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Showing papers in "Anesthesiology in 2018"


Journal ArticleDOI
TL;DR: Neuroinflammation drives widespread chronic pain via central sensitization and sex-dependent glial/immune signaling in chronic pain and new therapeutic approaches that control neuroinflammation for the resolution of chronic pain are discussed.
Abstract: Chronic pain is maintained in part by central sensitization, a phenomenon of synaptic plasticity, and increased neuronal responsiveness in central pain pathways after painful insults Accumulating evidence suggests that central sensitization is also driven by neuroinflammation in the peripheral and central nervous system A characteristic feature of neuroinflammation is the activation of glial cells, such as microglia and astrocytes, in the spinal cord and brain, leading to the release of proinflammatory cytokines and chemokines Recent studies suggest that central cytokines and chemokines are powerful neuromodulators and play a sufficient role in inducing hyperalgesia and allodynia after central nervous system administration Sustained increase of cytokines and chemokines in the central nervous system also promotes chronic widespread pain that affects multiple body sites Thus, neuroinflammation drives widespread chronic pain via central sensitization We also discuss sex-dependent glial/immune signaling in chronic pain and new therapeutic approaches that control neuroinflammation for the resolution of chronic pain

641 citations


Journal ArticleDOI
TL;DR: The working group recommends that ‘perioperative neurocognitive disorders’ be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period as well as two major classification guidelines used outside of anaesthesia and surgery.
Abstract: Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions.Two major classification guidelines (Diagnostic and Statistical Manual for Mental Disorders, fifth edition [DSM-5] and National Institute for Aging and the Alzheimer Association [NIA-AA]) are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).

417 citations


Journal ArticleDOI
TL;DR: The hypothesis that exposure to multiple, but not single, procedures requiring anesthesia before age 3 yr is associated with adverse neurodevelopmental outcomes is suggested, and changes in specific neuropsychological domains that are associated with behavioral and learning difficulties are suggested.
Abstract: Background:Few studies of how exposure of children to anesthesia may affect neurodevelopment employ comprehensive neuropsychological assessments. This study tested the hypothesis that exposure to multiple, but not single, procedures requiring anesthesia before age 3 yr is associated with adverse neu

378 citations


Journal ArticleDOI
TL;DR: A machine-learning algorithm based on thousands of arterial waveform features can identify an intraoperative hypotensive event 15 min before its occurrence with a sensitivity of 88% and specificity of 87% Further studies must evaluate the real-time value of such algorithms in a broader set of clinical conditions and patients
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicThe ability to predict intraoperative hypotension may advance the ability to prevent hypotension-associated complications effectivelyThe extent to which advanced waveform analysis of invasive arterial lines may provide meaningful forewarning r

302 citations


Journal ArticleDOI
TL;DR: Clinical investigations evaluating different preventative pharmacologic strategies that are routinely used by anesthesiologists in their daily clinical practices for preventing persistent postoperative pain are described.
Abstract: The development of chronic pain is considered a major complication after surgery. Basic science research in animal models helps us understand the transition from acute to chronic pain by identifying the numerous molecular and cellular changes that occur in the peripheral and central nervous systems. It is now well recognized that inflammation and nerve injury lead to long-term synaptic plasticity that amplifies and also maintains pain signaling, a phenomenon referred to as pain sensitization. In the context of surgery in humans, pain sensitization is both responsible for an increase in postoperative pain via the expression of wound hyperalgesia and considered a critical factor for the development of persistent postsurgical pain. Using specific drugs that block the processes of pain sensitization reduces postoperative pain and prevents the development of persistent postoperative pain. This narrative review of the literature describes clinical investigations evaluating different preventative pharmacologic strategies that are routinely used by anesthesiologists in their daily clinical practices for preventing persistent postoperative pain. Nevertheless, further efforts are needed in both basic and clinical science research to identify preclinical models and novel therapeutics targets. There remains a need for more patient numbers in clinical research, for more reliable data, and for the development of the safest and the most effective strategies to limit the incidence of persistent postoperative pain.

