Machine Learning for Anesthesiologists: A Primer: Erratum
In the infographic “Machine Learning for Anesthesiologists: A Primer” (Wanderer JP, Rathmell JP:Anesthesiology 2018; 129:A29) from the October 2018 issue of Anesthesiology, references 3 and 4 should be switched. (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Disruption of Rapid Eye Movement Sleep Homeostasis in Adolescent Rats after Neonatal Anesthesia: Erratum
In the article “Disruption of Rapid Eye Movement Sleep Homeostasis in Adolescent Rats after Neonatal Anesthesia” (Lunardi N, Sica R, Atluri N, Salvati KA, Keller C, Beenhakker MP, Goodkin HP, Zuo Z: Anesthesiology 2019; 130:981 –94), the figure 2 image and legend were incorrect. They should have appeared as follows: (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

If We Don ’t Learn from Our Critical Events, We’re Likely to Relive Them Debriefing Should Be the Norm
“…[I]nterdisciplinary team de-briefings, including members ofall involved role groups, is an essential step toward narrowing the patient safety gap that still remains... ” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Dynamic Cortical Connectivity during General Anesthesia in Healthy Volunteers
Editor ’s PerspectiveWhat We Already Know about This TopicAnesthetic-induced loss of consciousness is accompanied by changes in functional connectivity within and between brain networks.What This Article Tells Us That Is NewDespite a stable surgical level of anesthesia and the absence of noxious stimuli, connectivity patterns are not static but rather fluctuate dynamically and nonrandomly over time. These results suggest that single or static connectivity patterns may not be able to discriminate levels of consciousness.Background Recent studies of anesthetic-induced unconsciousness in healthy volunteers have focused ...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Pediatric Risk Stratification Is Improved by Integrating Both Patient Comorbidities and Intrinsic Surgical Risk
In this study, the authors used the American College of Surgeons National Surgical Quality Improvement Program Pediatric database to demonstrate the relationship between the intrinsic surgical risk and 30-day mortality and develop and validate an accessible risk stratification model that includes the surgical procedures in addition to the patient comorbidities and physical status.Methods A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database was performed. The incidence of 30-day mortality was the primary outcome. Surgical Current Procedural Terminology...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Dynamic Cortical Connectivity during General Anesthesia in Surgical Patients
Editor ’s PerspectiveWhat We Already Know about This TopicAnimal data, along with recent human observations (in this issue ofAnesthesiology*), suggest that cortical oscillations and connectivity shift dynamically during what appears to be stable general anesthesiaClinical evidence in the perioperative setting to support these observations is currently lackingWhat This Article Tells Us That Is NewDuring anesthesia and surgery, cortical networks display a dynamic interplay among brain states, rather than a static equilibriumThese findings suggest that a single measure of connectivity may not be a reliable correlate of ...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Syncopated Tempi of the Anesthetized Brain
“…[C]ompare the function of the conscious brain to that of an orchestra making music.” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Breathing under Anesthesia A Key Role for the Retrotrapezoid Nucleus Revealed by Conditional Phox2b Mutant Mice
Editor ’s PerspectiveWhat We Already Know about This TopicMany if not all drugs used in anesthesia and analgesia can produce potentially severe respiratory depressionMaintenance of breathing under anesthesia is linked to the drive exerted by the retrotrapezoid nucleus on the respiratory central pattern generatorThe retrotrapezoid nucleus neurons that stimulate breathing during anesthesia are carbon dioxide –sensitive noncatecholaminergic neurons that expressPhox2b, a master gene for the development of autonomic neuronsThe conditional mouse model with the +7Ala repeat mutation targeted to the retrotrapezoid nucl...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

