Showing papers in "Anesthesia & Analgesia in 2012"

The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis.

Abstract: BACKGROUND: Many clinical trials have demonstrated the effectiveness of gabapentin and pregabalin administration in the perioperative period as an adjunct to reduce acute postoperative pain. However, very few clinical trials have examined the use of gabapentin and pregabalin for the prevention of chronic postsurgical pain (CPSP). We (1) systematically reviewed the published literature pertaining to the prevention of CPSP (2 months after surgery) after perioperative administration of gabapentin and pregabalin and (2) performed a meta-analysis using studies that report sufficient data. A search of electronic databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, IPA, and CINAHL) for relevant English-language trials to June 2011 was conducted. METHODS: The following inclusion criteria for identified clinical trials were used for entry into the present systematic review: randomization; double-blind assessments of pain and analgesic use; report of pain using a reliable and valid measure; report of analgesic consumption; and an absence of design flaws, methodological problems or confounders that render interpretation of the results ambiguous. Trials that did not fit the definition of preventive analgesia and did not assess chronic pain at 2 or more months after surgery were excluded. RESULTS: The database search yielded 474 citations. Eleven studies met the inclusion criteria. Of the 11 trials, 8 studied gabapentin, 4 of which (i.e., 50%) found that perioperative administration of gabapentin decreased the incidence of chronic pain more than 2 months after surgery. The 3 trials that used pregabalin demonstrated a significant reduction in the incidence of CPSP, and 2 of the 3 trials also found an improvement in postsurgical patient function. Eight studies were included in a meta-analysis, 6 of the gabapentin trials demonstrated a moderateto-large reduction in the development of CPSP (pooled odds ratio [OR] 0.52; 95% confidence interval [CI], 0.27 to 0.98; P 0.04), and the 2 pregabalin trials found a very large reduction in the development of CPSP (pooled OR 0.09; 95% CI, 0.02 to 0.79; P 0.007). CONCLUSIONS: The present review supports the view that perioperative administration of gabapentin and pregabalin are effective in reducing the incidence of CPSP. Better-designed and appropriately powered clinical trials are needed to confirm these early findings. (Anesth Analg 2012;115:428–42)

Pediatric regional anesthesia network (PRAN): A multi-institutional study of the use and incidence of complications of pediatric regional anesthesia

Abstract: BACKGROUND: Regional anesthesia is increasingly used in pediatric patients to provide postoperative analgesia and to supplement intraoperative anesthesia. The Pediatric Regional Anesthesia Network was formed to obtain highly audited data on practice patterns and complications and to facilitate collaborative research in regional anesthetic techniques in infants and children. METHODS: We constructed a centralized database to collect detailed prospective data on all regional anesthetics performed by anesthesiologists at the participating centers. Data were uploaded via a secure Internet connection to a central server. Data were rigorously audited for accuracy and errors were corrected. All anesthetic records were scrutinized to ensure that every block that was performed was captured in the database. Intraoperative and postoperative complications were tracked until their resolution. Blocks were categorized by type and as single- injection or catheter (continuous) blocks. RESULTS: A total of 14,917 regional blocks, performed on 13,725 patients, were accrued from April 1, 2007 through March 31, 2010. There were no deaths or complications with sequelae lasting >3 months (95% CI 0–2:10,000). Single- injection blocks had fewer adverse events than continuous blocks, although the most frequent events (33% of all events) in the latter group were catheter- related problems. Ninety- five percent of blocks were placed while patients were under general anesthesia. Single- injection caudal blocks were the most frequently performed (40%), but peripheral nerve blocks were also frequently used (35%), possibly driven by the widespread use of ultrasound (83% of upper extremity and 69% of lower extremity blocks). CONCLUSIONS: Regional anesthesia in children as commonly performed in the United States has a very low rate of complications, comparable to that seen in the large multicenter European studies. Ultrasound may be increasing the use of peripheral nerve blocks. Multicenter collaborative networks such as the Pediatric Regional Anesthesia Network can facilitate the collection of detailed prospective data for research and quality improvement. (Anesth Analg 2012;115: 1353–64)

Perioperative fluid management strategies in major surgery: a stratified meta-analysis.

