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Lessons Learned From the Rapid Expansion of Intensive Care Unit Care to the Operating Room During the Coronavirus Disease 2019 Pandemic
Meleties, Anastasia MD*; Morikawa, Nicole MD*; Tanaka, Christopher Y. MD, FASE*; Choice, Curtis MD*; Berger, Jay MD, PhD
doi : 10.1213/ANE.0000000000005497
Anesthesia & Analgesia. 132(5):1179-1181, May 2021.
Logistical Considerations and Clinical Outcomes Associated With Converting Operating Rooms Into an Intensive Care Unit During the Coronavirus Disease 2019 Pandemic in a New York City Hospital
Mittel, Aaron M. MD*; Panzer, Oliver MD*; Wang, David S. MD*; Miller, Steven E. MD*; Schaff, Jacob E. MD*; Hastie, Maya Jalbout MD, EdD*; Sutherland, Lauren MD*; Brentjens, Tricia E. MD*; Sobol, Julia B. MD, MPH*; Cabredo, Almarie MSN, FNP†; Hastie, Jonathan MD
doi : 10.1213/ANE.0000000000005301
Anesthesia & Analgesia. 132(5):1182-1190, May 2021.
Coronavirus disease 2019 (COVID-19) emerged as a public health crisis that disrupted normal patterns of health care in the New York City metropolitan area. In preparation for a large influx of critically ill patients, operating rooms (ORs) at NewYork-Presbyterian/Columbia University Irving Medical Center (NYP-Columbia) were converted into a novel intensive care unit (ICU) area, the operating room intensive care unit (ORICU).
Coronavirus Disease 2019: Anesthesia Machine Circuit Pressure During Use as an Improvised Intensive Care Unit Ventilator
Pham, Vinh MD; Nguyen, Le MD; Hedin, Riley J. DO, MPH; Shaver, Courtney MS; Hammonds, Kendall A. P. MPH; Culp, William C. Jr MD
doi : 10.1213/ANE.0000000000005427
Anesthesia & Analgesia. 132(5):1191-1198, May 2021.
Use of anesthesia machines as improvised intensive care unit (ICU) ventilators may occur in locations where waste anesthesia gas suction (WAGS) is unavailable. Anecdotal reports suggest as much as 18 cm H2O positive end-expiratory pressure (PEEP) being inadvertently applied under these circumstances, accompanied by inaccurate pressure readings by the anesthesia machine. We hypothesized that resistance within closed anesthesia gas scavenging systems (AGSS) disconnected from WAGS may inadvertently increase circuit pressures.
Anesthesia and Sleep Medicine
Weingarten, Toby N.; Chung, Francis; Hillman, David R.
doi : 10.1213/ANE.0000000000005421
Anesthesia & Analgesia. 132(5):1199-1201, May 2021.
Society of Anesthesia and Sleep Medicine: Looking Back at a Decade, Looking Forward to the Next
Ramachandran, Satya Krishna
doi : 10.1213/ANE.0000000000005467
Anesthesia & Analgesia. 132(5):1202-1204, May 2021.
Prehabilitation With Brain Stimulation?
Kato, Risako; Solt, Ken
doi : 10.1213/ANE.0000000000005454
Anesthesia & Analgesia. 132(5):1344-1346, May 2021.
Enhanced Recovery After Surgery for Cesarean Delivery
Scott, Michael J.; Wrench, Ian
doi : 10.1213/ANE.0000000000005517
Anesthesia & Analgesia. 132(5):1359-1361, May 2021.
Counting Down the Hours: Tracking Postoperative Respiratory Depression
Nathan, Naveen
doi : 10.1213/ANE.0000000000005520
Anesthesia & Analgesia. 132(5):1205, May 2021.
Frequency and Temporal Distribution of Postoperative Respiratory Depressive Events
Driver, C. Noelle BS*; Laporta, Mariana L. MD*; Bergese, Sergio D. MD†; Urman, Richard D. MD‡; Di Piazza, Fabio MS§; Overdyk, Frank J. MD?; Sprung, Juraj MD, PhD*; Weingarten, Toby N. MD
doi : 10.1213/ANE.0000000000005478
Anesthesia & Analgesia. 132(5):1206-1214, May 2021.
The frequency and temporal distribution of postoperative respiratory depression (RD) events are not completely understood. This study determined the temporal distribution and frequency of RD episodes in postsurgical patients continuously monitored by bedside capnography and pulse oximetry.
Outcomes of Sleep Apnea Surgery in Outpatient and Inpatient Settings
Rosero, Eric B.; Joshi, Girish P.
doi : 10.1213/ANE.0000000000005394
Anesthesia & Analgesia. 132(5):1215-1222, May 2021.
Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility.
Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey
Berezin, Linor BSc*; Nagappa, Mahesh MD†; Wong, Jean MD*,‡; Clivatti, Jefferson MD§; Singh, Mandeep MD*; Auckley, Dennis MD?; Charchaflieh, Jean G. MD¶; Jonsson Fagerlund, Malin MD, PhD#,**; Gali, Bhargavi MD††; Joshi, Girish P. MD‡‡; Overdyk, Frank J. MD§§; Margarson, Michael MD??; Mokhlesi, Babak MD, MSc¶¶; Moon, Tiffany MD‡‡; Ramachandran, Satya K. MD##; Ryan, Clodagh M. MD***; Schumann, Roman MD†††,‡‡‡; Weingarten, Toby N. MD§§§; Won, Christine H.J. MD, MSc???,¶¶¶; Chung, Frances MD
doi : 10.1213/ANE.0000000000005446
Anesthesia & Analgesia. 132(5):1223-1230, May 2021.
Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine.
Association of Preoperative Pneumonia With Postsurgical Morbidity and Mortality in Children
Nafiu, Olubukola O. MD, FRCA, MS*; Mpody, Christian MD, PhD, MPH, MBA*; Kirkby, Stephen E. MD†; Samora, Julie B. MD, PhD‡; Tobias, Joseph D. MD
doi : 10.1213/ANE.0000000000005219
Anesthesia & Analgesia.132(5):1380-1388, May 2021.
Pneumonia is a common lower respiratory tract infection (LRI) and the leading cause of pediatric hospitalization in the United States. Given its frequency, children with pneumonia may require surgery during their hospital course. This poses serious anesthetic and surgical challenges because preoperative pulmonary status is among the most important risk factors for postoperative complications. Although recent adult data indicated that preoperative pneumonia was associated with poor surgical outcomes, comparable data in children are lacking. Therefore, our objective was to investigate the association of preoperative pneumonia with postoperative mortality and morbidity in children.
Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review
Cozowicz, Crispiana; Memtsoudis, Stavros G.
doi : 10.1213/ANE.0000000000005444
Anesthesia & Analgesia. 132(5):1231-1243, May 2021.
The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.
Chronic Opioid Use and Central Sleep Apnea, Where Are We Now and Where To Go? A State of the Art Review
Wang, David PhD*,†; Yee, Brendon J. PhD*,†; Grunstein, Ronald R. PhD*,†; Chung, Frances MBBS
doi : 10.1213/ANE.0000000000005378
Anesthesia & Analgesia. 132(5):1244-1253, May 2021.
Opioids are commonly used for pain management, perioperative procedures, and addiction treatment. There is a current opioid epidemic in North America that is paralleled by a marked increase in related deaths. Since 2000, chronic opioid users have been recognized to have significant central sleep apnea (CSA). After heart failure–related Cheyne-Stokes breathing (CSB), opioid-induced CSA is now the second most commonly seen CSA. It occurs in around 24% of chronic opioid users, typically after opioids have been used for more than 2 months, and usually corresponds in magnitude to opioid dose/plasma concentration. Opioid-induced CSA events often mix with episodes of ataxic breathing.
The Neural Circuits Underlying General Anesthesia and Sleep
Moody, Olivia A. PhD*,†; Zhang, Edlyn R. BSc*; Vincent, Kathleen F. PhD*,†; Kato, Risako PhD*,†; Melonakos, Eric D. PhD*,†,‡; Nehs, Christa J. PhD*,†,‡; Solt, Ken MD
doi : 10.1213/ANE.0000000000005361
Anesthesia & Analgesia. 132(5):1254-1264, May 2021.
General anesthesia is characterized by loss of consciousness, amnesia, analgesia, and immobility. Important molecular targets of general anesthetics have been identified, but the neural circuits underlying the discrete end points of general anesthesia remain incompletely understood. General anesthesia and natural sleep share the common feature of reversible unconsciousness, and recent developments in neuroscience have enabled elegant studies that investigate the brain nuclei and neural circuits underlying this important end point. A common approach to measure cortical activity across the brain is electroencephalogram (EEG), which can reflect local neuronal activity as well as connectivity among brain regions. The EEG oscillations observed during general anesthesia depend greatly on the anesthetic agent as well as dosing, and only some resemble those observed during sleep. For example, the EEG oscillations during dexmedetomidine sedation are similar to those of stage 2 nonrapid eye movement (NREM) sleep, but high doses of propofol and ether anesthetics produce burst suppression, a pattern that is never observed during natural sleep. Sleep is primarily driven by withdrawal of subcortical excitation to the cortex, but anesthetics can directly act at both subcortical and cortical targets. While some anesthetics appear to activate specific sleep-active regions to induce unconsciousness, not all sleep-active regions play a significant role in anesthesia. Anesthetics also inhibit cortical neurons, and it is likely that each class of anesthetic drugs produces a distinct combination of subcortical and cortical effects that lead to unconsciousness. Conversely, arousal circuits that promote wakefulness are involved in anesthetic emergence and activating them can induce emergence and accelerate recovery of consciousness. Modern neuroscience techniques that enable the manipulation of specific neural circuits have led to new insights into the neural circuitry underlying general anesthesia and sleep. In the coming years, we will continue to better understand the mechanisms that generate these distinct states of reversible unconsciousness.
