Showing papers in "Anesthesiology in 2014"

Myocardial Injury after Noncardiac Surgery: A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes

Abstract: Background Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer.

Abstract: Background The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. Methods A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. Results Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥ 20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. -21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). Conclusion Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.

Mechanisms of Acupuncture-Electroacupuncture on Persistent Pain

Abstract: In the last decade, preclinical investigations of electroacupuncture mechanisms on persistent tissue injury (inflammatory), nerve injury (neuropathic), cancer, and visceral pain have increased. These studies show that electroacupuncture activates the nervous system differently in health than in pain conditions, alleviates both sensory and affective inflammatory pain, and inhibits inflammatory and neuropathic pain more effectively at 2 to 10 Hz than at 100 Hz. Electroacupuncture blocks pain by activating a variety of bioactive chemicals through peripheral, spinal, and supraspinal mechanisms. These include opioids, which desensitize peripheral nociceptors and reduce proinflammatory cytokines peripherally and in the spinal cord, and serotonin and norepinephrine, which decrease spinal N-methyl-D-aspartate receptor subunit GluN1 phosphorylation. Additional studies suggest that electroacupuncture, when combined with low dosages of conventional analgesics, provides effective pain management which can forestall the side effects of often-debilitating pharmaceuticals.

Procedure-specific Risk Factor Analysis for the Development of Severe Postoperative Pain

Abstract: Background:Many studies have analyzed risk factors for the development of severe postoperative pain with contradictory results. To date, the association of risk factors with postoperative pain intensity among different surgical procedures has not been studied and compared.Methods:The authors selecte

Prospective External Validation of a Predictive Score for Postoperative Pulmonary Complications

Abstract: Background No externally validated risk score for postoperative pulmonary complications (PPCs) is currently available. The authors tested the generalizability of the Assess Respiratory Risk in Surgical Patients in Catalonia risk score for PPCs in a large European cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe). Methods Sixty-three centers recruited 5,859 surgical patients receiving general, neuraxial, or plexus block anesthesia. The Assess Respiratory Risk in Surgical Patients in Catalonia factors (age, preoperative arterial oxygen saturation in air, acute respiratory infection during the previous month, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration, and emergency surgery) were recorded, along with PPC occurrence (respiratory infection or failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis). Discrimination, calibration, and diagnostic accuracy measures of the Assess Respiratory Risk in Surgical Patients in Catalonia score's performance were calculated for the Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe cohort and three subsamples: Spain, Western Europe, and Eastern Europe. Results The full Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe data set included 5,099 patients; 725 PPCs were recorded for 404 patients (7.9%). The score's discrimination was good: c-statistic (95% CI), 0.80 (0.78 to 0.82). Predicted versus observed PPC rates for low, intermediate, and high risk were 0.87 and 3.39% (score Conclusions The Assess Respiratory Risk in Surgical Patients in Catalonia score predicts three levels of PPC risk in hospitals outside the development setting. Performance differs between geographic areas.

Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial.

Abstract: Background:This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noni

Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes.

Abstract: Background The authors investigated nationwide trends in opioid abuse or dependence during pregnancy and assessed the impact on maternal and obstetrical outcomes in the United States. Methods Hospitalizations for delivery were extracted from the Nationwide Inpatient Sample from 1998 to 2011. Temporal trends were assessed and logistic regression was used to examine the associations between maternal opioid abuse or dependence and obstetrical outcomes adjusting for relevant confounders. Results The prevalence of opioid abuse or dependence during pregnancy increased from 0.17% (1998) to 0.39% (2011) for an increase of 127%. Deliveries associated with maternal opioid abuse or dependence compared with those without opioid abuse or dependence were associated with an increased odds of maternal death during hospitalization (adjusted odds ratio [aOR], 4.6; 95% CI, 1.8 to 12.1, crude incidence 0.03 vs. 0.006%), cardiac arrest (aOR, 3.6; 95% CI, 1.4 to 9.1; 0.04 vs. 0.01%), intrauterine growth restriction (aOR, 2.7; 95% CI, 2.4 to 2.9; 6.8 vs. 2.1%), placental abruption (aOR, 2.4; 95% CI, 2.1 to 2.6; 3.8 vs. 1.1%), length of stay more than 7 days (aOR, 2.2; 95% CI, 2.0 to 2.5; 3.0 vs. 1.2%), preterm labor (aOR, 2.1; 95% CI, 2.0 to 2.3; 17.3 vs. 7.4%), oligohydramnios (aOR, 1.7; 95% CI, 1.6 to 1.9; 4.5 vs. 2.8%), transfusion (aOR, 1.7; 95% CI, 1.5 to 1.9; 2.0 vs. 1.0%), stillbirth (aOR, 1.5; 95% CI, 1.3 to 1.8; 1.2 vs. 0.6%), premature rupture of membranes (aOR, 1.4; 95% CI, 1.3 to 1.6; 5.7 vs. 3.8%), and cesarean delivery (aOR, 1.2; 95% CI, 1.1 to 1.3; 36.3 vs. 33.1%). Conclusions Opioid abuse or dependence during pregnancy is associated with considerable obstetrical morbidity and mortality, and its prevalence is dramatically increasing in the United States. Identifying preventive strategies and therapeutic interventions in pregnant women who abuse drugs are important priorities for clinicians and scientists.

Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology.

Abstract: Background Because of the lack of large obstetric anesthesia databases, the incidences of serious complications related to obstetric anesthesia remain unknown. The Society for Obstetric Anesthesia and Perinatology developed the Serious Complication Repository Project to establish the incidence of serious complications related to obstetric anesthesia and to identify risk factors associated with each. Methods Serious complications were defined by the Society for Obstetric Anesthesia and Perinatology Research Committee which also coordinated the study. Thirty institutions participated in the approximately 5-yr study period. Data were collected as part of institutional quality assurance and sent to the central project coordinator quarterly. Results Data were captured on more than 257,000 anesthetics, including 5,000 general anesthetics for cesarean delivery. There were 157 total serious complications reported, 85 of which were anesthesia related. High neuraxial block, respiratory arrest in labor and delivery, and unrecognized spinal catheter were the most frequent complications encountered. A serious complication occurs in approximately 1:3,000 (1:2,443 to 1:3,782) obstetric anesthetics. Conclusions The Serious Complication Repository Project establishes the incidence of serious complications in obstetric anesthesia. Because serious complications related to obstetric anesthesia are rare, there were too few complications in each category to identify risk factors associated with each. However, because many of these complications can lead to catastrophic outcomes, it is recommended that the anesthesia provider remains vigilant and be prepared to rapidly diagnose and treat any complication.

A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications?

Abstract: BACKGROUND Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications. The authors investigated whether preoperative diagnosis and prescription of continuous positive airway pressure therapy reduces these risks. METHODS Matched cohort analysis of polysomnography data and Manitoban health administrative data (1987 to 2008). Postoperative outcomes in adult OSA patients up to 5 yr before (undiagnosed OSA, n = 1,571), and any time after (diagnosed OSA, n = 2,640) polysomnography and prescription of continuous positive airway pressure therapy for a new diagnosis of OSA, were compared with controls at low risk of having sleep apnea (n = 16,277). Controls were matched by exact procedure, indication, and approximate date of surgery. Procedures used to treat sleep apnea were excluded. Follow-up was at least 7 postoperative days. Results were reported as odds ratio (95% CI) for OSA or subgroup versus controls. RESULTS In multivariate analyses, the risk of respiratory complications (2.08 [1.35 to 3.19], P < 0.001) was similarly increased for both undiagnosed and diagnosed OSA. The risk of cardiovascular complications, primarily cardiac arrest and shock, was significantly different (P = 0.009) between undiagnosed OSA (2.20 [1.16 to 4.17], P = 0.02) and diagnosed OSA patients (0.75 [0.43 to 1.28], P = 0.29). For both outcomes, OSA severity, type of surgery, age, and other comorbidities were also important risk modifiers. CONCLUSIONS Diagnosis of OSA and prescription of continuous positive airway pressure therapy were associated with a reduction in postoperative cardiovascular complications. Despite limitations in the data, these results could be used to justify and inform large efficacy trials of perioperative continuous positive airway pressure therapy in OSA patients.

