Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Impact of Methylprednisolone on Postoperative Quality of Recovery and Delirium in the Steroids in Cardiac Surgery Trial: A Randomized, Double-blind, Placebo-controlled Substudy: Erratum
In the article beginning on page 223 in the February 2017 issue, there is an error in the sentence, “The incidence of delirium for the control group was 10%, which was similar to that in patients given methylprednisolone (8%; OR, 0.31; 95% CI, 0.73 to 2.48;P = 0.357; table 3). ” The correct sentence is, “The incidence of delirium for the control group was 10%, which was similar to that in patients given methylprednisolone (8%; OR, 0.74; 95% CI, 0.40 to 1.37;P = 0.357; table 3). ” (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Meanwhile
You enter surgery. I wander off to find the waiting room. I try to sit, back propped. Computer on my lap, I scoff at headlines, ask too soon, “What time is it?” Not nearly late enough. I sign my name and number on the nurses’ log, then head downstairs for food and drink, the route the same as earlier but in reverse. Instead of getting takeout, I plop down at some small table, look around me as I eat. Few visitors appear as grim or g lum as I expected. Done, I leave my seat to someone else, go browse the gift shop, pay respect to portraits, find the chapel, pray. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Winner Announced: The Letheon 1st Annual Creative Writing Competition
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Right Ventricular Perfusion Physiology and Clinical Implications
Regulation of blood flow to the right ventricle differs significantly from that to the left ventricle. The right ventricle develops a lower systolic pressure than the left ventricle, resulting in reduced extravascular compressive forces and myocardial oxygen demand. Right ventricular perfusion has eight major characteristics that distinguish it from left ventricular perfusion: (1) appreciable perfusion throughout the entire cardiac cycle; (2) reduced myocardial oxygen uptake, blood flow, and oxygen extraction; (3) an oxygen extraction reserve that can be recruited to at least partially offset a reduction in coronary blood ...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery
The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments o...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Malignant Hyperthermia in the Post-Genomics Era New Perspectives on an Old Concept
This article reviews advancements in the genetics of malignant hyperthermia, new technologies and approaches for its diagnosis, and the existing limitations of genetic testing for malignant hyperthermia. It also reviews the variousRYR1-related disorders and phenotypes, such as myopathies, exertional rhabdomyolysis, and bleeding disorders, and examines the connection between these disorders and malignant hyperthermia. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Malignant Hyperthermia Susceptibility and Related Diseases
MALIGNANT hyperthermia (MH) is an inherited disorder of skeletal muscle that manifests clinically as a hypermetabolic crisis when a susceptible individual receives a halogenated inhalational anesthetic agent or succinylcholine.1 –3 The clinical signs that ensue from this exposure in susceptible individuals include hypercapnia, masseter muscle and/or generalized muscle rigidity, acidosis, peaked T waves that indicate hyperkalemia, and hyperthermia and are caused by the dysregulated entry of myoplasmic calcium, which results in a hypermetabolic cascade involving sustained muscular contractures, depletion of adenosine t...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Implementation and Evaluation of the Z-Score System for Normalizing Residency Evaluations
Conclusions The Baker system produced moderately reliable measures at our institution, suggesting that it may be generalizable to other training programs. Raw absolute scores required few assessment occasions to achieve 90% reliable measurements. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Right Atrial Myxoma with Cannon A Waves
WE present a pathologic central venous pressure (CVP) tracing secondary to a large mobile right atrial myxoma, which protruded from the lower septum toward the tricuspid valve during diastole (Supplemental Digital Content,http://links.lww.com/ALN/B528). The CVP waveform displayed cannon a waves (arrows) with a normal sinus rhythm (image A; ABP, arterial blood pressure). After resection, these pathologic waves ceased and an unremarkable CVP waveform developed (image B). (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

