Showing papers in "Anesthesia & Analgesia in 2009"
TL;DR: A large database of prospectively collected data on pediatric sedation/anesthesia outside the operating room provided by a wide range of pediatric specialists is used to delineate the nature and frequency of adverse events associated with propofol-based sedation/.
Abstract: OBJECTIVE: We used a large database of prospectively collected data on pediatric sedation/anesthesia outside the operating room provided by a wide range of pediatric specialists to delineate the nature and frequency of adverse events associated with propofol-based sedation/anesthesia care. PATIENTS AND METHODS: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of institutions dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients receiving sedation or sedation/anesthesia for procedures. The primary inclusion criterion was the need for some form of sedation/anesthesia to perform a diagnostic or therapeutic procedure outside the operating room. There were no exclusion criteria. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, procedure and recovery times, medication doses outcomes of anesthesia, airway interventions and adverse events were collected and reported using web-based data collection tool. For this study, we evaluated all instances where propofol was used as the primary
485 citations
TL;DR: NISHOTs are reviewed, focusing on the most recent concerns and literature, which focused on the morbidity and mortality of liberal versus restrictive red blood cell transfusion, as well as the potential dangers of transfusing “older” versus “younger” blood.
Abstract: As infectious complications from blood transfusion have decreased because of improved donor questionnaires and sophisticated infectious disease blood screening, noninfectious serious hazards of transfusion (NISHOTs) have emerged as the most common complications of transfusion. The category of NISHOTs is very broad, including everything from well-described and categorized transfusion reactions (hemolytic, febrile, septic, and allergic/urticarial/anaphylactic) to lesser known complications. These include mistransfusion, transfusion-related acute lung injury, transfusion-associated circulatory overload, posttransfusion purpura, transfusion-associated graft versus host disease, microchimerism, transfusion-related immunomodulation, alloimmunization, metabolic derangements, coagulopathic complications of massive transfusion, complications from red cell storage lesions, complications from over or undertransfusion, and iron overload. In recent years, NISHOTs have attracted more attention than ever before, both in the lay press and in the scientific community. As the list of potential complications from blood transfusion grows, investigators have focused on the morbidity and mortality of liberal versus restrictive red blood cell transfusion, as well as the potential dangers of transfusing "older" versus "younger" blood. In this article, we review NISHOTs, focusing on the most recent concerns and literature.
339 citations
TL;DR: This review focuses on the regulatory mechanisms of hemostasis and thrombin generation using multiple, simplified models of coagulation to help control bleeding without potentially increasing prothrombotic risks.
Abstract: Perioperative bleeding is a major challenge particularly because of increasing clinical use of potent antithrombotic drugs. Understanding current concepts of coagulation is important in determining the preoperative bleeding risk of patients, and in managing hemostatic therapy perioperatively. The serine protease thrombin plays pivotal roles in the activation of additional serine protease zymogens (inactive enzymatic precursors), cofactors, and cell-surface receptors. Thrombin generation is closely regulated to locally achieve rapid hemostasis after injury without causing uncontrolled systemic thrombosis. During surgery, there are major disturbances in coagulation and inflammatory systems because of hemorrhage/hemodilution, blood transfusion, and surgical stresses. Postoperative bleeding often requires allogeneic blood transfusions, which support thrombin generation and hemostasis. However, procoagulant activity and inflammation are increased postoperatively; thus, antithrombotic therapy may be required to prevent perioperative thrombotic complications. There have been significant advances in the management of perioperative hemostasis and thrombosis because of the introduction of novel hemostatic and antithrombotic drugs. However, a limitation of current treatment is that conventional clotting tests do not reflect the entire physiological processes of coagulation making optimal pharmacologic therapy difficult. Understanding the in vivo regulatory mechanisms and pharmacologic modulation of thrombin generation may help control bleeding without potentially increasing prothrombotic risks. In this review, we focus on the regulatory mechanisms of hemostasis and thrombin generation using multiple, simplified models of coagulation.
305 citations
TL;DR: There are currently limited data upon which to confidently make strong recommendations regarding how to conduct optimal CPB, and a critical need for randomized trials assessing clinically significant outcomes, particularly in high-risk patients.