Isoflurane-induced Apoptosis of Neurons and Oligodendrocytes in the Fetal Rhesus Macaque Brain

Abstract: There is mounting evidence that anesthetic and anticonvulsant drugs and alcohol cause widespread apoptotic neurodegeneration in the developing brains of several animal species,1–5 including nonhuman primates (NHPs),6–12 and that neonatal exposure to these agents is associated with long-term neurobehavioral disturbances in both rodents3,13–17 and NHPs.18 More importantly, there is recent evidence from several independent research groups suggesting that exposure of human infants to brief anesthesia is associated with increased risk for neurobehavioral impairment.19–25 Further complicating the picture is evidence that exposure of infant rhesus macaques to isoflurane causes apoptosis not only of neurons, but also of glial cells. Our recent findings10,11 indicate that in the neonatal NHP brain the vulnerable glial cell type is in the oligodendrocyte lineage, and oligodendrocytes become vulnerable at a time when they are just beginning to myelinate axons that interconnect neurons throughout the central nervous system. In the isoflurane-exposed neonatal NHP brains, apoptotic oligodendrocytes were distributed diffusely throughout many white matter (WM) regions, and the total number of dying oligodendrocytes in WM was approximately equal to the total number of dying neurons in gray matter. Isoflurane and related halogenated ethers are frequently used in pediatric and obstetric anesthesia. Thus, it is not uncommon for a human neonate or premature infant to be exposed to these agents. At this stage, the neurodevelopmental age of a human infant is equivalent to that of a third-trimester NHP fetus. Nothing is known regarding the vulnerability of the fetal primate brain to the apoptogenic action of isoflurane on either neurons or glia. Therefore, we administered isoflurane to pregnant rhesus macaques for 5 h at a gestational age of 120 days (G120; approximately mid-third trimester), and delivered the fetus by cesarean section 3 h later for histopathological evaluation of the brains. Here we will describe the effects of isoflurane on both neurons and glia in the G120 NHP brain, and will compare these effects in the fetal brain with those we have described previously in the isoflurane-exposed neonatal NHP brain.

Effects of sevoflurane and propofol on frontal electroencephalogram power and coherence.

Abstract: Background:The neural mechanisms of anesthetic vapors have not been studied in depth. However, modeling and experimental studies on the intravenous anesthetic propofol indicate that potentiation of γ-aminobutyric acid receptors leads to a state of thalamocortical synchrony, observed as coherent fron

Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the united states

Abstract: Background:There are few data regarding the utilization of opioids during pregnancy. The objective of this study was to define the prevalence and patterns of opioid use in a large cohort of pregnant women who were commercial insurance beneficiaries.Methods:Data for the study were derived from a deid

Cardiac Arrest during Hospitalization for Delivery in the United States, 1998–2011

Abstract: Cardiopulmonary arrest is a rare complication during pregnancy and the postpartum period. A number of unique interventions must be considered during resuscitation of the pregnant arrest victim, including the use of left uterine displacement, prompt and often challenging airway management, and an emergent operative delivery of the fetus. The International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science states that “research in the area of maternal resuscitation is lacking, and most of the science is extrapolated from nonpregnant women, manikin studies, or case reports.”1 The committee members called for “epidemiological studies… to document the incidence of cardiac arrest in pregnancy as there is a perception that it is increasing because of increased numbers of women with congenital heart conditions who are now having children.”1 The frequency of maternal cardiopulmonary arrest in the United States is unknown, and there are limited population- level data to inform guideline development or systems preparations for these rare emergencies. The objective of this analysis was to determine the frequency, distribution of potential etiologies, and survival rates of maternal cardiopulmonary arrest during delivery hospitalizations in the United States to provide insights into potentially avoidable maternal morbidity and mortality.

Accuracy and Precision of Continuous Noninvasive Arterial Pressure Monitoring Compared with Invasive Arterial Pressure: A Systematic Review and Meta-analysis

Abstract: Background:Continuous noninvasive arterial pressure monitoring devices are available for bedside use, but the accuracy and precision of these devices have not been evaluated in a systematic review and meta-analysis.Methods:The authors performed a systematic review and meta-analysis of studies compar

Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks.

Abstract: Background:Much controversy remains on the role of anesthesia technique and peripheral nerve blocks (PNBs) in inpatient falls (IFs) after orthopedic procedures. The aim of the study is to characterize cases of IFs, identify risk factors, and study the role of PNB and anesthesia technique in IF risk

Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study.

