Transesophageal Echocardiogram to the Rescue in Diagnosing Ascending Aortic Pseudoaneurysm: Comment
(Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Transesophageal Echocardiogram to the Rescue in Diagnosing Ascending Aortic Pseudoaneurysm: Reply
(Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Postoperative Delirium A Minefield of Markers and Mediators
“…burst suppression is better described as a ‘marker’ of an abnormal brain response to anesthesia and surgery—not a causal mediator.” (Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Dexmedetomidine and Cognitive Dysfunction after Critical Illness What Can (and Cannot) Be Extrapolated from Rodent Models
“Understanding how to prevent (or at least minimize) post–intensive care syndrome thus represents a new frontier in critical care.” (Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Perioperative Gabapentinoids Deflating the Bubble
“It is now clear that over the past two decades, evidence of benefit from routine perioperative administration of gabapentinoids has diminished, while evidence of harm has increased.” (Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain A Systematic Review and Meta-analysis
Conclusions No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients.Editor ’s PerspectiveWhat We Already Know about This TopicGabapentinoids such as gabapentin and pregabalin are often included in perioperative multimodal analgesia regimens in an attempt to reduce acute, subacute, and chronic pain after surgeryCurrent American Pain So...
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

This Month in Anesthesiology
(Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Science, Medicine, and the Anesthesiologist
Key Papers from the Most Recent Literature Relevant to Anesthesiologists (Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Seeing the Forest for the Trees: Reconsidering Perioperative Gabapentinoids
Complex Information for Anesthesiologists Presented Quickly and Clearly (Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Instructions for Obtaining A nesthesiology Continuing Medical Education (CME) Credit
(Source: Anesthesiology)
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Future Nobelist Richard Wilst ätter Synthesizes Tropacocaine: Raise a Cup of Java!
Dr. Carl Koller opened the medical community ’s eyes to the local anesthetic potential of cocaine in 1884. Cocaine’s success as a topical and spinal anesthetic surged coca leaf exports, first from South America and then from Java, whose stimulating trade also included coffee. Although local anesthetic tropacocaine was present in higher con centrations in Javanese coca plants, future Nobelist Richard Wilstätter braved antisemitism and synthesized tropacocaine with “keto-tropins” in Munich. Thereby simpler to produce than cocaine, tropacocaine featured longer shelf life, quicker anesthetic onset,...
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Beacon, Not Buccaneer: Ram ón Betances, Puerto Rican Patriot and Chloroform Pioneer
Nicknamed “El Padre de la Patria” (upper left), Ram ón Emeterio Betances y Alacán (1827 to 1898)—physician, writer, abolitionist, and Freemason—was the first political leader to espouse Puerto Rican nationalism. This gold-plated medallion celebrates the 185th anniversary of his birth in Cabo Rojo, or “El Pueblo de Cofres í”—hometown of infamous pirate Cofresí and historic lighthouseFaro de Morrillos (lower right). A bust of Betances appears next to the Masonic Lodge (Logia Cuna de Betances, upper left) that was built upon his birthplace. Betances complet...
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Byline Backstory No. 7: Following the Historic Footsteps of Snow in Anesthesia and Public Health
On one of my clinical rotations as a Johns Hopkins medical student, I worked alongside surgical resident Ira Rutkow, M.D., M.P.H. (upper left), who encouraged me to pursue the history of medicine and to follow him into Hopkins ’ (now Bloomberg) School of Public Health. There I met Professor George Comstock (upper right) who idolized John Snow, M.D., a British pioneer of both anesthesiology and epidemiology. Studying Snow ’s life and his ether inhaler (bottom) kindled my enthusiasm to pursue anesthesia history and then curate departmental anesthesia museums at Hopkins and then Yale. Examining epidemiology, the f...
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Prevalence of Complete Airway Closure According to Body Mass Index in Acute Respiratory Distress Syndrome Pooled Cohort Analysis
BackgroundComplete airway closure during expiration may underestimate alveolar pressure. It has been reported in cases of acute respiratory distress syndrome (ARDS), as well as in morbidly obese patients with healthy lungs. The authors hypothesized that complete airway closure was highly prevalent in obese ARDS and influenced the calculation of respiratory mechanics.MethodsIn apost hoc pooled analysis of two cohorts, ARDS patients were classified according to body mass index (BMI) terciles. Low-flow inflation pressure –volume curve and partitioned respiratory mechanics using esophageal manometry were recorded. The au...
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Tau Contributes to Sevoflurane-induced Neurocognitive Impairment in Neonatal Mice
This study tested the hypothesis that differences in brain Tau amounts and in the activity of mitochondria –adenosine triphosphate (ATP)–Nuak1–Tau cascade between the neonatal and adult mice contribute to the age-dependent effects of sevoflurane on cognitive function.Methods6- and 60-day-old mice of both sexes received anesthesia with 3% sevoflurane for 2  h daily for 3 days. Biochemical methods were used to measure amounts of Tau, phosphorylated Tau, Nuak1, ATP concentrations, and mitochondrial metabolism in the cerebral cortex and hippocampus. The Morris water maze test was used to evaluate cogni...
Source: Anesthesiology - July 14, 2020 Category: Anesthesiology Source Type: research

