On this page:
- Cardiothoracic Anesthesiology
- General Anesthesiology and Perioperative Medicine
- Liver Transplantation
- Neurosurgical Anesthesiology
- Obstetric Anesthesiology
- Pain Medicine
- Precision Medicine
- Thoracic Anesthesiology
See also a more extensive list of publications on perioperative medicine, enhanced recovery, decision support, and informatics on the website of the Division of Perioperative Medicine, under Our Specialties.
Bartoli-Leonard F, Saddic L, Aikawa E. (2020). Double-edged sword of ALDH2 mutations: one polymorphism can both benefit and harm the cardiovascular system. Eur Heart J. 2020 Jul 7;41(26):2453-2455. https://doi.org/10.1093/eurheartj/ehaa444
This comprehensive study provides compelling support for a role for ALDH2 deficiency in reducing the risk of AAD in both murine models and human patients through an miRNA-mediated phenotypic switch in aortic vSMCs.
Vikram Fielding-Singh, Mark D Willingham, Matthew A Fischer, Tristan Grogan, Peyman Benharash, Jacques P Neelankavil. A Population-Based Analysis of Intraoperative Cardiac Arrest in the United States. Anesth Analg. 2020 Mar;130(3):627-634.PMID: 31651456. DOI: 10.1213/ANE.0000000000004477.
Using a national administrative database, the authors performed a retrospective analysis of intraoperative cardiac arrest in the United States. Admissions involving an intraoperative cardiac arrest were rare but associated with high in-hospital mortality.
Kratzert W, Boyd E, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. Journal of Cardiovascular and Thoracic Anesthesiology 2019, in press. https://doi.org/10.1053/j.jvca.2019.03.005
The postoperative management of patients after PTE confronts intensivists with significant challenges specific to CTEPH disease and PTE surgery. Knowledge of underlying physiology, intraoperative management, and postoperative complications is imperative to optimize outcomes. Intensive care unit management by a multidisciplinary team can provide contemporary care in an evolving field of highly specialized patients.
Methangkool E, Howard-Quijano K, Scovotti JC, Mazor E, Grogan TR, Kratzert WB, Mahajan A. Regional Left Ventricular Myocardial Dysfunction After Cardiac Surgery Characterized by 3-Dimensional Strain. Anesthesia & Analgesia. doi: 10.1213/ANE.0000000000003785. Epub ahead of print March 20, 2019.
Postoperative changes in myocardial function are heterogeneous in nature, depending on the surgical procedure, and these changes may have long-term impacts on outcome. Therefore, 3D regional strain may be used to identify patients at risk for worsened postoperative outcomes, allowing early inventions to mitigate risk.
Neelankavil J, Goeddel LA, Dwarakanath S, Methangkool E, Feinman JW, Harvey R, Hatton K, Kostibas MP, Shah R, Ho JK, Patel PA, Howard-Quijano K, Nyhan D, Augoustides JA. Mentoring Fellows in Adult Cardiothoracic Anesthesiology for Academic Practice in the Contemporary Era-Perspectives From Mentors Around the United States. J Cardiothorac Vasc Anesth. 2020;34(2):521-529. doi:10.1053/j.jvca.2019.01.024. Epub 2019 Jan 9. https://pubmed.ncbi.nlm.nih.gov/30765207/
This special article presents perspectives on the mentoring of fellows for academic practice in adult cardiothoracic anesthesiology. A comprehensive mentoring model should address the areas of clinical care, educational expertise and exposure to scholarly activity.
Methangkool E, Howard-Quijano K, Mahajan A. Cardiac Dysrhythmias: Understanding Mechanisms, Drug Treatments, and Novel Therapies. Advances in Anesthesia, December 2018, Vol 36(1):181-199. Epub September 27, 2018.
This review article describes the mechanisms for cardiac arrhythmia generation and delineates different types of dysrhythmias that can occur under anesthesia. Potential medical and interventional therapies for these arrhythmias are also discussed.
Vaillancourt M, Chia P, Sarji S, Nguyen J, Hoftman M, Ruffenach G, Eghbali M, Mahajan A, Umar S. Autonomic nervous system involvement in pulmonary arterial hypertension. Respiratory Research, 18:201, https://doi.org/10.1186/s12931-017-0679-6, online publication Dec. 4, 2017.
Pulmonary arterial hypertension (PAH) is associated with increased sympathetic nervous system (SNS) activation, decreased heart rate variability, and presence of cardiac arrhythmias. Reduction of neurohormonal activation could be an effective therapeutic strategy. Direct methods such as cervical ganglion block, pulmonary artery denervation (PADN), and renal denervation have been employed to attenuate SNS activation in PAH. The authors summarize the multiple aspects of autonomic nervous system involvement in PAH, and discuss different strategies used to target the autonomic nervous system for treatment.
Fischer M, Salehi A, Sopher MJ, Vorobiof G, Shemin RJ. Ruptured Papillary Muscles after Chordae Preserving Bioprosthetic Mitral Valve Replacement. Accepted for publication in Annals of Thoracic Surgery, 2017.
Detection of masses shortly after valve surgery is rare; accurately assessing and making a differential diagnosis plays a crucial role in determining an appropriate surgical approach.
Green JB, Hart B, Cornett EM, Kaye AD, Salehi A, Fox CJ. Pulmonary Vasodilators and Anesthesia Considerations. Anesthesiology Clinics, June, 2017, Vol 35 221-232
Pulmonary hypertension is a complex disease process; understanding the characteristics and clinical implications of pulmonary vasodilators is of utmost importance in anesthesia practice.
Sheth K, Bernthal N, Ho H, Bergese S, Apfel C, Stoicea, N; Jahr J. Perioperative bleeding and non-steroidal anti-inflammatory drugs: An evidence-based literature review, and current clinical appraisal. Medicine. 99(31):e20042, July 31, 2020. doi: 10.1097/MD.0000000000020042. https://journals.lww.com/md-journal/Fulltext/2020/07310/Perioperative_bleeding_and_non_steroidal.1.aspx
A multidisciplinary panel conducted a clinical appraisal of bleeding risks associated with perioperative NSAID use. The appraisal consisted of review and assessment of the current published evidence related to the statement “In procedures with high bleeding risk, NSAIDs should always be avoided perioperatively.” We report the presented literature and proceedings of the subsequent panel discussion and national pilot survey results. The authors’ assessment of the statement based on current evidence was compared to the attempted national survey data, which revealed a wide range of opinions reflecting the ongoing debate around this issue in a small number of respondents.
