Anesthesia and Analgesia

Naik, Bhiken I. MBBCh*; Kuck, Kai PhD†; Saager, Leif MD, MMM‡; Kheterpal, Sachin MD, MBA§; Domino, Karen B. MD?; Posner, Karen L. PhD?; Sinha, Anik MS§; Stuart, Ami PhD†; Brummett, Chad M. MD§; Durieux, Marcel E. MD, PhD*; Vaughn, Michelle T. MPH§; Pace, Nathan L. MD, MStat†; the MPOG EOS Investigator Group

doi : 10.1213/ANE.0000000000005663

January 2022 - Volume 134 - Issue 1 - p 8-17

Opioids remain the primary mode of analgesia intraoperatively. There are limited data on how patient, procedural, and institutional characteristics influence intraoperative opioid administration. The aim of this retrospective, longitudinal study from 2012 to 2016 was to assess how intraoperative opioid dosing varies by patient and clinical care factors and across multiple institutions over time.

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Perioperative Opioid Consumption and Clinical Outcomes in Surgical Patients With a Pre-existing Opioid-Based Intrathecal Drug Delivery System

D’Souza, Ryan S. MD*; Warner, Matthew A. MD†; Olatoye, Oludare O. MD*; Langford, Brendan J. MD‡; Bruns, Danette L. RRT, LT§; Schroeder, Darrell R. MS?; Mauck, William D. MD*; Schaefer, Kalli K. BS*; Warner, Nafisseh S. MD*

doi : 10.1213/ANE.0000000000005662

January 2022 - Volume 134 - Issue 1 - p 35-43

Intrathecal drug delivery systems (IDDS) have been utilized for over 3 decades for management of chronic pain and spasticity. Patients with IDDS may present for surgical procedures unrelated to the IDDS device, although data are limited regarding perioperative outcomes.

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Postoperative Acute Kidney Injury Is Associated With Progression of Chronic Kidney Disease Independent of Severity

Privratsky, Jamie R. MD, PhD*,†; Krishnamoorthy, Vijay MD, MPH, PhD*; Raghunathan, Karthik MBBS, MPH*,‡; Ohnuma, Tetsu MD, MPH*; Rasouli, Mohammad R. MD§; Long, Thorir E. MD, PhD?; Sigurdsson, Martin I. MD, PhD¶,#

doi : 10.1213/ANE.0000000000005702

January 2022 - Volume 134 - Issue 1 - p 49-58

Both postoperative acute kidney injury (AKI) and preoperative chronic kidney disease (CKD) are associated with significantly worse outcomes following surgery. The relationship of both of these conditions with each other and with CKD progression after surgery remains poorly studied. Our objective was to assess if there was an interaction between preoperative kidney function estimated by preoperative estimated glomerular filtration rate (eGFR)/CKD stage, postoperative AKI, and eGFR/CKD progression within 1 year of surgery. Our hypothesis was that AKI severity would be associated with a faster time to eGFR/CKD stage progression within 1 year of surgery in a graded-fashion, which would be exacerbated by preoperative kidney dysfunction.

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Pro–Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma

Blaine, Kevin P. MD, MPH, FASA*; Dudaryk, Roman MD†

doi : 10.1213/ANE.0000000000005709

January 2022 - Volume 134 - Issue 1 - p 21-31

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the “1:1:1” combination of 1 units of red cells, 1 unit of plasma, and 1 donor’s worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient’s hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.

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Simulation Analysis of Flow Rate Variability During Microinfusions: The Effect of Vertical Displacement and Multidrug Infusion in Conventional Infusion Pumps Versus New Cylinder-Type Infusion Pumps

Oh, Eun Jung MD, PhD*; Hong, Kwan Young MD*; Lee, Jong-Hwan MD, PhD*; Kim, Duk Kyung MD, PhD*; Cho, Joongbum MD, PhD†; Min, Jeong-Jin MD, PhD*

doi : 10.1213/ANE.0000000000005736

January 2022 - Volume 134 - Issue 1 - p 59-68

Medication dosing errors can occur during microinfusions when there is vertical pump displacement or multidrug infusion through a single intravenous path. We compared flow rate variability between new-generation cylinder-type infusion pumps and conventional infusion pumps under simulated conditions.