Obesity and Obesity Hypoventilation, Sleep Hypoventilation, and Postoperative Respiratory Failure
Kaw, Roop; Wong, Jean; Mokhlesi, Babak
doi : 10.1213/ANE.0000000000005352
Anesthesia & Analgesia. 132(5):1265-1273, May 2021.
Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ?30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.
Pharmacologically Induced Ventilatory Depression in the Postoperative Patient: A Sleep-Wake State-Dependent Perspective
Doufas, Anthony G.; Weingarten, Toby N.
doi : 10.1213/ANE.0000000000005370
Anesthesia & Analgesia. 132(5):1274-1286, May 2021.
Pharmacologically induced ventilatory depression (PIVD) is a common postoperative complication with a spectrum of severity ranging from mild hypoventilation to severe ventilatory depression, potentially leading to anoxic brain injury and death. Recent studies, using continuous monitoring technologies, have revealed alarming rates of previously undetected severe episodes of postoperative ventilatory depression, rendering the recognition of such episodes by the standard intermittent assessment practice, quite problematic. This imprecise description of the epidemiologic landscape of PIVD has thus stymied efforts to understand better its pathophysiology and quantify relevant risk factors for this postoperative complication. The residual effects of various perianesthetic agents on ventilatory control, as well as the multiple interactions of these drugs with patient-related factors and phenotypes, make postoperative recovery of ventilation after surgery and anesthesia a highly complex physiological event. The sleep-wake, state-dependent variation in the control of ventilation seems to play a central role in the mechanisms potentially enhancing the risk for PIVD. Herein, we discuss emerging evidence regarding the epidemiology, risk factors, and potential mechanisms of PIVD.
Perioperative Management of Insomnia, Restless Legs, Narcolepsy, and Parasomnias
Hershner, Shelley; Auckley, Dennis
doi : 10.1213/ANE.0000000000005439
Anesthesia & Analgesia. 132(5):1287-1295, May 2021.
Obstructive sleep apnea (OSA) has been shown to increase risk of adverse perioperative events. More recently, investigators have begun to examine other common sleep disorders to assess how they may be impacted by the perioperative environment, as well as influence postoperative outcomes. There are a number of mechanisms by which such common sleep disorders (eg, insomnia, restless legs syndrome, narcolepsy, and parasomnias) may have consequences in the perioperative setting, both related to the underlying pathophysiology of the diseases as well as their treatments. This review will highlight the current state of the literature and offer recommendations for management of these conditions during the perioperative journey.
Integrating Sleep Knowledge Into the Anesthesiology Curriculum
Singh, Mandeep MBBS, MD, MSc*,†,‡; Gali, Bhargavi MD§; Levine, Mark MD*,?; Strohl, Kingman MD¶; Auckley, Dennis MD#
doi : 10.1213/ANE.0000000000005490
Anesthesia & Analgesia. 132(5):1296-1305, May 2021.
There is common ground between the specialties of anesthesiology and sleep medicine. Traditional sleep medicine curriculum for anesthesiology trainees has revolved around the discussion of obstructive sleep apnea (OSA) and its perioperative management. However, it is time to include a broader scope of sleep medicine–related topics that overlap these specialties into the core anesthesia residency curriculum. Five main core competency domains are proposed, including SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness (SLEEP WELL).
Perioperative Continuous Positive Airway Pressure Therapy: A Review With the Emphasis on Randomized Controlled Trials and Obstructive Sleep Apnea
Jonsson Fagerlund, M.; Franklin, K. A.
doi : 10.1213/ANE.0000000000005480
Anesthesia & Analgesia. 132(5):1306-1313, May 2021.
The perioperative use of continuous positive airway pressure (CPAP) therapy has increased substantially in recent years, particularly in relationship to the treatment of patients with known or suspected obstructive sleep apnea (OSA). OSA is common in the surgical population and is reported as an independent risk factor for postoperative complications, intensive care unit admission, and increased length of hospital stay. A large proportion of OSA patients are undiagnosed at the time of surgery and can therefore not be optimized preoperatively. Nowadays, golden standard treatment of moderate to severe OSA is nightly CPAP at home, often with an autotitration mode. Unfortunately, there are only a handful of randomized clinical trials investigating the effect of preoperative and/or postoperative CPAP treatment in OSA patients, so the perioperative guidelines are based on a combination of randomized clinical trials, observational studies, case studies, and expert opinions. In this review, we have summarized the current evidence regarding the use of perioperative CPAP therapy with an emphasis on patients with OSA. We identified 21 randomized, controlled trials that investigated the effect of CPAP on postoperative physiology and complications in surgical patients. Our review reveals evidence, suggesting that CPAP after surgery improves oxygenation and reduces the need for reintubation and mechanical ventilation after surgery. It is also evident that CPAP reduces apnea and hypopnea frequency and related hypoxemia after surgery. Poor adherence to CPAP in the perioperative setting is a limiting factor in assessing its potential to optimize postoperative cardiorespiratory outcomes. Studies of postoperative outcomes in patients who have previously been prescribed CPAP for OSA and are therefore familiar with its use could help to address this shortcoming, but they are unfortunately lacking. This shortcoming should be addressed in future studies. Furthermore, many of the studies of the postoperative effect of CPAP in OSA patents are small, and therefore, single-center studies and larger randomized, controlled multicenter studies are warranted.