Implications of Practice Variability: Comment
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Impact of Closed-loop Anesthesia on Cognitive Function: Comment
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Distribution of Ventilation in Pneumoperitoneum: Comment
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Sparking the Discussion about Vaping and Anesthesia: Comment
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Sparking the Discussion about Vaping and Anesthesia: Reply
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Perioperative Care for Patients with COVID-19: Comment
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Perioperative Care for Patients with COVID-19: Reply
(Source: Anesthesiology)
Source: Anesthesiology - July 13, 2020 Category: Anesthesiology Source Type: research

Body Habitus and Dynamic Surgical Conditions Independently Impair Pulmonary Mechanics during Robotic-assisted Laparoscopic Surgery A Cross-sectional Study
This study hypothesized that increasing body mass index is associated with more mechanical strain and alveolar collapse, and these impairments are exacerbated by pneumoperitoneum and Trendelenburg positioning.MethodsThis cross-sectional study measured respiratory flow, airway pressures, and esophageal pressures in 91 subjects with body mass index ranging from 18.3 to 60.6  kg/m2. Pulmonary mechanics were quantified at four stages: (1) supine and level after intubation, (2) with pneumoperitoneum, (3) in Trendelenburg docked with the surgical robot, and (4) level without pneumoperitoneum. Subjects were stratified into...
Source: Anesthesiology - July 9, 2020 Category: Anesthesiology Source Type: research

Assessment of Right Heart Function during Extracorporeal Therapy by Modified Thermodilution in a Porcine Model
This study aims to validate a new thermodilution technique during veno-arterial extracorporeal membrane oxygenation therapy using a pig model.MethodsSixteen healthy pigs were centrally cannulated for veno-arterial extracorporeal membrane oxygenation, and precision flow probes for blood flow assessment were placed on the pulmonary artery. After chest closure, cold boluses of 0.9% saline solution were injected into the extracorporeal membrane oxygenation circuit, right atrium, and right ventricle at different extracorporeal membrane oxygenation flows (4, 3, 2, 1 l/min). Rapid response thermistors in the extracorporeal membra...
Source: Anesthesiology - July 8, 2020 Category: Anesthesiology Source Type: research

Differential Ventilation Using Flow Control Valves as a Potential Bridge to Full Ventilatory Support during the COVID-19 Crisis From Bench to Bedside
ConclusionsDifferential ventilation using a single ventilator is feasible. Flow control valves enable delivery of stable tidal volume and PMAX similar to those provided by individual ventilators.Editor ’s PerspectiveWhat We Already Know about This TopicIn previous mass casualty situations that have resulted in intensive care unit or emergency room surge conditions, the use of ventilator splitting to ventilate two or more patients has been proposed.The concept has received renewed attention with the global COVID-19 pandemic.The impaired respiratory mechanics similar to the acute respiratory distress syndrome seen in C...
Source: Anesthesiology - July 2, 2020 Category: Anesthesiology Source Type: research

Granger Causality of the Electroencephalogram Reveals Abrupt Global Loss of Cortical Information Flow during Propofol-induced Loss of Responsiveness
This study therefore hypothesized that loss of wakefulness caused by propofol anesthesia should be associated with loss of information flow, as estimated by the effective connectivity in the scalp electroencephalogram (EEG) signal.MethodsEffective connectivity during anesthesia was quantified by applying bivariate Granger to multichannel EEG data recorded from 16 adult subjects undergoing a slow induction of, and emergence from, anesthesia with intravenous propofol. During wakefulness they were conducting various auditory and motor tasks. Functional connectivity using EEG coherence was also estimated.ResultsThere was an ab...
Source: Anesthesiology - July 1, 2020 Category: Anesthesiology Source Type: research

Volatile versus Total Intravenous Anesthesia for Cancer Prognosis in Patients Having Digestive Cancer Surgery A Nationwide Retrospective Cohort Study
ConclusionsOverall and recurrence-free survival were similar between volatile and intravenous anesthesia in patients having digestive tract surgery. Selection of the anesthetic approach for these patients should be based on other factors.Editor ’s PerspectiveWhat We Already Know about This TopicExperimental and clinical studies suggest that intravenous anesthesia may reduce cancer recurrence after potentially curative surgeryWhat This Article Tells Us That Is NewAmong more than 190,000 patients who had cancer surgery, overall and recurrence-free survival were comparable in patients who had propofol-based total intrav...
Source: Anesthesiology - July 1, 2020 Category: Anesthesiology Source Type: research