Abstract: BACKGROUND:Both “liberal” and “goal-directed” (GD) therapy use a large amount of perioperative fluid, but they appear to have very different effects on perioperative outcomes. We sought to determine whether one fluid management strategy was superior to the others.METHODS:We selected randomized contr

Life cycle greenhouse gas emissions of anesthetic drugs.

Abstract: BACKGROUND:Anesthesiologists must consider the entire life cycle of drugs in order to include environmental impacts into clinical decisions. In the present study we used life cycle assessment to examine the climate change impacts of 5 anesthetic drugs: sevoflurane, desflurane, isoflurane, nitrous ox

Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society Of Cardiovascular Anesthesiologists.

Abstract: TABLE OF CONTENTS PAGEIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . .46Methodology and Evidence Review . . . . . . .46Ultrasound-Guided Vascular Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Ultrasound Principles for Needle-Guided Catheter Placement . . . .

Fibrinogen and hemostasis: a primary hemostatic target for the management of acquired bleeding.

Abstract: Fibrinogen plays several key roles in the maintenance of hemostasis. Its cleavage by thrombin and subsequent polymerization to form fibrin strands provides the structural network required for effective clot formation. During cases of acute blood loss, attempts to maintain circulating volume and tissue perfusion often involve the infusion of crystalloids, colloids, and red blood cells. Intravascular volume resuscitation, although vital, frequently results in dilution of the remaining clotting factors and onset of dilutional coagulopathy. In such cases, fibrinogen is the first coagulation factor to decrease to critically low levels. There currently is a lack of awareness among physicians regarding the significance of fibrinogen during acute bleeding and, at many centers, fibrinogen is not monitored routinely during treatment. We reviewed current studies that demonstrate the importance of considering fibrinogen replacement during the treatment of acquired bleeding across clinical settings. If depleted, the supplementation of fibrinogen is key for the rescue and maintenance of hemostatic function; however, the threshold at which such intervention should be triggered is currently poorly defined. Although traditionally performed via administration of fresh frozen plasma or cryoprecipitate, the use of lyophilized fibrinogen (concentrate) is becoming more prevalent in some countries. Recent reports relating to the efficacy of fibrinogen concentrate suggest that it is a viable alternative to traditional hemostatic approaches, which should be considered. The prospective study of fibrinogen supplementation in acquired bleeding is needed to accurately assess the range of clinical settings in which this management strategy is appropriate, the most effective method of supplementation and a comprehensive safety profile of fibrinogen concentrate used for such an approach.

Procoagulant activity in hemostasis and thrombosis: Virchow's triad revisited.

Abstract: Virchow's triad is traditionally invoked to explain pathophysiologic mechanisms leading to thrombosis, alleging concerted roles for abnormalities in blood composition, vessel wall components, and blood flow in the development of arterial and venous thrombosis. Given the tissue-specific bleeding observed in hemophilia patients, it may be instructive to consider the principles of Virchow's triad when investigating mechanisms operant in hemostatic disorders as well. Blood composition (the function of circulating blood cells and plasma proteins) is the most well studied component of the triad. For example, increased levels of plasma procoagulant proteins such as prothrombin and fibrinogen are established risk factors for thrombosis, whereas deficiencies in plasma factors VIII and IX result in bleeding (hemophilia A and B, respectively). Vessel wall (cellular) components contribute adhesion molecules that recruit circulating leukocytes and platelets to sites of vascular damage, tissue factor, which provides a procoagulant signal of vascular breach, and a surface upon which coagulation complexes are assembled. Blood flow is often characterized by 2 key variables: shear rate and shear stress. Shear rate affects several aspects of coagulation, including transport rates of platelets and plasma proteins to and from the injury site, platelet activation, and the kinetics of fibrin monomer formation and polymerization. Shear stress modulates adhesion rates of platelets and expression of adhesion molecules and procoagulant activity on endothelial cells lining the blood vessels. That no one abnormality in any component of Virchow's triad fully predicts coagulopathy a priori suggests coagulopathies are complex, multifactorial, and interactive. In this review, we focus on contributions of blood composition, vascular cells, and blood flow to hemostasis and thrombosis, and suggest that cross-talk among the 3 components of Virchow's triad is necessary for hemostasis and determines propensity for thrombosis or bleeding. Investigative models that permit interplay among these components are necessary to understand the operant pathophysiology, and effectively treat and prevent thrombotic and bleeding disorders.