Abstract: BACKGROUND Dexmedetomidine, a potent α-2-adrenergic agonist, is widely used as sedative in critically ill patients. This pilot study was designed to assess the effect of dexmedetomidine administration on sleep quality in critically ill patients. METHODS Polysomnography was performed on hemodynamically stable critically ill patients for 57 consecutive hours, divided into three night-time (9:00 PM to 6:00 AM) and two daytime (6:00 AM to 9:00 PM) periods. On the second night, dexmedetomidine was given by a continuous infusion targeting a sedation level -1 to -2 on the Richmond Agitation Sedation Scale. Other sedatives were not permitted. RESULTS Thirteen patients were studied. Dexmedetomidine was given in a dose of 0.6 μg kg(-1) h(-1) (0.4 to 0.7) (median [interquartile range]). Compared to first and third nights (without dexmedetomidine), sleep efficiency was significantly higher during the second night (first: 9.7% [1.6 to 45.1], second: 64.8% [51.4 to 79.9], third: 6.9% [0.0 to 17.1], P < 0.002). Without dexmedetomidine, night-time sleep fragmentation index (7.6 events per hour [4.8 to 14.2]) and stage 1 of sleep (48.0% [30.1 to 66.4]) were significantly higher (P = 0.023 and P = 0.006, respectively), and stage 2 (47.0% [27.5 to 61.2]) showed values lower (P = 0.006) than the corresponding values (2.7 events per hour [1.6 to 4.9], 13.1% [6.2 to 23.6], 80.2% [68.9 to 92.8]) observed with dexmedetomidine. Without sedation, sleep was equally distributed between day and night, a pattern that was modified significantly (P = 0.032) by night-time dexmedetomidine infusion, with more than three quarters of sleep occurring during the night (79% [66 to 87]). CONCLUSION In highly selected critically ill patients, dexmedetomidine infusion during the night to achieve light sedation improves sleep by increasing sleep efficiency and stage 2 and modifies the 24-h sleep pattern by shifting sleep mainly to the night.

Comparative analysis of outcome measures used in examining neurodevelopmental effects of early childhood anesthesia exposure.

Abstract: Introduction Immature animals exposed to anesthesia display apoptotic neurodegeneration and neurobehavioral deficits. The safety of anesthetic agents in children has been evaluated using a variety of neurodevelopmental outcome measures with varied results. Methods The authors used data from the Western Australian Pregnancy Cohort (Raine) Study to examine the association between exposure to anesthesia in children younger than 3 yr of age and three types of outcomes at age of 10 yr: neuropsychological testing, International Classification of Diseases, 9th Revision, Clinical Modification-coded clinical disorders, and academic achievement. The authors' primary analysis was restricted to children with data for all outcomes and covariates from the total cohort of 2,868 children born from 1989 to 1992. The authors used a modified multivariable Poisson regression model to determine the adjusted association of anesthesia exposure with outcomes. Results Of 781 children studied, 112 had anesthesia exposure. The incidence of deficit ranged from 5.1 to 7.8% in neuropsychological tests, 14.6 to 29.5% in International Classification of Diseases, 9th Revision, Clinical Modification-coded outcomes, and 4.2 to 11.8% in academic achievement tests. Compared with unexposed peers, exposed children had an increased risk of deficit in neuropsychological language assessments (Clinical Evaluation of Language Fundamentals Total Score: adjusted risk ratio, 2.47; 95% CI, 1.41 to 4.33, Clinical Evaluation of Language Fundamentals Receptive Language Score: adjusted risk ratio, 2.23; 95% CI, 1.19 to 4.18, and Clinical Evaluation of Language Fundamentals Expressive Language Score: adjusted risk ratio, 2.00; 95% CI, 1.08 to 3.68) and International Classification of Diseases, 9th Revision, Clinical Modification-coded language and cognitive disorders (adjusted risk ratio, 1.57; 95% CI, 1.18 to 2.10), but not academic achievement scores. Conclusions When assessing cognition in children with early exposure to anesthesia, the results may depend on the outcome measure used. Neuropsychological and International Classification of Diseases, 9th Revision, Clinical Modification-coded clinical outcomes showed an increased risk of deficit in exposed children compared with that in unexposed children, whereas academic achievement scores did not. This may explain some of the variation in the literature and underscores the importance of the outcome measures when interpreting studies of cognitive function.

Postoperative changes in sleep-disordered breathing and sleep architecture in patients with obstructive sleep apnea

Abstract: Background:Anesthetics, analgesics, and surgery may profoundly affect sleep architecture and aggravate sleep-related breathing disturbances. The authors hypothesized that patients with preoperative polysomnographic evidence of obstructive sleep apnea (OSA) would experience greater changes in these p

Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the quality of recovery after ambulatory breast tumor resection.