Downey P, Ragalie W, Gudzenko V, Ardehali A. Ambulatory central veno-arterial extracorporeal membrane oxygenation in lung transplant candidates. J Heart Lung Transplant. 2019;38(12):1317-1319. doi:10.1016/j.healun.2019.09.006. https://pubmed.ncbi.nlm.nih.gov/31570291/
Kratzert WB, Gudzenko V. ECPR or Do Not ECPR-Who and How to Choose. J Cardiothorac Vasc Anesth. 2020;34(5):1195-1197. doi:10.1053/j.jvca.2020.01.037. https://pubmed.ncbi.nlm.nih.gov/32127263/
Kratzert WB, Boyd EK, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth. 2019;33(11):3110-3126. doi:10.1053/j.jvca.2019.03.005. https://pubmed.ncbi.nlm.nih.gov/30948200/
Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. In this review, the authors focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.
Dworsky JQ, Castle SC, Lee CC, Singh SP, Russell MM. Gerofit Prehabilitation Pilot Program: Preparing Frail Older Veterans for Surgery. J Healthc Qual. 2019;41(2):91-98. doi: 10.1097/JHQ.0000000000000185. PMID: 30688834
Older Veterans are increasingly undergoing surgery and are at particularly high risk of postoperative morbidity and mortality. Prehabilitation has emerged as a method to improve postoperative outcomes by enhancing the patient's preoperative condition. We present data from our prehabilitation pilot project and plans for expansion and dissemination of a nationwide quality improvement effort.
Anjum Anwar, MD, Christian Seger, MD, Ashley Tollefson, MD, Carol Ann B. Diachun, MD, MSEd, Pedro Tanaka, MD, and Soban Umar, MD, PhD. Medical education in the COVID-19 era: Impact on anesthesiology trainees. J Clin Anesth. 2020 Nov; 66: 109949. Published online 2020 Jun 1. doi: 10.1016/j.jclinane.2020.109949. PMCID: PMC7262539. PMID: 32504968.
Anesthesiologists have been on the frontlines of the COVID-19 pandemic as airway, Intensive Care Unit (ICU), and Perioperative Medicine specialists. At most Academic Anesthesiology Programs, trainees account for a significant proportion of their workforce. Although COVID-19 has perturbed Graduate Medical Education (GME) in all specialties, hands-on disciplines (including Anesthesiology) have been affected the most. Herein we briefly explore the impact of COVID-related changes on Anesthesiology training.
The authors comment on recent publications on handoffs beteen attending intensevists.
The authors comment on a recent article by Sevin and Jackson studying ICU survivors in the post-ICU setting.
Musa A, Acosta FL, Tuchman A, Movahedi R, Pendi K, Nassif L, Farhan SA, Muallem E, Gucev G. Addition of Intrathecal Morphine for Postoperative Pain Management in Pediatric Spine Surgery: A Meta-analysis. Clin Spine Surg. 2019 Apr;32(3):104-110. doi: 10.1097/BSD.0000000000000782. PMID: 30789492
The objective of this study was to determine whether adjunctive intrathecal morphine (ITM) reduces postoperative analgesic consumption following pediatric spine surgery. Addition of ITM in pediatric spine surgery produced a potent analgesic effect in the immediate postoperative period. Patients administered ITM did not request opiates as early as control and consumed fewer opiates by the second postoperative day. Furthermore, use of ITM did not increase complications such as respiratory depression, nausea, vomiting, or pruritus.
Musa A, Wang JC, Acosta FL, Movahedi R, Melkonian A, Shahbazi A, Safani D, Gucev G. Attitudes of Spine Surgeons Regarding Management of Preoperative Anxiety: A Cross-sectional Study. Clin Spine Surg. 2019 Feb;32(1):E1-E6. doi: 10.1097/BSD.0000000000000705. PMID: 30148730
This cross-sectional study aimed to investigate spine surgeons' attitudes regarding preoperative anxiety measurement, management, and responsibility. The majority of spine surgeons surveyed did not regularly measure preoperative anxiety, but would discuss its management if the subject was broached by the patient. Spine surgeons relied on a variety of methods to manage a patient's anxiety, but most preferred preoperative education and permitting the presence of family members. Responsibility for controlling preoperative anxiety was chiefly allocated to surgeons, anesthesiologists, and patients.
Musa A, Movahedi R, Wang JC, Safani D, Cooke C, Hussain SF, Tajran J, Hamid S, Gucev G. Assessing and reducing preoperative anxiety in adult patients: A cross-sectional study of 3661 members of the American Society of Anesthesiologists. J Clin Anesth. 2020 May 27;65:109903. doi: 10.1016/j.jclinane.2020.109903. Online ahead of print. PMID: 32473513.
This survey found that most anesthesiologists assess preoperative anxiety in their adult patients.
Anesthesiologists assessed preoperative anxiety by verbal discussion or questionnaire.
Albert Lee, Soban Umar, Nir Hoftman. A Novel Multi-ventilation Technique to split ventilators. MedRxiv May 2020. doi: https://doi.org/10.1101/2020.04.28.20083741
This study aims to explore splitting ventilators, or multi-ventilation, as a viable alternative in these demanding times. We investigated whether individualized tidal volume and positive end expiratory pressure (PEEP) delivery is possible to lungs of different compliances that are being simultaneously ventilated from one anesthesia ventilator.
Clyde T Matava, Pete G Kovatsis, Jennifer Lee Summers, Pilar Castro, Simon Denning, Julie Yu, Justin L Lockman, Britta Von Ungern-Sternberg, Stefano Sabato, Lisa K Lee, Ihab Ayad et al. Pediatric Airway Management in COVID-19 Patients - Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society
Anesth Analg 2020 Apr 13;10.1213/ANE.0000000000004872. doi: 10.1213/ANE.0000000000004872. Online ahead of print. PMID: 32287142 PMCID: PMC7173403 DOI: 10.1213/ANE.0000000000004872
The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has challenged medical systems and clinicians globally to unforeseen levels. COVID-19's rapid spread has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from six countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease.
Hofer IS, Cheng D, Grogan T, Fujimoto Y, Yamada T, Beck L, Cannesson M, Mahajan A MD PhD. Automated Assessment of Existing Patient's Revised Cardiac Risk Index Using Algorithmic Software. Anesth Analg. 2019 May;128(5):909-916. PMID: 29847379
Previous work in the field of medical informatics has shown that rules-based algorithms can be created to identify patients with various medical conditions; however, these techniques have not been compared to actual clinician notes nor has the ability to predict complications been tested. We hypothesize that a rules-based algorithm can successfully identify patients with the diseases in the Revised Cardiac Risk Index (RCRI).
Hofer IS, Burns M, Kendale S, Wanderer JP. Realistically Integrating Machine Learning into clinical practice: a road map of opportunities, challenges, and a potential future. Anesth Analg. 2020 May;130(5):1115-1118. doi: 10.1213/ANE.0000000000004575. PMID: 32287118
In this article, we hope to elucidate what machine learning is and why it will transform clinical care, discuss what it takes to implement machine learning in clinical care, address current limitations and drawbacks, and ultimately examine what the future of machine learning in health care may hold.
