Coupling Hoses then Coupling Pierrots with Pirouettes: William B. Kilbourne Peddles “Pain Stop” from Auburn, Maine
In 1877, William Bates Kilbourne (1850 to 1924) of Auburn, Maine, was granted United States Patent No. 189,941 for coupling threaded hoses. A dozen years later, Kilbourne ’s trade card advertised his namesake “Pain Stop” by coupling the image of a melancholic clown, the face-painted Pierrot, with the pirouetting Columbina (upper image). The clown was forever losing his love interest, Columbina, to the unpictured trickster, Harlequin. Although Kilbourne ’s panacea was “good for internal use in small doses, and excellent for external use,” could even “Pain Stop” relieve Pierrot...
Source: Anesthesiology - September 17, 2019 Category: Anesthesiology Source Type: research

Imaging the Injured Lung Mechanisms of Action and Clinical Use
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging —either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that a...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Transfusion-related Acute Lung Injury in the Perioperative Patient
Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

An Impacted Epidural Catheter
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Gigantic Pericardial Bronchogenic Cyst Compressing Superior Vena Cava and Coronary Artery
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Harlequin Syndrome Associated with Erector Spinae Plane Block
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Reversal of Partial Neuromuscular Block and the Ventilatory Response to Hypoxia A Randomized Controlled Trial in Healthy Volunteers
This study evaluated the effect of three strategies for reversal of a partial neuromuscular block on ventilatory control in 34 healthy male volunteers on the chemoreflex. The hypothesis was that the hypoxic ventilatory response is fully restored following the return to a train-of-four ratio of 1.Methods In this single-center, experimental, randomized, controlled trial, ventilatory responses to 5-min hypoxia (oxygen saturation, 80 ± 2%) and ventilation at hyperoxic isohypercapnia (end-tidal carbon dioxide concentration, 55 mmHg) were obtained at baseline, during rocuronium-induced partial neuromuscular block (train-o...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Atrophy of Diaphragm and Pectoral Muscles in Critically Ill Patients
Conclusions Ultrasound enables identification of specific early diaphragm atrophy that affects the majority of mechanically ventilated patients and septic shock patients. Diaphragm atrophy and pectoral muscle atrophy seem to be two unrelated processes. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Intraoperative Methadone in Surgical Patients A Review of Clinical Investigations
The relief of postoperative pain continues to pose a primary therapeutic challenge for clinicians. Despite the development and implementation of novel analgesic strategies over the past several decades, more than 50% of patients experience moderate-to-severe pain, even after “minor” surgical procedures.1 –3 Traditionally, shorter-acting opioids like morphine or hydromorphone have been administered as intermittent intravenous boluses to provide postoperative analgesia. However, this approach can produce widely fluctuating blood opioid concentrations, resulting in clinical responses that can range from inad...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Why We Write
It seems an incredible exercise of ego for me to assume that some random thought I might choose to record would be of any interest to others, yet we (as a species) have, historically, an incredible predisposition to write things down. From early pictographs to virtual blogs, humans are driven to document their experiences. Is it a bid for immortality, defying our transient, miniscule presence in this world, or is it truly philanthropic, hoping that someone might benefit from our experiences, our stories, and our mistakes? Do we write for ourselves or for others? (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Lung Pulse with Pneumothorax Examine the Thoracic Artery and Veins
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates
Conclusions Burnout, distress, and depression are notable among anesthesiology residents. Perceived institutional support, work –life balance, strength of social support, workload, and student debt impact physician well-being. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Postoperative Delirium and Postoperative Cognitive Dysfunction Overlap and Divergence
Conclusions Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