A Floating Object in the Left Atrium
INTRAOPERATIVE, real-time, three-dimensional transesophageal echocardiography (RT 3D TEE) has become common in addition to conventional two-dimensional (2D) TEE. However, an efficient application of RT 3D TEE to cardiac surgery is still evolving.1 The images were obtained from a 36-yr-old woman with Marfan syndrome during aortic root replacement and mitral valve plasty immediately after aortic unclamping. 2D TEE detected a floating object with acoustic shadow above the mitral valve in the left atrium (arrow, midesophageal mitral commissural view;left). (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Inadvertent Endotracheal Cuff Hyperinflation Diagnosed by Magnetic Resonance Imaging
ENDOTRACHEAL tube (ETT) cuff hyperinflation was incidentally diagnosed in a 5-yr-old maintained on N2O-free general anesthesia (Microcuff, 4.5  mm, inflated with 1.8 ml of air) during cardiac magnetic resonance imaging preceding catheterization. Magnetic resonance angiograms reformatted in coronal (image A) and sagittal (image B) planes of the trachea demonstrate pronounced tracheal distention (thin arrow) at the ETT cuff site, with a thinner contrast-enhanced layer of the tracheal wall (thick arrow), suggesting a degree of mucosal compression. Subsequent cuff manometer measurement demonstrated a pressure of ...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Images in Anesthesiology: Modified Cotton Swab Applicator for Nasal Sphenopalatine Ganglion Nerve Block
THE modified cotton swab applicator assembled from ubiquitous components found in most operating rooms is an alternative to costly commercial devices (Tx360 [Tian Medical, LLC, Grayslake, Illinois] and Sphenocath [Dolor Technologies, LLC, Salt Lake City, Utah]) for sphenopalatine ganglion nerve blocks. Anesthetizing the sphenopalatine ganglion is both diagnostic and therapeutic for cluster, migraine,1,2 and postdural puncture headaches.2 The largest of the four parasympathetic ganglions associated with the trigeminal nerve,3 the sphenopalatine ganglion, sits in the pterygopalatine fossa close to the sphenopalatine foramen ...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

This Month in: Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Chasing Unicorns: Debunking the Myths Around Reversal of Neuromuscular Blockade
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Science, Medicine, and the Anesthesiologist
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Analgesic Somnoform in Waterbury: “Nap-A-Minit” Adds Chlorides to the Bromide
From the Wood Library-Museum ’s Ben Z. Swanson Collection, this photograph (right) features signage (left) from a 1920s “Nap-A-Minit” dentist. From his office corner in Waterbury, Connecticut, Dr. Paul August Kumpitsch (1886 to 1949) was one of a large number of American dentists who so advertised their use of analgesic gas, either Somnoform or nitrous oxide-oxygen. Pioneered in Bordeaux, France, in 1901 by Dr. G eorges Rolland, Somnoform was an eclectic mixture of ethyl chloride, methyl chloride, and ethyl bromide, in a 12:7:1 ratio. A topical vapocoolant, Somnoform’s general anesthetic properties ...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Embracing Vitalized Air …with a Coupon: Dr. W. A. Dartt of Milwaukee
From a trade card of Dr. William Allen Dartt (1852 to 1917), the obverse (above) depicts two sleepy cherubs embracing in the moonlight as they balance precariously on a flowering sprig. The overprinting states, “This Card Good for VITALIZED AIR…. Unless this card is presented 50 Cents will be charged.” After writing his thesis on “Gold for Fillings” for his 1876 D.D.S. degree from the Philadelphia Dental College, Dartt struck gold again as Milwaukee’s leading advertiser of “vitalized air” a nesthesia (nitrous oxide adulterated by a trace mixture of ethyl alcohol with chlorof...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

America Helps Germany in “the Battle for Borocaine”
Manufactured by Sharp& Dohme of Baltimore, each corked vial (above) contained 20 soluble hypodermic tablets of Borocaine “under license from the British Drug Houses, Ltd., London.” Because each tablet contained 0.1 g of procaine borate, dissolving a tablet in 5 ml of sterile water yielded a 2% solution of this ester local anesthetic. Unfortunately for Borocaine’s British licensing firm, the American Medical Association’s Chemical Laboratory determined that the “formula 2(C13H20O2N2), 4H2O, 5B2O3, as given by the manufacturer …is incorrect; on the other hand, it appears...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