Epstein RH, Hofer IS, Salari V, Gabel E. Successful Implementation of a Perioperative Data Warehouse Using Another Hospital's Published Specification From Epic's Electronic Health Record System. Anesth Analg. 2020
PMID: 32332291 DOI: 10.1213/ANE.0000000000004806
Many hospitals have replaced their legacy anesthesia information management system with an enterprise-wide electronic health record system. Integrating the anesthesia data within the context of the global hospital information infrastructure has created substantive challenges for many organizations. A process to build a perioperative data warehouse from Epic was recently published from the University of California Los Angeles (UCLA), but the generalizability of that process is unknown. We describe the implementation of their process at the University of Miami (UM).
Kamdar, Nirav MD, MPP; Jalilian, Laleh MD. Telemedicine: A Digital Interface for Perioperative Anesthetic Care. Anesthesia & Analgesia: February 2020 - Volume 130 - Issue 2 - p 272-275
doi: 10.1213/ANE.0000000000004513. https://pubmed.ncbi.nlm.nih.gov/31934901/
This editorial discusses recent literature and developments in telemedicine and its use in anesthesiology.
Karen S Sibert, Jennifer L Long, Steven M Haddy. Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19). Cureus. 2020 May; 12(5): e8196. Published online 2020 May 19. doi: 10.7759/cureus.8196. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237060/
The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.
Jahr JS, Searle S, McCallum S, Mack R, Minger K, Freyer A, Du W, Hobson S. Platelet Function: Meloxicam injectable in Whole Blood Samples from Healthy Volunteers. Clinical Pharmacology in Drug Development 2020, 00(0) 1–8. DOI: 10.1002/cpdd.772. https://pubmed.ncbi.nlm.nih.gov/31961516/
Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective treatments for pain but may induce bleeding events due to platelet dysfunction associated with inhibition of cyclooxygenase (COX)-1 impairing thromboxane production. An intravenous nanocrystal formulation of meloxicam, a COX-2 preferential nonsteroidal anti-inflammatory drug, is under development for the treatment of moderate to severe pain. This single-center ex vivo study evaluated the effect of meloxicam intravenous and ketorolac on platelet function in whole blood samples from healthy volunteers.
Alexandre Joosten, Joseph Rinehart, Aurélie Bardaji, Philippe Van der Linden, Vincent Jame, Luc Van Obbergh, Brenton Alexander, Maxime Cannesson, Susana Vacas, Ngai Liu, Hichem Slama, Luc Barvais. Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery: A Randomized Controlled Trial. Anesthesiology. 2020 Feb;132(2):253-266. doi: 10.1097/ALN.0000000000003014.
We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia.
Ershoff BD, Grogan T, Hong JC, Chia PA, Gabel E, Cannesson M. Hydromorphone Unit Dose Affects Intraoperative Dosing: An Observational Study. Anesthesiology. 2020 May;132(5):981-991. doi: 10.1097/ALN.0000000000003176. Epub 2020 May. https://pubmed.ncbi.nlm.nih.gov/32053564/
Although clinical factors related to intraoperative opioid administration have been described, there is little research evaluating whether administration is influenced by drug formulation and, specifically, the unit dose of the drug. The authors hypothesized that the unit dose of hydromorphone is an independent determinant of the quantity of hydromorphone administered to patients intraoperatively.
Cecilia Canales, Christine Lee, Maxime Cannesson. Science Without Conscience Is but the Ruin of the Soul: The Ethics of Big Data and Artificial Intelligence in Perioperative Medicine. Anesth Analg. 2020 May;130(5):1234-1243.doi: 10.1213/ANE.0000000000004728. https://pubmed.ncbi.nlm.nih.gov/32287130/
Artificial intelligence-driven anesthesiology and perioperative care may just be around the corner. However, its promises of improved safety and patient outcomes can only become a reality if we take the time to examine its technical, ethical, and moral implications. In our article, we outline key principles of artificial intelligence for the perioperative physician and explore limitations and ethical challenges in the field.
Mišic VV, Gabel E, Hofer I, Rajaram K, Mahajan A. Machine Learning Prediction of Postoperative Emergency Department Hospital Readmission. Anesthesiology. 2020 May;132(5):968-980. doi: 10.1097/ALN.0000000000003140. 2020 May. https://pubmed.ncbi.nlm.nih.gov/32011336/
Although prediction of hospital readmissions has been studied in medical patients, it has received relatively little attention in surgical patient populations. Published predictors require information only available at the moment of discharge. The authors hypothesized that machine learning approaches can be leveraged to accurately predict readmissions in postoperative patients from the emergency department. Further, the authors hypothesize that these approaches can accurately predict the risk of readmission much sooner than hospital discharge.
Brent D Ershoff, Tristan Grogan, Joe C Hong, Pamela A Chia, Eilon Gabel, Maxime Cannesson. Hydromorphone Unit Dose Affects Intraoperative Dosing: An Observational Study. Anesthesiology 2020 May;132(5):981-991. doi: 10.1097/ALN.0000000000003176. https://pubmed.ncbi.nlm.nih.gov/32053564/
Although clinical factors related to intraoperative opioid administration have been described, there is little research evaluating whether administration is influenced by drug formulation and, specifically, the unit dose of the drug. This observational study using an interrupted time series analysis demonstrates that unit dose of hydromorphone (2 mg vs. 1 mg) is an independent determinant of the quantity of hydromorphone administered to patients in the intraoperative period.
Cecilia Canales, Maxime Cannesson, Danielle Perret. Humanism Training in Anaesthesiology Residency: A Framework to Help Move the Field Forward. Br J Anaesth. 2020 May;124(5):e212-e213. doi: 10.1016/j.bja.2020.02.007. Epub 2020 Mar 5. https://pubmed.ncbi.nlm.nih.gov/32147101/
Ira S Hofer, Christine Lee, Eilon Gabel, Pierre Baldi Maxime Cannesson. Development and Validation of a Deep Neural Network Model to Predict Postoperative Mortality, Acute Kidney Injury, and Reintubation Using a Single Feature Set. NPJ Digit Med. 2020 Apr 20;3:58. doi: 10.1038/s41746-020-0248-0. eCollection 2020. https://pubmed.ncbi.nlm.nih.gov/32352036/
During the perioperative period patients often suffer complications, including acute kidney injury (AKI), reintubation, and mortality. In order to effectively prevent these complications, high-risk patients must be readily identified. However, most current risk scores are designed to predict a single postoperative complication and often lack specificity on the patient level.
We hypothesized that machine learning (ML) can be used to create models to predict postoperative mortality, AKI, reintubation, and a combined outcome using a single set of features available at the end of surgery.
Christian Seger, Maxime Cannesson. Recent Advances in the Technology of Anesthesia. F1000Res. 2020 May 18;9:F1000 Faculty Rev-375. doi: 10.12688/f1000research.24059.1. eCollection 2020. https://pubmed.ncbi.nlm.nih.gov/32494358/
The practice of anesthesiology is inextricably dependent upon technology. Anesthetics were first made possible, then increasingly safe, and now more scalable and efficient in part due to advances in monitoring and delivery technology. Herein, we discuss salient advances of the last three years in the technology of anesthesiology.