248 citations


Journal ArticleDOI
TL;DR: A level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children is demonstrated.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicRegional anesthesia is associated with a low but poorly quantified incidence of complications.What This Article Tells Us That Is NewIn a prospective multicenter cohort of more than 100,000 blocks in children, there were no cases of permanent n

212 citations


Journal ArticleDOI
TL;DR: PEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery, and individualized PEEP settings could reduce postoperative atelectasis while improving intraoperative oxygenation and driving pressures, causing minimum side effects.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicIn patients with adult respiratory distress syndrome, physiologic tidal volume and positive end-expiratory pressure (PEEP) are protectiveIn patients without lung diseases undergoing mechanical ventilation under general anesthesia, optimal PEEP

167 citations


Journal ArticleDOI
TL;DR: While the optimal multimodal regimen is still not known, the authors’ findings encourage the combined use of multiple modalities in perioperative analgesic protocols.
Abstract: Background:Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utili

136 citations


Journal ArticleDOI
TL;DR: The authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies.
Abstract: For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.

132 citations


Journal ArticleDOI
TL;DR: Propofol anesthesia for colon cancer surgery is associated with better survival irrespective of tumor–node–metastasis stage, and simple propensity score adjustment produced similar findings.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicPropofol may better preserve host defenses against cancerWhether cancer recurrence is less likely with propofol than volatile anesthesia remains unknownWhat This Article Tells Us That Is NewThe authors conducted a propensity-matched retrospect

129 citations


Journal ArticleDOI
TL;DR: The success of this technique in predicting postinduction hypotension demonstrates feasibility of machine-learning models for predictive analytics in the field of anesthesiology, with performance dependent on model selection and appropriate tuning.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicThe ability to predict postinduction hypotension remains limited and challenging due to the multitude of data elements that may be consideredNovel machine-learning algorithms may offer a systematic approach to predict postinduction hypotension

Journal ArticleDOI
TL;DR: The various RYR1-related disorders and phenotypes, such as myopathies, exertional rhabdomyolysis, and bleeding disorders, are reviewed, and the connection between these disorders and malignant hyperthermia is examined.
Abstract: This article reviews advancements in the genetics of malignant hyperthermia, new technologies and approaches for its diagnosis, and the existing limitations of genetic testing for malignant hyperthermia. It also reviews the various RYR1-related disorders and phenotypes, such as myopathies, exertional rhabdomyolysis, and bleeding disorders, and examines the connection between these disorders and malignant hyperthermia.

Journal ArticleDOI
TL;DR: Deep neural networks can predict in-hospital mortality based on automatically extractable intraoperative data, but are not (yet) superior to existing methods.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicRobust predictions are required to compare perioperative mortality among hospitalsDeep neural network systems, a type of machine learning, can be used to develop highly nonlinear prediction modelsWhat This Article Tells Us That Is NewThe autho

Journal ArticleDOI
TL;DR: The study’s findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.
Abstract: What we already know about this topic WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated. Methods A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment. Results Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation. Conclusions Hypotension is a potentially modifiable risk factor for perioperative stroke. The study's findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.

Journal ArticleDOI
TL;DR: This review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and morphine, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety.
Abstract: Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.

Journal ArticleDOI
TL;DR: Under the study conditions, a colloid-based goal-directed fluid therapy was associated with fewer postoperative complications than a crystalloid one and this beneficial effect may be related to a lower intraoperative fluid balance when a balanced colloid was used.
Abstract: Background:The type of fluid and volume regimen given intraoperatively both can impact patient outcome after major surgery. This two-arm, parallel, randomized controlled, double-blind, bi-center superiority study tested the hypothesis that when using closed-loop assisted goal-directed fluid therapy,

Journal ArticleDOI
TL;DR: Patients who developed delirium had greater decline in a composite measure of cognition and in visuoconstruction and processing speed domains at 1 month and 1 yr after cardiac surgery, and the differences in cognitive change byDelirium were not significant at 1 yr, with the exception of processing speed.
Abstract: What We Already Know about This TopicCardiac surgery is associated with cognitive decline and postoperative deliriumThe relationship between postoperative delirium and cognitive decline after cardiac surgery is unclearWhat This Article Tells Us That Is NewThe development of postoperative delirium is

