Showing papers in "Anesthesiology in 2019"
TL;DR: A review of anatomy, potential mechanisms of action, and techniques and summary of clinical evidence for quadratus lumborum block.
Abstract: A review of anatomy, potential mechanisms of action, and techniques and summary of clinical evidence for quadratus lumborum block.
194 citations
TL;DR: Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicPostoperative delirium and postoperative cognitive dysfunction both occur in a substantial number of older surgical patientsPostoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, although their rela
144 citations
TL;DR: The results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered and suggest updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicDifficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists.Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient
142 citations
TL;DR: This review covers the basics of what is meant by artificial intelligence and machine learning for the practicing anesthesiologist, describing how decision-making behaviors can emerge from simple equations.
Abstract: Commercial applications of artificial intelligence and machine learning have made remarkable progress recently, particularly in areas such as image recognition, natural speech processing, language translation, textual analysis, and self-learning. Progress had historically languished in these areas, such that these skills had come to seem ineffably bound to intelligence. However, these commercial advances have performed best at single-task applications in which imperfect outputs and occasional frank errors can be tolerated.The practice of anesthesiology is different. It embodies a requirement for high reliability, and a pressured cycle of interpretation, physical action, and response rather than any single cognitive act. This review covers the basics of what is meant by artificial intelligence and machine learning for the practicing anesthesiologist, describing how decision-making behaviors can emerge from simple equations. Relevant clinical questions are introduced to illustrate how machine learning might help solve them-perhaps bringing anesthesiology into an era of machine-assisted discovery.
115 citations
TL;DR: Application of driving pressure–guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicDriving pressure (plateau minus end-expiratory airway pressure) is a target in patients with acute respiratory distress syndrome, and is proposed as a target during general anesthesia for patients with normal lungs. It has not been reported fo
115 citations
TL;DR: Days alive and out of hospital is a feasibly measured patient-centered outcome that is associated with clinically sensible patient characteristics, surgical complexity, in-hospital complications, and longer-term outcomes.
Abstract: Background Days alive and out of hospital is a potentially useful patient-centered quality measure for perioperative care in adult surgical patients. However, there has been very limited prior validation of this endpoint with respect to its ability to capture differences in patient-level risk factor profiles and longer-term postoperative outcomes. The main objective of this study was assessment of the feasibility and validity of days alive and out of hospital as a patient-centered outcome for perioperative medicine. Methods The authors evaluated 540,072 adults undergoing 1 of 12 major elective noncardiac surgical procedures between 2006 to 2014. Primary outcome was days alive and out of hospital at 30 days, secondary outcomes were days alive and out of hospital at 90 days and 180 days. Unadjusted and risk-adjusted adjusted analyses were used to determine the association of days alive and out of hospital with patient-, surgery-, and hospital-level characteristics. Patients with days alive and out of hospital at 30 days values less than the tenth percentile were also classified as having poor days alive and out of hospital at 30 days. The authors then determined the association of poor days alive and out of hospital at 30 days with in-hospital complications, poor days alive and out of hospital at 90 days (less than the tenth percentile), and poor days alive and out of hospital at 180 days (less than the tenth percentile). Results Overall median (interquartile range) days alive and out of hospital at 30, 90, and 180 days were 26 (24 to 27), 86 (84 to 87), and 176 (173 to 177) days, respectively. Median days alive and out of hospital at 30 days was highest for hysterectomy and endovascular aortic aneurysm repair (27 days) and lowest for upper gastrointestinal surgery (22 days). Days alive and out of hospital at 30 days was associated with clinically sensible patient-level factors (comorbidities, advanced age, postoperative complications), but not measured hospital-level factors (academic status, bed size). Of patients with good days alive and out of hospital at 30 days, 477,163 of 486,087 (98%) and 470,093 of 486,087 (97%) remained within this group (greater than the tenth percentile) at days alive and out of hospital at 90 and 180 days. Conclusions Days alive and out of hospital is a feasibly measured patient-centered outcome that is associated with clinically sensible patient characteristics, surgical complexity, in-hospital complications, and longer-term outcomes. Days alive and out of hospital forms a novel patient-centered outcome for future clinical trials and observational studies for adult surgical patients.