Abstract: In this review, we summarize the best available evidence to guide the conduct of adult cardiopulmonary bypass (CPB) to achieve "optimal" perfusion. At the present time, there is considerable controversy relating to appropriate management of physiologic variables during CPB. Low-risk patients tolerate mean arterial blood pressures of 50-60 mm Hg without apparent complications, although limited data suggest that higher-risk patients may benefit from mean arterial blood pressures >70 mm Hg. The optimal hematocrit on CPB has not been defined, with large data-based investigations demonstrating that both severe hemodilution and transfusion of packed red blood cells increase the risk of adverse postoperative outcomes. Oxygen delivery is determined by the pump flow rate and the arterial oxygen content and organ injury may be prevented during more severe hemodilutional anemia by increasing pump flow rates. Furthermore, the optimal temperature during CPB likely varies with physiologic goals, and recent data suggest that aggressive rewarming practices may contribute to neurologic injury. The design of components of the CPB circuit may also influence tissue perfusion and outcomes. Although there are theoretical advantages to centrifugal blood pumps over roller pumps, it has been difficult to demonstrate that the use of centrifugal pumps improves clinical outcomes. Heparin coating of the CPB circuit may attenuate inflammatory and coagulation pathways, but has not been clearly demonstrated to reduce major morbidity and mortality. Similarly, no distinct clinical benefits have been observed when open venous reservoirs have been compared to closed systems. In conclusion, there are currently limited data upon which to confidently make strong recommendations regarding how to conduct optimal CPB. There is a critical need for randomized trials assessing clinically significant outcomes, particularly in high-risk patients.
302 citations
TL;DR: The TF:FVIIa complex is essential for hemostasis and recombinant FVIIa is an effective hemostatic drug for the treatment of hemophilia patients with inhibitory antibodies.
Abstract: Tissue factor (TF) is a transmembrane receptor for Factor VII/VIIa (FVII/VIIa). It is constitutively expressed by cells surrounding blood vessels. The endothelium physically separates this potent "activator" from its circulating ligand FVII/FVIIa and prevents inappropriate activation of the clotting cascade. Breakage of the endothelial barrier leads to exposure of extravascular TF and rapid activation of the clotting cascade. TF is also expressed in certain tissues, such as the heart and brain, and provides additional hemostatic protection to these tissues. Small amounts of TF are also present in blood in the form of microparticles, which are small membrane vesicles derived from activated and apoptotic cells. Levels of microparticle TF increase in a variety of diseases, such as sepsis and cancer, and this so-called "blood-borne" TF may contribute to thrombosis associated with these diseases. Recombinant FVIIa has been developed as an effective hemostatic drug for the treatment of hemophilia patients with inhibitory antibodies. In addition, it is used for patients with bleeding that do not respond to conventional therapy. However, the mechanism by which recombinant FVIIa restores hemostasis has not been clearly defined. In conclusion, the TF:FVIIa complex is essential for hemostasis and recombinant FVIIa is an effective hemostatic drug.
288 citations
TL;DR: Clot strength increases in a fibrinogen concentration-dependent manner independent of platelet count, when analyzed by ROTEM, suggesting that EXTEM® (extrinsic activation) and FIBTEM may be useful in guiding fibr inogen repletion therapy.
Abstract: BACKGROUND:The binding of fibrinogen and fibrin to platelets is important in normal hemostasis. The extent of platelet-fibrin interaction can be measured as the viscoelastic strength of clot by rotational thromboelastometry (ROTEM®). In this study, we investigated the effect of fibrinogen concentrat
284 citations
TL;DR: Limited clinical experience with the ultrasound-guided arterial cannulation method suggests that this technique is associated with increased success of cannulation with fewer attempts, and research is needed to assess the safety of using the ulnar artery as an alternative to radial artery cannulation.