Journal ArticleDOI
TL;DR: Findings from neuroimaging pain research have benefitted clinical practice by providing clinicians with an educational framework to discuss the biopsychosocial nature of pain with patients, and brain-based biomarkers may provide an additional predictor of perioperative prognoses.
Abstract: Neuroimaging research has demonstrated definitive involvement of the central nervous system in the development, maintenance, and experience of chronic pain. Structural and functional neuroimaging has helped elucidate central nervous system contributors to chronic pain in humans. Neuroimaging of pain has provided a tool for increasing our understanding of how pharmacologic and psychologic therapies improve chronic pain. To date, findings from neuroimaging pain research have benefitted clinical practice by providing clinicians with an educational framework to discuss the biopsychosocial nature of pain with patients. Future advances in neuroimaging-based therapeutics (e.g., transcranial magnetic stimulation, real-time functional magnetic resonance imaging neurofeedback) may provide additional benefits for clinical practice. In the future, with standardization and validation, brain imaging could provide objective biomarkers of chronic pain, and guide treatment for personalized pain management. Similarly, brain-based biomarkers may provide an additional predictor of perioperative prognoses.

Journal ArticleDOI
TL;DR: A body of data that has linked specific genotypic or phenotypic findings with susceptibility to malignant hyperthermia is built upon and summarized and suggestions to anesthesiologists about the types of patients that should or should not receive a trigger-free general anesthetic are offered.
Abstract: Anesthesiology, V 128 • No 1 159 January 2018 M ALIGNANT hyperthermia (MH) is an inherited disorder of skeletal muscle that manifests clinically as a hypermetabolic crisis when a susceptible individual receives a halogenated inhalational anesthetic agent or succinylcholine.1–3 The clinical signs that ensue from this exposure in susceptible individuals include hypercapnia, masseter muscle and/or generalized muscle rigidity, acidosis, peaked T waves that indicate hyperkalemia, and hyperthermia and are caused by the dysregulated entry of myoplasmic calcium, which results in a hypermetabolic cascade involving sustained muscular contractures, depletion of adenosine triphosphate, and muscle cell death.4 The inheritance of pathogenic variants (i.e., mutations) in three genes are primarily associated with MH susceptibility and account for the genetic basis of approximately 70% of patients investigated (fig. 1). The majority of MH–associated variants are found within the RYR1 gene that encodes the skeletal muscle ryanodine receptor type I protein.2,5–7 This protein regulates the movement of calcium from the sarcoplasmic reticulum into the intracellular space of the muscle cell. In MH–susceptible individuals, abnormalities of the ryanodine receptor result in the accumulation of excessive myoplasmic calcium in the presence of one of the anesthetic triggering agents. Nearly 700 variants have been identified in RYR1; however, only 35 have been functionally validated as MH–causative pathogenic variants (an up-to-date list as well as the criteria for causality may be found at the European Malignant Hyperthermia Group website).8 The remainder await validation studies. The most common RYR1 variants that confer susceptibility to MH result from gain-of-function mutations in specific amino acids and regions of the RYR1 protein. These mutations may arise de novo or may be inherited, and the MH phenotype manifests variable expressivity and incomplete penetrance. Inheritance of MH causative pathogenic variants is suspected in individuals with a history of a likely MH clinical event or in those patients with a family history of MH susceptibility or a likely MH event. The mainstay of prevention of MH is the identification of these genetically susceptible individuals so that clinicians can then avoid triggering anesthetic agents. There is a wide range of both dominant and recessive disorders associated with RYR1 pathogenic variants, and many of these inherited myopathies and related conditions have been linked with MH susceptibility.9–11 Therefore, in clinical anesthesia practice, MH susceptibility has often been assumed in patients with nonspecific muscle weakness but without a definitive diagnosis. This shotgun approach is less than ideal because most causes of muscle weakness are not associated with MH susceptibility, and this process then only results in the inaccurate labeling of patients (and their families) who would otherwise be able to safely receive volatile anesthetic agents and succinylcholine. In this article, we build upon and summarize a body of data that have linked specific genotypic or phenotypic findings with susceptibility to MH and offer suggestions to anesthesiologists about the types of patients that should or should not receive a trigger-free general anesthetic. We discuss anesthetic management of certain congenital myopathies that may predispose to MH–like symptoms during general anesthesia, and we offer an approach to the anesthetic management of the undiagnosed patient with muscle weakness.

