Gender Inequality in Anesthesiology Research: An Overview of 2018

No abstract available

http://bit.ly/2Ig8HWe

Transient Tachypnea of Newborns Is Associated With Maternal Spinal Hypotension During Elective Cesarean Delivery: A Retrospective Cohort Study

BACKGROUND: The risk for transient tachypnea of newborns, a common cause of respiratory distress in the neonatal period, is 2- to 6-fold higher during elective cesarean delivery compared to vaginal delivery. Here, we evaluated the association between transient tachypnea of newborns and the degree and duration of predelivery maternal hypotension during spinal anesthesia for elective cesarean delivery. METHODS: Demographic data, details of anesthetic management, blood pressure measurements, and vasopressor requirement preceding delivery were compared between transient tachypnea newborns (n = 30) and healthy neonates (n = 151) with normal respiratory function born via elective cesarean delivery between July 2015 and February 2016. The degree and duration of hypotension were assessed using area under the curve for systolic blood pressure (SBP) ≤90 mm Hg and area under the curve for mean arterial pressure ≤65 mm Hg. After adjusting for confounders, multivariable logistic regression was used to evaluate the association between area under the curve for SBP and transient tachypnea of newborns. RESULTS: The median area under the curve for SBP was higher in cases of transient tachypnea of newborns (0.94; interquartile range, 0–28.7 mm Hg*min) compared to healthy controls (0; interquartile range, 0–3.30 mm Hg*min; P = .001). Similarly, median area under the curve for mean arterial pressure was also higher in cases of transient tachypnea of newborns (0; interquartile range, 0–18.6 mm Hg*min) compared to controls (0; interquartile range, 0–1.1 mm Hg*min; P = .01). Mothers of transient tachypnea newborns received significantly higher amounts of phenylephrine and ephedrine compared to controls (P = .001 and 0.01, respectively). Hence, the total vasopressor dose given to mothers in the transient tachypnea of newborn group was much higher than for the control group (P = .001). In the multivariable logistic regression, area under the curve for SBP was significantly associated with transient tachypnea of newborns (odds ratio, 1.02; 95% CI, 1.01–1.04, P = .005) after adjusting for gravidity and the type of anesthetic (spinal versus combined spinal epidural). CONCLUSIONS: Our results suggest that the degree and duration of maternal SBP

http://bit.ly/2GrRU0Y

Consensus Statement of the Malignant Hyperthermia Association of the United States on Unresolved Clinical Questions Concerning the Management of Patients With Malignant Hyperthermia

At a recent consensus conference, the Malignant Hyperthermia Association of the United States addressed 6 important and unresolved clinical questions concerning the optimal management of patients with malignant hyperthermia (MH) susceptibility or acute MH. They include: (1) How much dantrolene should be available in facilities where volatile agents are not available or administered, and succinylcholine is only stocked on site for emergency purposes? (2) What defines masseter muscle rigidity? What is its relationship to MH, and how should it be managed when it occurs? (3) What is the relationship between MH susceptibility and heat- or exercise-related rhabdomyolysis? (4) What evidence-based interventions should be recommended to alleviate hyperthermia associated with MH? (5) After treatment of acute MH, how much dantrolene should be administered and for how long? What criteria should be used to determine stopping treatment with dantrolene? (6) Can patients with a suspected personal or family history of MH be safely anesthetized before diagnostic testing? This report describes the consensus process and the outcomes for each of the foregoing unanswered clinical questions. Accepted for publication December 2, 2018. Funding: Travel, hotel, and some food expenses for the attendees at the consensus meeting were paid by the Malignant Hyperthermia Association of the United States The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Ronald S. Litman, DO, ML, Department of Anesthesiology & Critical Care, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104. Address e-mail to litmanr@email.chop.edu. © 2019 International Anesthesia Research Society

http://bit.ly/2Ii8YIm

In Response

No abstract available

http://bit.ly/2GsTGi3

Perioperative Epidural Use and Risk of Delirium in Surgical Patients: A Secondary Analysis of the PODCAST Trial

BACKGROUND: Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3. METHODS: This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding. RESULTS: In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32–1.35]; P= .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17–0.78]; P= .009). Adjusted pain scores (visual analog scale, 0–100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, −16 [95% CI, −26 to −7], P

http://bit.ly/2IdBE56

Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring

No abstract available

http://bit.ly/2GqnE6p

Clot Retraction: Lost in Interpretation?