Abstract: Consistent anatomic accessibility, ease of cannulation, and a low rate of complications have made the radial artery the preferred site for arterial cannulation. Radial artery catheterization is a relatively safe procedure with an incidence of permanent ischemic complications of 0.09%. Although its anatomy in the forearm and the hand is variable, adequate collateral flow in the event of radial artery thrombosis is present in most patients. Harvesting of the radial artery as a conduit for coronary artery bypass grafting, advances in plastic and reconstructive surgery of the hand, and its use as an entry site for cardiac catheterization has provided new insight into the collateral blood flow to the hand and the impact of radial arterial instrumentation. The Modified Allen's Test has been the most frequently used method to clinically assess adequacy of ulnar artery collateral flow despite the lack of evidence that it can predict ischemic complications in the setting of radial artery occlusion. Doppler ultrasound can be used to evaluate collateral hand perfusion in an effort to stratify risk of potential ischemic injury from cannulation. Limited research has demonstrated a beneficial effect of heparinized flush solutions on arterial catheter patency but only in patients with prolonged monitoring (>24 h). Conservative management may be equally as effective as surgical intervention in treating ischemic complications resulting from radial artery cannulation. Limited clinical experience with the ultrasound-guided arterial cannulation method suggests that this technique is associated with increased success of cannulation with fewer attempts. Whether use of the latter technique is associated with a decrease in complications has not yet been verified in prospective studies. Research is needed to assess the safety of using the ulnar artery as an alternative to radial artery cannulation because the proximity and attachments of the ulnar artery to the ulnar nerve may potentially expose it to a higher risk of injury.
282 citations
TL;DR: Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms, and more invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.
Abstract: Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.
280 citations
TL;DR: Prilocaine should not be used in children younger than 6-mo-old, in pregnant women, or in patients taking other oxidizing drugs, and the dose should be limited to 2.5 mg/kg.
Abstract: BACKGROUND:The purpose of this article is to summarize all episodes of local anesthetic-related methemoglobinemia found in the medical literature.METHODS:I performed a search of the American National Library of Medicine's PubMed with the following key words: “local anesthetic” and “methemoglobinemia
262 citations
TL;DR: Continuous EEG monitoring is most commonly used to detect and guide treatment of nonconvulsive seizures, including after convulsive status epilepticus, and is used to guide management of pharmacological coma for treatment of increased intracranial pressure.
Abstract: Because of recent technical advances, it is now possible to record and monitor the continuous digital electroencephalogram (EEG) of many critically ill patients simultaneously. Continuous EEG monitoring (cEEG) provides dynamic information about brain function that permits early detection of changes in neurologic status, which is especially useful when the clinical examination is limited. Nonconvulsive seizures are common in comatose critically ill patients and can have multiple negative effects on the injured brain. The majority of seizures in these patients cannot be detected without cEEG. cEEG monitoring is most commonly used to detect and guide treatment of nonconvulsive seizures, including after convulsive status epilepticus. In addition, cEEG is used to guide management of pharmacological coma for treatment of increased intracranial pressure. An emerging application for cEEG is to detect new or worsening brain ischemia in patients at high risk, especially those with subarachnoid hemorrhage. Improving quantitative EEG software is helping to make it feasible for cEEG (using full scalp coverage) to provide continuous information about changes in brain function in real time at the bedside and to alert clinicians to any acute brain event, including seizures, ischemia, increasing intracranial pressure, hemorrhage, and even systemic abnormalities affecting the brain, such as hypoxia, hypotension, acidosis, and others. Monitoring using only a few electrodes or using full scalp coverage, but without expert review of the raw EEG, must be done with extreme caution as false positives and false negatives are common. Intracranial EEG recording is being performed in a few centers to better detect seizures, ischemia, and peri-injury depolarizations, all of which may contribute to secondary injury. When cEEG is combined with individualized, physiologically driven decision making via multimodality brain monitoring, intensivists can identify when the brain is at risk for injury or when neuronal injury is already occurring and intervene before there is permanent damage. The exact role and cost-effectiveness of cEEG at the current time remains unclear, but we believe it has significant potential to improve neurologic outcomes in a variety of settings.
257 citations
TL;DR: Long-term survival for cardiac surgical patients who received one or two RBC units during index hospitalization was significantly decreased and exposure to 1 or 2 RBCs was associated with a 16% increased hazard of decreased survival after cardiac surgery.
Abstract: BACKGROUND:Exposure to red blood cell (RBC) transfusions has been associated with increased mortality after cardiac surgery. We examined long-term survival for cardiac surgical patients who received one or two RBC units during index hospitalization.METHODS:Nine thousand seventy-nine consecutive pati
TL;DR: A review of literature in the National Library of Medicine’s PubMed database for case reports on “Awareness” and “Anesthesia” for the time period between 1950 through August, 2005 suggested light anesthesia and a history of awareness as risk factors.