Journal ArticleDOI
TL;DR: Whatever the molecular mechanism, anesthesia led to a massive reconfiguration of the repertoire of functional brain states that became predominantly shaped by brain anatomy (high function-structure similarity), giving rise to a well-defined cortical signature of anesthesia-induced loss of consciousness.
Abstract: WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The mechanism by which anesthetics induce a loss of consciousness remains a puzzling problem. We hypothesized that a cortical signature of anesthesia could be found in an increase in similarity between the matrix of resting-state functional correlations and the anatomical connectivity matrix of the brain, resulting in an increased function-structure similarity. METHODS We acquired resting-state functional magnetic resonance images in macaque monkeys during wakefulness (n = 3) or anesthesia with propofol (n = 3), ketamine (n = 3), or sevoflurane (n = 3). We used the k-means algorithm to cluster dynamic resting-state data into independent functional brain states. For each condition, we performed a regression analysis to quantify function-structure similarity and the repertoire of functional brain states. RESULTS Seven functional brain states were clustered and ranked according to their similarity to structural connectivity, with higher ranks corresponding to higher function-structure similarity and lower ranks corresponding to lower correlation between brain function and brain anatomy. Anesthesia shifted the brain state composition from a low rank (rounded rank [mean ± SD]) in the awake condition (awake rank = 4 [3.58 ± 1.03]) to high ranks in the different anesthetic conditions (ketamine rank = 6 [6.10 ± 0.32]; moderate propofol rank = 6 [6.15 ± 0.76]; deep propofol rank = 6 [6.16 ± 0.46]; moderate sevoflurane rank = 5 [5.10 ± 0.81]; deep sevoflurane rank = 6 [5.81 ± 1.11]; P < 0.0001). CONCLUSIONS Whatever the molecular mechanism, anesthesia led to a massive reconfiguration of the repertoire of functional brain states that became predominantly shaped by brain anatomy (high function-structure similarity), giving rise to a well-defined cortical signature of anesthesia-induced loss of consciousness.

Journal ArticleDOI
TL;DR: The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery.
Abstract: Background:The interscalene nerve block provides analgesia for shoulder surgery, but is associated with diaphragm paralysis. One solution may be performing brachial plexus blocks more distally. This noninferiority study evaluated analgesia for blocks at the supraclavicular and anterior suprascapular

Journal ArticleDOI
TL;DR: None of the experimental drugs are adequate for therapeutic use in opioid-induced respiratory depression and all need further study of efficacy and toxicity, but all do highlight potential mechanisms of action and possible templates for further study and development.
Abstract: The ventilatory control system is highly vulnerable to exogenous administered opioid analgesics. Particularly respiratory depression is a potentially lethal complication that may occur when opioids are overdosed or consumed in combination with other depressants such as sleep medication or alcohol. Fatalities occur in acute and chronic pain patients on opioid therapy and individuals that abuse prescription or illicit opioids for their hedonistic pleasure. One important strategy to mitigate opioid-induced respiratory depression is cotreatment with nonopioid respiratory stimulants. Effective stimulants prevent respiratory depression without affecting the analgesic opioid response. Several pharmaceutical classes of nonopioid respiratory stimulants are currently under investigation. The majority acts at sites within the brainstem respiratory network including drugs that act at α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (ampakines), 5-hydroxytryptamine receptor agonists, phospodiesterase-4 inhibitors, D1-dopamine receptor agonists, the endogenous peptide glycyl-glutamine, and thyrotropin-releasing hormone. Others act peripherally at potassium channels expressed on oxygen-sensing cells of the carotid bodies, such as doxapram and GAL021 (Galleon Pharmaceuticals Corp., USA). In this review we critically appraise the efficacy of these agents. We conclude that none of the experimental drugs are adequate for therapeutic use in opioid-induced respiratory depression and all need further study of efficacy and toxicity. All discussed drugs, however, do highlight potential mechanisms of action and possible templates for further study and development.