Jahr JS, Guinn NR, Lowery DR, Shore-Lesserson L, Shander A. Blood Substitutes and Oxygen Therapeutics: A Review. Epub ahead of print. Anesthesia and Analgesia 2019, DOI: 10.1213/ANE.0000000000003957. https://pubmed.ncbi.nlm.nih.gov/30925560/
This article provides an up-to-date review of the history and development, clinical trials, new technology, and current standing of artificial oxygen carriers as an alternative to transfusion when blood is not an option.
Maxime Cannesson, Ira Hofer, Joseph Rinehart, Christine Lee, Kathirvel Subramaniam, Pierre Baldi, Artur Dubrawski, Michael R Pinsky. Machine Learning of Physiological Waveforms and Electronic Health Record Data to Predict, Diagnose and Treat Haemodynamic Instability in Surgical Patients: Protocol for a Retrospective Study. BMJ Open. 2019 Dec 2;9(12):e031988. doi: 10.1136/bmjopen-2019-031988. https://pubmed.ncbi.nlm.nih.gov/31796483/
About 42 million surgeries are performed annually in the USA. While the postoperative mortality is less than 2%, 12% of all patients in the high-risk surgery group account for 80% of postoperative deaths. New onset of haemodynamic instability is common in surgical patients and its delayed treatment leads to increased morbidity and mortality. The goal of this proposal is to develop, validate and test real-time intraoperative risk prediction tools based on clinical data and high-fidelity physiological waveforms to predict haemodynamic instability during surgery.
Brian L Hill, Robert Brown, Eilon Gabel, Nadav Rakocz, Christine Lee, Maxime Cannesson, Pierre Baldi, Loes Olde Loohuis, Ruth Johnson, Brandon Jew, Uri Maoz, Aman Mahajan, Sriram Sankararaman, Ira Hofer, Eran Halperin. An Automated Machine Learning-Based Model Predicts Postoperative Mortality Using Readily-Extractable Preoperative Electronic Health Record Data. Br J Anaesth. 2019 Dec;123(6):877-886. doi: 10.1016/j.bja.2019.07.030. Epub 2019 Oct 15. https://pubmed.ncbi.nlm.nih.gov/31627890/
Rapid, preoperative identification of patients with the highest risk for medical complications is necessary to ensure that limited infrastructure and human resources are directed towards those most likely to benefit. Existing risk scores either lack specificity at the patient level or utilise the American Society of Anesthesiologists (ASA) physical status classification, which requires a clinician to review the chart. We report on the use of machine learning algorithms, specifically random forests, to create a fully automated score that predicts postoperative in-hospital mortality based solely on structured data available at the time of surgery. This automated score outperforms the ASA physical status score, the Charlson comorbidity score, and the POSPOM score for predicting in-hospital mortality. Additionally, we integrate this score with a previously published postoperative score to demonstrate the extent to which patient risk changes during the perioperative period.
Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H, et al. A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Anesth Analg. 2019;10.1213/ANE.0000000000004393. doi:10.1213/ANE.0000000000004393. Online ahead of print 2019 Sep 18. https://pubmed.ncbi.nlm.nih.gov/31567318/
Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial.We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches.
Jalilian L, Cannesson C, Kamdar N. Remote Monitoring in the Perioperative Setting: Calling for Research and Innovation Ecosystem Development. Anesthesia & Analgesia, September 2019; 129(3): 640-641. DOI: 10.1213/ANE.0000000000004278.
In this editorial, the authors discuss the fact that anesthesiology is well positioned to lead in the development of remote surveillance technologies, given the field’s history in pioneering quality and patient safety in medicine and broad footprint across the health care landscape. They make the case that the trend in investigation into remote surveillance technologies has been growing across all medical fields, and it is essential to study clinical applications of these technologies in high-priority clinical processes and high-burden populations to understand if they live up to their promise of improving health care quality, standardizing processes, reducing morbidity, improving patient satisfaction, and reducing cost.
doi: 10.4103/joacp.JOACP_156_18. Epub Apr-Jun 2019. https://pubmed.ncbi.nlm.nih.gov/31303708/Apr-Jun 2019;35(2):192-196.
In this study, we sought to determine whether the dose in which midazolam was dispensed to anesthesiologists was associated with the quantity of midazolam administered perioperatively.
Gabel E, Shin J, Hofer I, Grogan T, Ziv K, Hong J, Dhillon A, Moore J, Mahajan A, Cannesson M. Digital Quality Improvement Approach Reduces the Need for Rescue Antiemetics in High-Risk Patients: A Comparative Effectiveness Study Using Interrupted Time Series and Propensity Score Matching Analysis. Anesthesia & Analgesia December 2018. Doi: 10.1213/ANE 0000000000003828. Epub ahead of print. https://www.ncbi.nlm.nih.gov/pubmed/30585897
Postoperative Nausea and Vomiting (PONV) affects 30% of all surgical patients and can lead to patient dissatisfaction, prolonged recovery times, and unanticipated hospital admissions. We hypothesized that an electronic medical record-based clinical decision support (CDS) approach that incorporates a new PONV pathway, education initiative, and personalized feedback reporting system can decrease the incidence of PONV. The study showed a decrease in incidence of PONV after implementation of the CDS.
Lee LK, Woodfin MY, Vadi MG, Grogan TR, Ross PJ, Applegate RL 2nd, Iravani M. A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport. BMC Anesthesiology December 2018. doi: 10.1186/s12871-018-0658-6. https://www.ncbi.nlm.nih.gov/pubmed/30579349
This study aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes. The study found no increased risk. There was an increased incidence of hemodynamic instability in the RO group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU.
Lee LK, Bernardo MKL, Grogan TR, Elashoff DA, Ren WHP. Perioperative Respiratory Adverse Event Risk Assessment in Children with Upper Respiratory Tract Infection: Validation of the COLDS Score. Pediatric Anesthesiology October 2018. doi: 10.1111/pan.13491. https://www.ncbi.nlm.nih.gov/pubmed/30281195
The decision to proceed with anesthesia and surgery has been controversial in pediatric patients with an upper respiratory tract infection. The COLDS score was proposed by Lee and August as a potential risk stratification scheme. The aim of the study was to evaluate the utility of the COLDS score in predicting perioperative respiratory adverse events and optimize its predictive abililty. The COLDS score has the potential to be a valuable risk assessment tool for prediction of perioperative respiratory adverse events and appears to have a better predictive value in certain subpopulations.