Abstract: BACKGROUND:Awareness during anesthesia is uncommon. The number of cases that are found in one single study are insufficient to identify and estimate the risks, causal factors and sequelae. One method of studying a large number of cases is to analyze reports of cases of awareness that have been publi
TL;DR: Prolonged isoflurane exposure in neonatal mice led to increased immediate brain cell degeneration, however, no significant reductions in adult neuronal density or deficits in spontaneous locomotion, spatial learning, or memory function were observed.
Abstract: BACKGROUND:Volatile anesthetics, such as isoflurane, are widely used in infants and neonates. Neurodegeneration and neurocognitive impairment after exposure to isoflurane, midazolam, and nitrous oxide in neonatal rats have raised concerns regarding the safety of pediatric anesthesia. In neonatal mic
TL;DR: The pathophysiology, clinical importance, and management of RV failure in cardiac surgery is reviewed, with a focus on right ventricular function.
Abstract: The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in cardiac surgery and heart transplantation. In the first article of this review, key features of RV anatomy, physiology, and assessment were presented. In this second part, we review the pathophysiology, clinical importance, and management of RV failure in cardiac surgery.
TL;DR: The results confirm the clinical suspicion that the risk of POVL is higher in cardiac and spine fusion surgery and show for the first time a higher risk of this complication in patients undergoing lower extremity joint replacement surgery.
Abstract: BACKGROUND: Perioperative visual loss (POVL) accompanying nonocular surgery is a rare and potentially devastating complication but its frequency in commonly performed inpatient surgery is not well defined. We used the Nationwide Inpatient Sample to estimate the rate of POVL in the United States among the eight most common nonocular surgeries. METHODS: More than 5.6 million patients in the Nationwide Inpatient Sample who underwent principal procedures of knee arthroplasty, cholecystectomy, hip/femur surgical treatment, spinal fusion, appendectomy, colorectal resection, laminectomy without fusion, coronary artery bypass grafting, and cardiac valve procedures from 1996 to 2005 were included. Rates of POVL, defined as any discharge with an International Classification of Diseases, Ninth Revision, Clinical Modification code of ischemic optic neuropathy (ION), cortical blindness (CB), or retinal vascular occlusion (RVO), were estimated. Potential risk factors were assessed by univariate and multivariable analyses. RESULTS: Cardiac and spinal fusion surgery had the highest rates of POVL. The national estimate in cardiac surgery was 8.64/10,000 and 3.09/10,000 in spinal fusion. By contrast, POVL after appendectomy was 0.12/10,000. Those undergoing cardiac surgery, spinal fusion, and orthopedic surgery had a significantly increased risk of developing ION, RVO, or CB. Patients younger than 18 yr had the highest risk for POVL, because of higher risk for CB, whereas those older than 50 yr were at greater risk of developing ION and RVO. Other significant positive predictors for some diagnoses of POVL were male gender, Charlson comorbidity index, anemia, and blood transfusion. There was no increased risk associated with hospital surgical volume. During the 10 yr from 1996 to 2005, there was an overall decrease in POVL in the procedures we studied. CONCLUSIONS: The results confirm the clinical suspicion that the risk of POVL is higher in cardiac and spine fusion surgery and show for the first time a higher risk of this complication in patients undergoing lower extremity joint replacement surgery. The prevalence of POVL in the eight most commonly performed surgical operations in the United States has decreased between 1996 and 2005. Increased odds of POVL with male gender and comorbidity index indicate that some risk factors for POVL may not presently be modifiable. The conclusions of this study are limited by factors affecting data accuracy, such as lack of data on the intraoperative course and inability to confirm the diagnostic coding of any of the discharges in the database. (Anesth Analg 2009;109:1534‐45)
TL;DR: Intraoperative alveolar recruitment with a VCM followed by PEEP 10 cm H2O is effective at preventing lung atelectasis and is associated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period in obese patients undergoing laparoscopic bariatric surgery.
Abstract: BACKGROUND:Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative at
TL;DR: The main cause of graft loss in patients receiving platelets was patient death with a functioning graft, and the findings suggest that platelet transfusions are an important risk factor for mortality after OLT.
