Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events A Randomized Controlled Trial
Background Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events.Methods Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk...
Source: Anesthesiology - May 15, 2018 Category: Anesthesiology Source Type: research

Energetics and the Root Mechanical Cause for Ventilator-induced Lung Injury
“The root mechanical cause that initiates ventilator- induced lung injury at the tissue level…remains elusive.” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2018 Category: Anesthesiology Source Type: research

Neutrophils A Therapeutic Target of Local Anesthetics?
“…should voltage- gated sodium channels be therapeutically tar geted in inflammation and ischemia-reperfusion injury?” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2018 Category: Anesthesiology Source Type: research

Type 2 Perioperative Myocardial Infarction Can We Close Pandora ’s Box?
“…what constitutes [perioperative] myocardial infarction, its subtypes, and treatment strategies[?]” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2018 Category: Anesthesiology Source Type: research

A Second Look at the Second Gas Effect
“…[T]he second gas effect is real, and not just a theoretical construct...” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2018 Category: Anesthesiology Source Type: research

Induction of Anesthesia for Children Should We Recommend the Needle or the Mask?
“Should all children now have intravenous inductions? Maybe, and maybe not.” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2018 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Targeted Genotyping Identifies Susceptibility Locus in Brain-derived Neurotrophic Factor Gene for Chronic Postsurgical Pain: Erratum
In the article beginning on page 587 in the March 2018 issue, additional clarification is needed in the abstract and discussion sections. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Buprenorphine Depresses Respiratory Variability in Obese Mice with Altered Leptin Signaling: Erratum
In the Online First article published on February 2, 2018, there were errors in figure 3C and figure 3D. In both panels, there was a black dot appearing to the right of the red bar. This dot was extraneous and has been deleted. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes: A Population-based Cohort Study: Erratum
In the article beginning on page 480 in the March 2018 issue, Dr. Wijeysundera ’s credentials were listed incorrectly in the byline. They should have appeared as Duminda N. Wijeysundera, M.D., Ph.D., F.R.C.P.C. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Fear in Perspective
I review the patient ’s chart. I enter the room and step around the curtain where she waits, ready for her operation. She is comfortably chatting with her grown son and daughter. Her elderly husband leans on his cane, head tilted to catch all the conversation. Views of the sun-dappled East River calm the mind. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Your Anesthesiologist Self
Your anesthesiologist self pockets memories: (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Averting Opioid-induced Respiratory Depression without Affecting Analgesia
The ventilatory control system is highly vulnerable to exogenous administered opioid analgesics. Particularly respiratory depression is a potentially lethal complication that may occur when opioids are overdosed or consumed in combination with other depressants such as sleep medication or alcohol. Fatalities occur in acute and chronic pain patients on opioid therapy and individuals that abuse prescription or illicit opioids for their hedonistic pleasure. One important strategy to mitigate opioid-induced respiratory depression is cotreatment with nonopioid respiratory stimulants. Effective stimulants prevent respiratory dep...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Abuse-deterrent Opioid Formulations
Abuse-deterrent opioid formulations have been suggested as one way to decrease the abuse, addiction, and overdose of orally prescribed opioids. Ten oral opioid formulations have received abuse-deterrent labeling by the U.S. Food and Drug Administration (FDA). Their properties consist of physical and/or chemical means by which the pills resist manipulation and create a barrier to unintended administration, such as chewing, nasal snorting, smoking, and intravenous injection. In this review, we describe the mechanisms of abuse-deterrent technology, the types of premarketing studies required for FDA approval, the pharmacology ...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Neurologic Considerations and Complications Related to Liver Transplantation
THE pathophysiology of liver failure is associated with multisystem derangement including metabolic disequilibrium, low systemic vascular resistance, hyperdynamic circulation, anemia, a rebalanced state of coagulation, and impaired cerebral autoregulation. Liver transplantation is the only definitive treatment for end-stage liver disease and, although outcomes after liver transplant continue to improve, the postoperative phase remains challenging for both patients and clinicians.1 Perioperative organ injury, including injury to the brain, is a leading cause of death in the United States.2 Compared to the transplantation of...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Cervical Deformity and Potential Difficult Airway Management in Klippel –Feil Syndrome
KLIPPEL –FEIL syndrome presents with a short neck and severe restriction of cervical motion.1 The accompanying magnetic resonance image demonstrates this neck deformity due to the fusion of cervical vertebrae (image A,arrow A) and severe central canal stenosis (image A,arrow B). A lateral cervical spine X-ray (image B) demonstrates cervical fusion (arrow A ’) but not the extent of spinal canal narrowing, and thus magnetic resonance imaging or computed tomography better informs preoperative airway assessment. Preoperative review of the imaging is instrumental to objective airway assessment, risk stratification, ...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Hemopericardium and Acute Cardiac Tamponade
HEMOPERICARDIUM leading to acute cardiac tamponade is a true emergency. The accompanying transesophageal echocardiography images exhibit such an occurrence. A significant effusion is layering both the ventricles (top panel). A large clot in the pericardial space is compressing the free wall of the right ventricle (bottom panel). Being thin-walled, the right atrium is most prone to compression (see video, Supplemental Digital Content,http://links.lww.com/ALN/B571, which demonstrates clot impinging on right atrium). Common causes include malignancy, aortic dissection, myocardial wall rupture, cardiac surgery, and chest traum...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Takayasu Arteritis and Complete Aortic Arch Branch Vessel Occlusions
TAKAYASU arteritis is a large vessel vasculitis of the aorta and its primary branches.1 Severe cases may involve complete occlusion of aortic arch branch vessels as noted in the computerized tomography from this 28-yr-old woman. Three-dimensional (A) and coronal (B) images from a contrast-enhanced computerized tomography demonstrate irregular severe stenosis of the right common carotid artery (red arrows) and complete occlusions of bilateral subclavian arteries (yellow arrows), the left common carotid artery (white brackets), and the left vertebral artery (white arrow inA). Note the hypertrophied right vertebral artery (gr...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Images in Anesthesiology: Spinal Subdural Hematoma after Spinal Drain for Endovascular Thoracic Aortic Aneurysm Repair
SPINAL drain is indicated as a standard of care in open and endovascular thoracic aortic aneurysm repair to protect the spinal cord from ischemic injury and paralysis. Unfortunately, subdural hematoma is a complication of spinal drain that can happen during needle insertion, cerebrospinal fluid drainage, and catheter removal. Symptoms of subdural hematoma can manifest as low back pain, muscle weakness, paralysis, bowel or bladder incontinence, orcauda equina syndrome. These sagittal (panel A) and axial (panel B) T1-weighted magnetic resonance images of the lumbar spine demonstrate a subdural hematoma at the L5 to S2 verteb...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

