HNF4A-related Fanconi syndrome in a Chinese patient: a case report and review of the literature

The p.R63W mutation in hepatocyte nuclear factor-4 alpha (HNF4A) leads to a heterogeneous group of disorders with various clinical presentations. Recently, patients with congenital hyperinsulinism and Fanconi syn...

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Virtual Reality Analgesia in Labor: The VRAIL Pilot Study—A Preliminary Randomized Controlled Trial Suggesting Benefit of Immersive Virtual Reality Analgesia in Unmedicated Laboring Women

This pilot study investigated the use of virtual reality (VR) in laboring women. Twenty-seven women were observed for equivalent time during unmedicated contractions in the first stage of labor both with and without VR (order balanced and randomized). Numeric rating scale scores were collected after both study conditions. Significant decreases in sensory pain −1.5 (95% CI, −0.8 to −2.2), affective pain −2.5 (95% CI, −1.6 to −3.3), cognitive pain −3.1 (95% CI, −2.4 to −3.8), and anxiety −1.5 (95% CI, −0.8 to −2.3) were observed during VR. Results suggest that VR is a potentially effective technique for improving pain and anxiety during labor. Accepted for publication June 6, 2018. D. P. Frey is currently affiliated with the Oregon Anesthesiology Group, Obstetric Anesthesiology, Providence Portland Medical Center, Portland, Funding: Funding for this study was provided by the Department of Anesthesiology, University of Michigan as well as in part by the National Institutes of Health (AR054115 and GM042725). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Clinical trial: NCT02926469 at https://ift.tt/2zCUsXv. Reprints will not be available from the authors. Address correspondence to David P. Frey, DO, Oregon Anesthesiology Group, Obstetric Anesthesiology, Providence Portland Medical Center, 707 SW Washington St, Suite 700, Portland, OR 97205. Address e-mail to VRAILQuestions@gmail.com. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Frequency of Operative Anesthesia Care After Traumatic Injury

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I–V), using data from a comprehensive, regional database—the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III–V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P

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A Systematic Review Evaluating Neuraxial Morphine and Diamorphine-Associated Respiratory Depression After Cesarean Delivery

The prevalence of neuraxial opioid–induced clinically significant respiratory depression (CSRD) after cesarean delivery is unknown. We sought to review reported cases of author-reported respiratory depression (ARD) to calculate CSRD prevalence. A 6-database literature search was performed to identify ARD secondary to neuraxial morphine or diamorphine, in parturients undergoing cesarean delivery. "Highest" (definite and probable/possible) and "lowest" (definite) prevalences of CSRD were calculated. Secondary outcomes included: (1) prevalence of CSRD associated with contemporary doses of neuraxial opioid, (2) prevalence of ARD as defined by each study's own criteria, (3) case reports of ARD, and (4) reports of ARD reported by the Anesthesia Closed Claims Project database between 1990 and 2016. We identified 78 articles with 18,455 parturients receiving neuraxial morphine or diamorphine for cesarean delivery. The highest and lowest prevalences of CSRD with all doses of neuraxial opioids were 8.67 per 10,000 (95% CI, 4.20–15.16) and 5.96 per 10,000 (95% CI, 2.23–11.28), respectively. The highest and lowest prevalences of CSRD with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62–8.77) and 1.08 per 10,000 (95% CI, 0.24–7.22), respectively. The prevalence of ARD as defined by each individual paper was 61 per 10,000 (95% CI, 51–74). One published case report of ARD met our inclusion criteria, and there were no cases of ARD from the Closed Claims database analysis. These results indicate that the prevalence of CSRD due to neuraxial morphine or diamorphine in the obstetric population is low. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Accepted for publication May 31, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Nadir Sharawi, MBBS, FRCA, MSc, Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 515, Little Rock, AR 72205. Address e-mail to nelsharawi@uams.edu. © 2018 International Anesthesia Research Society

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Ability of a New Smartphone Pulse Pressure Variation and Cardiac Output Application to Predict Fluid Responsiveness in Patients Undergoing Cardiac Surgery

BACKGROUND: Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS: We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32–36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS: Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60–0.84] vs 0.68 [0.54–0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54–0.92) and a specificity of 74% (95% CI, 0.55–0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42–0.88) and a specificity of 74% (95% CI, 0.48–0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP= 0.818 [P = .0001]; PPVPC= 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP= 0.645 [P = .19]; PPVPC= 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: −2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66–77). CONCLUSIONS: In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness. Accepted for publication June 7, 2018. A. Joosten and C. Boudart contributed equally and share first authorship. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Registration: Clinicaltrials.gov (NCT02692222). Reprints will not be available from the authors. Address correspondence to Alexandre Joosten, MD, Department of Anesthesiology, Hopital Erasme, 808 Rt de Lennik, 1070 Bruxelles, Brussels, Belgium. Address e-mail to Alexandre.Joosten@erasme.ulb.ac.be. © 2018 International Anesthesia Research Society

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Did ultrasound fulfill the promise of safety in regional anesthesia?

