Practice advisory for the prevention and management of operating room fires: An updated report by the American Society of Anesthesiologists Task Force on Operating room fires

Dexmedetomidine and cardiac arrest.

Monitoring of continuous blood pressure and cardiac output is important to prevent hypoperfusion and to guide fluid administration, but only few patients receive such monitoring due to the invasive nature of most of the methods presently available Noninvasive blood pressure can be determined continuously using finger cuff technology and cardiac output is easily obtained using a pulse contour method In this way completely noninvasive continuous blood pressure and cardiac output are available for clinical use in all patients that would otherwise not be monitored Developments and state of art in hemodynamic monitoring are reviewed here, with a focus on noninvasive continuous hemodynamic monitoring form the finger

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Noninvasive continuous hemodynamic monitoring.

To assess the impact of the lung recruitment maneuver on circulation following cardiac surgery. Prospective randomized cross-over study at the Departments of Anesthesia and Thoracic Surgery, Copenhagen University Hospital. Ten adult undergoing coronary artery bypass surgery. Patients were randomized to two durations of lung recruitment maneuvers (40 cmH2O airway pressure for 10 s and 20 s or vice versa after 5 min) administered immediately after surgery. Transesophageal echocardiography (left ventricular short axis view), pulse contour cardiac output, and arterial blood pressure were monitored continuously. Systemic and pulmonary arterial blood gases were sampled before and after each lung recruitment maneuver to calculate the intrapulmonary shunt. Left ventricular end-diastolic areas decreased significantly during both the 10-s and the 20-s lung recruitment maneuvers. Cardiac output was 5.6±0.8 l/min at baseline, decreasing by 3.0±1.1 l/min and 3.6±1.2 l/min during lung recruitment maneuvers of 10 and 20 s, respectively. Shunt decreased from 20±5% to 15±6% after the first lung recruitment maneuver and from 15±6% to 12±5% after the second. Lung recruitment maneuvers markedly reduced cardiac output and left ventricular end-diastolic areas in hemodynamically stable patients following cardiac surgery.

Lung recruitment maneuver depresses central hemodynamics in patients following cardiac surgery

Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires Jeffrey Apfelbaum;Robert Caplan;Steven Barker;Richard Connis;Charles Cowles;Jan Ehrenwerth;David Nickinovich;Donna Pritchard;David Roberson;Robert Caplan;Steven Barker;Richard Connis;Charles Cowles;Albert de Richemond;Jan Ehrenwerth;David Nickinovich;Donna Pritchard;David Roberson;Gerald Wolf; Anesthesiology

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Practice advisory for the prevention and management of operating room fires.

THE idea that reflexes originating in the heart can play a role in normal physiology dates to the 1860s. Until the 1950s, these reflexes, and the Bezold–Jarisch reflex (BJR) in particular, were regarded largely as pharmacological curiosities with the only practical application of the study of the BJR being the clinical use of a veratrum alkaloid as an antihypertensive agent. Since the 1860s, it had been known that injection of minute amounts (0.005 mg) of veratrine or its pure alkaloid components (veratrum) initiates a reflex which causes a rapid fall in blood pressure and heart rate in association with apnea. This “Von Bezold reflex” was classically defined in association with arrest of breathing, but more recently, it has been called the BJR and includes the triad of bradycardia, hypotension, and peripheral vasodilation. It is now understood that certain inhibitory reflexes, which have origin with cardiac sensory receptors, play a role in cardiovascular homeostasis. Activation of a subset of these receptors by diverse stimuli increases parasympathetic nervous system activity, inhibits sympathetic activity and is responsible for eliciting the BJR. Some anesthesiologists have suggested that the BJR may explain cardiovascular collapse reported during regional anesthesia techniques. This review focuses on the physiology of the BJR and its possible physiologic role in a number of clinical situations. It also provides discussion of the limited relevance of this reflex in regional anesthesia. The topic of clinical management will not be addressed given the paucity of data on this matter, but suggestions for future experimental direction are offered.

