; Brown, Stephen
      Abstract: imageBACKGROUND: Adolescent idiopathic scoliosis (AIS) surgery is associated with significant postoperative pain. Remifentanil is a short-acting opioid that is often used as a component of total intravenous anesthesia. Remifentanil has been implicated in acute opioid tolerance and opioid-induced hyperalgesia, resulting in increased postoperative pain and opioid consumption. This retrospective study sought to investigate the relationship between the dose of intraoperative remifentanil and cumulative postoperative opioid consumption through 72 hours following surgery for pediatric AIS patients.METHODS: We performed a retrospective chart review of adolescent patients undergoing posterior spine instrumentation under total intravenous general anesthesia at a single major pediatric center between January 2015 and October 2017. The relationship between intraoperative cumulative weight-adjusted remifentanil dose and logarithmic transformation of cumulative weight-adjusted opioid consumption through 72 hours following surgery was examined by regression analysis. A priori determined potential confounding variables were collected, including demographic data, perioperative analgesic agents (ie, ketamine, dexmedetomidine, and acetaminophen), surgical duration, vertebrae instrumented, and blood transfusion. Multivariable linear regression analysis was used to adjust for these possible confounding variables.RESULTS: Eighty-nine patients met inclusion criteria, of which 78 had complete data for analysis. Univariable linear regression analysis revealed no association between remifentanil dose and opioid consumption through 72 hours following surgery (slope = 0.79 [95% confidence interval [CI], 0.61-0.98; R2 = 0.0039; P = .588]). After adjustment for possible confounding factors, no relationship between remifentanil dose (regression coefficient (coeff.) −0.08; 95% CI, −1.59 to 1.43; P = .912) and opioid consumption through 72 hours was found (slope =0.90 [95% CI, −0.65 to 2.46]; R2 = 0.1634). Similar results were obtained when the model was repeated for opioid consumption in postanesthesia care unit (PACU).CONCLUSIONS: In this study examining adolescent patients undergoing surgery for idiopathic scoliosis, no association was found between the dose of intraoperative remifentanil and postoperative opioid consumption in the context of a propofol-based total intravenous anesthetic and multimodal analgesia. These results provide direction for future prospective controlled studies to further evaluate this relationship.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Quantitative Pupillometry as a Predictor of Pediatric Postoperative
           Opioid–Induced Respiratory Depression

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      Authors: Packiasabapathy; Senthil; Zhang, Xue; Ding, Lili; Aruldhas, Blessed W.; Pawale, Dhanashri; Sadhasivam, Senthilkumar
      Abstract: imageBACKGROUND: Safe postoperative pain relief with opioids is an unmet critical medical need in children. There is a lack of objective, noninvasive bedside tool to assess central nervous system (CNS) effects of intraoperative opioids. Proactive identification of children at risk for postoperative respiratory depression (RD) will help tailor analgesic therapy and significantly improve the safety of opioids in children. Quantitative pupillometry (QP) is a noninvasive, objective, and real-time tool for monitoring CNS effect-time relationship of opioids. This exploratory study aimed to determine the association of QP measures with postoperative RD, as well as to identify the best intraoperative QP measures predictive of postoperative RD in children.METHODS: After approval from the institutional review board and informed parental consent, in this prospective, observational study of 220 children undergoing tonsillectomy, QP measures were collected at 5 time points: awake preoperative baseline before anesthesia induction (at the time of enrollment [T1]), immediately after anesthesia induction before morphine administration (T2), 3 minutes after intraoperative morphine administration (T3), at the end of surgery (T4), and postoperatively when awake in postanesthesia recovery unit (PACU) (T5). Intraoperative use of opioid and incidence of postoperative RD were collected. Analyses were aimed at exploring correlations of QP measures with the incidence of RD and, if found significant, to develop a predictive model for postoperative RD.RESULTS: Perioperative QP measures of percentage pupil constriction (CONQ, P = .027), minimum pupillary diameter (MIN, P = .027), and maximum pupillary diameter (MAX, P = .034) differed significantly among children with and without postoperative RD. A predictive model including the minimum pupillary diameter 3 minutes after morphine administration (MIN3), minimum pupillary diameter normalized to baseline (MIN31), and percentage pupillary constriction after surgery (T4) standardized to baseline (T1) (CONQ41), along with the weight-based morphine dose performed the best to predict postoperative RD in children (area under the curve [AUC], 0.76).CONCLUSIONS: A model based on pre- and intraoperative pupillometry measures including CONQ, MIN, along with weight-based morphine dose-predicted postoperative RD in our cohort of children undergoing tonsillectomy. More studies with a larger sample size are required to validate this finding.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Effect of Intraoperative Arterial Hypotension on the Risk of Perioperative
           