109 citations
TL;DR: The latest evidence on perioperative IV fluid therapy for major surgery is reviewed, focusing on the type and volume of fluids, and including suitable criteria to guide such therapy, as the two topics are interrelated.
Abstract: A moderately liberal IV fluid regimen, using a balanced crystalloid, and consideration of the use of an advanced hemodynamic monitor in a setting of an enhanced recovery pathway are recommended for major surgery.
Supplemental Digital Content is available in the text.
105 citations
TL;DR: There was no significant difference in recurrence-free survival or overall survival between the two groups, and the results of this retrospective cohort study do not suggest specific selection of IV or inhalation anesthesia for breast cancer surgery.
Abstract: Editor’s PerspectiveWhat We Know about This TopicIV anesthesia may impair anticancer immunity less than volatile anesthesia and therefore reduce recurrence riskWhat This Article Tells Us That Is NewIn a large propensity-matched retrospective cohort analysis, the authors compared total IV and volatil
104 citations
TL;DR: This study evaluated the incidence and severity of postoperative hypotension and hypertension in adults recovering from abdominal surgery and the extent to which serious perturbations were missed by routine vital-sign assessments.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicIntraoperative and postoperative hypotension are associated with myocardial and kidney injury and 30-day mortalityIntraoperative blood pressure is measured frequently, but blood pressure on surgical wards is usually measured only every 4 to 6
92 citations
TL;DR: In this paper, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.
Abstract: In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.
88 citations
TL;DR: Reducing avoidable general anesthetics for cesarean delivery may improve safety of obstetric anesthesia care and reduce risk of adverse maternal outcomes.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicNeuraxial anesthesia is recommended in lieu of general anesthesia for cesarean deliveriesThe association of general anesthesia without a clinical indication with adverse events in cesarean deliveries remains poorly understoodWhat This Article
TL;DR: Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicRapid response to witnessed, pulseless cardiac arrest is associated with increased survival.What This Article Tells Us That Is NewAssessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that
TL;DR: The findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.
Abstract: Background:Compared with historic ventilation strategies, modern lung-protective ventilation includes lower tidal volumes (VT), lower driving pressures, and application of positive end-expiratory pressure (PEEP). The contributions of each component to an overall intraoperative protective ventilation
TL;DR: It is suggested that low levels of positive end-expiratory pressure reduce injury associated with atelectasis, and above a threshold level of power,Positive end- Expiratory Pressure causes lung injury and adverse hemodynamics, which is usually considered protective against ventilation-induced lung injury by reducing atelectrauma and improving lung homogeneity.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicPositive end-expiratory pressure protects against ventilation-induced lung injury by improving homogeneity of ventilation, but positive end-expiratory pressure contributes to the mechanical power required to ventilate the lungWhat This Article
TL;DR: The superior trunk block may be considered an alternative to traditional interscalene block for shoulder surgery and provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicInterscalene nerve block is commonly used for shoulder surgery for anesthesia and postoperative analgesiaUnfortunately, interscalene blocks commonly result in hemidiaphragmatic paralysisWhat This Article Tells Us That Is NewWhen interscalene b
TL;DR: A conceptual framework for understanding failure to rescue is provided, various associated patient- and system-level factors are discussed, and future directions of scientific inquiry for developing effective interventions that can be broadly implemented to improve postoperative outcomes across all hospitals are proposed.
Abstract: Over the past decade, failure to rescue-defined as the death of a patient after one or more potentially treatable complications-has received increased attention as a surgical quality indicator. Failure to rescue is an appealing quality target because it implicitly accounts for the fact that postoperative complications may not always be preventable and is based on the premise that prompt recognition and treatment of complications is a critical, actionable point during a patient's postoperative course. Although numerous patient and macrosystem factors have been associated with failure to rescue, there is an increasing appreciation of the key role of microsystem factors. Although failure to rescue is believed to contribute to observed hospital-level variation in both surgical outcomes and costs, further work is needed to delineate the underlying patient-level and system-level factors preventing the timely identification and treatment of postoperative complications. Therefore, the goals of this narrative review are to provide a conceptual framework for understanding failure to rescue, to discuss various associated patient- and system-level factors, to delineate the reasons it has become recognized as an important quality indicator, and to propose future directions of scientific inquiry for developing effective interventions that can be broadly implemented to improve postoperative outcomes across all hospitals.