Clinical relevance of the Bezold-Jarisch reflex.

Most surgical fires involve the airway but they can also occur in the surgical field. Herein, we report an intraoperative fire in the surgical field during repair of a bronchoesophageal fistula. During the portion of the surgery after the fistula was divided and the bronchus was open to atmosphere, continuous positive airway pressure was applied to the nondependent lung, and in conjunction with the use of electrocautery and dry sponges in the field, resulted in a fire. Anesthesia for thoracic surgery carries unique risks of fire because these patients frequently require large oxygen concentrations, special interventions for improving oxygenation, and have variable degrees of airway disruption. This report highlights unique safety concerns during anesthesia for thoracic surgery, and addresses more general safety issues relating to fire risk in all surgical patients.

Surgical field fire during a repair of bronchoesophageal fistula.

Background Cyclopropyl-methoxycarbonyl metomidate, or ABP-700, is a second generation analogue of etomidate, developed to retain etomidate's beneficial haemodynamic and respiratory profile but diminishing its suppression of the adrenocortical axis. The objective of this study was to characterise the safety and efficacy of 30-min continuous infusions of ABP-700, and to assess its effect on haemodynamics and the adrenocortical response in healthy human volunteers. Methods Five cohorts involving 40 subjects received increasing infusion doses of ABP-700, propofol 60 μg kg −1  min −1 or placebo. Safety was evaluated through adverse event (AE) monitoring, safety laboratory tests, and arterial blood gasses. Haemodynamic and respiratory stability were assessed by continuous monitoring. Adrenocortical function was analysed by adrenocorticotropic hormone (ACTH) stimulation tests. Clinical effect was measured using the modified observer's assessment of alertness/sedation (MOAA/S) and continuous bispectral index monitoring. Results No serious AEs were reported. Haemodynamic and respiratory effects included mild dose-dependent tachycardia, slightly elevated blood pressure, and no centrally mediated apnoea. Upon stimulation with ACTH, no adrenocortical depression was observed in any subject. Involuntary muscle movements (IMM) were reported, which were more extensive with higher dosing regimens. Higher dosages of ABP-700 were associated with deeper sedation and increased likelihood of sedation. Time to onset of clinical effect was variable throughout the cohorts and recovery was swift. Conclusions Infusions of ABP-700 showed a dose-dependent hypnotic effect, and did not cause severe hypotension, severe respiratory depression, or adrenocortical suppression. The presentation and nature of IMM is a matter of concern. Clinical trial registration NTR4735.

Safety and clinical effect of i.v. infusion of cyclopropyl-methoxycarbonyl etomidate (ABP-700), a soft analogue of etomidate, in healthy subjects.

Background:Cyclopropyl-methoxycarbonylmetomidate (ABP-700) is a new “soft” etomidate analog. The primary objectives of this first-in-human study were to describe the safety and efficacy of ABP-700 and to determine its maximum tolerated dose. Secondary objectives were to characterize the pharmacokine

A Phase 1, Single-center, Double-blind, Placebo-controlled Study in Healthy Subjects to Assess the Safety, Tolerability, Clinical Effects, and Pharmacokinetics-Pharmacodynamics of Intravenous Cyclopropyl-methoxycarbonylmetomidate (ABP-700) after a Single Ascending Bolus Dose

Jason Campagna

Papers

Clinical relevance of the Bezold-Jarisch reflex.

Surgical field fire during a repair of bronchoesophageal fistula.

Safety and clinical effect of i.v. infusion of cyclopropyl-methoxycarbonyl etomidate (ABP-700), a soft analogue of etomidate, in healthy subjects.

A Phase 1, Single-center, Double-blind, Placebo-controlled Study in Healthy Subjects to Assess the Safety, Tolerability, Clinical Effects, and Pharmacokinetics-Pharmacodynamics of Intravenous Cyclopropyl-methoxycarbonylmetomidate (ABP-700) after a Single Ascending Bolus Dose

Academic anesthesia and M.D.-Ph.D.s.