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      Authors: Wongtangman; Karuna; Wachtendorf, Luca J.; Blank, Michael; Grabitz, Stephanie D.; Linhardt, Felix C.; Azimaraghi, Omid; Raub, Dana; Pham, Stephanie; Kendale, Samir M.; Low, Ying H.; Houle, Timothy T.; Eikermann, Matthias; Pollard, Richard J.
      Abstract: imageBACKGROUND: Intraoperative cerebral blood flow is mainly determined by cerebral perfusion pressure and cerebral autoregulation of vasomotor tone. About 1% of patients undergoing noncardiac surgery develop ischemic stroke. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with an increased risk of perioperative ischemic stroke within 7 days after surgery.METHODS: Adult noncardiac surgical patients undergoing general anesthesia at Beth Israel Deaconess Medical Center and Massachusetts General Hospital between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as a decrease in mean arterial pressure (MAP) below 55 mm Hg, categorized into no intraoperative hypotension, short (30% from baseline on perioperative stroke. Analyses were adjusted for the preoperative STRoke After Surgery (STRAS) prediction score, work relative value units, and duration of surgery.RESULTS: Among 358,391 included patients, a total of 1553 (0.4%) experienced an early perioperative ischemic stroke. About 42% and 3% of patients had a MAP of below 55 mm Hg for a short and a prolonged duration, and 49% and 29% had a MAP decrease by>30% from baseline for a short and a prolonged duration, respectively. In an adjusted analysis, neither a MAP 30% (short duration: ORadj, 0.97; 95% CI, 0.67–1.42; P = .883 and prolonged duration: ORadj, 1.30; 95% CI, 0.89–1.90; P = .176) was associated with early perioperative stroke. A high a priori stroke risk quantified based on preoperatively available risk factors (STRAS prediction score) was associated with longer intraoperative hypotension (adjusted incidence rate ratio, 1.04; 95% CI, 1.04–1.05; P < .001 per 5 points of the STRAS prediction score).CONCLUSIONS: This study found no evidence to conclude that intraoperative hypotension within the range studied was associated with early perioperative stroke within 7 days after surgery. These findings emphasize the importance of perioperative cerebral blood flow autoregulation to prevent ischemic stroke.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Gender Differences in Compensation in Anesthesiology in the United States:
           Results of a National Survey of Anesthesiologists

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      Authors: Hertzberg; Linda B.; Miller, Thomas R.; Byerly, Stephanie; Rebello, Elizabeth; Flood, Pamela; Malinzak, Elizabeth B.; Doyle, Christine A.; Pease, Sonya; Rock-Klotz, Jennifer A.; Kraus, Molly B.; Pai, Sher-Lu
      Abstract: imageBACKGROUND: A gender-based compensation gap among physicians is well documented. Even after adjusting for age, experience, work hours, productivity, and academic rank, the gender gap remained and widened over the course of a physician’s career. This study aimed to examine if a significant gender pay gap still existed for anesthesiologists in the United States.METHODS: In 2018, we surveyed 28,812 physician members of the American Society of Anesthesiologists to assess the association of compensation with gender and to identify possible causes of wage disparities. Gender was the primary variable examined in the model, and compensation by gender was the primary outcome. Compensation was defined as the amount reported as direct compensation on a W-2, 1099, or K-1, plus all voluntary salary reductions (eg, 401[k], health insurance). The survey directed respondents to include salary, bonuses, incentive payments, research stipends, honoraria, and distribution of profits to employees. Respondents had the option of providing a point estimate of their compensation or selecting a range in $50,000 increments. Potential confounding variables that could affect compensation were identified based on a scoping literature review and the consensus expertise of the authors. We fitted a generalized ordinal logistic regression with 7 ranges of compensation. For the sensitivity analyses, we used linear regressions of log-transformed compensation based on respondent point estimates and imputed values.RESULTS: The final analytic sample consisted of 2081 observations (response rate, 7.2%). This sample represented a higher percentage of women and younger physicians compared to the demographic makeup of anesthesiologists in the United States. The adjusted odds ratio associated with gender equal to woman was an estimated 0.44 (95% confidence interval, 0.37–0.53), indicating that for a given compensation range, women had a 56% lower odds than men of being in a higher compensation range. Sensitivity analyses found the relative percentage difference in compensation for women compared to men ranged from −8.3 to −8.9. In the sensitivity analysis based on the subset of respondents (n = 1036) who provided a point estimate of compensation, the relative percentage difference (−8.3%; 95% confidence interval, −4.7 to −11.7) reflected a $32,617 lower compensation for women than men, holding other covariates at their means.CONCLUSIONS: Compensation for anesthesiologists showed a significant pay gap that was associated with gender even after adjusting for potential confounding factors, including age, hours worked, geographic practice region, practice type, position, and job selection criteria.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Immediate Effects of a Continuous Peripheral Nerve Block on Postamputation
           Phantom and Residual Limb Pain: Secondary Outcomes From a Multicenter
           Randomized Controlled Clinical Trial