Determining Associations and Estimating Effects with Regression Models in Clinical Anesthesia
There are an increasing number of “big data” studies in anesthesia that seek to answer clinical questions by observing the care and outcomes of many patients across a variety of care settings. This Readers’ Toolbox will explain how to estimate the influence of patient factors on clinical outcome, addressingbias andconfounding. One approach to limit the influence of confounding is to perform a clinical trial. When such a trial is infeasible, observational studies using robust regression techniques may be able to advance knowledge.Logistic regression is used when the outcome is binary (e.g., intracranial he...
Source: Anesthesiology - July 1, 2020 Category: Anesthesiology Source Type: research

Benefit and Risk Evaluation of Biased μ-Receptor Agonist Oliceridine versus Morphine
BackgroundTo improve understanding of the respiratory behavior of oliceridine, a μ-opioid receptor agonist that selectively engages the G-protein–coupled signaling pathway with reduced activation of the β-arrestin pathway, the authors compared its utility function with that of morphine. It was hypothesized that at equianalgesia, oliceridine will produce less respiratory depr ession than morphine and that this is reflected in a superior utility.MethodsData from a previous trial that compared the respiratory and analgesic effects of oliceridine and morphine in healthy male volunteers (n = 30) were reanalyzed. A...
Source: Anesthesiology - July 1, 2020 Category: Anesthesiology Source Type: research

Cost-effectiveness Analysis of Preoperative Screening Strategies for Obstructive Sleep Apnea among Patients Undergoing Elective Inpatient Surgery
ConclusionsThe cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.Editor ’s PerspectiveWhat We Already Know about This TopicObstructive sleep apnea is common, frequently undiagnosed, and associated with increased ri...
Source: Anesthesiology - June 26, 2020 Category: Anesthesiology Source Type: research

Computer-aided Discovery of a New Nav1.7 Inhibitor for Treatment of Pain and Itch
The objective of this study was to discover new candidate compounds with Nav1.7 inhibitor properties. The authors hypothesized that their approach would yield at least one new compound that inhibits sodium currentsin vitro and exerts analgesic and anti-itch effects in mice.MethodsIn silico structure-based similarity search of 1.5 million compounds followed by docking to the Nav1.7 voltage sensor of Domain 4 and molecular dynamics simulation was performed. Patch clamp experiments in Nav1.7-expressing human embryonic kidney 293 cells and in mouse and human dorsal root ganglion neurons were conducted to test sodium current in...
Source: Anesthesiology - June 26, 2020 Category: Anesthesiology Source Type: research

Androgenic Modulation of the Chloride Transporter NKCC1 Contributes to Age-dependent Isoflurane Neurotoxicity in Male Rats
BackgroundCognitive deficits after perinatal anesthetic exposure are well established outcomes in animal models. This vulnerability is sex-dependent and associated with expression levels of the chloride transporters NKCC1 and KCC2. The hypothesis was that androgen signaling, NKCC1 function, and the age of isoflurane exposure are critical for the manifestation of anesthetic neurotoxicity in male rats.MethodsFlutamide, an androgen receptor antagonist, was administered to male rats on postnatal days 2, 4, and 6 before 6  h of isoflurane on postnatal day 7 (ntotal = 26). Spatial and recognition memory were subsequently ...
Source: Anesthesiology - June 25, 2020 Category: Anesthesiology Source Type: research

COVID-19 Infection: Implications for Perioperative and Critical Care Physicians: Erratum
In the June 2020 issue, the article “COVID-19 Infection: Implications for Perioperative and Critical Care Physicians” (Greenland JR, Michelow MD, Wang L, London MJ. Anesthesiology 2020; 132: 1346 –61. doi: 10.1097/ALN.0000000000003303) contains an error in table 1. In the fifth row describing 52 cases, the Cardiac Injury column should be “23%,” not “12%.” (Source: Anesthesiology)
Source: Anesthesiology - June 24, 2020 Category: Anesthesiology Source Type: research

COVID-19 Infection: Perioperative Implications: Comment
(Source: Anesthesiology)
Source: Anesthesiology - June 22, 2020 Category: Anesthesiology Source Type: research

COVID-19 Infection: Perioperative Implications: Reply
(Source: Anesthesiology)
Source: Anesthesiology - June 22, 2020 Category: Anesthesiology Source Type: research

Robots Will Perform Anesthesia in the Near Future: Comment
(Source: Anesthesiology)
Source: Anesthesiology - June 19, 2020 Category: Anesthesiology Source Type: research

Robots Will Perform Anesthesia in the Near Future: Reply
(Source: Anesthesiology)
Source: Anesthesiology - June 19, 2020 Category: Anesthesiology Source Type: research

