Four-factor Prothrombin Complex Concentrate for the Management of Patients Receiving Direct Oral Activated Factor X Inhibitors
Direct oral anticoagulants (DOACs) have been approved for the prevention of stroke and systemic embolism in atrial fibrillation, treatment and secondary prevention of venous thromboembolism (VTE), and thromboprophylaxis after major orthopedic surgery. DOACs achieve anticoagulation by inhibiting specific coagulation factors; apixaban, betrixaban, edoxaban, and rivaroxaban inhibit activated factor X, whereas dabigatran inhibits thrombin (factor IIa). In contrast to vitamin K antagonists such as warfarin, DOACs have more predictable pharmacokinetics and pharmacodynamics and fewer interactions with other medications and food, ...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Pharmacodynamic Interaction of Remifentanil and Dexmedetomidine on Depth of Sedation and Tolerance of Laryngoscopy
Conclusions Low dexmedetomidine concentrations (EC50 of 0.49 ng/ml) are required to induce sedation as measured by the Patient State Index. Sensitivity to dexmedetomidine increases with age. Despite falling asleep, the majority of subjects remained arousable by calling the subject ’s name, “shake and shout,” or a trapezius squeeze, even when reaching supraclinical concentrations. Adding remifentanil does not alter the likelihood of response to graded stimuli. (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Early Postnatal Exposure to Isoflurane Disrupts Oligodendrocyte Development and Myelin Formation in the Mouse Hippocampus
Editor ’s PerspectiveWhat We Already Know about This TopicOligodendrocyte proliferation and maturation are prerequisites for myelination in the central nervous system. Disruption of these processes can lead to long-term impairment of neural function.Laboratory models demonstrate a variety of effects of anesthetics on the immature brain, but the consequences of early life anesthesia exposure on oligodendrocyte development have not been previously reported.What This Article Tells Us That Is NewExposure of 7-day-old mouse pups to isoflurane (1.5%, 4 h) results in lasting impairments of oligodendrocyte proliferation and ...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Reporting Laboratory and Animal Research in A nesthesiology The Importance of Sex as a Biologic Variable
“Consideration of sex as a biologic variable in conducting laboratory animal research—and inclusion of both sexes—is strongly encouraged.” (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Nitrous Oxide Impairs Axon Regeneration after Nervous System Injury in Male Rats
Editor ’s PerspectiveWhat We Already Know about This TopicNitrous oxide exposure can induce spinal cord neurodegeneration and related neuropathy in humans rendered susceptible by genetic or acquired risk factorsThe effects of nitrous oxide on the regeneration of nervous system following trauma has not been previously reportedWhat This Article Tells Us That Is NewInin vitro andin vivo experimental models of male rats, nitrous oxide exposure impairs folic acid-induced axonal regeneration of dorsal root and retinal ganglion neuronsThe beneficial effects of folic acid on functional recovery following spinal cord contusio...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Accuracy of Physical Function Questions to Predict Moderate-Vigorous Physical Activity as Measured by Hip Accelerometry
Conclusions Standardized physical function questions are highly sensitive but poorly specific to identify patients who achieve moderate physical activity. Additional strategies to evaluate functional capacity should be considered. (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Preoperative Assessment of Functional Capacity Looking beyond the Ability to Climb Stairs
“[H]ow might clinicians assess preoperative functional capacity in a more valid and prognostically accurate manner?” (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Intergenerational Effects of Sevoflurane in Young Adult Rats
Editor ’s PerspectiveWhat We Already Know about This TopicExposure to environmental stressors and endocrine disruptors can induce multigenerational effects resulting in neurobehavioral and other abnormalities in the offspringEarly-life anesthesia exposure in rodents alters neurocognitive function in their offspring, but whether exposure of adult animals affects offspring has not been previously reportedWhat This Article Tells Us That Is NewRepeated exposures of adult rats to sevoflurane (2.1%, three times, 3 h on every second day) induce neurobehavioral abnormalities in the exposed males and in male but not female pr...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Effect of Polyethylene-glycolated Carboxyhemoglobin on Renal Microcirculation in a Rat Model of Hemorrhagic Shock
Editor ’s PerspectiveWhat We Already Know about This TopicThe optimal fluid for resuscitation of hemorrhagic shock (crystalloid, colloid, or hemoglobin-containing) and mitigation of acute kidney injury is unknownWhat This Article Tells Us That Is NewIn a rat model of hemorrhagic shock comparing fluid resuscitation with blood, diluted blood, hydroxyethyl starch, or polyethylene-glycolated carboxyhemoglobin, all fluids restored urine output and creatinine clearance, but only blood and diluted blood improved renal Po2Postresuscitation histologic renal tubular damage was increased compared with nonresuscitated rats but s...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