Predicting the limits of cerebral autoregulation during cardiopulmonary bypass

Abstract: Because cerebral blood flow autoregulation is functional during cardiopulmonary bypass (CPB) using α-stat pH management, arterial blood pressure targets are empirically chosen often to a mean arterial blood pressure (MAP) of 50 mmHg depending on patient age, preoperative blood pressure, or medical history.1,2 The foundation of this practice, though, is based on data that are more than 15 years old and derived from patients who were generally younger and had fewer co-morbid conditions than patients in current practices.3-5 The accuracy of empiric targeting of MAP for identifying a pressure above the lower limit of autoregulation (LLA) in clinical practice is not known. Other data suggest a benefit of higher MAP during CPB on myocardial and neurologic outcomes, but these results have limitations and have not been independently reconfirmed.6-9 Importantly, whether the practice of targeting low MAP during CPB is appropriate for the increasing number of elderly patients with cerebral vascular disease is not known.10,11 Our group, in fact, has found a high frequency of hypoperfusion type “watershed” strokes after cardiac surgery that were associated with MAP during CPB that was ≥ 10 mmHg lower than before CPB.11 Real-time autoregulation monitoring can be accomplished by the continuous calculation of the correlation between transcranial Doppler-measured cerebral blood flow velocity of the middle cerebral artery and cerebral perfusion pressure (termed mean velocity index).12-14 Our group has demonstrated in laboratory experiments and in patients undergoing cardiac surgery that near-infrared spectroscopy (NIRS) signals provide an acceptable surrogate for monitoring changes in cerebral blood flow for autoregulation monitoring.15-17 The latter approach might provide a method for individualizing MAP during CPB without the need for specialized equipment and without the limitations of transcranial Doppler monitoring (e.g., need for trans-temporal insonating window, interference from electric cautery, movement artifact, etc). The hypothesis of this study was that real-time autoregulation monitoring using NIRS-based methods is more accurate for delineating the MAP at the LLA during CPB than empiric determinations based on age, preoperative history, and preoperative arterial blood pressure.18-20

Review article: cerebral near-infrared spectroscopy in adults: a work in progress.

Abstract: Near-infrared spectroscopy (NIRS) has potential as a noninvasive brain monitor across a spectrum of disorders. In the last decade, there has been a rapid expansion of clinical experience using NIRS to monitor cerebral oxygenation, and there is some evidence that NIRS-guided brain protection protocols might lead to a reduction in perioperative neurologic complications after cardiac surgery. However, there are no data to support the wider application of NIRS during routine surgery under general anesthesia, and its application in brain injury, where it might be expected to have a key monitoring role, is undefined. Although increasingly sophisticated apparatuses, including broadband and time-resolved spectroscopy systems, provide insights into the potential of NIRS to measure regional cerebral oxygenation, hemodynamics, and metabolism in real-time, these innovations have yet to translate into effective monitor-guided brain protection treatment strategies. NIRS has many potential advantages over other neuromonitoring techniques, but further investigation and technological advances are necessary before it can be introduced more widely into clinical practice.