General Anesthesia for Cesarean Delivery Occasionally Essential but Best Avoided
“…[I]n the absence of contraindications, neuraxial anesthesia has been and remains the gold standard anesthetic for cesarean delivery.” (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Respiratory Physiology for the Anesthesiologist
We present the actions of pressure, flow, and volume as the normal determinants of ventilation, and we review the resulting abnormalities in terms of changes of resistance and compliance. (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Activating α4β2 Nicotinic Acetylcholine Receptors Alleviates Fentanyl-induced Respiratory Depression in Rats
Editor ’s PerspectiveWhat We Already Know about This TopicOpioid-induced respiratory depression results in part from direct activation of μ-opioid receptors expressed in the inspiratory rhythm generator located in the ventrolateral medulla, the preBötzinger ComplexRespiratory neurons within the medulla also express nicotinic acetylcholine receptors, which are made up of five subunits, arranged symmetrically around a central poreActivation of the nicotinic acetylcholine receptor α4, α7, and β2 subunits increases respiratory rhythm, whereas activation of the nicotinic acetylcholine receptor &al...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Primum Non Nocere
I no longer remember his face yet (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Increased Reactivity of the Mesolimbic Reward System after Ketamine Injection in Patients with Treatment-resistant Major Depressive Disorder
Conclusions Single bolus ketamine administration rapidly triggers lasting changes in mesolimbic neural networks to improve pathologic reward and emotional processing in patients with major depressive disorder. (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Changes in Whole Brain Dynamics and Connectivity Patterns during Sevoflurane- and Propofol-induced Unconsciousness Identified by Functional Magnetic Resonance Imaging
Editor ’s PerspectiveWhat We Already Know about This TopicThe extent to which alterations within specific brain networks impairs communication among networks remains unknownWhat This Article Tells Us That Is NewIn a volunteer functional magnetic resonance study, general anesthesia reduced activity within and among networksSpecific between-network connectivity is necessary for consciousnessBackground A key feature of the human brain is its capability to adapt flexibly to changing external stimuli. This capability can be eliminated by general anesthesia, a state characterized by unresponsiveness, amnesia, and (most lik...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Anesthesiology
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

This Month in Anesthesiology
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Source: Anesthesiology - May 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 - May 15, 2019 Category: Anesthesiology Source Type: research

Anesthesia without Surgery: Unconsciousness is Metastable
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

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

Advertising Abbott ’s Pentothal from Antarctica to Toledo: A Bolus for Bowlus?
Following Army service as a 23rd Infantry combat medic in the Southern Pacific Theater of World War II, Thomas P. Bowlus (1923 to 2014) earned his A.B. at Michigan State Normal College in 1947, the same year that the Australian National Antarctic Research Expedition (A.N.A.R.E.) launched. After earning his M.D. from the University of Michigan in 1951, Dr. Bowlus returned to his native northwest Ohio for internship and medical practice in Toledo (upper left). A decade later, Abbott, the makers of the Pentothal brand of sodium thiopental, began mass-mailing advertising postcards from exotic locations around the world. The po...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Boston ’s Cushing Webber and the Late Doctor’s Early Use of “Perfectly Safe” Ether
Born in Boothby, Maine, Dr. Cushing Webber began practicing dentistry in Massachusetts in 1844, the year that Dr. Horace Wells demonstrated dental anesthesia with nitrous anesthesia in neighboring Connecticut. After Boston dentist William T. G. Morton demonstrated surgical anesthesia with ether in 1846, Dr. Webber began administering ether anesthetics in his own practice. By 1868 he was advertising his Washington Street dental partnership, with Dr. Charles C. Twichell, in the Boston directory. A compulsive and cautious dentist-anesthetist, Dr. Webber advertised on his business card (top, from the Wood Library-Museum &rsquo...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