Neural Selective Cryoneurolysis with Ice Slurry Injection in a Rat Model
Conclusions Ice slurry injection selectively targets the rat sciatic nerve, causing no damage to surrounding tissue. Injection of ice slurry around the rat sciatic nerve induced decreased nociceptive response from the baseline through neural selective cryoneurolysis.Editor ’s PerspectiveWhat We Already Know about This TopicAchieving long-lasting surgical site anesthesia can be problematicCryoneurolysis is effective in providing long-lasting analgesia, but current techniques are nonselective for neural tissueWhat This Article Tells Us That Is NewUsing a rat sciatic nerve block model, an injectable biocompatible ice sl...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Patient Blood Management Effectiveness and Future Potential
Before major surgery, 30 to 40% of patients are anemic, an important consideration that is associated with increased erythrocyte transfusions, prolonged hospital length of stay, more frequent intensive care admissions, infections, and thromboembolic events, and mortality.1 –4 Surgical bleeding contributes to anemia, increases transfusions, and independently increases mortality.5 In addition, transfusion of allogeneic blood products is associated with increased morbidity and mortality6 and increased costs, and allogeneic blood products are a limited resource.6 –8 Therefore, as a pragmatic solution, the concept o...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

An ER Doctor Finds His Daughter in Critical Condition
The operating room sounds oddly like jazz. (Source: Anesthesiology)
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

An Effective and Efficient Testing Protocol for Diagnosing Iron-deficiency Anemia Preoperatively
Background Iron-deficiency anemia is a common perioperative condition and increases perioperative morbidity and mortality. Timely diagnosis and treatment are important. This retrospective cohort study tested the hypothesis that a newly developed preprocedure evaluation protocol diagnoses more patients with iron-deficiency anemia than the traditional practice of obtaining a complete blood count followed by iron studies.Methods The preprocedure anemia evaluation is an order for a complete blood count and reflex anemia testing, which can be completed with a single patient visit. A hemoglobin concentration of 12  g/dl o...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Individualized Fluid Management Using the Pleth Variability Index A Randomized Clinical Trial
Conclusions Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications.Editor ’s PerspectiveWhat We Already Know about This TopicThe role of guided fluid management remains unclear, with contradictory trial results.The noninvasive plethysmographic variability index is one method of guiding fluid administration.What This Article Tells Us That Is NewThe investigators randomized 447 moderate-risk major arthroplasty patients to plethysmographic-guidedversus...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Assessing and Reversing the Effect of Direct Oral Anticoagulants on Coagulation
Direct oral anticoagulants have improved anticoagulation options for many patients, but they present challenges regarding monitoring and reversal of anticoagulant activity. Anesthesiologists are likely to encounter patients taking direct oral anticoagulants in a variety of clinical settings including scheduled procedures, emergency procedures, trauma, and critical care units. This review focuses on the pharmacokinetics of direct oral anticoagulants, testing methods to assess anticoagulant activity, and the use of reversal agents, to give the practicing anesthesiologist the necessary knowledge to manage situations encounter...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Setup of a Dedicated Coronavirus Intensive Care Unit Logistical Aspects
(Source: Anesthesiology)
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery A Systematic Review and Meta-analysis
Conclusions Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility.Editor ’s PerspectiveWhat We Already Know about This TopicPreoperative frailty has been associated with adverse postoperative outcomesIt remains unclear which frailty scale is the best predictor of adverse postoperative outcomesWhat This Article Tells Us That Is NewThis meta-analysis of 45 articles identified that specific frailty scales may be better predictors for so...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Flying with a Compass Goals of Care in the Perioperative Setting
I met VC in an inpatient progress note. I felt I was standing by the window, watching the attending on rounds come and sit by the bed of this dying retired family doctor. I could almost hear the pleasant, unhurried conversation about VC ’s life and what he wanted from what remained of it. The note immortalized in the electronic health record was written with poetic brevity and it was the most beautiful, succinct, and thorough description of goals of care I’d ever seen. (Source: Anesthesiology)
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research

Collapse of Global Neuronal States in Caenorhabditis elegans under Isoflurane Anesthesia
Background A comprehensive understanding of how anesthetics facilitate a reversible collapse of system-wide neuronal function requires measurement of neuronal activity with single-cell resolution. Multineuron recording was performed inCaenorhabditis elegans to measure neuronal activity at varying depths of anesthesia. The authors hypothesized that anesthesia is characterized by dyssynchrony between neurons resulting in a collapse of organized system states.Methods Using light-sheet microscopy and transgenic expression of the calcium-sensitive fluorophore GCaMP6s, a majority of neurons (n = 120) in theC. elegans head were s...
Source: Anesthesiology - June 17, 2020 Category: Anesthesiology Source Type: research