Lee LK, Burns RA, Dhamraits RS, Carter HF, Vadi MG, Grogan TR, Elashoff DA, Applegate RL 2nd, Iravani M. Retropsective Cohort Study on the Optimal Timing of Orogastric Tube/Nasogastric Tube Insertion in Infants with Pyloric Stenosis. Anesthisia and Analgesia September 2018. doi: 10.1213/ANE.0000000003805 https://www.ncbi.nlm.nih.gov/pubmed/30234537
Hypertrophic pyloric stenosis in infants can cause a buildup of gastric contents. Orogastric tubes (OGTs) or nasogastric tubes (NGTs) are often placed in patients with pyloric stenosis before surgical management to prevent aspiration. However, exacerbation of gastric losses may lead to electrolyte abnormalities that can delay surgery, and placement has been associated with increased risk of postoperative emesis. In this multicenter retrospective cohort study, data were extracted from the medical records of 481 patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis from March 2013 to June 2016. The study concluded that OGT/NGT placement on admission for pyloric stenosis is associated with a longer time to electrolyte correction in infants with abnormal laboratory values on presentation and, subsequently, a longer time until they are ready for surgery.
Hatib F, Jian Z, Buddi S, Lee C, Settels J, Sibert K, Rinehart J, Cannesson M. Machine-learning Algorithm to Predict Hypotension Based on High-fidelity Arterial Pressure Waveform Analysis. Anesthesiology 2018; 129:663-74. Epub June 2018. doi: 10.1097/ALN.0000000000002300 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2685008
With appropriate algorithms, computers can learn to detect patterns and associations in large data sets. The authors' goal was to apply machine learning to arterial pressure waveforms and create an algorithm to predict hypotension. The algorithm detects early alteration in waveforms that can herald the weakening of cardiovascular compensatory mechanisms affecting preload, afterload, and contractility.
Nguyen-Lee J, Moreland N, Sadoughi A, Borna R, Salehi A, Jahr J. Sugammandex: Clinical Pharmacokinetics and Pharmacodynamics. Curr Anesthesiol Rep 2018 April Epub April 2 2018. doi:10.1007/s40140-018-0266-5 https://link.springer.com/article/10.1007/s40140-018-0266-5
The purpose of this chapter is to provide an evidence-based understanding of the pharmacokinetics and pharmacodynamics of sugammadex. Sugammadex is a c-cyclodextrin that rapidely reverses the effect of aminosteroid nondepolarizing neuromuscular blocking agents (NMBAs) rocuronium and vecuronium by forming an inactive 1:1 complex. Sugammandex has been shown to be an effective agent in reversing the effects of NMBAs with an acceptable safety and efficacy profile.
- Curr Anesthesiol Rep November 2017 doi: https://doi.org/10.1007/s40140-017-0237-2
The purpose of this work is to provide a brief review of noninvasive cardiovascular and brain monitoring tools that could potentially decrease neurological complications in the perioperative period. Aging population is one of the most salient and ever-expanding issues affecting healthcare for the foreseeable future. Defining and implementing optimal perioperative care for this aging population is of increasing importance. During surgery, preserving brain perfusion is probably one of the most important parts of hemodynamic management and can be appropriately achieved by using several available cardiovascular and neurologic monitoring tools.
Mahajan A, Islam S, Schwartz M, Cannesson M. A hospital is not just a factory, but a complex adaptive system – Implications for perioperative care. Anesthesia & Analgesia: July 2017 – Vol 125, p 333-341.
The authors make the case that a hospital is not essentially a factory, and that engineering and manufacturing-derived redesign approaches will work only for noncomplex, low-variance, high-volume surgical episodes. Complex surgery and high-variance cases should be viewed as “complex adaptive systems”, which tend to self-organize and may resist or adapt unpredictably to attempts at control. Both approaches may be appropriate within the same hospital, and should be viewed as complementary rather than competitive.
Borna RM, Jahr JS, Kmiecik S, Mancuso KF, Kaye AD. Pharmacology of Octreotide: Clinical Implications for Anesthesiologists and Associated Risks. Anesthesiol Clin. 2017 Jun;35(2):327-339. doi: 10.1016/j.anclin.2017.01.021. http://www.anesthesiology.theclinics.com/article/S1932-2275(17)30026-5/abstract
Patients presenting with a history of foregut, midgut NETs or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high dose octreotide, which can minimize the incidence of intraoperative carcinoid crises. We recommend administration of a prophylactic 500 mcg bolus of octreotide intravenously and begin a continuous infusion of 500 mcg/hr for all NET patients during surgery, regardless of the location of their primary tumor or functional status. Advantages of octreotide include low cost of an infusion and excellent safety profile.
Jahr JS, Bergese SD, Sheth KR, Bernthal NM, Ho HS, Apfel CC. Current perspective on the use of opioids in perioperative practice: a multidisciplinary clinical appraisal. In Press, Pain Medicine, 2017.
With the current opioid epidemic and clinicians eager to find newer ways to treat acute pain, a multidisciplinary clinical appraisal surveyed 70,000 American Medical Association anesthesiologists, surgeons and orthopedists, to determine their preferred multimodal analgesia, and a panel also evaluated available modes of analgesia. The consensus was that multimodal analgesia, utilizing local anesthesia whenever possible, and non-opiate alternatives as analgesics, are the preferred methods of treatment.
Bernthal NM, Sheth KR, Bergese SD, Ho HS, Stoicea N, Apfel CC, Jahr JS. Non-steroidal anti-inflammatory drugs (NSAIDs) for pain management in joint surgery: an evidence-based literature review, national survey of physicians, and appraisal of the current clinical and scientific evidence. Accepted with revisions, just resubmitted, Journal of the American Orthopedic Society (JAAOS), 2017.
While growing evidence demonstrates the benefits of non-steroidal anti-inflammatory drugs (NSAIDS) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery. There is convincing evidence that NSAIDS administered locally in the joint provide pain management benefits following orthopeic procedures, yet questions remain about how to most effectively deliver NSAIDs to the joint, and improve availability and duration of effect.
V, Tieman D, Park E, Salehi A. Alpha-2 Agonists. Anesthesiology Clinics June 2017, Vol 35 233-245
Alpha-2 agonists have sedative, anxiolytic, analgesic and sympatholytic properties which allow for a wide variety of applications in anestheisology practice.
Brent D Ershoff, Christine K Lee, Christopher L Wray, Vatche G Agopian, Gregor Urban, Pierre Baldi, Maxime Cannesson. Training and Validation of Deep Neural Networks for the Prediction of 90-Day Post-Liver Transplant Mortality Using UNOS Registry Data. Transplant Proc. 2020;52(1):246-258. doi:10.1016/j.transproceed.2019.10.019. https://www.sciencedirect.com/science/article/pii/S0041134519309315#!
The development of predictive models of post-transplant mortality is crucial to avoid transplanting an individual with an unacceptably low probability of post-transplant survival.