An Update on One-Lung Ventilation in Children
Templeton, T. Wesley; Piccioni, Federico; Chatterjee, Debnath
doi : 10.1213/ANE.0000000000005077
Anesthesia & Analgesia. 132(5):1389-1399, May 2021.
One-lung ventilation in children continues to present technical and sometimes physiologic challenges to the clinician. The rarity of these cases at any single institution, however, has led to very few prospective trials to guide best practices. As a result, most clinicians continue to be guided by local tradition and preference. That said, the development of new bronchial blockers such as the EZ-Blocker or blocking devices such as the Univent tube have continued to evolve the practice of lung isolation in children. Further, the development of a variety of extraluminal blocker techniques has led to innovations in practice through a relatively diverse landscape of published case series offering different approaches to one-lung ventilation during the past 15 years. The Arndt bronchial blocker continues to represent the most well documented of these devices. Additionally, recent advances have occurred in our understanding of the relevant anatomic constraints of the lower pediatric airway. This review is intended to provide a comprehensive and practical update to practicing pediatric anesthesiologists to further their understanding of the modern practice of one-lung ventilation for thoracic surgery in children.
Sleep Loss in the Hospitalized Patient and Its Influence on Recovery From Illness and Operation
Hillman, David R.
doi : 10.1213/ANE.0000000000005323
Anesthesia & Analgesia. 132(5):1314-1320, May 2021.
Adequate sleep is essential to health and well-being. Adverse effects of sleep loss are evident acutely and are cumulative in their effect. These include impairment of cognition, psychomotor function, and mood, as well as cardiovascular, metabolic, and immune dysfunction including proinflammatory effects and increased catabolic propensity. Such effects are counterproductive to recovery from illness and operation, yet hospitalization challenges sleep through the anxieties, discomforts, and sleep environmental challenges faced by patients, the inadequate attention given to the needs of patients with preexisting sleep disorders, and the lack of priority these issues receive from hospital staff and their leaders. Mitigation of the adverse effects of noise, light, uncomfortable bedding, intrusive observations, anxiety, and pain together with attention to specific sleep needs and monitoring of sleep quality are steps that would help address the issue and potentially improve patient outcomes.
Airway Management in Surgical Patients With Obstructive Sleep Apnea
Seet, Edwin; Nagappa, Mahesh; Wong, David T.
doi : 10.1213/ANE.0000000000005298
Anesthesia & Analgesia. 132(5):1321-1327, May 2021.
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and the difficult airway is perhaps the anesthesiologists’ quintessential concern. OSA and the difficult airway share certain similar anatomical, morphological, and physiological features. Individual studies and systematic reviews of retrospective, case-control, and large database studies have shown a likely association between patients with OSA and the difficult airway; OSA patients have a 3- to 4-fold higher risk of difficult intubation, difficult mask ventilation, or a combination of both. The presence of OSA should initiate proactive perioperative management in anticipation of a difficult airway. Prudent intraoperative management comprises the use of regional anesthesia where possible and considering an awake intubation technique where there is the presence of notable difficult airway predictors and risk of rapid desaturation following induction of general anesthesia. Familiarity with difficult airway algorithms, cautious extubation, and appropriate postoperative monitoring of patients with OSA are necessary to mitigate perioperative risks.
Vulnerability to Postoperative Complications in Obstructive Sleep Apnea: Importance of Phenotypes
Altree, Thomas J. MBBS, FRACP*; Chung, Frances MBBS, FRCPC†; Chan, Matthew T. V. PhD‡; Eckert, Danny J. PhD
doi : 10.1213/ANE.0000000000005390
Anesthesia & Analgesia. 132(5):1328-1337, May 2021.
Obstructive sleep apnea (OSA) is a common comorbidity in patients undergoing surgical procedures. Patients with OSA are at heightened risk of postoperative complications. Current treatments for OSA focus on alleviating upper airway collapse due to impaired upper airway anatomy. Although impaired upper airway anatomy is the primary cause of OSA, the pathogenesis of OSA is highly variable from person to person. In many patients, nonanatomical traits play a critical role in the development of OSA. There are 4 key traits or “phenotypes” that contribute to OSA pathogenesis. In addition to (1) impaired upper airway anatomy, nonanatomical contributors include: (2) impaired upper airway dilator muscle responsiveness; (3) low respiratory arousal threshold (waking up too easily to minor airway narrowing); and (4) unstable control of breathing (high loop gain). Each of these phenotypes respond differently to postoperative factors, such as opioid medications. An understanding of these phenotypes and their highly varied interactions with postoperative risk factors is key to providing safer personalized care for postoperative patients with OSA. Accordingly, this review describes the 4 OSA phenotypes, highlights how the impact on OSA severity from postoperative risk factors, such as opioids and other sedatives, is influenced by OSA phenotypes, and outlines how this knowledge can be applied to provide individualized care to minimize postoperative risk in surgical patients with OSA.