Abstract: Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intrav

Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial.

Abstract: BACKGROUND Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension. Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration. The authors investigated whether this approach could result in reduced postoperative complication rate. METHODS In this single-center, double-blind, randomized, superiority trial, 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg·h of balanced Ringer's solution until the end of cystectomy and then 3 ml·kg·h until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg·h (low-volume group; n = 83) or 6 ml·kg·h of balanced Ringer's solution throughout surgery (control group; n = 83). Primary outcome was the in-hospital complication rate. Secondary outcomes were hospitalization time, and 90-day mortality. RESULTS In-hospital complications occurred in 43 of 83 patients (52%) in the low-volume group and in 61 of 83 (73%) in the control group (relative risk, 0.70; 95% CI, 0.55-0.88; P = 0.006). The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group (5 [6%] vs. 31 [37%]; relative risk, 0.16; 95% CI, 0.07-0.39; P < 0.0001 and 17 [20%] vs. 39 [48%], relative risk, 0.43; 95% CI, 0.26-0.60; P = 0.0003, respectively). The median hospitalization time was 15 days [range, 11, 27d] in the low-volume group and 17 days [11, 95d] in the control group (P = 0.02). The 90-day mortality was 0% in the low-volume group and 4.8% in the control group (P = 0.12). CONCLUSION A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time.

Factors Associated with Postoperative Exacerbation of Sleep-disordered Breathing

Abstract: Introduction:The knowledge on the mechanism of the postoperative exacerbation of sleep-disordered breathing may direct the perioperative management of patients with obstructive sleep apnea The objective of this study is to investigate the factors associated with postoperative severity of sleep-diso

Cell-based therapy for acute organ injury: preclinical evidence and ongoing clinical trials using mesenchymal stem cells.

Abstract: Critically ill patients often suffer from multiple organ failures involving lung, kidney, liver, or brain. Genomic, proteomic, and metabolomic approaches highlight common injury mechanisms leading to acute organ failure. This underlines the need to focus on therapeutic strategies affecting multiple

Effects of neostigmine reversal of nondepolarizing neuromuscular blocking agents on postoperative respiratory outcomes: a prospective study.

Abstract: Background:We tested the hypothesis that neostigmine reversal of neuromuscular blockade reduced the incidence of signs and symptoms of postoperative respiratory failure.Methods:We enrolled 3,000 patients in this prospective, observer-blinded, observational study. We documented the intraoperative use

High-mobility group box 1 protein initiates postoperative cognitive decline by engaging bone marrow-derived macrophages

Abstract: Background Aseptic trauma engages the innate immune response to trigger a neuroinflammatory reaction that results in postoperative cognitive decline. We sought to determine whether high-mobility group box 1 protein (HMGB1), an ubiquitous nucleosomal protein, initiates this process through activation and trafficking of circulating bone marrow-derived macrophages to the brain.

Accuracy of transthoracic lung ultrasound for diagnosing anesthesia-induced atelectasis in children.

Abstract: BACKGROUND The aim of this study was to test the accuracy of lung sonography (LUS) to diagnose anesthesia-induced atelectasis in children undergoing magnetic resonance imaging (MRI) METHODS Fifteen children with American Society of Anesthesiology's physical status classification I and aged 1 to 7 yr old were studied Sevoflurane anesthesia was performed with the patients breathing spontaneously during the study period After taking the reference lung MRI images, LUS was carried out using a linear probe of 6 to 12 MHz Atelectasis was documented in MRI and LUS segmenting the chest into 12 similar anatomical regions Images were analyzed by four blinded radiologists, two for LUS and two for MRI The level of agreement for the diagnosis of atelectasis among observers was tested using the κ reliability index RESULTS Fourteen patients developed atelectasis mainly in the most dependent parts of the lungs LUS showed 88% of sensitivity (95% CI, 74 to 96%), 89% of specificity (95% CI, 83 to 94%), and 88% of accuracy (95% CI, 83 to 92%) for the diagnosis of atelectasis taking MRI as reference The agreement between the two radiologists for diagnosing atelectasis by MRI was very good (κ, 087; 95% CI, 072 to 1; P < 00001) as was the agreement between the two radiologists for detecting atelectasis by LUS (κ, 090; 95% CI, 075 to 1; P < 00001) MRI and LUS also showed good agreement when data from the four radiologists were pooled and examined together (κ, 075; 95% CI, 069 to 081; P < 00001) CONCLUSION LUS is an accurate, safe, and simple bedside method for diagnosing anesthesia-induced atelectasis in children

Mechanical ventilation-associated lung fibrosis in acute respiratory distress syndrome: a significant contributor to poor outcome.