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Inflammatory Biomarker Levels After Propofol or Sevoflurane Anesthesia: A Meta-analysis

O’Bryan, Liam J. MD*; Atkins, Kelly J. DPsy*,†; Lipszyc, Adam MD*; Scott, David A. PhD*,†; Silbert, Brendan S. MB, BS*,†; Evered, Lis A. PhD*,†,‡

doi : 10.1213/ANE.0000000000005671

January 2022 - Volume 134 - Issue 1 - p 69-81

The perioperative inflammatory response may be implicated in adverse outcomes including neurocognitive dysfunction and cancer recurrence after oncological surgery. The immunomodulatory role of anesthetic agents has been demonstrated in vitro; however, its clinical relevance is unclear. The purpose of this meta-analysis was to compare propofol and sevoflurane with respect to biomarkers of perioperative inflammation. The secondary aim was to correlate markers of inflammation with clinical measures of perioperative cognition.

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Perioperative Diabetes Insipidus Caused by Anesthetic Medications: A Review of the Literature

Van Decar, Lauren M. MD*; Reynolds, Emily G. BS†; Sharpe, Emily E. MD‡; Harbell, Monica W. MD*; Kosiorek, Heidi E. MS*,§; Kraus, Molly B. MD*

doi : 10.1213/ANE.0000000000005344

January 2022 - Volume 134 - Issue 1 - p 82-89

Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 29 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.

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Anesthetic Management of Adults With Epidermolysis Bullosa

Mittal, Brita M. MD; Goodnough, Candida L. MD, PhD; Bushell, Erin MD; Turkmani-Bazzi, Sophia MD; Sheppard, Kelly MD

doi : 10.1213/ANE.0000000000005706

January 2022 - Volume 134 - Issue 1 - p 90-101

Epidermolysis bullosa (EB) is a group of rare, inherited diseases characterized by skin fragility and multiorgan system involvement that presents many anesthetic challenges. Although the literature regarding anesthetic management focuses primarily on the pediatric population, as life expectancy improves, adult patients with EB are more frequently undergoing anesthesia in nonpediatric hospital settings. Safe anesthetic management of adult patients with EB requires familiarity with the complex and heterogeneous nature of this disease, especially with regard to complications that may worsen during adulthood. General, neuraxial, and regional anesthetics have all been used safely in patients with EB. A thorough preoperative evaluation is essential. Preoperative testing should be guided by EB subtype, clinical manifestations, and extracutaneous complications. Advanced planning and multidisciplinary coordination are necessary with regard to timing and operative plan. Meticulous preparation of the operating room and education of all perioperative staff members is critical. Intraoperatively, utmost care must be taken to avoid all adhesives, shear forces, and friction to the skin and mucosa. Special precautions must be taken with patient positioning, and standard anesthesia monitors must be modified. Airway management is often difficult, and progressive airway deterioration can occur in adults with EB over time. A smooth induction, emergence, and postoperative course are necessary to minimize blister formation from excess patient movement. With careful planning, preparation, and precautions, adult patients with EB can safely undergo anesthesia.

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Impact of Intraoperative Data on Risk Prediction for Mortality After Intra-Abdominal Surgery

Yan, Xinyu MS*; Goldsmith, Jeff PhD*; Mohan, Sumit MD†,‡; Turnbull, Zachary A. MD, MBA§; Freundlich, Robert E. MD, MS, MSCI?; Billings, Frederic T. IV MD, MSc?; Kiran, Ravi P. MD‡,¶; Li, Guohua MD, DrPH‡,#; Kim, Minjae MD, MS‡,#

doi : 10.1213/ANE.0000000000005694

January 2022 - Volume 134 - Issue 1 - p 102-113

Risk prediction models for postoperative mortality after intra-abdominal surgery have typically been developed using preoperative variables. It is unclear if intraoperative data add significant value to these risk prediction models.

