Pure Nitrous Oxide and Possibly Phthisis from Dr. J. K. Carmichael
Brother of a horseman, James K. Carmichael (1864 to 1894) was raised in Rensselaer County, New York. After studying dentistry, he set up practice in Hartford, Connecticut. There he met the daughter of a harness maker, his future wife Jennie Pearl. Dr. Carmichael issued this trade card (top) from his Main Street “head-quarters for pure nitrous oxide gas” (bottom). A few years after his 1888 marriage, his pulmonary tuberculosis became so severe that a Dr. Pease had to cover the office. While battling “phthisis” at a health resort in Colebrook, New Hampshire, 29-yr-old Dr. Carmichael died. Back in the ...
Source: Anesthesiology - March 12, 2019 Category: Anesthesiology Source Type: research

Acid –Base Reports Need a Text Explanation
(Source: Anesthesiology)
Source: Anesthesiology - March 12, 2019 Category: Anesthesiology Source Type: research

Esophageal Pressure Monitoring in the Critically Ill Obese Subject
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Endovascular Retrieval of Broken Arterial Cannulas
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Automated Titration of Vasopressor Infusion Using a Closed-loop Controller In Vivo Feasibility Study Using a Swine Model
In this study of pigs with normovolemic hypotension induced by administration of sodium nitroprusside, an automated closed-loop vasopressor administration device was able to maintain mean arterial pressure within 5 mmHg of 80 mmHg for 98% of the intraoperative period. This suggests that norepinephrine can be accurately titrated using an automated infusion device in order to maintain target blood pressure.Background Multiple studies have reported associations between intraoperative hypotension and adverse postoperative complications. One of the most common interventions in the management of hypotension is vasopressor admini...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Aquaporin 5 –1364A/C Promoter Polymorphism Is Associated with Pulmonary Inflammation and Survival in Acute Respiratory Distress Syndrome
Editor ’s PerspectiveWhat We Already Know about This TopicAcute respiratory distress syndrome is defined according to clinical criteria, but lack of precise characterization may contribute to negative trials and impede personalized care. Polymorphisms of aquaporin-5, a key mediator of inflammation, may impact outcome.What This Article Tells Us That Is NewIn acute respiratory distress syndrome attributable to bacterial pneumonia, the C-allele of the aquaporin-5 –1364A/C promoter polymorphism is associated with less pulmonary inflammation and greater survival. This may improve characterization of acute respirator...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Acute Respiratory Distress Syndrome Biomarkers, Mechanisms, and Water Channels
“Genetic studies…have revealed associations between genotype and outcome in patients with ARDS.” (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Wake Up, Neurons! Astrocytes Calling
“Glia…now emerge as surprising actors in anesthetic mechanisms…[interfering] with energy production in glia leads to delayed emergence from anesthesia.” (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Morning in the Surgical Waiting Area
We drove through darkness, sky spread thick (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Operating Room Fires
Operating room fires are rare but devastating events. Guidelines are available for the prevention and management of surgical fires; however, these recommendations are based on expert opinion and case series. The three components of an operating room fire are present in virtually all surgical procedures: an oxidizer (oxygen, nitrous oxide), an ignition source (i.e., laser, “Bovie”), and a fuel. This review analyzes each fire ingredient to determine the optimal clinical strategy to reduce the risk of fire. Surgical checklists, team training, and the specific management of an operating room fire are also reviewed....
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Nitric Oxide Story
We examined the effects on systemic oxygenation and blood pressure of inhaling up to 80 parts per million by volume of NO at fraction of inspired oxygen 0.9 for up to 30 min by six inf ants with persistent pulmonary hypertension of the newborn. In all infants, this treatment rapidly and significantly increased preductal oxygen saturation; in five infants, postductal oxygen saturation and oxygen tensions also increased. Inhalation of NO did not cause systemic hypotension or raise m ethemoglobin. These data suggest that low levels of inhaled NO have an important role in the reversal of hypoxemia due to persistent pulm...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

B-lines Visualization and Lung Aeration Assessment Mind the Ultrasound Machine Setting
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Propofol-associated Green Hair Discoloration
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

A Neurologic Examination for Anesthesiologists Assessing Arousal Level during Induction, Maintenance, and Emergence
This article reviews the main components of the neurologic examination focusing primarily on the brainstem examination. It details the components of the brainstem examination that are most re levant for patient management during induction, maintenance, and emergence from general anesthesia. The examination is easy to apply and provides important complementary information about the patient’s arousal level that cannot be discerned from vital signs and electroencephalogram measures. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Driving Pressure during Thoracic Surgery A Randomized Clinical Trial
Conclusions Application of driving pressure –guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