My Brother ’s Ghost
In my grandfather ’s hospital, the ghosts are transient. (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Driving Pressure –guided Ventilation: Reply
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Driving Pressure –guided Ventilation: Comment
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Dexmedetomidine and the Upper Airway Not as Simple as We Hoped
“Breathing is truly a strange phenomenon of life, caught between the conscious and the unconscious, and peculiarly sensitive to both”1“[D]exmedetomidine seems to cause no less propensity for airway obstruction than does propofol at a similar level of sedation.” (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Extracorporeal Membrane Oxygenation 1-yr Outcome: Reply
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Extracorporeal Membrane Oxygenation 1-yr Outcome: Comment
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Effect of a Cognitive Aid on Reducing Sugammadex Use and Associated Costs A Time Series Analysis
Editor ’s PerspectiveWhat We Already Know about This TopicSugammadex provides rapid and effective reversal of neuromuscular blocks but is expensiveWhat This Article Tells Us That Is NewThe investigators tested the hypothesis that a cognitive aid to guide selective use of sugammadex reduced useThey conducted a segmented regression (interrupted time series) retrospective analysis before and after implementing the cognitive aid and informational meetings for their departmentSugammadex use and associated costs, which were increasing, decreased substantially after introduction of the cognitive aidBackground The authors ob...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

A Population-based Comparative Effectiveness Study of Peripheral Nerve Blocks for Hip Fracture Surgery
Conclusions Receipt of nerve blocks for hip fracture surgery is associated with decreased length of stay and health system costs, although small effect sizes may not reflect clinical significance for length of stay. (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Acoustic Shadowing Facilitates Ultrasound-guided Radial Artery Cannulation in Young Children
Conclusions Acoustic shadowingvia the use of double developing lines significantly improved the success rate of radial artery puncture in young children, compared with that achieved with the use of traditional ultrasound guidance. (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Vascular Endothelial Growth Factor A Signaling Promotes Spinal Central Sensitization and Pain-related Behaviors in Female Rats with Bone Cancer
This study tested the hypothesis that vascular endothelial growth factor A and vascular endothelial growth factor receptor 2 contribute to bone cancer pain regulation associated with spinal central sensitization.Methods This study was performed on female rats using a metastatic breast cancer bone pain model. Nociceptive behaviors were evaluated by mechanical allodynia, thermal hyperalgesia, spontaneous pain, and CatWalk gait analysis. Expression levels were measured by real-time quantitative polymerase chain reaction, western blot, and immunofluorescence analysis. Excitatory synaptic transmission was detected by whole-cell...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

This Month in Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Science, Medicine, and the Anesthesiologist
Key Papers from the Most Recent Literature Relevant to Anesthesiologists (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Safe Sedation Re-examined: Comparing the Respiratory Effects of Dexmedetomidine and Propofol
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

From Jerking Teeth to Clerking Harvard: Dr. Hiram Whitney and His Patients' Ethereal Requests
A lifelong native of Harvard, Massachusetts, Dr. Hiram Whitney (1815 to 1879) served as both a popular dentist and, for his final 13 yr, as the town clerk. Just 1 yr after Morton's public demonstration of surgical etherization, the 1848 “Environs of Boston” directory listed Dr. Whitney at the Warren Street address printed on this business card (above) from the Wood Library-Museum's Ben Z. Swanson Collection. In those early years of etherizing patients, many dentists were discouraged by the ethereal legacy of day-long accumulation of drowsy, nauseated patients in dental offices. Perhaps that is why Dr. Whitney w...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Dr. Rudolph Matas: Surgeon, Author, and an American Pioneer of Spinal Anesthesia
Born in Bonnet Carre, Louisiana (seered diamond,left), Rudolph Matas (1860 to 1957) was raised in Spain and then Texas before returning to his birth state for eventual medical schooling at the future Tulane University School of Medicine. After earning his M.D. at 19 yr of age, Dr. Matas began transforming himself into “the most learned surgeon” that Dr. Will Mayo had “ever known.” Along the way, in 1889, Dr. Matas would also conduct America's first spinal anesthetic. By December of 1940, Matas was completing his eighth year of penning (right) a five-volume medical history of Louisiana. (Copyright &c...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

