Antifibrinolytic Therapy and Perioperative Considerations
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a th...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Use of Uncrossmatched Erythrocytes in Emergency Bleeding Situations
UNCROSSMATCHED erythrocytes are a lifesaving bridge between a hemorrhaging patient of unknown ABO blood group not receiving erythrocyte transfusions and the provision of crossmatched units. Unless the recipient ’s ABO group is known, group O uncrossmatched erythrocytes will be issued, which are compatible with the preformed anti-A and/or anti-B (hemagglutinins) that are present in all recipients who are not blood group AB (table 1). Issuing group O erythrocyte units prevents acute, intravascular hemolytic reactions from occurring when uncrossmatched erythrocytes are transfused to a recipient of unknown ABO group. An ...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Relaxation before Debriefing during High-fidelity Simulation Improves Memory Retention of Residents at Three Months A Prospective Randomized Controlled Study
Conclusions There was an additional 25% of active participants who recalled the critical messages at three months when a relaxation break was performed before debriefing of scenarios. Benefits of relaxation to enhance learning should be considered for medical education. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

A Large Anterior Mediastinal Mass
A LARGE anterior mediastinal mass (AMM) poses significant challenges for hemodynamic and airway management. This image demonstrates a 19 x 11 x 10  cm B-cell lymphoma compressing the tracheobronchial tree and pulmonary arterial vasculature. AMMs are predominantly malignancies such as lymphomas or thymomas. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Images in Anesthesiology: Intraoral Lipomas
INTRAORAL lipomas can cause significant airway obstruction and lead to respiratory compromise. Additionally, they can grossly alter airway anatomy, making direct laryngoscopy challenging.1 Oropharyngeal lipomas arising from the posterior pharynx or supraglottic region may present particular challenges for the anesthesiologist, given that they are not always obvious on preoperative evaluation. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

This Month in: Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Searching for Quality: Hip Fractures and Type of Anesthesia
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - February 14, 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 - February 14, 2018 Category: Anesthesiology Source Type: research

“Frozen Air” Anesthetics in St. Louis by Columbia Dental Parlors
In the wake of the 1893 World Columbian Exposition, a number of “Columbia” Dental Parlors sprung up around the United States. The trade card from one of these parlors depicts four frogs assisting a fifth in rowing a single scull (top). The back of the card locates the parlors in the “Trust Building” at “4th and Locust” Streets, which apparently references a former St. Louis Trust Company Building in St. Louis, Missouri. Also on the reverse of this card is a reference to anesthesia with “Frozen Air” (bottom). From ether spray to ethyl chloride (and eventually to Somnoform), a ...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

From Malaysia and Spain: The Liebig Company Peppers the World with Capsaicin
A discoverer of chloroform, Professor Justus von Liebig inspired the Liebig Extract of Beef Company, which collected many herbs and spices, including chili peppers from around the world. One of the company ’s French-language trade cards depicted Malaysian workers on a spice plantation (upper left) and a Spanish lady collecting peppers in her Andalusian basket (lower right). Not lost on the Liebig Company was the fact that many early liniments, including snake oils, frequently provided topical pain relief by including capsaicin-spiced ingredients, courtesy of the chili pepper. (Copyright © the American Society of...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Slocum ’s Cocaine “Surprise” for Johnson Pillmore, M.D.
From the Wood Library-Museum ’s Ben Z. Swanson Collection, this illegibly postmarked cover (above) was sent to Johnson Pillmore, M.D., of Delta, New York. Fortunately, the “Columbus in Sight of Land” 1-cent stamp from the Columbian Issue assists us in dating this item. From Holly, Michigan, the Slocum Manufacturing Company was taking advantage of the 1893 World’s Columbian Exposition to advertise “Dental Surprise,” their new (?) “local anesthetic for painl ess extraction of teeth.” Suspicious of the novelty of Slocum’s wares, the journal editor of theDental Cosmos forwa...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Eucaine Lactate from H. K. Mulford Company of Philadelphia
Using a pharmacy schoolmate ’s financing and presidential leadership, Henry K. Mulford (1866 to 1937) reorganized his own namesake corporation in 1891 with himself as vice president. Soon “H. K. Mulford Company of Philadelphia” began synthesizing and compounding an astonishing array of pharmaceuticals, including (beta-)e ucaine lactate. Less toxic than alpha-eucaine, beta-eucaine had the additional advantage of stability in aqueous solutions sterilized by prolonged boiling. Sold by Mulford as “one-quarter grain” hypodermic tablets (above), the lactate formulation of eucaine was less irritating...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Lyin ’ with a Lion: Deceptive Advertising for “Vitalized Air” Anesthetics
Soon after earning his D.D.S. in 1891 from the Ohio College of Dental Surgery, Dr. Charley D. Richey set up practice in York, Pennsylvania. From Ohio dentists, Richey had mastered how to extend nitrous oxide ’s anesthetic duration by supplementing it with trace amounts of alcohol and chloroform. By concealing his anesthetic’s identity as “vitalized air” (bottom), he could reassure patients that they were not receiving nitrous oxide —the gas that many feared after reading press reports about laughing gas mishaps. “Vitalized air” reigned as a king of American dental anesthetics in th...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Oh Excellent Air Bag: Under the Influence of Nitrous Oxide, 1799 –1920
Oh Excellent Air Bag presents a curated collection of 12 scientific and popular works about nitrous oxide, spanning 1799 to 1920. Voyeuristic readers will enjoy reading the frequently explicit experiences of inhaling nobles. Readers who prefer a coherent history with a focus on characters, causes, and effects may be less satisfied. That reader will savor the historian Mike Jay ’s engaging introduction, but will be disappointed that each work does not have its own commentary. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