This Month in Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Reducing Harm from Opioids: New Approaches for a Pressing Problem
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Science, Medicine, and the Anesthesiologist
Key Papers from the Most Recent Literature Relevant to Anesthesiologists (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Streams of Unconsciousness II: Hypnosis Reflected in the Styx
Besides the amnesia associated with the underworld ’s River Lethe, Greco-Roman mythology reflected the hypnosis or heavy trance induced by a different plutonic river, the Styx. The invulnerability conferred by Stygian waters—which famously had missed shielding Achilles’s heel—ensured that Wrathful souls could flail into each other eternally while swimming in a ceaseless daze through the Styx. As illustrated by Gustave Dore for Dante’sDivine Comedy, Phlegyas is ferrying Dante and the poet Virgil (all standing, left to right,above) through the thrashing Wrathful and across this shadowy “Ri...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Yellow Journalism Highlights Postanesthetic Complications: Pulitzer versus Hearst
In 1898 in the second issue of the magazineVim, artist Leon Barritt (1851 to 1938) published his cartoon “The Big Type War of the Yellow Kids.” He depicted newspaper magnates Joseph J. Pulitzer (1847 to 1911,left) and William Randolph Hearst (1863 to 1951,right) fighting over stacked toy blocks spelling out “WAR.” (Both publishers had been accused of hyperbolic news coverage of events leading to and happening during the Spanish-American War.) Each newspaper titan is outfitted by cartoonist Barritt in the garb of the Yellow Kid, the cartoon character of another artist who was enticed by Hearst away f...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Charles Halpine or How Chloroform Killed Simultaneously a General and a Private
Born in Oldcastle, County Meath, Ireland, Charles Graham Halpine (1825 to 1868) emigrated to the United States in 1851. He worked as a journalist and editor in Boston, Washington, D.C., and then New York City, before joining the Union ’s 69th New York Volunteer Infantry. During the Civil War, he penned poetry and prose for periodicals and eventually books under the pseudonym of “Miles O’Reilly,” a hapless Irish private in the “47th Regiment New York Volunteers.” Progressively reassigned and promoted through the ranks, Halpine was photographed (above) as a lieutenant colonel. By the time ...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Method for Intraarticular Knee Injection
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