Society for ambulatory anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery

Abstract: The suitability of ambulatory surgery for a patient with obstructive sleep apnea (OSA) remains controversial because of concerns of increased perioperative complications including postdischarge death Therefore, a Society for Ambulatory Anesthesia task force on practice guidelines developed a consensus statement for the selection of patients with OSA scheduled for ambulatory surgery A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines Although the studies evaluating perioperative outcome in OSA patients undergoing ambulatory surgery are sparse and of limited quality, they do provide useful information that can guide clinical practice Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for ambulatory surgery, if they are able to use a continuous positive airway pressure device in the postoperative period Patients with a presumed diagnosis of OSA, based on screening tools such as the STOP-Bang questionnaire, and with optimized comorbid conditions, can be considered for ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid analgesic techniques On the other hand, OSA patients with nonoptimized comorbid medical conditions may not be good candidates for ambulatory surgery What other guidelines are available on this topic? The American Society of Anesthesiologists (ASA) practice guidelines for management of surgical patients with OSA published in 2006 Why was this guideline developed? The ASA guidelines are outdated because several recent studies provide new information such as validated screening tools for clinical diagnosis of OSA and safety of ambulatory laparoscopic bariatric surgery in OSA patients Therefore, an update on the selection of patients with OSA undergoing ambulatory surgery is warranted How does this guideline differ from existing guidelines? Unlike the ASA guidelines, this consensus statement recommends the use of the STOP-Bang criteria for preoperative OSA screening and considers patients' comorbid conditions in the patient selection process Also, current literature does not support the ASA recommendations that upper abdominal procedures are not appropriate for ambulatory surgery Why does this guideline differ from existing guidelines? This consensus statement differs from existing ASA guidelines because of the availability of new evidence

Oxygen desaturation index from nocturnal oximetry: a sensitive and specific tool to detect sleep-disordered breathing in surgical patients.

Abstract: INTRODUCTION:It is impractical to perform polysomnography (PSG) in all surgical patients suspected of having sleep disordered breathing (SDB). We investigated the role of nocturnal oximetry in diagnosing SDB in surgical patients.METHOD:All patients 18 years and older who visited the preoperative cli

Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature

Abstract: Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Perioperative Single Dose Ketorolac to Prevent Postoperative Pain: A Meta-Analysis of Randomized Trials

Abstract: BACKGROUND:Preventive analgesia using non-opioid analgesic strategies is recognized as a pathway to improve postoperative pain control while minimizing opioid-related side effects. Ketorolac is a nonsteroidal antiinflammatory drug frequently used to treat postoperative pain. However, the optimal dos

A placebo- and midazolam-controlled phase I single ascending-dose study evaluating the safety, pharmacokinetics, and pharmacodynamics of remimazolam (CNS 7056): Part I. Safety, efficacy, and basic pharmacokinetics.

Abstract: BACKGROUND:A new benzodiazepine, remimazolam, metabolized by tissue esterases to an inactive compound, CNS 7054, has been developed to permit a fast onset, a short and more predictable duration of sedative action, and a more rapid recovery profile than with currently available benzodiazepines. We re

A meta-analysis of the use of nonsteroidal antiinflammatory drugs for pediatric postoperative pain

Abstract: BACKGROUND:Opioid side effects are a great concern during the postoperative period in children. Nonsteroidal antiinflammatory drugs (NSAIDs) have been shown to effectively decrease postoperative pain, but their opioid-sparing effect is still controversial. In this present meta-analysis, we investiga

Does intraoperative ketamine attenuate inflammatory reactivity following surgery? A systematic review and meta-analysis.

Abstract: BACKGROUND:Reports regarding the ability of the anesthetic drug ketamine to attenuate the inflammatory response to surgery are conflicting. In this systematic review we examined the effect of perioperative ketamine administration on postoperative inflammation as assessed by concentrations of the bio

A pilot cohort study of the determinants of longitudinal opioid use after surgery.