Abstract: BACKGROUND: Platelet transfusions have been identified as an independent risk factor for survival after orthotopic liver transplantation (OLT). In this study, we analyzed the specific causes of mortality and graft loss in relation to platelet transfusions during OLT. METHODS: In a series of 449 consecutive adult patients undergoing a first OLT, the causes of patient death and graft failure were studied in patients who did or did not receive perioperative platelet transfusions. RESULTS: Patient and graft survival were significantly reduced in patients who received platelet transfusions, compared with those who did not (74% vs 92%, and 69% vs 85%, respectively at 1 yr; P <0.001). Lower survival rates in patients who received platelets were attributed to a significantly higher rate of early mortality because of acute lung injury (4.4% vs 0.4%; P = 0.004). There were no significant differences in other causes of mortality between the two groups. The main cause of graft loss in patients receiving platelets was patient death with a functioning graft. CONCLUSIONS: These findings suggest that platelet transfusions are an important risk factor for mortality after OLT. The current study extends previous observations by identifying acute lung injury as the main determinant of increased mortality. The higher rate of graft loss in patients receiving platelets is related to the higher overall mortality rate and does not result from specific adverse effects of transfused platelets on the grafted liver.
TL;DR: LAs can cause rapid cell death, which is primarily due to necrosis, and bupivacaine and lidocaine can trigger apoptosis with either increased time of exposure or increased concentration, which might be related to postoperative neurologic injury.
Abstract: BACKGROUND:In addition to inhibiting the excitation conduction process in peripheral nerves, local anesthetics (LAs) cause toxic effects on the central nervous system, cardiovascular system, neuromuscular junction, and cell metabolism. Different postoperative neurological complications are ascribed
TL;DR: Ketamine had a morphine-sparing effect after THA, even when morphine was combined with multimodal systemic analgesia, and facilitated rehabilitation at 1 mo and decreased postoperative chronic pain up to 6 mo after surgery.
Abstract: BACKGROUND:Ketamine has been shown to have a morphine-sparing effect soon after surgery Nevertheless, whether this effect still exists after being combined with nonsteroidal antiinflammatory drugs and acetaminophen, and whether ketamine can decrease chronic pain after nononcologic surgery remain un
TL;DR: It is indicated that preoperative and intraoperative IV lidocaine improves immediate postoperative pain management and reduces surgery-induced immune alterations.
Abstract: BACKGROUND:Surgery-associated tissue injury leads to nociception and inflammatory reaction, accompanied by increased production of proinflammatory cytokines. These cytokines can induce peripheral and central sensitization, leading to pain augmentation. Recently, a frequently used local anesthetic, l
TL;DR: Relevant postmortem findings explaining death in surgical ICU patients who died because of sepsis/septic shock were a continuous septic focus in approximately 80% and cardiac pathologies in 50%.
Abstract: Background Although detailed analyses of the postmortem findings of various critically ill patient groups have been published, no such study has been performed in patients with sepsis. In this retrospective cohort study, we reviewed macroscopic postmortem examinations of surgical intensive care unit (ICU) patients who died from sepsis or septic shock. Methods Between 1997 and 2006, the ICU database and autopsy register were reviewed for patients who were admitted to the ICU because of sepsis/septic shock, or who developed sepsis/septic shock at a later stage during their ICU stay and subsequently died from of sepsis/septic shock. Clinical data and postmortem findings were documented in all patients. Results Postmortem results of 235 patients (84.8%) were available for statistical analysis. The main causes of death as reported in the patient history were refractory multiple organ dysfunction syndrome (51.5%) and uncontrollable cardiovascular failure (35.3%). Pathologies were detected in the lungs (89.8%), kidneys/urinary tract (60%), gastrointestinal tract (54%), cardiovascular system (53.6%), liver (47.7%), spleen (33.2%), central nervous system (18.7%), and pancreas (8.5%). In 180 patients (76.6%), the autopsy revealed a continuous septic focus. The most common continuous foci were pneumonia (41.3%), tracheobronchitis (28.9%), peritonitis (23.4%), uterine/ovarial necrosis (9.8% of female patients), intraabdominal abscesses (9.1%), and pyelonephritis (6%). A continuous septic focus was observed in 63 of the 71 patients (88.7%) who were admitted to the ICU because of sepsis/septic shock and treated for longer than 7 days. Conclusions Relevant postmortem findings explaining death in surgical ICU patients who died because of sepsis/septic shock were a continuous septic focus in approximately 80% and cardiac pathologies in 50%. The most frequently affected organs were the lungs, abdomen, and urogenital tract. More diagnostic, therapeutic and scientific efforts should be launched to identify and control the infectious focus in patients with sepsis and septic shock.