France ’s Daniel Bovet and Gallamine, the First Synthetic Nondepolarizing Muscle Relaxant Used Clinically
A Swiss-born Italian pharmacologist, Daniel Bovet (1907 to 1992,right) was a research scientist famous for discovering the first antihistamine (1937) and for synthesizing (1947) gallamine, a reversible nondepolarizing muscle relaxant. Named by the multilingual Bovet after France (Latin:Gallia), gallamine was synthesized in Paris by Bovet as a bulky trisquaternary curariform compound. Ironically, high doses of gallamine triethiodide (boxed and branded as Flaxedil,left) released histamine, which Bovet had researched previously. His success with gallamine contributed to Bovet ’s forsaking his 18-yr career at the celebra...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Reverend James B. Dunn ’s Memorial Sermon for Sir James Y. Simpson: A Quarter for the Eulogy?
The professor of midwifery at the University of Edinburgh, Scotland, Sir James Young Simpson (1811 to 1870) passed away at 58 yr of age. His family was immediately extended the honor of his burial at Westminster Abbey, but they graciously declined. The day of Simpson ’s funeral was declared a memorial holiday in Scotland. More than 100,000 grateful citizens and visitors lined the streets of Edinburgh to witness Simpson’s funeral procession and to pay respect to the man who had introduced chloroform anesthesia. In memory of Simpson, the Gynaecological Society of Boston (right) asked Reverend James B. Dunn to del...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Not Electric, Not Eclectic, But Eclectric Oil and Dr. Thomas ’s “Trial by Jury”
One of the stranger annals of pain management involved “Eclectric Oil.” Although advertisements for this nostrum appeared as early as 1858, the name of New York’s Dr. S. N. Thomas (upper left andright) was associated with the oil by 1876. Americans ’ fascination with electricity and their romance with back-to-nature versions of medical practice resulted in a portmanteau of “electric” + “eclectic,” yielding “eclectric.” Eclectric Oil was an eclectic combination of alcohol, chloroform, camphor, and balsam fir with the tinctures of opium, guaiac, and catechu, as well...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Flowers on Dr. B. H. Pearce ’s Trade Card—Were Poppies in His Nitrous Oxide?
Barnum Herbert Pearce (1869 to 1952) learned that his hometown dentist had added a weak elixir of opium poppies to prolong the effects of nitrous oxide. This effort either anticipated or mimicked the early version of “Vegetable Vapor” patented by a Boston dentist. Pearce earned his D.D.S. in 1894 not in his native Ohio, but to the northwest, at the dental department of the University of Michigan. From there he moved east to Pennsylvania, and eventually set up a George Street office in the city of York, as a branch of the “Philadelphia Dental Parlors.” One of Dr. Pearce’s trade cards (above) de...
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Ultrasound-guided Popliteal Intraneural Approach: Comment
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Ultrasound-guided Popliteal Intraneural Approach: Reply
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Supraclav Suprascap Interscalene Shoulder Surgery: Comment
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Supraclav Suprascap Interscalene Shoulder Surgery: Reply
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Hospital-level Neuraxial Use in Orthopedics: Comment
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Hospital-level Neuraxial Use in Orthopedics: Reply
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Intubation in Operating Room versus Intensive Care: Comment
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Intubation in Operating Room versus Intensive Care: Reply
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Maintenance of Certification: Comment
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Maintenance of Certification: Reply
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Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Acknowledgment
The Editor-in-Chief and the Editors of Anesthesiology would like to thank the following individuals for their participation in the editorial review process. Their contributions are sincerely appreciated. (Source: Anesthesiology)
Source: Anesthesiology - May 15, 2019 Category: Anesthesiology Source Type: research