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A Simple Risk Scoring System for Predicting the Occurrence of Aspiration Pneumonia After Gastric Endoscopic Submucosal Dissection

Park, Kyemyung MD, PhD*; Kim, Na Young MD, PhD†; Kim, Ki Jun MD, PhD†; Oh, Chaerim MD†; Chae, Dongwoo MD, PhD*; Kim, So Yeon MD, PhD†

doi : 10.1213/ANE.0000000000005779

January 2022 - Volume 134 - Issue 1 - p 114-122

Aspiration pneumonia after endoscopic submucosal dissection (ESD) is rare, but can be fatal. We aimed to investigate risk factors and develop a simple risk scoring system for aspiration pneumonia.

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Interleukin-6 Is an Early Plasma Marker of Severe Postoperative Complications in Thoracic Surgery: Exploratory Results From a Substudy of a Randomized Controlled Multicenter Trial

Neff, Thomas A. MD*; Braun, Julia PhD†; Rana, Dhanu BA‡; Puhan, Milo MD, PhD†; Filipovic, Miodrag MD§; Seeberger, Manfred MD?; Stüber, Frank MD¶; Neff, Simona B. MD*; Beck-Schimmer, Beatrice MD‡,#,**; Schläpfer, Martin MD, MSc‡,#

doi : 10.1213/ANE.0000000000005639

January 2022 - Volume 134 - Issue 1 - p 123-132

Postoperative complications in surgery are a significant burden, not only for the patients but also economically. While several predicting factors have already been identified, it is still not well known if increased levels of inflammatory markers in the immediate perioperative phase correlate with a higher incidence of postoperative complications. This study aimed to evaluate which patient characteristics and intraoperative parameters correlate with increased plasma values of monocyte chemoattractant protein 1 (MCP-1) and interleukin 6 (IL-6) of thoracic surgery patients. A second goal was to explore whether MCP-1 and IL-6 are associated with the incidence of postoperative complications. We hypothesized that there is a positive association between inflammatory markers and the occurrence of complications within 6 months after surgery.

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Leftover Opioid Analgesics and Disposal Following Ambulatory Pediatric Surgeries in the Context of a Restrictive Opioid-Prescribing Policy

Stone, Amanda L. PhD*; Qu’d, Dima BS*; Luckett, Twila BSN*; Nelson, Scott D. PharmD, MS†; Quinn, Erin E. PharmD‡; Potts, Amy L. PharmD‡; Patrick, Stephen W. MD, MPH§,?; Bruehl, Stephen PhD*; Franklin, Andrew D. MD*

doi : 10.1213/ANE.0000000000005503

January 2022 - Volume 134 - Issue 1 - p 133-140

Opioid analgesics are commonly prescribed for postoperative analgesia following pediatric surgery and often result in leftover opioid analgesics in the home. To reduce the volume of leftover opioids and overall community opioid burden, the State of Tennessee enacted a policy to reduce initial opioid prescribing to a 3-day supply for most acute pain incidents. We aimed to evaluate the extent of leftover opioid analgesics following pediatric ambulatory surgeries in the context of a state-mandated restrictive opioid-prescribing policy. We also aimed to evaluate opioid disposal rates, methods of disposal, and reasons for nondisposal.

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The Evaluation of a Noninvasive Respiratory Volume Monitor in Mechanically Ventilated Neonates and Infants

Atkinson, Douglas B. MD*; Sens, Brooke A. BSN, RN*; Bernier, Rachel S. MPH*; Gomez-Morad, Andrea D. MD*; Imsirovic, Jasmin PhD†; Nasr, Viviane G. MD*

doi : 10.1213/ANE.0000000000005562

January 2022 - Volume 134 - Issue 1 - p 141-148

The respiratory volume monitor (RVM) (ExSpiron, Respiratory Motion Inc, Watertown, MA) uses thoracic impedance technology to noninvasively and continuously measure tidal volume (TV), respiratory rate (RR), and minute ventilation (MV). We aimed to validate the accuracy of the RVM to assess ventilation in neonates and infants by comparing it to spirometry.