The Devil Is in the Details Comparison of Postoperative Delirium and Neurocognitive Dysfunction
“The lingering uncertainty in how we characterize the cognitive change associated with postoperative cognitive dysfunction is an uncomfortable truth often lost in translation and buried in study methods.” (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Prothrombin Complex Concentrate-induced Disseminated Intravascular Coagulation Can Be Prevented by Coadministering Antithrombin in a Porcine Trauma Model
Conclusions According to this trauma model, 50 IU/kg PCC increases the risk of disseminated intravascular coagulation and other thromboembolic complications, most notably when coadministered with fibrinogen concentrate. The addition of antithrombin appears to reduce this risk. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Reversing Neuromuscular Blockade: Not Just the Diaphragm, but Carotid Body Function Too
“[After] neuromuscular block reversal…even when the train-of-four ratio [has] recovered to 1.0, the acute [ventilatory response to hypoxia can remain] significantly depressed.” (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Beyond Ventilator-induced Diaphragm Dysfunction New Evidence for Critical Illness-associated Diaphragm Weakness
“[E]arly diaphragm atrophy …was observed in most of the patients treated by invasive mechanical ventilation.” (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Opioid- and Motor-sparing with Proximal, Mid-, and Distal Locations for Adductor Canal Block in Anterior Cruciate Ligament Reconstruction A Randomized Clinical Trial
Editor ’s PerspectiveWhat We Already Know about This TopicAdductor canal nerve block is useful for a range of knee surgeries, although the optimal injection location has not been definedUnfortunately, analgesia achieved using adductor canal block is sometimes accompanied by unwanted motor blockWhat This Article Tells Us That Is NewProximal adductor canal injections were associated with lower first 24-h morphine consumption than when injections were more distalDecreases in quadriceps strength were similar whether the injection was made in a proximal, mid-, or distal adductor canal locationBackground The ideal location...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and Isoflurane-anesthetized Volunteers
Editor ’s PerspectiveWhat We Already Know about This TopicVolume kinetic modeling is an adaptation of pharmacokinetic modeling that characterizes the disposition of intravenously administered fluids using hemoglobin concentration as a natural tracerPopulation-based pharmacokinetic analysis enables assessment of variability between individuals and across populations and permits inclusion of covariates such as the presence or absence of anesthetization, body weight, and sex in the data analysisWhat This Article Tells Us That Is NewThe distribution of infused fluid after hemorrhage (7 ml/kg during 20 min) in a randomize...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Blood Purification and Mortality in Sepsis and Septic Shock A Systematic Review and Meta-analysis of Randomized Trials
Editor ’s PerspectiveWhat We Already Know about This TopicAmong patients with sepsis or septic shock, a variety of extracorporeal blood purification techniques are availableIndividual existing trials evaluating these options are underpowered to provide clear evidenceWhat This Article Tells Us That Is NewMeta-analysis of very low-quality randomized controlled trial evidence demonstrates a potential benefit of hemoperfusion, hemofiltration, or plasmapheresisAdditional high-quality trials demonstrating benefit in modern clinical practice are needed before recommending these therapiesBackground Sepsis and septic shock ar...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Maintaining Hemostatic Balance in Treating Disseminated Intravascular Coagulation
“The complexity of managing DIC [disseminated intravascular coagulation] is to balance both the bleeding and thrombotic complications that occur.” (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Internal Carotid Artery Blood Flow Response to Anesthesia, Pneumoperitoneum, and Head-up Tilt during Laparoscopic Cholecystectomy
Editor ’s PerspectiveWhat We Already Know about This TopicCardiac output is an independent regulator of cerebral blood flow in healthy awake humansThe relationship between cardiac output and cerebral blood flow in anesthetized patients undergoing laparoscopy has not been previously characterizedWhat This Article Tells Us That Is NewAt steady-state depth of anesthesia, in patients undergoing laparoscopic cholecystectomy, creation of pneumoperitoneum decreased cardiac output and internal carotid artery blood flow while mean arterial pressure and end-tidal carbon dioxide levels remained unchangedBackground Little is kno...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery A Systematic Review and Meta-analysis
Editor ’s PerspectiveWhat We Already Know about This TopicPectoralis-II block is a potential alternative to paravertebral blocks to provide regional analgesia for breast cancer surgeryWhat This Article Tells Us That Is NewThis meta-analysis includes 14 randomized trials comparing pectoralis-II block with paravertebral blocks and found that there were no differences in pain scores or opioid consumption between the two groups in patients having surgery for breast cancerPectoralis-II blocks were noninferior to paravertebral blocks in reducing pain intensity and morphine consumption for the first 24 h after surgery and b...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Oxidants Regulated Diaphragm Proteolysis during Mechanical Ventilation in Rats
Conclusions Prolonged controlled mechanical ventilation activates the proteasome and autophagy pathways in the diaphragm through oxidative stress. Pathway activation is accomplished, in part, through inhibition of microRNAs that negatively regulate autophagy-related genes. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Trends in Direct Hospital Payments to Anesthesia Groups A Retrospective Cohort Study of Nonacademic Hospitals in California
Conclusions Direct payments from hospitals are becoming a larger financial consideration for anesthesia groups in California serving nonacademic hospitals, and are larger for groups working at hospitals serving publicly insured patients. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Superior Trunk Block A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial
Editor ’s PerspectiveWhat We Already Know about This TopicInterscalene nerve block is commonly used for shoulder surgery for anesthesia and postoperative analgesiaUnfortunately, interscalene blocks commonly result in hemidiaphragmatic paralysisWhat This Article Tells Us That Is NewWhen interscalene block was compared with superior trunk block, less frequent hemidiaphragmatic paralysis was seen in the superior trunk block groupSuperior trunk block was noninferior to interscalene block in terms of worst pain scores in the recovery room, and superior trunk block patients were more satisfiedBackground Interscalene nerve ...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Cognitive Effects of Perioperative Pregabalin: Comment
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Cognitive Effects of Perioperative Pregabalin: Reply
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Resident Mental Health Time for Action
“Social media may be contributing to…elevated rates of [anesthesiology resident] distress.” (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Postoperative Delirium Is Associated with Long-term Decline in Activities of Daily Living
Conclusions Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome
This study shows that in the majority of adult patients with acute respiratory distress syndrome, both driving pressure and respiratory system compliance can be reliably measured during pressure support (assisted) ventilation.Higher driving pressure measured during pressure support (assisted) ventilation significantly associates with increased intensive care unit mortality, whereas peak inspiratory pressure does not.Lower respiratory system compliance also significantly associates with increased intensive care unit mortality.Background Driving pressure, the difference between plateau pressure and positive end-expiratory pr...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Down Under the Deep
I drew in a deep breath (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Crystalloid/Colloid Renal and Disability Outcomes: Comment
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Crystalloid/Colloid Renal and Disability Outcomes: Reply
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Combination of a δ-opioid Receptor Agonist and Loperamide Produces Peripherally-mediated Analgesic Synergy in Mice
Conclusions From these data we conclude that the loperamide –oxymorphindole combination synergistically reverses complete Freund’s adjuvant–induced inflammatory hyperalgesia. The authors also conclude that this interaction is mediated by opioid receptors located in the peripheral nervous system. (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Syntaxin1A Neomorphic Mutations Promote Rapid Recovery from Isoflurane Anesthesia in Drosophila melanogaster
Editor ’s PerspectiveWhat We Already Know about This TopicSyntaxin1A is a presynaptic molecule that plays a key role in vesicular neurotransmitter releaseMutations of syntaxin1A result in resistance to both volatile and intravenous anestheticsTruncated syntaxin1A isoforms confer drug resistance in cell culture and nematode models of anesthesiaWhat This Article Tells Us That Is NewResistance to isoflurane anesthesia can be produced by transiently expressing truncated syntaxin1A proteins in adult Drosophila fliesElectrophysiologic and behavioral studies in Drosophila show that mutations in syntaxin1A facilitate recover...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