From Fixing Photos to Fixing Cyanide Poisoning: Herschel's “Hypo” or Sodium Thiosulfate
In 1819, a soon-to-be-knighted John Herschel (1792 to 1871) discovered that hyposulfite of soda could “fix” or make photographic images permanent by dissolving away unexposed and otherwise insoluble silver salts. This British genius soon coined terms for his astronomical or botanical images as “negatives” or “positives” and for the art as “photography.” Even after it was renamed sodi um thiosulfate, hyposulfite of soda retained photographers’ nickname for it: “hypo.” An antidote for cyanide poisoning, sodium thiosulfate was supplied in ampoules to physicians...
Source: Anesthesiology - October 15, 2019 Category: Anesthesiology Source Type: research

Inflammatory Basis of Pulmonary Arterial Hypertension Implications for Perioperative and Critical Care Medicine
Pulmonary hypertension, defined as a resting mean pulmonary artery pressure greater than or equal to 25 mmHg, results from a myriad of conditions. The Fifth World Symposium on Pulmonary Hypertension proposed a classification system that organizes pulmonary hypertension into five groups based on common hemodynamic, pathophysiologic, and therapeutic parameters.1 This review focuses on pulmonary arterial hypertension (Group 1 pulmonary hypertension), a disease in which progressive pulmonary vascular obstruction, remodeling, and destruction lead to increased right ventricular afterload and hypertrophy, right heart failure, and...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Emergency Airway Management with a Laryngeal Mask Airway in a Patient with Massive Cervical Lipomas
(Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

My Personal Tryst with Ketamine Anesthesia
I spent a recent Saturday afternoon in the emergency department for an exceptionally painful thrombosed hemorrhoid. Because the operating rooms were unavailable, the surgeon suggested that he could make the small nick necessary to drain the clot in the emergency department procedure room with an emergency department physician serving as the anesthesia provider. As I was not technicallynon per os, having had water and a few raw carrots, the emergency department team decided to use ketamine for my anesthetic. The unpleasant side effects of ketamine are something I am well acquainted with as I have been a practicing physician...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Positive End-expiratory Pressure and Postoperative Atelectasis A Randomized Controlled Trial
Conclusions Withdrawing PEEP before emergence preoxygenation does not reduce atelectasis formation after nonabdominal surgery. Despite using 100% oxygen during awakening, postoperative atelectasis is small and does not affect oxygenation, possibly conditional on an open lung during anesthesia, as achieved by intraoperative PEEP. (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Partial Atrioventricular Canal Defect
(Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Intraoperative Application of Lung Ultrasound to Diagnose Alveolar Consolidation
(Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Modification of the World Health Organization Global Guidelines for Prevention of Surgical Site Infection Is Needed
“[T]he absence of harm, but without any benefit, should not be enough to encourage general use of hyperoxia.” (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