Journal ArticleDOI
TL;DR: Meta-analysis of five randomized controlled trials demonstrated that use of intraoperative processed electroencephalogram monitoring is associated with a decreased risk of postoperative delirium and cognitive dysfunction.
Abstract: What We Already Know about This TopicUp to 20% of patients undergoing major surgery experience postoperative delirium or cognitive dysfunctionIntraoperative management strategies to reduce the risk of postoperative delirium remain unclearWhat This Article Tells Us That Is NewThe heterogeneity of cog

Journal ArticleDOI
TL;DR: Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events, as shown in this single center open-label randomized controlled trial.
Abstract: Background Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events. Methods Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk factors for perioperative respiratory adverse events and deemed suitable for either technique of anesthesia induction were recruited and randomized to either intravenous propofol or inhalational sevoflurane. The primary outcome was the difference in the rate of occurrence of perioperative respiratory adverse events between children receiving intravenous induction and those receiving inhalation induction of anesthesia. Results Children receiving intravenous propofol were significantly less likely to experience perioperative respiratory adverse events compared with those who received inhalational sevoflurane after adjusting for age, sex, American Society of Anesthesiologists physical status and weight (perioperative respiratory adverse event: 39/149 [26%] vs. 64/149 [43%], relative risk [RR]: 1.7, 95% CI: 1.2 to 2.3, P = 0.002, respiratory adverse events at induction: 16/149 [11%] vs. 47/149 [32%], RR: 3.06, 95% CI: 1.8 to 5. 2, P Conclusions Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events. Visual abstract An online visual overview is available for this article at http://links.lww.com/ALN/B725.

Journal ArticleDOI
TL;DR: Data is reviewed suggesting that reduced network efficiency, constrained network repertoires, and changes in cortical dynamics create inhospitable conditions for information processing and transfer, which lead to unconsciousness.
Abstract: The heterogeneity of molecular mechanisms, target neural circuits, and neurophysiologic effects of general anesthetics makes it difficult to develop a reliable and drug-invariant index of general anesthesia. No single brain region or mechanism has been identified as the neural correlate of consciousness, suggesting that consciousness might emerge through complex interactions of spatially and temporally distributed brain functions. The goal of this review article is to introduce the basic concepts of networks and explain why the application of network science to general anesthesia could be a pathway to discover a fundamental mechanism of anesthetic-induced unconsciousness. This article reviews data suggesting that reduced network efficiency, constrained network repertoires, and changes in cortical dynamics create inhospitable conditions for information processing and transfer, which lead to unconsciousness. This review proposes that network science is not just a useful tool but a necessary theoretical framework and method to uncover common principles of anesthetic-induced unconsciousness.

Journal ArticleDOI
TL;DR: It is shown that opioid abuse and dependence are associated with increased readmission rates and healthcare utilization after surgery, and hospital length of stay and estimated hospital costs during initial admission and at readmission were higher in patients with opioid abuse or dependence.
Abstract: Background:Although opioids remain the standard therapy for the treatment of postoperative pain, the prevalence of opioid misuse is rising. The extent to which opioid abuse or dependence affects readmission rates and healthcare utilization is not fully understood. It was hypothesized that surgical p

Journal ArticleDOI
TL;DR: The use of an intraoperative decision support system with real-time visualizations was associated with improved process measures, but not postoperative clinical outcomes.
Abstract: Background:The authors hypothesized that a multiparameter intraoperative decision support system with real-time visualizations may improve processes of care and outcomes.Methods:Electronic health record data were retrospectively compared over a 6-yr period across three groups: experimental cases, in