In Reply
We gratefully acknowledge Dr. Patlaket al. for his constructive comments on our article.1 We fully agree with our colleague when he states that protracted ventilation is the main issue in brain-injured patients,2 because delaying extubation promotes morbidity and healthcare costs. The VISAGE (visual pursuit, swallowing, age, Glasgow coma scale for extubation) score1 was developed to help the physician in securing the challenging extubation process in neurocritical care patients. The fear of extubation failure is due to the lack of guidelines for extubation in neurologic patients, and there is a clear need for new clinical ...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Neurocritical Care Needs Predictive Scores That Succeed at Predicting Failure as Well as They Predict Success
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Statin Therapy before Cardiac Surgery: Neutral or Detrimental Effects?
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

In Reply
We would like to thank Bloomstoneet al. for their important comments on our study.1 We certainly agree with Bloomstoneet al. that fluid responsiveness should not be confused with hypovolemia. Being a fluid responder does not necessarily mean requiring additional intravenous fluids.Vice versa, fluid responsiveness should be determined before volume expansion, when clinical signs of hypovolemia suggest that patients might require additional intravenous fluids. Identifying hypovolemic patients might be challenging, however, given that standard hemodynamic parameters or biologic markers used during surgery may not be specific ...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Goal-directed Hemodynamic Therapy: Neither for Anyone, Neither the Same for Everyone
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Volume Responsiveness Alone Is Not an Indication for Volume Administration!
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

In Reply
We thank Dr. Wax for his response to our recent article on perioperative steroid management.1 Since the publication of our article, we have received several queries regarding the use of dexamethasone as a perioperative stress-dose steroid and appreciate the opportunity to further address this topic. As Dr. Wax aptly notes, dexamethasone has significantly more glucocorticoid potency than hydrocortisone, has no mineralocorticoid effect, and can be clinically effective in the prevention of postoperative nausea and vomiting. Indeed, the recommended antiemetic dose of dexamethasone (4  mg) has at least the same glucocort...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

One Size Fits All for Stress-dose Steroids
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

In Reply
We thank Dr. Vetrugnoet al., Drs. Jacobsohn and Grocott, and Dr. Iwasakiet al. for their interest and positive appreciations of our study, “Prevalence and Impact on Weaning of Pleural Effusion at the Time of Liberation from Mechanical Ventilation: A Multicenter Prospective Observational Study,” recently published in Anesthesiology.1 (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Accurate Quantification of Pleural Effusion and Cofactors Affecting Weaning Failure
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Impact of Weaning from Mechanical Ventilation: The Importance of Pleural Effusions and Their Effect on Pulmonary Vascular Resistance
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

“A Message in the Bottle”
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

In Reply
We thank Dr. Riopelle for his question. In the article,1 table 2 contains the results of unadjusted comparisons across study arms for all pain endpoints. In addition to these unadjusted comparisons, for the study ’s primary endpoint an analysis was performed to assess differences across study arms after adjusting for sex, American Society of Anesthesiologists status, and type of anesthesia. In all cases, the results of the unadjusted and adjusted comparisons across treatment groups were consistent. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Effect of Spinal versus General Anesthesia in Study Comparing Three Methods of Using Local Anesthetics to Achieve Post –knee Arthroplasty Pain
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