Lapisatepun W, Lapisatepun W, Agopian V, Xia VW.Lapisatepun W, et al. Venovenous Bypass During Liver Transplantation: A New Look at an Old Technique. Transplant Proc. 2020 Apr;52(3):905-909. doi: 10.1016/j.transproceed.2020.01.048. Epub 2020 Feb 27.Transplant Proc. 2020.PMID: 32113694. https://pubmed.ncbi.nlm.nih.gov/32113694/
Venovenous bypass (VVB) is a technique that was developed in the 1980s to mitigate untoward hemodynamic effects of complete cross-clamping of the inferior vena cava during liver transplantation (LT). Since the introduction of nonclassic surgical techniques, the interest in using VVB has decreased. Despite this, VVB is still commonly practiced today. In the last 2 decades, significant changes have been made in many aspects of LT. Here, we review new developments in VVB.
Sun K, Wang Y, Yan M, Xia VW.Sun K, et al. Pretransplant Left Ventricular Hypertrophy in Association With Postoperative Myocardial Injury in Liver Transplantation. Clin Transplant. 2020 May;34(5):e13847. doi: 10.1111/ctr.13847. Epub 2020 Mar 16.Clin Transplant. 2020.PMID: 32097498. https://pubmed.ncbi.nlm.nih.gov/32097498/
Pretransplant left ventricular hypertrophy (LVH) is a common finding during preoperative cardiac evaluation. We hypothesized that patients with pretransplant LVH were associated with a higher risk of postoperative myocardial injury (PMI) in adult patients undergoing liver transplantation (LT).
Gao W, Li J, Nguyen-Buckley C, Nguyen-Lee J, Wray C, Agopian V, Busuttil RW, Steadman RH, Xia VW.Gao W, et al. Intraoperative Hypertension and Thrombocytopenia Associated With Intracranial Hemorrhage After Liver Transplantation. Transplantation. 2020 Mar;104(3):535-541. doi: 10.1097/TP.0000000000002899.Transplantation. 2020.PMID: 31397798. https://pubmed.ncbi.nlm.nih.gov/31397798/
Intracranial hemorrhage (ICH) is a devastating complication. Although hypertension and thrombocytopenia are well-known risk factors for ICH in the general population, their roles in ICH after liver transplantation (LT) have not been well established. We performed a retrospective study and hypothesized that intraoperative hypertension and thrombocytopenia were associated with posttransplant ICH.
Nguyen-Buckley C, Wray CL, Zerillo J, et al. Recommendations From the Society for the Advancement of Transplant Anesthesiology: Liver Transplant Anesthesiology Fellowship Core Competencies and Milestones. Semin Cardiothorac Vasc Anesth. 2019;23(4):399-408. doi:10.1177/1089253219868918. Epub 2019 Aug 12. https://pubmed.ncbi.nlm.nih.gov/31402752/
Using the Accreditation Council for Graduate Medical Education guidelines for residency training as a model, the Society for the Advancement of Transplant Anesthesia Fellowship Committee in conjunction with the Liver Transplant Anesthesia Fellowship Task Force has developed the first proposed standardized core competencies and milestones for fellowship training in liver transplant anesthesiology.
Sun K, Wang Y, Yan M, Xia VW.Sun K, et al. Mild Preoperative Systolic Dysfunction Associated With the Use of Intraoperative Vasopressors but Not Postoperative Survival in Liver Transplantation. Transplant Proc. 2019 Jul-Aug;51(6):1892-1894.
doi: 10.1016/j.transproceed.2019.03.037. Epub 2019 Jun 24.Transplant Proc. 2019.PMID: 31248608. https://pubmed.ncbi.nlm.nih.gov/31248608/
Mild left ventricular systolic dysfunction (LVSD) is common in patients waiting for liver transplantation (LT), but its impact on intraoperative management and survival is poorly understood. In this study, we investigated if mild pretransplant LVSD was associated with the use of intraoperative vasopressors and 1-year survival after LT.
Agopian VG, Harlander-Locke MP, Markovic D, Dumronggittigule W, Xia V, Kaldas FM, Zarrinpar A, Yersiz H, Farmer DG, Hiatt JR, Busuttil RW. Evaluation of Early Allograft Function Using the Liver Graft Assessment Following Transplantation Risk Score Model. Jama Surg. 2018; 153:436-444. doi: 10.1001/jamasurg.2017.5040. https://www.ncbi.nlm.nih.gov/pubmed/29261831
The L-GrAFT risk score allows a highly accurate, individualized risk estimation of 3-month graft failure following LT that is more accurate than existing EAD and MEAF scores. Multicenter validation may allow for the adoption of L-GrAFT as a tool for evaluating the need for a retransplant, for establishing standardized grading of early allograft function across transplant centers, and as a highly accurate clinical end point in translational studies aiming to mitigate ischemia or reperfusion injury by modulating donor quality and recipient factors.
Fu H, Sun K, Li J, Gong W, Agopian V, Yan M, Busuttil RW, Steadman RH, Xia VW. Preoperative beta blockade and severe intraoperative bradycardia in liver transplantation. Clin Transplant. 2018 Oct 12:e13422. doi: 10.1111/ctr.13422. https://www.ncbi.nlm.nih.gov/pubmed/30312516
Preoperative NSBB was associated with severe intraoperative bradycardia in LT. In patients who receive preoperative NSBB, severe intraoperative bradycardia should be closely monitored in LT. Further studies assessing safety of preoperative NSBB and intraoperative bradycardia in LT are warranted.
Ershoff BD, Gordin JS, Vorobiof G, Elashoff D, Steadman RH, Scovotti JC, Wray CL. Improving the Prediction of Mortality in the High Model for End-Stage Liver Disease Score Liver Transplant Recipient: A Role for the Left Atrial Volume Index. Transplant Proc. 2018 Jun;(50)5:1407-1412. doi: 10.1016/j.transproceed.2018.03.017. PMID: 29880363
Left atrial volume index (LAVI) is an echocardiographic measurement used in assessing diastolic dysfunction, and is associated with mortality in many populations. In this retrospective cohort study including 254 patients, we investigated whether LAVI is an independent predictor of post-liver transplantation mortality using multivariable Cox regression. We further show that the inclusion of LAVI in multivariable model led to a statistically significant improvement in the ability to predict post-liver transplantation mortality. The incorporation of LAVI inb multivariable risk moels may be useful in the selection of transplant recipients with high MELD scores, and may be helpful in decreasing the probability of futile transplantation.
Xia V, Braunfeld M. Anesthesia management for organ donor. Anesth Clin 2017; 35(3):395-406. doi: 10.1016/j.anclin.2017.04.003. https://www.ncbi.nlm.nih.gov/pubmed/28784216
Potential organs for transplant need to maintain their viability during a series of insults, including the original disease, physiologic derangements during the dying process, ischemia, and reperfusion. Proper donor management before, during, and after procurement has potential to increase the number and qualityof organs from donors. Anesthesiologists need to understand the phsiologic derangements associated with brain death and the updated donor management during the periprocurement period.