In Ultrasound Images, All That Is Black Is Not Always Fluid
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Pump and Dump; Anesthesiologists Lead the Feed
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

In Reply
We thank Drs. Liang and Rice for their insightful comments on our study.1 There is no widely used or accepted reference method for blood glucose; therefore, the reference method used is a potentially confounding variable in studies of glucose meter accuracy. Perhaps the best choice for any study would be the predicate method for the device being studied, which for the Nova StatStrip (Nova Biomedical Corporation, USA) would be the plasma hexokinase method. The choice of reference method, however, needs to be weighed against other logistical aspects of study design. Specifically, cellular glycolysis occurring in the referenc...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Assessing Glucose Meter Accuracy: The Details Matter!
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

In Reply
We sincerely thank Drs. Vistisen and Scheeren for their insightful comments regarding our recent article.1 The authors pinpointed that calculating predictor and outcome variables from the same baseline may induce theoretical methodologic misinterpretations. Even though we agree with their point of view, we are convinced that it has less impact on our results. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Challenge of the Mini-fluid Challenge: Filling Twice without Creating a Self-fulfilling Prophecy Design
(Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Nonpeptide Orexin-2 Receptor Agonist Attenuates Morphine-induced Sedative Effects in Rats
This study aimed to explore the potential of a nonpeptide orexin receptor agonist to alleviate morphine-induced sedative effects.Methods Morphine sedative effects were evaluated as changes in electroencephalogram (EEG), locomotor activity, and acoustic startle response in rats (n = 5 to 9 per group). Effects of intracerebroventricular orexin-A and systemic orexin type-2 receptor agonist, YNT-185, on EEG changes induced by morphine were examined. Furthermore, the authors examined effects of morphine administered with or without YNT-185 on locomotor activity and on acoustic startle response.Results Morphine-induced, frequent...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Buprenorphine Depresses Respiratory Variability in Obese Mice with Altered Leptin Signaling
Background Opiate-induced respiratory depression is sexually dimorphic and associated with increased risk among the obese. The mechanisms underlying these associations are unknown. The present study evaluated the two-tailed hypothesis that sex, leptin status, and obesity modulate buprenorphine-induced changes in breathing.Methods Mice (n = 40 male and 40 female) comprising four congenic lines that differ in leptin signaling and body weight were injected with saline and buprenorphine (0.3  mg/kg). Whole-body plethysmography was used to quantify the effects on minute ventilation. The data were evaluated using three-wa...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Overexpression of µ-Opioid Receptors in Peripheral Afferents, but Not in Combination with Enkephalin, Decreases Neuropathic Pain Behavior and Enhances Opioid Analgesia in Mouse
Conclusions Increasing primary afferent expression of opioid receptors can decrease neuropathic pain-associated behaviors and increase systemic opioid analgesia through inhibition of peripheral afferent fiber activity. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