Effect of Inadequate Sleep on Clinician Performance
Saadat, Haleh
doi : 10.1213/ANE.0000000000005369
Anesthesia & Analgesia. 132(5):1338-1343, May 2021.
The negative impacts of sleep deprivation and fatigue have long been recognized. Numerous studies have documented the ill effects of impaired alertness associated with the disruption of the sleep-wake cycle; these include an increased incidence of human error–related accidents, increased morbidity and mortality, and an overall decrement in social, financial, and human productivity. While there are multiple studies on the impact of sleep deprivation and fatigue in resident physicians, far fewer have examined the effects on attending physicians, and only a handful addresses the accumulated effects of chronic sleep disturbances on acute sleep loss during a night call-shift. Moreover, the rapid and unprecedented spread of coronavirus disease 2019 (COVID-19) pandemic significantly increased the level of anxiety and stress on the physical, psychological, and the economic well-being of the entire world, with heightened effect on frontline clinicians. Additional studies are necessary to evaluate the emotional and physical toll of the pandemic in clinicians, and its impact on sleep health, general well-being, and performance.
Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean
Bollag, Laurent MD*; Lim, Grace MD, MS†; Sultan, Pervez MBChB, FRCA, MD (Res)‡; Habib, Ashraf S. MBBCh, MSc, MHSc, FRCA§; Landau, Ruth MD?; Zakowski, Mark MD¶; Tiouririne, Mohamed MD#; Bhambhani, Sumita MD**; Carvalho, Brendan MBBCh, FRCA, MDCH
doi : 10.1213/ANE.0000000000005257
Anesthesia & Analgesia. 132(5):1362-1377, May 2021.
The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.
Repetitive Anodal Transcranial Direct Current Stimulation Hastens Isoflurane-Induced Emergence and Recovery and Enhances Memory in Healthy Rats
Mansouri, Mohammad Taghi; Garc?a, Paul S.
doi : 10.1213/ANE.0000000000005379
Anesthesia & Analgesia. 132(5):1347-1358, May 2021.
Attaining a rapid and smooth return to consciousness after general anesthesia is a goal for clinical anesthesiologists. This study aimed to investigate the effects of repeated anodal transcranial direct current stimulation (atDCS) on emergence and recovery from isoflurane anesthesia in rats.
Count Data in Medical Research: Poisson Regression and Negative Binomial Regression
Schober, Patrick; Vetter, Thomas R.
doi : 10.1213/ANE.0000000000005398
Anesthesia & Analgesia. 132(5):1378-1379, May 2021.
Assessing Left Ventricular Early Diastolic Velocities With Tissue Doppler and Speckle Tracking by Transesophageal and Transthoracic Echocardiography
Mauermann, Eckhard MD, MSc*,†; Bouchez, Stefaan MD*; Bove, Thierry MD, PhD‡; Vandenheuvel, Michael MD*; Wouters, Patrick MD, PhD
doi : 10.1213/ANE.0000000000005469
Anesthesia & Analgesia. 132(5):1400-1409, May 2021.
Assessing diastolic dysfunction is essential and should be part of every routine echocardiography examination. However, clinicians routinely observe lower mitral annular velocities by transesophageal echocardiography (TEE) under anesthesia than described by awake transthoracic echocardiography (TTE). It would be important to know whether this difference persists under constant loading conditions. We hypothesized that mean early diastolic mitral annular velocity, measured by tissue Doppler imaging (TDI,
Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery
Khanna, Ashish K. MD, FCCP, FCCM*,†; Shaw, Andrew D. MB, FRCPC‡,§; Stapelfeldt, Wolf H. MD?; Boero, Isabel J. MD, MS¶; Chen, Qinyu MS¶; Stevens, Mitali PharmD, BCPS#; Gregory, Anne MD, MSc, FRCPC‡; Smischney, Nathan J. MD, MSc
doi : 10.1213/ANE.0000000000005374
Anesthesia & Analgesia. 132(5):1410-1420, May 2021.
Postoperative hypotension (POH) is associated with major adverse events. However, little is known about the association of blood pressure thresholds and outcomes in postoperative patients without intraoperative hypotension (IOH) on the general-care ward. We evaluated the association of POH with major adverse cardiac or cerebrovascular events (MACCE) in patients without IOH.
Ease of Application of Various Neuromuscular Devices for Routine Monitoring
Renew, J. Ross MD*; Hex, Karina CCRP*; Johnson, Patrick BS†; Lovett, Pamela CRNA, DNP*; Pence, Richard CRNA, MHA
doi : 10.1213/ANE.0000000000005213
Anesthesia & Analgesia. 132(5):1421-1428, May 2021.
Subjective evaluations to confirm recovery from neuromuscular blockade with a peripheral nerve stimulator (PNS) is inadequate. Quantitative monitors are the only reliable method to confirm adequate recovery of neuromuscular function. Unfortunately, many clinicians are unfamiliar with such devices and there is concern that the introduction of objective monitoring would be exceedingly laborious and could cause workflow delays. This study investigates how long it takes experienced nurse anesthetists to apply various neuromuscular devices as well as their perception regarding the ease of application.