The Pager Goes Off
The pager goes off. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function
Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers protection in ischemic heart disease. Major outcome studies have failed to confirm such a benefit, however. In fact, there is growing concern about potential harm associated with the use of thoracic epidural anesthesia in high-risk patients, although underlying mechanisms have not been identified. Since the latest review on this subject, a number of clinical and experimental studies have provided new information on the complex interaction between thoracic epidural anesthesia &n...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Down: Death through the Eyes of an Intern
I stood in the trauma bay of my hospital, watching snowflakes fall outside through the windows as we waited. A “red trauma”; gunshot wound to the head, per EMS radio. We always refer to the diagnosis, not the patient, at this stage when there is no person to know, and when the focus is just how to keep the diagnosis alive. Seeing as I did not have much to offer as a mere intern, I stood around twiddling my gloved thumbs, waiting for the gunshot to arrive. Since there were no diet orders to change or social workers to talk to, my minimal intern skills would prove useless in this trauma setting, so I would be abl...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Mitochondrial Function in Astrocytes Is Essential for Normal Emergence from Anesthesia in Mice
Editor ’s PerspectiveWhat We Already Know about This TopicIn mice, restriction of loss of the mitochondrial complex I geneNdufs4 to glutamatergic neurons confers a profound hypersensitivity to volatile anesthetics.Astrocytes are crucial to glutamatergic synapse functioning during excitatory transmission.What This Article Tells Us That Is NewIn a tamoxifen-activated astrocyte-specificNdufs4(KO) mouse, the induction EC50s for tail clamp in both isoflurane and halothane were similar between the control and astrocyte-specificNdufs4(KO) mice at 3 weeks after 4-hydroxy tamoxifen injection. However, the emergent concentrati...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-hospital Cardiac Arrest
Editor ’s PerspectiveWhat We Already Know about This TopicRapid response to witnessed, pulseless cardiac arrest is associated with increased survival.What This Article Tells Us That Is NewAssessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0  min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmi...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Acute Fatty Liver of Pregnancy Pathophysiology, Anesthetic Implications, and Obstetrical Management
Acute fatty liver of pregnancy is a potentially morbid obstetric complication characterized by acute hepatic failure secondary to fatty infiltration of the liver. The resultant effects include coagulopathy, electrolyte abnormalities, and multisystem organ dysfunction. Management of this condition requires an anesthesiologist ’s understanding of both its pathophysiology and its obstetric impact for appropriate recognition and management. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

The American Society of Anesthesiologists Practice Parameter Methodology
The methodology used during the development of American Society of Anesthesiologists evidence-based practice parameters, from conceptualization through final adoption of the documents, is described. Features of the methodology include the literature search, review and analysis, survey development and application, and consolidation of the full body of evidence used for preparing clinical practice recommendations. Anticipated risks of bias, validation of the process, and the importance of the documents for clinical use are discussed. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

This Month in Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 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 - February 12, 2019 Category: Anesthesiology Source Type: research

From Two Lungs to One: Optimizing Ventilation
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Never Mind Its Past Cocaine and Celery: Celerina ’s Alcohol “Treated” Alcoholism
Advertising its previously cocaine-laced panacea, Celerina, the Rio Chemical Company of St. Louis (and then New York City) released this ink blotter (upper panel) by 1916, promising that Celerina could still treat (lower panel) fatigue, infirmity, loss of energy, etc. The company may also have been reacting to the American Medical Association ’s blistering 1915 critique of Celerina’s vegetable cocktail (Cola, Viburnum, Celery, Ladyslipper, and Prickly Ash) as lacking “any recognizable activity.” As for treating “dipsomaniacs” with “84-proof” Celerina, the AMA exclaimed, &ldqu...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Etherist Crawford Long on a Cinderella Stamp
By founding the Cinderella Stamp Club (1959), editing their journalThe Cinderella Philatelist, and authoring their classic 152-page bookCinderella Stamps (1970), British brothers Leon and Maurice Williams popularized the collecting of stamp-like but nonpostal “emissions.” Philatelist James Mackay defined Cinderellas as “virtually anything resembling a postage stamp, but not issued for postal purposes by a government postal administration.” For anesthesiologists, one of the more interesting Cinderella stamps is this one (above) depicting the left profile of pioneering etherist Crawford W. Long, M.D. ...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Joining the Angels: Laughing-gas Advertising Divined by Dr. G. W. Chamberlain
An angel guides a young woman skyward (upper image) in this image from the obverse of a trade card from the Ben Z. Swanson Collection of the Wood Library-Museum. On the card ’s reverse, one box (lower) cites two of the weekdays that dental and “nitrous oxide gas” services would be provided at New Egypt, New Jersey, by George Whitehill Chamberlain, D.D.S. (1855 to 1905). In the early 1900s, understandably, most American physicians and dentists shied away from advertising death, dying, or the heavenly hereafter in any connection with th eir anesthetics. Could this 50-yr-old dentist have possibly been divini...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