GAS, PANDA, and MASK No Evidence of Clinical Anesthetic Neurotoxicity!
“The comfortable truth is…the likelihood that developmental anesthesia neurotoxicity may not exist in routine surgical procedures that occur in early life.” (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Management of Difficult Tracheal Intubation A Closed Claims Analysis
This article compared recent malpractice claims related to difficult tracheal intubation to historic claims using the Anesthesia Closed Claims Project database.Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. The number of claims during the induction phase of anesthesia in this report is comparable with the previous report of 1993 to 1999, but outcomes are poorer.Inadequate airway planning and judgment errors were contributors to patient harm. Almost three fourths exhibited judgment failures, which were more common in elective and urgent intubation procedures than emergency trac...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Pre-emergence Oxygenation and Postoperative Atelectasis
“[A]dministration of 100% oxygen to confer patient safety during emergence is unlikely to increase atelectasis if intraoperative PEEP is used.” (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries A Randomized Controlled Trial
Editor ’s PerspectiveWhat We Already Know about This TopicHispanic women choose epidural labor analgesia less commonly than non-Hispanic women. The causes of the healthcare disparity are unknown, and effective interventions are to be established.What This Article Tells Us That Is NewA language-concordant, educational program regarding labor epidurals during the first stage of labor, in addition to the routine prenatal education, is feasible and does not cause any negative effect.Such an intervention increases epidural use among Hispanic but not non-Hispanic women.It also reduces misconceptions regarding epidural anal...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants A Single-center, Retrospective Study
Editor ’s PerspectiveWhat We Already Know about This TopicSuccessful tracheal intubation of an infant may be a challenging skill to acquire due to differing anatomy and physiology compared to older children and adultsMultiple intubation attempts may be associated with increased complicationsWhat This Article Tells Us That Is NewIn a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopiesThere was also a 35% incidence of hypoxemia, defined as an oxygen saturation measurement less than 90%, during induction of anesthesiaThere was evidence for an a...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Current Difficult Airway Management —Not Good Enough!
“It is time for us to lift standards in crisis management for airway difficulties through a more rigorous approach to training, certification, and equipment availability…” (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Musings from an Unlikely Clinician –Scientist 2018 American Society of Anesthesiologists Excellence in Research Award
This article, which stems from the 2018 American Society of Anesthesiologists Excellence in Research Award Lecture, aims to encourage young investigators, offer advice, and share several early life experiences that have influenced the author ’s career as an anesthesiologist and clinician–scientist. The article also describes key discoveries that have increased understanding of the role of γ-aminobutyric acid type A (GABAA) receptors in health and disease. The author ’s research team identified the unique pharmacologic properties of extrasynaptic GABAA receptors and their role in the anesthetic state...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Assessment of Common Criteria for Awake Extubation in Infants and Young Children
Conclusions Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation. (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Propofol Anesthesia Alters Spatial and Topologic Organization of Rat Brain Metabolism
Editor ’s PerspectiveWhat We Already Know about This TopicGraph theory and network analysis have been applied to neuroimaging and neurophysiologic data in the anesthetized state, but there has been little formal analysis of metabolic networks.What This Article Tells Us That Is NewThe brains of rodents undergoing propofol anesthesia demonstrate reduced metabolic network connectivity and efficiency. These effects might inform the mechanism of the functional disconnections and network inefficiency observed during general anesthesia in humans.Background Loss of consciousness during anesthesia reduces local and global rat...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Supplemental Oxygen and the Risk of Surgical Site Infection Evidence of Compromised Data Requires Correction of Previously Published Meta-analysis
(Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Simulator Training Enhances Resident Performance in Transesophageal Echocardiography: Erratum
In the January 2014 issue, the article “Simulator Training Enhances Resident Performance in Transesophageal Echocardiography” (Ferrero NA, Bortsov AV, Arora H, Martinelli SM, Kolarczyk LM, Teeter EC, Zvara DA, Kumar PA: Anesthesiology 2014; 120:149 –59) lists an incorrect middle initial for coauthor Emily Teeter. Dr. Teeter’s middle initial should have been listed as “G,” not “C.” (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Learners and Luddites in the Twenty-first Century Bringing Evidence-based Education to Anesthesiology
Anesthesiologists are both teachers and learners and alternate between these roles throughout their careers. However, few anesthesiologists have formal training in the methodologies and theories of education. Many anesthesiology educators often teach as they were taught and may not be taking advantage of current evidence in education to guide and optimize the way they teach and learn. This review describes the most up-to-date evidence in education for teaching knowledge, procedural skills, and professionalism. Methods such as active learning, spaced learning, interleaving, retrieval practice, e-learning, experiential learn...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Outcomes of Sympathetic Blocks in the Management of Complex Regional Pain Syndrome A Retrospective Cohort Study
Conclusions The authors conclude that sympathetic blocks may be therapeutic in patients with complex regional pain syndrome regardless of preprocedure limb temperatures. The effects of sympathetic blocks do not predict the success of spinal cord stimulation. (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Adding Science to the Decision to Extubate Children
“[E]xpert judgments are challenging to study [objectively] because most decisions are based on an expert’s ability to integrate their knowledge and experience in a timely manner.” (Source: Anesthesiology)
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research