Agopian VG, Busuttil RW, Hong F, Min Y, Steadman RH, Wang Y, Xia VW. Venovenous Bypass Is Associated with a Lower Incidence of Acute Kidney Injury After Liver Transplantation in Patients with Compromised Pretransplant Renal Function. Anesthesia & Analgesia. 2017 Nov;125(5):1463-1470. doi: 10.1213/ANE.0000000000002311. https://www.ncbi.nlm.nih.gov/pubmed/28742776
The aim of this large retroactive study was to determine if VVB was associated with a lower incidence of posttransplant acute kidney injury (AKI). We demonstrated that utilization of intraoperative VVB was associated with a significantly lower incidence of posttransplant AKI in patients with compromised pretransplant renal function.
Wray, CL. Liver Transplantation in Patients With Cardiac Disease. Semin Cardiothorac Vasc Anesth. 2017 October; 1:1089253217736050. doi: 10.1177/1089253217736050 PMID: 29025297 https://www.ncbi.nlm.nih.gov/pubmed/29025297
A wide range of cardiovascular disorders may affect the LT patient. However, cardiac conditions that are most common in LT candidates include coronary artery disease (CAD), cirrhotic cardiomyopathy (CCM), and structural heart disease. In this review, these conditions are explored in the context of the perioperative cardiac evaluation of LT candidates.
Lunsford KE, Bodzin AS, Markovic D, Zarrinpar A, Kaldas FM, Gritsch HA, Xia V, Farmer DG, Danovitch GM, Hiatt JR, Busuttil RW, Agopian VG. Avoiding Futility in Simultaneous Liver-kidney Transplantation: Analysis of 331 Consecutive Patients Listed for Dual Organ Replacement. Ann Surg. 2017 May;265(5):1016-1024. doi: 10.1097/SLA.0000000000001801. PMID:27232249. https://www.ncbi.nlm.nih.gov/pubmed/27232249
We sought to evaluate outcomes and predictors of renal allograft futility (RAF-patient death or need for renal replacement therapy at 3 months) after simultaneous liver-kidney transplantation (SLKT). A retrospective single-center multivariate regression analysis was performed for adult patients undergoing SLKT. With 20% short-term loss of transplanted kidneys after SLKT, our data strongly suggest that renal transplantation should be deferred in liver recipients at high risk for RAF. Consideration for a kidney allocation variance to allow for delayed renal transplantation after liver transplantation may prevent loss of scarce renal allografts.
Huang S, Apinyachon W, Agopian VG, Wray CL, Busuttil RW, Steadman RH, Xia VW. Myocardial injury in patients with hemodynamic derangements during and/or after liver transplantation. Clin Transplant. 2016 Dec;30(12):1552-1557. doi: 10.1111/ctr.12855. Epub 2016 Oct 14. PMID:27653509 https://www.ncbi.nlm.nih.gov/pubmed/27653509
Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT were studied. We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.
Wang A, An X, Xia VW. Female Gender of the Recipient Is Independently Associated With Prolonged Ventilation Time and Hospital Stay After Liver Transplantation. Transplant Proc. 2016 Jan-Feb;48(1):120-2. doi: 10.1016/j.transproceed.2016.01.004. PMID:26915855. https://www.ncbi.nlm.nih.gov/pubmed/26915855
The aims of this study were to investigate the relationship between female gender and ventilation time and hospital stay after OLT. Female gender of the recipient is associated with significantly longer ventilation time and hospital stay after OLT and the management should be tailored to the unique characteristics and susceptibility to postoperative complications in female patients.
Zhao W, Ge X, Sun K, Agopian VG, Wang Y, Yan M, Busuttil RW, Steadman RH, Xia VW. Acute respiratory distress syndrome after orthotopic liver transplantation. J Crit Care. 2016 Feb;31(1):163-7. doi: 10.1016/j.jcrc.2015.09.028. Epub 2015 Oct 5. PMID:26601754. https://www.ncbi.nlm.nih.gov/pubmed/26601754
The aims of this study were to identify the incidence, preoperative and intraoperative risk factors, and impact of ARDS on outcomes in patients after orthotopic liver transplantation (OLT). Acute respiratory distress syndrome occurred at a rate of 4.1% following OLT in adult patients and was associated with preoperative encephalopathy, requirement of intubation, and total bilirubin and intraoperative large boluses of pressors. Acute respiratory distress syndrome was associated with increased mortality, longer ventilation time, and hospital stay.
Tiffany Y Hu, Sophie M Peeters, Daniel T Nagasawa, Nirav V Kamdar, Rachel P Brook, Jesse Sun, Sandy Park, Natalie C Moreland, Daniel Cruz, Luke Macyszyn, Marcella Calfon Press. Cangrelor Bridging Within 6 Months of a Drug-Eluting Stent in a Patient for Emergency Cervical Spine Surgery: A Case Report. A A Pract. 2019;13(2):69-73. doi:10.1213/XAA.0000000000000994. PMID: 30864953
The recommended duration of dual antiplatelet therapy after drug-eluting stent placement presents a dilemma for patients with recent stenting who require urgent or emergency noncardiac surgery. We present the case of a patient with recent drug-eluting stent placement (
Malekmohammadi M, Price CM, Hudson AE, DiCesare JAT, Pouratian N. Propofol-induced Loss of Consciousness Is Associated With a Decrease in Thalamocortical Connectivity in Humans. Brain. 2019 Aug 1;142(8):2288-2302. doi: 10.1093/brain/awz169. PMID: 31236577.
Although the molecular effects of many anaesthetics have been well characterized, a network-level explanation for how these changes lead to loss of consciousness remains unclear. Studies using electroencephalography have characterized changes in neural oscillations in the cortex at specific frequency bands during propofol-induced anaesthesia and modelling work suggests these changes result from changes in thalamocortical functional connectivity. The authors' observations support the theory that propofol-induced loss of consciousness is associated with disrupted thalamocortical communication.
Hudson, AE. Anesthesia as Decoupling? Anesthesiology Newly Published on May 26, 2020. https://doi.org/10.1097/ALN.0000000000003366
A cardinal effect of general anesthetics is loss of consciousness. However, disruption of consciousness may be a happy accident; that is, the fundamental common mechanism of anesthetic drug effect may have nothing to do with a special targeting of conscious processing, as opposed to a generic effect on all neurons. An emerging view is that the common effect of general anesthetics is to increase the modularity of communication networks—that is, anesthetics interrupt connections that normally exist between networks so that the networks are dominated by local activity—thereby disrupting the efficiency of information transfer through the organism and isolating the organism from its surroundings.
Jun H, Vacas S, et al. Dexmedetomidine prevents cognitive decline by enhancing resolution of High Mobility Group Box 1 protein-induced inflammation through a vagomimetic action in mice. Anesthesiology 5 2018, Vol.128, 921-931. doi:10.1097/ALN.0000000000002038
Inflammation initiated by damage-associated molecular patterns has been implicated for the cognitive decline associated with surgical trauma and serious illness. We determined whether resolution of inflammation mediates dexmedetomidine-induced reduction of damage-associated molecular pattern-induced cognitive decline. Conclusion: Dexmedetomidine resolves inflammation through vagomimetic (neural) and humoral pathways, thereby preventing damage-associated molecular pattern-induced cognitive decline.