No abstract available

http://bit.ly/2GsFu8K

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy

Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes. Accepted for publication December 11, 2018. Conflicts of Interest: See Disclosures at the end of the article. Funding: D.A.E. has received research support from Semnur Inc and Grunenthal for research unrelated to the topic or production of this manuscript. T.E.M. received research funding and is a consultant for Edwards Lifesciences and for Mallinckrodt. M.D.E. received research funding from the GE Foundation, Edwards Lifesciences, and Cheetah Medical for projects unrelated to this manuscript. The Perioperative Quality Initiative-4 consensus conference was supported by unrestricted educational grants from the American Society for Enhanced Recovery and the Perioperative Quality Initiative, which have received grants from Baxter, Bev MD, Cadence, Cheetah Medical, Edwards, Heron Pharmaceutical, Mallinckrodt, Medtronic, Merck, Trevena, and Pacira 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 (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to David A. Edwards, MD, PhD, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN. Address e-mail to david.a.edwards@vanderbilt.edu. © 2019 International Anesthesia Research Society

http://bit.ly/2Ig8DWu

Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients With Normal Airways

BACKGROUND: During induction of general anesthesia, it is common practice to delay neuromuscular blockade until the ability to deliver mask ventilation has been confirmed. However, the benefits of this approach have never been scientifically validated. We thus compared the early and late administration of rocuronium before and after checking mask ventilation to investigate the efficiency of mask ventilation and the time to tracheal intubation in patients with normal airways. METHODS: Patients (n = 114) were randomized to receive IV rocuronium either before (early rocuronium group, n = 58) or after (late rocuronium group, n = 56) checking mask ventilation. Expiratory tidal volumes (VTs) were measured at 10, 20, 30, 40, 50, and 60 seconds after apnea during mask ventilation. We graded the ease of mask ventilation and measured the time from apnea to tracheal intubation. The primary outcome was the average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea. The main secondary outcome was the time from apnea to tracheal intubation. STATA was used for statistical analysis. RESULTS: The average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea was larger in the early rocuronium group than in the late rocuronium group (552 mL breath−1 [165 mL breath−1] vs 393 mL breath−1 [165 mL breath−1], mean difference, 160 mL breath−1; 95% CI, 98−221 mL breath−1; P

http://bit.ly/2IcWEcw

Managing Complications in Paediatric Anaesthesia

No abstract available

http://bit.ly/2GpbgDX

Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors

BACKGROUND: Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. METHODS: With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. RESULTS: A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P

http://bit.ly/2Ig8xhA

A rare anal mass: anal leiomyoma presented as perianal fistula

Abstract

Leiomyoma of the anal canal originating from the internal anal sphincter is an extremely rare clinical entity. Generally, it does not produce any clinical signs unless it is large enough to cause obstruction, discomfort, bleeding or pain. The diagnosis is often made incidentally during rectal examination due to other perianal disease or check-up. Herein we report a case of internal anal sphincter leiomyoma diagnosed unexpectedly during rectal examination in a patient with perianal fistula, and treated successfully with surgical excision. We present a review of the literature, the diagnostic strategies, differential diagnosis, prognosis and treatment modalities of this lesion.

http://bit.ly/2BCgfgj

Anterior mediastinal tumor as a solitary lymph node metastasis of occult thyroid carcinoma

Abstract

Solitary metastasis of occult thyroid carcinoma to the anterior mediastinum is very rare. A 65-year-old woman was examined for anterior mediastinal tumor based on the FDG accumulation on PET. We resected the tumor by video-assisted thoracic surgery. A pathological examination revealed that the tumor was lymph node metastasis of papillary thyroid carcinoma. The postoperative examination showed that the tumor was a solitary lymph node metastasis of occult thyroid carcinoma. Primary thyroid carcinoma has not appeared in 2 years since the surgery, and careful follow-up has been continued.

http://bit.ly/2TPzeuQ

Hysteroscopic guided, laparoscopic excision of caesarean scar defect: video presentation of a combined technique