Journal ArticleDOI
TL;DR: The data suggest that commonly used agents in the perioperative period may impact tumor cell growth; these effects have been demonstrated in preclinical studies, and therefore their relevance to clinical management of patients undergoing cancer surgery remains to be determined.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicDexmedetomidine reduces cellular apoptosis, and it has been demonstrated previously that this antiapoptotic effect can not only increase cancer cell proliferation and migration but also reduce survival in experimental models of cancer growth.M

Journal ArticleDOI
TL;DR: The right ventricle is more sensitive than the left to α-adrenergic-mediated constriction, which may contribute to its greater propensity for coronary vasospasm as mentioned in this paper.
Abstract: Regulation of blood flow to the right ventricle differs significantly from that to the left ventricle. The right ventricle develops a lower systolic pressure than the left ventricle, resulting in reduced extravascular compressive forces and myocardial oxygen demand. Right ventricular perfusion has eight major characteristics that distinguish it from left ventricular perfusion: (1) appreciable perfusion throughout the entire cardiac cycle; (2) reduced myocardial oxygen uptake, blood flow, and oxygen extraction; (3) an oxygen extraction reserve that can be recruited to at least partially offset a reduction in coronary blood flow; (4) less effective pressure-flow autoregulation; (5) the ability to downregulate its metabolic demand during coronary hypoperfusion and thereby maintain contractile function and energy stores; (6) a transmurally uniform reduction in myocardial perfusion in the presence of a hemodynamically significant epicardial coronary stenosis; (7) extensive collateral connections from the left coronary circulation; and (8) possible retrograde perfusion from the right ventricular cavity through the Thebesian veins. These differences promote the maintenance of right ventricular oxygen supply-demand balance and provide relative resistance to ischemia-induced contractile dysfunction and infarction, but they may be compromised during acute or chronic increases in right ventricle afterload resulting from pulmonary arterial hypertension. Contractile function of the thin-walled right ventricle is exquisitely sensitive to afterload. Acute increases in pulmonary arterial pressure reduce right ventricular stroke volume and, if sufficiently large and prolonged, result in right ventricular failure. Right ventricular ischemia plays a prominent role in these effects. The risk of right ventricular ischemia is also heightened during chronic elevations in right ventricular afterload because microvascular growth fails to match myocyte hypertrophy and because microvascular dysfunction is present. The right coronary circulation is more sensitive than the left to α-adrenergic-mediated constriction, which may contribute to its greater propensity for coronary vasospasm. This characteristic of the right coronary circulation may increase its vulnerability to coronary vasoconstriction and impaired right ventricular perfusion during administration of α-adrenergic receptor agonists.

Journal ArticleDOI
TL;DR: This supraclavicular, in-plane, real-time, ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and effective method to insert central venous catheters in preterm infants.
Abstract: Background The aim of this retrospective analysis was to evaluate the clinical effectiveness of the supraclavicular ultrasound-guided cannulation of the brachiocephalic vein in preterm infants. Methods The ultrasound probe was placed in the supraclavicular region so as to obtain the optimum sonographic long-axis view of the brachiocephalic vein. By using a strict in-plane approach the brachiocephalic vein was cannulated by advancing a 22- or 24-gauge iv cannula from lateral to medial under the long axis of the ultrasound probe under real-time ultrasound guidance into the vein. Results One hundred and forty-two cannulations in infants weighing between 0.59 and 2.5 kg (median: 2.1; CI: 2.0 to 2.2) were included. Ultimate success rate was 94% (134 of 142). One cannulation attempt was required in 100 (70%) patients, two attempts in 21 (15%), and three attempts in 13 (9%). The smaller the weight of the infant the more attempts were needed. More attempts also were needed for the right brachiocephalic vein, which was primarily targeted in 75 (53%) neonates. One (1%) inadvertent arterial puncture was noted. Conclusions This supraclavicular, in-plane, real-time, ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and effective method to insert central venous catheters in preterm infants.