Abstract: BACKGROUND: Determinants of the duration of opioid use after surgery have not been reported. We hypothesized that both preoperative psychological distress and substance abuse would predict more prolonged opioid use after surgery. METHODS: Between January 2007 and April 2009, a prospective, longitudinal inception cohort study enrolled 109 of 134 consecutively approached patients undergoing mastectomy, lumpectomy, thoracotomy, total knee replacement, or total hip replacement. We measured preoperative psychological distress and substance use, and then measured the daily use of opioids until patients reported the cessation of both opioid consumption and pain. The primary end point was time to opioid cessation. All analyses were controlled for the type of surgery done. RESULTS: Overall, 6% of patients continued on new opioids 150 days after surgery. Preoperative prescribed opioid use, depressive symptoms, and increased self-perceived risk of addiction were each independently associated with more prolonged opioid use. Preoperative prescribed opioid use was associated with a 73% (95% confidence interval [CI] 0.51%–87%) reduction in the rate of opioid cessation after surgery (P 0.0009). Additionally, each 1-point increase (on a 4-point scale) of self-perceived risk of addiction was associated with a 53% (95% CI 23%–71%) reduction in the rate of opioid cessation (P 0.003). Independent of preoperative opioid use and self-perceived risk of addiction, each 10-point increase on a preoperative Beck Depression Inventory II was associated with a 42% (95% CI 18%–58%) reduction in the rate of opioid cessation (P 0.002). The variance in the duration of postoperative opioid use was better predicted by preoperative prescribed opioid use, self-perceived risk of addiction, and depressive symptoms than postoperative pain duration or severity. CONCLUSIONS: Preoperative factors, including legitimate prescribed opioid use, self-perceived risk of addiction, and depressive symptoms each independently predicted more prolonged opioid use after surgery. Each of these factors was a better predictor of prolonged opioid use than postoperative pain duration or severity. (Anesth Analg 2012;115:694–702)

Assessing the impact on global climate from general anesthetic gases

Abstract: Although present in the atmosphere with a combined concentration approximately 100,000 times lower than carbon dioxide (i.e., the principal anthropogenic driver of climate change), halogenated organic compounds are responsible for a warming effect of approximately 10% to 15% of the total anthropogen

Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery.

Abstract: BACKGROUND:Perioperative systemic lidocaine has been shown to have beneficial postoperative analgesic effects. The only previous study examining the use of lidocaine in the outpatient setting did not detect an opioid-sparing effect after hospital discharge. More importantly, it is unknown whether sy

A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012.

Abstract: Contemporary comparisons of reusable and single-use perioperative textiles (surgical gowns and drapes) reflect major changes in the technologies to produce and reuse these products. Reusable and disposable gowns and drapes meet new standards for medical workers and patient protection, use synthetic lightweight fabrics, and are competitively priced. In multiple sciencebased life cycle environmental studies, reusable surgical gowns and drapes demonstrate substantial sustainability benefits over the same disposable product in natural resource energy (200%–300%), water (250%–330%), carbon footprint (200%–300%), volatile organics, solid wastes (750%), and instrument recovery. Because all other factors (cost, protection, and comfort) are reasonably similar, the environmental benefits of reusable surgical gowns and drapes to health care sustainability programs are important for this industry. Thus, it is no longer valid to indicate that reusables are better in some environmental impacts and disposables are better in other environmental impacts. It is also important to recognize that large-scale studies of comfort, protection, or economics have not been actively pursued in the last 5 to 10 years, and thus the factors to improve both reusables and disposable systems are difficult to assess. In addition, the comparison related to jobs is not well studied, but may further support reusables. In summary, currently available perioperative textiles are similar in comfort, safety, and cost, but reusable textiles offer substantial opportunities for nurses, physicians, and hospitals to reduce environmental footprints when selected over disposable alternatives. Evidenced-based comparison of environmental factors supports the conclusion that reusable gowns and drapes offer important sustainability improvements. The benefit of reusable systems may be similar for other reusables in anesthesia, such as laryngeal mask airways or suction canisters, but life cycle studies are needed to substantiate these benefits. (Anesth Analg 2012;114:1055–66)

Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998-2008.