The On-call Anesthesiologist: A Physiological Fireman?
Cosack& Company ’s 1881 image ofThe Fireman depicts a partially dressed rescuer prepared to leap out of bed —with his right foot planted on the floor and his right hand resting on his trouser-covered fire boots. Ready to launch from sleep at a moment’s notice, the fireman reminds me of the on-call anesthesiologist. Rather than extinguishing flames, the physician-anesthetist is prepared to battle the h eat of malignant hyperthermia. Whether racing off to command an airway or to administer unscheduled anesthetics for ambulanced traumas, “takeback” open-heart cases, or emergency C-sections, t...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Other Factors Affect the Occurrence of Perioperative Respiratory Adverse Events
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Improving External Validity May Jeopardize Internal Validity
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Is a Single Dose of Propofol Good Enough to Prevent Respiratory Complications beyond the Induction Phase?
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Does Intravenous versus Inhalational Induction of Anesthesia Only Decrease Perioperative Respiratory Events during the Induction Period?
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

In Reply
I appreciate the constructive comments of Nguyenet al. with regard to the recent trial published by Ramgolamet al.1 and the accompanying editorial inAnesthesiology.2 I certainly agree with the observation that the work station used may have an impact on how long an inhalational induction would take, and this may have an impact on the likelihood of complications during induction; however, in this case it transpires that the researchers did not use a Draeger Primus (Draeger, Germany) for induction but, as is common in Australia, used a separate anesthesia system with a back bar that connected to a T-piece where wash-in times...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

In Reply
We thank our international colleagues for their interest in our study, “Inhalationalversus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial, ”1 and have summarized our responses as follows. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Opiates and IV Acetaminophen
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

When Large Administrative Databases Provide Less Relevant Information than Randomized Studies
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

In Reply
We welcome the thoughtful comments by Dr. Steadman and Riouet al., in reply to our study.1 We aimed to evaluate the use of IV acetaminophen and its association with outcomes including opioid utilization, opioid-related adverse effects, and cost and length of hospitalization. Dr. Steadman mentioned several limitations of our study —some justified (and mentioned in our study’s Limitations section) and some less so—and observational research in general. Dr. Steadman states that “A better study would be a randomized double-blinded one in which the only variable would be the use of IV acetaminophenversus...
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Experimental Controls in Lipid Resuscitation Therapy
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Metabolite Palmitoylcarnitine Mediates Intralipid Cardioprotection Rather Than Membrane Receptors
(Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

In Reply
We have carefully read the letters from Fettiplaceet al. and Zaugget al. regarding our paper1 and would like to respond to their comments. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Enhanced Recovery for Major Abdominopelvic Surgery
Over the last decade, enhanced recovery protocols have become common practice across the country at countless institutions. These protocols entail a multimodal approach to reduce the effects of surgical stress and improve outcomes.1 From a surgical standpoint, this includes the use of minimally invasive techniques and improved patient education before surgery. As anesthesiologists, this has affected the way that we must think aboutnon per os status, fluid therapy, and perioperative pain management. (Source: Anesthesiology)
Source: Anesthesiology - February 12, 2019 Category: Anesthesiology Source Type: research

Caseous Calcification of the Mitral Annulus Mimic and Malady
(Source: Anesthesiology)
Source: Anesthesiology - January 25, 2019 Category: Anesthesiology Source Type: research

Images in Anesthesiology: Inadvertent Extracorporeal Membrane Oxygenation Cannulation across a Patent Foramen Ovale
Extracorporeal membrane oxygenation cannula malposition represents one of the most consequential complications from surgical placement, as demonstrated in the case of this 54-yr-old woman placed on venovenous extracorporeal membrane oxygenation because of primary graft dysfunction after bilateral lung transplantation and persistent hypoxemia. Chest radiograph (image A) demonstrates the position of the outflow cannula (19-French) —accessed through the right femoral vein—within the right atrium. The inflow cannula (21-French) was accessedvia the left femoral vein into the inferior vena cava in this patient. Trans...
Source: Anesthesiology - January 25, 2019 Category: Anesthesiology Source Type: research

Measuring Clinical Productivity of Anesthesiology Groups Surgical Anesthesia at the Facility Level
Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. Wit...
Source: Anesthesiology - January 25, 2019 Category: Anesthesiology Source Type: research

Non –steady State Modeling of the Ventilatory Depressant Effect of Remifentanil in Awake Patients Experiencing Moderate-to-severe Obstructive Sleep Apnea
Editor ’s PerspectiveWhat We Already Know about This TopicPatients with obstructive sleep apnea are often said to have increased sensitivity to opioid-induced ventilatory depressionWhat This Article Tells Us That Is NewThe hypothesis that patients with moderate-to-severe obstructive sleep apnea are more sensitive to remifentanil-induced ventilatory depression was tested in 20 control patients with mild or no obstructive sleep apnea and 30 patients with moderate-to-severe obstructive sleep apnea, defined as an apnea/hypopnea index of 15 or more episodes per hour of sleepThe predicted remifentanil effect site concentra...
Source: Anesthesiology - January 25, 2019 Category: Anesthesiology Source Type: research

Sphygmomanometer for Invasive Blood Pressure Monitoring in a Medical Mission
(Source: Anesthesiology)
Source: Anesthesiology - January 25, 2019 Category: Anesthesiology Source Type: research