TL;DR: In a rat model of Escherichia coli-induced pneumonia, extracellular vesicles derived from human umbilical cord mesenchymal stromal cells primed with interferon-&ggr; more effectively attenuated E. coli–induced lung injury than did extrace cellular vesicle from naïve mesenchyal stomal cells, possibly by enhanced macrophage phagocytosis and killing.
Abstract: Background Human umbilical cord mesenchymal stromal cells possess considerable therapeutic promise for acute respiratory distress syndrome. Umbilical cord mesenchymal stromal cells may exert therapeutic effects via extracellular vesicles, while priming umbilical cord mesenchymal stromal cells may further enhance their effect. The authors investigated whether interferon-γ-primed umbilical cord mesenchymal stromal cells would generate mesenchymal stromal cell-derived extracellular vesicles with enhanced effects in Escherichia coli (E. coli) pneumonia. Methods In a university laboratory, anesthetized adult male Sprague-Dawley rats (n = 8 to 18 per group) underwent intrapulmonary E. coli instillation (5 × 10 colony forming units per kilogram), and were randomized to receive (a) primed mesenchymal stromal cell-derived extracellular vesicles, (b) naive mesenchymal stromal cell-derived extracellular vesicles (both 100 million mesenchymal stromal cell-derived extracellular vesicles per kilogram), or (c) vehicle. Injury severity and bacterial load were assessed at 48 h. In vitro studies assessed the potential for primed and naive mesenchymal stromal cell-derived extracellular vesicles to enhance macrophage bacterial phagocytosis and killing. Results Survival increased with primed (10 of 11 [91%]) and naive (8 of 8 [100%]) mesenchymal stromal cell-derived extracellular vesicles compared with vehicle (12 of 18 [66.7%], P = 0.038). Primed-but not naive-mesenchymal stromal cell-derived extracellular vesicles reduced alveolar-arterial oxygen gradient (422 ± 104, 536 ± 58, 523 ± 68 mm Hg, respectively; P = 0.008), reduced alveolar protein leak (0.7 ± 0.3, 1.4 ± 0.4, 1.5 ± 0.7 mg/ml, respectively; P = 0.003), increased lung mononuclear phagocytes (23.2 ± 6.3, 21.7 ± 5, 16.7 ± 5 respectively; P = 0.025), and reduced alveolar tumor necrosis factor alpha concentrations (29 ± 14.5, 35 ± 12.3, 47.2 ± 6.3 pg/ml, respectively; P = 0.026) compared with vehicle. Primed-but not naive-mesenchymal stromal cell-derived extracellular vesicles enhanced endothelial nitric oxide synthase production in the injured lung (endothelial nitric oxide synthase/β-actin = 0.77 ± 0.34, 0.25 ± 0.29, 0.21 ± 0.33, respectively; P = 0.005). Both primed and naive mesenchymal stromal cell-derived extracellular vesicles enhanced E. coli phagocytosis and bacterial killing in human acute monocytic leukemia cell line (THP-1) in vitro (36.9 ± 4, 13.3 ± 8, 0.1 ± 0.01%, respectively; P = 0.0004) compared with vehicle. Conclusions Extracellular vesicles from interferon-γ-primed human umbilical cord mesenchymal stromal cells more effectively attenuated E. coli-induced lung injury compared with extracellular vesicles from naive mesenchymal stromal cells, potentially via enhanced macrophage phagocytosis and killing of E. coli.