New Opioid Analgesic Approvals and Outpatient Utilization of Opioid Analgesics in the United States, 1997 through 2015
Conclusions There has been a dramatic increase in prescriptions dispensed for opioid analgesics since 1997 and an increasing number of opioid analgesic approvals; however, the number of prescriptions dispensed has declined since 2012 despite an increasing number of approvals. Examination of dispensed prescriptions shows a shifting and complex market where multiple factors likely influence prescribing; the approval of new products alone may not be sufficient to be a primary driver of increased prescribing.Visual Abstract An online visual overview is available for this article athttp://links.lww.com/ALN/B705. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Pharmacokinetic Properties of a Sufentanil Sublingual Tablet Intended to Treat Acute Pain
Conclusions The time course of a single 30- µg dose was consistent with onset of analgesia and redosing frequency observed in clinical trials. Sublingual sufentanil tablets provide the opportunity to noninvasively and rapidly treat moderate-to-severe pain in a monitored setting. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Benefit versus Severe Side Effects of Opioid Analgesia Novel Utility Functions of Probability of Analgesia and Respiratory Depression
Conclusions The utility function was successfully further developed, allowing assessment of specific conditions in terms of wanted and unwanted effects. This approach can be used to compare the toxic effects of drugs relative to their intended effect and may be a useful tool in the development of new compounds to assess their advantage over existing drugs. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Dexmedetomidine Prevents Cognitive Decline by Enhancing Resolution of High Mobility Group Box 1 Protein –induced Inflammation through a Vagomimetic Action in Mice
Background Inflammation initiated by damage-associated molecular patterns has been implicated for the cognitive decline associated with surgical trauma and serious illness. We determined whether resolution of inflammation mediates dexmedetomidine-induced reduction of damage-associated molecular pattern –induced cognitive decline.Methods Cognitive decline (assessed by trace fear conditioning) was induced with high molecular group box 1 protein, a damage-associated molecular pattern, in mice that also received blockers of neural (vagal) and humoral inflammation-resolving pathways. Systemic and neuroinflammation was ass...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Influence of Cardiac Output on the Pharmacokinetics of Sufentanil in Anesthetized Pigs
Conclusions Cardiac output influences the pharmacokinetics of sufentanil. Simulations suggest that in the case of increased cardiac output, the dose should be increased to avoid inadequate drug effect at the expense of prolonged recovery, whereas for low cardiac output the dose should be reduced, and a faster recovery may be expected. (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Effects of Ambient Temperature and Forced-air Warming on Intraoperative Core Temperature A Factorial Randomized Trial
Background The effect of ambient temperature, with and without active warming, on intraoperative core temperature remains poorly characterized. The authors determined the effect of ambient temperature on core temperature changes with and without forced-air warming.Methods In this unblinded three-by-two factorial trial, 292 adults were randomized to ambient temperatures 19 °, 21°, or 23°C, and to passive insulation or forced-air warming. The primary outcome was core temperature change between 1 and 3 h after induction. Linear mixed-effects models assessed the effects of ambient temperature, warming method...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization A Population-based Study
Background Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.Methods Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inh...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Opioid Abuse or Dependence Increases 30-day Readmission Rates after Major Operating Room Procedures A National Readmissions Database Study
Background Although opioids remain the standard therapy for the treatment of postoperative pain, the prevalence of opioid misuse is rising. The extent to which opioid abuse or dependence affects readmission rates and healthcare utilization is not fully understood. It was hypothesized that surgical patients with a history of opioid abuse or dependence would have higher readmission rates and healthcare utilization.Methods A retrospective cohort analysis was performed of patients undergoing major operating room procedures in 2013 and 2014 using the National Readmission Database. Patients with opioid abuse or dependence were i...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Does Aerobic Respiration Produce Carbon Dioxide or Hydrogen Ion and Bicarbonate?
Maintenance of intracellular pH is critical for clinical homeostasis. The metabolism of glucose, fatty acids, and amino acids yielding the generation of adenosine triphosphate in the mitochondria is accompanied by the production of acid in the Krebs cycle. Both the nature of this acidosis and the mechanism of its disposal have been argued by two investigators with a long-abiding interest in acid –base physiology. They offer different interpretations and views of the molecular mechanism of this intracellular pH regulation during normal metabolism. Dr. John Severinghaus has posited that hydrogen ion and bicarbonate are...
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

The Heat Is On Clinical Implications of Intraoperative Thermoregulation Research
“...surgical demands for both a cool operating room AND no forced-air warming appear inconsistent with good practice.” (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

μ-Opioid Receptor Agonists Do They Have Utility in the Treatment of Acute Pain?
“Can the concept of the utility function help us understand the benefit to risk relationship of a pure μ-opioid receptor agonist…?” (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Frontiers in Opioid Pharmacology
“…clinicians learned long ago how to exploit [opiate] receptors to relieve pain.” (Source: Anesthesiology)
Source: Anesthesiology - April 18, 2018 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - March 13, 2018 Category: Anesthesiology Source Type: research