In Reply
We thank Drs. Bowdle and Sheu for their interest and thoughtful comments on our recent article,1 which reported a low risk of complications from intraarterial brachial pressure monitoring during cardiac surgery. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Does the Brachial Artery Lack Effective Collaterals?
(Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Transcriptional Changes in Dorsal Spinal Cord Persist after Surgical Incision Despite Preemptive Analgesia with Peripheral Resiniferatoxin
Background Peripheral nociceptors expressing the ion channel transient receptor potential cation channel, subfamily V, member 1, play an important role in mediating postoperative pain. Signaling from these nociceptors in the peri- and postoperative period can lead to plastic changes in the spinal cord and, when controlled, can yield analgesia. The transcriptomic changes in the dorsal spinal cord after surgery, and potential coupling to transient receptor potential cation channel, subfamily V, member 1 –positive nociceptor signaling, remain poorly studied.Methods Resiniferatoxin was injected subcutaneously into rat hi...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Pharmacodynamics and Pharmacokinetics of Lidocaine in a Rodent Model of Diabetic Neuropathy
Conclusions We demonstrate increased sensitivity of the diabetic neuropathic nerve toward local anesthetics, and prolonged residence time of local anesthetics in the diabetic neuropathic nerve. In this rodent model of neuropathy, both pharmacodynamic and pharmacokinetic mechanisms contribute to prolonged nerve block duration. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Using Activity Trackers to Quantify Postpartum Ambulation A Prospective Observational Study of Ambulation after Regional Anesthesia and Analgesia Interventions
Background Early postoperative ambulation is associated with enhanced functional recovery, particularly in the postpartum population, but ambulation questionnaires are limited by recall bias. This observational study aims to objectively quantify ambulation after neuraxial anesthesia and analgesia for cesarean delivery and vaginal delivery, respectively, by using activity tracker technology. The hypothesis was that vaginal delivery is associated with greater ambulation during the first 24  h postdelivery, compared to cesarean delivery.Methods Parturients having first/second cesarean delivery under spinal anesthesia o...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Targeted Genotyping Identifies Susceptibility Locus in Brain-derived Neurotrophic Factor Gene for Chronic Postsurgical Pain
Conclusions This study demonstrated that genetic variation ofBDNF is associated with an increased risk of chronic postsurgical pain. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Astrocytic N-Myc Downstream-regulated Gene –2 Is Involved in Nuclear Transcription Factor κB–mediated Inflammation Induced by Global Cerebral Ischemia
This study investigated the role of N-Myc downstream-regulated gene –2 in nuclear transcription factor κB–mediated inflammation in ischemia models.Methods Mice (n = 6 to 12) with or without nuclear transcription factor κB inhibitor pyrrolidinedithiocarbamate pretreatment were subjected to global cerebral ischemia for 20 min. Pure astrocyte cultures or astrocyte-neuron cocultures (n = 6) with or without pyrrolidinedithiocarbamate pretreatment were exposed to oxygen-glucose deprivation for 4 h or 2 h. Astrocy tic nuclear transcription factor κB and N-Myc downstream-regulated...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