TL;DR: A greater number of hours worked per week and a higher amount of student debt were associated with a higher risk of distress and depression, but not burnout, while perceived institutional support, work-life balance, strength of social support, workload, and student debt impact physician well-being.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicBurnout has been identified in approximately 50% of residents and practicing physiciansWhat This Article Tells Us That Is NewBased on survey data from 2013 to 2016, the prevalence of burnout, distress, and depression in anesthesiology resident
TL;DR: In patients with ARDS, plateau pressure, driving pressure, and respiratory system compliance can be measured during assisted ventilation, and both higher driving pressure and lower compliance are associated with increased mortality.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicHigher driving pressure during controlled mechanical ventilation is known to be associated with increased mortality in patients with acute respiratory distress syndrome.Whereas patients with acute respiratory distress syndrome are initially ma
TL;DR: Nociception level–guided analgesia during major abdominal surgery resulted in 30% less intraoperative remifentanil consumption and inadequate anesthesia events, compared to standard practice.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicThe nociception level index (Medasense Biometrics Ltd., Ramat Gan, Israel), is a reliable measure of moderate to intense noxious stimulation during anesthesia and surgeryWhat This Article Tells Us That Is NewIn a randomized trial in patients h
TL;DR: Bronchoalveolar lavage neutrophil extracellular trap concentrations and ventilator-free days was not significantly associated with mechanical ventilation duration in pneumonia-related ARDS.
Abstract: Background Neutrophil extracellular traps have been associated with tissue damage. Whether these are involved in the pathogenesis of human acute respiratory distress syndrome (ARDS) and could be a potential therapeutic target is unknown. The authors quantified bronchoalveolar and blood neutrophil extracellular traps in patients with pneumonia-related ARDS and assessed their relationship with ventilator-free days. Methods Immunocompetent patients with pneumonia and moderate or severe ARDS (n = 35) and controls (n = 4) were included in a prospective monocentric study. Neutrophil extracellular trap concentrations were quantified (as DNA-myeloperoxidase complexes) in bronchoalveolar lavage fluid and serum by enzyme-linked immunosorbent assay. The relationship between bronchoalveolar lavage neutrophil extracellular trap concentrations and the primary clinical endpoint (i.e., the number of live ventilator-free days at day 28) was assessed using linear regression analyses. Results There was no significant relationship between bronchoalveolar lavage neutrophil extracellular trap concentrations and ventilator-free days by multiple regression analysis (β coefficient = 2.40; 95% CI, -2.13 to 6.92; P = 0.288). Neutrophil extracellular trap concentrations were significantly higher in bronchoalveolar lavage than in blood of ARDS patients (median [first to third quartiles]:154 [74 to 1,000] vs. 26 [4 to 68] arbitrary units, difference: -94; 95% CI, -341 to -57; P 0.99) and the number of ventilator-free days at day 28 (22 [14 to 25] vs. 14 [0 to 21] days; difference: -5; 95% CI, -15 to 0; P = 0.066) did not significantly differ between patients with higher (n = 17) versus lower (n = 18) bronchoalveolar neutrophil extracellular trap concentrations. Conclusions Bronchoalveolar neutrophil extracellular trap concentration was not significantly associated with mechanical ventilation duration in pneumonia-related ARDS.
TL;DR: This study tested the hypothesis that goal-directed colloid administration during elective abdominal surgery decreases 30-day major complications more than goal- directed crystalloid administration and found no evidence of renal or other toxicity.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicCrystalloid solutions leave the circulation quickly, whereas colloids remain for hours, thus promoting hemodynamic stability. However, colloids are expensive and promote renal toxicity in critical care patients. Whether goal-directed intraoper
TL;DR: Three infusion rates of norepinephrine for prophylaxis against postspinal hypotension during cesarean delivery were compared according to the following: systolic blood pressure, heart rate, frequency of intraoperative hypertension, Frequency of bradycardia, and neonatal outcomes.