Perioperative Ulnar Neuropathy: A Contemporary Estimate of Incidence and Risk Factors
Pulos, Bridget P. MD*; Johnson, Rebecca L. MD*; Laughlin, Ruple S. MD†; Njathi-Ori, Catherine W. MD*; Kor, Todd M. MD*; Schroeder, Darrell R. MS‡; Warner, Mary E. MD*; Habermann, Elizabeth B. PhD§; Warner, Mark A. MD
doi : 10.1213/ANE.0000000000005407
Anesthesia & Analgesia. 132(5):1429-1437, May 2021.
Retrospective and prospective studies 2 decades ago from the authors’ institution reported the incidence of perioperative ulnar neuropathy persisting for at least several months in a noncardiac adult surgical population to be between 30 and 40 per 100,000 cases. The aim of this project was to assess the incidence and explore risk factors for perioperative ulnar neuropathy in a recent cohort of patients from the same institution using a similar definition for ulnar neuropathy.
Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting
Parks, Dale A. PhD*; Short, Roland T. MD*; McArdle, Philip J. MD*; Liwo, Amandiy MD*; Hagood, Joshua M. BS*; Crump, Sandra J. DNP*; Bryant, Ayesha S. MD*; Vetter, Thomas R. MD†; Morgan, Charity J. PhD‡; Beasley, T. Mark PhD‡,§; Jones, Keith A. MD
doi : 10.1213/ANE.0000000000005481
Anesthesia & Analgesia. 132(5):1438-1449, May 2021.
Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies.
Evaluation of Drug Wastage in the Operating Rooms and Intensive Care Units of a Regional Health Service
Barbariol, Federico MD*; Deana, Cristian MD*; Lucchese, Francesca MD*; Cataldi, Giuseppe MD†; Bassi, Flavio MD*; Bove, Tiziana MD‡; Vetrugno, Luigi MD‡; De Monte, Amato MD
doi : 10.1213/ANE.0000000000005457
Anesthesia & Analgesia. 132(5):1450-1456, May 2021.
Pharmacological treatments for critical processes in patients need to be initiated as rapidly as possible; for this reason, it is a standard of care to prepare the main anesthesia and emergency drugs in advance. As a result, 20%–50% of the prepared drugs remain unused and are then discarded. Decreasing waste by optimizing drug use is an attractive strategy for meeting both cost containment and environmental sustainability. The primary end point of this study was to measure the actual amount of drug wastage in the operating rooms (ORs) and intensive care units (ICUs) of a Regional Health Service (RHS). The secondary end point was to analyze and estimate the economic implications of this waste for the Health Service and to suggest possible measures to reduce it.
Demographic Trends From 2005 to 2015 Among Physicians With Accreditation Council for Graduate Medical Education–Accredited Anesthesiology Training and Active Medical Licenses
Zhou, Yan PhD*; Sun, Huaping PhD*; Wang, Ting PhD*; Harman, Ann E. PhD*; Keegan, Mark T. MB, BCh†; Macario, Alex MD, MBA‡; Minhaj, Mohammed M. MD, MBA§; Chaudhry, Humayun J. DO, MS?; Young, Aaron PhD?; Warner, David O. MD
doi : 10.1213/ANE.0000000000005332
Anesthesia & Analgesia. 132(5):1457-1464, May 2021.
A temporary decrease in anesthesiology residency graduates that occurred around the turn of the millennium may have workforce implications. The aims of this study are to describe, between 2005 and 2015, (1) demographic changes in the workforce of physicians trained as anesthesiologists; (2) national and state densities of these physicians, as well as temporal changes in the densities; and (3) retention of medical licenses by mid- and later-career anesthesiologists.
Slow Dynamics of Acute Postoperative Pain Intensity Time Series Determined via Wavelet Analysis Are Associated With the Risk of Severe Postoperative Day 30 Pain
Baharloo, Raheleh MS*; Principe, Jose C. PhD*; Fillingim, Roger B. PhD†; Wallace, Margaret R. PhD‡; Zou, Baiming PhD§; Crispen, Paul L. MD?; Parvataneni, Hari K. MD¶; Prieto, Hernan A. MD¶; Machuca, Tiago N. MD, PhD#; Mi, Xinlei PhD**; Hughes, Steven J. MD#; Murad, Gregory J. A. MD††; Rashidi, Parisa PhD*; Tighe, Patrick J. MD, MS
doi : 10.1213/ANE.0000000000005385
Anesthesia & Analgesia. 132(5):1465-1474, May 2021.
Evidence suggests that increased early postoperative pain (POP) intensities are associated with increased pain in the weeks following surgery. However, it remains unclear which temporal aspects of this early POP relate to later pain experience. In this prospective cohort study, we used wavelet analysis of clinically captured POP intensity data on postoperative days 1 and 2 to characterize slow/fast dynamics of POP intensities and predict pain outcomes on postoperative day 30.