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      Authors: Ilfeld; Brian M.; Khatibi, Bahareh; Maheshwari, Kamal; Madison, Sarah J.; Ali Sakr Esa, Wael; Mariano, Edward R.; Kent, Michael L.; Hanling, Steven; Sessler, Daniel I.; Eisenach, James C.; Cohen, Steven P.; Mascha, Edward J.; Yang, Dongsheng; Padwal, Jennifer A.; Turan, Alparslan; the PAINfRE Investigators
      Abstract: imageBACKGROUND: We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported.METHODS: Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article.RESULTS: Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0–2.5] vs 3.3 [0–5.0], median difference (98.75% confidence interval [CI]) of −1.0 (−3.0 to 0) for phantom pain (P = .001) and 0 [0–0] vs 0 [0–4.3], and median difference 0.0 (−2.0 to 0.0) for residual limb pain (P < .001). Pain’s interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0–10] vs 10 [0–40], median difference (98.75% CI) of 0.0 (−16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance.CONCLUSIONS: This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Effects of the ABCB1 c.3435C>T (rs1045642) Polymorphism on Heat Pain
           Perception in Opioid-Free Adults With Chronic Pain

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      Authors: Hooten; W. Michael; Hu, Danqing; Cunningham, Julie M.
      Abstract: imageBACKGROUND: The adenosine triphosphate-binding cassette, subfamily B, member 1 gene (ABCB1) encodes P-glycoprotein (P-gp) that influences the intracellular transport of solutes including endogenous opioid peptides. The primary objective of this study was to determine the effects of the ABCB1 polymorphism c.3435C>T (rs10454642) on heat pain (HP) perception in a group of opioid-free adults with chronic pain.METHODS: Opioid-free adults with chronic pain consecutively admitted to a pain rehabilitation program comprised the study cohort (N = 134). Individuals were genotyped for the c.3435C>T (rs10454642) polymorphism. The polymorphism was analyzed with nonparametric tests using a dominant (cytosine-cytosine [CC] versus cytosine-thymine [CT] + thymine-thymine [TT]) and recessive (CC + CT versus TT) model of allele effects. Quantitative sensory testing was performed using the Computer Aided Sensory Evaluator IV system.RESULTS: The distribution of genotypes was 22% (N = 29) for CC, 45% (N = 60) for CT, and 33% (N = 45) for TT (Hardy-Weinberg, P> .1). A significant association was observed between the recessive model and HP threshold. Standardized values of HP threshold were significantly greater in the TT group than the CC + CT group (median difference, −0.77; 95% confidence interval [CI], −1.49 to −0.23; P = .005), and the effect size estimate was small (Cliff delta = 0.30). In the dominant model, no significant difference in HP threshold was observed between the CC and CT + TT groups (median difference, −0.45; 95% CI, −1.15 to 0.00; P = .108).CONCLUSIONS: These results posit that the efflux of endogenous opioid peptides is reduced in individuals with the TT genotype due to lower expression of P-gp, which, in turn, results in higher HP threshold. This study contributes to the emerging understanding of how the ABCB1 c.3435C>T polymorphism contributes to pain perception in opioid-free adults with chronic pain and provides the foundation for investigating the potential effects of this polymorphism on the clinical course of chronic pain.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • A Randomized, Multicenter, Open-Label, Blinded End Point, Phase 2,
           Feasibility, Efficacy, and Safety Trial of Preoperative Microvascular
           Protection in Patients Undergoing Major Abdominal Surgery