Abstract: Background Norepinephrine has been recently introduced for prophylaxis against postspinal hypotension during cesarean delivery; however, no data are available regarding its optimum dose. The objective of this study is to compare three infusion rates of norepinephrine for prophylaxis against postspinal hypotension during cesarean delivery. Methods The authors conducted a double-blinded, randomized, controlled study including full-term pregnant women scheduled for cesarean delivery. Norepinephrine infusion was commenced after subarachnoid block. Patients were randomized into three groups, which received norepinephrine with starting infusion rates of 0.025 μg · kg(-1) · min(-1), 0.050 μg · kg(-1) · min(-1), and 0.075 μg · kg(-1) · min(-1). Infusion was stopped when intraoperative hypertension occurred. The primary outcome was the frequency of postspinal hypotension (defined as decreased systolic blood pressure less than 80% of the baseline reading). The three groups were compared according to the following: systolic blood pressure, heart rate, frequency of intraoperative hypertension, frequency of bradycardia, and neonatal outcomes. Results Two hundred eighty-four mothers were included in the analysis. The frequency of postspinal hypotension was lower for both the 0.050-μg · kg(-1) · min(-1) dose group (23/93 [24.7%], odds ratio: 0.45 [95% CI: 0.24 to 0.82], P = 0.014) and the 0.075-μg · kg(-1) · min(-1) dose group (25/96 [26.0%], odds ratio: 0.48 [95% CI:0.26 to 0.89], P = 0.022) compared with the 0.025-μg · kg(-1) · min(-1) dose group (40/95 [42.1%]). The two higher-dose groups (the 0.050-μg · kg(-1) · min(-1) group and the 0.075-μg · kg(-1) · min(-1) group) had higher systolic blood pressure and lower heart rate compared with the 0.025 μg · kg(-1) · min(-1) group. The three groups were comparable in the frequency of intraoperative hypertension, incidence of bradycardia, and neonatal outcomes. Conclusions Both the 0.050-μg · kg(-1) · min(-1) and 0.075-μg · kg(-1) · min(-1) norepinephrine infusion rates effectively reduced postspinal hypotension during cesarean delivery compared with the 0.025-μg · kg(-1) · min(-1) infusion rate.
TL;DR: Among the PEEP titration strategies tested, setting PEEP according to a PEEPDECREMENTAL trial preceded by a recruitment maneuver obtained the best lung function by decreasing lung overdistension and collapse, restoring lung elastance, and oxygenation suggesting lung tissue recruitment.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicObesity increases the propensity to atelectasis in acute respiratory distress syndrome, but the optimal approach to reversing this atelectasis is uncertainWhat This Article Tells Us That Is NewA clinical crossover study comparing three approac
TL;DR: It is found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicPectoralis-II block is a potential alternative to paravertebral blocks to provide regional analgesia for breast cancer surgeryWhat This Article Tells Us That Is NewThis meta-analysis includes 14 randomized trials comparing pectoralis-II block
TL;DR: The results suggest that single or static connectivity patterns may not be able to discriminate levels of consciousness, and changes in connectivity over time will likely yield more information as a marker or mechanism of surgical anesthesia than any single pattern.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicAnesthetic-induced loss of consciousness is accompanied by changes in functional connectivity within and between brain networks.What This Article Tells Us That Is NewDespite a stable surgical level of anesthesia and the absence of noxious stim
TL;DR: Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.
Abstract: Background Postoperative delirium is one of the most common complications in the elderly surgical population. However, its long-term outcomes remain largely to be determined. Therefore a prospective cohort study was conducted to determine the association between postoperative delirium and long-term decline in activities of daily living and postoperative mortality. The hypothesis in the present study was that postoperative delirium was associated with a greater decline in activities of daily living and higher mortality within 24 to 36 months after anesthesia and surgery. Methods The participants (at least 65 yr old) having the surgeries of (1) proximal femoral nail, (2) hip replacement, or (3) open reduction and internal fixation under general anesthesia were enrolled. The Confusion Assessment Method algorithm was administered to diagnose delirium before and on the first, second, and fourth days after the surgery. Activities of daily living were evaluated by using the Chinese version of the activities of daily living scale (range, 14 to 56 points), and preoperative cognitive function was assessed by using the Chinese Mini-Mental State Examination (range, 0 to 30 points). The follow-up assessments, including activities of daily living and mortality, were conducted between 24 and 36 months after anesthesia and surgery. Results Of 130 participants (80 ± 6 yr, 24% male), 34 (26%) developed postoperative delirium during the hospitalization. There were 32% of the participants who were lost to follow-up, resulting in 88 participants who were finally included in the data analysis. The participants with postoperative delirium had a greater decline in activities of daily living (16 ± 15 vs. 9 ± 15, P = 0.037) and higher 36-month mortality (8 of 28, 29% vs. 7 of 75, 9%; P = 0.009) as compared with the participants without postoperative delirium. Conclusions Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.
TL;DR: Activation of PBN glutamatergic neurons is helpful to accelerate the transition from general anesthesia to an arousal state, which may provide a new strategy in shortening the recovery time after sevoflurane anesthesia.