Dimethyl Fumarate Reduces Oxidative Stress and Pronociceptive Immune Responses in a Murine Model of Complex Regional Pain Syndrome
Guo, Tian-Zhi MD*; Shi, Xiaoyou MD†,‡; Li, Wenwu PhD†,‡; Wei, Tzuping PhD*; Kingery, Wade S. MD*; Clark, J. David MD, PhD
doi : 10.1213/ANE.0000000000005440
Anesthesia & Analgesia. 132(5):1475-1485, May 2021.
Complex regional pain syndrome (CRPS) is a highly disabling cause of pain often precipitated by surgery or trauma to a limb. Both innate and adaptive immunological changes contribute to this syndrome. Dimethyl fumarate (DMF) works through the nuclear factor erythroid 2–related factor 2 (Nrf2) transcription factor and other targets to activate antioxidant systems and to suppress immune system activation. We hypothesized that DMF would reduce nociceptive, functional, and immunological changes measured in a model of CRPS.
Pharmacology of General Anesthetics: Quantitative History of Research Attractiveness
Kissin, Igor; Vlassakov, Kamen V.
doi : 10.1213/ANE.0000000000005441
Anesthesia & Analgesia. 132(5):1486-1488, May 2021.
Environmental Externalities of Switching From Inhalational to Total Intravenous Anesthesia
Kostrubiak, Marc R. MA*; Johns, Zachary R. BA†; Vatovec, Christine M. PhD‡; Malgeri, Megan P. MD§; Tsai, Mitchell H. MD, MMM, FASA, FAACD
doi : 10.1213/ANE.0000000000005448
Anesthesia & Analgesia. 132(5):1489-1493, May 2021.
Integrating Prehabilitation in the Preoperative Clinic: A Paradigm Shift in Perioperative Care
Carli, Francesco MD, MPhil*; Awasthi, Rashami MSc*; Gillis, Chelsia RD, PhD*; Baldini, Gabriele MD, MSc*; Bessissow, Amal MS, Msc†; Liberman, Alexander Sender MD‡; Minnella, Enrico Maria MD, PhD
doi : 10.1213/ANE.0000000000005471
Anesthesia & Analgesia. 132(5):1494-1500, May 2021.
Anatomy of a Soldier
Genuis, Katrina
doi : 10.1213/ANE.0000000000005418
Anesthesia & Analgesia. 132(5):e64, May 2021.
Acute Neuro Care: Focused Approach to Neuroemergencies
Babu, Roshan; Akca, Ozan
doi : 10.1213/ANE.0000000000005435
Anesthesia & Analgesia. 132(5):e65, May 2021.
ABC of Quality Improvement in Healthcare
Deflandre, Eric P.
doi : 10.1213/ANE.0000000000005463
Anesthesia & Analgesia. 132(5):e66-e67, May 2021.
Pediatric Anesthesia, an Issue of Anesthesiology Clinics
Anderson, Thomas Anthony
doi : 10.1213/ANE.0000000000005470
Anesthesia & Analgesia. 132(5):e68, May 2021.
Yao & Artusio’s Anesthesiology: Problem-Oriented Patient Management, 9th ed
Mokini, Zhirajr; Vrenozi, Dhurata; Forget, Patrice
doi : 10.1213/ANE.0000000000005476
Anesthesia & Analgesia. 132(5):e69-e70, May 2021.
Gregory’s Pediatric Anesthesia, 6th ed
Goldfarb, Tally; Ambardekar, Aditee P.
doi : 10.1213/ANE.0000000000005477
Anesthesia & Analgesia. 132(5):e71, May 2021.
Brown’s Atlas of Regional Anesthesia, 6th ed
Radke, Oliver C.
doi : 10.1213/ANE.0000000000005485
Anesthesia & Analgesia. 132(5):e72, May 2021.
Neuromuscular Blocking Agents in the ICU: Why Work Blindfolded?
Rosboch, Giulio Luca MD; Ceraolo, Edoardo MD; Balzani, Eleonora MD; Brazzi, Luca MD, PhD
doi : 10.1213/ANE.0000000000005353
Anesthesia & Analgesia. 132(5):e73, May 2021.
In Response
Rezaiguia-Delclaux, Saïda; Stéphan, François
doi : 10.1213/ANE.0000000000005354
Anesthesia & Analgesia. 132(5):e74, May 2021.
The Future Within Reach
Kopanczyk, Rafal; Bhatt, Amar M.; Al-Qudsi, Omar H.
doi : 10.1213/ANE.0000000000005425
Anesthesia & Analgesia. 132(5):e74-e75, May 2021.
In Response
Myrberg, Tomi
doi : 10.1213/ANE.0000000000005426
Anesthesia & Analgesia. 132(5):e75-e76, May 2021.
Sedation Safety and Satisfaction
Nielsen, James R.
doi : 10.1213/ANE.0000000000005437
Anesthesia & Analgesia. 132(5):e76, May 2021.