A Cocaine Beverage …from Brooklyn: Ola Laboratories’ Spicy Blend of Cola, Coca, and Maté
Even though the United States government had tightened restrictions on the public ’s access to cocaine and coca leaf products, Brooklyn’s Ola Laboratories, Inc., copyrighted in 1935 its “invigorating” drink as “Ola” (above). The beverage blended “coca leaf, kola nuts, [and yerba] maté,” flavored with fruit, spices, and bitters and combined with caramel, sugar cane juice, and carbonated water. By combining one of North Americans’ most popular beverage combinations—cola with coca— with one of South Americans’ favorites—yerba ma té, Ol...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
We thank Dr. Roth for his thoughtful comments about our article.1 He makes the important observation that when assistants are asked to perform an additional duty, they tend to reflexively use their dominant hand. Therefore, he suggests that cricoid pressure (CP) should be applied with the nondominant hand, if there is any possibility that the assistant applying CP will be asked to perform an additional task. We agree with Dr. Roth ’s suggestion. Perhaps trainees should practice performing the CP maneuver using either hand so they can easily switch back and forth depending on the circumstances. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Cricoid Pressure: Effective Measure or Ritual?
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Should the Dominant or Nondominant Hand Be Used for Applying Cricoid Pressure?
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
We appreciate the comments from Dr. Jha. According to the study protocol, all patients received a cardiac output monitor aiming to optimize fluid status and cardiac index. Therefore, as our data show, with norepinephrine or vasopressin, we did not observe either a reduction in the cardiac index or a worsening of tissue perfusion and oxygenation parameters as lactate and central venous oxygen saturation.1 Furthermore, the incidence of low cardiac output and cardiogenic shock in the norepinephrine and vasopressin groups was not different. We attribute this to the fact that we assessed the fluid status and used inotropes regu...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
Drs. Fan and Faraday write with concerns about the Vasopressin and Cardiac Surgery Trial1 and my editorial2; I agree with some, but not all, of their points. My first point of agreement is the criticism that clinical treatment was not protocolized; however, in most randomized controlled trials, nonrandomized care is most often not protocolized for simple logistical reasons. The point is that nonprotocolized care was used in both masked arms of the Vasopressin and Cardiac Surgery Trial. Greater use of dobutamine in the norepinephrine group in the Vasopressin and Cardiac Surgery Trial could have been because vasopressin had ...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Vasopressin versus Norepinephrine after Cardiopulmonary Bypass
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: A Discussion of the Level of Evidence
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Use of Vasopressin in Vasoplegic Syndrome with Reduced Ejection Fraction: Asking for Trouble
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
We thank Drs. Avidan and Weiniger for their comments related to our article, “Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients.”1 They posit that the addition of objective examples to the previously subjective American Society of Anesthesiologists Physical Status (ASA-PS) Classification System may hinder the universal application of the ASA-PS score by unnecessarily increasing the complexity of the system. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
I thank Drs. Avidan and Weiniger for their comments on my article.1 Their suggestion and use of the acronym KISS (keep it simple stupid) summarizes the point of my editorial much more succinctly than my two pages. I could not agree more with them that adding nonvalidated examples to a simple, “commonsense” categorization may hobble the time-honored utility and universal use of the American Society of Anesthesiologists (ASA) Physical Status Classification System. I smiled when I saw the veterinary reference in their letter. I had originally referenced a study using the ASA classificat ion in veterinary anesthesi...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Keep American Society of Anesthesiologists Physical Status Classification System Simple, Stupid
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
We appreciate Monteset al.’s interest in our article. In their 2015 Anesthesiology article, the authors analyzed data from 2,929 patients who were candidates for inguinal hernia repair (men), hysterectomy (women), or thoracotomy (men) under general, regional, or local anesthesia with sedation. Four hundred and two patients (all male) underwent thoracotomy.1 Approximately 4.4 months after surgery, 37.6% of the thoracotomy patients had chronic postsurgical pain. We think the size of the study —nearly 3,000 patients enrolled—is quite remarkable. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Preoperative Prediction of Chronic Postsurgical Pain after Thoracotomy: Need for Adequately Sized Population-based Samples
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

In Reply
WE thank Dr. Solomkinet al. for their Letter to the Editor regarding our critical editorial on perioperative hyperoxia and surgical site infection (SSI).1 A Letter was expected and desirable to settle issues where we are at variance. We will therefore make fully clear that we are not arguing against the statistical tools that have been used to calculate the meta-analyses that serve as the basis for the World Health Organization (WHO) recommendations for perioperative hyperoxia. We are also pleased to read that the WHO panel considers their primary analysis of perioperative hyperoxia to prevent SSI statistically insignifica...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

World Health Organization Responds to Concerns about Surgical Site Infection Prevention Recommendations
(Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Effects of Changes in Arterial Carbon Dioxide and Oxygen Partial Pressures on Cerebral Oximeter Performance
Background Cerebral oximetry (cerebral oxygen saturation; ScO2) is used to noninvasively monitor cerebral oxygenation. ScO2 readings are based on the fraction of reduced and oxidized hemoglobin as an indirect estimate of brain tissue oxygenation and assume a static ratio of arterial to venous intracranial blood. Conditions that alter cerebral blood flow, such as acute changes in Paco2, may decrease accuracy. We assessed the performance of two commercial cerebral oximeters across a range of oxygen concentrations during normocapnia and hypocapnia.Methods Casmed FORE-SIGHT Elite (CAS Medical Systems, Inc., USA) and Covidien I...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