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A Processed Electroencephalogram–Based Brain Anesthetic Resistance Index Is Associated With Postoperative Delirium in Older Adults: A Dual Center Study

Cooter Wright, Mary MS*; Bunning, Thomas MD*; Eleswarpu, Sarada S. MD*; Heflin, Mitchell T. MD, MHS†; McDonald, Shelley R. DO, PhD†; Lagoo-Deenadalayan, Sandhya MD, PhD‡; Whitson, Heather E. MD†,§; Martinez-Camblor, Pablo PhD?; Deiner, Stacie G. MS, MD¶; Berger, Miles MD, PhD*,§,#

doi : 10.1213/ANE.0000000000005660

January 2022 - Volume 134 - Issue 1 - p 149-158

Some older adults show exaggerated responses to drugs that act on the brain. The brain’s response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG–based measure of the brain’s resistance to volatile anesthetics and hypothesized that low scores on it would be associated with postoperative delirium risk.

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Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial

Berger, Miles MD, PhD*; Eleswarpu, Sarada S. MD*; Cooter Wright, Mary MS*; Ray, Anna M. MD†; Wingfield, Sarah A. MD‡; Heflin, Mitchell T. MD§; Bengali, Shahrukh MD?; Udani, Ankeet D. MD, MSEd*

doi : 10.1213/ANE.0000000000005677

January 2022 - Volume 134 - Issue 1 - p 159-170

Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes.

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Validation of the Lusaka Formula: A Novel Formula for Weight Estimation in Children Presenting for Surgery in Zambia

Phiri, Hope MBChB, MMed*; Foy, Katie E. MBBS, MRes, FRCA†; Bowen, Lowri MBBCh, MRCS, FRCA‡; Bould, M. Dylan MBChB, MEd, MRCP, FRCA§

doi : 10.1213/ANE.0000000000005797

January 2022 - Volume 134 - Issue 1 - p 171-177

In children, the use of actual weight or predicted weight from various estimation methods is essential to reduce harm associated with dosing errors. This study aimed to validate the new locally derived Lusaka formula on an independent cohort of children undergoing surgery at the University Teaching Hospital in Lusaka, Zambia, to compare the Lusaka formula’s performance to commonly used weight prediction tools and to assess the nutritional status of this population.

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Preclinical Proficiency-Based Model of Ultrasound Training

Fatima, Huma MD*; Mahmood, Feroze MD*; Mufarrih, Syed Hamza MD*; Mitchell, John D. MD*; Wong, Vanessa BS*; Amir, Rabia MD*; Hai, Ting MD*; Montealegre, Mario MD*; Jones, Stephanie B. MD*; Knio, Ziyad O. BS†; Matyal, Robina MD*

doi : 10.1213/ANE.0000000000005510

January 2022 - Volume 134 - Issue 1 - p 178-187

Graduate medical education is being transformed from a time-based training model to a competency-based training model. While the application of ultrasound in the perioperative arena has become an expected skill set for anesthesiologists, clinical exposure during training is intermittent and nongraduated without a structured program. We developed a formal structured perioperative ultrasound program to efficiently train first-year clinical anesthesia (CA-1) residents and evaluated its effectiveness quantitatively in the form of a proficiency index.

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Are the Placement, Maintenance, and Removal of Femoral and Sciatic Catheters Associated With Bleeding Complications in Vascular Patients on Antithrombotics? A Single-Center, Retrospective Cohort Study

Wardhan, Richa MD; Michel, Ralph MD; Vasilopoulos, Terrie PhD; Yen, Erin DO

doi : 10.1213/ANE.0000000000005743

January 2022 - Volume 134 - Issue 1 - p 188-193

Information on the safety of placement, maintenance, and removal of peripheral nerve blocks in the presence of therapeutic or prophylactic antithrombotics is limited to case reports.

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Low Skeletal Muscle Mass Is Associated With Perioperative Neurocognitive Disorder Due To Decreased Neurogenesis in Rats

Nemoto, Akira MD*; Goyagi, Toru MD, PhD*; Nemoto, Wataru PhD†; Nakagawasai, Osamu PhD†; Tan-No, Koichi PhD†; Niiyama, Yukitoshi MD, PhD*

doi : 10.1213/ANE.0000000000005681

January 2022 - Volume 134 - Issue 1 - p 194-203

Perioperative neurocognitive disorder (PND) is a postsurgical complication associated with neuroinflammation and impaired hippocampal neurogenesis, in which brain-derived neurotrophic factor (BDNF) plays a key role. Sarcopenia refers to age-related muscle loss that causes cognitive decline, muscle atrophy, and postoperative delirium. Rats with tail suspension (TS) were used to represent a low-activity model, which involves decreased hind limb function by TS. This hind limb unloading by TS can induce sarcopenia in 2 weeks. However, the relationship between PND and muscle atrophy is unclear. In this experiment, we investigated whether preoperative muscle atrophy induced by TS would affect neurogenesis and accelerate PND in rats.