This Month in Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 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 - August 13, 2019 Category: Anesthesiology Source Type: research

Full Strength, but Impaired Response: Neuromuscular Blockade and the Carotid Body
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Anesthetic Inductions from Hexobarbital to Pentothal: Counting Down from 6 to 5?
The search for ultra-short-acting intravenous induction agents focused initially on hexobarbital. That methylated oxybarbiturate was discovered in 1932 by German researchers H. Weese and W. Scharpf. Marketed by the Bayer Company in Europe as Evipan, hexobarbital was distributed by New York ’s Winthrop Chemical Company as “Evipal Soluble” (above). Hexobarbital has a six-carbon side-ring of cyclohexene. Contrast that with the thiobarbiturate that supplanted hexobarbital: sodium thiopental (branded Pentothal by Abbott Laboratories, USA), which has a five-carbon side chain of pentane. (Copyright © the Am...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Dr. Frank A. Shattuck ’s Unfolding “Specialty, the Administration of Nitrous Oxide Gas”
According to New York City directories, Dr. Frank Alton Shattuck ran his dental office at 297 West Twelfth Street from roughly 1883 through 1887. So, this four-page advertising folder (lower right) was apparently printed sometime in the mid-1880s. Trained under a dental preceptor, Dr. Shattuck advertised his practice as embracing “all branches of the profession.” On the inside of this elegant folder from the Wood Library-Museum’s Ben Z. Swanson Collection, Dr. Shattuck trumpets that his practice includes “as a specialty, the administration of Nitrous Oxide Gas” (upper left). (Copyright © ...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Antipodal Views on Branding Amylocaine as Stovaine: Modesty or Political Correctness?
After surgeons revealed in 1904 that researcher Ernest A. Fourneau (1872 to 1949) had synthesized an alternative local anesthetic to cocaine, his Parisian firm, Poulenc Fr ères, branded his amylocaine as “Stovaine” for their English-speaking consumers. Over the years, that branding has been viewed quite differently by anesthesia museum curators in the southern and northern hemispheres. In Australia, “Stovaine” was characterized by Drs. C. M. Ball and R. N. We sthorpe as “modestly named with an anglicized version of his own name (Fourneau meaning furnace or stove).” However, in the...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