Inflammation Drives Pulmonary Arterial Hypertension
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Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Sounds Impossible, but It ’s Knot
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Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Fatal Iatrogenic Pituitary Apoplexy after Surgery for Neuroophthalmological Disorder
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Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Difficult Social Circumstances
Some children and infants admitted to the pediatric intensive care unit are described by the admitting nurse and doctor as having “difficult social circumstances.”  The phrase gets under my skin every time I hear it. What are the motives for describing a chaotic or impoverished life with this euphemism? Wherever you work, a similar phrase is bound to be used for patients who appear on your operating list or who are admit ted to the emergency department or pediatric intensive care unit. These are the children with the electrocardiogram dots still stuck onto their chest from a procedure a month ago, the in...
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Preparation for and Management of “Failed” Laryngoscopy and/or Intubation
An airway manager ’s primary objective is to provide a path to oxygenation. This can be achieved by means of a facemask, a supraglottic airway, or a tracheal tube. If one method fails, an alternative approach may avert hypoxia. We cannot always predict the difficulties with each of the methods, but these difficulti es may be overcome by an alternative technique. Each unsuccessful attempt to maintain oxygenation is time lost and may incrementally increase the risk of hypoxia, trauma, and airway obstruction necessitating a surgical airway. We should strive to optimize each effort. Differentiation between failed laryngo...
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Central Venous Pressure Waveform Artifact while Transducing a Single Lumen Port
(Source: Anesthesiology)
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Perioperative Fluid Therapy for Major Surgery
The goal of IV fluid administration is to restore and maintain tissue fluid and electrolyte homeostasis and central euvolemia, while avoiding salt and water excess. This will in turn facilitate tissue oxygen delivery without causing harm. Achieving optimal IV fluid therapy should improve perioperative outcomes and is a key component in many perioperative guidelines and pathways.1,2 IV fluids, like other medications, should only be given in well-defined protocols according to individual needs.3 (Source: Anesthesiology)
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Nociception-guided versus Standard Care during Remifentanil –Propofol Anesthesia A Randomized Controlled Trial
Editor ’s PerspectiveWhat We Already Know about This TopicThe nociception level index (Medasense Biometrics Ltd., Ramat Gan, Israel), is a reliable measure of moderate to intense noxious stimulation during anesthesia and surgeryWhat This Article Tells Us That Is NewIn a randomized trial in patients having major abdominal surgery, compared to standard practice, nociception level-guided analgesia resulted in 30% less intraoperative remifentanil consumptionBackground The multidimensional index of nociception, the nociception level, outperforms blood pressure and heart rate in detection of nociceptive events during anest...
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

α2δ-1–Bound N -Methyl- d -aspartate Receptors Mediate Morphine-induced Hyperalgesia and Analgesic Tolerance by Potentiating Glutamatergic Input in Rodents
Conclusionsα2δ-1–BoundN-methyl-d-aspartate receptors contribute to opioid-induced hyperalgesia and tolerance by augmenting presynapticN-methyl-d-aspartate receptor expression and activity at the spinal cord level. (Source: Anesthesiology)
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

Lung Recruitment in Obese Patients with Acute Respiratory Distress Syndrome
Editor ’s PerspectiveWhat We Already Know about This TopicObesity increases the propensity to atelectasis in acute respiratory distress syndrome, but the optimal approach to reversing this atelectasis is uncertainWhat This Article Tells Us That Is NewA clinical crossover study comparing three approaches to titrate positive end-expiratory pressure (PEEP; according to a fixed table, according to end-expiratory esophageal pressure, and targeting the best compliance during a decremental PEEP trial) found that a recruitment maneuver followed by decremental PEEP minimized atelectasis and overdistension, and best restored c...
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research

An Anesthesiologist ’s Perspective on the History of Basic Airway Management The “Modern” Era, 1960 to Present
This fourth and last installment of my history of basic airway management discusses the current (i.e., “modern”) era of anesthesia and resuscitation, from 1960 to the present. These years were notable for the implementation of intermittent positive pressure ventilation inside and outside the operating room. Basic airway management in cardiopulmonary resuscitation (i.e., expired air ventilation) was de-emphasized, as the “A-B-C” (airway-breathing-circulation) protocol was replaced with the “C-A-B” (circulation-airway-breathing) intervention sequence. Basic airway management in the operati...
Source: Anesthesiology - May 1, 2019 Category: Anesthesiology Source Type: research