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      Authors: Yanase; Fumitaka; Tosif, Shervin H.; Churilov, Leonid; Yee, Ken; Bellomo, Rinaldo; Gunn, Kerry; Kim, Chang; Krizhanovskii, Camilla; Hahn, Robert G.; Riedel, Bernhard; Weinberg, Laurence
      Abstract: imageBACKGROUND: The endothelial glycocalyx, a carbohydrate-rich layer coating all endothelial surfaces, plays a fundamental role in the function of microcirculation. The primary aim of this study was to evaluate the feasibility of using dexamethasone and albumin to protect the endothelial glycocalyx in patients undergoing abdominal surgery. Secondary and exploratory outcomes included efficacy and safety.METHODS: We conducted a multicenter, open-label, blinded end point, phase 2, randomized trial. Patients undergoing colorectal, pancreas, or liver surgery were recruited and randomized to receive either intravenous dexamethasone (16 mg) and 20% albumin (100 mL) at induction of anesthesia, then 200 mL of 20% albumin with each subsequent 1000 mL of crystalloid administered (dexamethasone and albumin [Dex-Alb] group), or crystalloid fluid only with no dexamethasone (control group). Feasibility end points included patient recruitment and retention, consent rate, and successful study drug administration. The primary efficacy end point was the measurement of plasma syndecan-1 level on postoperative day (POD) 1, and secondary end points were heparan sulfate levels and inflammatory markers measured at 4 perioperative timepoints. Safety end points included errors in administration of the intervention, hyperglycemia, occurrence of postoperative complications, and patient retention.RESULTS: Seventy-two patients were randomized. All feasibility end points were achievable. There were no statistically significant differences observed in median (interquartile range) syndecan-1 levels on POD 1 (39 ng·mL−1 [20–97] in the Dex-Alb group versus 41 ng·mL−1 [19–84] in the control group; difference in medians −2.1, 95% confidence interval [CI], −13 to 8.6; P = .69). The Dex-Alb group had lower POD 1 heparan sulfate levels (319 ng·mL−1 [161–717] in the Dex-Alb group versus 1422 [670–2430] ng·mL−1 in the control group; difference in medians −1085, 95% CI, −1779 to −391) and C-reactive protein (CRP) levels on POD 1 (48 [29–77] mg·L−1 in the Dex-Alb group versus 85 mg·L−1 [49–133] in the control group; difference in medians −48, 95% CI, −75 to −21). Fewer patients had one or more postoperative complication in the Dex-Alb group than in the control group (6 [17%] vs 18 patients [50%]; odds ratio = 0.2, 95% CI, 0.06–0.6).CONCLUSIONS: Intravenous dexamethasone and albumin administration was feasible but did not reduce syndecan-1 on POD 1 in patients undergoing abdominal surgery. Given the clinically important CIs observed between the groups for heparan sulfate, CRP, and postoperative complications, a larger trial assessing the associations between dexamethasone and albumin administration and these outcomes is warranted.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Apelin-13 Reverses Bupivacaine-Induced Cardiotoxicity via the Adenosine
           Monophosphate–Activated Protein Kinase Pathway

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      Authors: Ye; Yingchao; Cai, Yaoyao; Xia, Erjie; Shi, Kejian; Jin, Zhousheng; Chen, Hongfei; Xia, Fangfang; Xia, Yun; Papadimos, Thomas J.; Xu, Xuzhong; Liu, Le; Wang, Quanguang
      Abstract: imageBACKGROUND: Cardiotoxicity can be induced by the commonly used amide local anesthetic, bupivacaine. Bupivacaine can inhibit protein kinase B (AKT) phosphorylation and activated adenosine monophosphate–activated protein kinase alpha (AMPKα). It can decouple mitochondrial oxidative phosphorylation and enhance reactive oxygen species (ROS) production. Apelin enhances the phosphatidylinositol 3-kinase (PI3K)/AKT and AMPK/acetyl-CoA carboxylase (ACC) pathways, promotes the complete fatty acid oxidation in the heart, and reduces the release of ROS. In this study, we examined whether exogenous (Pyr1) apelin-13 could reverse bupivacaine-induced cardiotoxicity.METHODS: We used the bupivacaine-induced inhibition model in adult male Sprague Dawley (SD) rats (n = 48) and H9c2 cardiomyocyte cell cultures to explore the role of apelin-13 in the reversal of bupivacaine cardiotoxicity, and its possible mechanism of action. AMPKα, ACC, carnitine palmitoyl transferase (CPT), PI3K, AKT, superoxide dismutase 1 (SOD1), and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (p47-phox) were quantified. Changes in mitochondrial ultrastructure were examined, and mitochondrial DNA, cell viability, ROS release, oxygen consumption rate (OCR) were determined.RESULTS: Apelin-13 reduced bupivacaine-induced mitochondrial DNA lesions in SD rats (P < .001), while increasing the expression of AMPKα (P = .007) and PI3K (P = .002). Furthermore, apelin-13 blocked bupivacaine-induced depolarization of the mitochondrial membrane potential (P = .019) and the bupivacaine-induced increases in ROS (P = .001). Also, the AMPK pathway was activated by bupivacaine as well as apelin-13 (P = .002) in H9c2 cardiomyocytes. Additionally, the reduction in the PI3K expression by bupivacaine was mitigated by apelin-13 in H9c2 cardiomyocytes (P = .001). While the aforementioned changes induced by bupivacaine were not abated by apelin-13 after pretreatment with AMPK inhibitor compound C; the bupivacaine-induced changes were still mitigated by apelin-13, even when pretreated with PI3K inhibitor-LY294002.CONCLUSIONS: Apelin-13 treatment reduced bupivacaine-induced oxidative stress, attenuated mitochondrial morphological changes and mitochondrial DNA damage, enhanced mitochondrial energy metabolism, and ultimately reversed bupivacaine-induced cardiotoxicity. Our results suggest a role for the AMPK in apelin-13 reversal of bupivacaine-induced cardiotoxicity.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Hemodynamic and Intestinal Microcirculatory Changes in a Phenylephrine
           Corrected Porcine Model of Hemorrhage