An International, Multicenter, Observational Study of Cerebral Oxygenation during Infant and Neonatal Anesthesia
Conclusions Mild and moderate low cerebral saturation occurred frequently, whereas severe low cerebral saturation was uncommon. Low mean arterial pressure was common and not well associated with low cerebral saturation. Unrecognized severe desaturation lasting 3  min or longer in infants seems unlikely to explain the subsequent development of neurocognitive abnormalities. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Effects of Forced Air Warming on Airflow around the Operating Table
Conclusions Airflow caused by forced air warming is well counteracted by downward laminar airflow from the ceiling. Thus it would be less likely to cause surgical field contamination in the presence of sufficient laminar airflow. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

No Differences in Renal Function between Balanced 6% Hydroxyethyl Starch (130/0.4) and 5% Albumin for Volume Replacement Therapy in Patients Undergoing Cystectomy A Randomized Controlled Trial
Conclusions With respect to renal function and kidney injury, this study indicates that albumin 5% and balanced hydroxyethyl starch 6% have comparable safety profiles in noncritically ill patients undergoing major surgery. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Crystalloid versus Colloid for Intraoperative Goal-directed Fluid Therapy Using a Closed-loop System A Randomized, Double-blinded, Controlled Trial in Major Abdominal Surgery
Background The type of fluid and volume regimen given intraoperatively both can impact patient outcome after major surgery. This two-arm, parallel, randomized controlled, double-blind, bi-center superiority study tested the hypothesis that when using closed-loop assisted goal-directed fluid therapy, balanced colloids are associated with fewer postoperative complications compared to balanced crystalloids in patients having major elective abdominal surgery.Methods One hundred and sixty patients were enrolled in the protocol. All patients had maintenance-balanced crystalloid administration of 3  ml · kg–1&...
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Prevalence of Potentially Distracting Noncare Activities and Their Effects on Vigilance, Workload, and Nonroutine Events during Anesthesia Care
Conclusions Both nurse anesthetists and residents performed potentially distracting tasks of a personal and/or educational nature in a majority of cases. Self-initiated distractions were rarely associated with events. This study suggests that anesthesia professionals using sound judgment can self-manage nonclinical activities. Future efforts should focus on eliminating more cognitively absorbing and less escapable distractions, as well as training in distraction management. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

A Retrospective Analysis of the Clinical Effectiveness of Supraclavicular, Ultrasound-guided Brachiocephalic Vein Cannulations in Preterm Infants
Conclusions This supraclavicular, in-plane, real-time, ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and effective method to insert central venous catheters in preterm infants. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Neostigmine Administration after Spontaneous Recovery to a Train-of-Four Ratio of 0.9 to 1.0 A Randomized Controlled Trial of the Effect on Neuromuscular and Clinical Recovery
Conclusions Administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness.Visual Abstract An online visual overview is available for this article. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Effects of Hypercapnia on Acute Cellular Rejection after Lung Transplantation in Rats
Conclusions Hypercapnia ameliorated acute cellular rejection in a rat lung transplantation model. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Failure of Isoflurane Cardiac Preconditioning in Obese Type 2 Diabetic Mice Involves Aberrant Regulation of MicroRNA-21, Endothelial Nitric-oxide Synthase, and Mitochondrial Complex I
Conclusions Failure of isoflurane cardiac preconditioning in obese type 2 diabetic db/db mice is associated with aberrant regulation of microRNA-21, endothelial nitric-oxide synthase, and mitochondrial respiratory complex I. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Comparison of an Updated Risk Stratification Index to Hierarchical Condition Categories
Conclusions Risk Stratification discrimination and minimum-variance predictions make it superior to Hierarchical Condition Categories. The Risk Stratification Index provides a solid basis for care-quality metrics and for provider comparisons. (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

A Primer for Diagnosing and Managing Malignant Hyperthermia Susceptibility
“…how should we approach the practical dilemma of anesthetizing patients who may be MH [malignant hyperthermia]–susceptible?” (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Vigilance Research and Just Culture Principles Challenges for a Connected Perioperative World
“…[do] non–patient care activities . . . help to maintain vigilance, despite the seeming contradiction[?]” (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research

Central Venous Catheters in Small Infants
“Preterm infants have substantial intravenous therapeutic needs over prolonged periods of time.” (Source: Anesthesiology)
Source: Anesthesiology - December 12, 2017 Category: Anesthesiology Source Type: research