The Appearance and Disappearance of Dr. Edwin J. Thompson, Lynn ’s Celebrated Administrator of Nitrous Oxide
In 1879, I. A. Collins glued a copy of his cabinet photograph (upper) of a dental office in Lynn, Massachusetts, to an advertising card for dentist Edwin J. Thompson (ca. 1842 to 1912). Above the firm of Alfred Cross& Co., Clothiers, the dentist placed signage in the second-floor bay windows reading, “Teeth Extracted with Nitrous Oxide Gas” (lower left) by “Dr. Thompson Dentist” (lower middle). Through the open flanking window (lower right), photographer Collins may have captured the fleeting appearances of Dr. Thompson himself and an assistant gazing through the glazing. In 1912, the citizens o...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Turning Trash Cans into Iron Lungs: Dr. Robert M. Coffey, the “Genius of Juneau”
Portland surgical pioneer Robert Calvin Coffey named his youngest son Robert Mayo Coffey (1906 to 1972,right). The latter earned his M.D. at the University of Michigan and returned with his wife to his native Oregon. By 1937 the couple and their two young daughters were living in Juneau, Alaska. When neighboring children were quarantined with infantile paralysis, the resourceful Dr. Coffey began converting trash cans into iron lungs (left), just in case any children developed breathing difficulties. Electrical valves on Coffey ’s “pressure and reserve tanks” alternated positive and negative pressures for ...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Practical Operating Theater Management: Measuring and Improving Performance and Patient Experience
Because most anesthesiologists work in the operating room setting, anesthesiologists are involved with the management of the operating room suite (or “theater”). Even if they are not responsible for the management, anesthesiologists still want to understand the decision-making process and metrics that affect their daily schedule and duties. In the United States, anesthesiologists can attend in-person conferences and seminars on leadership, pr actice management, and operating room management offered by national associations, online webinars and resources, and textbooks. Although these offerings will give anesthe...
Source: Anesthesiology - August 13, 2019 Category: Anesthesiology Source Type: research

Adjunctive Corticosteroid Treatment in Septic Shock
Interest in the role of the adrenal cortex in the recovery from an infection dates back nearly 100 yr. More than six decades of research on the role of corticosteroid supplementation as an adjunctive treatment for sepsis and septic shock failed to reveal conclusive results. Recently two large-scale randomized controlled trials have added substantial new data to inform opinion regarding the role of corticosteroids in the treatment of septic shock.1,2 In this article, we review the background, the current state of the evidence, and ongoing areas of uncertainty in this field and provide suggestions for clinical practice. (Source: Anesthesiology)
Source: Anesthesiology - July 17, 2019 Category: Anesthesiology Source Type: research

Failure to Rescue as a Surgical Quality Indicator Current Concepts and Future Directions for Improving Surgical Outcomes
Over the past decade, failure to rescue —defined as the death of a patient after one or more potentially treatable complications—has received increased attention as a surgical quality indicator. Failure to rescue is an appealing quality target because it implicitly accounts for the fact that postoperative complications may not always be preventable and is based on the premise that prompt recognition and treatment of complications is a critical, actionable point during a patient’s postoperative course. Although numerous patient and macrosystem factors have been associated with failure to rescue, there is a...
Source: Anesthesiology - July 17, 2019 Category: Anesthesiology Source Type: research