Vacas S, Van de Wiele B. Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices. Surg Neurol Int. 2017 Dec 6;8:291. doi: 10.4103/sni.sni_301_17. eCollection 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/29285407/
Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain. Development of standardized pain management and enhanced recovery after surgery (ERAS) protocols are necessary and crucial to optimize outcomes and patient satisfaction and reduce health care costs. Strategies to ameliorate craniotomy pain demand interventions during all phases of patient care: preoperative, intraoperative, and postoperative interventions. Opioids remain the mainstay for pain relief, but patient-controlled analgesia, NSAIDs, standardization of pain management, bio/behavioral interventions, modification of head dressings as well as patient-centric management are useful opportunities that potentially improve patient care.
Blumenthal E, Rao R, Murphy A, Gornbein J, Hong R, Mariarty JM, Kahn DA, Janzen C. Pilot Study of Intra-Aortic Balloon Occlusion to Limit Morbidity in Patients with Adherent Placentation Undergoing Cesarean Hysterectomy. American Journal of Perinatology Reports, Vol. 8, No. 2, pp. e57-63. doi: 10.1055/s-0038-1641736
We study whether using an intra-aortic balloon (IAB) during cesarean hysterectomy decreases delivery morbidity in 35 patients with suspected morbidly adherent placentation. We did not detect statistically significant differences in overal surgical complications, bladder complications, ICU admissions, surgical duration ot blood transfusions. However, larger studies may be warranted given the potential for extreme morbidity in these cases.
Lenis AT1, Golla V, Lec PM, Johnson DC, Faiena I, Lee C, Rahman S, Chamie K. The association between N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, and clinical outcomes in patients undergoing robotic-assisted radical cystectomy. World Journal of Urology, 17 Feb 2020. DOI: 10.1007/s00345-020-03117-y.
To assess the impact of N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, on the post-operative recovery of patients undergoing robotic-assisted radical cystectomy for bladder cancer.
Kim SS, Niu X, Elliott IA, Jiang JP, Dann AM, Damato LM, Chung H, Girgis MD, King JC, Hines OJ, Rahman S, Donahue TR. Epidural Analgesia Improves Postoperative Pain Control but Impedes Early Discharge in Patients Undergoing Pancreatic Surgery. Pancreas. 2019 May/Jun;48(5):719-725. doi: 10.1097/MPA.0000000000001311. https://journals.lww.com/pancreasjournal/Fulltext/2019/05000/Epidural_Analgesia_Improves_Postoperative_Pain.20.aspx
The aim of this study was to evaluate the impact of epidural analgesia (EA) on postoperative length of stay (LOS), expeditious discharge, and pain relief after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).
Kamdar N, Hoftman N, Rahman S, Cannesson, M. Opioid-Free Analgesia in the Era of Enhanced Recovery After Surgery and the Surgical Home: Implications for Postoperative Outcomes and Population Health. Anesthesia & Analgesia, Vol. 125, No. 4, pp. 1089-91.
Aggressive opioid-based postoperative pain control has been demonized as a major contributor to the national opioid addiction epidemic and its associated morbidity, ultimately leading to many preventable deaths. We must actively work to curtail the detrimental path from acute surgical pain to chronic pain syndromes that may culminate in opioid addiction.
Sniderman, M. Epidural Injections Contraindicated for Lumbar Radiculopathy in May-Thurner Syndrome: A Case Report. A&A Case Reports: Post Author Corrections: July 10, 2017 doi: 10.1213/XAA.0000000000000597
Lumbar radiculopathy is one of the most common reasons patients see a pain doctor. Unfortunately, when IVC obstruction is causing the symptoms, routine epidural injections will not help.
Jonathan S. Jahr, MD Sergio D. Bergese, MD Ketan R. Sheth, MD, FACS Nicholas M. Bernthal, MD Hung S. Ho, MD, FACS Nicoleta Stoicea, MD, PhD Christian C. Apfel, MD, PhD, MBA. Current Perspective on the Use of Opioids in Perioperative Medicine: An Evidence-Based Literature Review, National Survey of 70,000 Physicians, and Multidisciplinary Clinical Appraisal. Pain Medicine, pnx191, https://doi.org/10.1093/pm/pnx191. Published: 16 August 2017
Opioids remain a key component of multimodal perioperative analgesia, and strategic opioid use based on clinical considerations and patient-specific needs represents an opportunity to support improved postoperative outcomes and satisfaction. Future studies should focus on identifying optimal procedure-specific and patient-centered approaches to multimodal perioperative analgesia.
Iravani M, Lee L, Cannesson M. Standardized care versus precision medicine in the perioperative setting: Can point-of-care testing help bridge the gap? Anesthesia & Analgesia: April 2017 – Vol 124, p 1347-1353.
The authors analyzed the tension between the need to develop efficient, reproducible protocols for healthcare, and the equally compelling need to use the tools of genetics and genomics to provide patients with individualized “precision” health care. They suggest that as point-of-care (POC) testing is becoming better and faster, soon patients may undergo targeted genetic testing during preoperative visits, enabling precise selection of medications for intraoperative and postoperative management depending on the findings.
Hoftman N, Eikermann E, Shin J, Buckley J, Navab K, Abtin F, Grogan T, Cannesson M, Mahajan A. Utilizing Forced Vital Capacity to Predict Low Lung Compliance and Select Intraoperative Tidal Volume During Thoracic Surgery. Anesthesia & Analgesia: Published online ahead of print, 2017 March 8.
Tidal volume selection during mechanical ventilation utilizes dogmatic formulas that only consider a patient's predicted body weight (PBW). In this study, the authors investigate whether forced vital capacity (FVC) correlates better to total lung capacity than PBW, predicts low pulmonary compliance, and provides an alternative method for tidal volume selection. FVC is more strongly correlated to total lung capacity than to PBW, and a cutoff of about 3.5 L can be utilized to predict low pulmonary compliance.
Buckley JC, Brown AP, Shin JS, Rogers KM, Hoftman NN. A Comparison of the Haider Tube-Guard(R) Endotracheal Tube Holder Versus Adhesive Tape to Determine if This Novel Device Can Reduce Endotracheal Tube Movement and Prevent Unplanned Extubation. Anesthesia & Analgesia: 2016 May; 122(5): 1439-43. doi: 10.1213/ANE.0000000000001222. https://www.ncbi.nlm.nih.gov/pubmed/26983051
This clinical trial compared the standard tape method for securing endotracheal tubes during surgery to the Haider Tube Guard, a novel device designed to secure an endotracheal tube. With each patient acting has their own control, the ETT was secured with tape and a 15N force applied. A bronchoscope was then used to measure ETT movement within the airway, and the experiment was then repeated, this time with the Haider TubeGuard securing the ETT. Study results demonstrated that the Haider TubeGuard was superior at securing the ETT compared to all standard tapes, reducing both mean motion as well as potential extubation.