Abstract: BACKGROUND The use of total joint arthroplasties is increasing worldwide. In this work we aim to elucidate recent trends in demographics and perioperative outcomes of patients undergoing total hip (THA) or total knee arthroplasty (TKA). METHODS Data from the US Nationwide Impatient Sample between 1998 and 2008 were gathered for primary THAs and TKAs. Trends in patient age, comorbidity burden, length of hospitalization, frequency of major perioperative complications, and in-hospital mortality were analyzed. In-hospital outcomes were reported as events per 1000 inpatient days to account for changes in length of hospitalization over time. Deyo index, discharge status, and the interaction effect of time and discharge status were included in the adjusted trend analysis for morbidity. RESULTS Between 1998 and 2008, the average age of patients undergoing TKA and THA decreased by 2 to 3 years (P < 0.001). The average length of stay decreased by approximately 1 day over the time interval studied (P < 0.001). The percentage of patients being discharged home declined from 29.7% to 25.4% after TKA and from 29.3% to 24.2% after THA, in favor of dispositions to long- and short-term care facilities (P < 0.0001). Comorbidity burden as measured by the Deyo comorbidity index increased by 35% and 30% for TKA and THA patients, respectively (P < 0.0001). After TKA, there was an increase in the incidence of the following major complications: pulmonary embolism (coefficient estimate [CE] 0.069; 95% confidence interval [CI], 0.059-0.079; P < 0.0001), sepsis (CE 0.034; 95% CI, 0.014-0.054; P = 0.001), nonmyocardial infarction cardiac complications (CE 0.038; 95% CI, 0.035-0.041; P < 0.0001), and pneumonia (CE 0.039; 95% CI, 0.031-0.047; P < 0.0001). After THA, there was an increase in the incidence of the following major complications: pulmonary embolism (CE 0.031; 95% CI, 0.012-0.049; P = 0.001), sepsis (CE 0.060; 95% CI, 0.039-0.081; P < 0.0001), nonmyocardial infarction cardiac complications (CE 0.040; 95% CI, 0.036-0.043; P < 0.0001), and pneumonia (CE 0.039; 95% CI, 0.029-0.048). In-hospital mortality declined after both TKA (CE -0.059; 95% CI, -0.077 to -0.040; P < 0.0001) and THA (CE -0.068; 95% CI, -0.086 to -0.051; P < 0.0001). CONCLUSION Between 1998 and 2008, trends show increases in several major in-hospital complications after THA and TKA, including pulmonary embolism, sepsis, nonmyocardial infarction cardiac complications, and pneumonia. Despite the increase in complications, declining in-hospital mortality was noted over this period.

Increased long-term mortality after a high perioperative inspiratory oxygen fraction during abdominal surgery: follow-up of a randomized clinical trial.

Abstract: BACKGROUND:A high perioperative inspiratory oxygen fraction (80%) has been recommended to prevent postoperative wound infections. However, the most recent and one of the largest trials, the PROXI trial, found no reduction in surgical site infection, and 30-day mortality was higher in patients given

A review of the impact of phenylephrine administration on maternal hemodynamics and maternal and neonatal outcomes in women undergoing cesarean delivery under spinal anesthesia.