Purpose of review Ultrasound guidance has become the accepted standard of practice for peripheral regional anesthesia. Despite evidence supporting the efficacy of ultrasound-guided regional anesthesia, its impact on patient safety has been less clear. Recent findings Evidence has been consistent that ultrasound guidance reduces the incidence of vascular injury, local anesthetic systemic toxicity, pneumothorax and phrenic nerve block. Within the limited global scope of the epidemiology and etiologic complexity of perioperative (including block-related) peripheral nerve injury, there has not been consistent evidence that ultrasound guidance is associated with a reduced incidence of nerve injury. However, a recently published retrospective cohort study has demonstrated that the incidence of short-term nerve injury was decreased with ultrasound guidance compared with nerve stimulation. Ultrasound has led to development of novel blocks, approaches and refinement of existing ones, which may contribute to patient safety. Summary Ultrasound has revolutionized the way we approach regional anesthesia and contributed to patient safety. It is important to note that patient safety does not hinge on one single technology. Patient safety in regional anesthesia relies on a well trained practitioner to pay meticulous attention to indication, block and patient selection, anatomy, pharmacology, equipment and technique. Correspondence to Michael J. Barrington, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia. Tel: +61 3 9288 2211; e-mail: Michael.BARRINGTON@svha.org.au Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Traumatic brain injured patients: primum non nocere

Purpose of review Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI. Recent findings Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired. Summary Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population. Correspondence to Dr Dhuleep S. Wijayatilake, Department of Anaesthesia and Intensive Care Medicine, Queens Hospital, Rom Valley Way, Romford RM7 0AG, UK. Tel: +44 1708503727; e-mail: sanjay.wijayatilake@nhs.net Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Stratification of neuropathic pain patients: the road to mechanism-based therapy?

Purpose of review It has been demonstrated that within one pain entity, patients may report highly heterogenic sensory signs and symptoms. Although mechanism might differ fundamentally between those patients, yet the treatment recommendations are uniform throughout all phenotypes. Therefore, the introduction of new stratification tools could pave the way to an individualized pain treatment. Recent findings In the past, retrospective stratifications of patients successfully identified responders to certain pharmacological treatments. This indicated predictive validity and reliability of this classification tool in those patient subgroups. Further on, these observations have been confirmed in prospective studies. Summary This review focusses on recent achievements in neuropathic pain and suggests a promising implementation of an individualized pharmacological therapy in the future. Correspondence to Dr Ralf Baron, MD, Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany. Tel: +49 431 500 23911; fax: +49 431 500 23914; e-mail: r.baron@neurologie.uni-kiel.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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New blocks for the same old joints

Purpose of review New block techniques are being constantly developed or old techniques modified to improve outcomes after surgery. This review discusses the reasons why new block techniques need to be developed to match the needs of contemporary anesthetic practice. Recent findings New block techniques have been developed for joint surgeries of both upper and lower extremities. New upper extremity blocks focus on decreasing the risk of complications like diaphragmatic paresis and improving the quality of blocks. Techniques for lower extremity surgeries are being performed distally, closer to the joints, to minimize weakness of the extremity. A review of the available evidence for these techniques is undertaken to get an understanding of the indications and limitations of these techniques. Summary Future studies need to be undertaken to further refine these techniques and produce evidence of support for analgesic efficacy, safety, and reliability. Correspondence to Sanjay K. Sinha, MBBS, Department of Anesthesiology, St. Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105, USA. E-mail: sanjaysinha@comcast.net Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Regional anesthesia by nonanesthesiologists

Purpose of review As the evidence supporting the notion that regional anesthesia improves patient outcomes grows, utilization of regional anesthesia techniques has similarly increased. Best care should not be restricted by the background of care providers, however, the evidence replicating benefits of regional anesthesia when it is delivered by nonanesthesiologists is unclear. In this review, the provision of regional anesthesia by nonanesthesiologists is discussed so that readers can come to their own conclusions. Recent findings Regional anesthesia procedures are performed by nonanesthesiology physicians such as emergency physicians, critical care specialists, and surgeons. Patients benefit from the provision of regional anesthesia by these groups, but inconsistencies exist in training, service provision, and collaboration between these specialties and anesthesiologists. Nonphysician anesthesia providers also provide regional anesthesia. There are limited data on outcomes or benefits of this nonphysician-provided service, but consideration of team-based care and alternative models of care based upon geographical need is worthwhile. Summary The provision of regional anesthesia requires the accumulation of a suitable knowledge, skills, and behaviors that can be taught. Whilst it may not be appropriate for all techniques to be performed by all individuals, the possession of these competencies with the appropriate training and quality assurance means that more patients may ultimately benefit from the provision of regional anesthesia services. Correspondence to Amit Pawa, BSc(Hons), MBBS(Hons), FRCA, EDRA, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, SE1 9RT London, UK. Tel: +44 207 188 0644; fax: +44 207 188 0642; e-mail: amit.pawa@gstt.nhs.uk. Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Neuroanesthesiology: building the path to superior clinical care through research and education

No abstract available

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