In Response
Barends, Clemens R. M.; Absalom, Anthony R.
doi : 10.1213/ANE.0000000000005438
Anesthesia & Analgesia. 132(5):e77, May 2021.
Intraoperative Anaphylaxis: Definition Determines Detection
Clark, Michael G.; Schaffer, Andrew J.; Freundlich, Robert E.
doi : 10.1213/ANE.0000000000005449
Anesthesia & Analgesia. 132(5):e77-e78, May 2021.
In Response
Burbridge, Mark A.
doi : 10.1213/ANE.0000000000005450
Anesthesia & Analgesia. 132(5):e78-e79, May 2021.
Cardiac ERAS Studies: Importance of Blinding
Markham, Travis H.; Liang, Yafen; Zaki, John F.
doi : 10.1213/ANE.0000000000005451
Anesthesia & Analgesia. 132(5):e79, May 2021.
In Response
Grant, Michael C.
doi : 10.1213/ANE.0000000000005452
Anesthesia & Analgesia. 132(5):e79-e80, May 2021.
Administering Norepinephrine Peripherally Is Safe, as Long as There Is No IV Extravasation
Richardson, Connor P.; Noonan, Mackenzie A.; McHughs, Stephen M.
doi : 10.1213/ANE.0000000000005461
Anesthesia & Analgesia. 132(5):e80-e81, May 2021.
In Response
Pancaro, Carlo; Kheterpal, Sachin; Lirk, Philipp
doi : 10.1213/ANE.0000000000005462
Anesthesia & Analgesia. 132(5):e81-e82, May 2021.
Consider Urinary Creatinine Clearance for Perioperative Acute Kidney Injury Management
Schmitt, Johan MD; Danguy Des Deserts, Marc MD; Radavidson, Anthony MD; Giacardi, Christophe MD
doi : 10.1213/ANE.0000000000005472
Anesthesia & Analgesia. 132(5):e82-e83, May 2021.
In Response
Zarbock, Alexander; Saadat-Gilani, Khaschayar; Meersch, Melanie
doi : 10.1213/ANE.0000000000005473
Anesthesia & Analgesia. 132(5):e83-e84, May 2021.
Blood Products During Extracorporeal Membrane Oxygenation: Why and How to Use?
Jin, Yu; Liu, Jinping
doi : 10.1213/ANE.0000000000005474
Anesthesia & Analgesia. 132(5):e85, May 2021.
In Response
Qin, Caroline X.; Frank, Steven M.; Bembea, Melania M.
doi : 10.1213/ANE.0000000000005475
Anesthesia & Analgesia. 132(5):e85-e86, May 2021.
The Scientific Principles of Multimodal Monitoring Technique for Peripheral Nerve Blocks: Evidence Toward a New Beginning?
Ip, Vivian H. Y.; Sondekoppam, Rakesh V.; Tsui, Ban C. H.
doi : 10.1213/ANE.0000000000005483
Anesthesia & Analgesia. 132(5):e86-e88, May 2021.
In Response
Choquet, Olivier; Capdevila, Xavier
doi : 10.1213/ANE.0000000000005484
Anesthesia & Analgesia. 132(5):e88-e89, May 2021.
Is Aspirin Effective in Preventing Intensive Care Unit Admission in Patients With Coronavirus Disease 2019 Pneumonia?
Giorgi-Pierfranceschi, Matteo
doi : 10.1213/ANE.0000000000005401
Anesthesia & Analgesia. 132(5):e89-e90, May 2021.
In Response
Chow, Jonathan H.; Mazzeffi, Michael A.
doi : 10.1213/ANE.0000000000005402
Anesthesia & Analgesia. 132(5):e90, May 2021.
Keeping an Open Mind: Tracheostomy for Patients With Coronavirus Disease 2019
McGrath, Brendan A.; Pelosi, Paolo; Brenner, Michael J.
doi : 10.1213/ANE.0000000000005419
Anesthesia & Analgesia. 132(5):e90-e92, May 2021.
In Response
Bassi, Massimiliano MD; Ruberto, Franco MD; Poggi, Camilla MD; Diso, Daniele MD; Anile, Marco MD; De Giacomo, Tiziano MD; Pecoraro, Ylenia MD; Carillo, Carolina MD; Pugliese, Francesco MD; Venuta, Federico MD; Vannucci, Jacopo MD
doi : 10.1213/ANE.0000000000005420
Anesthesia & Analgesia. 132(5):e92-e93, May 2021.
Universal Gloving and Hand Hygiene With Gloves On: Concerns
Sahni, Neeru; Gandhi, Komal A.; Biswal, Manisha
doi : 10.1213/ANE.0000000000005459
Anesthesia & Analgesia. 132(5):e93-e94, May 2021.
In Response
Bowdle, Andrew MD, PhD, FASE; Jelacic, Srdjan MD, FASE; Shishido, Sonia DO; Munoz-Price, L. Silvia MD, PhD
doi : 10.1213/ANE.0000000000005460
Anesthesia & Analgesia. 132(5):e94-e95, May 2021.