Abstract: Phenylephrine is effective for the management of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery under spinal anesthesia. While ephedrine was previously considered the vasopressor of choice in obstetric patients, phenylephrine is increasingly being used. This is largely due to studies suggesting improved fetal acid-base status with the use of phenylephrine as well as the low incidence of hypotension and its related side effects with prophylactic phenylephrine regimens. This review highlights the effects of phenylephrine compared with ephedrine on maternal hemodynamics (arterial blood pressure, heart rate, and cardiac output), and occurrence of intraoperative nausea and vomiting. The impact of the administration of phenylephrine as a bolus for the treatment of established hypotension compared with its administration as a prophylactic infusion is discussed. This article also reviews the impact of phenylephrine compared with ephedrine on uteroplacental perfusion, and fetal outcomes such as neonatal acid-base status and Apgar scores. The optimum dosing regimen for phenylephrine administration is also discussed.

The beneficial effect of transversus abdominis plane block after laparoscopic cholecystectomy in day-case surgery: a randomized clinical trial.

Abstract: BACKGROUND:Laparoscopic cholecystectomy is associated with postoperative pain of moderate intensity in the early postoperative period. Recent randomized trials have demonstrated the efficacy of transversus abdominis plane (TAP) block in providing postoperative analgesia after abdominal surgery. We h

Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations.

Abstract: BACKGROUND:In this study, we updated the state of knowledge on unplanned tracheal extubations in the intensive care unit. We focused on the following topics: incidence, risk factors, reintubation after unplanned extubation, outcomes, and prevention. Based on this review, recommendations were made fo

Cartoon distraction alleviates anxiety in children during induction of anesthesia.

Abstract: Background We performed this study to determine the beneficial effects of viewing an animated cartoon and playing with a favorite toy on preoperative anxiety in children aged 3 to 7 years in the operating room before anesthesia induction. Methods One hundred thirty children aged 3 to 7 years with ASA physical status I or II were enrolled. Subjects were randomly assigned to 1 of 3 groups: group 1 (control), group 2 (toy), and group 3 (animated cartoon). The children in group 2 were asked to bring their favorite toy and were allowed to play with it until anesthesia induction. The children in group 3 watched their selected animated cartoon until anesthesia induction. Children's preoperative anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS) and parent-recorded anxiety Visual Analog Scale (VAS) the night before surgery, in the preanesthetic holding room, and just before anesthesia induction. Results In the preanesthetic holding room, the group 2 mYPAS and parent-recorded anxiety VAS scores were significantly lower than those of groups 1 and 3 (mYPAS: P = 0.007; parent-recorded anxiety VAS: P = 0.02). In the operating room, the children in group 3 had the lowest mYPAS and parent-recorded anxiety VAS scores among the 3 groups (mYPAS: P Conclusions Allowing the viewing of animated cartoons by pediatric surgical patients is a very effective method to alleviate preoperative anxiety. Our study suggests that this intervention is an inexpensive, easy to administer, and comprehensive method for anxiety reduction in the pediatric surgical population.

Acute Kidney Injury After Lung Resection Surgery: Incidence and Perioperative Risk Factors

Abstract: BACKGROUND:Postoperative acute kidney injury (AKI) is associated with increased perioperative morbidity and mortality in a variety of surgical settings, but has not been well studied after lung resection surgery. In the present study, we defined the incidence of postoperative AKI, identified risk fa

Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success.

Abstract: The development of the laryngeal mask airway in 1981 was an important first step toward widespread use and acceptance of the extraglottic airway (EGA). The term extraglottic is used in this review to encompass those airways that do not violate the larynx, in addition to those with a supraglottic pos

University of Queensland vital signs dataset: development of an accessible repository of anesthesia patient monitoring data for research.