TL;DR: IOP reached peak levels at the end of steep Trendelenburg position (T5), on average 13 mm Hg higher than the preanesthesia induction (T1) value, whereas age, body mass index, blood loss, volume of IV fluid administered, mean airway pressure, and desflurane concentration were not predictive.
Abstract: BACKGROUND:Intraocular pressure (IOP) increases in steep Trendelenburg positioning, but the magnitude of the increase has not been quantified. In addition, the factors contributing to this increase have not been studied in robot-assisted prostatectomy cases. In this study, we sought to quantify the
TL;DR: Introducing a 19-s alarm delay and automatically detecting suctioning, repositioning, oral care, and washing could reduce the number of ineffective and ignored alarms from 934 to 274.
Abstract: INTRODUCTION:In an intensive care unit, alarms are used to call attention to a patient, to alert a change in the patient's physiology, or to warn of a failure in a medical device; however, up to 94% of the alarms are false. Our purpose in this study was to identify a means of reducing the number of
TL;DR: SVV predicts fluid responsiveness with an acceptable sensitivity and specificity and is also a potential surrogate for continuous monitoring of &Dgr;PP.
Abstract: BACKGROUND: Respiratory variations in arterial pulse pressure ( PP) are accuratepredictors of fluid responsiveness in mechanically ventilated patients. The aim ofour study was to assess the ability of a novel algorithm for automatic estimation ofstroke volume variation (SVV) to predict fluid responsiveness in mechanicallyventilated patients.METHODS: We studied 25 patients referred for coronary artery bypass grafting. SVVwas continuously displayed by the Vigileo/FloTrac system. All patients wereunder general anesthesia, mechanical ventilation and were also monitored with apulmonary artery catheter. SVV and PP were recorded simultaneously before andafter an intravascular volume expansion (VE) (500 mL hetastarch). Responders toVE were defined as patients whose cardiac index obtained using thermodilutionincreased by more than 15% after VE.RESULTS: Agreement between PP and SVV over the 50 pairs of collected data was 1.3% 2.8% (mean bias sd). Seventeen patients were responders to VE. Athreshold PP value of 10% allowed discrimination of responders to VE with asensitivity of 88% and a specificity of 87%. A threshold SVV value of 10% alloweddiscrimination of responders to VE with a sensitivity of 82% and a specificity of88%.CONCLUSION: SVV predicts fluid responsiveness with an acceptable sensitivity andspecificity and is also a potential surrogate for continuous monitoring of PP.
TL;DR: Subanalyses suggest that a cell saver may be beneficial only when it is used for shed blood and/or residual blood or during the entire operative period, and Processing cardiotomy suction blood with acell saver only during cardiopulmonary bypass has no significant effect on blood conservation and increases fresh frozen plasma transfusion.
Abstract: BACKGROUND:Cell salvage may be used during cardiac surgery to avoid allogeneic blood transfusion. It has also been claimed to improve patient outcomes by removing debris from shed blood, which may increase the risk of stroke or neurocognitive dysfunction. In this study, we sought to determine the ov
TL;DR: CPSP patients present with diverse sensory symptoms and its pathophysiology is still poorly understood, and Amitriptyline and lamotrigine are effective treatments.
Abstract: BACKGROUND:Central poststroke pain (CPSP) is a disabling morbidity occurring in 8%–14% of patients with stroke It is infrequently recognized and difficult to manageOBJECTIVE:We systematically reviewed the pathophysiology and treatment of CPSPMETHODS:We conducted a Medline search using the key wor
TL;DR: In this paper, the authors conducted a randomized, single-blind, prospective, controlled pilot study to determine whether indicated preoperative testing can be eliminated without increasing the perioperative incidence of adverse events in selected patients undergoing ambulatory surgery.