L-arginine and Arginase Products Potentiate Dexmedetomidine-induced Contractions in the Rat Aorta
Conclusions These results suggest that when vascular nitric oxide homeostasis is impaired, the potentiation of the vasoconstrictor effect of dexmedetomidine byl-arginine depends on arginase activity and the production of urea and ornithine. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Sevoflurane Blocks the Induction of Long-term Potentiation When Present during, but Not When Present Only before, the High-frequency Stimulation
Conclusions Sevoflurane blocks long-term potentiation formation if present during the high-frequency stimulation; this blockage of long-term potentiation does not persist if sevoflurane is discontinued before the high-frequency stimulation. These results may explain why short periods of insufficient sevoflurane anesthesia may lead to recall of painful or traumatic events during surgery. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Bupivacaine Indirectly Potentiates Glutamate-induced Intracellular Calcium Signaling in Rat Hippocampal Neurons by Impairing Mitochondrial Function in Cocultured Astrocytes
Background Bupivacaine induces central neurotoxicity at lower blood concentrations than cardiovascular toxicity. However, central sensitivity to bupivacaine is poorly understood. The toxicity mechanism might be related to glutamate-induced excitotoxicity in hippocampal cells.Methods The intracellular free Ca2+ concentration ([Ca2+]i), mitochondrial membrane potential, and reactive oxygen species generation were measured by fluorescence and two-photon laser scanning microscopy in fetal rat hippocampal neurons and astrocytes.Results In astrocyte/neuron cocultures, 300 μM bupivacaine inhibited glutamate-induced increases i...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Physiologic Evaluation of Ventilation Perfusion Mismatch and Respiratory Mechanics at Different Positive End-expiratory Pressure in Patients Undergoing Protective One-lung Ventilation
This study sought to determine the combined physiologic effects of positive end-expiratory pressure and low VT during one-lung ventilation.Methods Data from 41 patients studied during general anesthesia for thoracic surgery were collected and analyzed. Shunt fraction, high V/Q and respiratory mechanics were measured at positive end-expiratory pressure 0  cm H2O during bilateral lung ventilation and one-lung ventilation and, subsequently, during one-lung ventilation at 5 or 10  cm H2O of positive end-expiratory pressure. Shunt fraction and high V/Q were measured using variation of inspired oxygen fraction and ...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Four Types of Pulse Oximeters Accurately Detect Hypoxia during Low Perfusion and Motion
Background Pulse oximeter performance is degraded by motion artifacts and low perfusion. Manufacturers developed algorithms to improve instrument performance during these challenges. There have been no independent comparisons of these devices.Methods We evaluated the performance of four pulse oximeters (Masimo Radical-7, USA; Nihon Kohden OxyPal Neo, Japan; Nellcor N-600, USA; and Philips Intellivue MP5, USA) in 10 healthy adult volunteers. Three motions were evaluated: tapping, pseudorandom, and volunteer-generated rubbing, adjusted to produce photoplethsmogram disturbance similar to arterial pulsation amplitude. During m...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Effect of Thoracic Epidural Ropivacaine versus Bupivacaine on Lower Urinary Tract Function A Randomized Clinical Trial
This study aimed to compare the risk of bladder dysfunction with ropivacaineversus bupivacaine using postvoid residuals and maximum flow rates. Our hypothesis was that ropivacaine would result in lower postvoid residuals, because ropivacaine has been shown to have less effect on motor blockade.Methods In this single-center, parallel-group, randomized, double-blind superiority trial, 42 patients undergoing open renal surgery were equally allocated to receive epidural bupivacaine 0.125% or ropivacaine 0.2%, and 36 were finally included. Inclusion criterion was normal bladder function. Patients underwent urodynamic investigat...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Temporal Trends in Difficult and Failed Tracheal Intubation in a Regional Community Anesthetic Practice
Background When tracheal intubation is difficult or unachievable before surgery or during an emergent resuscitation, this is a critical safety event. Consensus algorithms and airway devices have been introduced in hopes of reducing such occurrences. However, evidence of improved safety in clinical practice related to their introduction is lacking. Therefore, we selected a large perioperative database spanning 2002 to 2015 to look for changes in annual rates of difficult and failed tracheal intubation.Methods Difficult (more than three attempts) and failed (unsuccessful, requiring awakening or surgical tracheostomy) intubat...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Prediction of Bispectral Index during Target-controlled Infusion of Propofol and Remifentanil A Deep Learning Approach
Background The discrepancy between predicted effect-site concentration and measured bispectral index is problematic during intravenous anesthesia with target-controlled infusion of propofol and remifentanil. We hypothesized that bispectral index during total intravenous anesthesia would be more accurately predicted by a deep learning approach.Methods Long short-term memory and the feed-forward neural network were sequenced to simulate the pharmacokinetic and pharmacodynamic parts of an empirical model, respectively, to predict intraoperative bispectral index during combined use of propofol and remifentanil. Inputs of long ...
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes A Population-based Cohort Study
Conclusions Hip fracture surgery patients at hospitals that use more than 20 to 25% neuraxial anesthesia have improved survival independent of patient-level anesthesia type and other confounders. The underlying causal mechanism for this association requires a prospective study to guide improvements in perioperative care and outcomes of hip fracture patients.Visual Abstract An online visual overview is available for this article athttp://links.lww.com/ALN/B634. (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Advancing Patient Safety in Airway Management
“…[W]e are making airway management safer. What remains to be studied is which advances in airway management have an im pact on patient safety events.” (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Artificial Intelligence for Everyone
“…machine learning to model the interaction of remifentanil and propofol on processed electroencephalogram…. Is this the end of clinical pharmacology?” (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Do Anesthetic Choices Signal Quality?
“…measuring anesthesia care at the institutional level might offer insights as to other unmeasured aspects of an institution’s quality and performance.” (Source: Anesthesiology)
Source: Anesthesiology - February 14, 2018 Category: Anesthesiology Source Type: research

Announcements
(Source: Anesthesiology)
Source: Anesthesiology - January 17, 2018 Category: Anesthesiology Source Type: research

Call for Papers Point of Care Ultrasound in Perioperative, Critical Care, and Pain Medicine
(Source: Anesthesiology)
Source: Anesthesiology - January 17, 2018 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - January 17, 2018 Category: Anesthesiology Source Type: research