Abstract: Data recorded from the devices used to monitor a patient's vital signs are often used in the development of displays, alarms, and information systems, but high-resolution, multiple-parameter datasets of anesthesia monitoring data from patients during anesthesia are often difficult to obtain. Existing databases have typically been collected from patients in intensive care units. However, the physical state of intensive care patients is dissimilar to those undergoing surgery, more frequent and marked changes to cardiovascular and respiratory variables are seen in operating room patients, and additional and highly relevant information to anesthesia (e.g., end-tidal agent monitoring, etc.) is omitted from these intensive care databases. We collected a set of high-quality, high-resolution, multiple-parameter monitoring data suitable for anesthesia monitoring research. Vital signs data were recorded from patients undergoing anesthesia at the Royal Adelaide Hospital. Software was developed to capture, time synchronize, and interpolate vital signs data from Philips IntelliVue MP70 and MP30 patient monitors and Datex-Ohmeda Aestiva/5 anesthesia machines into 10 millisecond resolution samples. The recorded data were saved in a variety of accessible file formats. Monitoring data were recorded from 32 cases (25 general anesthetics, 3 spinal anesthetics, 4 sedations) ranging in duration from 13 minutes to 5 hours (median 105 min). Most cases included data from the electrocardiograph, pulse oximeter, capnograph, noninvasive arterial blood pressure monitor, airway flow, and pressure monitor and, in a few cases, the Y-piece spirometer, electroencephalogram monitor, and arterial blood pressure monitor. Recorded data were processed and saved into 4 file formats: (1) comma-separated values text files with full numerical and waveform data, (2) numerical parameters recorded in comma-separated values files at 1-second intervals, (3) graphical plots of all waveform data in a range of resolutions as Portable Network Graphics image files, and (4) graphical overview plots of numerical data for entire cases as Portable Network Graphics and Scalable Vector Graphics files. The complete dataset is freely available online via doi:102.100.100/6914 and has been listed in the Australian National Data Service Collections Registry. The present dataset provides clinical anesthesia monitoring data from entire surgical cases where patients underwent anesthesia, includes a wide range of vital signs variables that are commonly monitored during surgery, and is published in accessible, user-friendly file formats. The text and image file formats let researchers without engineering or computer science backgrounds easily access the data using standard spreadsheet and image browsing software. In future work, monitoring data should be collected from a wider range and larger number of cases, and software tools are needed to support searching and navigating the database.

Comparative life cycle assessment of disposable and reusable laryngeal mask airways.

Abstract: BACKGROUND: Growing awareness of the negative impacts from the practice of health care on the environment and public health calls for the routine inclusion of life cycle criteria into the decision-making process of device selection. Here we present a life cycle assessment of 2 laryngeal mask airways (LMAs), a one-time-use disposable Unique™ LMA and a 40-time-use reusable Classic™ LMA. METHODS: In life cycle assessment, the basis of comparison is called the “functional unit.” For this report, the functional unit of the disposable and reusable LMAs was taken to be maintenance of airway patency by 40 disposable LMAs or 40 uses of 1 reusable LMA. This was a cradle-to-grave study that included inputs and outputs for the manufacture, transport, use, and waste phases of the LMAs. The environmental impacts of the 2 LMAs were estimated using SimaPro life cycle assessment software and the Building for Environmental and Economic Sustainability impact assessment method. Sensitivity and simple life cycle cost analyses were conducted to aid in interpretation of the results. RESULTS: The reusable LMA was found to have a more favorable environmental profile than the disposable LMA as used at Yale New Haven Hospital. The most important sources of impacts for the disposable LMA were the production of polymers, packaging, and waste management, whereas for the reusable LMA, washing and sterilization dominated for most impact categories. DISCUSSION: The differences in environmental impacts between these devices strongly favor reusable devices. These benefits must be weighed against concerns regarding transmission of infection. Health care facilities can decrease their environmental impacts by using reusable LMAs, to a lesser extent by selecting disposable LMA models that are not made of certain plastics, and by ordering in bulk from local distributors. Certain practices would further reduce the environmental impacts of reusable LMAs, such as increasing the number of devices autoclaved in a single cycle to 10 (−25% GHG emissions) and improving the energy efficiency of the autoclaving machines by 10% (−8% GHG emissions). For both environmental and cost considerations, management and operating procedures should be put in place to ensure that reusable LMAs are not discarded prematurely.