Abstract: BACKGROUND: Preoperative testing has been criticized as having little impact on perioperative outcomes. We conducted a randomized, single-blind, prospective, controlled pilot study to determine whether indicated preoperative testing can be eliminated without increasing the perioperative incidence of adverse events in selected patients undergoing ambulatory surgery. METHODS: One thousand sixty-one eligible patients were randomized either to have indicated preoperative testing or no preoperative testing. In the indicated testing group, patients received indicated preoperative testing: a complete blood count, electrolytes, blood glucose, creatinine, electrocardiogram, and chest radiograph according to the Ontario Preoperative Testing Grid as per current practice, whereas in the no testing group, no testing was ordered. The investigators, data collectors, and patient outcome reviewers were blinded to the group assignment. The primary outcome measures were the rate of perioperative adverse events and the rates of adverse events within 7 and 30 days after surgery. RESULTS: Patients’ age, gender, American Society of Anesthesiologists status, type of surgery, and anesthesia were similar between the two groups. There were no significant differences in the rates of perioperative adverse events and the rates of adverse events within 30 days after surgery between the no testing group and the indicated testing group. Hospital revisits 7 days were higher in the indicated testing group (P 0.05). None of the adverse events were related to the indicated testing or no testing. CONCLUSIONS: This pilot study showed that there was no increase in the perioperative adverse events as a result of no preoperative testing in our study population. A larger study is needed to demonstrate that indicated testing may be safely eliminated in selected patients undergoing ambulatory surgery without increasing perioperative complications. (Anesth Analg 2009;108:467‐75)
TL;DR: Several new devices have been marketed which have the ability to monitor CO noninvasively and, in some cases, assess the patient’s ability to respond to fluid challenges, including esophageal Doppler monitors.
Abstract: With advancing age and increased co-morbidities in patients, the need for monitoring devices during the perioperative period that allow clinicians to track physiologic variables, such as cardiac output (CO), fluid responsiveness and tissue perfusion, is increasing. Until recently, the only tool available to anesthesiologists to monitor CO was either a pulmonary artery catheter or transesophageal echocardiograph. These devices have their limitations and potential for morbidity. Several new devices (including esophageal Doppler monitors, pulse contour analysis, indicator dilution, thoracic bioimpedance and partial non-rebreathing systems) have recently been marketed which have the ability to monitor CO noninvasively and, in some cases, assess the patient's ability to respond to fluid challenges. In this review, we will describe these new devices including the technology, studies on their efficacy and the limitations of their use.
TL;DR: No difference in mortality was found between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.
Abstract: BACKGROUND:Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.METHODS
TL;DR: A randomized study is required to demonstrate that there really is a causal impact from and TBIS <45 on postoperative mortality and, if it does, the effect is probably very weak in comparison with co-morbidity as assessed by ASA physical score, the preexisting malignancy status at surgery and age.
Abstract: BACKGROUND: A correlation between deep anesthesia (defined as time with Bispectral Index (BIS) l45; T-BIS l45 and death within 1. yr after surgery has previously been reported. In order to confirm or refute these findings, we evaluated T-BIS (l45) as an independent risk factor for death within I and 2 yr after surgery and also the impact of malignancy, the predominant cause of death in the previous report. METHODS: Mortality within 2 yr after surgery, causes of death and the occurrence of malignant disease at the time of surgery were identified in a cohort of 4087 BIS-monitored patients. Statistically significant univariate predictors of mortality were identified. In order to allow for comparison with previous data, the following multivariate analysis was first done without, and thereafter with, preexisting malignancy status, the predominant cause of death. RESULTS: One-hundred-seventy-four (4.3%) patients died within I yr and another 92 during the second year (totaling 6.5% in 2 yr). T-BIS l45 was a significant predictor of 1- and 2-yr mortality when preexisting malignant disease was not among the co-variates (hazard ratio [HR] 113 [1.01-1.27] and 1.18 [1.08-1.29], respectively). Further exploration confined the significant relation between postoperative mortality and T-BIS l45 to Patients with preexisting malignant diagnoses associated with extensive Surgery and less favorable prognosis. The most powerful predictors of 2-yr mortality in the model, including preexisting malignancy, were ASA physical score class IV (HR 19.3 [7.31-51.1]), age g80 yr (HR 2.93 [1.79-4.79]), and preexisting malignancy associated with less favorable prognosis (HR 9.30 [6.60-13.1]). When the initial multivariate regression was repeated using preexisting malignancy status among the co-variates in the model, the previously significant relation between 1, and 2-yr mortality and T-BIS l45 did not reach statistical significance. CONCLUSION: Using a similar set of co-variates as in previous work, we confirmed the statistical relation between 1-yr mortality and T-BIS l45, and we extended this observation to 2-yr mortality. However, this relation is sensitive to the selection of co-variates in the statistical model, and a randomized study is required to demonstrate that there really is a causal impact from and T-BIS (l45) on postoperative mortality and, if it does, the effect is probably very weak in comparison with co-morbidity as assessed by ASA physical score, the preexisting malignancy status at surgery and age.