Abstract

With increasing rates of delivery by caesarean section has come an increase in rates of associated complications, including caesarean scar defect. Whilst the management of this issue remains controversial, evidence is building for surgical management of such a defect for resolution of menstrual symptoms, pain and subfertility. We present a case report and surgical video of a hysteroscopic guided, laparoscopic excision of a caesarean scar defect. Following the successful management of this case and a literature review of the technique, we conclude this to be a safe, feasible and effective procedure with a low rate of complications.

http://bit.ly/2TPzaLC

Multiple cutaneous metastasis of synchronous urothelial carcinoma of the bladder and the renal pelvis: a case report

Cutaneous metastatic disease arising from urinary tract carcinoma is rare and associated with a poor prognosis. We report a case of metastatic disease occurring in a patient treated for synchronous urothelial ...

http://bit.ly/2BCOh4e

Anesthesia Outside the Operating Room

No abstract available

http://bit.ly/2N4uizF

Recent Advances in Anesthesiology

No abstract available

http://bit.ly/2SR0JqP

Society for Neuroscience in Anesthesiology & Critical Care (SNACC) Neuroanesthesiology Education Milestones for Resident Education

Background: The Accreditation Council for Graduate Medical Education (ACGME) has introduced competency-based assessments (milestones) for resident education. However, the existing milestones for Anesthesiology are not specific to Neuroanesthesiology. The Society for Neuroscience in Anesthesiology & Critical Care (SNACC) commissioned a task force to adapt the ACGME anesthesiology milestones for use in Neuroanesthesiology training, and to provide recommendations for implementing milestones. Methods: A 7-member expert task force supported by an advisory committee developed the initial milestones by consensus. Written permission was given by the ACGME. The milestones were refined following 3-month pilot use in 14 departments across the United States and inputs from SNACC members. Final milestones were approved by the SNACC Board of Directors. Results: Twelve Neuroanesthesiology-specific milestones in 5 major ACGME domains are recommended; these were identified as most pertinent to this subspecialty rotation. These pertain to patient care (7 milestones), medical knowledge (2 milestones), practice-based learning and improvement (1 milestone), and interpersonal and communication skills (2 milestones). Each milestone was described in detail, with clear outline of expectations at various levels of training. Conclusions: The SNACC Neuroanesthesiology milestones provide a framework for reviewing resident performance and are expected to facilitate improved use of ACGME milestones during Neuroanesthesiology subspecialty training. The task force recommends that the target should be to accomplish level 4 or higher milestones by the end of residency training. Individual programs should decide the implications of a resident not meeting the expected milestones. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Deepak Sharma, MD, DM, Departments of Anesthesiology & Pain Medicine and Neurological Surgery, Division of Neuroanesthesiology & Perioperative Neurosciences, University of Washington, Seattle, WA, P.O. Box #359724, 325, 9th Ave., Seattle, WA 98104 (e-mail: dsharma@uw.edu). Received December 15, 2018 Accepted January 7, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

http://bit.ly/2GDSuIa

Cerebrospinal Fluid Glucose and Lactate Levels After Subarachnoid Hemorrhage: A Multicenter Retrospective Study

Background: In patients with subarachnoid hemorrhage (SAH), abnormalities in glucose and lactate metabolism have been described using cerebral microdialysis. Glucose and lactate concentrations in cerebrospinal fluid (CSF) are more easily accessible, but scarce data are available in this setting. The aim of this study is to assess the relationship of CSF glucose and lactate with blood concentrations and with unfavorable neurological outcome after SAH. Methods: A retrospective cohort study was conducted in 5 European University intensive care units. Patients aged 18 years and above who were admitted after a nontraumatic SAH over a 4-year period (2011 to 2014) were included if they had an external ventricular drain placed, daily analysis of CSF including glucose (±lactate) concentrations for 1 to 4 consecutive days, and concomitant analysis of glucose and lactate concentrations in the arterial blood. Results: A total of 144 patients were included in the final analysis (median age: 58 [49 to 66] y; male sex: 77/144). Median time from admission to external ventricular drain placement was 1 (0 to 3) day; median Glasgow Coma Scale on admission was 10 (7 to 13), and CT-scan Fisher scale was 4. A total of 81 (56%) patients had unfavorable neurological outcome at 3 months (Glasgow Outcome Scale ≤3). There was a weak correlation between blood and CSF glucose (r2=0.07, P=0.007), and between blood and CSF lactate levels (r2=0.58, P

http://bit.ly/2tjbtjp

International Multicenter Survey of Perioperative Management of External Ventricular Drains: Results of the EVD Aware Study