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      Authors: Davies; Simon J.; Mythen, Monty
      Abstract: imageBACKGROUND: Intraoperative hypotension is a common event, and a recent study suggests that maintenance of blood pressure may reduce complications. The splanchnic circulation provides a reservoir of blood that can be mobilized during hemorrhage; hence, intestinal microcirculation is sensitive to volume changes. The aim of this study was to assess the impact of hemorrhage on intestinal microcirculation and hemodynamics, and the effects of phenylephrine on these parameters.METHODS: Eight anesthetized, mechanically ventilated Yorkshire/Landrace crossbreed pigs were studied. Graded hemorrhage was performed with the removal of 20% of blood volume in 5% increments. Hemodynamic and intestinal microcirculatory measurements were performed at each stage with side-stream dark field microscopy, following which mean arterial pressure (MAP) was corrected with phenylephrine to baseline values and measurements repeated. A repeated measurement 1-way analysis of variance (ANOVA) was used to compared changes from baseline measurements.RESULTS: The mean baseline microcirculation score was 42 (standard deviation [SD] = 5). A 5% hemorrhage decreased the microcirculation score by a mean difference of 19 (95% confidence interval [CI], 12-27; P < .0001), and an additional 5% hemorrhage further reduced the microcirculation score by a mean difference of 12 (95% CI, 4-19; P = .0001). Subsequent hemorrhage or administration of phenylephrine did not significantly change the microcirculation scores except when phenylephrine was administered at the 15% hemorrhage stage, which increased the microcirculation score by a mean difference of 7 (95% CI, 1-13; P = .003). All hemodynamic variables were returned to baseline values following hemorrhage by the phenylephrine infusion.CONCLUSIONS: Intestinal microcirculatory flow is reduced early in hemorrhage and is uncorrected by phenylephrine infusion. Hemodynamic changes associated with hemorrhage are corrected by phenylephrine and do not reflect microcirculatory flow status.
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Perspectives on Pain: A Visual Interpretation of Chronic Headaches

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      Authors: Rasmussen; Hannah K.
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Pick a Nice Dream

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      Authors: Camann; William
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Anesthesia Equipment: Principles and Applications, 3rd ed

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      Authors: Williams; Murray; Davies, Simon J.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Resources for Optimal Care of Emergency Surgery

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      Authors: Heilbronner Samuel; Anna R.; Steiner, Luzius A.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: Is It
           Really a Matter of Timing'

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      Authors: Pozzi; Federico; Palazzo, Nadia; Veronese, Giacomo; Stagni, Giuliana; Sattin, Luca; Bastia, Luca; Curto, Francesco; Chieregato, Arturo
      Abstract: imageNo abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • In Response

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      Authors: Mubashir; Talha; Arif, Abdul A.; Ernest, Prince; Maroufy, Vahed; Chaudhry, Rabail; Balogh, Julius; Suen, Colin; Reskallah, Alexander; Williams, George W.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Transfusion Thresholds in Cardiac Surgery

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      Authors: Schonberger; Robert B.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • In Response

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      Authors: Joshi; Ravi V.; Wilkey, Andrew L.; Greilich, Philip E.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • Sarcopenia After Sleeve Gastrectomy: A Concern of Anesthesiologists

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      Authors: Tabboush; Zafer S.
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
  • In Response

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      Authors: Yu; Jiawen; Che, Lu; Xu, Li
      Abstract: No abstract available
      PubDate: Fri, 01 Oct 2021 00:00:00 GMT-
       
 
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