Abstract: One of the most challenging problems in critical care medicine is the management of patients with the acute respiratory distress syndrome. Increasing evidence from experimental and clinical studies suggests that mechanical ventilation, which is necessary for life support in patients with acute respiratory distress syndrome, can cause lung fibrosis, which may significantly contribute to morbidity and mortality. The role of mechanical stress as an inciting factor for lung fibrosis versus its role in lung homeostasis and the restoration of normal pulmonary parenchymal architecture is poorly understood. In this review, the authors explore recent advances in the field of pulmonary fibrosis in the context of acute respiratory distress syndrome, concentrating on its relevance to the practice of mechanical ventilation, as commonly applied by anesthetists and intensivists. The authors focus the discussion on the thesis that mechanical ventilation-or more specifically, that ventilator-induced lung injury-may be a major contributor to lung fibrosis. The authors critically appraise possible mechanisms underlying the mechanical stress-induced lung fibrosis and highlight potential therapeutic strategies to mitigate this fibrosis.

A comparison of propofol- and dexmedetomidine-induced electroencephalogram dynamics using spectral and coherence analysis.

Abstract: Background:Electroencephalogram patterns observed during sedation with dexmedetomidine appear similar to those observed during general anesthesia with propofol. This is evident with the occurrence of slow (0.1 to 1 Hz), delta (1 to 4 Hz), propofol-induced alpha (8 to 12 Hz), and dexmedetomidine-indu

OPRM1 A118G gene variant and postoperative opioid requirement: a systematic review and meta-analysis.

Abstract: BACKGROUND Although a number of studies have investigated the association of the OPRM1 A118G polymorphism with pain response, a consensus has not yet been reached. METHODS The authors searched PubMed, EMBASE, and the Cochrane Library to identify gene-association studies that explored the impact of the OPRM1 A118G polymorphism on postoperative opioid requirements through July 2013. Two evaluators independently reviewed and selected articles on the basis of prespecified selection criteria. The authors primarily investigated the standardized mean difference (SMD) of required amounts of opioids between AA homozygotes and G-allele carriers. The authors also performed subgroup analyses for race, opioid use, and type of surgery. Potential bias was assessed using the Egger's test with a trim and fill procedure. RESULTS Three hundred forty-six articles were retrieved from databases, and 18 studies involving 4,607 participants were included in the final analyses. In a random-effect meta-analysis, G-allele carriers required a higher mean opioid dose than AA homozygotes (SMD, -0.18; P = 0.003). Although there was no evidence of publication bias, heterogeneity was present among studies (I(2) = 66.8%). In the subgroup meta-analyses, significance remained robust in Asian patients (SMD, -0.21; P = 0.001), morphine users (SMD, -0.29; P <0.001), and patients who received surgery for a viscus (SMD, -0.20; P = 0.008). CONCLUSIONS The OPRM1 A118G polymorphism was associated with interindividual variability in postoperative response to opioids. In a subpopulation, identifying OPRM1 A118G polymorphism may provide valuable information regarding the individual analgesic doses that are required to achieve satisfactory pain control.

Lung ultrasound predicts well extravascular lung water but is of limited usefulness in the prediction of wedge pressure.

Abstract: Background:Pulmonary congestion is indicated at lung ultrasound by detection of B-lines, but correlation of these ultrasound signs with pulmonary artery occlusion pressure (PAOP) and extravascular lung water (EVLW) still remains to be further explored. The aim of the study was to assess whether B-li

Electrical Stimulation of the Ventral Tegmental Area Induces Reanimation from General Anesthesia

Abstract: Background:Methylphenidate or a D1 dopamine receptor agonist induces reanimation (active emergence) from general anesthesia. The authors tested whether electrical stimulation of dopaminergic nuclei also induces reanimation from general anesthesia.Methods:In adult rats, a bipolar insulated stainless