Introduction: The perioperative management of patients with external ventricular drains (EVDs) is not well defined, and adherence to published management guidelines unknown. This study investigates practice, patterns, and variability in the perioperative management of patients with EVDs. Methods: A 31-question survey was sent to 1830 anesthesiologists from 27 institutions in North America, Europe, and Asia. A perioperative EVD Guideline Adherence Score was calculated for the preoperative, transport and intraoperative periods. Differences in management practices between neuroanesthesiologists and non-neuroanesthesiologists, and factors affecting EVD guideline adherence, were examined using bivariate significance tests and linear regression. Results: Among a sample of 599 anesthesiologists (survey response rate, 32.7%), compared with non-neuroanesthesiologists, neuroanesthesiologists were more likely to include baseline neurological examination (P=0.023), hourly cerebrospinal fluid output (P=0.006) and color (P

http://bit.ly/2GGMtuk

Glucose and Lactate Concentrations in Cerebrospinal Fluid After Traumatic Brain Injury

Background: Studies in which brain metabolism has been monitored using microdialysis have indicated decreases in cerebral glucose concentration and increases in lactate concentration in patients with traumatic brain injury (TBI). However, few data are available on glucose and lactate concentrations in the cerebrospinal fluid (CSF) of TBI patients. This study investigates the relationship between CSF glucose and lactate concentrations and outcomes after TBI. Methods: Consecutive adult (>18 y) TBI patients were admitted to our 35-bed medicosurgical between 2011 and 2014 and were included in the study if they met the following inclusion criteria: presence of an external ventricular drain (EVD) for intracranial pressure monitoring, daily analysis of CSF glucose and lactate concentrations for 4 consecutive days, and concomitant measurements of blood glucose/lactate concentrations. Neurological outcome was assessed at 3 months using the extended Glasgow Outcome Scale (GOS), and unfavorable outcome defined as a GOS 1 to 4. Results: Of 151 TBI patients who had an EVD, 56 met the inclusion criteria. Most EVDs were placed on the day of intensive care unit admission, and maintained for 10 (interquartile range: 6 to 14) days. On day 1, there was a weak but significant correlation between blood and CSF glucose concentrations (R2=0.07, P=0.04), and a greater correlation between blood and CSF lactate (R2=0.32, P

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Intubating Laryngeal Mask Airway-assisted Flexible Bronchoscopic Intubation is Associated With Reduced Cervical Spine Motion When Compared With C-MAC Video Laryngoscopy-guided Intubation: A Prospective Randomized Cross Over Trial

Background: In the evolving research into cervical spine mechanics during airway intervention, new devices are being constantly added to the armamentarium of anesthesiologists. In this study we compared cervical spine movement during orotracheal intubation using an intubating laryngeal mask airway (LMA Fastrach) assisted flexible bronchoscope or video laryngoscope. Materials and Methods: In total, 40 consenting patients without history of abnormalities of cervical spine and planned for elective neuroradiologic interventions in the angiography suite were enrolled in this randomized crossover trial. Every patient was subjected to LMA Fastrach-guided flexible bronchoscopic as well as video laryngoscopy guided intubation. Cervical spine motion at the occipital bone, C1-C5 vertebrae, the occiput-C1, C1-C2, C2-C3 and C4-C5 junctions was investigated using continuous fluoroscopy during intubation. The primary outcome of the study was combined craniocervical motion from occiput to C5 between the 2 intubation techniques. Results: There was less (62%) combined craniocervical movement from occiput to C5 during the LMA Fastrach-flexible bronchoscopy-guided technique as compared with video laryngoscopy-guided intubation (17.55±14.23 vs. 28.95±11.58 degrees, respectively; P

http://bit.ly/2GDStUC