Abstract: Editor’s PerspectiveWhat We Already Know about This TopicThe parabrachial nucleus is a brainstem region involved in arousal.Brain regions involved in arousal regulate anesthetic induction and emergence.What This Article Tells Us That Is NewUsing chemogenetic techniques, activation of parabrachial nu
TL;DR: This clinical trial is consistent with the results of two other recent human studies, Pediatric Anesthesia Neurodevelopment Assessment (PANDA) and Mayo Anesthesia Safety in Kids (MASK), providing strong evidence that a short exposure to general anesthesia at a young age does not result in detectable alterations in neurodevelopmental outcome.
Abstract: Two decades ago, the possibility that anesthetics could harm the developing brain was identified in rodents. This work has been replicated in multiple species, including subhuman primates, raising serious concern in the anesthesia community and leading to a U.S. Food and Drug Administration warning on the use of anesthetic agents in young children. Heated discussions have divided healthcare providers and policy makers on the risks versus benefits of general anesthesia and surgery in pediatric populations. The major reason for this long-standing debate is that some human cohort studies have found an association between early exposure to anesthesia and subsequent neurodevelopmental alterations, while others have not. Recently, the only prospective clinical trial addressing whether anesthetics contribute to long-term neurodevelopmental delays in children was published in Lancet, and the news is good. This multisite randomized controlled trial compared regional and general anesthesia for their effects on neurodevelopmental outcome and apnea in infants. This study, commonly known as the general anesthesia spinal (GAS) trial, included more than 700 children undergoing inguinal hernia repair during early life who were randomized to either sevoflurane-based general or awake-spinal anesthesia. Both the primary and secondary outcomes of the study demonstrated no association between 1 h of sevoflurane anesthesia in early life and cognitive composite scores at the age 2 yr or full-scale intelligence quotient from the Wechsler Preschool and Primary Scale of Intelligence test at the age of 5 yr when compared to spinal anesthesia. This clinical trial is consistent with the results of two other recent human studies, Pediatric Anesthesia Neurodevelopment Assessment (PANDA) and Mayo Anesthesia Safety in Kids (MASK), providing strong evidence that a short exposure to general anesthesia at a young age does not result in detectable alterations in neurodevelopmental outcome. This is an important update, as most infants undergoing anesthesia and surgery have exposures to anesthetics that are comparable in length to those of infants in the GAS, PANDA, and MASK studies. Thus, as parents and physicians, we can assume that the findings of these studies are relevant to a wide range of infants having general anesthesia for short elective surgical procedures. What remains unknown is whether longer exposures to anesthetics have an effect on long-term cognitive performance. These surgical procedures are relatively rare and may be associated with underlying disease processes such that any adverse outcome identified in the course of such studies may merely be a marker of a phenotype predisposed to neurotoxicity. One is left wondering whether the Food and Drug Administration warning on the use of anesthetics in young children should be eliminated due to the lack of reasonable clinical evidence that general anesthetics or sedatives are associated with adverse neurocognitive outcomes in humans or whether delay of surgical procedures for fear of the unknown is justified. While the Food and Drug Administration amended the initial 2016 warning on the use of anesthetics and sedatives in young children to suggest that they may be associated with adverse neurocognitive outcomes when used for 3 h or more, the warning is based on preclinical studies that may have little validity in humans. Being practicing anesthesiologists and parents, we have spent many restless nights wondering what the better “The comfortable truth is...the likelihood that developmental anesthesia neurotoxicity may not exist in routine surgical procedures that occur in early life.” 2019
TL;DR: A literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects is described and a theoretical framework for quality of provided healthcare (structure-process-outcome) is used to understand the checklists' possible impact on patient safety.
Abstract: The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. Surgical safety checklists may be used as some of the tools to prevent such complications. Use of checklists may reduce critical workload by eliminating issues that are already controlled for. The global introduction of the World Health Organization Surgical Safety Checklist aimed to improve safety in both anesthesia and surgery and to reduce complications and mortality by better teamwork, communication, and consistency of care. This review describes a literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects and using a theoretical framework for quality of provided healthcare (structure-process-outcome) to understand the checklists' possible impact on patient safety.