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Spinal Neuronal GRK2 Contributes to Preventive Effect by Electroacupuncture on Cisplatin-Induced Peripheral Neuropathy in Mice

Ma, Xue BD*; Chen, Yu BD*; Li, Xiao-Chen BD*; Mi, Wen-Li PhD*; Chu, Yu-Xia PhD*; Wang, Yan-Qing PhD*,†,‡; Mao-Ying, Qi-Liang PhD*,‡

doi : 10.1213/ANE.0000000000005768

January 2022 - Volume 134 - Issue 1 - p 204-215

The main symptoms of chemotherapy-induced peripheral neuropathy (CIPN) include pain and numbness. Neuronal G protein–coupled receptor kinase 2 (GRK2) plays an important role in various pain models. Cisplatin treatment can induce the activation of proinflammatory microglia in spinal cord. The purpose of this study was to investigate the role of spinal neuronal GRK2 in cisplatin-induced CIPN and in the prevention of CIPN by electroacupuncture (EA).

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Anesthesia and World War II: When the Battlefield Becomes a Research Field—A Bibliometric Analysis of the Influence of World War II on the Development of Anesthesiology

Jakus, Lien MD*; Docquier, Pierre-Louis PhD†; Veyckemans, Francis MD‡; Reding, Raymond PhD§

doi : 10.1213/ANE.0000000000005745

January 2022 - Volume 134 - Issue 1 - p 216-224

At the outbreak of World War II (WWII), anesthesiology was struggling to establish itself as a medical specialty. The battlefield abruptly exposed this young specialty to the formidable challenge of mass casualties, with an urgent need to provide proper fluid resuscitation, airway management, mechanical ventilation, and analgesia to thousands. But while Europe was suffering under the Nazi boot, anesthesia was preparing to rise to the challenge posed by the impending war. While war brings death and destruction, it also opens the way to medical advances. The aim of this study is to measure the evolution of anesthesia owing to WWII. We conducted a retrospective observational bibliometric study involving a quantitative and statistical analysis of publications. The following 7 journals were selected to cover European and North American anesthesia-related publications: Anesthesia & Analgesia, the British Journal of Anaesthesia, Anesthesiology, Schmerz-Narkose-Anaesthesie, Surgery, La Presse Médicale, and The Military Surgeon (later Military Medicine). Attention was focused on journal volumes published between 1920 and 1965. After reviewing the literature, we selected 12 keywords representing important advances in anesthesiology since 1920: “anesthesia,” “balanced anesthesia,” “barbiturates,” “d-tubocurarine,” “endotracheal intubation,” “ether,” “lidocaine,” “morphine,” “spinal anesthesia,” “thiopental,” “transfusion,” and “trichloroethylene.” Titles of original articles from all selected journals editions between 1920 and 1965 were screened for the occurrence of 1 of the 12 keywords. A total of 26,132 original article titles were screened for the occurrence of the keywords. A total of 1815 keywords were found. Whereas Anesthesia & Analgesia had the highest keyword occurrence (493 citations), Schmerz-Narkose-Anaesthesie had the lowest (38 citations). The number of publications of the 12 keywords was significantly higher in the postwar than in the prewar period (65% and 35%, respectively; P < .001). Not surprisingly, the anesthesiology journals have a higher occurrence of keywords than those journals covering other specialties. The overall occurrence of keywords also showed peaks during other major conflicts, namely the Spanish Civil War (1936–1939), the Korean War (1950–1953), and the Vietnam War (1955–1975). For the first time, this study demonstrates statistically the impact of WWII on the progress of anesthesiology. It also offers an objective record of the chronology of the major advances in anesthesiology before and after the conflict. While the war arguably helped to enhance anesthesiology as a specialty, in return anesthesiology helped to heal the wounds of war.

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